GERIATRIC CARE - Health Care - ثالث ثانوي

التعليم Link to digital lesson CHAPTER www.ien.edu.sa 2 GERIATRIC CARE Case Study Investigation Reem is living with and taking care of her 87-year-old grandmother Maryam while she is in nursing school. Her grandmother has lost her hearing; her eyesight is dimming, and she is losing weight, strength, and endurance. Maryam loves to be with people, but her husband and many of her friends have passed away. She has become forgetful and no longer goes out; she misses meeting her friends. At the end of the chapter, you will be asked to list the ways in which Maryam is experiencing the physical and emotional changes associated with aging. LEARNING OBJECTIVES After completing this chapter, you should be able to: • Differentiate between the myths and facts of different aspects of aging. Identify at least two physical changes in aging in each body system. • Demonstrate methods of providing care to the elderly individual who is experiencing physical changes of aging. List five factors that cause psychosocial changes in aging. ⚫ Describe at least six methods to assist an elderly individual in adjusting to psychosocial changes. Describe the causes and effects of confusion and disorientation in the elderly. • Create a reality orientation program. KEY TERMS Alzheimer's disease cerebrovascular accident arteriosclerosis delirium incontinence nocturia arthritis dementia osteoporosis atherosclerosis dysphagia dyspnea autonomy bronchitis cataracts 60 CHAPTER 2 ucation GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 60 emphysema glaucoma reality orientation senile lentigines thrombus transient ischemic attacks (TIAS) 14/06/2023 10:26

INTRODUCTION A survey from the Saudi General Authority for Statistics carried out in 2017 (the Saudi Elderly Survey) found that there were 1,050,885 people aged 65+ years living in Saudi Arabia, making up 3.23% of the total population. Today, most individuals can expect to live into their 70s, and many individuals enjoy healthy and happy lives into their 80s and 90s (Figure 2-1A). In each age group, women generally live slightly longer than their male counterparts (Figure 2-1B). This age group uses health care services frequently, so it is essential for a health care provider to understand the special needs of the elderly population. Percentage of total population 45% 39.4% 40% 35% 30% 25% 20% 15% 10% 5% 0% 65-69 26.3% 18.7% 15.7% 70-74 75-79 Age (years) FIGURE 2-1A Percentage of people over 65 years of age in Saudi Arabia identified in the 2017 Saudi Elderly Survey. Percentage split 52% 51% 50% 49% 48% 47% 46% 65-69 70-74 75-79 80+ Age (years) Men Women 80+ FIGURE 2-1B Difference in percentages of men and women aged 65 years and over identified in the 2017 Saudi Elderly Survey. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 61 GERIATRIC CARE 61 | 14/06/2023 10:26

62 CHAPTER 2 وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 62 2:1 MYTHS ABOUT AGING Aging is a normal process and leads to normal changes in body structure and function. Even though few people want to grow old, it is a natural event in everyone's life. Gerontology is the scientific study of aging and the problems of the old. Geriatric care is care provided to older individuals. Through the study of the aging process and the elderly, many facts on aging have been established. However, many myths, or false beliefs, still exist regarding aging and elderly individuals. It is essential for the health care provider to be able to distinguish fact from myth when providing geriatric care. Myth: Anyone over a certain set age, such as 65, is "old." • Fact: Old is determined less by the number of years lived and more by how an individual thinks, feels, and behaves. For example, to a 10-year-old, a 35-year-old is old. It is important to remember that many individuals are active, productive, and self-sufficient into their 80s and even 90s. Too often, the term old becomes synonymous with worthless or worn-out. Better terms would be experienced or mature. . Myth: Elderly people are incompetent and incapable of making decisions or handling their own affairs. • Fact: Older individuals may make better decisions and judgments because they frequently base their decisions on many years of experience and knowledge. In addition, studies have proved that older people are able to concentrate, learn new skills, and evaluate new information. Myth: All elderly people lose their memory. • • Fact: It is not inevitable that you will lose memory function as you age. In the 2017 Saudi Elderly Survey, only 1.2% of people over 65 had Alzheimer's disease. There are many things that you can do to train your brain and maintain your memory, such as solving crosswords or complex puzzles. Even though some older people do experience confusion and disorientation, the majority of elderly individuals remain mentally competent until they die. Myth: Being old means being sick or disabled. • Fact: Because of healthier lifestyles, better nutrition, regular exercise, preventive health care, new medications, and technological advances, most elderly individuals are in general good health. Having good access to health care, stress reduction, and maintaining a proper body weight are additional factors that can help to slow the aging process. Advancements in diagnosing and treating heart disease, hypertension, diabetes, and similar chronic conditions have also improved the general health of the elderly. Today, many individuals in their 80s and 90s have no major disabilities or illnesses, and have a good quality of life. 14/06/2023 10:26

Myth: Elderly individuals do not want to work—that is, the goal of the elderly is to retire and, prior to retirement, they lose interest in work. • Fact: Many individuals remain productive into their 70s and even 80s (Figure 2-2). In Saudi Arabia, 22% of older men continue to work beyond the age 65. Studies have shown that the older employee has good attendance, performs efficiently, and readily learns new skills. Employers, desiring good work ethics and experience, frequently recruit and hire older employees. Many retired individuals do not want a full-time job, but they return to part-time positions or serve as consultants or volunteers. Myth: Retired people have nothing to do with their lives. • Fact: Many retired people enjoy full and active lives. They engage in travel, hobbies, sports, social activities, family events, and community activities.The Saudi Elderly Survey found that many older people undertake voluntary work in religious, social, cultural, and other areas of life. checkpoint 1. What is gerontology? 2. Why are more elderly individuals in general good health? FIGURE 2-2 Many individuals remain productive into their 70s and even 80s. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 63 GERIATRIC CARE 63 14/06/2023 10:26

64 CHAPTER 2 عزوة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 64 2:2 PHYSICAL CHANGES IN AGING As aging occurs, certain physical changes occur in all individuals. These changes are a normal part of the aging process. It is important to note that most of the changes are gradual and take place over a long period. In addition, the rate and degree of change varies among individuals. Physical structures and functions are affected by disease and can increase the speed and degree of the changes. Lifestyle, nutrition, social environment, and limited access to medical care can also have effects. Most physical changes in aging involve a decrease in the function of body systems. Body processes slow down. There is a corresponding decrease in energy level. If an individual can recognize these changes as a normal part of aging, the individual can usually learn to adapt to and cope with the changes. INTEGUMENTARY SYSTEM Some of the most obvious effects of aging are seen in the integumentary system (the outermost layer of the body—skin, hair, nails, and glands) (Figure 2-3): . Production of new skin cells decreases with age. The sebaceous (oil) and sudoriferous (sweat) glands become less active. FIGURE 2-3 Some of the most obvious effects of aging are seen on the skin. 14/06/2023 10:26

• Circulation to the skin decreases and causes coldness, dryness, and poor healing of injured tissue. The hair loses color, and hair loss occurs. Decreases in body function lead to physical or structural changes: The skin becomes dry, less elastic, and fragile, making it prone to skin tears and injury. • Itching is common. Dark yellow or brown colored spots, called senile lentigines, appear. When the structure of the fatty tissue layer of the skin diminishes, lines and wrinkles develop. • The nails become thick, tough, and brittle. • A decrease in fatty tissue and poor circulation causes the older adult to frequently feel cold. Hypothermia, a below-normal body temperature, can be a serious problem for the elderly. Good skin, nail, and hair care are essential: • • • Mild soaps should be used as many soaps cause dryness. Bath oils or moisturizing lotions are recommended to combat dryness and itching. Daily baths can also contribute to dry, itchy skin; baths or showers two or three times a week with partial baths on other days are recommended. Brushing the hair helps stimulate circulation and production of oil. Any sores or injuries to the skin should be cared for immediately. It is important to keep injured areas clean and free from infection. • When elderly people notice sores or injuries that do not heal, they should get medical help. Frequently, the elderly person requires a room temperature that is higher than normal and free from drafts. Proper diet, exercise, good hygiene, decreased sun exposure, use of sunscreen while outdoors, and careful skin care can help to slow and even decrease the normal physical changes in the integumentary system. MUSCULOSKELETAL SYSTEM As aging occurs, muscle structures lose tone, volume, and strength. Examples of degenerative diseases in aging include: Osteoporosis, a condition in which calcium and other minerals are lost from the bones, causes the bones to become brittle and more likely to fracture or break. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 65 GERIATRIC CARE 65 | 14/06/2023 10:26

66 CHAPTER 2 وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 66 Arthritis, an inflammation of the joints, causes the joints to become stiff, less flexible, and painful. The ribcage becomes more rigid, and the bones in the vertebral column press closer together (compress). These physical and structural changes cause the elderly individual to experience a gradual loss in height, decreased muscular function and mobility, and weakness. Movement is slower, and the sense of balance is less sure. Falls occur easily and often result in fractures of the hips, arms, or legs. Fine finger movements, such as those required when buttoning clothes or tying shoes, are often difficult for the elderly individual. • Elderly individuals should be encouraged to exercise as much as their physical conditions permit (Figure 2-4). This helps to keep muscles active and joints as flexible as possible. Even slow, daily walks help to maintain muscle tone. Range-of-motion exercises can also maintain muscle strength. • A diet rich in protein, calcium, and vitamins can slow the loss of minerals from the bones and maintain muscle structure. Medications, together with a daily intake of calcium and vitamin D, can slow the progress of osteoporosis. Extra attention must be paid to the environment so it is safer for the elderly person. Grab bars in the bathroom, handrails in halls and on stairs, and other similar devices aid in ambulation. • When the sense of balance is poor, an elderly person may need support during ambulation. The use of walkers and quad canes is frequently recommended. In addition, well-fitting shoes with nonslip soles and flat heels can help prevent falls. Self-stick strips and bands can replace buttons and shoestrings to make dressing easier. FIGURE 2-4 Elderly individuals should be encouraged to exercise as much as their physical conditions permit. 14/06/2023 10:26

• A consultation with a physician, physical therapist, or occupational therapist can provide an elderly individual with information on the latest and most effective adaptive devices to maintain independence. CIRCULATORY SYSTEM In the circulatory system, the heart muscle becomes less efficient at pushing blood into the arteries, and cardiac output decreases with aging. Structurally, the blood vessels narrow and become less elastic. Blood flow to the brain and other vital organs may decrease. Blood pressure may increase or decrease. Many elderly individuals do not notice any changes while at rest. They are more aware of functional changes when exercise, stress, excitement, illness, and other similar events call for increases in the body's need for oxygen and nutrients. During these periods, they experience weakness, dizziness, numbness in the hands and feet, and a rapid heart rate. Elderly individuals who experience circulatory structural and functional changes should avoid strenuous exercise or overexertion. They need periods of rest during the day. Moderate exercise, according to the individual's ability to tolerate it, stimulates circulation and helps to prevent the formation of a thrombus, or blood clot. Support stockings, antiembolism hose, and not using garters or tight bands around the legs also help prevent blood clots. If an individual is confined to a bed or wheelchair, range-of-motion exercises help circulation. If high blood pressure is present, a diet low in salt or sodium and, in some cases, fat may be recommended. Individuals with circulatory system disease should follow the diet and exercise plans recommended by their doctors. RESPIRATORY SYSTEM Respiratory muscles become weaker with age. The ribcage becomes more rigid. The alveoli (air sacs in the lungs) become thinner and less elastic, which decreases the exchange of gases between the lungs and bloodstream. The bronchioles (air tubes in the lungs) also lose elasticity. Structural changes in the larynx lead to a higher-pitched and weaker voice. Chronic conditions such as emphysema, in which the alveoli lose their elasticity, or bronchitis, in which the bronchioles become inflamed, decrease the efficiency and function of the respiratory system even more severely. • These structural changes frequently cause the elderly individual to experience dyspnea, or difficult breathing. Breathing becomes more rapid, and they have difficulty coughing up secretions from the lungs. This makes them more susceptible to respiratory infections such as colds and pneumonia. • Learning to alternate activity with periods of rest is important to avoid dyspnea. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 67 GERIATRIC CARE 67 | 14/06/2023 10:26

FIGURE 2-5 Individuals who remain mentally active usually show fewer mental changes. 2ABO 3 5 JKL 6 7 PORS 8 TUV *O M1 MNO 9WXYZ M2 # FIGURE 2-6 Large numbers on a cell phone can help improve vision. • Proper body alignment can also ease breathing difficulties. • The elderly individual with respiratory problems may sleep with two or three pillows elevating the upper body to make breathing easier. . . • Avoiding polluted air, such as that in smoke-filled rooms, is essential. Breathing deeply and coughing at frequent intervals helps clear the lung passages and increase lung capacity. Elderly individuals with chronic respiratory functional issues often use oxygen on a continuous basis. Portable oxygen units allow many individuals to continue to lead active lives. NERVOUS SYSTEM Physical changes to the structures in the nervous system affect many body functions. Blood flow to the brain decreases, and there is a progressive loss of brain cells. This loss of structural functioning interferes with thinking, reacting, interpreting, and remembering. The senses of taste, smell, vision, and hearing diminish. Nerve endings are less sensitive, and there is a decreased ability to respond to pain and other stimuli. • As these structural and functional changes occur, the elderly individual may experience memory loss. Short-term memory is usually affected. For example, an individual may not remember what they ate for breakfast but does remember the entire menu from their retirement party. Long-term memory and intelligence do not always decrease. It may take elderly individuals longer to react, but given enough time, they can think and react appropriately. Individuals who remain mentally active and involved in current events usually show fewer mental changes (Figure 2-5). Studies have shown that most elderly adults remain mentally competent throughout their lifespans. . Changes in vision cause problems in reading small print or seeing objects at a distance. There is a decrease in peripheral (side) vision and night vision. The eyes take longer to adjust from light to dark, and there is an increased sensitivity to glare. Elderly individuals are 68 CHAPTER 2 وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 68 14/06/2023 10:26

also more prone to the development of cataracts, where the normally transparent lens of the eye becomes cloudy or opaque. Glaucoma, a condition in which the intraocular pressure of the eye increases and interferes with vision, is also more common in the elderly. Proper eye care, prescription glasses/lenses, medical treatment of cataract or glaucoma, larger numbers on a cell phone, and proper lighting can all improve vision (Figure 2-6). Hearing loss usually occurs gradually in the elderly. The individual may speak more loudly than usual, ask for words to be repeated, and not hear high-frequency sounds such as the ringing of a telephone. Problems may be more apparent when there is a lot of background noise. For example, an elderly person may not hear well in a crowded restaurant where music is playing and many other people are talking. A hearing aid can help resolve some hearing problems. However, in cases of severe structural nerve damage, a hearing aid will not eliminate the problem. In addition, many individuals resist using hearing aids. If a person wears a hearing aid, it is important to keep the aid in good working condition by changing batteries, keeping the aid clean, and checking to make sure the individual is wearing it correctly. When a person has a hearing impairment, it is important to talk slowly and clearly. Avoid speaking excessively loudly. Facing individuals while talking to them also helps in many situations. Eliminating background noise, such as that produced by a radio or television, also increases the ability to hear. ⚫ A decrease in the senses of taste and smell frequently affects the appetite. Elderly individuals often complain that food is tasteless and add sugar, salt, or pepper. Attractive foods with a variety of textures and tastes may help stimulate the appetite. The decrease in the sense of smell may also make the elderly individual less sensitive to the smell of gas, chemicals, smoke, and other dangerous odors. A smoke detector, chemical detectors, and careful monitoring of the environment can help eliminate this danger. • Decreased sensation of pain and other stimuli can lead to injuries. The elderly are more susceptible to burns, frostbite, cuts, fractures, muscle strain, and many other injuries. At times, elderly people are not even aware of injury or disease because they do not sense pain. It is important for elderly individuals to handle hot or cold items with extreme care, and to be aware of dangers in the environment. Changes in the structure and function of the nervous system usually occur gradually over a long period of time. This allows an individual time to adapt to the changes and learn to accommodate them. However, it is sometimes necessary for someone else to assist when the changes become severe. For example, many elderly individuals continue to drive cars. Because of slower reaction times, however, these individuals may be more prone to having automobile accidents. When an elderly person shows impaired driving ability, it often becomes necessary for a family member or the law to prevent the individual from driving. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 69 GERIATRIC CARE 69 | 14/06/2023 10:26

70 وزارة التعليم Ministry of Education 2024-1446 CHAPTER 2 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 70 DIGESTIVE SYSTEM Physical changes in the digestive system occur when fewer digestive juices and enzymes are produced, the function of muscle action becomes slower and peristalsis decreases, teeth are lost, and liver function decreases. . Dysphagia, or difficult swallowing, is a frequent complaint of the elderly. Less saliva and a slower gag reflex contribute to this problem. In addition, the structural loss of teeth or use of poor-fitting dentures makes it more difficult to chew food properly. Another common complaint is indigestion, which results from slower digestion of foods caused by decreased digestive juices. • Flatulence (gas) and constipation are common because of decreased peristalsis and poor diet. The decreased sensation of taste also contributes to a poor appetite and diet. Good oral hygiene, repair or replacement of damaged teeth, and a relaxed eating atmosphere can contribute to better chewing and digestion of food. Most elderly people find it is best to avoid dry, fried, and fatty foods because such foods are difficult to chew and digest. High-fiber and high-protein foods with different tastes and textures are recommended. Careful use of seasonings and herbs to improve taste also increases appetite. It is important to avoid excessive seasonings because they can cause indigestion. Because metabolism slows, fewer calories are needed to maintain body weight. Careful monitoring of weight is important to prevent obesity. Increasing fluid intake makes swallowing easier, helps prevent constipation, and aids kidney function. URINARY SYSTEM With aging, the kidneys become smaller and less efficient at producing urine. Poor circulation to the kidneys and a decrease in the number of nephrons result in a functional loss of ability to concentrate the urine, which causes a loss of electrolytes and fluids. The ability of the bladder to hold urine decreases. Sometimes the bladder does not empty completely and urine is retained in the bladder—a major cause of bladder infections. The elderly person may find it necessary to urinate more frequently. • Nocturia, or urination at night, is common and disrupts the sleep pattern. Also, retention of urine in the bladder causes bladder infections. Men frequently experience enlargement of the prostate gland, which makes urination difficult and causes urinary retention. • Loss of muscle tone results in incontinence, or the inability to control urination. Incontinence may also result from treatment for prostatic hypertrophy (enlargement of the prostate gland), or from treatment for prostate cancer. 14/06/2023 10:26

Many elderly individuals decrease fluid intake to cut down on the frequent need to urinate. This can cause dehydration, constipation, kidney disease, and infection. Elderly individuals should be encouraged to increase fluid intake to improve kidney function. To decrease incidents of nocturia, most fluids should be taken before evening. Regular trips to the bathroom, wearing clothing that is easy to remove, and using absorbent pads as needed can help the individual who has mild incontinence. Bladder training programs can also help increase bladder capacity and lead to more control over urination in incontinent persons. An indwelling catheter may be needed if all urinary control is lost. When structural changes in the urinary system cause poor functioning of the kidneys, waste substances can build up in the bloodstream and can cause serious illness. It is thus important to keep the kidneys functioning as efficiently as possible. ENDOCRINE SYSTEM Changes in the endocrine system result in increased production of some hormones, such as parathormone and thyroid-stimulating hormone, and decreased production of other hormones, such as thyroxin, estrogen, progesterone, and insulin. Because hormones affect many body functions, several physical changes may occur. The immune system of the body functions less effectively, and elderly individuals are more prone to disease. The basal metabolic rate decreases, resulting in complaints of feeling cold, tired, and less alert (Figure 2-7). Intolerance to glucose can develop, resulting in increased blood glucose levels. FIGURE 2-7 A lap blanket can help when a patient complains of feeling cold. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 71 GERIATRIC CARE 71 | 14/06/2023 10:26

72 CHAPTER 2 وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 72 As with the other body systems, changes in the endocrine system occur slowly over a long period of time. Many elderly individuals are not as aware of changes in this system. Proper exercise, adequate rest, medical care for illness, a balanced diet, and a healthy lifestyle all help decrease the effects caused by changes in hormone activity. REPRODUCTIVE SYSTEM The decrease of the female hormones estrogen and progesterone cause physical changes in a woman's body. In some cases, a weakness in its supporting tissues causes the uterus to sag downward, a condition known as prolapse. Decreasing levels of the male hormone testosterone also produce changes in the male body. SUMMARY Aging causes many physical, structural, and functional changes in all body systems. The rate and degree of the changes vary in different individuals, but all elderly individuals experience some degree of change. Providing means of adapting to and coping with changes allows elderly people to enjoy life even with physical limitations. It is important for all health care providers to learn to recognize changes and provide methods for dealing with them. Tolerance, patience, and empathy are essential. checkpoint 1. Give two specific examples of how the nervous system's functions are affected because of structural changes affecting blood flow to the brain. 2. Why might elderly people be more prone to developing disease? 2:3 PSYCHOSOCIAL CHANGES IN AGING In addition to physical changes, elderly individuals also experience psychological and social changes. Some individuals cope with these changes effectively, but others experience extreme frustration and mental distress. It is important for the health care provider to be aware of the psychosocial changes and stresses experienced by the elderly. 14/06/2023 10:26

WORK AND RETIREMENT Most adults spend a large portion of their days working. Many associate their feelings of self-worth with the jobs they perform. They are proud to state that they are nurses, electricians, teachers, lawyers, or administrative assistants. In addition, social contact while working is a major form of interaction with others. Retirement is often viewed as an end to the working years. Many individuals are able to enjoy retirement and find other activities to replace job roles. Some individuals find part-time or consultant-type jobs after retirement from their primary jobs. Other individuals become active in volunteer work or take part in community or club activities. These individuals find satisfactory replacements for the feelings of self- worth once provided by their jobs. However, some elderly individuals feel a major sense of loss upon retirement. They may experience stress, and they can become depressed. SOCIAL RELATIONSHIPS Social relationships change throughout life. Among the elderly, these changes may occur more frequently. Often, children marry and move away. If a spouse dies, the "couple" image is replaced by one of "widow" or "widower." As a person ages, more friends and relatives die, and social contacts decrease. Some elderly individuals are able to adjust to these changes by making new friends and establishing new social contacts. Mosques and community groups provide many social activities for the elderly. By taking part in these activities, individuals who made friends readily throughout their lives can continue to do so as they grow older. Some elderly individuals find it difficult to cope with the continuous loss of friends and relatives. The death of a spouse is frequently devastating to an elderly individual, especially when a couple has had a close relationship for many years. Psychological help is essential in these cases. LIVING ENVIRONMENTS Changes in living environments create psychosocial changes. Most elderly individuals prefer to remain in their own homes. They feel secure surrounded by familiar environments. The loss of autonomy (self-governance or the ability to decide for oneself by making choices and pursuing a course of action) can be frustrating and upsetting. If the elderly person feels secure, coping becomes much easier. (Figure 2-8) وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 73 GERIATRIC CARE 73 | 14/06/2023 10:26

74 CHAPTER 2 وزوج التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 74 INDEPENDENCE Most individuals want to be independent and self-sufficient. Even 2-year- olds begin to learn autonomy as they assert their right to choose and strive to be independent. Just as children learn that there are limits to independence, the elderly learn that independence can be threatened with age. Physical disability, illness, decreased mental ability, and other factors can all lead to a loss of independence in the elderly. Individuals who once were autonomous and took care of themselves find it necessary to ask others for assistance. After driving for a lifetime, elderly individuals might find that they can no longer drive safely. They may have stopped driving or no longer have personal transportation. They have to depend on others to take them where they need to go. In addition, physical limitations prevent them from cooking meals, washing, cleaning, and, in some cases, even taking care of themselves. Frustration, anger, and depression can develop. Any care provided to elderly individuals should allow as much independence and autonomy as possible. Assistance should be provided as needed for the individual's safety, but the individual should be encouraged to do as much as possible. For example, a health care team member should encourage elderly persons to choose their clothing and dress themselves, even if this takes longer. Self-stick strips can replace buttons to make the task of dressing easier and to provide more independence. This helps the elderly individual to retain a feeling of autonomy, adapt to the situation, and maintain a sense of self-worth. At all times, elderly individuals should be allowed as much choice as possible to help them maintain their individuality. FIGURE 2-8 If the elderly person feels secure, coping becomes much easier. 14/06/2023 10:27

DISEASE AND DISABILITY Elderly people are more prone to disease and disability. Disease is usually defined as any condition that interferes with the normal function of the body. Common examples in the elderly include diabetes, heart disease, chronic obstructive pulmonary disease, arthritis, and osteoporosis. A disability is defined as a physical or mental defect or handicap that interferes with normal functions. Hearing impairments, visual defects, or the inability to walk caused by a fractured hip are examples. Diseases sometimes cause permanent disabilities. For example, a cerebrovascular accident (a stroke) can result in permanent paralysis of one side of the body, or hemiplegia. When disease or disability affects the functioning of the body, an individual may experience psychological problems. When this occurs in an elderly individual already stressed by other changes or circumstances, it can be traumatic. A fractured hip can cause an elderly individual who had been living independently to need to rely more than they want on their family. Disease or disability frequently occurs suddenly and does not allow for gradual adjustment, causing coping to be much more difficult. Sick people often have fears of death, chronic illness, loss of function, and pain. These are normal fears, and these individuals need time to adjust to their situations. Listen to them as they express these fears, and be patient and understanding. If they cannot discuss their feelings, accept this reticence and provide supportive care (Figure 2-9). SUMMARY Psychosocial changes can be major sources of stress in the elderly. As changes occur, the individual must learn to accommodate the changes and function in new situations. It is important to remember that older adults have survived many crises in their lives and have learned many different coping methods. These individuals must be encouraged to use their existing strengths and coping skills. With support, understanding, and patience, the health care provider can assist elderly individuals as they learn to adapt. checkpoint 1. How might elderly individuals adjust to changes to social relationships? 2. In what way can elderly people retain their autonomy? وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 75 GERIATRIC CARE 75 | 14/06/2023 10:27

لعليم 76 CHAPTER 2 Minister of Education 2024- GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 76 FIGURE 2-9 Provide supportive care and listen to sick individuals as they express their fears. 14/06/2023 10:27

2:4 CONFUSION AND DISORIENTATION IN THE ELDERLY Although most elderly individuals remain mentally alert until death, some experience periods of confusion and disorientation. Signs of confusion or disorientation include talking incoherently, not knowing their own names, not recognizing others, wandering aimlessly, lacking awareness of time or place, displaying hostile or combative behavior (Figure 2-10), hallucinating, regressing in behavior, paying less attention to personal hygiene, and being unable to respond to simple commands. CAUSES OF CONFUSION AND DISORIENTATION Delirium is the term used when confusion or disorientation is a temporary condition caused by a treatable condition. Some possible causes include: • Stress or depression caused by physical or psychosocial changes. • Kidney disease, which interferes with electrolyte balance; respiratory disease, which decreases oxygen; and liver disease, which interferes with metabolism. Elderly individuals are more sensitive to medications, and drugs can accumulate in the body and cause confusion and disorientation. • Poor nutrition or lack of fluid intake can interfere with mental ability. FIGURE 2-10 Hostile or combative behavior often signals feelings of frustration or confusion. وزارة التعيه Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 77 GERIATRIC CARE 77 | 14/06/2023 10:27

78 وزارة التعليم Ministry of Education 2024-1446 CHAPTER 2 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 78 Frequently, identification and treatment of any of these conditions decreases and even eliminates the confusion and disorientation. For example, changing a medication or giving it in smaller doses may restore normal function. Disease or damage to the brain can sometimes result in chronic confusion or disorientation: • A cerebrovascular accident, or stroke, which damages brain cells, is one possible cause. A blood clot can obstruct blood flow to the brain, or a vessel can rupture and cause hemorrhaging in the brain. Arteriosclerosis, a condition in which the walls of blood vessels become thick and lose their elasticity, is common in elderly individuals. If the vessels become narrow because of deposits of fat and minerals, such as calcium, the condition is called atherosclerosis. These conditions can cause transient ischemic attacks (TIAs), or ministrokes, which result in temporary periods of diminished blood flow to the brain. Each time an attack occurs, more damage to brain cells results. • Dementia is a loss of mental ability characterized by a decrease in intellectual ability, loss of memory, impaired judgment, personality change, and disorientation. When the symptoms are caused by high fever, kidney infection, dehydration, hypoxia (lack of oxygen), drug toxicity, or other treatable conditions, the condition is called delirium or, in some cases, acute dementia. When the symptoms are caused by permanent, irreversible damage to brain cells, the condition is called chronic dementia. Cerebrovascular accidents, arteriosclerosis, and TIAS can be contributing causes to chronic dementia. One theory suggests that chronic dementia is caused by a complete lack or an inadequate amount of an enzyme. Whatever the cause, chronic dementia is usually regarded as a progressive, irreversible disease. Science Alzheimer's disease is a form of dementia that causes progressive changes in brain cells. Individuals with Alzheimer's disease lack a neurotransmitter, or chemical, that allows messages to pass between nerve cells in the brain. This results in the death of neurons and the development of tangles. Alzheimer's disease can occur in individuals as young as 40 years of age but frequently occurs in those in their 60s and 70s. The cause is unknown, but there are many theories currently being researched. A genetic defect, a missing enzyme, toxic effects of aluminum, a virus, and the faulty metabolism of glucose have all been implicated as possible causes. Whatever the cause, Alzheimer's disease is viewed as a terminal, incurable brain disease usually lasting from three to ten years. 14/06/2023 10:27

FIGURE 2-11 A patient with Alzheimer's disease may forget how common objects are used and have problems with many activities of daily living. وزارة التعليم Ministry of Education 2024-1446 - In the early stages, the individual exhibits self-centeredness, a decreased interest in social activities, memory loss, mood and personality changes, anxiety, agitation, depression, poor judgment, confusion regarding time and place, and an inability to plan and follow through with many activities of daily living (Figure 2-11). - As the disease progresses, night-time restlessness occurs, mood swings become frequent, personal hygiene is ignored, confusion and forgetfulness become severe, perseveration or repetitious behavior occurs, the ability to understand others and speak coherently decreases, weight begins to fluctuate, paranoia and hallucinations increase, and full-time supervision becomes necessary. - In the terminal stages, the individual experiences total disorientation regarding person, time, and place; becomes incoherent and is unable to communicate with words; loses control of bladder and bowel functions; develops seizures; loses weight despite eating a balanced diet; becomes totally dependent; and finally, lapses into a coma and dies. Death is frequently caused by pneumonia, infections, complications from falls, and kidney failure. Progress through the various stages of this disease varies among individuals. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 79 GERIATRIC CARE 79 | 14/06/2023 10:27

CHAPTER 2 80 وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 80 Diagnosing Alzheimer's disease is difficult and can only be confirmed when amyloid plaques are found during an autopsy after death. Testing for Alzheimer's disease is based on individual situations. - Usually, a brain scan (computed tomography or magnetic resonance imaging) is done to rule out other conditions that may mimic the symptoms-such as a neoplasm, hematoma, or cerebrovascular disease. Blood tests may also be done to determine if a chemical or hormonal imbalance or vitamin deficiency is causing the behavior. - - Clinical assessment using diagnostic mental testing that evaluates how questions are answered and tasks are performed provides diagnostic accuracy in many cases. Although there is no cure for Alzheimer's disease, several different medications have shown promise in improving memory and thinking skills in the earlier stages of the disease. Other drugs that act to increase blood flow to the brain and clear away the amyloid plaques are currently being tested. In addition, medications that treat common symptoms of Alzheimer's disease, such as depression or anxiety, may be prescribed. Early diagnosis and intervention is essential. CARING FOR CONFUSED OR DISORIENTED INDIVIDUALS Safety Whatever the cause of confusion or disorientation, certain courses of care should be followed. A primary concern is to provide a safe and secure environment. Dangerous objects such as drugs, poisons, scissors, knives, razors, power tools, cleaning solutions, matches, and lighters should be kept out of reach and in a locked area. If the individual tends to wander, doors and windows should be secure. In severe cases, special sensors may be attached to the leg or wrist of the disoriented individual (Figure 2-12). The sensors alert others if the individual starts to leave a specific area. Many of the sensors also have GPS tracking abilities. 11080516 CTT94.3 215.485 FIGURE 2-12 Special sensors may be attached to the leg or wrist of a disoriented individual. 14/06/2023 10:27

9 11 V T FIGURE 2-13 Activities for a confused or disoriented individual should be kept simple and last for short periods of time. FIGURE 2-14 A large clock can help an elderly individual keep track of time and daily activities. Following the same routine is also important. Meals, baths, dressing, walks, and bedtime should each occur at approximately the same time each day. Any change in routine can cause stress and confusion. Even though the individual should be encouraged to be as active as possible, activities should be kept simple and last for short periods of time (Figure 2-13). A calm, quiet environment is also important. Loud noises, crowded rooms, and excessive commotion can cause the individual to become agitated and even more disoriented. Reality orientation consists of activities that help promote awareness of person, time, and place. The activities can be followed by anyone caring for the confused individual, whether the care is in the home or in a long- term care facility. Some aspects of reality orientation are the following: • Be calm and gentle when approaching the individual. • Address the person by the name they prefer. . • State your name and correct the person if they call you a wrong name. For example, if a patient thinks you are their daughter, say, “I am not your daughter, Fatima. I am Sara, your nurse for today." • Make constant references to day, time, and place: "It is 8 o'clock on Tuesday morning and time for breakfast." • Use clocks, calendars, and information boards to point out time, day, and activities (Figure 2-14). • Maintain a constant, limited routine. Keep the individual oriented to day-night cycles. During the day, encourage the person to wear regular clothes. Also, open the curtains and point out the sunshine. At night, close the curtains, use night lights if necessary, and promote quiet and rest. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 81 GERIATRIC CARE 81 | 14/06/2023 10:27

FIGURE 2-15 Use appropriate touch to communicate with a disoriented individual, unless this causes agitation. Speak slowly and clearly, and ask simple questions. • Never rush or hurry the individual. . . Repeat instructions patiently. Allow time for the individual to respond. Encourage conversations about familiar things. • Allow the individual to reminisce or remember past experiences. • Encourage the use of a television or radio, but avoid overstimulating the individual. Make sure the individual uses sensory aids such as glasses and hearing aids (if needed), and that the devices are in good working order. Keep familiar objects and pictures within view. Avoid moving the person's furniture or belongings. • Do not argue with incorrect statements. Gently provide correct information if the person is able to accept the information without agitation. For example, when a person states it is time to dress for work, say, "You don't have to go to work today. You retired seven years ago. . Use appropriate touch to communicate with the person, unless this causes agitation (Figure 2-15). Avoid arguments or recriminations. When you find an elderly resident in the wrong area, do not say, "You know you are not supposed to be here." Instead, say, "Let me show you how to get to your room." • Encourage independence and self-help. Always treat the person with with respect and dignity. Reality orientation is usually effective during the early stages of confusion or disorientation. In later stages, when the individual is not able to respond, it can cause increased anxiety and agitation. When patient assessment shows that this is occurring, avoid confronting the patient with reality. For example, do not tell a patient who wants to see her husband that her husband died ten years ago. Instead, ask her to tell you about her husband and allow her to reminisce. Provide supportive care to allow the patient to maintain dignity and express feelings. Caring for a confused or disoriented individual can be frustrating at times. Continual assessment of the 82 83jg التعليم Ministry of Education 2024-1446 CHAPTER 2 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 82 14/06/2023 10:27

individual's abilities and problems is needed to design a health care program that will allow the individual to function within the level of their ability. Patience, consistency, and sincere caring are essential on the part of the health care provider. checkpoint 1. What is Alzheimer's disease? 2. List five methods of reality orientation used when caring for confused patients. 2:5 MEETING THE NEEDS OF THE ELDERLY Providing care to the elderly can be a challenging but rewarding experience. It is important to remember that the needs of the elderly do not differ greatly from the needs of any other individual. They have the same physical and psychological needs as any person at any age. However, these needs are sometimes intensified by physical or psychosocial changes that disrupt the normal life pattern. When this occurs, the elderly individual needs understanding, acceptance, and the knowledge that someone cares. Islamic law (Sharia) and the specific values, customs, and traditions of Saudi society call for reverence and respect for the elderly. Supporting the elderly and raising awareness of their rights is important in caring for them. The United Nations General Assembly sets out principles relating to the elderly, which were adopted in 1991: . • Independence: Older people should always have adequate food, water, shelter, clothing, health care, the possibility of gainful employment, education, and training. Participation: The older generation should contribute to making policies that directly affect their well-being. Care: Opportunities for family and health care should be available for the elderly, in their own homes, or in a care or treatment facility. • Self-realization: Older people should have opportunities to develop through access to the educational, cultural, religious, and recreational resources of society in general (Figure 2-16). Dignity: Older people should be enabled to live in conditions of dignity and security, without being subject to any exploitation or abuse, physical or mental, and be treated fairly regardless of their age, gender, racial, or ethnic background, or whether they are disabled, and regardless of their financial status. In 2022, the Saudi Council of Ministers approved a law to protect the rights of elderly people and their care. This law aims to enhance the status وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 83 GERIATRIC CARE 83 | 14/06/2023 10:27

and well-being of the elderly, as well as maintaining their security and safety, protecting their rights, and ensuring their proper family and community care. There are provisions in the law to protect the physical and psychological rights of older people. The law also aims to promote volunteer activities in elderly care and offering special facilities for them in public and commercial places, residential areas, and mosques. Article 27 of the Saudi Basic Law states that: "the state guarantees the right of the citizen and his family, in case of emergency, disease, disability, and old age, and supports the social security system, and encourages institutions and individuals to contribute to charitable works". Initiatives have been developed that aim to improve the quality of life and raise the level of services provided to the elderly in society in general and in care homes. Initiatives within the framework of the National Transformation Program are now establishing models for meeting the needs of the elderly, including health services, physiotherapy, and recreational facilities. In the private sector, there are specialized civil associations for the elderly, whose services cover all regions of the Kingdom. Waqar is a non-profit charitable association that has been set up to support the elderly in Saudi Arabia. The association aims to: Complement the sectors that serve the elderly. • Create programs and initiatives that suit older people, in addition to contributing to improving the types of services provided to them. Raise awareness of the needs of the elderly and their care. Enhance the status of the elderly in society, highlighting their role, and raising awareness of their issues. FIGURE 2-16 Older people should have opportunities to develop through access to the educational, cultural, religious, and recreational resources of society in general. 84 CHAPTER 2 فروة التـ Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 84 wepo apdoad a sara o m© 128 тон заут зале эм Po anaest ડાબી river will cast him 14/06/2023 10:27

Freedom from abuse is another important aspect of care. Abuse of the elderly can be physical, verbal, or psychological. Handling the individual roughly, denying food, water, or medication, yelling or screaming at the person, or causing fear are all forms of abuse. Abuse is sometimes difficult to prove. Frequently, the abuser is a family member or caretaker. Elderly individuals may want to protect the abuser or may even feel that they deserve the abuse. It is important for any health care team member who sees or suspects abuse of the elderly to report it to the proper agency. checkpoint 1. What is Waqar? 2. What should a health care team member do if they see or suspect abuse of an elderly person? Today's Research Tomorrow's Health Care People Living to 200 Years of Age? Aging has always been considered a normal deterioration of the human body. This concept changed when Cynthia Kenyon, a geneticist at the University of California, and her research team discovered a set of genes in worms that seemed to regulate aging. By suppressing the action of one of the genes, Kenyon was able to increase a worm's lifespan by six times and keep it young. Research started with a mutant tiny nematode worm, about 1 millimeter long, that appeared to live about 50% longer than other nematode worms. By looking for mutant genes, Kenyon discovered the daf-2 gene, a gene that controls the aging process. Further research. showed that the daf-2 gene allows body tissues to respond to hormones. The mutant daf-2 gene reduced this activity, making the tissue less responsive to hormones and allowing it to delay the aging process. A second gene, the daf-16 gene, was identified as the "fountain of youth" gene because it promotes youthfulness. These genes allowed the mutant worms not only to delay the aging process but also to remain youthful, similar to a 95-year-old functioning like a 45-year-old. The research showed that aging is regulated by genetics. Kenyon and other researchers are now working with roundworms, organisms as small as commas that get old and wrinkled in only ten days and rarely live longer than two weeks. By altering the worm's DNA daf-2 gene, the researchers were able to increase the roundworm's lifespan to as much as 10-12 weeks. Additional studies throughout the world have shown that people living more than 100 years were more likely to have this same genetic mutation. If additional research can lead to an application of these factors in humans, aging can be postponed, and age- related diseases can be prevented. This is because age is the largest risk factor for many diseases. An individual is much more likely to experience development of a cancerous tumor at age 70 than at age 30. Other researchers using this information are extending the lifespan of mice by more than 30% and are continuing to experiment with other mammals that have genes similar to those of humans. Their goal is to develop drugs that mimic the effects of the genes in the long-lived animals. If they succeed, many of the age-related diseases may be preventable, and individuals may remain youthful and productive throughout their lifespans. وزارة التعـ Case Study Investigation Conclusion Were you able to name several physical and emotional changes that Maryam is experiencing as a part of aging? What are some ways in which Reem can help to support Maryam's efforts to remain autonomous and involved? ци W desi stry of Education -1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 85 GERIATRIC CARE 85 | 14/06/2023 10:27