Assessment of the Older Adult

Chapter 4

Assessment is a crucial foundation of the nursing process which in turn is the foundation of nursing care.

Nursing-focused assessment of older adults occurs across all settings: hospitals, homes, long-term care facilities, senior centers, congregate living units, hospice facilities, and independent or group nursing practices.

Setting dictates the way data collection and analysis are managed.

Introduction

Identify strengths and limitations so that effective and appropriate interventions can be delivered to support, promote, and restore optimum function to prevent disability and dependence.

To ensure a patient-centered approach, take into consideration: the interrelationship between physical and psychosocial aspects of aging; an assessment of the nature of disease and disability and their effects on functional status; tailor the nursing assessment to the individual.

Purpose of Older Adult Assessment

Factors such as:

Reduced ability to respond to stress

Increased frequency and multiplicity of loss

Physical changes associated with normal aging

May combine to place older adults at high risk for loss of functional ability

Interrelationship Between Physical and Psychosocial Aspects of Aging

Aging does not necessarily result in disease and disability.

Chronic disease increases vulnerability to functional decline.

Self-reported vague signs and symptoms such as lethargy, incontinence, decreased appetite, and weight loss can indicate functional impairment.

Physical frailty is a major contributor to the need for long-term care.

The Effects of Disease and Disability on Functional Status

Difficult to differentiate normal age-related findings from indicators of disease or disability

Essential to determine what is “normal” versus what may be an indicator of disease or disability so that treatable conditions are not disregarded

Disease vs. Normal Aging

Decreased response to stress

Altered pharmacokinetic and pharmacodynamic responses to drugs

Decreased immune response

Increased risk for syncope

Increased insulin resistance and glucose intolerance

Assessment Concerns Due to Age-Related Changes

In times of physical and emotional stress, older people will not always exhibit the expected or classic signs and symptoms.

The characteristic presentation of illness in older adults is more commonly one of blunted or atypical signs and symptoms.

Presenting signs and symptoms may be unrelated to the actual problem.

Expected signs and symptoms may not be present at all.

Atypical Presentation of Illness

Delirium is one of the most common, atypical presentations of illness in older adults – sudden change in cognitive function

Dementia is a global, sustained deterioration of cognitive function which includes significant cognitive decline over time, deficits in learning and memory, language, executive function, attention, perceptual and motor skills, and social interactions.

Delirium predominantly affects attention and is typically reversible; dementia predominantly affects memory and is irreversible.

Delirium vs. Dementia

Complex because of multiple associated characteristics of delirium and dementia

Not uncommon for an ACS to be superimposed on dementia

Recognize that only subtle evidence may be present to indicate the existence of a problem

Families and friends can be valuable sources of data regarding the onset, duration, and associated symptoms.

Dementia Assessment

The overall atmosphere established by the nurse should be one that conveys trust, caring, and confidentiality.

Environment is important.

Consider patient needs

Cultural considerations (see cultural awareness box)

Nursing Assessment of the Older Person

Consider sensory and musculoskeletal changes

Provide an environment that gives the opportunity to demonstrate assets and capabilities that allow functioning within the limitations imposed by chronic disease

The Assessment Environment

Is a comprehensive, nursing-focused health assessment providing a subjective account of the current and past health status

Alerts the nurse to focus on key areas of the physical examination requiring further investigation

Topics for health teaching can be identified.

Can serve as a life review

Should include assessment of functional, cognitive, affective, and social well-being

The Nursing Health History

A goal-directed interviewing process helps the patient share the pertinent information.

Guided reminiscence can elicit valuable data and can promote a supportive therapeutic relationship.

Work with the patient to establish the organization of the interview

Consider personal space requirements

Use touch to convey respect, caring, and sensitivity

The Interviewer

Major factors that require special consideration while gathering the health history include: Sensory-perceptual deficits, anxiety, reduced energy level, pain, multiple and inter-related health problems, and a tendency to reminisce.

See Table 4.4 to management these factors

When using EMR face the patient, alternate inputting data with talking to maintain eye contact

The Patient

Health History Format (1 of 2)

Patient profile or biographic data

Family profile

Occupational profile

Living environment profile

Resources and support systems

Descriptions of typical day

Present health status

Medications

Immunization/health screening status

Allergies

Nutrition

Past health status

Family history

Review of systems

Health History Format (2 of 2)

The nurse knows that the best way to obtain an accurate assessment is to implement which of the following? (Select all that apply.)

a. Turn off the television or mute the sound.

b. Provide privacy by closing the curtains.

c. Ask only yes or no questions to keep older adult on task.

d. Request the patient’s family wait in the waiting room.

e. Turn on the over-bed light to increase illumination.

Quick Quiz!

ANS: A, B, E

Answer to Quick Quiz

Determines patient strengths and capabilities, as well as disabilities and limitations

Verifies and gains objective support for subjective findings

Gathers objective data not previously known

SPICES is an efficient acronym to help identify patient problems in six common areas which may lead to increasing mortality risk, increased cost, and longer hospitalizations.

Physical Assessment

Sleep disorders

Problems with eating or feeding

Incontinence (of bowel or bladder)

Confusion

Evidence of falls

Skin breakdown

SPICES

Be alert to the older patient’s energy level

Respect the patient’s modesty

Sequence the assessment to keep position changes to a minimum

Make sure the patient is comfortable

Explain each step in simple terms

Warn of any discomfort that might occur and probe painful areas last

Take advantage of “teachable moments”

General Guidelines

The ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs)

The Katz Index of ADLs

Specialized care units known as acute care for elders (ACE) units have been developed in hospitals around the country to better address these issues.

Functional Status Assessments

Determines the patient’s level of cognitive function (which implies all those processes associated with mentation or intellectual function)

Montreal Cognitive Assessment (MoCA)

The Mini-Cog

The Geriatric Depression Scale—short form GDS

Cognitive/Affective Assessment

Social function is correlated with physical and mental function.

An individual’s social well-being may positively affect his or her ability to cope with physical impairments and the ability to remain independent.

A satisfactory level of social function is a significant outcome in and of itself.

The relationship family plays a central role in the overall level of health and well-being.

Social Assessment

Results can validate history and physical examination findings and identify potential health problems not previously identified.

Laboratory Data

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