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NUR 3289: Gerontology – Nursing Reflective Journaling Assignment Reflective journal writing – Students will reflect on their attitudes, values, beliefs, and knowledge about aging and older adults as they begin and progress through the course. They will communicate via a written format within Angel at least weekly during the course via a drop box entitled “Reflections”. (Worth 20% of grade.) Some of you may have kept a journal in the past or currently journal. If so, this activity will probably be very familiar and comfortable for you. This may be a new activity, however, for some of you, and you may think – Just what can I write about? For those of you that may be a little apprehensive, consider the following questions for reflection and journaling: 1. What was the most interesting thing I read regarding aging and older adults this week? 2. What were some of the things I learned this week? 3. Is there anything I previously thought was true, but now question? 4. Did anything surprise me? 5. Have my opinions about aging and older adults changed? 6. What have I learned that I may be able to use in the future? 7. What do I still have questions about? 8. What are some things that I would like to study in more detail? 9. Is there anything that happened in my personal or professional life relating to aging and older adults that affected me this week? What challenged me relating to this situation? What was I feeling at the time of this incident? What was I thinking? Have my values changed? 10. Have any experiences challenged my assumptions or customary ways of thinking? 11. Will any experiences I have had this week change my future behavior or attitudes? 12. Have I had any experiences that will change my professional behavior? 13. What are my strengths relating to interacting with and caring for older adults? Consider what has happened that has made you feel happy or content relating to caring for older patients and their families. Your reflection and journaling do not have to conform to this format, but use what you find helpful and please share additional thought-provoking questions and realizations with me. Required Reading: 1. Read and study in Ebersole, Hes, Touhy, Jett, & Luggen: Chapters 1, pp. 1 – 25, and 16, pp. 412 – 427). *OR Read Touhy & Jett, Ebersole & Hess’ Toward Healthy Aging: Human Needs & Nursing Response (Chapter 1, pp. 1 – 20, and Chapter 13, pp. 225-239) Additional Required Resources: 1. The longevity game at http://www.nmfn.com/tn/learnctr–lifeevents–longevity 2. The Frontline program, “Living Old” at http://www.pbs.org/wgbh/pages/frontline/livingold/ 3. “Zimmers My Generation” video at http://www.youtube.com/videos 4. “A New Look at the Old” series at http://www.nursingcenter.com/library/static.asp?pageid=527873#titles Online Activities: 1. Read Ebersole, Hess, Tougy, Jett, & Luggen, Toward Health Aging: Human Needs & Nursing Response (Chapters 1 and Chapters 16). *OR Read Touhy & Jett, Ebersole & Hess’ Toward Healthy Aging: Human Needs & Nursing Response (Chapter 1 and Chapter 13) 2. As you are completing your reading assignment in Ebersole et al., reflect on the Case Studies, Critical Thinking Questions, and Research Questions found in each chapter. 3. Review the animations and videos online for applicable content. You can access this material by going to http://evolve.elsevier.com/Ebersole/TwdHlthAging/ 4. Explore the links to websites at this Evolve Student Resources site as well. The sites have been selected to supplement chapter content. 5. Go to http://www.pbs.org/wgbh/pages/frontline/livingold/ Read the Introduction and view the full video program. After viewing the video, click on “The Big Issues” and explore “The Cost of Care”. 6. * Go to http://www.youtube.com/videos Search for “Zimmers My Generation” and view the video entitled “The Zimmers (New video edit v.2) Released 28/05/07. After you have viewed the video, reflect on the following questions: · Why do you think this video was produced? · What issue(s) of aging to you think the producers of this video wanted to emphasize? · Where was the “Zimmers My Generation” video produced? · What is the approximate age of the lead singer? · Is this a song from his generation? · The funds generated by this video go to which organization? · This organization tries to raise awareness of what issue(s) of aging? · What is the mission of this organization? · What types of information are contained on this organization’s website? · What are some comparable organizations in the United States? · How are they similar and how do they differ from this organization in the UK?
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Chapter 16
Environmental Safety
and Security
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Feeling Secure as One Ages
Involves sensing an identity with one’s personally significant space, whether at home or a care facility
Depends on perceived familiarity and predictability of life-space in which one moves or interacts
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Feeling Secure as One Ages
Perceptions of security and feeling safe strongly influenced by cognitive capabilities and ability to problem solve
Nurses can encourage older persons to participate in steps to organize environment
Use reminders and calendars to gain greater control over time
Create simple maps to outline “territory” in which they expect to move
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Feeling Secure as One Ages
Healthy People 2000/2010
More than 400 Americans die each day from injuries
Motor vehicle accidents, firearms, falls, and fires responsible for many of these deaths
Violent crime also a concern
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Influences of Changing Health and Disability on Safety and Security
Physical Vulnerability
Vulnerability to environmental risks and mistreatment by others increases as people become less physically or cognitively able to recognize or cope with real or potential hazards
Important to emphasize strong influence of stress, whether it is physical, emotional, mental, or spiritual in nature
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Influences of Changing Health and Disability on Safety and Security
Vulnerability to Environmental Temperatures
Many older adults exposed to temperature extremes in own dwellings
Preventive measures require attentiveness to impending climate changes, as well as protective alternatives
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Influences of Changing Health and Disability on Safety and Security
Hyperthermia
Body temperature increases above normal ranges because of environmental or metabolic heat loads
Body temperature above 38° C (100.4° F)
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Interventions to Prevent Hyperthermia
Drink 2 to 3 L of cool fluid daily
Minimize exertion, especially during heat of day
Stay in air-conditioned places, or use fans when possible
Wear hats and loose clothing of natural fibers when outside; remove most clothing when indoors
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Interventions to Prevent Hyperthermia
Take tepid baths or showers
Apply cold, wet compresses, or immerse hands and feet in cool water
Evaluate medications for risk of hyperthermia
Avoid alcohol
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Influences of Changing Health and Disability on Safety and Security
Hypothermia
Medical emergency requiring comprehensive assessment of neurological activity, oxygenation, renal function, fluid and electrolyte balance
Core temperatures below 35° C (95° F)
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Influences of Changing Health and Disability on Safety and Security
Factors Associated with Low Body Temperatures in Elderly
Aging
Low environmental temperature
Thinness and malnutrition
Poverty
Living alone
Nocturia/night rising
Orthostatic hypotension
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Influences of Changing Health and Disability on Safety and Security
Factors Increasing Risk of Hypothermia in Elderly
Thermoregulatory impairment
Conditions that decrease heat production
Conditions that increase heat loss
Conditions that impair central or peripheral control of thermoregulation
Drugs that interfere with thermoregulation
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Influences of Changing Health and Disability on Safety and Security
Vulnerability to Natural Disasters
Older people are at great risk during and after disasters
Nurses must participate in disaster planning to support older people during these times
Older people may be less likely to seek formal or informal help than younger people during disasters and may not get as much assistance as younger individuals
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Effects of Changing
Life Situations
Change is usually stressful, regardless of whether change is perceived as positive or negative
Changing life situations for older adults can affect safety and security by posing unfamiliar routes, routines, and persons in the environment
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Effects of Changing
Life Situations
Auto Safety
Factor often contributing to feelings of isolation for older adults is decision, sometimes imposed by others, to give up one’s driver’s license and no longer drive
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Safe Driving Tips
Plan travel route in advance; carry map of area
Wear seat belt
Keep eyes on road
Avoid distractions. If necessary to use cell phone, first pull over at convenient place
Follow 4-second rule when following another vehicle
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Safe Driving Tips
Obey traffic and motor vehicle laws, signs, signals
Adjust speed to road and weather conditions
Drive with doors locked, windows rolled up
Park car in visible, well-lighted area
Expect the unexpected and always drive defensively
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Effects of Changing
Life Situations
Neighborhood Security
Significant contributor to fear of crime among elderly is socioeconomic deterioration of neighborhood and loss of neighbors
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Crimes Against Older Adults
Risks and Vulnerability
Living alone, memory impairments, loneliness may make elders more susceptible to crime
Older people are more likely to be victims of consumer fraud and scams that include telemarketing fraud, e-mail scams, undelivered services
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Crimes Against Older Adults
Fraudulent Schemes Against Elders
Trusting elderly persons may be duped into giving money to pen pals, Internet acquaintances, phony religious causes, new acquaintances who “need help”
Door-to-door contractors
IRS Impersonators
Medical fraud
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Fire Safety for Elders
Risk Factors for Elders
Economic or climatic conditions may promote use of ill-kept heating devices
Attempts to cook over open flame while wearing loose-fitting clothing
Inability to manage spattering grease from frying pan can often start fire from which elder cannot escape
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Fire Safety for Elders
Reducing Fire Risks in Group Residential Settings
Noncombustible building materials
Sprinkler systems
Smoke detectors
Closed air spaces
Written fire procedures
Orientation of personnel
Assessment of environment by fire prevention officials
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Fire Safety for Elders
Reducing Fire Risks in Group Residential Settings
Personnel protocols should address these issues:
Predetermined staff members should be given specific duties and posts
Notification procedures for fire department and personnel should be clearly described
Management of exit maneuvers should be assigned and specifically described
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Measures to Prevent
Fires and Burns
Do not smoke in bed or when sleepy
When cooking, do not wear loose-fitting clothing
Set thermostats for water heater or faucets so that water does not become too hot
Install portable hand fire extinguisher in kitchen
Keep access to outside door(s) unobstructed
Identify emergency exits in public buildings
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Measures to Prevent
Fires and Burns
If you consider entering boarding or foster home, check to see that it has smoke detectors, sprinkler system, fire extinguishers
Wear clothing that is nonflammable or treated with permanent fire-retardant finish
Fabrics of animal hair, wool, and silk are less flammable
Use several electrical outlets rather than overloading one outlet
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Fire Safety for Elders
Reducing Fire Risks at Home
Potentially hazardous substances are found in most homes and should be surveyed regularly
If substance is rarely or never used, eliminate it from the home
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Fire Hazards in the Home
Flammable liquids (e.g., gasoline, acetone, lacquer thinner)
Combustible liquids (e.g., lighter fluid, kerosene, turpentine)
Gas leaks
Rubbish and trash stored near stove, water heater, furnace
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Fire Hazards in the Home
Christmas trees and lights that are frayed or poorly insulated
Smoking in bed or discarding burning cigarettes
Overloaded or worn electrical systems
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Role of Assistive Technology
Decreasing need for personal care
Enhancing independence and ability to live safely at home
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Role of Assistive Technology
Arizona Technology Access Program
Controller woven into fabric of clothes or worn as pin that will turn lights on and off, open doors, control thermostat
Controller operated by hand or voice that will operate any household appliance
Voice recognition computers
Body monitors that automatically call an emergency number when person falls
Laser-guided canes for the blind
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Chapter 1
Gerontological Nursing and an Aging Society
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Study of Aging
Religious and Secular Movements
Puritans
Victorian Age
Later
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Study of Aging
Reverse Ageism
Largely attributable to gerontology professionals of “baby boom” confronting their own aging
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Gerontology
Biomedicalization of Aging
Aging seen as biomedical problem that must be reversed, eradicated, or held at bay as long as possible
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Gerontology
Who Will Care for an Aging Society?
Demand is critical for gerontological nurses and other health professionals prepared to deliver care to growing numbers of older people
Growing concern is lack of adequate staffing, particularly professional nurses, in nursing homes
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Gerontology
Organizations Devoted to Gerontology Research and Practice
Gerontological Society of America (GSA)
American Society on Aging (ASA)
Association for Gerontology in Higher Education (AGHE)
National Council on Aging (NCOA)
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Development of
Gerontological Nursing
Gerontic Nurse Pioneers and Leaders
Origins of gerontological nursing rooted in England
Began with Florence Nightingale
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Development of
Gerontological Nursing
Gerontological Nursing Education
Schools of nursing now include gerontological nursing content in curricula
Continued need to increase numbers of faculty with preparation in gerontological nursing
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Development of
Gerontological Nursing
Gerontological Nursing Roles
Functions in variety of settings—hospital, home, subacute and long-term care facilities, community
Advanced practice gerontological nurses
Mission is to preserve function, enhance health, and enhance quality of life and dying
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Aging Today
Demographics of Aging
Aging in the United States
Gender issues
Diversity
Global aging
Western Europe and Japan have more older people than young people
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Diversity of the older population
(Redrawn from U.S. Census Bureau, 2004.)
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Aging Today
Chronological Age
The old
Parents of baby boomers make up majority of present old numerically
Nonagenarians and centenarians
Expanding group of very old (90+)
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Age self-identification
(Redrawn from National Council on the Aging, Inc., American perceptions of aging in the 21st century, telephone survey, Jan-Feb 2000. Available at www.ncoa.org.)
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Aging Today
Attitudes Toward Aging
Elders
Children
Health care students
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Aging Today
Research and Aging
Research and gerontological knowledge strongly influenced by federal bulletins distributed nationwide to indicate research most likely to receive federal funding
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Aging Today
Nursing Research
Studies
Dementia
Reducing falls
Use of restraints
Pain management
Delirium
Humane end-of-life care
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Aging Today
Politics of Aging
White House Conferences on Aging
Make recommendations to President and Congress to help guide national aging policies
Older Americans Act
Delivers community-based services through state Area Agencies on Aging (AAAs)
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Top 10 Resolutions
of 2005 WHCoA
Reauthorize Older Americans Act
Develop coordinated, comprehensive long-term care strategy by supporting public and private sector initiatives that address financing, choice, quality, service delivery, and paid and unpaid workforce
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Top 10 Resolutions
of 2005 WHCoA
Ensure that older Americans have transportation options to retain mobility and independence
Strengthen and improve Medicaid program for seniors
Strengthen and improve Medicare program for seniors
Support geriatric education and training for all health care professionals, paraprofessionals, health profession students, and direct care workers
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Top 10 Resolutions
of 2005 WHCoA
Promote innovative models of non-institutional long-term care
Improve recognition, assessment, and treatment of mental illness and depression among older Americans
Attain adequate numbers of health care personnel in all professions who are skilled, culturally competent, and specialized in geriatrics
Improve state and local integrated delivery systems
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Aging Today
Business of Aging
Major marketing attention extended to elderly
American Association of Retired Persons (AARP)
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Gerontological Nursing and Aging:
The Future
Baby Boomers
Informed and educated
Alerted to importance of preparing early for “good” old age
Expect much higher quality of life as they age than did their elders
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Gerontological Nursing and Aging:
The Future
Global Challenges
Policies needed to meet income, health, and long-term care needs for men and women throughout world
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“N
40 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com
CE2
Continuing Education
HOURS
OVERVIEW: Although people age at different rates, changes to the com-
position of the human body are a hallmark of aging. As a result of such
changes, disease can present differently in a person over 65 years old than
it would in a younger adult or child. This article identifies the critical
indicators of underlying conditions, including changes in mental status,
loss of function, decrease in appetite, dehydration, falls, pain, dizziness,
and incontinence. It also describes the presentation of diseases common
to older adults, including depression, infection, cardiac disease, gastroin-
testinal disorders, thyroid disease, and type 2 diabetes.
PRESENTATION
of ILLNESS in
OLDER ADULTS
If you think you know what you’re
looking for, think again.
Elaine J. Amella is an associate dean for research and an associate professor at Medical University of
South Carolina College of Nursing, Charleston. Contact author: amellaej@musc.edu. This article is the
second in a series that’s supported in part by a grant from the Atlantic Philanthropies to the
Gerontological Society of America. Nancy A. Stotts, EdD, RN, FAAN (nancy.stotts@nursing.ucsf.edu),
and Carole E. Deitrich, MS, GNP, RN (carole.deitrich@nursing.ucsf.edu), are the series editors. The
author of this article has no significant ties, financial or otherwise, to any company that might have an
interest in the publication of this educational activity.
By Elaine J. Amella, PhD, APRN,BC
O SINGLE, CHRONOLOGICAL TIMETABLE OF HUMAN AGING EXISTS.”
This is one conclusion of the Baltimore Longitudinal Study on Aging,
which since 1958 has tracked more than 1,000 people from age 20 to over
age 90 in an attempt to define “normal” physiologic human aging.1
Although in most aging people cardiac muscles thicken, arteries stiffen,
lung tissues diminish, brain and spinal cord degenerate, kidneys shrink, and
bladder muscles weaken, they do so at varying rates in different people. In
fact, organs age at different rates within each person; for example, lungs
can continue going strong as kidneys begin to fail.
ajn@lww.com AJN ▼ October 2004 ▼ Vol. 104, No. 10 41
Taken from Aging in America: The Years Ahead, by photographer Ed Kashi and writer Julie Winokur.
Adding to the confusion is the fact that people
over 65 years old (“older adults”) take more med-
ications than their younger counterparts; this
polypharmacy can lead to a change of mental sta-
tus, a symptom that may mistakenly be attributed
to old age. In short, to inadequately trained clini-
cians, some normal aspects of aging can appear as
manifestations of disease while other changes can
mask early signs of illness.2 For example, a
decreased ability to regulate body temperature puts
older adults at higher risk for hypothermia, and it
also decreases their ability to promptly respond to
pathogens by initiating an inflammatory process
(through fever). This can lead to the overtreatment
of a relatively healthy person or cause a clinician to
miss important clues of an acute disorder requiring
treatment.
To differentiate disease from normal aging
requires assessment skills developed specifically for
the older adult and an understanding of the aging
process, as well as an understanding of the factors
that produce altered presentations of several ill-
nesses in older adults.
HOW THE BODY AGES
While it’s been acknowledged that family history,
environment, and lifestyle influence aging, there are
many theories as to which physiologic changes
cause the body to age—and how they do so. While
research continues, one fact is incontrovertible:
changes in overall body composition are a hallmark
of aging.
Alterations in cell replication. One significant
change is how cells replicate. Much of what we rec-
ognize as aging is governed by changes in cells’ abil-
ity to reproduce over a lifetime. Researchers have
identified telomeres, the stretches of DNA that pro-
tect both ends of chromosomes, as an important
factor in human aging. Human cells are thought to
divide about 50 to 70 times over a lifetime.3 With
each replication, telomeres shorten, allowing chro-
mosomes to stay intact. Over time, telomeres
shorten until the cell is no longer able to replicate,
resulting in cell death, or senescence. While “limited
replication or ‘replicative senescence’ is no longer
seen as the main issue of ageing—nonetheless, los-
ing the ability to divide may well undermine tissues
that must produce fresh cells quickly. For instance,
it could hamper the immune system’s capacity to
respond to novel pathogens and may underlie the
slower wound healing of the elderly.”4
Oxidative stress is the damage caused to cellular
proteins by free radicals, the toxic compounds
released by the metabolism of oxygen and also
found in the environment (for example, in smoke
and smog). Cigarette smoking, poor diet, and other
lifestyle factors can also trigger free-radical activity.
Over the course of a lifetime, free radicals bombard
42 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com
CASE STUDY
What’s causing this patient’s confusion?
Three days after undergoing an open reduction and inter-nal fixation of a fractured hip, 82-year-old Carol
Thompson is admitted to the hospital after her daughter found
her bruised body crumpled at the bottom of a flight of stairs.
Although once very independent, Ms. Thompson is now con-
fused and uncooperative. She is pulling at her dressing and
unwilling to keep her hip-abduction pillow in place. The
social worker recommends placement in a nursing home.
You suspect that something else could be causing Ms.
Thompson’s decline. From the chart you learn she fell
down poorly lighted stairs and lay there for more than 18
hours before being found. Suspecting a slow bleed into
her brain from a subdural hematoma, you wonder if any-
one has determined if Ms. Thompson hit her head when
she fell. You check her pupils and her major cranial
nerves. Because she was dehydrated on admission, she
received a large amount of IV fluids. Wondering if she
received too much too quickly—perhaps worsening unde-
tected heart disease—you check her pulses and blood
pressure and note any edema or neck-vein distention. You
ask her daughter to bring in her medicine vials, and note
that her daily levothyroxine (Synthyroid) was not ordered
since admission.
Ms. Thompson’s surgery was complicated and lasted
longer than expected; she did not receive a transfusion.
You wonder if she might still be recovering from the anes-
thesia and check to see if hemoglobin and hematocrit lev-
els were checked postoperatively; they were tested only on
day one. Despite pressurized devices and the use of anti-
coagulant, you consider that she might have had a small
stroke or other vascular insult. Finally, you wonder about
pain management. Not only is Ms. Thompson recovering
from major surgery, but she also has significant arthritis.
Could her pain be adequately treated with the opioid anal-
gesic ordered? You check her vital signs, perform a neuro-
logic examination, assess for delirium using the Confusion
Assessment Method, note her comfort level using the
Checklist of Nonverbal Pain Indicators, examine her oral
mucosa and conjunctiva for paleness, and review her med-
ication record using the Beers Criteria for Potentially
Inappropriate Medication Use in the Elderly.
In consultation with the orthopedic surgeon and the
nurse practitioner managing her care, you arrange for the
levothyroxine to be restarted, blood work to be drawn,
and a change in pain medication to a sustained-release
and breakthrough morphine agent. You also ask her
daughter to meet with health care providers to discuss a
longer hospital stay—until the medical issues causing this
possible delirium can be addressed. You arrange for her
daughter to visit outside of visiting hours and you remind
her to bring in her mother’s eyeglasses.
Ms. Thompson’s delirium begins to lift in about 24
hours. Within 48 hours, she is participating with her treat-
ment plan and looking forward to returning home.
cells, eventually causing cell mutation and senes-
cence; as a result, oxidative stress has been recog-
nized as a factor in the pathogenesis of cancer and
heart disease. A link to the general decline in physi-
ologic functioning that occurs with age has also
been hypothesized.5
INDICATORS
Early recognition of indicators of underlying health
problems, including change in mental status, falls,
dehydration, decrease in appetite, pain, loss of func-
tion, dizziness, and incontinence, can mean an oppor-
tunity to initiate treatment while recovery is still
possible.6 (These problems aren’t inherent to aging.)
An in-depth examination is required to determine
cause, especially because some indicators have both
physiologic and psychological origins. (See Aging of
the Body’s Systems, page TK.) Key to providing
appropriate treatment to older adults is establishing
a baseline that goes beyond the usual history and
physical parameters to examine mental, functional,
nutritional, and social-support status. A history that
contains information about the health of siblings,
partners, and children can provide clues to family
history, environment, and lifestyle. Baseline informa-
tion should be gathered upon admission to a facility,
and whenever the patient’s condition changes.
Community-dwelling older adults should be
assessed at least once a year. More frequent evalua-
tions are warranted for patients with chronic prob-
lems, such as memory loss or joint disease.
Change in mental status is a common harbinger
of disease, drug toxicity, or psychological trauma in
older adults. The primary causes of delirium and
acute states of confusion are adverse effects from
medication, drug–drug interactions, or toxic levels
of medication in the blood.7 Whenever older
patients are unable to focus their thoughts or expe-
rience a sudden change in mental status (occurring
over one day, a few days, or even weeks), the nurse
should suspect medication toxicity. This is especially
important when the patient has recently received
anesthesia or new medications. The assumption
that older adults are normally confused is incorrect
ajn@lww.com AJN ▼ October 2004 ▼ Vol. 104, No. 10 43
MED SURGE
With age, the body’s reaction to medication changes.
For Groucho Marx, old age was not a subject of rever-ence. “Anyone can get old,” he said. “All you have to
do is live long enough.” Of course, a clinician knows what
a comedian doesn’t: living “long enough” these days usu-
ally entails a medication regimen—and with this comes a
high risk of adverse drug events and drug–drug interac-
tions. The fact is, even in otherwise healthy older adults,
changes in body composition influence the absorption, dis-
tribution, and clearance of medications.30
Absorption. According to Williams, “In older persons,
absorption is generally complete, just slower. In addition to
age-related changes, common medical conditions such as
heart failure may reduce the rate and extent of absorption.”30
Distribution. As people age, they lose lean body mass
gain and adipose tissue gain. Because there is less fluid
available, water-soluble medications can reach toxic levels
more quickly. Furthermore, the increase in adipose tissue
means that fat-soluble drugs (predominantly the psychotrop-
ics) are absorbed into these less well-vascularized fat stores,
and it takes longer for the drug to reach a therapeutic level
(as well as longer for them to be excreted from the system).
Vigilant monitoring is required with potentially nephrotoxic
medications, including antimicrobials, cardiovascular
agents, H2-antagonists, oral hypoglycemics (especially the
sulfonylureas), and nonsteroidal antiinflammatory agents.
Protein malnutrition is common in underweight and obese
older adults. This means that there are fewer binding sites for
protein-binding drugs such as warfarin (Coumadin and others)
or phenytoin (Dilantin and others); causing more “free” drug
to circulate and putting the patient at greater risk for adverse
effects such as bleeding or confusion. Protein malnutrition is
determined by using prealbumin level less than 15 mg/dL,
serum albumin level less than 3.2 g/dL, total lymphocyte count
less than 1500 � mm3, transferrin level less than 200 mg/dL,
and serum cholesterol level less than160 mg/dL.31
Clearance. With decrease in kidney and liver function-
ing, clearance and excretion of drugs also takes longer. The
nurse needs to closely monitor serum protein level (normal
range 5.5 to 9.0 g/dL) and albumin level (normal range
3.5 to 5.5 g/dL), as well as renal and liver functions to help
the older patient avoid toxicity or undertreatment.32
Assessing kidney function and drug toxicity. Measures of
serum creatinine, used to assess excretion for many drugs,
are related to muscle mass and thus aren’t a good measure
of kidney functioning in a frail individual or one who has lost
muscle mass due to immobility. Contact the physician or
pharmacist if there’s any doubt regarding the nephrotoxicity
of the drug, and use the Cockcroft–Gault formula to calculate
the creatinine clearance (see Cockcroft–Gault Equation for
Calculating Creatinine Clearance, page TK). Creatinine
clearance, a measure of the glomerular filtration rate, is a
valuable way to note decline in kidney function in older
adults. Accepted clearances are published for each drug,
but the nurse should be especially concerned in patients with
a clearance of less than 50 mL/min, which is indicative of a
prerenal state.33 The pharmacist should be consulted about
the need for dose adjustment, and monitoring of renal func-
tion should continue.
Presence of these signs point to a diagnosis of delir-
ium and warrant a complete diagnostic assessment.
Falls don’t necessarily imply a change in condi-
tion; however, the circumstances of a fall should be
investigated to determine whether the cause was
environmental or health related. In short, a new
onset of falls should always be seen as a symptom
of illness until proven otherwise. Falls should be
considered within the context of the following com-
plex problems:
• cardiac—syncope, orthostasis, cardiac arrhythmias
• musculoskeletal—poor posture, osteoporosis,
loss of strength
• neurologic—poor balance and gait, vertigo, and
dizziness
• change in mental status—a slow intracranial
hemorrhage
• sensory—loss of vision or hearing, poorly lighted
areas
• functional—general weakness
• continence—slipped on urine, hurrying to bath-
room
• psychological—fear of falling, unusual limitation
of activities
In determining the details of the fall, ask: Did the
person black out or feel dizzy prior to the fall?
Could he have hit his head when he fell? Was he
wearing eyeglasses or a hearing aid, if needed?
While numerous assessments should be done, sev-
eral are critical: complete a baseline mental status
examination; question the patient about dizziness
(see “Dizziness,” below); assess orthostasis through
lying, seated, and standing blood pressure; check
heart rate and electrocardiogram for possible atrial
fibrillation; and complete a neurologic assessment—
especially noting possible changes related to stroke
and head trauma.10
Assessment for poor balance and gait can be
accomplished with the timed up-and-go test: ask the
patient to rise out of chair, walk 10 feet, turn around,
return to the chair, and sit down.11 (Remain close in
case the patient begins to fall.) Look for shuffling
gait, lack of arm swing, unequal shoulder or hip
height (which can indicate spinal deformity or leg
shortening), the ability to turn without support, and
the ability to stand and sit in a controlled fashion.
The timed up-and-go test should be accomplished in
20 seconds or less. Further referral is indicated if the
and may cause clinicians to miss one of the most
important symptoms of undiagnosed illness.
Delirium. In addition to medications, other pri-
mary causes of delirium include dehydration,
hypoxia, metabolic disturbances, untreated anemia,
nutritional deficiencies, and infection (especially
those of the respiratory and urinary tracts).8
Secondary causes include untreated thyroid disease,
vitamin deficiency (especially B12), and decreased
sensory input from loss of vision or hearing.
Patients who are unable to see or hear others are
often disorientated. When necessary, eyeglasses and
hearing aids are a simple intervention.
When possible, familiar routines and care can
help reorient patients to new environments. For the
older adult, sudden location changes—for example,
a move from a nursing home to a hospital—can be
confusing and trigger delirium.
If caught in time, delirium can be reversible. At
minimum, assessment should include the following
three questions that are part of the Confusion
Assessment Method:
1. Did the confusion happen rather quickly—for
example, since admission or the onset of illness—
and are there times during the day when the person
is more confused than at other times?
2. Is this person easily distracted and inattentive
to tasks or conversations?
3. Does the person have an altered level of con-
sciousness—is he overly alert, groggy, or stuporous?9
44 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com
TRY THIS
A resource for geriatric tools.
Several types of assessments are needed to determineif changes in a patient’s health are due to a change
in health status or to normal aging. Yet while numerous
assessment tools exist, few have been either developed
for or modified to meet the norms of aging. An excellent
resource for nurses working with older adults is the “Try
This” series, sponsored by the Hartford Institute for
Geriatric Nursing. Available both in print and on the
Internet (at www.geronurseonline.org, this series is
focused on assessing common problems and symptoms
in older adults. Through “Try This,” nurses can gain
access to a wide variety of resources, including the
Beers Criteria for Potentially Inappropriate Medication
Use in the Elderly and tools used to assess mental status
or confusion (the Mini Mental State Examination or the
Confusion Assessment Method), pain or discomfort
(Checklist of Nonverbal Pain Indicators), and falling (Fall
Risk Assessment). In addition to providing the tool, “Try
This” provides directions for administration and guid-
ance on the interpretation of results.
Want to discuss what you’ve read in this article or other issues related to
nurses caring for older adults? Go to
www.nursingcenter.com/ajnolderadults to
participate in a discussion forum with the
series authors and editors.
patient takes more than 30 seconds to complete the
task.
Medications should be reviewed and special note
taken of psychoactive drugs (especially sedatives),
drugs that lower blood pressure, and those that
cause hypoxia or hypoglycemia. People with
dementia or delirium are 50% more likely to fall
and thus need careful assessment and monitoring.12
Those who fall will fall again until the cause is diag-
nosed and corrected.
Dehydration is common in older adults because
decreased muscle mass means that they have less
free water, the extracellular water that predomi-
nates in muscle tissue. Additionally, the thirst
response is blunted with age—this can result in
inadequate fluid intake.13 Chronic dehydration is
more likely to occur in older adults, especially those
who are unable to hold a glass steadily, such as
nursing home patients or those with dementia.
During acute dehydration, which may result
from vomiting, diarrhea, or fever, which may cause
metabolic rates to increase, the kidneys do not con-
centrate urine; older adults are then at risk for fur-
ther dehydration. Noting basic parameters as
orthostatic hypotension, dryness of the oral mem-
branes, poor skin turgor, and urine color and
amount, as well as checking for elevated serum
sodium (above 145 mEq/L) and osmolarity (outside
the range of 280 to 300 mOsm/kg), can alert the
nurse to further action.
Decrease in appetite or early satiety is not always
classic anorexia but may mean other problems are
fomenting.14 In older adults, worsening of heart fail-
ure and early-onset pneumonia can present with this
symptom before any other.
Pain can change markedly with age. Like younger
adults, older adults experience both acute and
chronic pain. However, the two groups may use dif-
ferent words to describe their pain (for example,
older adults may complain of “aches” or “discom-
fort”) and older adults may have difficulty pinpoint-
ing the exact origin of pain, especially if it occurs
below the waist and is reported as “crampy.”
Furthermore, people with chronic pain may have dif-
ficulty evaluating their pain on the common 0-to-10
scale in which 0 means no pain. Commonly used
tools for assessing pain in older adults include the
visual analog scale, the verbal descriptor scale, and
the Wong–Baker FACES Pain Rating Scale.15
In people with dementia, special attention must
be paid to nonverbal cues. For example, someone
with dementia who is unable to ask for analgesia
may express pain by grimacing, moaning, crying
out, or resisting a caregiver’s attempts to move the
patient’s body. Additionally, peripheral and sensori-
motor neuropathy may cause people with diabetes
to be unaware of trauma to the extremities. Thus, in
both these populations, careful and frequent exam-
ination of all vague complaints of pain is necessary.
Such examination may entail a review of the
patient’s history and records for potential causes of
pain, an assessment of current pain, and a review of
all medications in the patient’s regimen. The
patient’s beliefs about use of pain medication should
be examined—especially myths about addiction—
and the patient’s family should be contacted for fur-
ther information.16
Loss of functional ability can be significant in
active people and in those with extremely limited
mobility. Fatigue and decline in activity may signal
anemia, thyroid disease, infection, or cardiovascular
or pulmonary insufficiency. While numerous assess-
ments exist to test ability, both the Katz Index of
Activities of Daily Living and the Barthel Index
were developed specifically for older adults.
However, the most effective way to monitor func-
tion is to establish a baseline by observing the
patient as he performs his usual routines and then
assess function regularly, especially during a decline
in health. Timely referral to rehabilitation programs
may allow older adults to regain prior capacity—
before the onset of permanent decline.
Dizziness is a common complaint. As people
age, they are more likely to report sensations such
as vertigo, lightheadedness, disequilibrium, or a
vague sense of dizziness. Careful questioning about
ajn@lww.com AJN ▼ October 2004 ▼ Vol. 104, No. 10 45
COCKCROFT–GAULT EQUATION FOR
CALCULATING CREATININE CLEARANCE
Creatinine clearance* � (140 � age) � weight (kg)
serum creatinine (mg/dL) � 72 (� 0.85 for women)
* Special considerations: For patients over 90 years old, use age 90. For obese patients, use the
ideal body weight:
Men = 50 kg � 2.3 kg for every inch over 5 feet
Women = 45.5 kg � 2.3 kg for over every inch over 5 feet
Cockcroft DW, Gault MH. Nephron 1976;16(1):31- 41
Nursing assessments include checking for irregular
pulses, measuring orthostatic blood pressure,
reviewing the patient’s most recent electrocardio-
gram, and asking about hearing loss or ringing in the
ears. Neurologic assessments are also required. Note
balance as the patient walks heel to toe, observing if
he begins to fall to one side or grabs on to objects for
stability. Note his ability to perceive position (for
example, can he close his eyes and still correctly
detect direction as the nurse moves his big toe up and
down?). Watch for swaying when the patient is
standing with his eyes closed. Finally, measure
the circumstances surrounding the episode is
required: Was the patient getting up suddenly, lean-
ing his head backward, sitting still, or moving?
Questioning about the sensation itself is also
important: Did the patient perceive the room spin-
ning? Was he faint or woozy? Was he unsteady or
off balance?
Dizziness can be a symptom of anemia, arrhyth-
mia, depression, infection, ear disease, acute myocar-
dial infarction, eye problems, stroke, cerebral
tumors, vasovagal response, or cerumen impaction
in the ear. It can also be a sign of drug toxicity.17
46 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com
TABLE 1. AGING OF THE BODY’S SYSTEMS
Body System Physiologic Changes Expected Signs or Symptoms
Skin • Loss of subcutaneous tissue and thinning
of dermis
• Underlying tissue more fragile; inabili-
ty to respond to heat or cold quickly;
proneness to heat stroke; loss of mois-
ture; wrinkling
Sensory • Loss of lid elasticity
• Ocular changes in cornea, iris, pupil,
lens
• Auditory canal narrows
• Calcification of ossicles
• Changes in organ of Corti
• Olfactory bulb and cells decrease
• Eyelids drop or turn inward
• Increased astigmatism; need for more
light; glare problematic; need for eye-
glasses
• Cataracts
• Increased cerumen
• Hearing loss
• Impaired sound transmission, tinnitus
• Inability to discriminate odors
Cardiovascular • Decreased stress response
• Stiffer valves
• Conductivity altered
• Vessels less elastic
• Diminished cardiac output
• Diastolic murmurs
• More ectopic beats; less ability to
respond to changes in blood pressure
• Poorer perfusion to vital organs with
resulting hypoxia; varicosities; peripher-
al pulses not always palpable
Pulmonary • Enlargement and rigidity of chest wall
• Airway collapse
• Poorer expansion with less efficient
exchange; shallower breathing; less
effective cough
• Oxygen exchange less efficient espe-
cially under stress
Gastrointestinal • Increase in occurrence of hiatal hernia
and decrease in intraabdominal
strength
• Reduced gastric acid
• Slower neural transmission
• Weakening of intestinal walls
• Reflux
• Peptic ulcers
• Vitamin deficiency
• Constipation and incontinence
• Diverticulosis
extraocular movements by asking the patient to
watch as you slowly outline the letter “H,” noting
any rapid back-and-forth eye movements as he fol-
lows your hand.
Incontinence isn’t unique to older adults, but
new-onset urinary incontinence should always be
investigated. In older adults incontinence often
occurs as a result of a urinary tract infection, limited
mobility, or metabolic problems such as hyper-
glycemia or hypercalcemia. Other causes include the
use of medications such as diuretics or sedatives, the
latter of which can inhibit the person’s ability to rec-
ognize the need to use the toilet and slow his move-
ment toward the bathroom. While many techniques
can be used to rehabilitate people with urge or stress
urinary incontinence or urinary retention, these
reversible causes must be investigated first.18 A dip
stick urine test to look for the presence of the
nitrites and blood usually found during infection
can provide excellent clues for further workup.19
PRESENTATION OF DISEASE
Infection. It is believed that immunity deteriorates
with age as a result of decreasing T lymphocyte
ajn@lww.com AJN ▼ October 2004 ▼ Vol. 104, No. 10 47
Ebersole P. Age-related changes. In: Ebersole P, et al., editors. Toward healthy aging. Human needs and nursing responses.
Philadelphia: Mosby; 2004. p. 74-80.
Renal • Decrease in blood flow, glomeruli,
renin, and filtration
• Increased creatinine clearance; loss
of ability to concentrate urine and
conserve water; poor response to
stress
Musculoskeletal • Shrinking vertebral discs, loss of bone mass
• Muscle atrophy
• Loss of height by 1.5 to 3 in.; fracture
more common
• Decrease in strength and stamina;
atrophy
Neurologic • Diminished stage 3–4 (deep) sleep
• Decreased proprioception
• Altered pain sensation
• Tactile sense decreases
• Sleep disorders, especially in different
environments (hospital)
• Difficulty in changing position or
achieving balance
• Decreased perception of pain
• Loss of sensation in extremities
Immune • Decrease in thymus mass and
production
• Increase in immunoglobulins
• Decline in cell-mediated immunity; reac-
tivation of disease (tuberculosis, herpes)
• Autoimmune response not associated with
disease
Endocrine • Loss of sensitivity to insulin
• Diminished sex hormones
• Blood glucose does not return to normal
as quickly
• Benign prostatic hyperplasia; testicular
firmness; vaginal dryness and atrophy;
longer time to orgasm
Body System Physiologic Changes Expected Signs or Symptoms
function.20 With age, the thymus gland decreases in
size and function. As a result, the effectiveness of
the T lymphocyte response to antigens decreases.
Rates of infection rise steadily with age, and mor-
tality rates are sometimes two to three times higher
for the same diseases seen in younger people. There
is also an increase in certain cancers and autoim-
mune diseases with aging. Because of lower basal
metabolic rates, older adults have lower core tem-
peratures. Thus, a patient with a normal tempera-
ture or a low-grade fever may actually be
experiencing a significant temperature hike.
Additionally, with age, the body’s ability to trigger
an inflammatory response to pathogens slows,
making temperature an imprecise measure of the
severity of infection. When assessing for infection,
it’s critical to have an accurate baseline temperature
and to note any recent changes such as confusion
or decreased activity.
Presentation. Because the symptoms of infections
change with age—for example, fever and chills are
replaced with confusion or decreased functional
ability—they often go undetected in older adults
until the infection has reached an acute stage.
Additionally, many older adults who use non-
steroidal antiinflammatory drugs for painful muscu-
loskeletal conditions have their inflammatory
response altered, so at intake nurses should always
question patients about recent use of antipyretic
medications. The following list describes possible
presentations of the infections most commonly
occurring in older adults:
• pneumonia—increased respiratory rate with
decreased appetite and functioning
• urinary tract infections—incontinence, increased
confusion and falls
Skin infections are often missed in older adults,
who may be difficult to undress or move from a
wheelchair. Cellulitis can occur in people with vas-
cular disease; early signs may be missed in people
with chronic dependent edema.
Alterations in gastrointestinal status have many
causes, including low-level dehydration, slower
peristalsis, chronic neuromuscular disease, or even
lack of mobility related to osteoarthritis (which can
make the older adult prone to constipation). Other
causes of gastrointestinal distress may present in the
older adult as follows:
• Upper or lower GI bleeding may present insidi-
ously with signs of dehydration and crampy
abdominal pain that’s difficult to localize.
• GI obstruction can present without the usual
boardlike abdomen, but instead with cramps,
dehydration, stringy stool or diarrhea, and vague
complaints of feeling unwell.
• Diverticulosis may present with diffuse pain and
a low-grade temperature that signal inflamma-
tion, infection, or even perforation.
48 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com
TIPS FOR NURSES BY
HEALTH CARE SETTING
Hospital nurses
• Confusion is not inevitable. Look for neurologic
events or new medication.
• Many hospitalized older adults suffer from chronic
dehydration accelerated by acute illness.
• Not all older adults have high fevers with infection.
Other symptoms can include increased respiratory
rate, falls, incontinence, or confusion.
Nursing home nurses
• Pain is undertreated in older adults with dementia.
Look for nonverbal cues such as grimacing or
resistance to care.
• Decline in functional ability (even minor declines,
such as the inability to sit upright in a chair) may
be a signal of new illness.
• Residents with less muscle mass—both the frail and
the obese—are at much higher risk for toxicity from
protein-binding drugs such as phenytoin (Dilantin
and others) and warfarin (Coumadin and others).
Ambulatory care nurses
• Complaints of fatigue or decreased ability to do
usual activities may be signs of anemia, thyroid
problems, depression, or neurologic and cardiac
problems.
• Severe gastrointestinal problems in older adults
don’t always present with the acute symptoms seen
in younger patients. Ask about constipation,
crampy sensations, and changes in bowel habits.
• Older adults reporting increased dyspnea and confu-
sion, especially those with a cardiac history, should
be sent to the ED; these are the most common presen-
tation of myocardial infarction in this population.
• Depression is common among older adults with
chronic illnesses. Watch for lack of interest in for-
mer activities, significant personal losses, or
changes in role or home life.
Home care nurses
• Falls should be investigated further, focusing on
balance, gait, and neurologic issues.
• Older adults being treated for late-stage heart dis-
ease should be monitored for loss of appetite as
an early symptom of impending failure.
• Drug–drug interactions in older patients who are
seeing more than one provider and taking multiple
medications are common. Watch for signs.
Assessment. When assessing for alterations in
gastrointestinal status, first observe the contour of
the abdomen, looking for old scars that might indi-
cate adhesions. Then, using the stethoscope, listen
in all four abdominal quadrants for the presence of
bowel sounds. Percussion of the abdomen helps
nurses determine whether the bowel is filled with
feces or air. Special attention should be paid to any
bruits or masses in older adults with poorly con-
trolled hypertension; these may signal an abdominal
aortic aneurysm and should be confirmed with an
ultrasound or computed tomographic (CT) scan.
Finally, light followed by deep palpation will help
isolate painful areas, determine the existence of
masses, and identify distention of the bladder. A
patient’s report of blood in the stool or changes in
stool color may be unreliable since the patient may
be unable to clearly see the toilet contents.
Appendicitis. Although often considered a dis-
ease of young adulthood, appendicitis also occurs in
older adults. The rate of morbidity and mortality
with appendicitis increases with age from 1% in the
general population to 70% in older adults.21 Among
older adults, appendicitis is often misdiagnosed as
bowel obstruction and surgical treatment is delayed,
resulting in a higher rate of perforation. The four
classic symptoms—right lower-quadrant pain, ele-
vated white blood counts, fever, and anorexia—are
still present and quite predictive but are often
missed because health care providers may not sus-
pect appendicitis in older patients. Thorough
abdominal examination, blood work, careful evalu-
ation of reports of pain and decline in appetite, and
evaluation using abdominal and pelvic CT scans
can reduce the potentially devastating effects.
Cardiac disease. In the most acute insult,
myocardial infarction, the classic symptom is not
crushing chest pain and diaphoresis, but sudden
onset of dyspnea often accompanied by anxiety and
confusion. Recognition of these signs and symp-
toms can result in early detection and treatment.
The damaged heart muscle is unable to adequately
perfuse, which causes associated symptoms such as
confusion (caused by decreased cerebral profusion)
or a drop in urine output (caused by decreased renal
perfusion). The absence of ischemic pain is particu-
larly evident among persons with long-standing
angina and those with poorly controlled diabetes.
Heart failure. The beginning signs of worsening
heart failure may be hard to detect in an inactive
older adult with dependent edema. Often, the only
changes noted may be a decreased appetite, weight
gain of 2 to 3 lbs., and complaints of poor sleep.
Teaching patients and caregivers these simple signs
could ensure appropriate treatment and help
patients to avoid future hospitalizations.
Nurses need to be cautious about the aggressive
administration of IV fluids delivered to people with
heart disease and long-standing, poorly controlled
hypertension; they may be at high risk for heart fail-
ure. Aggressive treatment is required for those iden-
tified as high risk. Critical observations include
sudden onset of confusion or increased anxiety,
increase in respiratory rate, widening pulse pres-
sure, weight change from baseline, overwhelming
fatigue, and anorexia.
Type 2 diabetes. As blood glucose rises, the older
adult may not experience the three Ps: polyuria,
polydipsia, and polyphagia. Instead, the patient is
more likely to become dehydrated, confused,
develop incontinence related to glycosuria, and later
develop a wasting disorder with weight loss instead
of gain. Confusion is an early symptom of hypo-
glycemia. If older adults are treated with certain
oral hypoglycemic agents that stimulate insulin pro-
duction (such as sustained-release glipizide
[Glucotrol XL and others]), their risk for acute
hypoglycemia increases because they are less able to
create and store glycogen for transformation to
blood glucose when blood levels drop. This is espe-
cially problematic if the person lives alone and has
no one to remind him to eat during illness or other
times of stress. The American Diabetes Association
recommends that people in the following categories
be screened for diabetes: those with a family history
of the disease; those with a body mass index greater
than 25; those with hypertension or elevated lipids;
members of high-risk racial or ethnic groups such as
African Americans, Latinos, Native Americans,
Asian Americans, or Pacific Islanders; and those
with a history of vascular disease with a fasting
plasma glucose level of greater than 126 mg/dL.22
Thyroid disease. Fatigue and tremor, two of the
most common symptoms of thyroid problems, may
be missed or absent in old age. The gland itself may
be hard to palpate as it slips lower and deeper into
the neck. Instead, hyperthyroidism presenting in old
age is often seen with new onset atrial fibrillation,
weight loss, proximal muscle weakness, and confu-
ajn@lww.com AJN ▼ October 2004 ▼ Vol. 104, No. 10 49
THE ABSENCE OF ISCHEMIC PAIN IS
PARTICULARLY EVIDENT AMONG
PERSONS WITH LONG-STANDING
ANGINA AND THOSE WITH POORLY
CONTROLLED DIABETES.
Because the complaints of younger and older
adults may be different, it’s important to use an
instrument specific to assessing depression in older
adults. One such instrument is the Geriatric
Depression Scale, which is available at www.
hartfordign.org/resources/education/tryThis.html.
Depression scales developed specifically for older
adults don’t focus on somatic complaints or fatigue,
as these may be manifestations of chronic illness.
Older adults often present with confusion, lack of
interest in life, or unwillingness to participate in the
examination (providing answers such as “Why are
you bothering me?”). Asking the questions, “Are
you sad or blue?” and “Have you stopped doing
things that once gave you pleasure?” are simple
screening questions to detect depression. Nurses
must ask specifically about plans for self-harm
when self-destructive thoughts are stated. ▼
REFERENCES
1. National Institute on Aging. Research for a new age. 1993.
http://www.niapublications.org/ pubs/research/index.asp.
2. Ebersole P. Age-related changes. In: Ebersole P, et al., editors.
Toward healthy aging. Human needs and nursing responses.
Philadelphia: Mosby; 2004. p. 79-108.
3. Siegel L. Are telomeres the key to aging and cancer? 2004.
http://gslc.genetics.utah.edu/ features/telomeres.
4. Tilley A. Ageing. An overview. 2002. http://www.
ibmsscience.org/general/ageing.htm.
5. Sohal RS. Role of oxidative stress and protein oxidation in
the aging process. Free Radic Biol Med 2002;33(1):37-44.
6. Flacker JM. What is a geriatric syndrome anyway? J Am
Geriatr Soc 2003;51(4):574-6.
7. Gleason OC. Delirium. Am Fam Physician 2003;67(5):
1027-34.
8. Foreman MD, et al. Delirium in elderly patients: an
overview of the state of the science. J Gerontol Nurs
2001;27(4):12-20.
9. Inouye SK, et al. Clarifying confusion: the confusion assess-
ment method. A new method for detection of delirium. Ann
Intern Med 1990;113(12):941-8.
10. Resnick. Preventing falls in acute care. In: Mezey M, et al.,
editors. Geriatric nursing protocols for best practice. New
York: Springer; 2003. p. 141-64.
11. Bischoff HA, et al. Identifying a cut-off point for normal
mobility: a comparison of the timed ‘up and go’ test in com-
munity-dwelling and institutionalised elderly women. Age
Ageing 2003;32(3):315-20.
12. Nowalk MP, et al. A randomized trial of exercise programs
among older individuals living in two long-term care facili-
ties: the FallsFREE program. J Am Geriatr Soc
2001;49(7):859-65.
13. Hodgkinson B, et al. Maintaining oral hydration in older
adults: a systematic review. Int J Nurs Pract 2003;9(3):S19-28.
14. van Staveren WA, et al. Regulation of appetite in frail per-
sons. Clin Geriatr Med 2002;18(4):675-84.
15. Herr K. Chronic pain: challenges and assessment strategies.
J Gerontol Nurs 2002;28(1):20-7; quiz 54-5.
16. Horgas A, McLennon S. Pain management. In: Ebersole P,
et al., editors. Toward healthy aging. Human needs and
nursing responses. Philadelphia: Mosby; 2004. p. 229-50.
sion, while hypothyroidism may have few, if any,
symptoms.23 Many older adults have subclinical
thyroid disease and may suffer cardiac disease and
osteoporosis before treatment is initiated; nurses
should carefully assess complaints of fatigue in all
older adults.
Assessment. To assess endocrine problems, the
thyroid can be palpated in the neck as the trachea is
stabilized and the person is asked to turn his head.
Thyroid stimulating hormone remains the preferred
indicator of thyroid disease (the normal range for
adults is 0.4 to 4 µIU/mL) and needs to be closely
monitored in older adults taking amiodarone
(Cardarone and others) for heart disease.24
Depression is the most commonly occurring men-
tal health problem for older adults, especially in
those with chronic illness and those living in institu-
tions.25 As the rate of suicides is highest in older
white men, early assessment and treatment of
depression is paramount.26 However, many older
adults avoid complaining of feeling sad or depressed,
which can make it difficult for health care practition-
ers to recognize this problem in their patients.27
Additionally, the societal expectation that older
adults are tired, complain, and have little interest in
life may disguise the most common symptoms of
depression: fatigue, somatic symptoms that don’t
seem to have an origin in pathology, and a decrease
in activities the person formerly enjoyed. Failure to
recognize that most older adults find satisfaction and
joy in life can deprive patients of treatment that
could vastly improve the quality of their lives.
Assessment. Kurlowicz recommends screening
for depression in the following high-risk groups:
alcohol or substance abusers; people with dementia,
stroke, cancer, arthritis, hip fracture, myocardial
infarction, chronic lung disease, or Parkinson dis-
ease; those suffering from functional disability, espe-
cially new onset; widows or widowers; caregivers;
and those who are isolated or lacking social sup-
port.28 Furthermore, certain medications, especially
digitalis (Digoxin and others), propranolol (Inderal
and others), and benzodiazepines, are associated
with depression.29
50 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com
Complete the CE test for this article by
using the mail-in form available in this
issue or visit NursingCenter.com’s
“CE Connection” to take the test and find
other CE activities and “My CE Planner.”
THE 8TH ANNUAL NURSES IMPROVING
CARE FOR HEALTHSYSTEM ELDERS
LEADERSHIP CONFERENCE
January 31 to February 1, 2005
Marriot Financial Center Hotel,
New York City
For more information, visit
www.nicheprogram.org.
17. Eaton DA, Roland PS. Dizziness in the older adult, part 1.
Evaluation and general treatment strategies. Geriatrics
2003;58(4):28-30, 3-6.
18. Wyman JF. Treatment of urinary incontinence in men and
older women: the evidence shows the efficacy of a variety of
techniques. Am J Nurs 2003;(Suppl):26-35.
19. Thurlow KL. Infections in the elderly: part 2. Emerg Med
Serv 2002;31(4):44.
20. Aspinall R. Age-related changes in the function of T cells.
Microsc Res Tech 2003;62(6):508-13.
21. Storm-Dickerson TL, Horattas MC. What have we learned
over the past 20 years about appendicitis in the elderly? Am
J Surg 2003;185(3):198-201.
22. Standards of medical care in diabetes. Diabetes Care
2004;27(Suppl 1):S15-35.
23. Margolius S, Reed R. Thyroid disease. In: Ham R, et al.,
editors. Primary care geriatrics. A care-based approach. St.
Louis, MO: Mosby; 2002. p. 517-24.
24. Demers LM, Spencer CA. Laboratory medicine practice
guidelines: laboratory support for the diagnosis and moni-
toring of thyroid disease. Clin Endocrinol (Oxf)
2003;58(2):138-40.
25. Birrer RB, Vemuri SP. Depression in later life: a diagnostic
and therapeutic challenge. Am Fam Physician
2004;69(10):2375-82.
26. Chima F. Elderly suicidality. Human behavior and social
environment perspective. J Human Behav Soc Environ
2002;6(4):21-6.
27. Nelson J, Battista D. Diagnosis and treatment of late-life
depression. Clin Nurse Spec 2002:69-71.
28. Kurlowicz L. Depression in older adults. In: Mezey M, et al.,
editors. Geriatric nursing protocols for best practice. New
York: Springer; 2003. p. 185-205
29. Blazer DG. Depression in late life: review and commentary.
J Gerontol A Biol Sci Med Sci 2003;58(3):249-65.
30. Willlams CM. Using medications appropriately in older
adults. Am Fam Physician 2002;66(10):1917-24.
31. Family Practice Notebook. Lab markers of malnutrition.
2000. http://www.fpnotebook.com/ PHA48.htm.
32. Payne K. Total serum protein. 2004. http://my.webmd.com/
hw/health_guide_atoz/ hw43614.asp.
33. Veterans Health Administration, Department of Defense.
VHA/DoD clinical practice guideline for the management of
chronic kidney disease and pre-ESRD in the primary care
setting. Washington, DC: Department of Veterans’ Affairs;
2001.
ajn@lww.com AJN ▼ October 2004 ▼ Vol. 104, No. 10 51
GENERAL PURPOSE: To present registered professional
nurses with an overview of the aging process and
the factors that produce altered presentations of sev-
eral illnesses in older adults.
LEARNING OBJECTIVES: After reading this article and
taking the test on the next page, you will be able to
• discuss the pathophysiology of the aging
process and the ways it predisposes older
adults to illness.
• describe the assessment process for older adults, as
well as the possible causes of abnormal findings.
• list specific examples of the altered presentation
of common disorders in older adults.
To earn continuing education (CE) credit, follow these
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and TK (or a photocopy). Each question has only one
correct answer.
2. Complete the registration information (Box A) and help
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This continuing education activity for 2 contact hours
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Continuing Education
HOURS
40 AJN t October 2007 t Vol. 107, No. 10 http://www.nursingcenter.com
How ToHow To
try thistry this
D
By Terry Fulmer, PhD, RN, FAAN
Continuing Education
2 HOURS
Ed
Ec
ks
te
in
Fulmer
A framework of six ‘marker conditions’ can help
focus assessment of hospitalized older patients.
SPICES
Overview: Fulmer SPICES is a framework for
assessing older adults that focuses on six common
“marker conditions”: sleep problems, problems
with eating and feeding, incontinence, confusion,
evidence of falls, and skin breakdown. These con-
ditions provide a snapshot of a patient’s overall
health and the quality of care. The SPICES assess-
ment, done regularly, can signal the need for more
specific assessment and lead to the prevention
and treatment of these common conditions. For a
free online video demonstrating the use of SPICES,
go to http://links.lww.com/A100.
L
ucy Semple, an 84-year-old resi-
dent of a long-term care facility,
was brought to the ED on a
Monday morning complaining of
hip pain. The previous morning
she had fallen on the way to the bathroom.
(This case is a composite, based on my expe-
rience.) At the time of the fall she insisted
that she was fine, but her pain worsened dur-
ing the day and she slept poorly that night.
Ms. Semple waited in the ED from 9 AM
until 2 PM on Monday. Because all of the
beds were full in the ED holding area, Ms.
Semple was left on a stretcher in the hallway.
At 2 PM she was taken for an X-ray, which
showed a fracture of the right femoral neck.
After the surgeon finished the evaluation, the
nurses prepared Ms. Semple for surgery. She had
not eaten since lunch on Sunday. She was taken to
the operating room at 5 PM on Monday. The oper-
ation lasted three hours, and she was brought to the
recovery room by 8:30 PM in moderate-to-severe
pain (8 out of 10 on a 0-to-10 Faces pain-rating
scale). Food and fluids were offered after she could
safely swallow, but she said her pain was making
her nauseated and she ate nothing.
Ms. Semple was transferred to the orthopedic
unit at 11 PM and received an opioid for pain
throughout the night. She slept poorly, at one point
screaming, “Operator, operator, where’s my
mother?” During morning rounds, a nurse sug-
gested that this “delightfully demented lady” would
“probably need haloperidol [Haldol] to control her
behavior.” It was further noted that there was a
small reddened area, without exudate, on her coc-
cyx and that she had been incontinent of urine dur-
ing the night and been placed in absorbent briefs.
THE NEED FOR THE SPICES FRAMEWORK
When I became a nurse in the 1970s, we had much
less evidence than we do now on how best to assess
common geriatric conditions. This often forced us
to rely on quick fixes that didn’t prevent or improve
those conditions. If someone was incontinent, for
example, a Foley catheter was inserted. Restraints
and medications were used to treat confusion. If
someone had trouble eating, a nasogastric tube was
inserted. To treat problems with sleep, sedatives
were given. When I became a geriatric nurse spe-
cialist, I’d go to a cardiac unit and say, “I’m Terry
Fulmer, and I’m here to help you care for your older
ajn@wolterskluwer.com AJN t October 2007 t Vol. 107, No. 10 41
patients. Do you have any problems that I might
help you with?” The nurses would usually say
something like, “No; the patient has an anterior
wall MI, and we’re working on getting the medica-
tion titrated and maybe there’ll be a pacemaker
inserted.”
It became clear that we needed a new frame-
work for assessing this population. The Nurses
Improving Care for Health System Elders
(NICHE) project has been identifying and helping
hospitals implement best practices for the care
of older adults since the early 1990s.1, 2 (See The
Atlantic Philanthropies Supports Better Care of
Older Adults, page 43.) The NICHE project helps
hospitals assess the quality of care they give to older
adults and provides four nursing-care models, evi-
dence-based protocols for assessing older adults,
and educational materials to help hospitals imple-
ment effective systemic changes.2, 3
The Fulmer SPICES framework, which was
developed in 1988,3 was implemented as part of the
geriatric resource nurse model of care in the
NICHE project. SPICES is an acronym that focuses
nurses on six “marker conditions” in older adults
rather than on the disease or injury for which a
patient was hospitalized. These conditions, also
sometimes referred to as syndromes, are common,
preventable, and may signal a need for more in-
depth assessment.
• Sleep disorders
• Problems with eating and feeding
• Incontinence
• Confusion
• Evidence of falls
• Skin breakdown
read it watch it try it
Web Video
Watch a video demonstrating the use and
interpretation of the Fulmer SPICES frame-
work at http://links.lww.com/A100.
A Closer Look
Get more information on the assessment
and care of older adults.
Try This: SPICES
This is SPICES in its original form.
See page 45.
42 AJN t October 2007 t Vol. 107, No. 10 http://www.nursingcenter.com
How ToHow To
try thistry this
D
The presence of these conditions, alone or in
combination, can lead to increased death rates,
higher costs, and longer hospitalizations in elderly
patients.4-7 The need for such a framework will
become even more urgent as the number of people
ages 65 to 84 doubles between 2000 and 2030,
from 30 million to more than 61 million, according
to U.S. Census Bureau projections.8 New models of
care will be needed in all settings to accommodate
the rapidly rising number of people living with one
or more chronic conditions.9
Hospitals face particular challenges; as Ms.
Semple’s case illustrates, there’s a great potential for
functional decline in hospitalized older adults. If a
SPICES assessment had been performed after Ms.
Semple’s first night of hospitalization, she would
have received a positive result for all six conditions.
MARKER CONDITIONS
It can be debated whether SPICES covers all the
conditions that are the most serious markers of
health in older patients. While constipation and
depression, for example, are also significant, the
SPICES framework is not a comprehensive list of
what can go wrong in a hospitalized older adult.
Rather, it’s intended to be a mnemonic device cov-
ering “geriatric vital signs” that, taken together,
provide a good overview of a geriatric patient’s
response to the care given and point to the need for
more detailed assessment when necessary.10 For
example, if the patient reports to a nurse perform-
ing a SPICES assessment that she or he is sleeping
poorly, further assessment might reveal that the
cause is inadequately controlled pain. In this way
the many complex connections among apparently
unrelated problems in older adults can become
clearer to nurses and help guide their plans of care.
Sleep disruption is common in hospitalized
patients.11, 12 While there have been no national
prevalence studies on sleep problems in hospital-
ized older adults, sleep disruption is common in
that population. (For more information, see “Sleep
Disruption in Older Adults,” May.) The stress of
hospitalization, being awakened for routine care,
pain, the effects of medications, changes in environ-
ment, and noise can all further compromise sleep
during hospitalization.
Assessing the patient. If a patient is cognitively
intact, you can simply ask, “How well do you usu-
ally sleep?” In the case of Ms. Semple, the nurses
could see that her sleep was fitful. Her pain and the
medication she received for it may have played a
role in her sleep disruption. Later, when she’s lucid,
she can be asked about her usual sleep patterns and
habits. Every effort must be made to create a good
environment for sleep for older adults; such mea-
sures might include minimizing conversation in
hallways and at the nurses’ station during sleeping
hours and limiting nursing interventions during this
time—which might, for example, mean postponing
a 4 AM blood pressure measurement if the patient is
clinically stable.
SPICES is one of the many assessment tools and
best practice approaches presented in the Hartford
Institute’s Try This: Best Practices in Nursing Care
to Older Adults (www.hartfordign.org/trythis).
Two Try This tools can be used to further evaluate
a patient whose SPICES assessment suggests there
is a sleep problem: The Epworth Sleepiness Scale
(www.hartfordign.org/publications/trythis/issue06.
pdf) and The Pittsburgh Sleep Quality Index (www.
hartfordign.org/publications/trythis/issue06_1 ).
More detail will be provided in upcoming articles
and videos in this series.
Problems with eating and feeding. One study
found that 20% of hospitalized older adults were
undernourished.13 Weight loss, low body mass index,
and malnutrition have repeatedly been associated
with higher mortality rates in older adults in all set-
tings.14, 15 These problems may be most apparent in
patients who are anorexic or unable to feed them-
selves. A small study of hospitalized older adults by
St-Arnaud-McKenzie and colleagues found close
associations between poorly controlled pain and
aversion to food and between hunger and a sense of
physical well-being.16 The ability to feed oneself is a
basic activity of daily living. Hospitalized older
adults often have practical difficulties when feeding
themselves: the bedside table is out of reach, utensils
are hard to use because of IV lines, or food is cold by
the time they are able to reposition themselves.
Assessing the patient. Ms. Semple’s nurses were
able to see that she had no appetite on the evening
immediately after her surgery; when asked why, she
reported that her pain was nauseating her. In order
to improve her appetite, better pain management is
required, and her desire and ability to eat should
be assessed again the following morning and
throughout her hospital stay. Research is needed to
improve our understanding of problems with eat-
ing and feeding in hospitalized older adults. For
a more detailed approach to assessment, see the
Try This tool Assessing Nutrition in Older Adults
(www.hartfordign.org/publications/trythis/issue_9.
pdf), which will be featured in a future article in
this series.
Incontinence, of either bladder or bowel, in hos-
pitalized older adults can vary in severity and may
result from delirium or dementia, reduced function
because of illness, medications that interfere with
the ability to detect bladder fullness, disrupted abil-
ity to walk to a bathroom or use a bedside com-
mode, and passive restraints such as IV lines,
catheters, or traction devices. Although urinary
incontinence, like weight loss, has shown close
associations with longer hospitalization, poor out-
come, and a poor sense of physical well-being,4, 17
one small exploratory study found that nurses often
view incontinence as inevitable in this population
and tend to use “containment” strategies such as
pads rather than promoting continence.18 A litera-
ture search turned up no recent prevalence and inci-
dence rates of incontinence in older hospitalized
patients, but in 1991 the Centers for Disease
Control and Prevention reported that from 1984 to
1987, 15% to 34% of hospitalized older adults had
urinary incontinence.19
Assessing the patient. Ms. Semple’s incontinence
was initially assessed through observation. When
she is oriented and responsive, she should be asked
such questions as “Do you usually have difficulty
reaching the toilet?” and “What can we do to help
you now?” Urinary incontinence can often be pre-
vented using interventions such as a voiding sched-
ule; once it does occur, it can be either acute and
reversible or chronic and irreversible. An indwelling
catheter should be used only as a last resort. Further
assessment of Ms. Semple’s incontinence might have
been done using the Try This tool Urinary Inconti-
nence Assessment (www.hartfordign.org/publications/
trythis/issue11 ), which will be featured in this
series.
Confusion, whether temporary or more long-
term, afflicts many hospitalized older adults. A
study at one hospital found that almost one-third of
patients age 70 or older suffered delirium within 24
hours of admission.20 And in a study of 118 consec-
utively admitted ICU patients ages 65 and older,
70% developed delirium in the ICU, as did 31% of
those with a “normal mental status” at the time of
admission.21 Hospitalization can disrupt older
adults’ eating and sleeping patterns and medication
dosages and schedules, which may disorient those
in an unfamiliar environment. Nurses should assess
older patients for confusion, attempt to prevent its
occurrence, and intervene to reverse and alleviate
the fear that this condition can provoke.
Assessing the patient. Ms. Semple’s confusion was
ajn@wolterskluwer.com AJN t October 2007 t Vol. 107, No. 10 43
The Atlantic Philanthropies has awarded the HartfordInstitute for Geriatric Nursing, part of New York
University’s College of Nursing, a $5 million, five-year grant
to expand its NICHE (Nurses Improving Care for Health
System Elders) program. Since 1996, the Hartford Institute
has administered NICHE, which has as its vision that all
patients ages 65 and older be given sensitive and exem-
plary care. NICHE is a national geriatric nursing program
that helps hospitals achieve systematic nursing change to
benefit older patients. It is currently implemented in 225 hos-
pitals in more than 40 states and parts of Canada.
Many nurses are unaware of the ways in which older
adults differ from younger patients in terms of symptoms
and appropriate treatment. Hospitals are recognizing that
such teaching is necessary to prepare their organizations
for the future. The Atlantic Philanthropies grant will help
NICHE build its internal capacity, dramatically improve the
program’s “tool kit”—particularly its measurement and
reporting capacity—and initiate outreach to accelerate
adoption of the program by additional hospitals.
When hospitals first join the NICHE program, they send a
team to a conference where they learn about the various ele-
ments of the NICHE tool kit. NICHE is a modular program
that offers hospitals an array of options to improve their nurs-
ing resources for older adults. The most frequently used com-
ponent, the Geriatric Resource Nurse model, helps hospitals
train interested and motivated nurses in best practices for the
care of older adults. These nurses then become resources for
their colleagues, and many go on to become certified in
gerontologic nursing. Some hospitals have adopted the
Acute Care of the Elderly model, and others have instituted
hospital-wide programs to address specific issues such as
falls prevention, skin care, incontinence, and delirium.
The NICHE program aims to expand to 600 or more
hospitals during the five-year grant period. The project’s
current plan includes regional and audio conferences and
a new Web site for NICHE members that will offer interac-
tive, Wikipedia-type technology, enabling users to share
information about best practices in the care of older adults.
For more information, go to www.nicheprogram.org.—Liz
Capezuti, PhD, RN, APRN-BC, FAAN, associate professor
and codirector, John A. Hartford Foundation Institute for
Geriatric Nursing, New York University College of
Nursing, New York City: ec65@nyu.edu.
The Atlantic Philanthropies Supports
Better Care of Older Adults
The NICHE program now has a strong mandate to expand its programs.
44 AJN t October 2007 t Vol. 107, No. 10 http://www.nursingcenter.com
How ToHow To
try thistry this
D
first assessed through observation. The nurse’s com-
ment that Ms. Semple was “delightfully demented”
suggests the assumption, common among health care
providers, that all older adults in long-term care have
dementia; it also reveals a lack of communication
with the long-term care facility staff about the
patient’s usual mental status as well as with the ED
staff about her mental status at the time of admis-
sion. The suggestion to give haloperidol may have
been premature because Ms. Semple’s change in
cognitive status might have been alleviated by
reducing her pain medication or by engaging a fam-
ily member to help orient her. Ms. Semple’s nurses
could have used the following Try This tools for
more detailed assessment of Ms. Semple’s mental
status: Mental Status Assessment of Older Adults:
The Mini-Cog (www.hartfordign.org/publications/
trythis/issue03 ) and The Confusion Assessment
Method (www.hartfordign.org/publications/trythis/
issue13 ), both of which will be featured in this
series.
Evidence of falls. According to a literature
review by Tinetti and colleagues, approximately
30% of community-dwelling adults ages 65 and
older fall each year.22 Stevens and colleagues esti-
mated the cost of nonfatal falls among people in the
United States ages 65 and older in 2000 to have
been more than $19 billion.23 A literature review by
Oliver and colleagues notes that the most consis-
tently identified risk factors for falls in hospitalized
patients are confusion, gait instability, urinary
incontinence or frequency, a history of falls, and the
administration of sedatives and hypnotic drugs.24 A
program instituted by Fonda and colleagues
reduced falls by 19% over a two-year period at a
hospital for the elderly in Australia; the program
reviewed toileting protocols and instituted the use
of nonslip bedside mats, identification and surveil-
lance of patients at risk for falling, glow-in-the-dark
commode seats, and staff orientation on falls pre-
vention, among other measures.25 It’s important to
determine which hospitalized older adults have a
history of falls and take measures to anticipate and
prevent them. If a patient who has no history of falls
does so while in the hospital, assessment and treat-
ment should focus on identifying possible iatrogenic
causes.
Assessing the patient. Ms. Semple’s hospitaliza-
tion was known to be the result of a fall. When she
is able to answer, she can be asked, “Is this the first
time you’ve fallen?” The long-term care facility
should also be consulted to find out whether Ms.
Semple has a history of falls. The fact that she fell in
the long-term care facility and her SPICES assess-
ment was positive for evidence of falls should moti-
vate her nurses to further assess her risk of future
falls by using a tool such as Fall Risk Assessment
for Older Adults: The Hendrich II Model (www.
hartfordign.org/publications/trythis/issue08 ), to
be highlighted in a future article in this series.
Skin breakdown—specifically pressure ulcers—
can be fatal in older adults. The one-day 1999
National Pressure Ulcer Prevalence Survey found
that of nearly 43,000 acute care patients, 14.8%
had a pressure ulcer; 61% of these were in patients
age 71 or older.26 Skin breaks down in immobilized
patients when pressure reduces the blood supply to
an area and the tissue dies. Some of the major risk
factors and causes are older age; bed rest; neuropa-
thy, which can impair the detection of pain; poor
nutrition; cognitive impairment, which can impede
self-care or recognition of a problem; friction and
shearing against bedsheets; and urinary inconti-
nence resulting in moisture in areas over bony
prominences.
Assessing the patient. Ms. Semple had several of
the above risk factors. The redness on her coccyx
was identified through physical examination and
should have immediately led to measures to prevent
the progression of skin breakdown, such as the use
of a pressure-relieving mattress, turning every two
hours, putting her on a voiding schedule instead of
applying absorbent pads, and using a pressure ulcer
assessment tool such as the Braden Scale for Predicting
Pressure Sore Risk (see Try This, Predicting Pressure
Ulcer Risk, www.hartfordign.org/publications/trythis/
issue05 ).
Go to http://links.lww.com/A100 towatch a nurse use the Fulmer SPICES to
assess an older woman for common geriatric
problems and discuss ways to meet the chal-
lenges of administering it and interpreting
and quickly acting on findings. Then watch
the health care team plan short- and long-
term interventions to address the woman’s
condition.
View this video in its entirety and then
apply for CE credit at www.nursingcenter.
com/AJNolderadults; click on the How to
Try This series. All videos are free and in a
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Issue Number 1, Revised 2007 Series Editor: Marie Boltz, PhD, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing
Fulmer SPICES: An Overall Assessment Tool for Older Adults
By: Meredith Wallace, PhD, APRN, CS, Fairfield University School of Nursing, and
Terry Fulmer, PhD, APRN, GNP, FAAN, New York University College of Nursing
WHY: Normal aging brings about inevitable and irreversible changes. These normal aging changes are partially
responsible for the increased risk of developing health-related problems within the elderly population. Prevalent
problems experienced by older adults include: sleep disorders, problems with eating or feeding, incontinence, confusion,
evidence of falls, and skin breakdown. Familiarity with these commonly-occurring disorders helps the nurse prevent
unnecessary iatrogenesis and promote optimal function of the aging patient. Flagging conditions for further assessment
allows the nurse to implement preventative and therapeutic interventions (Fulmer, 1991; Fulmer, 1991).
BEST TOOL: Fulmer SPICES, developed by Terry Fulmer, PhD, APRN, FAAN at New York University College of Nursing,
is an efficient and effective instrument for obtaining the information necessary to prevent health alterations in the older
adult patient (Fulmer, 1991; Fulmer, 1991; Fulmer, 2001). SPICES is an acronym for the common syndromes of the
elderly requiring nursing intervention:
S is for
Sleep Disorders
P is for
Problems with Eating or Feeding
I is for
Incontinence
C is for
Confusion
E is for
Evidence of Falls
S is for
Skin Breakdown
TARGET POPULATION: The problems assessed through SPICES occur commonly among the entire older adult
population. Therefore, the instrument may be used for both healthy and frail older adults.
VALIDITY AND RELIABILITY: The instrument has been used extensively to assess older adults in the hospital setting,
to prevent and detect the most common complications (Fulmer, 2001; Lopez, et al, 2002; Pfaff, 2002; Turner, J., et al,
2001; NICHE). Psychometric testing has not been done.
STRENGTHS AND LIMITATIONS: The SPICES acronym is easily remembered and may be used to recall the common
problems of the elderly population in all clinical settings. It provides a simple system for flagging areas in need of further
assessment and provides a basis for standardizing quality of care around certain parameters. SPICES is an alert system
and refers to only the most frequently-occurring health problems of older adults. Through this initial screen, more
complete assessments are triggered. It should not be used as a replacement for a complete nursing assessment.
Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, College of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic
format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.
ajn@wolterskluwer.com AJN t October 2007 t Vol. 107, No. 10 45!
Fulmer SPICES: An Overall Assessment Tool for Older Adults
Adapted from Fulmer, T. (1991). The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91- 93.
© Copyright Lippincott Williams & Wilkins, http://lww.com.
Patient Name: Date:
SPICES EVIDENCE
Yes No
Sleep Disorders
Problems with Eating or Feeding
Incontinence
Confusion
Evidence of Falls
Skin Breakdown
MORE ON THE TOPIC:
Best practice information on care of older adults: www.ConsultGeriRN.org.
Fulmer, T. (1991). The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91- 93.
Fulmer, T. (1991). Grow Your Own Experts in Hospital Elder Care. Geriatric Nursing, March/April 1991, 64-66.
Fulmer, T. (2001). The geriatric resource nurse: A model of caring for older patients. American Journal of Nursing, 102, 62.
Lopez, M., Delmore, B., Ake, J., Kim, Y., Golden, P., Bier, J., & Fulmer, T. (2002). Implementing a Geriatric Resource Nurse Model. Journal of
Nursing Administration, 32(11), 577-585.
Nurses Improving the Care of the Hospitalized Elderly (NICHE) project at the Hartford Institute for Geriatric Nursing, http://www.hartfordign.org.
Pfaff, J. (2002). The Geriatric Resource Nurse Model: A culture change. Geriatric Nursing, 23(3), 140-144.
Turner, J. T., Lee, V., Fletcher, K., Hudson, K., & Barton, D. (2001). Measuring quality of care with an inpatient elderly population: The geriatric
resource nurse model. Journal of Gerontological Nursing, 27(3), 8-18.
A SERIES PROVIDED BY
The Hartford Institute for Geriatric Nursing
EMAIL: hartford.ign@nyu.edu
HARTFORD INSTITUTE WEBSITE: www.hartfordign.org
CONSULTGERIRN WEBSITE: www.ConsultGeriRN.org
#46 AJN t October 2007 t Vol. 107, No. 10 http://www.nursingcenter.com
ajn@wolterskluwer.com AJN t October 2007 t Vol. 107, No. 10 47
established. Face validity has been established with
one interdisciplinary group at one hospital3, 10 and
should be replicated, and formal content-validity
testing has been conducted at diverse work sites.
The effect of the racial and ethnic backgrounds of
nurses and patients on the administration of SPICES
has not been tested and is open to research. t
Terry Fulmer is the Erline Perkins McGriff professor and
dean of the College of Nursing at New York University
(NYU), New York City. She is also a codirector of the John
A. Hartford Foundation Institute for Geriatric Nursing.
Contact author: terry.fulmer@nyu.edu.
How to Try This is a three-year project funded by a grant
from the John A. Hartford Foundation to the Hartford
Institute for Geriatric Nursing at NYU’s College of Nursing in
collaboration with AJN. This initiative promotes the Hartford
Institute’s geriatric assessment tools, Try This: Best Practices in
Nursing Care to Older Adults: www.hartfordign.org/trythis. The
print series will include 30 articles and corresponding videos, all
of which will be available for free online at www.nursingcenter.
com/AJNolderadults. Sherry A. Greenberg, MSN, APRN, BC,
GNP (sherry@familygreenberg.com), and Nancy A. Stotts,
EdD, RN, FAAN (nancy.stotts@nursing.ucsf.edu), are coedi-
tors of the series. These articles and videos are to be used for
educational purposes only.
Routine use of a Try This tool may require formal review
and approval by your employer.
REFERENCES
1. Geriatric models of care: which one’s right for your institu-
tion? Nurses Improving Care to the Hospitalized Elderly
(NICHE) Project. Am J Nurs 1994;94(7):21-3.
2. Mezey M, et al. Nurses Improving Care to Health System
Elders (NICHE): implementation of best practice models. J
Nurs Adm 2004;34(10):451-7.
3. Fulmer TT. The geriatric nurse specialist role: a new model.
Nurs Manage 1991;22(3):91-3.
4. Anpalahan M, Gibson SJ. Geriatric syndromes as predictors
of adverse outcomes of hospitalization. Intern Med J 2007.
Epub ahead of print.
For more information on SPICES and other geriatric assess-
ment tools and best practices, go to www.hartfordign.org,
the Web site of the John A. Hartford Foundation–funded
Hartford Institute for Geriatric Nursing at New York
University College of Nursing. The institute focuses on
improving the quality of care provided to older adults by
promoting excellence in geriatric nursing practice, educa-
tion, research, and policy. Download the original Try This
document on SPICES by going to www.hartfordign.org/
publications/trythis/issue01 .
To see links to many geriatrics institutions and asso-
ciations, as well as gerontology-related journals and
resources, curriculum guides, gerontology and education
centers, and listservs, go to www.hartfordign.org/links/
geriatric_links.html.
And go to www.nursingcenter.com/AJNolderadults and
click on the How to Try This link to access all articles and
videos in this series.
Online Resources
USING SPICES
In most cases the SPICES framework will be used
to complement other, more detailed assessment
strategies. A SPICES card can be completed on the
day of admission and on each day of hospitaliza-
tion for each patient age 65 or older. The card can
be created and reproduced by using a three-by-five-
inch index card with S–P–I–C–E–S written on the
vertical axis and yes and no check boxes by each
condition. (See Fulmer SPICES: An Overall
Assessment Tool for Older Adults, page 45). In set-
tings using electronic medical records, the card can
be converted to an electronic file.
Positive responses should be noted in the
patient’s record, and preventive strategies should be
detailed for any of the six marker conditions not
present on assessment. Positive responses should
lead to more detailed assessment. For example, if a
patient is positive for “skin breakdown” or for the
erythema that precedes skin breakdown, the nurse
can then apply a well-established assessment tool
such as the Braden Scale.
The bigger picture. The SPICES framework can
also be used for unit-wide quality improvement. As
nurses begin to see patterns emerging in their unit’s
SPICES data, they can review the literature for best-
practice protocols. In a study conducted on one
pulmonary and renal unit, each nurse filled out a
SPICES card for every patient over the age of 65 for
one month, with the goal of creating a nutritional
screening tool.27 They compiled data from more
than 200 cards and found that sleep problems and
problems with eating and feeding were the most
prevalent conditions documented. Although these
results were not surprising (many of the patients
had difficulty breathing or were metabolically
unstable because of renal disease), the data helped
the nurses determine which patients needed more
detailed assessment. This information also helped
them establish clinical practice protocols for older
adults on the unit, such as assessing for medications
that might decrease appetite or offering patients
their main meal at either lunch or breakfast.
The SPICES card can likewise help nurses see
what did not happen on the unit in any given
period. If a cardiac unit collects SPICES cards for
older adults for an entire month and can report that
there have been no documented SPICES conditions,
that success will only reinforce the effectiveness of
determining and implementing best practices.
CONSIDER THIS
Psychometric testing of the SPICES framework has
been minimal, and interrater reliability has not been
48 AJN t October 2007 t Vol. 107, No. 10 http://www.nursingcenter.com
How ToHow To
try thistry this
D
5. Ensrud KE, et al. Frailty and risk of falls, fracture, and mor-
tality in older women: the study of osteoporotic fractures. J
Gerontol A Biol Sci Med Sci 2007;62(7):744-51.
6. Landi F, et al. Pressure ulcer and mortality in frail elderly
people living in community. Arch Gerontol Geriatr 2007;44
Suppl 1:217-23.
7. Wakefield BJ, Holman JE. Functional trajectories associated
with hospitalization in older adults. West J Nurs Res
2007;29(2):161-77.
8. U.S. Census Bureau. Table 2a. Projected population of the
United States, by age and sex: 2000 to 2050. Washington,
DC; 2004. http://www.census.gov/ipc/www/usinterimproj/
natprojtab02a .
9. American Hospital Association. When I’m 64: how
boomers will change health care. Chicago; 2007 Jul.
http://www.aha.org/aha/content/2007/pdf/070508-boomer-
report .
10. Inouye SK, et al. The Yale Geriatric Care Program: a model
of care to prevent functional decline in hospitalized elderly
patients. J Am Geriatr Soc 1993;41(12):1345-52.
11. Freedman NS, et al. Patient perception of sleep quality and
etiology of sleep disruption in the intensive care unit. Am J
Respir Crit Care Med 1999;159(4 Pt 1):1155-62.
12. Tranmer JE, et al. The sleep experience of medical and sur-
gical patients. Clin Nurs Res 2003;12(2):159-73.
13. Guigoz Y, et al. Identifying the elderly at risk for malnutri-
tion. The Mini Nutritional Assessment. Clin Geriatr Med
2002;18(4):737-57.
14. Kagansky N, et al. Poor nutritional habits are predictors of
poor outcome in very old hospitalized patients. Am J Clin
Nutr 2005;82(4):784-91.
15. Nguyen ND, et al. Bone loss, weight loss, and weight fluc-
tuation predict mortality risk in elderly men and women. J
Bone Miner Res 2007;22(8):1147-54.
16. St-Arnaud-McKenzie D, et al. Hunger and aversion: drives
that influence food intake of hospitalized geriatric patients.
J Gerontol A Biol Sci Med Sci 2004;59(12):1304-9.
17. Teunissen D, et al. “It can always happen”: the impact of
urinary incontinence on elderly men and women. Scand J
Prim Health Care 2006;24(3):166-73.
18. Dingwall L, McLafferty E. Do nurses promote urinary con-
tinence in hospitalized older people? An exploratory study. J
Clin Nurs 2006;15(10):1276-86.
19. Urinary incontinence among hospitalized persons aged 65
years and older—United States, 1984–1987. MMWR Morb
Mortal Wkly Rep 1991;40(26):433-6.
20. Edlund A, et al. Delirium in older patients admitted to gen-
eral internal medicine. J Geriatr Psychiatry Neurol
2006;19(2):83-90.
21. McNicoll L, et al. Delirium in the intensive care unit: occur-
rence and clinical course in older patients. J Am Geriatr Soc
2003;51(5):591-8.
22. Tinetti ME, et al. Fall-risk evaluation and management:
challenges in adopting geriatric care practices. Gerontologist
2006;46(6):717-25.
23. Stevens JA, et al. The costs of fatal and non-fatal falls
among older adults. Inj Prev 2006;12(5):290-5.
24. Oliver D, et al. Risk factors and risk assessment tools for
falls in hospital in-patients: a systematic review. Age Ageing
2004;33(2):122-30.
25. Fonda D, et al. Sustained reduction in serious fall-related
injuries in older people in hospital. Med J Aust
2006;184(8):379-82.
26. Amlung SR, et al. The 1999 National Pressure Ulcer
Prevalence Survey: a benchmarking approach. Adv Skin
Wound Care 2001;14(6):297-301.
27. Phaneuf C. Screening elders for nutritional deficits. Am J
Nurs 1996;96(3):58-60.
GENERAL PURPOSES: To present registered professional
nurses with information on Fulmer SPICES, a framework
for assessing older adults that focuses on six common
“marker conditions” and provides a snapshot of overall
health and quality of care.
LEARNING OBJECTIVES: After reading this article and taking
the test on the next page, you will be able to
• present an overview of the SPICES framework for assess-
ing older adults.
• review the background information on the need for and
basis of the SPICES framework.
• plan the appropriate interventions for marker conditions
that the framework identifies.
TEST INSTRUCTIONS
To take the test online, go to our secure Web site at www.
nursingcenter.com/CE/ajn.
To use the form provided in this issue,
• record your answers in the test answer section of the CE
enrollment form between pages 56 and 57. Each ques-
tion has only one correct answer. You may make copies
of the form.
• complete the registration information and course evalua-
tion. Mail the completed enrollment form and registration
fee of $19.95 to Lippincott Williams and Wilkins CE
Group, 2710 Yorktowne Blvd., Brick, NJ 08723, by
October 31, 2009. You will receive your certificate in four
to six weeks. For faster service, include a fax number and
we will fax your certificate within two business days of
receiving your enrollment form. You will receive your CE
certificate of earned contact hours and an answer key to
review your results. There is no minimum passing grade.
DISCOUNTS and CUSTOMER SERVICE
• Send two or more tests in any nursing journal published by
Lippincott Williams and Wilkins (LWW) together, and
deduct $0.95 from the price of each test.
• We also offer CE accounts for hospitals and other health
care facilities online at www.nursingcenter.com. Call
(800) 787-8985 for details.
PROVIDER ACCREDITATION
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LWW is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
LWW is also an approved provider of continuing nurs-
ing education by the American Association of Critical-
Care Nurses #00012278 (CERP category A), District of
Columbia, Florida #FBN2454, and Iowa #75. LWW
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is also provider approved by the California Board of
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