Care of the Older Adult: A Nursing Study Guide

Care of the older adult is a high-yield nursing topic that blends normal aging physiology with atypical illness presentations, medication safety, and functional assessment. This note organizes the essentials you need for safe practice and exam success.

Key Definitions

• Gerontology: the study of aging and care of older adults; goals are to promote health, maintain function, and preserve dignity.
• Ageism: discrimination or stereotyping based on age; leads to undertreatment of pain, depression, and other conditions.
• Older adult: generally age 65 and older, subdivided into:
  • Young-old: 65–74
  • Middle-old: 75–84
  • Old-old: 85+

Normal Physiological Changes of Aging

• Cardiovascular: decreased vessel compliance and baroreceptor sensitivity → hypertension, orthostatic hypotension.
• Respiratory: decreased lung elasticity and weaker cough → increased pneumonia risk.
• Renal: decreased GFR → increased medication toxicity risk.
• Musculoskeletal: sarcopenia (muscle loss) and decreased bone density → falls and fractures.
• Sensory: presbycusis (high-frequency hearing loss) and presbyopia → communication difficulty and fall risk.
• Integumentary: thinner skin with decreased elasticity → skin tears and pressure injuries.

Clinical pearls:

• Sarcopenia increases fall risk and functional decline.
• Always measure orthostatic vital signs in older adults with dizziness or falls.
• With presbycusis, patients hear low-pitched voices better than high-pitched ones — do not shout.

Atypical Presentation of Illness

Decision rule: New confusion (delirium) in an older adult = assume infection or acute illness until proven otherwise.

• UTI, pneumonia, and MI may present with confusion, falls, or decreased appetite instead of classic dysuria, cough, or chest pain.
• Infection can be afebrile; confusion alone may be the only sign.
• Hypoactive delirium presents as quiet, withdrawn, or lethargic behavior — often missed because the patient is not agitated.
• Priority action for new confusion: assess for delirium, identify the underlying cause (infection, dehydration, medication), and notify the provider.

Delirium vs Dementia

• Sundowning: increased confusion and agitation in the evening; can occur in both delirium and dementia.
• Priority for delirium: identify and treat the underlying cause (infection, dehydration, medications).
• Priority for dementia: support function, ensure safety, and provide caregiver education.

Geriatric Syndromes

• Beers Criteria lists medications to avoid in older adults. High-risk classes include:
  • Benzodiazepines → falls
  • Anticholinergics → confusion
  • NSAIDs → GI bleeding and renal impairment
• Start low, go slow: initiate medications at lower doses; reduce doses of renally cleared drugs.

Functional Assessment

• ADLs (Activities of Daily Living): bathing, dressing, toileting, transferring, eating, grooming. Loss indicates significant decline.
• IADLs (Instrumental ADLs): managing finances, preparing meals, shopping, managing medications. IADLs decline before ADLs.
• Mini-Cog (three-item recall + clock drawing): briefest dementia screen.
• Confusion Assessment Method (CAM): used to screen for delirium.
• Functional decline guides discharge planning and home health referrals.

Restraints and Agitation Management

• Agitation is often caused by delirium, pain, or unmet needs (hunger, thirst, toileting). Do not assume agitation = dementia.
• Use non-pharmacologic interventions first: calm environment, frequent reorientation, pain management, fluids, toileting.
• Restraints (physical or chemical) are a last resort to prevent imminent harm. They require:
  • A provider order
  • A face-to-face evaluation within 1 hour
• Never use restraints for staff convenience, punishment, or in place of monitoring.

Medication Decision Rules

• Renal function declines with age → reduce doses of renally cleared drugs.
• Avoid anticholinergics (e.g., diphenhydramine, oxybutynin) — cause confusion, constipation, urinary retention.
• Avoid benzodiazepines as first-line for anxiety or insomnia — increase fall risk and cognitive impairment.
• Start low, go slow with all new medications.

Fall Prevention

• Fall risk factors: history of falls, gait impairment, polypharmacy (especially benzodiazepines and antihypertensives), and orthostatic hypotension.
• Priority interventions:
  • Medication review to deprescribe high-risk drugs
  • Home safety assessment (remove rugs, improve lighting)
  • Vitamin D supplementation
• Measure orthostatic vital signs in any older adult with falls or dizziness. Significant drop: ≥20 mmHg systolic or ≥10 mmHg diastolic upon standing.

Communication

• Hearing loss: face the patient, speak clearly and slowly, reduce background noise. Do not shout.
• Cognitive impairment: use short, simple sentences; allow extra response time.
• Address patients by their preferred name (Mr., Mrs., Ms.). Avoid "honey," "sweetie," or "dear."

Elder Abuse

• Signs: unexplained injuries, fear of caregiver, poor hygiene, malnutrition, dehydration, financial exploitation.
• Types: physical, emotional, sexual, financial, neglect, abandonment.
• Priority action: report suspected abuse to Adult Protective Services. Do not confront the caregiver.

Common Exam Traps

• New confusion is often the first sign of UTI or pneumonia — even without fever.
• Hypoactive delirium (quiet, withdrawn) is easily missed; a quiet patient is not necessarily stable.
• Pain is undertreated in older adults due to fear of side effects — treat pain based on the patient’s report.
• Do not use the back of the hand for skin turgor — elasticity decreases with age. Use the sternum or forehead.
• Do not dismiss functional decline as "normal aging" — investigate the cause.

Key takeaways

• Normal aging includes decreased GFR, sarcopenia, presbycusis, and orthostatic hypotension — but functional decline is not normal.
• New confusion = assume infection or delirium until proven otherwise; hypoactive delirium is easily missed.
• Delirium is acute and reversible; dementia is chronic and progressive.
• Avoid benzodiazepines, anticholinergics, and NSAIDs; apply Beers Criteria and "start low, go slow."
• Use non-pharmacologic interventions first for agitation; restraints are a last resort.
• Report suspected elder abuse to Adult Protective Services without confronting the caregiver.