Nursing Care of

the Older Adults

IN CHRONIC ILLNESS
Table of contents

Disturbances in Sensory Perception

2 Chronic Confusion

Impaired Verbal Communication

1
Disturbances
in Sensory
Perception
 EYES: COMMON COMPLAINTS, PROBLEMS
AND CONDITIONS
Appear as dots, wiggly lines, or clouds that a person may see moving in the
Floaters
field of vision. They become more pronounced when a person is looking at a
and plain background. Floaters occur more often after age 50, as tiny clumps of
Flashers gel or cellular debris float in the vitreous humor in front of the retina.

Results in quantity and quality of tear production diminish with aging.

Stinging, burning, or a scratchy sensation are common complaints of the
Dry Eyes individual with dry eye. Episodes of excess tearing may occur following a
period of discomfort, dryness, pain, redness, and possibly discharge in the
eyes.

Most common complaint of adults older than age 40 is a diminished ability to

focus clearly on close objects (arm’s length) such as a newspaper. The lenses
Presbyopia
lose its ability to focus on close objects. Accommodation is impaired as the
lens thickens and loses its elasticity.
 EYES: COMMON COMPLAINTS, PROBLEMS
AND CONDITIONS

It is a chronic inflammation of the eyelid margins commonly found in

Blepharitis
older adults. It may be caused by seborrheic dermatitis or infection.

It is a group of disease that can result in vision loss and lead to blindness
due to damage to the optic nerve. The most common form, open angle,
Glaucoma
has few, if any symptoms and may cause partial vision loss before it is
detected.

It is the most common disorder found in the aging adult. Although

Cataracts cataracts are considered an “age-related” condition, it can occur in
individuals in their 40’s and 50s but typically does not have a significant
effect on vision.
 EARS: COMMON COMPLAINTS, PROBLEMS
AND CONDITIONS

Itching within the external auditory canal, results from age-related

PRURITIS atrophic changes in the skin. Atrophy of the epithelium and epidermal
sebaceous glands results in dryness. Often, chronic pruritus of the ear
canal results from an itch-scratch-itch cycle initiated by dry skin. The
problem may be exacerbated by efforts to retard and remove dry earwax
buildup.

It is a reversible, often overlooked, cause of conductive hearing loss.

CERUMEN With increasing age, atrophic changes in the sebaceous and apocrine
IMPACTION glands lead to drier cerumen. These changes in the cerumen coupled
with a narrowed auditory canal and stiffer, coarser hairs lining the canal
led to cerumen impaction.
 EARS: COMMON COMPLAINTS, PROBLEMS
AND CONDITIONS

A chronic combination of both conductive and sensorineural hearing

TINNITUS loss. It is a subjective sensation of noise in the ear, defined as a ringing,
buzzing, or hissing. Individuals at any age may experiences tinnitus, but
its prevalence increases with advancing age.

A sensorineural hearing loss, is the most common form of hearing loss in

older adults. Typically, the loss is bilateral, resulting in difficulty hearing
PRESBYCUSIS high-pitched tones and conversational speech. It affects men more than
women. The cause of presbycusis remains unclear. Studies designed to
identify a direct cause have proven no clear correlation.
 NURSING INTERVENTIONS/IMPLEMENTATION
The following nursing interventions should take place in hospitals or extended-care facilities:
1. Ensure that all caregivers are aware of the person’s sensory problems.
2. Make appropriate sensory contact before beginning care.
3. Determine the best methods for communicating with older adults
4. Modify the environment to reduce risks.
5. Verify that prostheses such as eyeglasses and hearing aids are functional.

The following interventions should take place in the home:

1. Modify the home environment to compensate for sensory changes.
2. Assist sensorially impaired people in developing techniques or acquiring
devices that will help compensate for losses.
2
Chronic
Confusion
 Chronic Confusion
• Anything that damages or interferes with the normal functioning of the
cerebral cortex can result in cognitive (i.e., thinking and judgment) problems.

• Sensory changes can result in behaviors that mimic cognitive problems but
actually are not. The two should not be confused. Sensory misperception
should be ruled out before further cognitive assessment is performed.

• The term confusion is used to describe a wide range of behaviors. Confusion is

defined as a mental state characterized by disorientation regarding time,
place, or person that leads to bewilderment, perplexity, lack of orderly
thought, and the inability to choose or act decisively and to perform activities
of daily living. NANDA International identifies the following nursing diagnoses
that relate to confusion: acute confusion, chronic confusion, ineffective
impulse control, and impaired memory (NANDA International, 2014).
 Types of Confusion:

Acute confusion, often called delirium, is characterized by

Acute disturbances in cognition, attention, memory, and perception.
Confusion This type of confusion is usually caused by a physiologic process
that affects the autonomic nervous system.

Chronic confusion or dementia is progressive and variable in

nature and may usually involve problems with memory recall,
Chronic problem-solving, language, and attention. Also, there can be
Confusion difficulties with perception, rationalizing, judgment, abstract
thinking, communication, emotional expression, and the
performance of routine tasks.
Signs and Symptoms Risk Factors

• Memory Loss • Age

• Disorientation • Family History
• Language Difficulties • Genetics
• Impaired Judgment • Cardiovascular Health
• Personality Changes • Diabetes
• Difficulty with Activities of • Smoking and Alcohol
Daily Living • Head Injuries
• Loss of Motor Skills • Social Isolation
• Hallucinations or Delusions • Depression
• Medications
 Mnemonic Assessment for DELIRIUM COMPONENT &
CONSIDERATIONS
COMPONENTS CONSIDERATIONS
Any recent change in medications, increase or decrease in dosage, change from
specific brand to a generic. Pay special attention to sedative hypnotics (including
Drug use alcohol), antidepressants, opioids, antipsychotics, anticholinergics, anticonvulsants,
antiparkinson medications, and H2 blocking medications.
Abnormal levels of calcium, sodium, or magnesium often related to malnutrition or
Electrolytr Imbalance dehydration
Lack of Drugs Missed medication dose
Check for urinary tract infection (UTI), signs of inflammation, respiratory congestion,
Infection etc., remembering that the signs may be subtle in the older adult
Reduced Sensory input Visual or hearing impairment, failure to use glasses or hearing aids, social isolation

Intracranial problems Recent head injury, history of stroke, meningitis, history of seizure
Urinary retention Recent anesthesia, history of benign prostatic hyperplasia, recent catheter removal
and/or Fecal Impaction fecal impaction
Myocardial problems Anginal symptoms, abnormal electrocardiogram (ECG), recent cardiac surgery
 Difference Between
Delirium and Dementia
DELIRUM DEMENTIA

Rapid onset: hours to days Slower onset: months to years

Reduced level of consciousness No change in level of
consciousness (initially)
Variable course over 24 hours Stable over 24 hours
Increased or decreased psychomotor Impaired memory with loss of abstract
activity Disturbed sleep/wake patterns thinking, judgment, language skills (aphasia),
Disorientation and perceptual disturbances, motor skills (apraxia), and ability to recognize
possible visual and auditory familiar people or objects (agnosia)
hallucinations Memory impairment
Decreased attention span with disorganized
thinking
Generally reversible if underlying problem Generally, not reversible
is identified and treated; may recur
Types of Dementia:
1. PRIMARY DEMENTIA
Types of primary dementia include:
• Alzheimer’s disease: Symptoms include short-term memory loss, confusion, personality
and behavior changes. Trouble talking, remembering distant memories and issues with
walking happen later in the disease. Alzheimer’s disease mainly affects adults who are
older — up to 10% of those over age 65 and about 50% of people older than 85 have
the disease. Family history is an important risk factor. Approximately 60% to 80% of
people with dementia have this type.
• Vascular Dementia: It’s caused by conditions such as strokes or atherosclerosis, which
block and damage blood vessels in your brain. Symptoms include memory problems,
confusion and trouble concentrating and completing tasks. The decline may appear
suddenly (following a major stroke) or in steps (following a series of mini strokes). Risk
factors include high blood pressure, diabetes and high cholesterol levels. About 15% to
25% of people with dementia have vascular dementia.
Types of Dementia:
1. PRIMARY DEMENTIA
Types of primary dementia include:
• Lew Body Dementia: This condition involves the buildup of clumps of proteins — called
Lewy bodies — in your brain’s nerve cells Symptoms include movement and balance
problems, changes in sleep patterns, memory loss, planning and problem-solving
difficulties, and visual hallucinations and delusions.
• Frontotemporal Dementia( (FTD): This dementia results from damage to the frontal
and temporal lobes of your brain. It causes changes in social behavior, personality,
and/or loss of language skills (speaking, understanding or forgetting the meaning of
common words) or motor coordination.
• Mixed Dementia: This is a combination of two or more types of dementia. The most
common combination is Alzheimer’s disease with vascular dementia. It’s often hard to
diagnose because symptoms of one dementia may be more obvious and/or many symptoms
of each type overlap. The decline is faster in people who have mixed dementia compared
with those who only have one type.
Types of Dementia:
2. SECONDARY DEMENTIA
Types of secondary dementia include:
• Huntington’s disease: A single defective gene causes this brain disorder. The disease
causes a breakdown in your brain’s nerve cells, which causes body movement control
problems, as well as thinking, decision-making and memory trouble, and personality
changes.
• Parkinson’s disease: Many people in the later stages of Parkinson’s disease develop
dementia. Symptoms include trouble with thinking and memory, hallucinations and
delusions, depression and trouble with speech.
• Creutzfeldt-Jakob disease: This rare infective brain disease affects about only 1 in 1
million people. An abnormal protein in your brain called prions causes the disease.
These prions clump together and cause nerve cell death in your brain. Symptoms
include problems with thinking, memory, communication, planning and/or judgment,
confusion, behavior changes, agitation and depression.
Types of Dementia:
2. SECONDARY DEMENTIA
Types of secondary dementia include:
• Wernicke Korsakoff syndrome: This brain disorder is caused by a severe thiamine
(vitamin B1) deficiency. This can result in bleeding in key areas related to memory in
your brain. It’s most caused by alcohol use disorder but can also be due to malnutrition
and chronic infection. Symptoms include double vision, loss of muscle coordination,
and difficulty processing information, learning new skills and remembering things.

• Traumatic brain injury: Repeated blows to your head can cause this injury. It’s most
often seen in football players, boxers, soldiers and people who’ve had a vehicle
accident. Dementia symptoms, which appear years later, include memory loss,
behavior or mood changes, slurred speech and headaches.
Types of Dementia:
3. DEMENTIAS DUE TO REVERSIBLE CAUSES
Types includes:
• Normal pressure hydrocephalus (NPH): This condition happens when cerebrospinal fluid
(CSF) builds up in your brain’s spaces (ventricles). NPH can be caused by a brain infection,
brain injury, brain bleed or previous brain surgery. Symptoms include poor balance,
forgetfulness, trouble paying attention, mood swings, frequent falls and loss of bladder
control. Your healthcare provider can drain excess fluid through the surgical placement of a
shunt (tube).
• Vitamin deficiency: Not getting enough vitamin B1, B6, B12 cooper and vitamin E in your
diet can cause dementialike symptoms.
• Infections: Infections that can cause dementialike symptoms include HIV infection, syphilis
and Lyme disease. Symptoms reported with COVID19 infection include “brain fog” and acute
delirium. Because of the inflammation and stroke risk seen with COVID19 infection, both
short and long-term cognitive effects are being investigated. Urinary tract infections (UTIs)
and infections in your lungs in the elderly can also result in dementialike symptoms.
Types of Dementia:
3. DEMENTIAS DUE TO REVERSIBLE CAUSES
Types includes:
• Metabolic and endocrine conditions: Conditions that can mimic dementia include
Addison’s disease, Cushing’s disease, low blood sugar (hypoglycemia) exposure to
heavy metals (like arsenic or mercury), high calcium levels (hypercalcemia, often due to
hyperparathyroidism), liver cirrhosis and thyroid problems.
• Medication side effects: Some medications, in some people, can mimic dementia
symptoms. These include sleeping pills, antianxiety drugs, antidepressants, antiseizure
drugs, antiparkinson drugs, nonbenzodiazepine sedatives, narcotic pain relievers,
statins and others.
• Other causes: Other causes of dementialike symptoms include brain tumors and
subdural hematomas (brain bleeds between your brain’s surface and the covering over
your brain).
 NURSING INTERVENTIONS/IMPLEMENTATION
The following nursing interventions should take place in hospitals or extended-care facilities:
1. Assess behavior on admission and at regular intervals.
2. Provide assistive sensory devices
3. Orient the person to person, place, and time, and provide any other important
situational information, but do not force the issue, because it can lead to agitation.
Address the person by the name he or she responds to best.
4. Provide a structured environment that ensures safety yet enables the person to
keep active as long as possible.
5. Provide continuity.
6. Administer psychotherapeutic medications as ordered.
7. Avoid use of physical and chemical restraints.
8. Structure participation in activities of daily living.
 NURSING INTERVENTIONS/IMPLEMENTATION
The following nursing interventions should take place in hospitals or extended-care facilities:
9. Structure the environment to minimize disruption; avoid sudden changes of room
or environment.
10. Develop a plan to deal with “acting out” behaviors.
11. Use effective communication skills.
12. Consult with family and the multidisciplinary team.
 PHARMACOLOGICALMANAGEMENT

Pharmacological management for dementia in older adults primarily

focuses on addressing the cognitive and behavioral symptoms associated
with the condition. While there is no cure for most forms of dementia,
medications can help manage some of the symptoms and improve the
individual's quality of life. The choice of medication depends on the type
of dementia and the specific symptoms. Here are some common
medications used in the pharmacological management of dementia:
PHARMACOLOGICAL MANAGEMENT

Cholinesterase Inhibitors:
• These medications (e.g., donepezil, rivastigmine, galantamine) are primarily used to treat
Alzheimer's disease but may also be considered for other types of dementia with cholinergic
deficits.
• Cholinesterase inhibitors work by increasing the levels of acetylcholine, a neurotransmitter
involved in memory and cognitive function.
• They may help improve cognitive function, reduce behavioral symptoms, and delay symptom
progression.
• Side effects can include nausea, vomiting, diarrhea, and loss of appetite.

NMDA Receptor Antagonists:

• Memantine is a medication approved for the treatment of moderate to severe Alzheimer's
disease. It works by regulating the activity of glutamate, another neurotransmitter involved in
learning and memory.
• Memantine can help improve cognitive function, particularly in individuals with more advanced
dementia.
• Common side effects include dizziness, headache, and confusion.
PHARMACOLOGICAL MANAGEMENT

Antipsychotic Medications:
• Antipsychotic drugs like risperidone or aripiprazole may be prescribed to manage severe
behavioral symptoms, such as agitation, aggression, or hallucinations.
• Their use should be carefully monitored, as they can have significant side effects, including
sedation, weight gain, and an increased risk of stroke in older adults with dementia. They should
be used with caution and only when necessary.

Antidepressant Medications:
• Some antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), may be used to
manage mood and behavioral symptoms in dementia.
• SSRIs like sertraline or citalopram can help with symptoms of depression, anxiety, and agitation.

Other Medications:
• Depending on the individual's specific symptoms and needs, other medications like anxiolytics
(for anxiety), mood stabilizers (for mood swings), or sleep medications (for sleep disturbances)
may be considered.
PHARMACOLOGICAL MANAGEMENT

➢ It's important to note that pharmacological management of dementia

should always be part of a broader treatment plan that includes non-
pharmacological approaches, such as behavioral interventions and
support for caregivers.
➢ Additionally, the use of these medications should be carefully
monitored by a healthcare professional, and the benefits and potential
risks should be weighed for everyone.
➢ Treatment plans should be individualized based on the type and stage
of dementia, the presence of other medical conditions, and the
person's response to medications. Regular follow-up visits with a
healthcare provider are essential to assess the effectiveness of
treatment and make any necessary adjustments.
KEY ASPECTS OF NURSING MANAGEMENT FOR DEMENTIA:
Assessment and Diagnosis
• Conduct a thorough assessment to determine the type and stage of dementia, as well as any
underlying medical conditions or comorbidities.
• Identify the individual's strengths, limitations, and preferences.
Person-Centered Care:
• Develop a person-centered care plan that respects the individual's values, preferences, and past
life experiences.
• Involve the individual in decision-making to the extent possible.

Communication:
• Use clear, simple, and non-verbal communication techniques to facilitate understanding.
• Be patient, listen actively, and provide reassurance.
Cognitive Stimulation:
• Engage the person in activities that stimulate cognitive function, memory, and problem-solving
skills.
• Encourage reminiscence therapy, music therapy, and other forms of mental stimulation
KEY ASPECTS OF NURSING MANAGEMENT FOR DEMENTIA:
Behavioral Management:
• Implement strategies to manage behavioral symptoms such as agitation, aggression, or
wandering.
• Use redirection, distraction, and positive reinforcement to address challenging behaviors.
Medication Management:
• Administer and monitor medications as prescribed, ensuring compliance and addressing any side
effects.
• Educate family members and caregivers about the purpose and potential risks of medications.
Safety Measures:
• Create a safe environment by removing potential hazards and implementing fall prevention
strategies.
• Use alarms or monitoring systems to prevent wandering, especially in advanced stages.
Nutrition and Hydration:
• Monitor and ensure proper nutrition and hydration.
• Adapt meal plans to accommodate dietary preferences and restrictions.
KEY ASPECTS OF NURSING MANAGEMENT FOR DEMENTIA:
Mobility and Activities of Daily Living (ADLs):
• Assist with ADLs as needed, maintaining the individual's dignity and independence for as long as
possible.
• Encourage regular physical activity to promote mobility and reduce the risk of falls.
Pain Management:
• Assess and manage pain, as individuals with dementia may have difficulty expressing their
discomfort.
• Use pain assessment tools and consult with healthcare providers as needed.
Family and Caregiver Support:
• Educate and provide support to family members and caregivers, including training on dementia
care techniques.
• Offer respite care options to give caregivers a break.
Emotional and Psychological Support
• Address emotional needs by providing a supportive and empathetic environment.
• Consider counseling or support groups for individuals and their families.
KEY ASPECTS OF NURSING MANAGEMENT FOR DEMENTIA:
Advance Care Planning:
• Assist with advance care planning, including discussions about end-of-life care and legal matters.
Continuity of Care:
• Ensure that care is coordinated across healthcare settings, such as hospitals, nursing homes, and
home care services, to provide seamless care transitions.

Regular Evaluation and Documentation:

• Continuously assess the individual's condition and document changes in cognitive, physical, and
emotional status.
• Adjust the care plan as needed to meet evolving needs.

Nursing management for dementia in older adults requires a compassionate and patient-centered
approach, recognizing the uniqueness of each person's experience with the condition. Collaboration
with a multidisciplinary healthcare team, including physicians, therapists, social workers, and other
specialists, is crucial to provide holistic care and support for individuals with dementia and their
families.
3
IMPAIRED
VERBAL
COMMUNICATION
SPEECH
• The term used to refer to spoken language.
• The normal physiologic changes of aging affect the quality of speech.
• Normal speech in older adults tends to be slower, softer, less fluent, less rhythmic,
and breathier than in younger individuals, and it often has a tremulous quality.
• Patients who suffer from neurologic damage affecting muscle control may experience
more than usual difficulty with speech articulation, a condition called dysarthria.
LANGUAGE
• A broad term that includes all modes of spoken or symbolic communication.
• Language allows us to send and receive messages from other humans. We use
language to convey our ideas and to make our wishes known to others.
• People who lose the ability to use language or to speak are likely to experience
problems. Older adults with impaired verbal communication skills often become
depressed, agitated, and frustrated; they feel excluded from normal social
interactions.
THE MOST COMMON LANGUAGE PROBLEM
SEEN IN OLDER ADULTS IS CALLED APHASIA
(OR DYSPHASIA).
 Comparison of Common Types of Aphasia

BROCA APHASIA WERNICKE APHASIA

Lesion in frontal lobe Lesion in temporal lobe

Expressive or motor Receptive or sensory

Speech is slow, labored, Speech is rapid, fluent,

hesitant, nonfluent, poorly normal in tone, clearly
articulated articulated, and long
and rambling
Short sentences with little May follow stereotyped
grammatical structure patterns
Nonsense or jargon speech
indicates noncomprehension
Classification of APHASIA:
Receptive Aphasia
• The person has difficulty understanding language Not the same as deafness.
• Communication problems in deaf people are caused by mechanical or
neurologic defects that do not allow sounds to enter the nervous system.
• People suffering from receptive aphasia hear sounds normally but are unable
to give these sounds meaning.
• In some cases, this loss is complete; in others, only specific language reception
is lost. Some people cannot understand spoken words but can understand
written words.
• Others can repeat the spoken words but cannot give any meaning to them.
Still others can understand single words but not sentences or word
combinations.
Classification of APHASIA:
Expressive Aphasia

• The person is unable to express himself or herself using language.

• Like receptive aphasia, expressive aphasia comes in more than one form.
• Broca aphasia is a common form in which the person can understand
verbal and written language but is unable to speak words fluently. The
area of the brain that coordinates the muscles of speech is damaged. This
form of aphasia is particularly frustrating because the person knows what
he or she wants to say but cannot get the words out.
• In Wernicke aphasia, the person can speak, but the words produced may
be nonsensical or have little connection with reality
Classification of APHASIA:
Global Aphasia

• The person loses the ability both to understand language and to express
himself or herself using language.
• Used when receptive and expressive language skills are lost.
• People suffering from global aphasia are profoundly affected.
• If any communication ability remains, it is in the form of a single sound
that may be repeated with a variety of pitches, rhythms, and emphasis.
 Classification of APHASIA:

Receptive Aphasia The person has difficulty understanding language

Expressive Aphasia
The person is unable to express himself or
herself using language.

The person loses the ability both to understand

Global Aphasia language and to express himself or herself using
language.
 NURSING INTERVENTIONS/IMPLEMENTATION
The following nursing interventions should take place in hospitals or extended-care
facilities:
1. Assess the older adult’s communication problems and abilities.
2. Identify specific approaches that are effective for each person.
3. Document in the care plan the selected techniques that facilitate
communication.
4. Explain effective communication techniques to family members and friends.
5. Teach verbally impaired older adults methods for their specific communicating
needs.
6. Consult with a speech therapist/pathologist to determine the most effective
communication strategies.
Thank you!