COURSE TITLE: GERIATRIC NURSING

Introduction

Gerontology is the scientific study of the process and problems of aging. It deals with the
problems of adaptation, and the diseases of the aging people.

Geriatrics is a branch of medicine concerned with the medical problems and care of the
elderly. It focuses on the diseases and disabilities associated with older people rather than
their age.

Geriatric nursing is concerned with the needs of the older people, planning implementation
and evaluation of nursing interventions to maintain a level of wellness consistent with the
limitations imposed by the aging process. Geriatric nursing involves the care of aging people
and emphasises on the promotion of the highest possible quality of life and wellness.
Gerontology or Geriatric nursing is a specialty of nursing pertaining to older adults. Here,
nurses work in collaboration with older adults, their families and communities to support
healthy aging, maximum functioning and quality of life. It involves the fulfilment of the
special needs and requirements that are unique to senior citizens. This includes assisted
living, adult day care, long term adult care, hospice care and home care. Eldercare
emphasizes the social and personal requirements with daily activities and healthcare.

The specialty draws on knowledge about complex factors that affect health of older adults.
Older adults are more prone to chronic health conditions than younger adults

Aging is a natural process of gains and losses common to all living organisms, although many
people approach and consider aging as though it were an illness. Every living organism
begins aging continuously and constantly from the time of conception.

Various factors influence the aging process that is hereditary, nutrition, health status, life
experiences, environment, activities and stress which provide unique effects in each
individual. People age in different ways and at different rates. With aging there is a gradual
and progressive slowing of behaviour and functioning but not all changes in older adults are
due to aging. Aging presents a gradual increase in vulnerability to disease.

Aging has been viewed differently by different people. Whereas to some it means power,
authority, wisdom and respect, others consider it as a forced retirement leading to a state of
dependency, loss of charm and of physical strength. To most, aging implies physiological and
psychosocial changes that are reflected in their reduced income, lesser activities, and
consequential loss of status, both in the family and in the society.

There are a lot of misconceptions and unfair descriptions of the elderly people such as:

 Being useless

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  Returning to child-like behaviour
 Obtaining little satisfaction from life
 Becoming sick and frail
 Losing one’s mind
 Looking gray and wrinkled.

These are not valid descriptions for the outcomes of aging for most people, thus aging is not
a crippling disease. Therefore, fulfilment of life opportunities, usefulness, and joy are usually
part of aging. A realistic understanding of the aging process can promote a positive attitude
towards aging. Nurses should therefore be concerned with keeping the older adults at
his/her optimal functional level. The goal is wellness regardless of the level of physical,
cognitive or emotional impairment.

Definition of terms

Geriatrics:This is a branch of medicine concerned with medical problems and care of the old.
It focuses on diseases and disabilities associated with older people rather than their age.

Gerontology

It is the scientific study of the process and problems of aging. It deals with the problems of
adaptation and diseases of the aging people.

Geriatric nursing is concerned with assessing the needs of the older people, planning,
implementation and evaluation of nursing interventions to maintain a level of wellness
consistent with the limitations imposed by the aging process.

Gerontological nursing involves the care of aging people and emphasizes the promotion of
highest possible quality of life and wellness.

Age: a stage of development at which the body has arrived, as measured by physical and
laboratory standards, to what is normal for an individual of the same chronological age.

Aging: Aging is the progressive decline in the function and performance, which accompanies
advancing years. It is the process of growing old, resulting in part from the failure of body cells
to function normally or to produce new body cells to replace those that are dead or
malfunctioning. There are bio-medical and philosophical views about aging.

Aging has both subjective and objective dimensions. Objective aging begins at birth.
Chronologically and legally, 65years of age and above is considered as old age. The law
identifies the senior citizens as persons of 65yrs and above and this is the retirement age for
most countries and professions. The older people can be further divided into:

The young old – 65yrs – 74yrs

The middle old – 75yrs – 84yrs

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The old old – 85yrs- infinitive

Subjectively age is related to personal feeling, age in the identity card, cognitive age, social
age, compensative age and perceived age.

TYPES OF AGING

There are four types of Aging:

a) The biological age of an individual can be defined as an estimate of the individual's

present position with respect to his potential life span.
b) Psychological age, by definition, refers to the adaptive capacities of individuals, that
is, how well they can adapt to changing environmental demands in comparison with
the average
c) Functional age is closely related to psychological age. Functional age is an individual's
level of capacities relative to others of his age for functioning in a given human
society.
d) Social age refers to the roles and social habits of an individual with respect to other
members of a society.

Most gerontologists prefer to classify people according to functional age which is related to
physical independence, social and psychological functioning. All older adults of the same
chronological age do not function at the same level

Senility: The general state of reduced mental and physical vigor associated with aging.

Senescence: The state of being old or to grow old.

Ageism: This is a gerontological concept defined as the process of systematic stereotyping

and discrimination against people because they are old. In other words, it is an attitude that
discriminates, separates, stigmatizes, or otherwise disavantages older adults on the basis of
chronological age. However, while some cultures view aging as a thing to look forward to
because wisdom comes with age, others view it as a time of uselessness and less respect.

As individuals grow older changes are witnessed in the physical, cognitive and social realms.

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Health modification associated with aging

Affected organ or Physiologic change Clinical manifestation

system
Body composition - Decreased lean body mass, - Changes in drug
- Decreased creatinin production levels,
- Decreased muscular mass - Decreased
- Decreased skeletal mass strength,
- Decreased total body water - Tendency towards
- Increased adipose tissue until age dehydration
60, then it starts dropping until
death.
cells - Increased DNA damage and - Increased cancer
decrease DNA repair capacity. risk
- Accelerated cell senescence.
- Increased fibrosis

CNS/PNS - Decreased nervous system - Tendency towards

stimulation parkinsonian
- Increased parasympathetic activity symptoms(e.g
- Decreased signal transduction increased muscle
tone and
decreased arm
swing)
- Exaggerated
response to
anticholinergic
drugs
Ears - Loss of high frequency of hearing - Decreased ability
to recognise
speech
Endocrine System - decreased estrogen and - Increased
progesterone secretion incidence of
(Menopause) diabetes
- Decreased - Decreased muscle
testosterone(Andropaus) mass
- Decreased growth hormone - Decreased bone
secretion mass
- Decreased vit D absorption and - Increased fracture
activation risk
- Increased incidence of thyroid - Vaginal dryness,
abnormalities dyspareumia
- Increased insulin resistance and - Changes in skin
glucose intolerance - Tendency towards
- Increased bone mineral loss water intoxication
- Increased secretion of ADH in
response to osmolar stimuli

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Eyes - Decreased lens flexibility - Presbyopia
- Increased time for papillary - Increased glare and
reflexes difficulty adjusting
- Increased incidence of cataracts to changes in
lighting
- Decreased visual
acuity
GIT - Decreased blood flow to the GIT - Tendency towards
- Decreased transit time constipation and
diarhea
Heart - Decreased heart rate - Tendency towards
- less increase in heart rate in syncope
response to decrease in BP - Decreased ejection
- Decreased diastolic relaxation fraction
- Increased atrioventricular - Decreased rates of
conduction time atrial fibrillation
- Increased atrial and ventricular - Decreased rates of
displacement diastolic
dysfunction and
diastolic heart
failure
Immune System - Decreased T-cell function - Prone to some
- Decreased B=cell function infections.
- Decreased
antibody responses
to immunization or
infection but
increased
autoimmunity.
joints - Degeneration of cartilaginous - Tightening of joints
tissues - Tendency towards
- Fibrosis osteoarthritis
- Decreased glycosylation and cross- - Loss of tissue
linking elasticity
Kidneys - Decreased renal blood flow - Changes in drugs
- Decreased renal mass levels with high risk
- Decreased glomerular filtration of adverse drug
- Decreased renal tubular secretion effects
and reabsorption - Tendency toward
- Decreased ability to excrete a free dehydration
water load
Liver - Decreased hepatic mass - Changes in drug
- Decreased hepatic blood flow levels
- Decreased activity of P-
450enzyme system
nose - Decreased smell - Decreased taste
and consequent
decreased appetite
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 - Increased
likelihood of
nosebleeds

Pulmonary - Decreased vital capacity - Increased likelihood

system - Decreased lung elasticity of shortness of breath
- Increased residual volume during vigorous
- decreased Forced expiratory volume exercise if people are
in 1 second. normally sedentary or
- Increased V/Q if exercise is done at
(ventilation/perfusion)mismatch high altitudes
- Increased risks of
death due to
pneumonia
- Increased risk of
serious complications
for patients with a
pulmonary disorder
vasculatur - Decreased endothelin - Tendency towards
e dependent vasodilation hypertension
- Increased peripheral
resistance

Theories of Aging
Throughout history people have been disturbed by the mystery of aging and there have
been several searches for the function of youth and a possible key to immortality. Individuals
have tried and continue to try out practices designed to prolong life like injections of
embryonic tissue or repeated transfusion with teenage blood. Today the use of nutritional
supplements and cosmetic creams to maintain youth and delay onset of old age are
widespread, and are even a very lucrative form of business.

Despite all these attempts aging still occurs because no single factor has been identified to
cause or prevent aging. Theories have been advanced to explain the complexities of the
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aging process. The primary aim of most of these theories is to provide a better
understanding of the aging process, so that people age in a healthier fashion and postpone
some of the negative consequences of growing old.

Priority has shifted from life extension to postponement of the onset of chronic disease with
the purpose of keeping people healthy and active for a longer period rather than keeping
them alive for a longer period of time.

Aging theories offer varying degrees of universality, validity and reliability which nurses can
use to better understand factors that may positively and negatively influence the health and
wellbeing of persons of all ages.

Biological Theories

The process of biological aging differs from species to species as well as for individuals. We
can predict general organ changes that occur as a result of aging but no two individual’s age
identically. Varying degrees of physiological changes, capacities and limitations are found
within the same age group.

Also, the rate of aging is not the same for the various body systems. An individual may show
a marked decline in one system while another system demonstrates no significant change.
To explain biological aging, theorists have explored many factors both internal and external
to the human body.

1) Genetic Factors(program theory)

Here, it is believed that people inherit a genetic program that determines their specific life
expectancy. This program theory claims that animals including humans are born with a
genetic program or biological clock that determines lifespan. This theory has been supported
by a positive relationship between parental age and filial lifespan. According to them,
senescence is under genetic control and occurs at the cellular level.

Genetic mutations are thought to be responsible for aging by causing organ decline in the
function of tissues, organs and systems.

Some theorists think that a growth substance fails to be produced resulting in the cessation
of cell growth and reproduction.

2) Cross-linking agents

This theory proposes that cellular divisions are threatened as a result of a chemical reaction
in which a cross linking agent attaches itself to a DNA strand and prevents the normal
parting of strands during mitosis/meiosis.

These cross-linking agents subsequently accumulate forming aggregates that impede cellular
transport and ultimately the body’s organs and systems fail. This is thought to be the cause
of decreased collagen elasticity associated with aging.
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The Cross-Linking Theory of Aging is also referred to as the Glycosylation Theory of Aging. In
this theory it is the binding of glucose (simple sugars) to protein, (a process that occurs
under the presence of oxygen) that causes various problems. Once this binding has occurred
the protein becomes impaired and is unable to perform as efficiently. Living a longer life is
going to lead to the increased possibility of oxygen meeting glucose and protein and known
cross-linking disorders include senile cataract and the appearance of tough, leathery and
yellow skin.

Diabetes is often viewed as a form of accelerated aging and the age related imbalance of
insulin and glucose tolerance leads to numerous problems; these have been called
Syndrome X. In fact, diabetics have 2-3 times the numbers of cross-linked proteins when
compared to their healthy counterparts. The cross-linking of proteins may also be
responsible for cardiac enlargement and the hardening of collagen, which may then lead to
the increased susceptibility of a cardiac arrest. Cross linked proteins have also been
implicated in renal disorders.

It is also theorized that sugars binding to DNA may cause damage that leads to malformed
cells and thus cancer.

One obvious example to reduce the risk of cross-linking is to reduce sugar (and also simple
carbohydrates) in one’s diet. Some pharmacological interventions that could help reduce the
carbohydrate/ starch/ glucose intake and affect, include Acarbose and Metformin.

3) Free Radicals

Free radicals are highly reactive molecules containing extra electrical energy and are
generated from oxygen metabolism. They can result from normal metabolism, reactions
with other free radicals or oxidation of ozone, pesticides and other pollutants. These
molecules damage proteins, enzymes and DNA thereby replacing molecules that contain
useful biological information with faulty molecules that create genetic disorder. These free
radicals are selfperpetuating and so generate other free radicals.

Physical damage of the body occurs as the damage of these molecules accumulates over
time. However, the body has natural antioxidants that can counter the effects of the free
radicals such as Vit C, E and B-carotene.

4) Autoimmune Reactions

The thymus and the bone marrow which are the primary organs of the immune system are
believed to be affected by the aging process. There is a corresponding decline in the T-cells
as well as the humoral immune response. This is evident in the incidence of infections and
cancers with age.

Because of this reduction in the immune activities, some theorists believe that there is an
increase in the autoimmune response with age. The body misidentifies aged, irregular cells

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as foreign agents and attacks them. Others think that the cells may remain normal but the
decline in the immunochemical system leads to a malfunction and misidentification of the
cells. Antibodies are formed to get rid of the misidentified cells from the body thus killing
them.

5) Wear and Tear

These theories attribute aging to wear and tear on the body over time as it performs its
highly specialized functions.

6) Stress

The effects of stress on physical and psychological health have been widely demonstrated.
Stress can lead to many adverse effects and lead to condition like gastric ulcers, heart
attacks, etc.

However this theory is limited in its universality because individuals react differently to life’s
stresses.

7) Disease

Bacteria, fungi, viruses and other micro organisms are thought to be responsible for certain
changes during the aging process. In some cases pathogens may be present in the body for
long periods before beginning to affect the body systems.

8) Nutrients

It is believed that what we eat significantly influence how we age. Obesity and overweight
shorten life. The quality of the diet as well as the quantity, are important because nutrient
deficiency or excess may cause disease.

Recently, nutritional supplements like ( Vit E, bee pollen, ginseng, morringa etc are believed
to promote healthy aging.

Some theories suggest that some contributions to aging include; radiation and environment.

Other theories include the membrane theory which suggests that as we grow older the cell
membrane becomes less lipid (less watery and more solid). This impedes its efficiency to
conduct normal function and in particular there is a toxic accumulation.

The Hayflick Limit Theory: suggests that the human cell is limited in the number of times it
can divide. Part of this theory may be affected by cell waste accumulation as explained in the
membrane theory. It is also thought that nutrition has an effect on cells, with overfed cells

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dividing much faster than underfed cells. Thus, calorie restriction in animals significantly
increases their life span. In essence less fed animals live longer.

The Hayflick Limit indicates the need to slow down the rate of cell division if we want to live
long lives. Cell division can be slowed down by diet and lifestyle etc.

The Mitochondrial Decline Theory

The mitochondria are the power producing organelles found in every cell of every organ.
Their primary job is to create Adenosine Triphosphate (ATP) and they do so in the various
energy cycles that involve nutrients. ATP is literally the life-giving chemical because every
movement, thought and action we make is generated from it. Yet very little ATP can be
stored in the body. Thus it becomes apparent that the mitochondria have to be very efficient
and healthy, in order to produce a continuous supply of essential ATP for the necessary
repair and regenerative process to occur.

Under normal conditions the mitochondria are fiery furnaces and subject themselves to a lot
of free radical damage. They also lack most of the defenses found in other parts of the body,
so as we age the mitochondria become less efficient, fewer in number and larger. If a
particular organ’s mitochondria fail, then so does that organ (which of course can lead to
death).

Psychosocial Theories

These theories of aging explore the mental processes, behaviour and feelings of persons
throughout the lifespan. They also consider the mechanisms people use to meet the
challenges they face in old age while addressing the impact of society and the elderly on
each other.

1) Disengagement Theory: This theory views aging as a process in which society and the
individual gradually withdraw or disengage from each other, to the mutual
satisfaction and benefit of both. The benefit here is that they can reflect and be
centred on themselves having been freed from societal roles. To the society, it
establishes an orderly means for transferring power from the old to the young,
making it possible for society to continue functioning after these people die.

This is rather controversial theory because many older persons desire to remain engaged
and do not want their primary satisfaction to be derived from reflection what they have
achieved so far. E.g some politicians, university professors and senior volunteers who
provide a valuable service to society may not want to disengage.

2) Activity Theory: This theory proclaims that an older person should continue a
middle-aged lifestyle, denying the existence of old age as long as possible, and that
society should apply the same norms to the old age as it does to middle age and
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 avoid reducing interest, activity and involvement as its members grow old. This
theory suggests ways of maintaining activity in the presence of multiple loses
associated with the aging process like substituting intellectual activities for physical
activities when physical power declines, replacing work roles with other roles with
other roles when retirement occurs, establishing new friendships when old ones are
lost. Declining health, loss of roles and reduced income are to be resisted and
overcome instead of being accepted.

The merit of this theory is seen in the fact that activity is generally accepted to be more
desirable in maintaining physical, mental and social wellbeing. Encouraging an active life
style among the aged is consistent with this theory and societal values. A supportive
phenomenon to this theory is the reluctance of many older persons to accept themselves as
old.

A problem with this theory is the assumption that all elderly people would desire and be
able to maintain an active lifestyle. This is not the case for all old persons. Some prefer their
world to shrink in line with their decreasing capacities and resources.

3) Continuity Theory: This theory is also referred to as the developmental theory, and
relates personality and disposition towards certain actions in old age to similar
factors during other phases of the life cycle. Personality and basic patterns of
behaviour are said to remain unchanged as the individual ages. People who are
active at 20yrs will most likely be active at 70yrs and the inactive ones will probably
not be active in society when they age. According to this theory, the unique features
of each individual allow for multiple adaptations to aging and possible a variety of
reactions. Aging is a complex process and this theory considers that the current
activities of the young are laying and foundation for their old age.

Developmental Tasks

Some theorists have described the process of healthy psychosocial aging as the result the
successful fulfilment of developmental tasks. Developmental tasks are the challenges that
must be met and adjustments that must be made in response to life experiences which are
part of an adults continued growth through the life span.

Erik Erikson(1963) described eight stages through which human beings progress from infancy
to old age and the challenges that confront individuals during each stage. The challenge of
old age is to accept and find meaning in the life the person has lived which gives the
individual ego integrity that aids in adjusting and coping with the reality of aging and
mortality. Feelings of not having lived a satisfactory life, anger, bitterness and inadequacy
can lead to inadequate ego integrity or despair.

Robert Peck (1968) refined Erikson’s description of old age and detailed three specific
challenges facing the elderly that influence the outcome of ego integrity or despair. These
include;
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 - Developing satisfaction from oneself as a person rather than through parental or
occupational roles.

- Finding psychological pleasure rather than becoming absorbed with health problems
or physical limitations imposed by aging.

- Achieving satisfaction through reflection on one’s post life and accomplishments

rather than being preoccupied with the number of year’s life to live.

Robert Butler and Myrna Levis outlined major tasks of later life as;

- Adjusting to one’s infirmities

- Developing a sense of satisfaction with life that has been lived

- Preparing for death

At the general level, we can identify that old people go through challenges which may
increase the problems associated with aging or may facilitate their adaptation to the aging
process. Some of these tasks include;

- Adjusting to retirement

- Accepting help from others as dependency increases

- Learning new affectionate roles with one’s children who are now mature adults

- Establishing ongoing satisfying affectionate roles with grandchildren and other

members of the family

- Being a good companion to an aging spouse

- Facing the loss of one’s spouse

- Finding and preserving mutually satisfying friendships outside the family circle

- Choosing and maintaining social activities and functions appropriate to health,

energy and interests

- Maintaining a sense of moral integrity in the face of disappointments in life’s hopes

and dreams

- Making good adjustments to failing powers as aging diminishes strengths and

abilities.

- Adopting interests and activities to reserves of vitality and energy of the aging body

- Mastering new methods of dealing with the physical environment as a person with
occasional or permanent disabilities

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 - Preparing for inevitable end of life that allows one to live and die in peace

Conclusively, aging is caused by several different mechanisms and results from a complex
interplay between environmental and genetic factors.

Healthcare Implication of Aging Theories

Healthcare providers play a significant role in helping aging persons experience in health,
fulfilment and a sense of wellbeing. Health care providers must be aware of the tremendous
impact their own attitudes towards aging can have on patients.

Health care providers who consider aging as a progressive decline ending in death may view
age as a depressing, useless period and worsen hopelessness and helplessness in older
patients. On the other hand, people who consider aging as a process of continuous
development may appreciate old age as an opportunity to gain new satisfaction and
understanding, and so strive to promote joy and a sense of purpose in patients.

The biological, psychological and social processes of aging are interrelated and
interdependent. Loss of a social role affects an individual’s sense of purpose and often
speeds physical decline. Poor health may precipitate retirement from work, promote social
isolation and development of a weakened self concept. So, healthcare providers need to be
open minded in choosing aging theories to use in the care of older adults and should not
always take into account the limitations of these theories.

Autonomy, Dependence and disability ( definitions)

Autonomy refers to quality of having the ability or tendency to function independently.

When a person is not competent the decision may be made by a surrogate. This is known as
‘substituted’ judgement.

The right to self-determination covers all decisions about one’s care and treatment,
including the removal of life support treatment measures as well as hormone replacement
therapy.

As people age, there is progressive disability influenced by advancing age, comorbid

conditions and frailty. It is important for the health care providers to understand the normal
physiologic effects of aging and their effects on rehabilitation. E.g Older adults with
parkinson’s disease experience postural problems and contracture of the hips and shoulders
and some may experience depression. Essential elements of rehabilitation are stretching,
coordination, and gait training.

Functionally, an old person who presents with neurological disorders like dementia, require
close follow up and are more dependent on the nurse and the caregivers.

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Nutritional problems of the Elderly
Older persons are particularly vulnerable to malnutrition. Since the lean body mass and the
basal metabolic rate decline with age, an older person’s energy requirement per kilogram of
body weight is also reduced, thus nutritional requirements are not well defined.

Aging affects other nutrient needs that is some increase while some reduce. Therefore there
is a great need to review current recommended daily nutrient allowances for this group with
the help of WHO guidelines.

Malnutrition: many diseases suffered by older persons are the result of dietary factors
some which have been there since infancy. Degenerative diseases such as cardiovascular and
cerebrovascular disease, diabetes, osteoporosis and cancer, which are among the most
common diseases affecting older people, are all diet-affected. Micronutrient deficiencies are
often common in elderly people.

Dehydration: Age-related changes include a reduced sensation to thirst, and this may be
more pronounced in those with Alzeimer’s disease or in those that have suffered a stroke

Factors affecting the nutritional input of the elderly

 Inadequate fluid and food intake and lack of variety in foods they eat.
 the price of foods rich in micronutrients
 Loss of cognitive function and deteriorating vision also hinder good health and
dietary habits in old age.
 Reduced renal function
 Changes in functional ability
Common Risks factors for dehydration
 Older age
 Residing in a long-term care
 Requiring assistance with foods
 Incontinence
 Cognitive impairment/confusion
 Impaired functional status and assistance required for feeding
 Inadequate numbers of trained staff to assist
 Depression
 Multiple medications particularly diuretics
 Acute illness, diarrhoea and vomiting

Generally, a reduction in saturated fat and salt intake could reduce blood cholesterol
concentrations thus reducing the burden of cardiovascular disease and increasing the intake
of fruits and vegetables by one to two servings daily could cut cardiovascular risk by 30%.
(WHO, 2016) .

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Encourage older adults to drink water, milk or juice with meal, and keep favourite beverages
nearby.

Signs of dehydration: fatigue, dizziness, thirst, dark urine, headache, dry mouth/nose,
dry skin and cramping.

Gait Disturbances
Gait disturbances are a major cause of mobility problems among the elderly. Stiff and
inactive joints, muscle cramps, reduced range of motion are challenges that must be
confronted by the elderly. Activity and mobility are vital to the total health of the elderly.
The causes of gait disturbances are many and may include; musculoskeletal disorders, N.S
disorders, anxiety etc. Gait disturbances are a major cause of falls among the elderly. It may
result in injury, disability, decreased mobility and decreased confidence in abilities.

common gait disturbances;

1) Ataxic gait: An unsteady, uncoordinated and staggering gait often associated with
sway. It is associated with neurogenic disorders and intoxicated. Feet are raised high
while stepping and then dropped flat on the floor.
2) Foot Stepping (Steppage gait): There is increased hip and knee flexion in order to
clear the foot from the floor. Footdrop is evident. Feet are raised high while stepping
and then slapped down against the floor ( toe first then heel unlike in normal gait
where the heel usually strikes the floor before the toes. It is associated with
neurogenic disease, paralysis of dorsoflexor muscles and peroneal nerve damage.
3) Hemiplegic gait (spastic paralysis): Unilateral foot drop and foot dragging, There are
short steps and cross-knee (scissor) movement. The leg is circumducted and the arm
flexed and held close to the side. It is associated with unilateral upper motor neuron
disease (hemiplegia) cerebral palsy.
4) Parkinsonian gait (Festinating gait): While walking, the neck, trunk and knees flex and
the body is rigid. There is delayed start with short, quick shuffling steps. The speed
may increase as if the patient is unable to stop. It is typical of parkison’s disease.
5) Scissor gait: Slow, short steps. Stiff gait with legs crossing while stepping.
6) Gait of Old age: Diminished speed, balance with short uncertain steps with possible
hip and knee flexion.

Bladder Elimination

Age related changes in the urinary tract may cause various elimination problems. Frequency
is one of the most annoying and results from decreased ability of the bladder to expand that
reduces capacity. The effects of this frequency are worse on the patient at night given that
the elderly may also have problems with vision. This predisposes them to accidents and
threaten their safety.

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Inefficient neurologic control of bladder emptying and weaker bladder muscles may promote
the retention of large volumes of urine. Retention can predispose older persons to the
development of UTI. Symptoms of urine retention include:

- Urinary frequency
- Straining
- Dribbling
- Palpable bladder
- Feelings that the bladder has not been emptied

When individuals who are unable to ambulate independently are placed on wheelchairs,
unnecessary incontinence may result if toileting assistances is not provident. Ambulation
trips and activities should be planned to allow bathroom breaks at frequent intervals. Night
lights should be used to improve visibility during night trips to the bathroom. Environmental
hazards that could cause falls should be removed. Reduction of fluids immediately before
bedtime may help (but fluids should not be significantly reduced). If multiple episodes of
nocturia occur, medical evaluation may be done to ensure that no urinary tract problem is
present.

Interventions to Prevent/reduce urine retention and promote voiding include;

- Good fluid intake

- Voiding in upright position
- Massaging the bladder
- Rocking back and forth
- Running water
- Soaking hands in warm water

Urinary incontinence; the inability to control elimination of urine is not a normal occurrence
with advanced age although age-related changes increase the risk of this problem.
Incontinence reflects a physical or mental disorder and demands thorough evaluation. Some
stress incontinence may be present in women who have had multiple pregnancies or in
person who postpone voiding after they sense the urge. About 30% of the elderly in the
community and 30% of hospitalized adults have urinary incontinence. The problem is twice
as prevalent in women as compared to men. The following are the various types of
incontinence;

1) Stress incontinence caused by weak supporting pelvic muscles. When pressure is

placed on the pelvic floor as occur in laughing, sneezing, coughing or involuntary lost.
2) Overflow incontinence: Is associated with bladder neck obstructions and
medications. Bladder muscles fail to contract or the periurethral muscles fail to
release leading to an excessive accumulation of urine in the bladder.

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3) Functional incontinence caused by dermentia, disabilities that prevents independent
toileting, inaccessibility to the bathroom. Medications that impair cognition or any
other factors that interfere the ability to reach the bathroom.
4) Urgency/urge incontinence caused by UTIs, enlargement of the prostate or bladder
wall humours. Irritation or spasms of the bladder wall cause sudden elimination of
urine.
5) Neurogenic incontinence arising from lesions in the cerebral cortex or disturbances
along the natural path way. There is an inability to sense the urge to void or control
urine.
Care of patients with incontinence
- Ensure a comprehensive evaluation to identify the cause.
- Identify individual voiding patterns that is frequency, sensation of signal to void, time
between the signals is inability to hold urine, the amount of urine in each voiding.
- If potential for bladder control exist, initiate bladder retraining program.
- Monitor intake and output
- Ensure that the bathroom is easily accessible or provide bedside commode or bedpan
- Offer at least 1.5l of liquids daily unless contraindicated
- Encourage patient to lean forward while voiding
- Instruct female patient on kegel exercises
- Provide urinary sheaths e.g catheters, diapers etc
- Modify the environment to accommodate incontinence by protecting mattress
- Provide good ventilation
- Discuss cause of incontinence with the patient
- Check patient for wetness and change clothing prn
- Thoroughly clean and dry the patient’s skin
- Ensure privacy
- Assist patient in dressing
- Ensure that the patient’s dignity is not tampered with.

Factors Contributing to a long and healthy life

1) Diet: A positive health state that can contribute to longevity is supported by reducing
saturated fats in diet, limiting daily fat consumption to less than 30% of calorie
intake, avoiding obesity, decreasing the amount of animal food eaten, substituting
natural complex sugars for refined sugars, and increasing the consumption of whole
grains, vegetables and fruits.
2) Activity: Exercise is an important ingredient to good health. It does the following;
o Increases strength and endurance
o Promotes cardiopulmonary function
o Effects of activity can promote a healthy aging process
3) Play and Laughter: Laughter causes a release of substances (endorphins) that reduce
the perception of pain. It also

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 - Stimulates the immune system and
- Reduces stress

Finding humour in daily routines and experiencing joy despite problems contributes to
good health.

4) Faith: A strong faith, church attendance and prayer are directly related to lower rates
of physical and mental illness. Religion and spirituality can have a positive effect on
the length and quality of life.
5) Empowerment: A loss of control over one’s life and circumstances can impair
physical and mental health and diminished self-care independence. Maximum
control and decision making can have a positive effect on morbidity and mortality.
6) Stress Management: Stress has many negative consequences. The unique stresses
that accompany aging such as onset of chronic conditions, retirement, death of
spouse etc can have significant detrimental effects. Minimising stress and using
effective stress management techniques can have positive effects on aging.

Limitations in treating conditions in the Elderly

 Medical co-morbidities
 Less efficacy of certain medications
 Limited dosing flexibility
 Prolonged illness
 Non-compliance which can be;
o Unintentional as a result of confusion, forgetfulness which is common among
the elderly
o Intentional in order to minimise adverse effects or save money.

Minimising adverse effects of drugs among the elderly

 Whenever possible, use non-pharmacological treatments
 Lowest feasible dose (often less than half usual adult dose)
 Smallest number of medications/simplest dose regimens
 Be familiar drug effects in elderly
 Simple verbal/written instructions for every medication
 Presenting symptoms may be a result of medications (not old age)
 Regular review chronic -may be possible to stop medications or reduce dose if renal
function declines
 Make sure the carer understands treatment

Complex needs of older people

Older people reaching the end of life frequently have multiple debilitating diseases (such as
dementia, osteoporosis and arthritis). As such, palliative care should be integrated into
chronic disease management. This is a skill integral to geriatric medicine, other areas of care
for older people and palliative care.

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The wide range of health needs of older people often requires joint working between many
sectors, such as specialists in care for older people and palliative, primary and social care.
Both palliative care and care for older people have been relatively neglected in the past and
now need to grow and be linked better.
Important aspects include:
 the need for palliative and primary care clinicians to receive training in the health of
older people and to know about syndromes affecting older people that are not
typically included in palliative care, such as urinary incontinence and falls;
 better knowledge about the age-related changes of the pharmacokinetics of opiates
for pain management and the polypharmacy (more drugs are prescribed than
clinically indicated or there are too many to take) associated with comorbidity ;
 a holistic approach by health professionals to explore any problems that may reduce
people’s quality of life, not just those directly related to the life-limiting disease;
 the need for palliative physicians to improve their familiarity with long-term care,
such as the administrative and clinical issues associated with older people living and
dying in care homes.
 training of health care professionals in community settings so that people can be
cared for in their place of choice and so that discharge from hospital to home is well
managed;
 joint working and new models of integrated care between specialists in palliative
care and specialists in care for older people, including training in palliative care for
such specialists and training for palliative care within geriatrics.

Menopause
 Permanent cessation of reproductive and hormonal cycles (menses)
 Transition into menopause is initiated by
– changes in the ovary
– changes in the brain
 Transition is characterized by large and irregular hormonal swings
Depletion of follicles initiates menopause
Progression to menopause
 Total number of ova in the ovary declines
 Number of ova per cycle declines
 Increased abnormalities in eggs
 Disruption in hormonal environment
 Fertilization abnormalities
– delayed fertlization
– chromosomal abnormalities
 Brain control of reproductive cycles becomes irregular
 Brain structures responsible for cyclicity are estradiol dependent and become less
responsive
 Prolonged exposure to estrogens (like cortisol) may be neurotoxic
 Neurotransmitter changes
 At menopause hormonal cycles become irregular
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 Environmental influences on the onset of menopause
• Nutrition
• Parity
• Smoking
• Contraception
Hormonal changes in menopause
• Plasma estradiol declines (620 to 40 pM/L)
• Extraovarian tissues convert androgens to estrone by aromatization
• Sex-hormone binding globulin declines
• Failure of ovarian progesterone production
• Ovary and adrenal synthesize androgens
– testosterone
– androstenedione
– dehydroepiandrosterone(DHEA)(S) declines with age
Consequences of hormonal changes in menopause
 Reproductive organ atrophy
- Oviducts
- uterus and cervix
- vagina and vulva
- mammary glands
 Loss of vaginal epithelial glycogen
– reduced lactobacilli populations
– rise in vaginal pH
– increase in UTIs
– antibiotics increase yeast infestation and vaginitis
 Urinary (and GI) tract changes
– stress and urge incontinence due to loss of contractile tissue
– reduced autonomic sphincter control
 Circulatory (autonomic) instability
– hot flashes (flushes)
– tachycardia (palpitations)
– anxiety
– sweating
– paresthesia (“creepy” sensations)
 CNS changes
– headaches
– insomnia
– depression
– irritability
– mood swings

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 Skin changes
– thinning due to reduced collagen production
– water loss
– loss of elasticity
– wrinkling
 Masculinization
– hirsutism
– voice changes
 Metabolic changes
– abdominal fat distribution
– insulin resistance
– hypertension
– autoimmune disease
 Cardiovascular health
– Increased plasma lipids: LDL, HDL,TG
– Increased risk for atherosclerosis
– Increased risk of CHD
Andropause
 Is andropause analogous to menopause?
 Transition is gradual
 Functional impairments are gradual
Aging-associated changes in male reproductive system
 Reduced pituitary response to GNRH
 Decreased secretion of androgens
 Increased opioid action
 Reduced androgen receptor sensitivity
 Reduced DHEAS release
 Insulin resistance
 Decreased TSH secretion
 Decreased GH-IGF-I secretion
 Reduced spermatogenesis due to fewer Sertoli cells
 Reduced libido
 Reduced erectile function
– spontaneous
– stimulated

Consequences of aging-associated changes in male reproductive hormones

 Reduced spatial cognition
– spatial attention
– visual perception

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 – object identification
– visual memory
 Changes in mood
– depression
– agitation
 Musculo-skeletal changes
– increased bone resorption
– decreased bone formation
– osteoporosis
– osteoarthritis
– loss of some types of muscle fibers
– loss of muscle strength
Hormone replacement treatment of menopause and andropause
 Rationale for treatment
– relief of symptoms
– prevention and treatment of osteoporosis
– reduction of risk of CHD morbidity and mortality
 Estrogens
– esters or conjugated
– pills,creams, or patches
– effectiveness ( BMD,cognitive)
– uterine cancer problem
 Estrogens opposed by progesterone
 Estrogen-testosterone combination
 Side effects of Testosterone therapy
– prostate cancer
– hair loss
– gynecomastia
– skeletal BMD

Special needs for Women

Older women are susceptible to heart diseases, cancer and osteoporosis among the
nutritional-related conditions of aging. Decrease oestrogen levels after menopause reduces
women’s protection from heart diseases. A reduction in fat intake to 30% can be beneficial
in reducing risks of heart diseases in older women as well as risk for breast cancers. Reducing
alcohol consumption also reduces risks for breast cancers.

Nearly all women are affected by some degree of osteoporosis at the age of 70. The loss of
bone is increased by decrease oestrogen levels, obesity, inactivity, smoking and excessive
consumption of caffeine and alcohol.

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The risk of fractures from brittle bones is high and so there is need to prevent bone loss. An
oestrogen replacement therapy or a daily intake of at least 1000mg of calcium can help to
prevent risk for osteoporosis.

Objectives of the National Health Strategy concerning the elderly

The WHO primary aim of the Health of Older People Strategy is to develop an integrated
approach to health and disability support services that is responsive to older peoples’ varied
and changing needs. This approach, the integrated continuum of care, means that an older
person is able to access needed services at the right time, in the right place and from the
right provider.

The strategy has been developed in response to three key drivers for change:

 concerns about the lack of strategic policy development and planning for health and
disability support services for older people;

 the desire to implement the WHO Positive Aging strategy within the health sector;

 and the rapid increase in the number, and ethnic diversity, of people over 65 years of
age.

Some older people are frail and vulnerable and require high levels of care and disability
support. The strategy covers the full range of services available to older people to keep well
and to continue to live safely in the community. This includes health promotion,

treatment for acute episodes of ill health, rehabilitation to support recovery, ongoing
support for people who are disabled and palliative care. The focus is on older people as
participants in decision making at the individual and community level, and at the broader
policy, planning and service development levels.

Who the strategy is for the Elderly

This strategy focuses on people aged 65 and over. The integrated approach to service
provision that it sets out will particularly benefit those older people who have high and
complex needs that cross service boundaries.

Cameroon participated in the interregional conference in Bangkok (Thailand)

from 28 November to 1 December 2006(Min of Justice Report on Human Rights-Republic of
Cameroon, 2006). The objective of the conference was to build the capacity of Member
States towards the implementation of Plan of Action on the Elderly. Cameroon Government
was granted support by the UN to draw up a national programme on the elderly.

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Although progress has been made in the protection of the rights of the elderly, the following
difficulties still hinder the success of the initiative:

 the majority of the elderly in Cameroon live in rural areas which are often
inaccessible;

 more than 2/3 of the elderly in Cameroon benefit neither from social security
nor retirement benefits;

 financial means to fund social security reforms for the elderly are limited;

 few or no experts are available in this domain;

 few institutions exist to cater for the elderly and the handicapped; and

 the elderly are attached more to traditional rites than to modern health facilities.

The following eight objectives identify areas where change is essential if the vision is to be
achieved.

1. Older people, their families should be able to make well-informed choices about
options for healthy living, health care and/or disability support needs.

2. Policy and service planning will support quality health and disability support
programmes integrated around the needs of older people.

3. Funding and service delivery will promote timely access to quality integrated health
and disability support services for older people, family and carers.

4. The health and disability support needs of older people will be met by appropriate,
integrated health care and disability support services.

5. Population-based health initiatives and programmes will promote health and

wellbeing in older age.

6. Older people will have timely access to primary and community health services in
order to help improve and maintain their health and functioning.

7. Admission to general hospital services will be integrated with any community-based

care and support that an older person requires.

8. Older people with high and complex health and disability support needs will have
access to flexible, timely and co-ordinated services and living options that take
account of family and their carer needs.

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