Gerontological & Gerontological & Community Community

Based Nursing:Based Nursing:

Psychosocial TheoriesPsychosocial TheoriesCognitive and Social ChangesCognitive and Social Changes

Family roles & Relationships in Aging Family roles & Relationships in Aging

Psychosocial Needs of Older Psychosocial Needs of Older AdultsAdults

Chronologoic, Biologic,Chronologoic, Biologic,Psychological & Social agingPsychological & Social aging

Lifecycle- of agingLifecycle- of aging

Social Theories of AgingSocial Theories of Aging

Disengagement TheoryDisengagement Theory

(Cummings & Henry 1961)(Cummings & Henry 1961) Activity Theory (Maddox 1963)Activity Theory (Maddox 1963) Continuity Theory (Havinghurst Continuity Theory (Havinghurst

et. al. 1968) et. al. 1968) Link between personality traits & Link between personality traits &

how one ages-how one ages-

Bernice Neugarten et. al 1968)Bernice Neugarten et. al 1968)

Social TheoriesSocial Theoriescont’dcont’d Age-Stratification Theory-Age-Stratification Theory-Historical Historical

contest- cohort groupscontest- cohort groups((Marshall 1996Marshall 1996)) Challenges activity & disengagement Challenges activity & disengagement

theories: Structuring of ages- Young-old; theories: Structuring of ages- Young-old; middle-old; Old-oldmiddle-old; Old-old

Encompass social & cultural expressions of Encompass social & cultural expressions of agingaging

Social Exchange Theory- i.e. Social Exchange Theory- i.e. intergenerational programs ( Social intergenerational programs ( Social exchange- elders give back to exchange- elders give back to society/family society/family

Psychosocial Theories of Psychosocial Theories of AgingAging

Jung’s Theories of PersonalityJung’s Theories of Personality- ““Last half of life has purpose of it’s Last half of life has purpose of it’s

own”own”- Time for inner growth, self-Time for inner growth, self-

awareness & reflection.awareness & reflection.

Developmental TheoriesDevelopmental Theories

Eric Erikson’s-Eric Erikson’s- 8 8thth stage of life stage of life

(Ego Integrity vs. Despair)- later reconsidered the (Ego Integrity vs. Despair)- later reconsidered the either /or concept.either /or concept.

Peck(1968) Identified specific developmental Peck(1968) Identified specific developmental task of old agetask of old age::

Ego differentiation VS. role preoccupationEgo differentiation VS. role preoccupation Body transcendence VS. Body preoccupationBody transcendence VS. Body preoccupation Ego transcendence VS. ego preoccupationEgo transcendence VS. ego preoccupation Havinghurst’s Developmental TasksHavinghurst’s Developmental TasksMiddle-age & Later Maturity (Box 7-2)Middle-age & Later Maturity (Box 7-2) Theory of Gerotranscendecnce – similar to Theory of Gerotranscendecnce – similar to

Erikson’s concept of integrity& Maslow’s Self-Erikson’s concept of integrity& Maslow’s Self-actualizationactualization

Spirituality & AgingSpirituality & Aging

Ability to experience /integrate Ability to experience /integrate meaning & purpose in life meaning & purpose in life

A connection with music, art, A connection with music, art, nature, or a greater powernature, or a greater power

Assess /identify elders at risk for Assess /identify elders at risk for Spiritual distressSpiritual distress

Cognition & AgingCognition & Aging

Normal vs. abnormal changesNormal vs. abnormal changes

Memory & CognitonMemory & Cogniton

MemoryMemory Long term memory remains intactLong term memory remains intact Short term memory diminishedShort term memory diminished Processing affected by stressProcessing affected by stress

Cognition in the older adultCognition in the older adult

LearningLearning Use simple association rather than analysisUse simple association rather than analysis Verbal and abstract abilities are approximately Verbal and abstract abilities are approximately

equalequal Basic intelligence unchangedBasic intelligence unchanged Creative thought declinesCreative thought declines Factors that affect learning:Factors that affect learning:

MotivationMotivation Attention spanAttention span Delayed transmissionDelayed transmission Perceptual defecitsPerceptual defecits IllnessIllness

Normal Age-Associated changes Normal Age-Associated changes of the Neurological Systemof the Neurological System Brain changesBrain changes

NeurochemicalNeurochemical StructuralStructural Neuropsychological changesNeuropsychological changes

Small decrease in brain weightSmall decrease in brain weight 7-8% decrease7-8% decrease

Loss of neurons in selective brain Loss of neurons in selective brain structuresstructures Accumulation of neuritic plaques and Accumulation of neuritic plaques and

neurofibrillary tanglesneurofibrillary tangles Neurochemical changesNeurochemical changes

Decreased activity of catecholamine synthesisDecreased activity of catecholamine synthesis Decrease amounts of neurotransmitters: Decrease amounts of neurotransmitters:

serotonin, noradrenaline, and dopamineserotonin, noradrenaline, and dopamine

Normal Age-relatedNormal Age-relatedMemory ChangesMemory Changes

Memory peaks between the Memory peaks between the ages of 20-30ages of 20-30

Followed by a subtle decline Followed by a subtle decline until age 60until age 60

After 60, memory difficulties After 60, memory difficulties become more pronouncedbecome more pronounced

Memory Storage and RetrievalMemory Storage and Retrieval

Short-term memory: lasts 7-10 Short-term memory: lasts 7-10 seconds and can only hold 4-7 items seconds and can only hold 4-7 items at onceat once

Intermediate memory: Lasts 24-48 Intermediate memory: Lasts 24-48 hours.hours.

Long-term memory: What happened Long-term memory: What happened beyond 48 hoursbeyond 48 hours

Successful memory relies on all Successful memory relies on all threethree

Normal Age-Related Normal Age-Related Memory ChangesMemory Changes Slower ThinkingSlower Thinking

All body systems become less efficient with age, All body systems become less efficient with age, including thinking and problem-solving abilities.including thinking and problem-solving abilities.

The speed of learning and recall decreases, so The speed of learning and recall decreases, so it may require more time to learn new things or it may require more time to learn new things or retrieve information.retrieve information.

Difficulty Paying AttentionDifficulty Paying Attention Many memory problems are due to problems of Many memory problems are due to problems of

attention, not retentionattention, not retention Reduction in the ability to concentrate as a Reduction in the ability to concentrate as a

person ages makes it harder to rememberperson ages makes it harder to remember More susceptible to distractions and More susceptible to distractions and

interruptionsinterruptions

Normal Age-Related Normal Age-Related Memory Changes cont’dMemory Changes cont’d More memory cues may be required for More memory cues may be required for

recallrecall Memory cue can be a word, picture, smell, Memory cue can be a word, picture, smell,

rhyme or anything associated with rhyme or anything associated with information/eventsinformation/events

Physical Changes of the Brain that may Physical Changes of the Brain that may affect memoryaffect memory

1.1. Enlargement of the ventricular systemEnlargement of the ventricular system Ventricles enlarge, possibly because the cells Ventricles enlarge, possibly because the cells

surrounding the ventricles are lost.surrounding the ventricles are lost.2.2. Widening of the sulci (the grooves) on the Widening of the sulci (the grooves) on the

surface of the brainsurface of the brain3.3. Reduced brain weight and brain volumeReduced brain weight and brain volume

Probably caused by the loss of neuronsProbably caused by the loss of neurons

Normal Age-Related Normal Age-Related Memory Changes cont’dMemory Changes cont’d Other factors that interfere with Other factors that interfere with

basis memorybasis memory Visual changesVisual changes Hearing changesHearing changes SleepSleep PainPain MedicationsMedications Depression and other mood Depression and other mood

disordersdisorders

Age associated memory Age associated memory changeschanges Forgetting specific details and Forgetting specific details and

names of people, but remembering names of people, but remembering them laterthem later

Able to learn new material but may Able to learn new material but may have difficulty with information have difficulty with information retrievalretrieval

General awareness of memory General awareness of memory impairmentimpairment

Memory impairment does not Memory impairment does not interfere with daily functioninginterfere with daily functioning

Cognitive ImpairmentCognitive Impairment

Currently estimated that over 4 million Currently estimated that over 4 million American have some form of dementiaAmerican have some form of dementia

This number will grow to 14 million by 2050 This number will grow to 14 million by 2050 unless a cure or prevention is foundunless a cure or prevention is found

Each year in the US more than a million Each year in the US more than a million people are newly diagnosed with a chronic people are newly diagnosed with a chronic brain disease or disorderbrain disease or disorder

Currently 10% of people > 65 yo and nearly Currently 10% of people > 65 yo and nearly 50% of those >85 yo have dementia50% of those >85 yo have dementia

Disorders of the Neurological Disorders of the Neurological SystemSystem Alzheimer'sAlzheimer's

Non-reversible and progressive Non-reversible and progressive form of dementia that reduces the form of dementia that reduces the ability to think, remember, reason, ability to think, remember, reason, judge and concentratejudge and concentrate

Eventually prevents performance Eventually prevents performance of ADLsof ADLs

Personality and language abilities Personality and language abilities declinedecline

Accounts for ~66% of dementiasAccounts for ~66% of dementias

Alzheimer’sAlzheimer’s

PrevalencePrevalence 4 million Americans have been 4 million Americans have been

diagnosed with Alzheimer’s type diagnosed with Alzheimer’s type dementiadementia

10% of people >75 y.o. are affected10% of people >75 y.o. are affected 47% of people > 85 y.o. are affected47% of people > 85 y.o. are affected

Risk factorsRisk factors Advanced ageAdvanced age Family history of first-degree relatives Family history of first-degree relatives

diagnosed with ADdiagnosed with AD

Alzheimer’s DiseaseAlzheimer’s Disease

Clinical presentationClinical presentation Progression of symptoms and time Progression of symptoms and time

appearance is unique to the individualappearance is unique to the individual Very early stageVery early stage

Usually considered questionable dementiaUsually considered questionable dementia Forgets names, events, phone numbersForgets names, events, phone numbers Gets lost in familiar surroundingsGets lost in familiar surroundings

Early/Mild stageEarly/Mild stage Loss of recent memoryLoss of recent memory Forgets bills, misplaces itemsForgets bills, misplaces items

Alzheimer’s DiseaseAlzheimer’s Disease

Middle/Moderate stageMiddle/Moderate stage Increased memory lossIncreased memory loss Makes up stories to compensateMakes up stories to compensate WanderingWandering Gait changes to small stepsGait changes to small steps

Late/Severe stageLate/Severe stage Inability to perform ADLsInability to perform ADLs Little response to stimuliLittle response to stimuli Loss of body weight, bodily functionsLoss of body weight, bodily functions Susceptibility to infectionSusceptibility to infection

10 Warning signs of 10 Warning signs of Alzheimer’sAlzheimer’s1.1. Memory LossMemory Loss2.2. Difficulty perfuming familiar tasksDifficulty perfuming familiar tasks3.3. Problems with languageProblems with language4.4. Disorientation to time and placeDisorientation to time and place5.5. Poor or decreased judgmentPoor or decreased judgment6.6. Problems with abstract thinkingProblems with abstract thinking7.7. Misplacing thingsMisplacing things8.8. Changes in mood or behaviorChanges in mood or behavior9.9. Changes in personalityChanges in personality10.10. Loss of initiativeLoss of initiative

Pharmacologic Treatment of Pharmacologic Treatment of Alzheimer’sAlzheimer’s Medications should be used when all other Medications should be used when all other

methods of management have failed and methods of management have failed and the benefits outweigh the risksthe benefits outweigh the risks

Psychotropic medications i.e.Psychotropic medications i.e. AriceptAricept

Donepezil is used to treat mild to moderate Donepezil is used to treat mild to moderate confusion (dementia) related to Alzheimer's confusion (dementia) related to Alzheimer's disease. disease.

An enzyme blocker that works by restoring An enzyme blocker that works by restoring the balance of natural substances the balance of natural substances (neurotransmitters) in the brain.(neurotransmitters) in the brain.

Other Common Problems r/t Other Common Problems r/t Alzheimer’sAlzheimer’s

WanderingWandering Nutrition/HydrationNutrition/Hydration Home SafetyHome Safety

Non-Alzheimer’s DementiaNon-Alzheimer’s Dementia

Development of multiple cognitive Development of multiple cognitive impairments, including the loss of memoryimpairments, including the loss of memory

Attributable toAttributable to Metabolic disorders Metabolic disorders

Thyroid, renal failure, liver failureThyroid, renal failure, liver failure ToxinsToxins Infections and neoplasmsInfections and neoplasms s/e of drugss/e of drugs Nutritional deficienciesNutritional deficiencies Degenerative neurological diseasesDegenerative neurological diseases Cerebral vascular injuries, ischemias,(vascular Cerebral vascular injuries, ischemias,(vascular

dementia) or traumadementia) or trauma

DeliriumDelirium

AKA acute confusional state, acute AKA acute confusional state, acute brain syndrome, toxic psychosis, etc.brain syndrome, toxic psychosis, etc.

Transient cognitive disorder with a Transient cognitive disorder with a rapid onset and brief durationrapid onset and brief duration

Typical clinical presentationTypical clinical presentation Reduced ability to maintain attentionReduced ability to maintain attention Disorganized thinkingDisorganized thinking Difficulty in focusingDifficulty in focusing

Interacting with Patients Interacting with Patients with Dementiawith Dementia Positive interactions can prevent Positive interactions can prevent

frustration for all parties, and help in frustration for all parties, and help in understanding and meeting the understanding and meeting the needs of the patient.needs of the patient.

Techniques to enhance interaction Techniques to enhance interaction and prevent problem behaviorsand prevent problem behaviors Approach the pt from the front, Approach the pt from the front,

establishing eye contact, speaking establishing eye contact, speaking slowly, and using short sentences and slowly, and using short sentences and simple wordssimple words

Interacting with Patients Interacting with Patients with Dementia cont’dwith Dementia cont’d

Ask yes/no questions. An open-ended Ask yes/no questions. An open-ended question is difficult to answer for a cognitively question is difficult to answer for a cognitively impaired patientimpaired patient

Repeat, restate and paraphrase as needed, to Repeat, restate and paraphrase as needed, to help the patient understandhelp the patient understand

Speak literally and in concrete terms. Speak literally and in concrete terms. Abstract thought is difficult for a patient with Abstract thought is difficult for a patient with dementia to interpretdementia to interpret

Break down directions or tasks into simple Break down directions or tasks into simple steps and the cue the patient s needed at steps and the cue the patient s needed at each stepeach step

Refrain from arguing or attempting to use Refrain from arguing or attempting to use logiclogic

Reduce environmental stimulus Reduce environmental stimulus Allow the patient the time to do as much as Allow the patient the time to do as much as

he/she can for him/herselfhe/she can for him/herself

StrokeStroke

Intracerebral hemorrhageIntracerebral hemorrhage Ischemic strokeIschemic stroke TIAsTIAs

Acute focal neurological signs than Acute focal neurological signs than symptoms lasting <24 hourssymptoms lasting <24 hours

Brief stroke-like event resulting in block Brief stroke-like event resulting in block of blood flow to brainof blood flow to brain

Precedes stroke in 50 -70% of casesPrecedes stroke in 50 -70% of cases 1/3 will have a stroke within 5 years1/3 will have a stroke within 5 years

Parkinson’s DiseaseParkinson’s Disease

Early stage PDEarly stage PD First symptoms: mild, slight tremor in First symptoms: mild, slight tremor in

had at rest.had at rest. Purposeful movements such as Purposeful movements such as

brushing teeth become slow and difficultbrushing teeth become slow and difficult Medications: Symmetrol, Elderpryl, Medications: Symmetrol, Elderpryl,

Parlodel, PermaxParlodel, Permax Mid-stage PDMid-stage PD

Increased symptomsIncreased symptoms Decreasing affect of medicationsDecreasing affect of medications Add levodopa (Sinemet)Add levodopa (Sinemet)

Parkinson’s DiseaseParkinson’s Disease

Late-stage PDLate-stage PD Decreasing effects of medicationsDecreasing effects of medications Increasing difficulty with balance, Increasing difficulty with balance,

increased muscle contractions, increased muscle contractions, problems initiating movement, problems initiating movement, involuntary abnormal posture, involuntary abnormal posture, nightmares, orthostatic hypotension, nightmares, orthostatic hypotension, constipation, rigid face, depression, constipation, rigid face, depression, dementiadementia

Newer therapies: Requip, MirapexNewer therapies: Requip, Mirapex

Cognitive AssessmentsCognitive Assessments

Instrumental activities of daily Instrumental activities of daily living (IADL)living (IADL) BathingBathing DressingDressing ToiletingToileting TransferringTransferring ContinenceContinence FeedingFeeding

Cognitive MeasuresCognitive Measures

Mini-Mental State Exam (MMSE)Mini-Mental State Exam (MMSE) 30 item instrument used to screen for 30 item instrument used to screen for

cognitive deficienciescognitive deficiencies Used in determination of dementia or Used in determination of dementia or

deliriumdelirium Tests orientation, short-term memory, Tests orientation, short-term memory,

calculation ability, language and calculation ability, language and constructionconstruction

Must be administered exactly as written Must be administered exactly as written

Roles & Relationships in Older Roles & Relationships in Older AdultsAdults

Close sustaining relationships have a Close sustaining relationships have a positive effectpositive effect ↓ ↓ stressstress ↑ ↑ mental healthmental health ↑ ↑ life satisfactionlife satisfaction Married people have better support Married people have better support

systemsystem Married people have better incomeMarried people have better income Married people have better nutritionMarried people have better nutrition

RelationshipsRelationships

FriendsFriends Shrinking social networkShrinking social network

Organizations & neighborhoodsOrganizations & neighborhoods Promotion of social contactsPromotion of social contacts

Factors that affect social networkFactors that affect social network Family membersFamily members FriendsFriends HealthHealth IndependenceIndependence ““Gerontological orphan”Gerontological orphan”

FamiliesFamilies

RolesRoles What are they?What are they? What have they been?What have they been? How are they changing?How are they changing?

CaregiversCaregivers

May includeMay include FamilyFamily FriendsFriends Paid/unpaid workersPaid/unpaid workers

““giving back”giving back” Can be very stressfulCan be very stressful

CaregiversCaregivers

May includeMay include FamilyFamily FriendsFriends Paid/unpaid workersPaid/unpaid workers

““giving back”giving back” Can be very stressfulCan be very stressful