Gerontological Nursing (9th Ed) - Eliopoulos (Wolters Kluwer)

Gerontological
Nursing
Ninth Edition
2
Gerontological
Nursing
Ninth Edition
Charlotte Eliopoulos, PhD, MPH, RN

Specialist in Holistic Gerontological Care
Acquisitions Editor: Natasha McIntyre

Director of Product Development: Jennifer K. Forestieri
Development Editor: Meredith L. Brittain
Editorial Assistant: Leo Gray
Production Project Manager: Priscilla Crater
Design Coordinator: Elaine Kasmer
Illustration Coordinator: Jennifer Clements
Manufacturing Coordinator: Karin Duffield
Production Services/Compositor: SPi Global
9th Edition
Copyright © 2018 Wolters Kluwer
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by
any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and
retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and
reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees
are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce
Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com
(products and services).
Nursing diagnoses in this title are reprinted with permission from: Herdman, T.H. & Kamisuru, S. (Eds.) Nursing Diagnoses —
Definitions and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John
Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses
refer to the definitions and defining characteristics of the diagnoses listed in this work.
987654321
Printed in China
Cataloging in Publication data available on request from publisher

ISBN 9780060000387
This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties
as to accuracy, comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and
consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data
and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a
reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical
judgments and for any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information, independent professional verification of medical
diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and
healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised
to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other
things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly
if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent
permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property,
as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.
LWW.com
4
Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and U.S. Virgin Islands.
atasha McIntyre
Acquisitions Editor: N
Director of Product Development: Jennifer K. Forestieri
Development Editor: Meredith L. Brittain
Editorial Assistant: Leo Gray
Production Project Manager: Priscilla Crater
Design Coordinator: Elaine Kasmer
Illustration Coordinator: Jennifer Clements
Manufacturing Coordinator: Karin Duffield
Production Services/Compositor: SPi Global
9th Edition
Copyright © 2018 Wolters Kluwer
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by
any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and
retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and
reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees
are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce
Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com
(products and services).
Nursing diagnoses in this title are reprinted with permission from: Herdman, T.H. & Kamisuru, S. (Eds.) Nursing Diagnoses —
Definitions and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John
Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses
refer to the definitions and defining characteristics of the diagnoses listed in this work.
987654321
Printed in China
Cataloging in Publication data available on request from publisher

ISBN 9781496377258
This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties
as to accuracy, comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and
consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data
and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a
reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical
judgments and for any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information, independent professional verification of medical
diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and
healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised
to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other
things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly
if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent
permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property,
as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.
LWW.com
5
6
This book is dedicated to my husband, George Considine, for his unending patience, support, and
encouragement.
7
Preface
Whether they are aware of it or not, most nurses today are doing some form of gerontological
nursing. Hospitals are caring for increasing numbers of older adults whose age-related changes,
multiple diagnoses, and psychosocial complexities present many challenges. Settings that provide
long-term care are expanding beyond the nursing home. More older adults are remaining in the
community and presenting new demands for nursing services to be provided in innovative ways.
Growing numbers of older individuals are heading multigenerational households and caring for
younger family members, which brings them into contact with nurses in specialties beyond geriatrics.
Not only do older individuals have a greater presence in various specialties but they also are
presenting new challenges. They are better informed about their health conditions and expect to
have explanations for treatment decisions. Many are using complementary and alternative therapies
and desire approaches that integrate those therapies into conventional care. They not only want
their diseases managed but they also want to enhance their function so they can enjoy an active,
meaningful life. They may make choices that forfeit treatments that can extend the quantity of life for
those that offer the freedom to enjoy a high quality of life for whatever time remains. Such
challenges demand that nurses not only be knowledgeable about aging and geriatric care but also
skillful at assessing that which is important to the older person and providing care that addresses the
person holistically. It is indeed an exciting time to be a gerontological nurse!
Gerontological Nursing has evolved since its first publication. In the early editions of the text, the
focus was on providing facts about the aging process and the unique modifications that were
necessary to properly assess, plan, and provide care to older adults. We now understand that a “one
size fits all” approach to nursing older adults is inappropriate as the diversity of this population grows.
In addition to expecting from the gerontological nurse assistance with managing their medical
conditions, today’s older adults may seek guidance on the selection of brain exercises to improve
mental function, the value of an herbal supplement over their prescription drug, strategies to fill the
void resulting from retiring from a job they enjoyed, suggestions for the best lubricant to facilitate
sexual intercourse, opinions as to the value of marijuana in controlling their pain, and
recommendations for the best type of approach to reduce their wrinkles. This edition of
rovides the evidence-based knowledge that can help the gerontological
Gerontological Nursing p
nurse address, with competency and sensitivity, the complexities of meeting the comprehensive,
holistic needs of the older population.
8
Text Organization
Gerontological Nursing, Ninth Edition, is organized into five units. Unit 1, The Aging Experience,
provides basic knowledge about the older population and the aging process. The growing cultural
and sexual diversity of this population is discussed, along with the navigation of life transitions and
the changes to the body and mind that typically are experienced.
Unit 2, Foundations of Gerontological Nursing, provides an understanding of the development

and scope of the specialty, along with descriptions of the various settings that provide services to
older persons. This unit reviews legal and ethical issues that are relevant to gerontological nursing
and offers guidance in applying a holistic model to gerontological care.
Unit 3, Health Promotion, addresses the importance of measures to prevent illness and
maximize function. Chapters dedicated to nutrition and hydration, sleep and rest, comfort and pain
management, safety, and medications guide the nurse in promoting basic health and preventing
avoidable complications. A chapter dedicated to spirituality supports the holistic approach that is
meaningful in gerontological care. In addition, because people often feel sufficiently comfortable with
nurses to discuss sensitive matters, a chapter on sexuality and intimacy is included.
Unit 4, Geriatric Care, encompasses chapters dedicated to respiration, circulation, digestion and
bowel elimination, urinary elimination, reproductive system health, mobility, neurologic function,
vision and hearing, endocrine function, skin health, and cancer. A review of the impact of aging,
interventions to promote health, the unique presentation and treatment of illnesses, and integrative
approaches to illness are discussed within each of these areas. In addition to a chapter on mental
health disorders, a chapter reviewing delirium and dementia is included in recognition of the
prevalence and care challenges of these conditions in the geriatric population. Because chronic
conditions affect most of this population, the last chapter of this unit is dedicated to nursing actions
that can assist older individuals in living a full life with chronic conditions.
The unique challenges gerontological nurses face in various care settings are discussed in Unit
hapters in this unit cover rehabilitative care, acute
5, Settings and Special Issues in Geriatric Care. C
care, long-term care, family caregiving, and end-of-life care.
9
Features
A variety of features enrich the content:
Learning Objectives prepare the reader for outcomes anticipated in reading

the chapter. Chapter Outlines present an overview of the chapter’s content.
Terms to Know define new terms pertaining to the topic.
Communication Tips offer suggestions to facilitate patient education and information
exchange with older adults.
Consider This Case features present clinical situations that offer opportunities for critical
thinking. Concept Mastery Alerts clarify fundamental nursing concepts to improve the reader’s
understanding of potentially confusing topics, as identified by Misconception Alerts in
Lippincott’s Adaptive Learning Powered by prepU.
Key Concepts emphasize significant facts.
Points to Ponder pose questions to stimulate thinking related to the content.
Assessment Guides outline the components of general observations, interview, and physical
assessment of major body systems.
Nursing Diagnosis Highlights provide an overview of selected nursing diagnoses common in
older adults.
Nursing Care Plans demonstrate the steps in developing nursing diagnoses, goals, and
actions from identified needs.
Bringing Research to Life presents current research and describes how to apply that
knowledge in practice.
Practice Realities pose real-life examples of challenges that could be faced by a nurse
in practice. Critical Thinking Exercises guide application.
Resources and References assist with additional exploration of the topic.
10
Teaching and Learning Package

A comprehensive teaching/learning package has been developed to assist faculty
and students. Resources for Instructors
Tools to assist you with teaching your course are available upon adoption of this text at
http://thePoint.lww.com/Eliopoulos9e.
An E-book on gives you access to the book’s full text and images online.
The Test Generator lets you put together exclusive new tests from a bank containing hundreds
of questions to help you in assessing your students’ understanding of the material. Test
questions link to chapter learning objectives. This test generator comes with a bank of more
than 900 questions. PowerPoint Presentations provide an easy way for you to integrate the
textbook with your students’ classroom experience, via either slide shows or handouts. Multiple
choice and true/false questions are integrated into the presentations to promote class
participation and allow you to use i-clicker technology.
Clinical Scenarios posing What If questions (and suggested answers) give your students an
opportunity to apply their knowledge to a client case similar to the one they might encounter in
practice. Assignments (and suggested answers) include group, written, clinical, and web
assignments. An Image Bank lets you use the photographs and illustrations from this textbook
in your PowerPoint slides or as you see fit in your course.
A QSEN Competency Map and a BSN Essentials Map show you how content connects with
these important competencies.
Suggested Answers to the Critical Thinking Exercises in the book allow you to gauge
whether students’ answers are on the right track by giving you main points that students are
expected to address in the answers.
Plus a Sample Syllabus, Strategies for Effective Teaching, and Learning Management
System Cartridges.
Resources for Students

An exciting set of free resources is available to help students review material and become even
more familiar with vital concepts. Students can access all these resources at
http://thePoint.lww.com/Eliopoulos9e using the codes printed in the front of their textbooks.
Current Journal Articles offer access to current research available in Wolters Kluwer
journals. Watch & Learn Video Clips explain How to Assist a Person Who Is Falling,
Alternatives to Restraints, and the Five Stages of Grief. (Icons in the textbook direct readers to
relevant videos.) Recommended Readings expand the network of available information.
Plus Learning Objectives from the textbook, Nursing Professional Roles and
Responsibilities, and Heart and Breath Sounds.
11
12
A Fully Integrated Course Experience

We are pleased to offer an expanded suite of digital solutions and ancillaries to support instructors
and students using Gerontological Nursing, Ninth Edition. To learn more about any solution, please
contact your local Wolters Kluwer representative.
Lippincott CoursePoint+
Lippincott CoursePoint+ i s an integrated digital learning solution designed for the way students
learn. It is the only nursing education solution that integrates:
Leading content in context: Content provided in the context of the student learning path
engages students and encourages interaction and learning on a deeper level.
Powerful tools to maximize class performance: Course-specific tools, such as adaptive
learning powered by prepU, provide a personalized learning experience for every student.
Real-time data to measure students’ progress: Student performance data provided in an
intuitive display lets you quickly spot which students are having difficulty or which concepts the
class as a whole is struggling to grasp.
Preparation for practice: Integrated virtual simulation and evidence-based resources improve
student competence, confidence, and success in transitioning to practice.
vSim for Nursing: Co-developed by Laerdal Medical and Wolters Kluwer, vSim for
Nursing simulates real nursing scenarios and allows students to interact with virtual
patients in a safe, online environment.
Lippincott Advisor for Education: With over 8,500 entries covering the latest
rovides
evidence-based content and drug information, Lippincott Advisor for Education p
students with the most up-to-date information possible, while giving them valuable
experience with the same point-of care content they will encounter in practice.
Training services and personalized support: To ensure your success, our dedicated
educational consultants and training coaches will provide expert guidance every step of the
way.
13
Simulation and Other Resources
vSim for Nursing | Gerontology, a virtual simulation

platform (available via ). Co-developed by Laerdal Medical and Wolters Kluwer, vSim for
Nursing | Gerontology i ncludes 12 gerontology patient scenarios that correspond to the National
League for Nursing (NLN) Advancing Care Excellence for Seniors (ACES) Unfolding Cases.
vSim for Nursing | Gerontology helps students develop clinical competence and
decision-making skills as they interact with virtual patients in a safe, realistic environment. vSim
for Nursing records and assesses student decisions throughout the simulation, then provides a
personalized feedback log highlighting areas needing improvement.
Lippincott DocuCare (available via

thePoint). Lippincott DocuCare combines web-based electronic health record simulation
software with clinical case scenarios. Lippincott DocuCare’s nonlinear solution works well in the
classroom, simulation lab, and clinical practice.
14
Reviewers
Carol Amann, PhD, RN-BC, CDP

Assistant Professor for the Villa Maria School of Nursing
Gannon University
Erie, Pennsylvania
Jan Atwell, MSN, RN
Clinical Assistant Professor

Missouri State University
Springfield, Missouri
Judy L. Barrera, RN, CNS
Clinical Learning Lab Coordinator

Galen College of Nursing
Louisville, Kentucky
Evelyn Biray, RN, MS, PMed, CCRN, CMSRN
Professor of Nursing
Long Island University Brooklyn
New York, New York
Dr.Melissa Brock , MSM, MSN, ANP-C, DHEd
Nursing Professor
Indiana Wesleyan University
Indianapolis, Indiana
Celeste Brown-Apoh, RN, MSN
Instructor
Rowan College at Burlington County
Pemberton, New Jersey
Jean Burt, MSN, RN
Instructor
Wilbur Wright College
Chicago, Illinois
Nicola Contreras, MSN, RN
VN/ADN Faculty
15
San Antonio, Texas
Sherri Cozzens, RN, MS
Nursing Faculty
De Anza College
Cupertino, California
Jodie Fox, MSN, RN-BC
Assistant Professor
Viterbo University
Lacrosse, Wisconsin
Florida Freeman, PhD, MSN, RN
Professor of Nursing
University of St. Francis
Joliet, Illinois
Betsy D. Gulledge, PhD, RN, CNE,

NEA-BC Associate Dean/Assistant
Professor of Nursing Jacksonville State
University
Jacksonville, Alabama
Kris Hale, MSN, RN
Professor/Department Chair
San Diego City College
San Diego, California
Cheryl Harrington, MSN, RN, MHA
Clinical Simulation Specialist

Morningside College
Sioux City, Iowa
Mary Jane Holman, RN
Instructor
Louisiana State University Shreveport
Shreveport, Louisiana
Laly Joseph, DVM, DNP, MSN, RN, C, ARNP,
BC Clinical Assistant Professor

Fairleigh Dickinson University
Teaneck, New Jersey
16
Ronnie Knabe, MSN, RN, CCRN
Associate Professor, Nursing
Bakersfield College
Bakersfield, California
Amy Langley
Health Science Division Director

Snead State Community College
Boaz, Alabama
Debora Lemon, MN, RN
Associate Professor
Lewis-Clark State College
Lewiston, Idaho
Susan McClendon, MSN, RN, CNS
Nursing Faculty
Lakeland Community College
Kirkland, Ohio
Mary Alice Momeyer, DNP, ANP-BC,
GNP-BC Assistant Clinical Professor

The Ohio State University
College of Nursing
Columbus, Ohio
Jon F. Nutting, MA, RN-BC
Instructor
Tampa Bay Campus
St. Petersburg, Florida
Teresa M. Page, DNP, EdS, MSN, RN,
FNP-BC Assistant Professor of Nursing

Liberty University
Lynchburg, Virginia
LoriAnn Pajalich, MS, RN, CNS,
GCNS-BC Assistant Professor of Nursing

Wilkes University
Wilkes-Barre, Pennsylvania
17
Debra Parker, DNP, RN
Assistant Professor
Indiana Wesleyan University
Marion, Indiana
Cordelia Schaffer, MSN, RN, CHPN
Associate Professor
Westminster College
Salt Lake City, Utah
Crystal Schauerte-O'Connell
Program Coordinator, Year 2

Algonquin College
Ottawa, Ontario
Maura C. Schlairet, EdD, MA, MSN, RN, CNL
(A/H) Professor of Nursing

Valdosta State University
Valdosta, Georgia
Nichole Spencer, MSN, APRN, ANP-C
Assistant Professor of Nursing

William Jewell College
Liberty, Missouri
Carolyn Sue-Ling, MSN, MPA, RN
Instructor
University of South Carolina Aiken
Aiken, South Carolina
Michael T. Valenti, AAS, BS, MS

Long Island University
Brookville, New York
Stephanie Vaughn, PhD, RN, CRRN,
FAHA Professor/Director School of Nursing

California State University, Fullerton
Fullerton, California
Erica Williams-Woodley, MSN, NP
18
Bronx Community College
New York, New York
Jane Zaccardi, MA, RN, GCNS-BC
Director of Practical Nursing and Health Occupations Programs

Johnson County Community College
Overland Park, Kansas
For a list of the contributors to the Instructor Resources and a list of the reviewers of the Test
Generator questions accompanying this book, please visit http://thepoint.lww.com/Eliopoulos9e.
19
Acknowledgments
There are many individuals who played important roles in the birth and development of this book. I
will always be grateful to Bill Burgower, a Lippincott editor, who decades ago responded to my
urging that the new specialty of gerontological nursing needed resources by encouraging me to write
the first edition of Gerontological Nursing. Many fine members of the Wolters Kluwer team have
guided and assisted me since, including Natasha McIntyre, Acquisitions Editor, who consistently
offered encouragement and direction; Meredith Brittain, Senior Development Editor, who brought a
new set of eyes to the book and ironed out the rough edges through her fine editorial skills; Dan
Reilly and Leo Gray, Editorial Assistants at different points in this project, who attended to the details
that contribute to a quality finished product; and Priscilla Crater, Production Project Manager, who
shepherded the book from manuscript through printed pages.
Lastly, I am deeply indebted to those mentors and leaders in gerontological care who generously
offered encouragement and the many older adults who have touched my life and showed me the
wisdom and beauty of aging. The insight these individuals provided could have never been learned
in a book!
Charlotte Eliopoulos
20
Brief Contents
UNIT 1 THE AGING EXPERIENCE

1 The Aging Population
2 Theories of Aging
3 Diversity
4 Life Transitions and Story
5 Common Aging Changes
UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6

The Specialty of Gerontological Nursing
7 Holistic Assessment and Care Planning
8 Legal Aspects of Gerontological Nursing
9 Ethical Aspects of Gerontological Nursing
10 Continuum of Care in Gerontological Nursing
UNIT 3 HEALTH PROMOTION

11 Nutrition and Hydration
12 Sleep and Rest
13 Comfort and Pain Management
14 Safety
15 Spirituality
16 Sexuality and Intimacy
17 Safe Medication Use
UNIT 4 GERIATRIC CARE

18 Respiration
19 Circulation
20 Digestion and Bowel Elimination
21 Urinary Elimination
22 Reproductive System Health
23 Mobility
24 Neurologic Function
25 Vision and Hearing
21
26 Endocrine Function
27 Skin Health
28 Cancer
29 Mental Health Disorders
30 Delirium and Dementia
31 Living in Harmony With Chronic Conditions
UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32

Rehabilitative and Restorative Care
33 Acute Care
34 Long-Term Care
35 Family Caregiving
36 End-of-Life Care
Index
22
Contents
UNIT 1 THE AGING EXPERIENCE

1 The Aging Population
Views Of Older Adults Through History
Characteristics Of The Older Adult Population
Population Growth and Increasing Life Expectancy

Marital Status and Living Arrangements
Income and Employment
Health Insurance
Health Status
Implications Of An Aging Population
Impact of the Baby Boomers

Provision of and Payment for Services
2 Theories of Aging
Biological Theories Of Aging
Stochastic Theories
Nonstochastic Theories
Sociologic Theories of Aging
Disengagement Theory
Activity Theory
Continuity Theory
Subculture Theory
Age Stratification Theory
Psychological Theories of Aging
Developmental Tasks
Gerotranscendence
Nursing Theories of Aging
Functional Consequences Theory

Theory of Thriving
Theory of Successful Aging
Applying Theories of Aging to Nursing Practice
3 Diversity
Increasing Diversity Of The Older Adult Population
Overview Of Diverse Groups Of Older Adults In The United States
Hispanic Americans
Black Americans
Asian Americans
Jewish Americans
23
Native Americans
Muslims
Gay, Lesbian, Bisexual, and Transgender
Older Adults Nursing Considerations For Culturally Sensitive
Care Of Older Adults 4 Life Transitions and Story
Ageism
Changes In Family Roles And Relationships
Parenting
Grandparenting
Loss Of Spouse
Retirement
Loss of the Work Role

Reduced Income
Changes In Health And Functioning
Cumulative Effects Of Life Transitions
Shrinking Social World

Awareness of Mortality
Responding To Life Transitions
Life Review and Life Story

Self-Reflection
Strengthening Inner Resources
5 Common Aging Changes

Changes To The Body
Cells
Physical Appearance
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Reproductive System
Musculoskeletal System
Nervous System
Sensory Organs
Endocrine System
Integumentary System
Immune System
Thermoregulation
Changes To The Mind
Personality
Memory
Intelligence
24
Learning
Attention Span
Nursing Implications Of Age-Related Changes
UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6

The Specialty of Gerontological Nursing
Development Of Gerontological Nursing
Core Elements Of Gerontological Nursing Practice
Evidence-Based Practice
Standards
Competencies
Principles
Gerontological Nursing Roles
Healer
Caregiver
Educator
Advocate
Innovator
Advanced Practice Nursing Roles
Self-Care And Nurturing
Following Positive Health Care Practices

Strengthening and Building Connections
Committing to a Dynamic Process
The Future Of Gerontological Nursing
Utilize Evidence-Based Practices

Advance Research
Promote Integrative Care
Educate Caregivers
Develop New Roles
Balance Quality Care and Health Care Costs
7 Holistic Assessment and Care Planning

Holistic Gerontological Care
Holistic Assessment Of Needs
Health Promotion–Related Needs

Health Challenges–Related Needs
Requisites to Meet Needs
Gerontological Nursing Processes
Examples Of Application
Applying the Holistic Model: The Case of Mrs. D

The Nurse As Healer
Healing Characteristics
25
8 Legal Aspects of Gerontological
Nursing Laws Governing Gerontological Nursing
Practice
Legal Risks In Gerontological Nursing
Malpractice
Confidentiality
Patient Consent
Patient Competency
Staf Supervision
Medications
Restraints
Telephone Orders
Do Not Resuscitate Orders
Advance Directives and Issues Related to Death
and Dying Elder Abuse
Legal Safeguards For Nurses
9 Ethical Aspects of Gerontological

Nursing Philosophies Guiding Ethical Thinking
Ethics In Nursing
External and Internal Ethical Standards

Ethical Principles
Cultural Considerations
Ethical Dilemmas Facing Gerontological Nurses
Changes Increasing Ethical Dilemmas for Nurses

Measures to Help Nurses Make Ethical Decisions
10 Continuum of Care in Gerontological
Nursing Services In The Continuum Of Care For Older Adults
Supportive and Preventive Services
Partial and Intermittent Care Services
Complete and Continuous Care Services
Complementary and Alternative Services
Matching Services To Needs
Settings And Roles For Gerontological Nurses
UNIT 3 HEALTH PROMOTION 11

Nutrition and Hydration
Nutritional Needs Of Older Adults
Quantity and Quality of Caloric Needs

Nutritional Supplements
Special Needs of Women
Hydration Needs Of Older Adults
Promotion Of Oral Health
26
Threats To Good Nutrition
Indigestion and Food Intolerance

Anorexia
Dysphagia
Constipation
Malnutrition
Addressing Nutritional Status And Hydration In Older
Adults 12 Sleep and Rest

Age-Related Changes in Sleep
Circadian Sleep–Wake Cycles

Sleep Stages
Sleep Ef iciency and Quality
Sleep Disturbances
Insomnia
Nocturnal Myoclonus and Restless Legs
Syndrome Sleep Apnea
Medical Conditions That Af ect Sleep
Drugs That Af ect Sleep
Other Factors Af ecting Sleep
Promoting Rest and Sleep in Older Adults
Pharmacologic Measures to Promote Sleep

Nonpharmacologic Measures to
Promote Sleep Pain Control
13 Comfort and Pain Management

Comfort
Pain: A Complex Phenomenon
Prevalence Of Pain In Older Adults
Types of Pain
Pain Perception
Ef ects of Unrelieved Pain
Pain Assessment
An Integrative Approach To Pain Management
Complementary Therapies
Dietary Changes
Medication
Comforting
14 Safety
Aging And Risks To Safety
Importance Of The Environment To Health And
Wellness Impact Of Aging On Environmental Safety
And Function Lighting
27
Temperature
Colors
Scents
Floor Coverings
Furniture
Sensory Stimulation
Noise Control
Bathroom Hazards
Fire Hazards
Psychosocial Considerations
The Problem Of Falls
Risks and Prevention

Risks Associated With Restraints
Interventions To Reduce Intrinsic Risks To Safety
Reducing Hydration and Nutrition Risks

Addressing Risks Associated With Sensory
Deficits Addressing Risks Associated With
Mobility Limitations Monitoring Body
Temperature
Preventing Infection
Suggesting Sensible Clothing
Using Medications Cautiously
Avoiding Crime
Promoting Safe Driving
Promoting Early Detection of Problems
Addressing Risks Associated With Functional
Impairment 1
5 Spirituality
Spiritual Needs
Love
Meaning and Purpose
Hope
Dignity
Forgiveness
Gratitude
Transcendence
Expression of Faith
Assessing Spiritual Needs
Addressing Spiritual Needs
Being Available
Honoring Beliefs and Practices
Providing Opportunities for Solitude
28
Promoting Hope
Assisting in Discovering Meaning in Challenging
Situations Facilitating Religious Practices
Praying With and for
16 Sexuality and Intimacy

Attitudes Toward Sex And Older Adults
Realities Of Sex In Older Adulthood
Sexual Behavior and Roles

Intimacy
Age-Related Changes and Sexual Response
Menopause As A Journey To Inner Connection
Symptom Management and Patient Education

Self-Acceptance
Andropause
Identifying Barriers To Sexual Activity
Unavailability of a Partner
Psychological Barriers
Medical Conditions
Erectile Dysfunction
Medication Adverse Ef ects
Cognitive Impairment
Promoting Healthy Sexual Function
17 Safe Medication Use

Effects Of Aging On Medication Use
Polypharmacy and Interactions

Altered Pharmacokinetics
Altered Pharmacodynamics
Increased Risk of Adverse Reactions
Promoting The Safe Use Of Drugs
Avoiding Potentially Inappropriate Drugs: Beers

Criteria Reviewing Necessity and Ef ectiveness of
Prescribed Drugs Promoting Safe and Ef ective
Administration
Providing Patient Teaching
Monitoring Laboratory Values
Alternatives To Drugs
Review Of Selected Drugs
Analgesics
Antacids
Antibiotics
Anticoagulants
Anticonvulsants
29
Antidiabetic (Hypoglycemic) Drugs
Antihypertensive Drugs
Nonsteroidal Anti-inflammatory Drugs
Cholesterol-Lowering Drugs
Cognitive Enhancing Drugs
Digoxin
Diuretics
Laxatives
Psychoactive Drugs
UNIT 4 GERIATRIC CARE

18 Respiration
Effects Of Aging On Respiratory Health
Respiratory Health Promotion
Selected Respiratory Conditions
Chronic Obstructive Pulmonary Disease

Pneumonia
Influenza
Lung Cancer
Lung Abscess
General Nursing Considerations For Respiratory
Conditions Recognizing Symptoms

Preventing Complications
Ensuring Safe Oxygen Administration
Performing Postural Drainage

Promoting Productive Coughing
Using Complementary Therapies
Promoting Self-Care
Providing Encouragement
19 Circulation
Effects Of Aging On Cardiovascular Health
Cardiovascular Health Promotion
Proper Nutrition
Adequate Exercise
Cigarette Smoke Avoidance
Stress Management
Proactive Interventions
Cardiovascular Disease And Women
Selected Cardiovascular Conditions
Hypertension
30
Hypotension
Congestive Heart Failure
Pulmonary Emboli
Coronary Artery Disease
Hyperlipidemia
Arrhythmias
Peripheral Vascular Disease
General Nursing Considerations For Cardiovascular
Conditions Prevention
Keeping the Patient Informed

Preventing Complications
Promoting Circulation
Providing Foot Care
Managing Problems Associated With Peripheral
Vascular Disease Promoting Normality
Integrating Complementary Therapies
20 Digestion and Bowel Elimination

Effects Of Aging On Gastrointestinal Health
Gastrointestinal Health Promotion
Selected Gastrointestinal Conditions And Related Nursing
Considerations Dry Mouth (Xerostomia)

Dental Problems
Dysphagia
Hiatal Hernia
Esophageal Cancer
Peptic Ulcer
Cancer of the Stomach
Diverticular Disease
Colorectal Cancer
Chronic Constipation
Flatulence
Intestinal Obstruction
Fecal Impaction
Fecal Incontinence
Acute Appendicitis
Cancer of the Pancreas
Biliary Tract Disease
21 Urinary Elimination
Effects Of Aging On Urinary Elimination
Urinary System Health Promotion
31
Selected Urinary Conditions
Urinary Tract Infection

Urinary Incontinence
Bladder Cancer
Renal Calculi
Glomerulonephritis
General Nursing Considerations For Urinary
Conditions 22 Reproductive System

Health
Effects Of Aging On The Reproductive System
Reproductive System Health Promotion
Selected Reproductive System Conditions
Problems of the Female Reproductive

System Problems of the Male
Reproductive System
23 Mobility
Effects Of Aging On Musculoskeletal Function
Musculoskeletal Health Promotion
Promotion of Physical Exercise in All Age

Groups Exercise Programs Tailored for
Older Adults
The Mind–Body Connection
Prevention of Inactivity
Nutrition
Selected Musculoskeletal Conditions
Fractures
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis
Gout
Podiatric Conditions
General Nursing Considerations For Musculoskeletal
Conditions Managing Pain

Preventing Injury
Promoting Independence
24 Neurologic Function
Effects Of Aging On The Nervous System
Neurologic Health Promotion
Selected Neurologic Conditions
Parkinson’s Disease
Transient Ischemic Attacks
Cerebrovascular Accidents
General Nursing Considerations For Neurologic
Conditions Promoting Independence
32
Preventing Injury
25 Vision and Hearing

Terms to Know
Effects of Aging on Vision and Hearing
Sensory Health Promotion
Promoting Vision
Promoting Hearing
Assessing Problems
Selected Vision and Hearing Conditions and Related Nursing
Interventions Visual Deficits

Hearing Deficits
General Nursing Considerations for Visual and Hearing
Deficits 26 Endocrine Function

Effects Of Aging On Endocrine Function
Selected Endocrine Conditions And Related Nursing
Considerations Diabetes Mellitus

Hypothyroidism
Hyperthyroidism
27 Skin Health
Effects Of Aging On The Skin
Promotion Of Skin Health
Selected Skin Conditions
Pruritus
Keratosis
Seborrheic Keratosis
Skin Cancer
Vascular Lesions
Pressure Injury
General Nursing Considerations For Skin Conditions
Promoting Normalcy
Using Alternative Therapies
28 Cancer
Aging And Cancer
Unique Challenges for Older Persons With

Cancer Explanations for Increased Incidence
isk Factors, Prevention, And Screening
in Old Age R
Treatment
Conventional Treatment
Complementary and Alternative Medicine
Nursing Considerations For Older Adults With Cancer
Providing Patient Education
33
Promoting Optimum Care
Providing Support to Patients and Families
29 Mental Health Disorders

Aging And Mental Health
Promoting Mental Health In Older Adults
Selected Mental Health Conditions
Depression
Anxiety
Substance Abuse
Paranoia
Nursing Considerations For Mental Health Conditions
Monitoring Medications
Promoting a Positive Self-Concept
Managing Behavioral Problems
30 Delirium and Dementia

Delirium
Dementia
Alzheimer’s Disease
Other Dementias
Caring for Persons With Dementia
31 Living in Harmony With Chronic Conditions

Chronic Conditions And Older Adults
Goals For Chronic Care
Assessment Of Chronic Care Needs
Maximizing The Benefits Of Chronic Care
Selecting an Appropriate Physician

Using a Chronic Care Coach
Increasing Knowledge
Locating a Support Group
Making Smart Lifestyle Choices
Using Complementary and Alternative Therapies
Factors Affecting The Course Of Chronic Care
Defense Mechanisms and Implications

Psychosocial Factors
Impact of Ongoing Care on the Family
The Need for Institutional Care
Chronic Care: A Nursing Challenge
UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32

Rehabilitative and Restorative Care
Rehabilitative And Restorative Care
34
Living With Disability
Importance of Attitude and Coping

Capacity Losses Accompanying
Disability
Principles Of Rehabilitative Nursing
Functional Assessment
Interventions To Facilitate And Improve Functioning
Facilitating Proper Positioning

Assisting with Range-of-Motion Exercises
Assisting with Mobility Aids and Assistive
Technology Teaching About Bowel and
Bladder Training Maintaining and Promoting
Mental Function Using Community Resources
33 Acute Care
Risks Associated With Hospitalization Of Older
Adults Surgical Care
Special Risks for Older Adults

Preoperative Care Considerations
Operative and Postoperative Care
mergency Care
Considerations E
Infections
Discharge Planning For Older Adults
34 Long-Term Care
Development Of Long-Term Institutional Care
Before the 20th Century

During the 20th Century
Lessons to Be Learned From History
Nursing Homes Today
Nursing Home Standards

Nursing Home Residents
Nursing Roles and Responsibilities
Other Settings For Long-Term Care
Assisted Living Communities

Community-Based and Home Health Care
Looking Forward: A New Model Of Long-Term
Care 35 Family Caregiving

The Older Adult’s Family
Identification of Family Members

Family Member Roles
Family Dynamics and Relationships
Scope Of Family Caregiving
Long-Distance Caregiving
Protecting The Health Of The Older Adult And Caregiver 35
Family Dysfunction And Abuse

Rewards Of Family Caregiving
36 End-of-Life Care
Definitions Of Death
Family Experience With The Dying Process
Supporting The Dying Individual
Stages of the Dying Process and Related Nursing

Interventions Rational Suicide and Assisted Suicide
Physical Care Challenges
Spiritual Care Needs
Signs of Imminent Death
Advance Directives
Supporting Family And Friends
Supporting Through the Stages of the Dying

Process Helping Family and Friends After a
Death
Supporting Nursing Staff
Index
36
Index of Selected Features
Consider This Case
For Chapter 1
For Chapter 2
For Chapter 3
For Chapter 4
For Chapter 5
For Chapter 6
For Chapter 7
For Chapter 8
For Chapter 9
For Chapter 10
For Chapter 11
For Chapter 12
For Chapter 13
For Chapter 14
For Chapter 15
For Chapter 16
For Chapter 17
For Chapter 18
For Chapter 19
For Chapter 20
For Chapter 21
For Chapter 22
For Chapter 23
For Chapter 24
For Chapter 25
For Chapter 26
For Chapter 27
For Chapter 28
For Chapter 29
For Chapter 30
For Chapter 31
37
For Chapter 32
For Chapter 33
For Chapter 34
For Chapter 35
For Chapter 36
38
Assessment Guides
Assessment Guide 11-1 Nutritional

Status Assessment Guide 13-1 Pain
Assessment Guide 15-1 Spiritual Needs

Assessment Guide 16-1 Sexual Health
Assessment Guide 18-1 Respiratory Function
Assessment Guide 19-1 Cardiovascular Function
Assessment Guide 20-1 Gastrointestinal
Function Assessment Guide 21-1 Urinary
Function Assessment Guide 22-1 Reproductive
System Health Assessment Guide 23-1
Musculoskeletal Function Assessment Guide
24-1 Neurologic Function Assessment Guide
25-1 Vision and Hearing Assessment Guide 27-1
Skin Status
Assessment Guide 29-1 Mental Health

Assessment Guide 30-1 Mental Health
39
Nursing Care Plans
Nursing Care Plan 7-1 Holistic Care For Mrs. D

Nursing Care Plan 18-1 The Older Adult With Chronic Obstructive Pulmonary
Disease Nursing Care Plan 19-1 The Older Adult With Heart Failure
Nursing Care Plan 20-1 The Older Adult With Hiatal Hernia
Nursing Care Plan 20-2 The Older Adult With Fecal Incontinence
Nursing Care Plan 21-1 The Older Adult With Urinary Incontinence
Nursing Care Plan 22-1 The Older Adult Recovering From Prostate
Surgery Nursing Care Plan 23-1 The Older Adult With Osteoarthritis
Nursing Care Plan 24-1 The Older Adult With A Cerebrovascular Accident: Convalescence
Period Nursing Care Plan 25-1 The Older Adult With Open-Angle Glaucoma
Nursing Care Plan 30-1 The Older Adult With Alzheimer’s Disease
40
UNIT 1 The Aging Experience

1. The Aging Population
2. Theories of Aging
41
3. Diversity
4. Life Transitions and Story
5. Common Aging Changes
42
CHAPTER 1
The Aging Population

43
CHAPTER OUTLINE
Views Of Older Adults Through History
Characteristics Of The Older Adult Population
Health Insurance
Health Status
Implications Of An Aging Population
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Explain the different ways in which older adults have been viewed throughout history.
2. Describe characteristics of today’s older population in regard to:
life expectancy
marital status
living arrangements
income and employment
health status
3. Discuss projected changes in future generations of older people and the implications for health care.
TERMS TO KNOW
Comorbidity: the simultaneous presence of multiple chronic conditions
Compression of morbidity: hypothesis that serious illness and decline can be delayed or postponed so that an extended life
expectancy results in more functional, healthy years
Life expectancy: the length of time that a person can be predicted to live
Life span: the maximum years that a person has the potential to live
“Families forget their older relatives … most people become senile in old age … Social Security
provides every older person with a decent retirement income … a majority of older people reside in
nursing homes … Medicare covers all health care–related costs for older people.” These and other
myths continue to be perpetuated about older people. Misinformation about the older population is an
injustice not only to this age group but also to persons of all ages who need accurate information to
prepare realistically for their own senior years. Gerontological nurses must know the facts about the
older population to effectively deliver services and educate the general public.
44
45
VIEWS OF OLDER ADULTS THROUGH HISTORY
The members of the current older population in the United States have offered the sacrifice,
strength, and spirit that made this country great. They were the proud GIs who served in wars, the
brave immigrants who ventured into a new country, the bold entrepreneurs who took risks that
created wealth and opportunities for employment, the campus rebels who advocated for the rights of
minorities, and the unselfish parents who struggled to give their children a better life. They have
earned respect, admiration, and dignity. Today, older adults are viewed with positivism rather than
prejudice, knowledge rather than myth, and concern rather than neglect. This positive view was not
always the norm, however.
Historically, societies have viewed their elder members in a variety of ways. In the time of
Confucius, there was a direct correlation between a person’s age and the degree of respect to which
he or she was entitled. The early Egyptians dreaded growing old and experimented with a variety of
potions and schemes to maintain their youth. Opinions were divided among the early Greeks. Plato
promoted older adults as society’s best leaders, whereas Aristotle denied older people any role in
governmental matters. In the nations conquered by the Roman Empire, the sick and aged were
customarily the first to be killed. And, woven throughout the Bible is God’s concern for the well-being
Exodus
of the family and desire for people to respect elders (Honor your father and your mother …
20:12). Yet, the honor bestowed on older adults was not sustained.
Medieval times gave rise to strong feelings regarding the superiority of youth; these feelings were
expressed in uprisings of sons against fathers. Although England developed Poor Laws in the early
17th century that provided care for the destitute and enabled older persons without family resources
to have some modest safety net, many of the gains were lost during the Industrial Revolution. No
labor laws protected persons of advanced age; those unable to meet the demands of industrial work
settings were placed at the mercy of their offspring or forced to beg on the streets for sustenance.
The first significant step in improving the lives of older Americans was the passage of the Federal
Old Age Insurance Law under the Social Security Act in 1935, which provided some financial
security for older persons. The profound “graying” of the population started to be realized in the
1960s, and the United States responded with the formation of the Administration on Aging,
enactment of the Older Americans Act, and the introduction of Medicaid and Medicare, all in 1965
(Box 1-1).
Box 1-1 Publicly Supported Programs of Benefit

to Older Americans
1900 Pension laws passed in some states
1935 Social Security Act
1961 First White House Conference on Aging
1965 Older Americans Act: nutrition, senior employment, and transportation
programs Administration on Aging
Medicare (Title 18 of Social Security Act)

Medicaid (Title 19 of Social Security Act) for poor and disabled of any age
46
1972 Supplemental Security Income (SSI) enacted
1991 Omnibus Budget Reconciliation Act (nursing home reform law) implemented
Since that time, American society has demonstrated a profound awakening of interest in older
persons as their numbers have grown. A more humanistic attitude toward all members of society has
benefited older adults, and improvements in health care and general living conditions ensure that
more people have the opportunity to attain old age and live longer, more fruitful years in later
adulthood than previous generations (Fig. 1-1).
FIGURE 1-1 • It is important for gerontological nurses to be as concerned with adding quality to the
lives of older adults as they are with increasing the quantity of years.
47
CHARACTERISTICS OF THE OLDER ADULT
POPULATION
Older adults are generally defined as individuals aged 65 years and older. At one time, all persons
over 65 years of age were grouped together under the category of “old.” Now it is recognized that
much diversity exists among different age groups in late life, and older individuals can be further
categorized as follows:
young-old: 65 to 74 years
old: 75 to 84 years
oldest-old 85+
The profile, interests, and health care challenges of each of these subsets can be vastly different.
For example, a 66-year-old may desire cosmetic surgery to stay competitive in the executive job
market; a 74-year-old may have recently remarried and want to do something about her dry vaginal
canal; an 82-year-old may be concerned that his arthritic knees are limiting his ability to play a round
of golf; and a 101-year-old may be desperate to find a way to correct her impaired vision so that she
can enjoy television.
In addition to chronological age, or the years a person has lived since birth, functional age is a
term used by gerontologists to describe physical, psychological, and social function; this is relevant
in that how older adults feel and function may be more indicative of their needs than their
chronological age. Perceived age is another term that is used to describe how people estimate a
person’s age based on appearance. Studies have shown a correlation between perceived age and
health, in addition to how others treated older adults based on perceived age and the resultant health
of those older adults (Sutin, Stephan, Carretta, & Terracciano, 2014).
How people feel or perceive their own age is described as age identity. Some older adults will
view peers of similar age as being older than themselves and be reluctant to join senior groups and
other activities because they see the group members as “old people” and different from themselves.
Any stereotypes held about older people must be discarded; if anything, greater diversity rather
than homogeneity will be evident. Further, generalizations based on age need to be eliminated as
behavior, function, and self-image can reveal more about priorities and needs than chronological age
alone.
COMMUNICATION TIP
Not all persons of the same age will be similar in terms of language style, familiarity with
current terms, use of technology, education, and life experience. Communication style and
method must be based on assessed language competency, style, and preference of the
individual.
48
49
There was a significant growth in the number of older people for most of the 20th century. Except for
the 1990s, the older population grew at a rate faster than that of the total population under age 65.
The U.S. Census Bureau projects that a substantial increase in the number of individuals over age
65 will occur between 2010 and 2030 due to the impact of the baby boomers, who began to enter
this group in 2011. In 2030, it is projected that this group will represent nearly 20% of the total U.S.
population.
Currently, persons older than 65 years represent more than 13% of the population in the United
States. This growth of the older adult population is due in part to increasing life expectancy.
Advancements in disease control and health technology, lower infant and child mortality rates,
improved sanitation, and better living conditions have increased life expectancy for most Americans.
More people are surviving to their senior years than ever before. In 1930, slightly more than 6 million
persons were aged 65 years or older, and the average life expectancy was 59.7 years. The life
expectancy in 1965 was 70.2 years, and the number of older adults exceeded 20 million. Life
expectancy has now reached 78.2 years, with over 34 million persons exceeding age 65 years
(Table 1-1). Not only are more people reaching old age, but they are living longer once they do; the
number of people in their 70s and 80s has been steadily increasing and is expected to continue to
increase. The population over age 85 years is projected to double by the year 2036 and triple by
2049. The life span currently is 122 years for humans.
TABLE 1-1 Differences in Life Expectancy at Birth by Race, Sex, and Hispanic Origin
Source: National Center for Health Statistics. (2013). Table 18. Life expectancy at birth, at age 65, and at age 75 by sex, race, and
national
origin: United States, selected years. Health, United States, 2013. Hyattsville, MD: National Center for Health Statistics. Retrieved
from http://www.cdc.gov/nchs/data/hus/hus13.pdf#018; U.S. Census Bureau. Table 10. Projected life expectancy at birth by sex,
race, and Hispanic origin for the United States. Retrieved from
http://www.census.gov/population/projections/data/national/2012/summarytables.html
KEY CONCEPT
More people are achieving and spending longer periods of time in old age than ever before in
history.
Although life expectancy has increased, it still differs by race and gender, as Table 1-1 shows. From
the late 1980s to the present, the gap in life expectancy between white people and black people has
widened because the life expectancy of the black population has declined. The U.S. Department of
Health and Human Services attributes the declining life expectancy of black people to heart disease,
cancer, homicide, diabetes, and perinatal conditions. This reality underscores the need for nurses to
be concerned with health and social issues
50
of persons of all ages because these impact a population’s aging process.
Whereas the gap in life expectancy has widened among the races, the gap is narrowing between
the sexes. Throughout the 20th century, the ratio of men to women had steadily declined to the point
where there were fewer than 7 older men for every 10 older women. The ratio declined with each
advanced decade. However, in the 21st century, this trend is changing, and the ratio of men to
women is increasing.
Although living longer is desirable, of significant importance is the quality of those years. More
years to life means little if those additional years consist of discomfort, disability, and a poor quality of
life. This has led to a hypothesis advanced by James Fries, a professor of medicine at Stanford
University, called the compression of morbidity (Fries, 1980; Swartz, 2008). This hypothesis
suggests that if the onset of serious illness and decline would be delayed, or compressed, into a few
years prior to death, people could live a long life and enjoy a healthy, functional state for most of their
lives.
POINT TO PONDER
A higher proportion of older adults in our society means that younger age groups will be
carrying a greater tax burden to support the older population. Should young families sacrifice to
support services for older adults? Why or why not?
51
The higher survival rates of women, along with the practice of women marrying men older than
themselves, make it no surprise that more than half of women older than 65 years are widowed, and
most of their male contemporaries are married. Married people have a lower mortality rate than do
unmarried people at all ages, with men having a larger advantage.
Most older adults live in a household with a spouse or other family member, although more than
twice the number of women than men live alone in later life. The likelihood of living alone increases
with age for both sexes. Most older people have contact with their families and are not forgotten or
neglected. Realities of the aging family are discussed in greater detail in Chapter 35.
KEY CONCEPT
Women are more likely to be widowed and living alone in late life than are their male counterparts.
52

The percentage of older people living below the poverty level has been declining, with about 10%
now falling into this category. However, older adults still do face financial problems. Most older
people depend on Social Security for more than half of their income (Box 1-2). Women and minority
groups have considerably less income than do white men. Although the median net worth of older
households is nearly twice the national average because of the high prevalence of home ownership
by elders, many older adults are “asset rich and cash poor.” The recent decline in housing prices,
however, has made that asset a less valuable one for many older adults.
Box 1-2 Social Security and Supplemental Security

Income
Social Security: a benefit check paid to retired workers of specific minimum age (e.g., 65
years), disabled workers of any age, and spouses and minor children of those workers.
Benefits are not dependent on financial need. It is intended to serve as supplement to other
sources of income in retirement.
Supplemental Security Income (SSI): a benefit check paid to persons over age 65 and/or
persons with disabilities based on financial need.
Although the percentage of the total population that older adults represent is growing, they constitute
a steadily declining percentage of workers in the labor force. The withdrawal of men from the
workforce at earlier ages has been one of the most significant labor force trends since World War II.
There has been, however, a significant rise in the percentage of middle-aged women who are
employed, although there has been little change in the labor force participation of women 65 years of
age and older. Most baby boomers are expressing a desire and need to continue working as they
enter retirement age.
CONSIDER THIS CASE
Mr. and Mrs. Murdock are both 67 years of age and in good
health. Mr. Murdock owns and manages several investment properties that require him to
maintain records, respond to tenants’ service calls, and plan maintenance work. Mrs. Murdock
is a nurse who works in a community health center for children. Both of them are working
full-time and enjoy their work; however, they both admit that their energy level is not what it
used to be and that it takes them
53
more time to complete activities than it did in the past.
Although she does see positives to her work activities, Mrs. Murdock feels that after many
years of working, she deserves to relax and enjoy other activities. When she suggests to her
husband that he either retire or, at the least, reduce his work activities so that they can enjoy
this season of life together, he is adamant about continuing to work because he believes the
income is beneficial to maintaining their lifestyle and he has no other activities that he is
interested in doing. She thinks he is being unrealistic, claims that they can “get along just fine
on Social Security,” and repeatedly reminds him that they are at the age when people retire.
THINK CRITICALLY
What issues would be helpful for each of these individuals to consider regarding their
decision to retire or continue working?
What challenges could each of these individuals potentially face if they continued to work
for another 5 years? 10 years?
What actions could the Murdocks have taken in the past to face their decisions about
continued work or retirement differently?
What are the implications to society of people like the Murdocks continuing to stay in the
labor force?
KEY CONCEPT
Although Social Security was intended to be a supplement to other sources of income for older
adults, it is the main source of income for more than half of all these individuals.
54
HEALTH INSURANCE
This decade has shaken the health care reimbursement systems in the United States, and changes
will be unfolding as the need to assure that every American will have access to health care is
balanced against unsustainable costs to support that care. Passed in 1965 as Title 18 of the Social
Security Act, Medicare is the health insurance program for older adults who are eligible for Social
Security benefits. This federally funded program primarily covers hospital and physician services with
very limited skilled home health and nursing home services under Part A. Preventive services and
nonskilled care (e.g., personal care assistance) are not covered. To supplement the basic coverage,
a person can purchase Medicare Part B, which includes physician and nursing services, x-rays,
laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal
dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs
for organ transplant recipients, chemotherapy, hormonal treatments, and other outpatient medical
treatments administered in a doctor’s office. Part B also assists with the payment of durable medical
equipment, including canes, walkers, wheelchairs, and mobility scooters for those with mobility
impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy,
as well as one pair of eyeglasses following cataract surgery, and oxygen for home use are also
covered. Medicare Part C or Medicare Advantage Plans give people the option of purchasing
coverage through private insurance plans to cover benefits not provided by Medicare Parts A and B
plus additional services. Although regulated and funded by the federal government, these plans are
managed by private insurance companies. Some of these plans also include prescription drug
benefits, known as a Medicare Advantage Prescription Drug Plan or Medicare Part D.
Persons who meet the income criteria can qualify for Medicaid, the health insurance program for
the poor of any age. This program was developed at the same time as Medicare and is Title 19 of
the Social Security Act. Medicaid supplements Medicare for poor elderly individuals, and most
nursing home care is paid for by this program. Medicaid is supported by federal and state funding.
Provisions in the Affordable Care Act expand Medicaid benefits to many older persons who did not
previously qualify for the program.
People of any age can purchase long-term care insurance to cover health care costs not paid by
Medicare or other health insurance. These policies can provide benefits for home care, respite, adult
day care, nursing home care, assisted living, and other services. Policies vary in waiting periods,
amount of funds paid per day or month, and types of services that qualify. Although beneficial,
long-term care insurance has not attracted a significant number of subscribers. Part of the reason for
this is that policies are expensive for older adults, and although less costly for persons of younger
age groups, younger and healthier individuals tend not to think about long-term care.
55
Health Status
The older population experiences fewer acute illnesses than younger age groups and a lower death
rate from these problems. However, older people who do develop acute illnesses usually require
longer periods of recovery and have more complications from these conditions.
Chronic illness is a major problem for the older population. Most older adults have at least one
chronic disease, and typically, they have multiple chronic conditions, termed comorbidity, that
requires them to manage the care of several conditions simultaneously (Box 1-3). Chronic conditions
result in some limitations in activities of daily living and instrumental activities of daily living for many
individuals. The older the person is, the greater the likelihood of difficulty with self-care activities and
independent living.
Box 1-3 Ten Leading Chronic Conditions
Affecting Population Aged 65 Years and
Older
1. Arthritis
2. High blood pressure
3. Hearing impairments
4. Heart conditions
5. Visual impairments (including cataracts)
6. Deformities or orthopedic impairments
7. Diabetes mellitus
8. Chronic sinusitis
9. Hay fever and allergic rhinitis (without asthma)
10. Varicose veins
Source: Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion. Retrieved
April 14, 2012 from http://www.cdc.gov/chronicdisease/index.html
KEY CONCEPT
The chronic disorders most prevalent in the older population are ones that can have a
significant impact on independence and the quality of daily life.
Chronic diseases are also the leading causes of death (Table 1-2). A shift in death rates from various
causes of death has occurred over the past three decades; deaths from heart disease have declined,
whereas those from cancer have increased.
TABLE 1-2 Leading Causes of Death for Persons 65 Years of Age and Older
56
From
National Center for Health Statistics. (2016). Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes
of death in selected age groups, by race and sex: United States, 2013. National Vital Statistics Reports, Vol. 65, No. 2, February
16, 2016. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_02.pdf
Concept Mastery Alert

When planning health education sessions for older adults that address the health risks they
face, the nurse should provide teaching about cancer risks, screening, recognition, and
treatment. Often, educational sessions prioritize heart disease, although deaths from this cause
are declining while cancer deaths are rising.
Despite the advances in the health status of the older population, disparities exist. Studies have
found that older minorities have lower levels of health and function. The number of older Hispanics,
blacks, and Asians admitted to nursing homes has been increasing, whereas the number of older
white nursing home residents has been declining (Feng, Fennell, Tyler, Clark, & Mor, 2011).
57
IMPLICATIONS OF AN AGING POPULATION
The growing number of persons older than 65 years impacts health and social service agencies and
health care providers—including gerontological nurses—that serve this group. As the older adult
population grows, these agencies and providers must anticipate future needs of services and
payment for these services.
58
In anticipating needs and services for future generations of older adults, gerontological nurses must
consider the realities of the baby boomers—those born between 1946 and 1964—who will be the
next wave of senior citizens. Their impact on the growth of the older population is such that it has
been referred to as a demographic tidal wave. Baby boomers began entering their senior years in
2011 and will continue to do so until 2030. Although they are a highly diverse group, representing
people as different as Bill Clinton, Bill Gates, and Cher, they do have some clearly defined
characteristics that set them apart from other groups:
Most have children, but this generation’s low birth rate means that they will have fewer biologic
children available to assist them in old age.
They are better educated than preceding generations with slightly more than half having
attended or graduated from college.
Their household incomes tend to be higher than other groups, partly due to two incomes (three
out of four baby boomer women are in the labor force), and most own their own homes
They favor a more casual dress code than do previous generations of older adults.
They are enamored with “high-tech” products, are likely to own a computer, and spend several
hours online daily.
Their leisure time is scarcer than other adults, and they are more likely to report feeling
stressed at the end of the day.
As inventors of the fitness movement, they exercise more frequently than do other adults.
Some assumptions can be made concerning the baby boomer population as senior adults. They are
informed consumers of health care and desire a highly active role in their care; their ability to access
information often enables them to have as much knowledge as their health care providers on some
health issues. They are most likely not going to be satisfied with the conditions of today’s nursing
homes and will demand that their long
term care facilities be equipped with bedside Internet access, gymnasiums, juice bars, pools, and
alternative therapies. Their blended families may need special assistance because of the potential
caregiving demands of several sets of stepparents and stepgrandparents. Plans for services and
architectural designs must take these factors into consideration.
COMMUNICATION TIP
Many baby boomers want to be informed health care consumers and are comfortable
communicating via e-mail and text messages. They may prefer electronic appointment
reminders and reports from diagnostic tests rather than telephone calls, and they appreciate
links to fact sheets about their conditions and treatments. However, some members of this
generation are not tech savvy and prefer traditional communication means, so it is important to
ask about preferred style of communication during the assessment.
59
60
The growing number of persons older than 65 years also impacts the government that is the source
of payment for many of the services older adults need. The older population has higher rates of
hospitalization, surgery, and physician visits than other age groups (Table 1-3), and this care is more
likely to be paid by federal dollars than private insurers or older adults themselves.
TABLE 1-3 Average Length of Hospital Stay
National Center for Health Statistics. (2013). Health, United States, 2013. Table 98. Average length of stay in nonfederal short-stay
hospitals, by sex, age, and selected first-listed diagnosis: United States, selected years 1990–2010. Retrieved from
http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2011-a.pdf
Less than 5% of the older population is in a nursing home, assisted living community, or other
institutional setting at any given time. Approximately one in four older adults will spend some time in
a nursing home during the last years of their lives. Most people who enter nursing homes as private
pay residents spend their assets by the end of 1 year and require government support for their care;
most of the Medicaid budget is spent on long-term care.
As the percentage of the advanced-age population grows, society will face an increasing demand
for the provision of and payment for services to this group. In this era of budget deficits, shrinking
revenue, and increased competition for funding of other special interests, questions may arise about
the ongoing ability of the government to provide a wide range of services for older adults. There may
be concern that the older population is using a disproportionate amount of tax dollars and that limits
should be set.
Gerontological nurses must be actively involved in discussions and decisions pertaining to the
rationing of services so that the rights of older adults are expressed and protected. Likewise,
gerontological nurses must assume leadership in developing cost-effective methods of care delivery
that do not compromise the quality of services to older adults.
KEY CONCEPT
Gerontological nurses need to be advocates in ensuring that cost-containment efforts do not
jeopardize the welfare of older adults.
61
BRINGING RESEARCH TO LIFE
Geographical Variation in Health-Related Quality of Life Among Older US Adults,
1997–2010
Source: Kachan, D., Tannebaum, S. L., LeBanc, W. G., McClure, L. A., & Lee, D. J. (2014).
Preventing Chronic Disease, 11:140023. doi: 10.5888/pcd11.140023#_blank. Retrieved from
http://dx.doi.org/10.5888/pcd11.140023
Although the health-related quality of life (HRQOL) has been considered a predictor of morbidity and
mortality, there had not been an exploration of its geographic variation. This study sought to
investigate this issue by comparing the HRQOL in all of the states and the District of Columbia using
the Health and Activities Limitation Index (HALex), in which higher values indicated better health.
Data from the National Health Interview Survey for people aged 65 and older were analyzed as part
of the study.
According to the study, the lowest health scores were found among older residents of Alaska,
Alabama, Arkansas, Mississippi, and West Virginia, and the highest health scores were found among
residents of Arizona, Delaware, Nevada, New Hampshire, and Vermont. Residents in the Northeast
had health scores higher than those in the Midwest and South after adjustment for
sociodemographics, health behaviors, and survey design. It was noted that older adults who
migrated from the South to other states had higher disability rates. Older Floridians had a higher life
expectancy than did older persons in other states, attributed to a high degree of compliance with
physical exercise recommendations and a lower prevalence of smoking. Older Alaskans had the
highest prevalence of drinking of all states, which could contribute to their low health scores.
Understanding differences in health status among states and the factors affecting them could
assist in identifying and tailoring health promotion and education needs for persons of all ages that
could contribute to healthier future generations of older adults.
62
PRACTICE REALITIES
You are in the break room of a hospital unit where several of the nurses are eating the birthday cake
of Nurse Clark who is celebrating her 66th birthday. “I’m so glad to have coworkers like you and
work that gives me a sense of purpose,” Nurse Clark commented as she thanked everyone and left
the room.
Nurse Blake, in a low voice commented to the person sitting next to her, “I just don’t get it. I’m
half her age and this job drains me, so you know it’s got to be taking its toll on her. Plus, we often get
stuck doing the heavy work that she can’t do.”
“I know she doesn’t have the physical capabilities that some others may,” says Nurse Edwards,
“but she sure is a storehouse of information and the patients love her.”
“Yes, but that isn’t helping my back when I have to pick up the slack for her,” responds Nurse
Blake.
What are the challenges of having different generations in the workplace? Should allowances be
made for older workers, and if so, what can be done to support these?
63
CRITICAL THINKING EXERCISES
1. What factors influence a society’s willingness to provide assistance to and display a positive
attitude toward older individuals (e.g., general economic conditions for all age groups)?
2. List the anticipated changes in the characteristics of the older population of the future, and
describe the implications for nursing.
3. What problems may older women experience as a result of gender differences in life expectancy
and income?
4. What are some of the differences between older white and black Americans?
64
Chapter Summary
Increases in life expectancy have resulted in persons over the age of 65 years now constituting more
than 13% of the U.S. population. Although life expectancy has increased in general, the black
population has a lower life expectancy than does the white population, reinforcing the importance of
addressing health and social problems throughout the life span to promote longer and healthier life
expectancies. In addition to extending life, there also must be concern for the compression of
morbidity to assure added years of life are high-quality ones.
The primary source of health insurance for older adults is Medicare. Medicaid provides
supplemental insurance for individuals with low incomes.
Although acute conditions occur at a lower rate in older adults than younger age groups, when
they do develop they usually result in more complications and longer periods for recovery. Chronic
conditions are the major health problems among older persons, with a majority being affected by at
least one chronic disease. Chronic conditions contribute to the leading causes of death.
Baby boomers, a group composed of persons born between 1946 and 1964, have begun
entering their senior years and are changing the profile of the older population. They are highly
diverse, are better educated, have fewer children, have had higher incomes, and are greater users
of technology than previous generations. Gerontological nurses will be challenged to recognize
diversity among older adults as they assist these individuals in health promotion and disease
management activities.
65
Online Resources
National Center for Health Statistics
http://www.cdc.gov/nchs
66
References
Feng, Z., Fennell, M. L., Tyler, D. A., Clark, M., & Mor, V. (2011). Growth of racial and ethnic
minorities in U.S. nursing homes driven by demographics and possible disparities in options. Health
Affairs, 33(7), 1358–1365.
Fries, J. F. (1980). Aging, natural death, and the compression of morbidity. New England Journal of
Medicine, 303(3), 130–135.
Sutin, A. R., Stephan, Y., Carretta, H., & Terracciano, A. (2014). Perceived discrimination and
physical, cognitive, and emotional health in older adulthood. American Journal of Geriatric
Psychiatry, 22(3), 164–167. Swartz, A. (2008). James Fries: healthy aging pioneer. American
Journal of Public Health, 98(7), 1163–1166.
Recommended Readings
Recommended Readings associated with this chapter can be found on the Web site that
accompanies the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of
recommended readings and additional resources associated with this chapter.
67
CHAPTER 2
Theories of Aging
68
CHAPTER OUTLINE
Biological Theories Of Aging
Stochastic Theories
Sociologic Theories of Aging
Disengagement Theory
Activity Theory
Continuity Theory
Subculture Theory
Age Stratification Theory
Psychological Theories of Aging
Developmental Tasks
Gerotranscendence
Nursing Theories of Aging
Functional Consequences Theory
Theory of Thriving
Theory of Successful Aging
Applying Theories of Aging to Nursing Practice
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Discuss the change in focus regarding learning about factors influencing aging.
2. List the major biological theories of aging.
3. Describe the major psychosocial theories of aging.
4. Identify factors that promote a healthy aging process.
5. Describe the way in which gerontological nurses can apply theories of aging to nursing practice.
TERMS TO KNOW
Aging:the process of growing older that begins at birth
Nonstochastic theories:explain biological aging as resulting from a complex, predetermined process
Stochastic theories:view the effects of biological aging as resulting from random assaults from both the internal and external
environment
For centuries, people have been intrigued by the mystery of aging and have sought to understand it,
some in hopes of achieving everlasting youth and others seeking the key to immortality. Throughout
history, there have been numerous searches for a fountain of youth, the most famous being that of
Ponce de León. Ancient Egyptian and Chinese relics show evidence of concoctions designed to
prolong life or achieve immortality, and various other cultures have proposed specific dietary
regimens, herbal mixtures, and rituals for similar ends. Ancient life extenders, such as extracts
prepared from tiger testicles, may seem ludicrous until they are compared with more modern
measures such as injections of embryonic tissue and Botox. Even persons who
69
would not condone such peculiar practices may indulge in nutritional supplements, cosmetic creams,
and exotic spas that promise to maintain youth and delay the onset or appearance of old age.No
single known factor causes or prevents aging; therefore, it is unrealistic to think that one theory can
explain the complexities of this process. Explorations into biological, psychological, and social aging
continue, and although some of this interest focuses on achieving eternal youth, most sound
research efforts aim toward a better understanding of the aging process so that people can age in a
healthier fashion and postpone some of the negative consequences associated with growing old. In
fact, recent research has concentrated on learning about keeping people healthy and active for a
longer period of time, rather than on extending their lives in a state of long
term disability. Recognizing that theories of aging offer varying degrees of universality, validity, and
reliability, nurses can use this information to better understand the factors that may positively and
negatively influence the health and well-being of persons of all ages.
70
BIOLOGICAL THEORIES OF AGING
The process of biological aging differs not only from species to species but also from one human
being to another. Some general statements can be made concerning anticipated organ changes, as
described in Chapter 5; however, no two individuals age identically (Fig. 2-1). Varying degrees of
physiologic changes, capacities, and limitations will be found among peers of a given age group.
Further, the rate of aging among different body systems within one individual may vary, with one
system showing marked decline while another demonstrates no significant change.
FIGURE 2-1 • Aging is a highly individualized process, demonstrated by the differences between
persons of similar ages.
KEY CONCEPT
The aging process varies not only among individuals but also within different body systems of
the same person.
To explain biological aging, theorists have explored many factors, both internal and external to the
human body, and have divided them into two categories: stochastic and nonstochastic. Stochastic
theories view the
71
effects of aging as resulting from random assaults from both the internal and external environment.
Nonstochastic theories see aging changes resulting from a complex, predetermined process.
72
Stochastic Theories
Cross-Linking Theory
The cross-linking theory proposes that cellular division is threatened as a result of radiation or a
chemical reaction in which a cross-linking agent attaches itself to a DNA strand and prevents normal
parting of the strands during mitosis. Over time, as these cross-linking agents accumulate, they form
dense aggregates that impede intracellular transport; ultimately, the body’s organs and systems fail.
An effect of cross-linking on collagen (an important connective tissue in the lungs, heart, blood
vessels, and muscle) is the reduction in tissue elasticity associated with many age-related changes.
Free Radicals and Lipofuscin Theories

The free radical theory suggests that aging is due to oxidative metabolism and the effects of free
radicals (Hayflick, 1985). Free radicals are highly unstable, reactive molecules containing an extra
electrical charge that 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 can damage proteins, enzymes, and DNA by replacing molecules that contain
useful biological information with faulty molecules that create genetic disorder. It is believed that
these free radicals are self-perpetuating; that is, they generate other free radicals. Physical decline
of the body occurs as the damage from these molecules accumulates over time. However, the body
has natural antioxidants that can counteract the effects of free radicals to an extent. Also,
beta-carotene and vitamins C and E are antioxidants that can offer protection against free radicals.
There has been considerable interest in the role of lipofuscin “age pigments,” a lipoprotein
by-product of oxidation that can be seen only under a fluorescent microscope, in the aging process.
Because lipofuscin is associated with the oxidation of unsaturated lipids, it is believed to have a role
similar to that of free radicals in the aging process. As lipofuscin accumulates, it interferes with the
diffusion and transport of essential metabolites and information-bearing molecules in the cells. A
positive relationship exists between an individual’s age and the amount of lipofuscin in the body.
Investigators have discovered the presence of lipofuscin in other species in amounts proportionate to
the life span of the species (e.g., an animal with one tenth the life span of a human being
accumulates lipofuscin at a rate approximately 10 times greater than human beings).
Wear and Tear Theories

The comparison of the body’s wearing down to machines that lost their ability to function over time
arose during the Industrial Revolution. Wear and tear theories attribute aging to the repeated use
and injury of the body over time as it performs its highly specialized functions. Like any complicated
machine, the body will function less efficiently with prolonged use and numerous insults (e.g.,
smoking, poor diet, and substance abuse).
In recent years, the effects of stress on physical and psychological health have been widely
discussed. Stresses to the body can have adverse effects and lead to conditions such as gastric
ulcers, heart attacks, thyroiditis, and inflammatory dermatoses. However, because individuals react
differently to life’s stresses—one
73
person may be overwhelmed by a moderately busy schedule, whereas another may become
frustrated when faced with a slow, dull pace—the role of stress in aging is inconclusive.
Evolutionary Theories
Evolutionary theories of aging are related to genetics and hypothesize that the differences in the
aging process and longevity of various species occur due to interplay between the processes of
mutation and natural selection (Ricklefs, 1998; Gavrilov & Gavrilova, 2002). Attributing aging to the
process of natural selection links these theories to those that support evolution.
There are several general groups of theories that relate aging to evolution. The mutation
accumulation theory s uggests that aging occurs due to a declining force of natural selection with
age. In other words, genetic mutations that affect children will eventually be eliminated because the
victims will not have lived long enough to reproduce and pass this to future generations. Genetic
mutations that appear late in life, however, will accumulate because the older individuals they affect
will have already passed these mutations to their offspring.
The antagonistic pleiotropy theory suggests that accumulated mutant genes that have negative
effects in late life may have had beneficial effects in early life. This is assumed to occur either
because the effects of the mutant genes occur in opposite ways in late life as compared with their
effects in early life or because a particular gene can have multiple effects—some positive and some
negative.
iffers from other evolutionary theories by proposing that aging is

The disposable soma theory d
related to the use of the body’s energy rather than to genetics. It claims that the body must use
energy for metabolism, reproduction, maintenance of functions, and repair, and with a finite supply of
energy from food to perform these functions, some compromise occurs. Through evolution,
organisms have learned to give priority of energy expenditure to reproductive functions over those
functions that could maintain the body indefinitely; thus, decline and death ultimately occur.
KEY CONCEPT
Evolutionary theories suggest that aging “is fundamentally a product of evolutionary forces, not
biochemical or cellular quirks … a Darwinian phenomenon, not a biochemical one” (Rose,
1998).
Concept Mastery Alert

The evolutionary theory of aging proposes that people are living longer due to the emphasis on
natural selection through reproduction, whereas the biogerontology theory of aging attributes
longer life to the prevention and control of pathogens.
74
Biogerontology
The study of the connection between aging and disease processes has been termed biogerontology
(Miller, 1997). Bacteria, fungi, viruses, and other organisms are thought to be responsible for certain
physiologic changes during the aging process. In some cases, these pathogens may be present in
the body for decades before they begin to affect body systems. Although no conclusive evidence
exists to link these pathogens with the body’s decline, interest in this theory has been stimulated by
the fact that human beings and animals have enjoyed longer life expectancies with the control or
elimination of certain pathogens through immunization and the use of antimicrobial drugs.
75
Apoptosis
Apoptosis is the process of programmed cell death that continuously occurs throughout life due to
biochemical events (Green, 2011). In this process, the cell shrinks and there is nuclear and DNA
fragmentation, although the membrane maintains its integrity. It differs from cell death that occurs
from injury in which there is swelling of the cell and loss of membrane integrity. According to this
theory, this
programmed cell death is part of the normal developmental process that continues
throughout life. Genetic Theories
roposes that animals and

Among the earliest genetic theories, the programmed theory of aging p
humans are born with a genetic program or biological clock that predetermines the life span
(Hayflick, 1965). Various studies support this idea of a predetermined genetic program for life span.
For example, studies have shown a positive relationship between parental age and filial life span.
Additionally, studies of in vitro cell proliferation have demonstrated that various species have a finite
number of cell divisions. Fibroblasts from embryonic tissue experience a greater number of cell
divisions than those derived from adult tissue, and among various species, the longer the life span,
the greater the number of cell divisions. These studies support the theory that senescence—the
process of becoming old—is under genetic control and occurs at the cellular level (Harvard Gazette
Archives, 2001; Martin, 2009; U
niversity of Illinois at Urbana-Champaign, 2002).
lso proposes a genetic determination for aging. This theory holds that genetic
The error theory a
mutations are responsible for aging by causing organ decline as a result of self-perpetuating cellular
mutations, as illustrated in Figure 2-2.
76
FIGURE 2-2 • The error theory proposes a genetic determination for aging.
Other theorists think that aging results when a growth substance fails to be produced, leading to the
cessation of cell growth and reproduction. Others hypothesize that an aging factor responsible for
development and cellular maturity throughout life is excessively produced, thereby hastening aging.
Some hypothesize that the cell’s ability to function and divide is impaired. Although minimal research
has been done to support the theory, aging may be the result of a decreased ability of RNA to
synthesize and translate messages.
77
POINT TO PONDER
What patterns of aging are apparent in your biological family? What can you do to influence these?
Autoimmune Reactions
The primary organs of the immune system, the thymus and bone marrow, are believed to be
affected by the aging process. The immune response declines after young adulthood. The weight of
the thymus decreases throughout adulthood, as does the ability to produce T-cell differentiation. The
level of thymic hormone declines after age 30 and is undetectable in the blood of persons older than
60 years (Goya, Console, Herenu, Brown, & Rimoldi, 2002; Williams, 1995). Related to this is a
decline in the humoral immune response, a delay in the skin allograft rejection time, a reduction in
the intensity of delayed hypersensitivity, and a decrease in the resistance to tumor cell challenge.
The bone marrow stem cells perform less efficiently. The reduction in immunologic functions is
evidenced by an increase in the incidence of infections and many cancers with age.
Some theorists believe that the reduction in immunologic activities also leads to an increase in
autoimmune response with age. One hypothesis regarding the role of autoimmune reactions in the
aging process is that the cells undergo changes with age, and the body misidentifies these aged,
irregular cells as foreign agents and develops antibodies to attack them. An alternate explanation for
this reaction could be that cells are normal in old age, but a breakdown of the body’s
immunochemical memory system causes it to misinterpret normal cells as foreign substances.
Antibodies are formed to attack and rid the body of these “foreign” substances, and cells die.
CONSIDER THIS CASE
You volunteer with a service organization that is involved with

several community projects. Mrs. Janus, one of the volunteers you work with, shares with you
and the other volunteers that she and her husband have become distributors for “a fantastic
product that makes you look and feel younger.” She claims they have been using the product
for nearly a year and have seen significant improvements in the way they look and feel. The
couple is in their 70s and are attractive and
78
active.
Mrs. Janus passes out invitations to you and the other volunteers to attend a meeting at
their home to learn more about the products. Many of the volunteers show considerable
interest and indicate they will attend. One of the volunteers then turns to you and says, “You’re
a nurse. Do you think these things work?”
THINK CRITICALLY
How can consumers judge the validity of claims of antiaging products?
What evidence-based advice can be given to aging persons to help them reduce the
potential for some of the negative outcomes of aging?
Neuroendocrine and Neurochemical Theories

Neuroendocrine and neurochemical theories suggest that aging is the result of changes in the brain
and endocrine glands. Some theorists claim that specific anterior pituitary hormones promote aging.
Others believe that an imbalance of chemicals in the brain impairs healthy cell division throughout
the body.
Radiation Theories
The relationship between radiation and age continues to be explored. Research using rats, mice,
and dogs has shown that a decreased life span results from nonlethal doses of radiation. In human
beings, repeated exposure to ultraviolet light is known to cause solar elastosis, the “old age” type of
skin wrinkling that results from the replacement of collagen by elastin. Ultraviolet light is also a factor
in the development of skin cancer. Radiation may induce cellular mutations that promote aging.
Nutrition Theories
The importance of good nutrition throughout life is a theme hard to escape in our nutrition-conscious
society. It is no mystery that diet impacts health and aging. Obesity is shown to increase the risk of
many diseases and shorten life (NIDDK, 2001; Preston, 2005; Taylor & Ostbye, 2001).
The quality of diet is as important as the quantity. Deficiencies of vitamins and other nutrients and
excesses of nutrients such as cholesterol may cause various disease processes. Recently,
increased attention has been given to the influence of nutritional supplements on the aging process;
vitamin E, bee pollen, ginseng, gotu kola, peppermint, and kelp are among the nutrients believed to
promote a healthy, long life (Margolis, 2000; Smeeding, 2001). Although the complete relationship
between diet and aging is not well understood, enough is known to suggest that a good diet may
minimize or eliminate some of the ill effects of the aging process.
KEY CONCEPT
79
It is beneficial for nurses to advise aging persons to scrutinize products that claim to cause, stop, or
reverse the aging process.
Environmental Theories
Several environmental factors are known to threaten health and are thought to be associated with
the aging process. The ingestion of mercury, lead, arsenic, radioactive isotopes, certain pesticides,
and other substances can produce pathologic changes in human beings. Smoking and breathing
tobacco smoke and other air pollutants also have adverse effects. Finally, crowded living conditions,
high noise levels, and other factors are thought to influence how we age.
POINT TO PONDER
Do you believe nurses have a responsibility to protect and improve the environment? Why or why
not? 80

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What evidence-based advice can be given to aging persons to help them reduce the potential for some of the negative outcomes of aging?

What evidence-based advice can be given to aging persons to help them reduce the potential for some of the negative outcomes of aging?

What are some of the theories discussed around what causes the aging process?

What are some of the theories discussed around what causes the aging process?

Gerontological

Charlotte Eliopoulos, ​PhD, MPH, RN

Acquisitions Editor: ​Natasha McIntyre

Copyright © 2018 Wolters Kluwer

Cataloging in Publication data available on request from publisher

Copyright © 2018 Wolters Kluwer

Cataloging in Publication data available on request from publisher

Unit 2, ​Foundations of Gerontological Nursing​, provides an understanding of the development

Learning Objectives ​prepare the reader for outcomes anticipated in reading

Teaching and Learning Package

and students. ​Resources for Instructors

Resources for Students

A Fully Integrated Course Experience

Simulation and Other Resources

vSim for Nursing | Gerontology,​ a virtual simulation

Lippincott DocuCare ​(available via

Carol Amann, ​PhD, RN-BC, CDP

Jan Atwell, ​MSN, RN

Clinical Assistant Professor

Judy L. Barrera, ​RN, CNS

Clinical Learning Lab Coordinator

Evelyn Biray, ​RN, MS, PMed, CCRN, CMSRN

Celeste Brown-Apoh, ​RN, MSN

Jean Burt, ​MSN, RN

Nicola Contreras, ​MSN, RN

Sherri Cozzens, ​RN, MS

Jodie Fox, ​MSN, RN-BC

Florida Freeman, ​PhD, MSN, RN

Betsy D. Gulledge, ​PhD, RN, CNE,

Kris Hale, ​MSN, RN

Cheryl Harrington, ​MSN, RN, MHA

Clinical Simulation Specialist

Mary Jane Holman, ​RN

Laly Joseph, ​DVM, DNP, MSN, RN, C, ARNP,

BC Clinical Assistant Professor

Health Science Division Director

Debora Lemon, ​MN, RN

Susan McClendon, ​MSN, RN, CNS

GNP-BC Assistant Clinical Professor

Jon F. Nutting, ​MA, RN-BC

Teresa M. Page, ​DNP, EdS, MSN, RN,

FNP-BC Assistant Professor of Nursing

LoriAnn Pajalich, ​MS, RN, CNS,

GCNS-BC Assistant Professor of Nursing

Cordelia Schaffer, ​MSN, RN, CHPN

Program Coordinator, Year 2

Maura C. Schlairet, ​EdD, MA, MSN, RN, CNL

(A/H) Professor of Nursing

Nichole Spencer, ​MSN, APRN, ANP-C

Assistant Professor of Nursing

Carolyn Sue-Ling, ​MSN, MPA, RN

Michael T. Valenti, ​AAS, BS, MS

Assistant Professor of Nursing

Stephanie Vaughn, ​PhD, RN, CRRN,

FAHA Professor/Director School of Nursing

Charlotte Eliopoulos, PhD, MPH, RN

Acquisitions Editor: Natasha McIntyre

Unit 2, Foundations of Gerontological Nursing, provides an understanding of the development

Learning Objectives prepare the reader for outcomes anticipated in reading

and students. Resources for Instructors

vSim for Nursing | Gerontology, a virtual simulation

Lippincott DocuCare (available via

Carol Amann, PhD, RN-BC, CDP

Jan Atwell, MSN, RN

Judy L. Barrera, RN, CNS

Evelyn Biray, RN, MS, PMed, CCRN, CMSRN

Celeste Brown-Apoh, RN, MSN

Jean Burt, MSN, RN

Nicola Contreras, MSN, RN

Sherri Cozzens, RN, MS

Jodie Fox, MSN, RN-BC

Florida Freeman, PhD, MSN, RN

Betsy D. Gulledge, PhD, RN, CNE,

Kris Hale, MSN, RN

Cheryl Harrington, MSN, RN, MHA

Mary Jane Holman, RN

Laly Joseph, DVM, DNP, MSN, RN, C, ARNP,

Debora Lemon, MN, RN

Susan McClendon, MSN, RN, CNS

Jon F. Nutting, MA, RN-BC

Teresa M. Page, DNP, EdS, MSN, RN,

LoriAnn Pajalich, MS, RN, CNS,

Cordelia Schaffer, MSN, RN, CHPN

Maura C. Schlairet, EdD, MA, MSN, RN, CNL

Nichole Spencer, MSN, APRN, ANP-C

Carolyn Sue-Ling, MSN, MPA, RN

Michael T. Valenti, AAS, BS, MS

Stephanie Vaughn, PhD, RN, CRRN,

Erica Williams-Woodley, MSN, NP

Jane Zaccardi, MA, RN, GCNS-BC

UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6

UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32

UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6

UNIT 3 HEALTH PROMOTION 11

Adults 12 Sleep and Rest

And Function Lighting

Conditions Recognizing Symptoms

Considerations Dry Mouth (Xerostomia)

Conditions 22 Reproductive System

Conditions Managing Pain

Conditions Promoting Independence

Interventions Visual Deficits

Deficits 26 Endocrine Function

Considerations Diabetes Mellitus

UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32