Chapter 13: Geriatric Nursing — Aging, Polypharmacy, and End-of-Life Care

Older adults are the fastest-growing segment of the population and the highest consumers of healthcare. Geriatric nursing requires understanding how aging alters physiology, pharmacology, and the presentation of illness — while maintaining the dignity and autonomy of every patient.

Normal Changes of Aging

System	Normal Age-Related Changes	Clinical Implications
Cardiovascular	Decreased cardiac reserve, arterial stiffness	Orthostatic hypotension; slower response to fluid changes
Respiratory	Decreased lung elasticity, reduced cough reflex	Atelectasis risk; aspiration pneumonia
Renal	GFR decreases ~1% per year after age 40	Drug accumulation; monitor creatinine
Neurological	Decreased dopamine, acetylcholine; slower reflexes	Fall risk; delirium susceptibility
Musculoskeletal	Sarcopenia, decreased bone density	Falls, fractures, limited mobility
Skin	Thinning, decreased moisture, reduced sensation	Pressure injury risk; poor wound healing
Immune	Immunosenescence	Atypical infection presentation; reduced fever response

Atypical presentation in older adults: infection may present as confusion, falls, or anorexia rather than classic fever/WBC elevation.

Polypharmacy

Polypharmacy is defined as the concurrent use of 5 or more medications. It is prevalent in older adults and associated with adverse drug events, falls, hospitalizations, and death.

The Beers Criteria (AGS): identifies medications that are potentially inappropriate in older adults. Key categories:

• Antihistamines (diphenhydramine): anticholinergic effects — confusion, urinary retention, falls
• Benzodiazepines: fall risk, cognitive impairment, respiratory depression
• NSAIDs: GI bleeding, renal impairment, fluid retention
• Skeletal muscle relaxants (cyclobenzaprine): sedation, anticholinergic effects
• Oral hypoglycemics (glibenclamide/glyburide): prolonged hypoglycemia in elderly
• Antipsychotics: increased mortality in dementia patients (black box warning)

Fall Prevention

Falls are the leading cause of injury death in adults ≥ 65. Risk factors: gait instability, polypharmacy (≥4 medications), vision impairment, orthostatic hypotension, incontinence, environmental hazards.

ABCDE of Fall Prevention: A — Assess risk (Morse Fall Scale), B — Bed alarm, C — Call light within reach, D — De-clutter environment, E — Educate patient/family.

Delirium vs. Dementia

Feature	Delirium	Dementia
Onset	Acute (hours to days)	Gradual (months to years)
Course	Fluctuating	Progressive
Consciousness	Impaired (clouded)	Usually intact until late
Reversibility	Often reversible if cause treated	Largely irreversible
Common causes	Infection, medications, metabolic	Alzheimer’s, vascular, Lewy body

Delirium prevention (HELP protocol): orientation, early mobilization, sleep hygiene, hearing/vision aids, hydration.

End-of-Life Care

Palliative care: improving quality of life for patients and families facing life-threatening illness — can be provided alongside curative treatment.

Hospice care: comfort-focused care for patients with prognosis ≤ 6 months; patient has chosen not to pursue curative treatment.

Signs of imminent death: Cheyne-Stokes respirations, mottling (livedo reticularis), cooling of extremities, fixed/dilated pupils, jaw relaxation, death rattle (secretions).

Nursing role: expert symptom management (pain, dyspnea, nausea), dignity preservation, family support, spiritual care, clear communication about goals of care.

Advance Directives: Living Will, POLST (Physician Orders for Life-Sustaining Treatment), Healthcare Proxy/DPOAHC.

Key Checklist

• Identify five medications on the Beers Criteria and explain the specific risk each poses in older adults
• Distinguish delirium from dementia using four clinical features and describe two evidence-based delirium prevention strategies
• Describe five signs of imminent death and explain the nurse’s role in supporting the patient and family during the dying process