Chapter 21: Care of the Older Client

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Welcome to the Deep Dive.

Today, we're looking into something really vital, the care of older adults.

Yeah, it's a topic that affects so many of us, personally and professionally.

Absolutely.

And it might seem simple on the surface, but there's actually a lot of nuance there, isn't there?

There really is.

So our mission today is to pull out the really core knowledge on caring for older clients.

We want to build a clear, practical understanding, all based on

solid nursing principles.

Exactly.

And for this Deep Dive, we're using Chapter 21 from the Saunders Comprehensive Review for the NCLE -XPN Examination, the seventh edition.

Which is a key resource for nurses.

Oh, definitely.

It's a standard.

So you know the information is reliable and clinically relevant.

We're basically highlighting the must -know points for you from that chapter.

Think of this as your focused guide to the essentials of geriatric care, straight from that source.

We'll cover the key concepts, assessment points, safety, the whole picture, but you know, without getting totally overwhelmed.

Right.

Whether you're in healthcare needing a refresher, or maybe you're just interested in understanding aging betters for family or friends, this should be really helpful.

Okay, let's jump in.

The source starts with the basics.

Aging and gerontology.

What are we actually defining here?

Well, aging fundamentally is this ongoing process.

It involves changes, biological, psychological, and social changes that happen all through life.

From birth to death?

From birth right through to death, yeah.

It's really a whole life perspective, not just about the later years.

Okay, the entire journey.

And gerontology, how does that fit in?

Gerontology is simply the study of that aging process.

It's the field that digs into all the different aspects of getting older, physically, mentally, socially.

Got it.

Aging is the process, gerontology is the study.

Simple enough.

So now let's get into the physiological changes.

This is often what people notice first, right?

How the body changes.

For sure.

And it affects nearly every system.

Let's start with the integumentary system, skin, hair, nails.

Okay, what happens there?

Well, one common thing is loss of pigment.

Hair goes gray,

skin tone can change, you also see wrinkling, of course.

And importantly for care, the outer layer of skin, the epidermis, it actually thins out.

Which means?

It means the skin is more prone to bruising, even tearing.

You have to be gentler.

Right, makes sense.

What else?

Skin loses some of its elasticity, its turgor, and the layer of fat underneath, the subcutaneous fat, decreases.

So it's less plump, maybe?

Kinda, yeah.

It affects how the skin feels and bounces back, and also plays a role in temperature regulation.

Nails often get thicker, but they tend to grow slower.

Interesting.

And sweating, perspiration, that usually decreases too.

Which leads to dryness.

Exactly.

Dry, itchy, scaly skin is really common.

You might also see things like seborrheic dermatitis, that's sort of an overgrowth, thick and flaky skin, and keratosis,

those age spots or raised spots.

Okay, quite a few changes in the skin.

Now let's shift to the neurological system.

Nerves, brain, reflexes.

This feels really central to functioning.

It absolutely is.

A key change is that reflexes slow down.

Reaction times aren't quite as fast.

Okay.

You might also notice slight tremors, or maybe more difficulty with fine motor things, like buttoning a shirt.

Balance can be affected too.

And that's a big one, right?

The balance issue.

Huge.

Yeah.

Because it directly links to the risk of falls, which is a major concern.

Our source really stresses this.

The neurological changes combined with musculoskeletal changes we'll get to, they significantly up that fall risk.

Good point.

What else happens neurologically?

Sleep patterns often change.

Waking up more during the night is common.

They also become more susceptible to temperature extremes, both hypothermia, getting too cold, and hypothermia overheating.

And memory.

That's often a concern people have.

Right.

There can be some decline in short -term memory, remembering recent things.

But long -term memory, things from the past, that usually holds up pretty well.

That distinction is helpful.

Okay, so connecting neurological to musculoskeletal muscles, bones, joints.

How do these changes work together, especially thinking about falls?

Well, the musculoskeletal system sees a decrease in muscle mass and strength.

That's muscle atrophy.

So less strength overall.

Yes.

And that naturally leads to decreased mobility, less range of motion in the joints, less flexibility, and problems with coordination and stability.

How does that look in terms of how they move, like their walk?

Yeah, their gait often changes.

You might see shorter steps.

In a wider base, they stand with their feet a bit further apart.

Trying to be more stable.

Exactly.

It's usually an unconscious adaptation to improve balance.

Posture can change too, and they might actually lose a bit of height due to spinal changes.

The book mentions figure 21 to 1 showing this.

Okay.

Bones become more brittle, which increases fracture risk if they do fall.

Joint capsules can deteriorate, leading to stiffness or pain.

And you might see kyphosis, that increased curve in the upper spine.

So weaker muscles, less balanced brittle bones.

You can really see how the fall risk increases.

Definitely.

It all ties together.

All right.

Let's move to the cardiovascular system.

The heart blood vessels.

How does the aging impact this crucial system?

The heart muscle itself can become less compliant, less stretchy.

The valves can thicken and get more rigid.

And what does that mean for function?

It can lead to decreased cardiac output.

The heart just doesn't pump quite as much blood with each beat.

And the blood return back to the heart might be less efficient too.

So maybe less energy tires more easily.

The source mentions lower exercise tolerance.

That's right.

And their ability to respond when the heart needs to work harder, like during exercise or stress, that response is diminished.

What about heart rate and blood pressure?

Resting heart rate might actually decrease slightly.

Peripheral pulses, like in the wrists or feet, might feel weaker.

Blood pressure though, often tends to increase.

But importantly, they're also more prone to postural hypotension.

That sudden drop in blood pressure when standing up.

Exactly.

Which again is another risk factor for dizziness and falls.

Wow.

Falls keep coming up.

Okay.

Next system.

Respiratory.

Breathing.

The chest wall itself becomes less stretchy, less compliant.

The respiratory muscles can weaken.

And inside the lungs.

The alveoli, those little air sacs where oxygen exchange happens, they can decrease in size and number.

Does their breathing rate change much?

Usually the rate itself, breaths per minute at rest, stays about the same.

But the depth of each breath might decrease.

So less oxygen intake overall.

Potentially, yes.

And critically, their ability to cough effectively and clear out mucus or sputum is often reduced.

Which makes them more vulnerable to lung infections like pneumonia?

Precisely.

A less effective cough is a setup for trouble.

Okay.

How about the hematological system, the blood itself?

Well, hemoglobin and hematocrit levels related to red blood cells and oxygen carrying, they often trend towards the lower end of the normal range.

Okay.

Interestingly, there's often an increased risk of blood clotting.

And another point, there's less protein in the blood available for certain medications to bind to.

How does that affect medications?

It can change how the medication is distributed in the body and how it works, potentially leading to stronger effects or side effects.

Good to know.

Now the immune system, we know that's vital for fighting infection.

Yeah.

And it generally shows some decline with age.

You tend to see lower counts of certain white blood cells, lymphocytes, and changes in antibody production.

So the bottom line is decreased resistance.

Yes.

Decreased resistance to infections and diseases.

They might get sick more easily and maybe take longer to recover.

That ties back to what you said about respiratory infections too.

Okay.

Onto the GI system, gastrointestinal, digestion, nutrition.

A few key things here.

Their basal metabolic rate tends to decrease.

So they generally need fewer calories.

But does their appetite stay the same?

Often?

No.

Appetite can decrease and so can the sense of thirst.

This can lead to lower intake of food and fluids.

Lean body mass also tends to decrease.

What about digestion itself?

Stomach emptying might slow down a bit.

Constipation becomes more common.

And that decreased thirst sensation combined with kidney changes we'll discuss makes dehydration a real risk.

Dehydration, right?

And what about physically eating?

Tooth loss can be an issue.

And difficulty chewing or swallowing that's dysphagia becomes more prevalent.

All of this impacts their nutrition.

So paying attention to intake, hydration, and swallowing ability is key.

What about the endocrine system, the hormones?

Generally speaking, there's a decrease in the secretion of many hormones, though it varies.

The overall metabolic rate decreases, as we mentioned.

And glucose tolerance often decreases too.

Their bodies might not handle sugar as well, and there can be some insulin resistance.

Okay.

Next up, the renal system, kidneys and bladder.

Crucial for waste and fluids.

Right.

Kidney size and overall function tend to decrease.

Their ability to concentrate urine lessens.

The glomeruli filtration rate, a key measure of kidney filtering goes down.

And the bladder.

Bladder capacity often shrinks, and more urine might be left behind after avoiding residual urine.

What does that lead to?

An increased risk of urinary tract infections, UTIs, and potentially incontinence.

And very importantly for medication safety, the kidney's ability to excrete drugs is often impaired.

That's huge for medication, and toxicity risk.

We'll definitely circle back to meds.

Okay.

Reproductive system changes.

For men, testosterone production usually decreases, tests might get smaller, and prostate changes are common, often causing urinary issues.

And for women?

Hormone secretion, like estrogen, decreases, leading to menopause.

Vaginal changes can occur too, like less muscle tone and lubrication.

And sexual function.

For both men and women, there's potential for changes in sexual function or dysfunction, but it's really variable.

It depends a lot on overall health, meds, and other factors.

Okay.

Lastly, for physiological changes, the special senses.

Vision, hearing, taste, smell, touch.

These are so important for quality of life.

Absolutely.

Vision often declines, visual acuity gets worse, accommodation focusing between near and far slows down.

Adjusting to light changes takes longer.

Peripheral vision.

Glare.

Peripheral vision can narrow, and sensitivity to glare increases.

Presbyopia, that difficulty with close -up focus needing reading glasses is very common.

Cataracts can develop too.

Hearing loss is also common, especially for high -pitched sounds.

That's called presbycusis.

Okay.

Taste and smell.

Both can diminish.

Food might not taste the same, sense of smell might decrease.

And touch.

Pain.

Pitch sensation can change.

And interestingly, pain awareness might actually decrease in some older adults.

Less pain awareness.

That seems counterintuitive.

It does, but it means they might not notice injuries or problems as quickly, which can delay getting help.

Wow.

That's a really thorough look at the physical changes.

It really paints a picture of how interconnected everything is and how it impacts daily life.

Now let's switch gears slightly to psychosocial concerns, the mental and social side of aging.

This is just as important.

A major challenge is adjusting to changes in physical health, maybe mental health too, and how that impacts their well -being and independence.

That fear of losing independence or becoming a burden must be significant.

Very much so.

Retirement is another huge transition adjusting to loss of income, maybe the loss of the structure and identity that came with work.

Losing skills or roles they used to have.

Exactly.

Coping with those changes in role function and maybe changes in their social life.

Friends moving away or passing on.

Dealing with loss is a big theme.

Right.

The quantity and quality of relationships might diminish.

Yes.

And coping with bereavement.

There can also be increased dependence on support systems, maybe government programs, and just navigating access to those.

And the cost of healthcare, medications,

that's a huge stressor.

These psychosocial factors can really impact mental health, can't they?

Let's talk about that.

Depression, for instance.

Yes.

The increased dependency we sometimes see can lead to feelings of hopelessness,

helplessness, less perceived control.

Lower self -esteem.

Lower self -esteem, lower self -worth.

And all of that can feed into depression, which can really interfere with their daily life.

And grief, you mentioned loss earlier.

It's not just about losing people, is it?

Not at all.

Grief can be a reaction to losing physical abilities, losing independence, social roles, even a sense of purpose or spiritual connection.

It's broader than we sometimes think.

Isolation is another concern.

Feeling alone, wanting contact, but not having it.

Yeah, social isolation is a serious risk factor.

It can worsen depression and other mental health issues.

And sadly, depression can sometimes lead to thoughts of suicide.

Which is why it's absolutely critical any talk of suicide, any threat, must be taken extremely seriously.

Always.

Definitely.

Our source also mentions the importance of distinguishing between depression, delirium, and dementia.

They can look similar sometimes.

Right.

Table 21 -1 of the chapter is helpful here.

It compares them based on things like onset, how fast it started the course, level of consciousness,

alertness.

It helps clinicians tell them apart, which is crucial for proper treatment.

Okay.

Another common issue, pain.

Very common.

Often linked to those musculoskeletal changes we talked about, like arthritis.

And the source stresses monitoring it closely because unrelieved pain really limits function, right?

Absolutely.

It impacts everything.

Mobility, sleep, mood, independence.

When assessing pain, remember they might not always say,

Look for nonverbal cues.

Yes.

Restlessness, agitation, maybe moaning or crying.

Changes in behavior alongside asking them directly, of course.

And interventions.

What's the approach?

It's multifaceted.

Monitor for signs, figure out pain patterns and triggers, see how it impacts their daily activities.

Then use non -drug methods, distraction, relaxation, massage, maybe biofeedback.

Alongside medications.

Yes.

Administer prescribed pain meds, make sure they understand how to take them, and crucially evaluate if the interventions are actually working.

Is the pain getting better?

Okay.

Let's talk about infection next.

You mentioned they're more susceptible due to immune changes.

Right.

And a key point from the source is that confusion can be a very common, sometimes the first sign of infection in an older adult.

Especially UTIs, urinary tract infections.

Especially UTIs, yes.

But really any infection.

Because their immune response is altered, we have to be super vigilant.

And the signs might not be the classic ones, like fever.

Exactly.

Box 21 -1 lists these nonspecific signs.

Sudden loss of appetite, apathy or lack of interest, a change in their usual functional ability, confusion, shortness of breath, new falls, fatigue, new incontinence, self -neglect, maybe subtle vital sign changes like a faster breathing rate.

So we need to look beyond the obvious signs.

Definitely.

Recognizing those subtle changes is key for catching infections early.

Okay.

This leads us perfectly into medications.

A really complex area for older adults.

Hugely complex.

Major problems include adverse drug effects, drug interactions,

medication errors, non -compliance or adherence issues, polypharmacy.

Polypharmacy taking multiple medications.

Yes.

Taking many different drugs at the same time.

And of course, cost is often a barrier too.

The source mentions the beers criteria.

What's that?

It's a list developed by the American Geriatric Society of medications considered potentially inappropriate for older adults because the risks might outweigh the benefits.

Box 21 -2 lists examples, certain painkillers, antidepressants, blood pressure meds, incontinence drugs, muscle relaxants, sedatives.

Good resource to be aware of.

And we shouldn't forget over -the -counter meds, right?

Absolutely critical to ask about those.

They can interact just like prescription drugs.

And that polypharmacy issue itself needs constant attention.

What's the recommendation?

Routinely review all meds, prescription and OTC.

See if anything can be stopped or simplified.

Fewer meds mean lower risk of side effects, interactions, duplication, and it can improve quality of life and maybe even save money.

Dosage is another big factor.

They often need less.

Much less.

Often.

Due to changes in kidney function, liver function, body composition, the source suggests starting doses might be like one -third to one -half the standard adult dose.

Wow, that's a significant difference, which means monitoring is even more critical.

Extremely critical.

Monitor closely for side effects, adverse reactions, and if the drug is actually working.

Remember that impaired kidney function means drugs hang around longer, increasing toxicity risk.

And you mentioned a sudden change in mental status could be a drug reaction.

Yes, that's a red flag.

Always consider medications if an older person suddenly becomes confused or has a significant mental status change.

And always check for interactions when multiple drugs are involved.

What about practical tips, like using pharmacies?

The advice is to try and use one single pharmacy if possible.

That way the pharmacist has the full picture and can help spot potential problems.

And tell all doctors everything.

Yes.

Every single provider needs to know about every single medication, supplement,

everything they're taking.

The chapter also details specific safety measures for giving meds in a priority nursing actions box.

Right.

Really practical stuff like sitting them upright to prevent choking, checking for dry mouth, using liquids if swallowing is tough.

Crushing pills.

Only if it's safe for that specific pill, never crush and terracotta or time release ones.

And if you do crush, mix it with something like applesauce.

Maybe sugar -free if they have diabetes.

Okay.

What else?

Suppositories should be room temp, not freezing cold.

Watch injection sites for bleeding.

Avoid immobile limbs for injections if possible.

Monitor if they're actually taking the meds.

Are they compliant?

Can they read the labels?

Can they tell pills apart?

Pill organizers, those cassettes could be really helpful.

That box also goes into intense detail about administering oral meds if someone is at risk for aspiration, for choking.

Yes.

That's super important for safety.

It lays out the steps very clearly.

Starting with checking the order, the seven rights.

Right.

Checking the prescription against the record.

Clarifying anything unclear.

Making sure you have the right patient, right drug, right dose, right time, right route, right reason, right documentation.

Reviewing labs, assessing for contraindications like being in PO.

Positioning is key, right?

High foulers.

High foulers?

Sitting up.

Then assess their aspiration risk using a tool or policy.

Check their swallow, their cough, their gag reflex.

And if you're worried.

Collaborate.

Talk to the RN, the doctor, the speech therapist before giving anything by mouth if there's a serious concern.

Then preparing the med.

Easiest form to swallow.

Check rights again.

Crush only if, okay, mix appropriately.

No crushing sustain release.

Use liquids if you can, thicken if needed.

Avoid straws.

They can actually increase aspiration risk sometimes.

Then checking rights one last time at the bedside.

Final check.

Give one pill at a time.

Make sure they swallow effectively.

Then ensure comfort, safety, and document everything properly.

That level of detail really shows how careful you need to be.

Okay, shifting to a very difficult topic.

Elder abuse.

It is difficult, but we have to talk about it.

It can happen in different ways.

Yeah.

Domestic mistreatment is abuse or neglect at home, usually by family or a caregiver.

Physical neglect abandonment.

Yes.

Then there's institutional mistreatment, which happens in facilities like nursing homes or hospitals.

And also self -neglect.

Self -neglect.

That's when a competent person chooses not to care for themselves adequately, impacting their health and safety.

It's tricky because competent adults generally have the right to refuse care.

Who is most at risk for abuse?

The source points out that those who are most dependent due to immobility or cognitive issues like dementia or confusion are at the highest risk.

The chapter refers to another chapter, 64, for more detail.

And there's a critical thinking scenario answer about suspected abuse.

What's the guidance there?

The absolute priority is to report it.

Follow state laws and agency policies for reporting suspected or known abuse to the authorities.

And when interacting with the potential victim.

Conduct a thorough assessment, but do it privately, with empathy, non -judgmentally.

Reassure them.

Help them think about safety planning, resources, even if they aren't ready to leave the situation right then.

Empower them with information.

Such a critical responsibility for health care providers.

Okay, finally, the chapter wraps up with practice questions to reinforce the learning.

Let's quickly touch on the key takeaways from those.

Sure.

Question 186 was about digoxin toxicity.

The point was that decreased lean body mass and decreased kidney function in older adults increased that risk.

187 looked at promoting autonomy and long -term care.

The answer was letting the client choose their social activities.

Simple choice, big impact.

188 asked about effective coping with loss.

Examples were looking at old photos, visiting a grave, participating in senior center activities, things that acknowledge the loss, but also engage with life.

189 was about communicating with someone hearing impaired, first step.

Stand directly in front of them.

190 focused on presbycusis, that high frequency hearing loss.

The tip, use lower pitched tones when speaking.

191 asked about normal age -related changes.

Things like declining vision, higher risk of UTIs, waking up more at night.

Those are expected changes.

192 was about feeding someone at risk for aspiration,

positioning.

Upright in a chair is safest.

193 asked about the best exercise for health maintenance.

Walking three to five times a week for 30 minutes is a great option.

194 was about promoting reminiscence.

Having storytelling hours is a good way to do that.

And 195 highlighted the highest risk for elder abuse.

A 90 -year -old woman with advanced Alzheimer's emphasizing that vulnerability factor.

Right, those questions really pull together some key concepts.

They really do.

So reflecting on everything we've covered, it's been a truly comprehensive dive, hasn't it?

From the fundamental physiological changes in every system.

To the psychosocial adjustments, mental health concerns like depression and differentiating it from delirium or dementia.

Right, through pain management, recognizing those tricky signs of infection, navigating the complexities of medications, including specific safety protocols and priority actions.

And tackling the very serious issue of elder abuse and our responsibilities there.

Were there any aha moments for you revisiting this material?

Maybe the nonspecific infection signs or the details on med administration?

I think reinforcing the subtle signs of illness is always important.

Confusion as a sign of a UTI, for example.

And the sheer number of factors influencing medication, safety dosage, excretion, interactions, polypharmacy.

It really underscores the need for vigilance.

Absolutely.

And for you listening, we hope this detailed walkthrough helps you connect these concepts to your own situation, whether that's in your professional practice or maybe in caring for older family members.

Understanding these unique needs is just so crucial.

It really is foundational for providing compassionate and effective care.

We've covered a lot from Chapter 21 of the Saunders Comprehensive Review, hitting all the key nursing concepts, assessment guidelines,

safety protocols, priority actions, and reviewing those questions, aiming for that complete coverage.

Yes, definitions.

The physiological rundown, system by system, psychosocial aspects, mental health, pain, infection, meds in detail, abuse, and the practice questions.

It's a solid overview of the chapter's core content.

And maybe a final thought to leave you with.

Considering how prevalent elder abuse is and how vulnerable some older adults are, what's our collective responsibility, not just as professionals but as a society, to be aware, to recognize the signs, and to act?

That's a powerful question to reflect on.

And of course, if you want even more depth, diving into the Saunders book itself or other reliable gerontology resources is always a great next step.

Thank you so much for joining us for this deep dive into the care of the older adults.

Thank you.