Geriatric Nursing

Physiological Changes of Aging by Body System

System	Normal Age-Related Changes	Nursing Implications
Cardiovascular	↓ arterial compliance (stiffness → ↑ SBP) ↓ maximal HR (max HR ≈ 220 − age) ↓ baroreceptor sensitivity → orthostatic hypotension ↓ CO (especially with stress/exercise) Valvular thickening (aortic sclerosis) ↓ SA node cells → ↑ risk of arrhythmias	Assess for orthostatic BP changes (lying, sitting, standing after 1–3 min); use gradual position changes; monitor for silent MI (atypical — fatigue, dyspnea, confusion, not chest pain)
Respiratory	↓ elastic recoil (↑ compliance → air trapping) ↓ chest wall compliance (kyphosis, calcification) ↓ respiratory muscle strength ↓ alveolar surface area → ↓ diffusion ↓ mucociliary clearance → ↑ infection risk ↓ FEV₁, FVC, PaO₂	↑ risk of pneumonia (leading cause of death in elderly); encourage immunizations (influenza, pneumococcal, RSV, Tdap); teach deep breathing/incentive spirometry; observe for atypical presentation of pneumonia (confusion, ↓ appetite, falls, without fever)
Neurological	↓ brain weight and volume (cerebral atrophy) ↓ neurotransmitter synthesis (dopamine, acetylcholine) ↓ nerve conduction velocity Slowed reflexes and reaction time ↓ proprioception (↑ fall risk) ↓ sense of smell and taste	Allow extra time for responses; use clear, simple instructions; assess for cognitive decline (not normal aging); safety measures (falls, wandering, medication adherence)
Musculoskeletal	Sarcopenia (↓ muscle mass and strength) ↓ bone density (osteoporosis — especially women) Degenerative joint changes (OA) ↓ intervertebral disc height → loss of height (2–3″ by age 80) Stiffening of ligaments and tendons	↑ fall risk; encourage weight-bearing exercise (if safe), strength training, calcium (1200 mg/day), vitamin D (800–1000 IU/day); assess for frailty; use assistive devices; pad bony prominences
Renal	↓ renal mass (↓ nephrons) ↓ GFR (~10% per decade after 40) ↓ renal blood flow ↓ concentrating ability → dehydration risk ↓ drug clearance	Monitor renal function (serum creatinine may be falsely normal due to ↓ muscle mass — use BUN and eGFR); carefully dose nephrotoxic drugs; avoid NSAIDs if possible; encourage hydration
GI	↓ saliva production (xerostomia — med-induced more than aging) ↓ esophageal motility (dysphagia risk) ↓ gastric acid secretion (atrophic gastritis) ↓ peristalsis → constipation ↓ liver size and blood flow → ↓ drug metabolism	Assess for dysphagia (choking, pocketing food, weight loss); encourage fiber, fluids, activity for constipation; evaluate polypharmacy effects on GI function; monitor for malnutrition
Integumentary	↓ dermal thickness, collagen, elastin ↓ sebaceous and sweat gland activity ↓ subcutaneous fat Slower wound healing Senile purpura (easy bruising), lentigines (age spots)	Assess skin daily (especially pressure points); use emollients, gentle cleansers, avoid tape on fragile skin; pad bony prominences; reposition q2h; prevent shearing/friction
Sensory	Presbyopia (↓ accommodative ability) Presbycusis (↓ high-frequency hearing) ↑ risk of cataracts, glaucoma, macular degeneration ↓ olfactory and gustatory sensitivity → ↓ appetite	Face patient when speaking (allow lip-reading); deep voices heard better than high-pitched; ensure glasses and hearing aids are in place; adequate lighting; large-print materials; assess for vision/hearing deficits contributing to social withdrawal
Endocrine	↓ insulin sensitivity (↑ risk type 2 DM) ↓ thyroid function (↓ T₃), ↑ TSH slightly ↓ vitamin D synthesis and activation ↓ sex hormones (menopause, andropause)	Screen for DM (BG can be affected by meds, illness); monitor for atypical presentation of thyroid disease; ensure adequate Ca/vitamin D
Immunologic	↓ T-cell function (↓ cell-mediated immunity) ↓ antibody response to vaccines ↓ febrile response to infection ↑ autoantibodies (↑ autoimmune conditions)	↑ pneumonia, UTI, shingles, influenza; infection may present with confusion, falls, anorexia — NOT fever; vaccinate! Shingrix (recombinant zoster vaccine) for all adults ≥ 50

Clinical Pearl: Normal aging is NOT dementia, incontinence, depression, or falls — these are pathologic and warrant investigation. "Atypical presentation" is the rule in geriatrics: infection may present as confusion or falls without fever; MI may be "silent" with only fatigue or dyspnea.

Common Geriatric Conditions

Delirium vs. Dementia

Feature	Delirium	Dementia
Onset	Acute (hours–days)	Insidious (months–years)
Course	Fluctuating (wax and wane; worse at night — sundowning)	Progressive, gradual decline
Consciousness	Altered (clouded, hyper/hypoalert)	Clear until late stages
Attention	Impaired — cannot focus/sustain	Intact early; declines later
Thinking	Disorganized, rambling, incoherent	Impoverished (difficulty with abstraction)
Hallucinations	Common (especially visual)	Possible (especially in Lewy body dementia)
Reversibility	Potentially reversible (treat underlying cause)	Irreversible (except reversible causes)
Causes	I WATCH DEATH: Infectious, Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia, Deficiencies (B₁₂, thiamine), Endocrine (thyroid), Acute vascular, Toxins/drugs, Heavy metals	Alzheimer's (60–80%), vascular, Lewy body, frontotemporal, Parkinson's, etc.

Clinical Pearl: Delirium is a MEDICAL EMERGENCY. The CAM (Confusion Assessment Method) is the standard screening tool: (1) acute onset + fluctuating course, (2) inattention, AND EITHER (3) disorganized thinking OR (4) altered level of consciousness. Non-pharmacologic interventions first: reorientation, ambient lighting, minimize room changes, glasses/hearing aids, early mobilization, sleep hygiene. Avoid antipsychotics unless patient is a danger to self/others.

Alzheimer's Disease

Progressive neurodegenerative disease; plaques (β-amyloid) and tangles (tau protein)
Stages:
- Mild (early): short-term memory loss, word-finding difficulty, misplacing items, subtle personality changes, difficulty with complex tasks
- Moderate: significant memory loss (forgets own history), wandering, sundowning, agitation, needs help with ADLs, incontinence may begin
- Severe (late): bedbound, total dependence, dysphagia, cannot recognize family, nonverbal, contractures, seizures occur
Medications: Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) — modest benefit. NMDA antagonist (memantine) — for moderate-severe
Nursing care: reality orientation (mild), validation therapy (moderate), structured routine, safety (wandering alarms, fall prevention), skin integrity, feeding/dysphagia precautions, caregiver support

Parkinson's Disease

Loss of dopamine-producing neurons in substantia nigra; dopamine/acetylcholine imbalance
TRAP mnemonic: Tremor (resting, "pill-rolling"), Rigidity (cogwheel), Akinesia/bradykinesia, Postural instability (late sign)
Other: masked face (hypomimia), shuffling gait, festination, micrographia, dysphagia, drooling, depression, autonomic dysfunction, slowed speech
Medications: Levodopa/Carbidopa (gold standard) — do NOT give with high-protein meals; dopamine agonists (pramipexole, ropinirole); MAO-B inhibitors (selegiline, rasagiline); COMT inhibitors (entacapone)
Nursing: fall risk! Encourage ambulation but assess for freezing. Medication timing is critical — do not miss doses (can cause severe rigidity and immobility). Assess for dysphagia (aspiration risk). Skin care, bowel regimen (constipation common)

Falls

Leading cause of injury and death in older adults; ~30% of community-dwelling adults ≥ 65 fall each year
Risk factors: history of falls, gait/balance problems, muscle weakness, polypharmacy (≥ 4 meds), vision impairment, environmental hazards, orthostatic hypotension, fear of falling, cognitive impairment
Screening: Get Up and Go test — time > 12–14 sec = high fall risk
Prevention: multifactorial! Medication review (deprescribe), strength/balance training (Tai Chi, PT), vitamin D supplementation, vision correction, home safety assessment (grab bars, non-slip mats, remove rugs, adequate lighting), footwear assessment
Post-fall: assess for injury (head bleed in anticoagulated patient!), vital signs, neuro check, labs (CBC, BMP, TSH, B₁₂), ECG, orthostatic vitals, root cause analysis

Urinary Incontinence

Type	Description	Causes / Management
Stress	Leakage with ↑ intra-abdominal pressure (cough, laugh, sneeze, exercise)	Weakened pelvic floor (childbirth, aging). Management: Kegel exercises, biofeedback, pessary, vaginal estrogen (topical), sling surgery
Urge (OAB)	Sudden strong urge to void followed by leakage	Detrusor overactivity, bladder irritation. Management: bladder training, timed voiding, anticholinergics (oxybutynin, tolterodine), mirabegron (β₃-agonist), pelvic floor PT
Overflow	Incomplete bladder emptying, frequent small voiding, dribbling	Outlet obstruction (BPH), neuropathy (DM), detrusor underactivity. Management: double void, Crede maneuver, catheterization, treat underlying cause
Functional	Leakage due to inability or unwillingness to reach toilet	Immobility, cognitive impairment, environmental barriers. Management: scheduled toileting, commode at bedside, environmental modifications, treating underlying cause
Transient (DIAPPERS)	Acute/reversible incontinence	Delirium, Infection (UTI), Atrophic urethritis/vaginitis, Pharmacologic, Psychologic, Endocrine (hyperglycemia), Restricted mobility, Stool impaction

Clinical Pearl: Incontinence is NOT a normal part of aging. ALWAYS assess for reversible causes first (DIAPPERS). Anticholinergic medications for urge incontinence should be used cautiously in older adults — they can cause confusion, constipation, dry mouth, and increased fall risk. Mirabegron is often preferred.

Polypharmacy

Use of ≥ 5 medications (some define as > 5, some as any potentially unnecessary meds)
Consequences: adverse drug reactions, drug-drug interactions, ↑ falls, ↑ hospitalizations, ↑ costs, ↓ adherence, geriatric syndromes
Beers Criteria (AGS): list of potentially inappropriate medications in older adults.
- Avoid: benzodiazepines (↑ falls, cognitive decline), anticholinergics (diphenhydramine, amitriptyline), long-acting sulfonylureas (glyburide — ↑ hypoglycemia), NSAIDs (chronic use — ↑ GI bleed, renal injury, HTN), meperidine
- Use with caution: digoxin, warfarin, SSRIs, diuretics, opioids
Nursing: "Brown bag" medication review (have patient bring ALL medications — including OTC, herbals, supplements — to appointment). Assess for STOPP/START criteria. Simplify regimen. Teach each drug's purpose

Depression in Older Adults

NOT normal aging. Often underdiagnosed due to atypical presentation
S/S: anhedonia, sleep disturbance, appetite changes, fatigue, psychomotor changes, hopelessness, suicide ideation, anxiety, somatic complaints (pain, GI symptoms), cognitive complaints (pseudodementia)
Screening: PHQ-9, Geriatric Depression Scale (GDS) — short form 15-item version is common
Risk factors: chronic illness, pain, bereavement, social isolation, disability, substance use, female, prior depression, dementia
Management: SSRIs (first-line — lower doses; watch for hyponatremia, GI bleeding), psychotherapy (CBT), exercise, social engagement. Suicide risk is HIGH in older white males

Malnutrition

"Anorexia of aging": multifactorial — ↓ taste/smell, polypharmacy, dysphagia, oral health, social isolation, depression, dementia
Screening: MNA (Mini Nutritional Assessment), weight loss (≥ 5% in 1 month or ≥ 10% in 6 months is concerning), BMI < 20–22
Consequences: ↓ immune function, sarcopenia, frailty, pressure ulcers, falls, ↑ morbidity/mortality
Interventions: liberalize diet (remove dietary restrictions if appropriate), assist with feeding, oral supplements, dental care, treat depression, social dining (congregate meals), assess for feeding assistance needs

Pressure Ulcers (Injuries)

Stage	Description
Stage 1	Non-blanchable erythema of intact skin
Stage 2	Partial-thickness skin loss; shallow open ulcer with red-pink wound bed; no slough
Stage 3	Full-thickness skin loss; subcutaneous fat visible; may have slough and/or undermining/tunneling
Stage 4	Full-thickness tissue loss with exposed bone, tendon, or muscle; slough/eschar may be present
Unstageable	Full-thickness tissue loss; base covered with slough (yellow/tan/green) or eschar (tan/brown/black); cannot determine stage until debrided
Deep Tissue Injury (DTI)	Purple/maroon localized area of intact skin or blood-filled blister; deep tissue damage from pressure/shear

Common sites: sacrum/coccyx (most common), heels, trochanters, ischial tuberosities (sitting), elbows, occiput
Braden Scale: predicts pressure injury risk (sensory perception, moisture, activity, mobility, nutrition, friction/shear). Score ≤ 18 = at risk; ≤ 9 = very high risk
Prevention: reposition q2h, pressure-relieving surfaces/specialty mattresses, keep skin clean and dry, moisture barrier, nutrition optimization, offload heels, no donut devices!

Geriatric Assessment Tools

Tool	Purpose	How to Administer	Scoring
MMSE (Folstein Mini-Mental State Exam)	Cognitive screening; orientation, memory, attention, language, visuospatial	11 items: orientation (5), registration (3), attention/counting (5), recall (3), naming, repetition, 3-step command, reading, writing, copying. Takes ~7–10 min	Score /30. ≥ 24 normal, 20–24 mild impairment, 13–20 moderate, < 12 severe. Influenced by education, language, sensory deficits
Clock-Draw Test	Quick (< 2 min) screen for executive function / visuospatial	Give patient blank paper and ask: "Draw a clock face with all the numbers. Then draw hands to show ten minutes past eleven."	Various scoring; most common: 1 = perfect; 2 = minor errors; 3 = inaccurate spacing; 4 = moderate difficulty; 5 = severe disorganization. Can be done serially
Get Up & Go Test (Timed Up & Go — TUG)	Mobility and fall risk assessment	Patient rises from armchair (seat ~46 cm), walks 3 m at normal pace, turns, walks back, sits down. May use usual walking aid	Time in seconds. < 10 sec = normal; 10–19 = good mobility (low fall risk); 20–29 = borderline (moderate fall risk); ≥ 30 = impaired mobility (high fall risk, may need assistance)
Barthel Index	Functional status / ADL independence	10 items: feeding, bathing, grooming, dressing, bowel/bladder control, toilet use, transfer, mobility, stairs. Rate independence/dependence	0–100 (higher = more independent). ≥ 60 = moderately dependent; ≤ 40 = severely dependent. Used to track functional decline or improvement
Braden Scale	Pressure injury risk	6 subscales: sensory, moisture, activity, mobility, nutrition, friction/shear. Each scored 1–4 (friction 1–3)	6–23. ≤ 18 = at risk; ≤ 14 = moderate risk; ≤ 9 = very high risk
PHQ-9	Depression screening	9-item self-report based on DSM-5 criteria; past 2 weeks	0–27. ≥ 10 = moderate depression; ≥ 15 = moderately severe; ≥ 20 = severe
Geriatric Depression Scale (GDS)	Depression in older adults (yes/no format, less somatic focus)	15-item or 30-item version	≥ 5 (15-item) = suggestive of depression; ≥ 10 = almost always depression

Clinical Pearl: The MoCA (Montreal Cognitive Assessment) is more sensitive than the MMSE for detecting mild cognitive impairment (MCI) and vascular cognitive impairment. It includes executive function, abstraction, clock-draw, and trail-making. Score /30, cut-off < 26. MMSE is still widely used but copyrighted; the SLUMS (St. Louis University Mental Status) exam is a free alternative.

Elder Abuse

Types of Elder Abuse

Type	Definition	Signs
Physical	Infliction of pain/injury	Bruises, fractures, burns, lacerations in unusual or patterned locations; inconsistent history; delay seeking care; reluctance to speak in front of caregiver
Sexual	Non-consensual sexual contact	Bruising or bleeding in genital/anal area; unexplained STIs; torn/broken underclothing; fearfulness, withdrawal
Emotional / Psychological	Infliction of distress through verbal/nonverbal acts	Withdrawal, rocking, ambivalence, agitation, low self-esteem, sleep disturbance, caregiver isolates elder; elder appears fearful of caregiver
Financial	Illegal or improper use of elder's resources	Unexplained withdrawal of funds, sudden changes in will, missing possessions, unpaid bills despite adequate funds, elder not receiving care that resources should provide
Neglect	Failure to meet care needs (intentional or unintentional)	Dehydration, malnutrition, poor hygiene, soiled clothing, untreated medical conditions, pressure ulcers, contractures, medication mismanagement
Abandonment	Desertion of elder by responsible person	Elder left alone in a hospital, facility, or public place with no designated caregiver; unsafe living conditions

Risk Factors & Reporting

Risk factors: Social isolation, cognitive impairment (dementia), functional dependence, shared living with abuser, caregiver stress, female, advanced age (> 80), history of domestic violence, substance abuse in caregiver
Assessment: Use the Elder Abuse Suspicion Index (EASI) or direct questioning: "Has anyone at home hurt you?" "Are you afraid of anyone?" "Has anyone taken your money without permission?"
Reporting:
- All 50 states have mandatory reporting laws for suspected elder abuse
- Report to Adult Protective Services (APS) and/or local law enforcement
- In long-term care facilities, report to the state Ombudsman and/or state survey agency
- You do NOT need proof — only reasonable suspicion. The reporter's identity is confidential
- Failure to report is a misdemeanor in many states

Clinical Pearl: Elder abuse is severely underreported — for every 1 case reported, an estimated 24 go unreported. When interviewing a suspected elder abuse victim, interview the elder ALONE (out of caregiver's hearing range). Use open-ended questions. Most elders do not want to leave their homes — the priority is safety and stopping the abuse, not placement.