CARE FOR THE ELDERLY PATIENTS AND CHRONIC DISEASES

GERIATRIC CARE

1. Objectives.
Understanding the aging process.
Identifying the geriatric heath care risks
Explaining the geriatric assessment methods.
Justifying the need for special care for elderly population
Define the elderly population
Understand the giant geriatric syndromes
Explain the meaning of healthy aging
Recognize the common causes of dementia
Discuss the common preventive measures for elderly people
Conceptualizing the role of physician when caring of old person.
The number of elderly persons aged above 65 years are increasing every day. Ageing or growing old, is a
normal physiological (functional) process. Normal changes occur in body structure and function.
Because of these changes, the elderly have special needs. They are also at greater risk for illness, chronic
diseases, and injuries. Many of these persons continue to live healthy and happy. Some live in their own
homes, others live with their relatives. Let us discuss various body changes as person grow old.
Definition of ageing:
Ageing is a physiological process is associated with complex changes in all organs. Aging can be defined
as the decline and deterioration of functional properties at the cellular, tissue, and organ level; the
accumulation of biological changes over time leading to decreased biological functioning and impaired
ability to adapt to stressors.
Aging is a physiological process; it’s associated with complex changes in all organs. 2- The accumulation
of biological changes over time leading to decreased biological functioning and impaired ability to adapt
to stressors.
Ageing is a universal phenomenon comprising of gradual loss of cells leading to deterioration of organ
functions in a human body. Age related alteration affects across the elderly population and their body
function diminishes.
Ageing is not a “disease” but the elderly population are more susceptible to various diseases due to
decreased immune response and poor regenerating capacity.
Healthy aging refers to the process of developing and maintaining the functional ability that enables
well-being in older age.
Principles of Geriatrics:
1.Aging is not a disease:

2.  Aging occurs at different rates.  Between individuals.  Within individuals in different organ systems.
2. Geriatric conditions are chronic, multiple, multifactorial.
3. Reversible conditions are underdiagnosed and undertreated.
4. Function and quality of life are important outcomes.
5. Social support and patient preferences are critical aspects.
6. Geriatrics is multidisciplinary issues.
7. Cognitive and affective disorders prevalent and undiagnosed at early stages
8. Iatrogenic disease common and often preventable.
9. Care is provided in multiple settings.
10. Ethical and end of life issues guide practice.
“The Typical geriatric Patient” 1- Has a Chronic Disease 2- Multiple Co-morbidities 3- Uses Multiple
Drugs 4- Social isolation and poverty 5- ↓ Physiological Function
Common geriatric syndromes.
Dementia & Delerium
Depression
Urinary incontinence
Falls + Gait + Mobility Impairment
Fragility: loss of capacity
Sarcopenia: loss of muscle
Characteristics of elderly
- Frailty 2- Mental problems 3- Polypharmacy and iatrogenic 4- Agitation & anxiety 5- Driving issues 6-
Risk of falls 7- Loss of motivation 8- Executive Function
CARE OF ELDERLY AT HOME
The elderly person must be treated as a human being, as the one who is valuable, irnportant,and
special. You, as home based care providers must also treat the person as someone who thinks, acts, and
make decisions. You will be taking care of elderly persons at home. Each elderly has fears, needs and
rights. This sub-section will help you understand and communicate with persons you serve, help and
care for. The whole person has physical, social, psychological, and spiritual needs which cannot be
separated from each other. Each aspect relates to and depends on others. As a social being, a person
talks and communicates with each other. While caring for old age person, you must keep in mind that
ageing is a normal, process, not an illness or disease.

3. Principles of Care of Elderly at Home
For providing safe care at home, you should follow the principles mentioned below: ,
1)Follow the person's care plan so that the care is the same from day to day.
2)Respect family's beliefs and ways of doing things as far as possible.
3)Provide clean, safe, well ventilated atmosphere to the patient.
4)Keep the environment in and out of the house very clean.
5)- Keep a calm, quiet environment where there is no noise and confusion.
6)Provide safe and secure appliances to the patient at home. Be sensitive to feelings and needs of
an individual.
7)Call the person by name and identify yourself.
8)Explain what you are doing and why you are helping the patient in his care.
9)Provide a clock, calendar, and familiar objects to help the person to become familiar with the
surrounding.
10)Practice hand washing before and after any procedure.
11)Collect facts about home, patient and environment and plan care.
12)Encourage healthy nutrition practices, involve him in his meal planning.
13)Guide the family members to report the observation made by them.
14)You must maintain good interpersonal relations with the patient and their family , members.
As a home based care provider you should remember the following points while' 'taking care of
elderly:
1)Promotion of Self Respect and Dignity
Encourage the maximum of personal choice, decision-making and participation in their own
care on the part of the patients. Respect for the elderly person's feelings and emotions should
be shown. Limitation of physical and mental abilities does not mean that the individual should
be treated as being incapable of normal human feeling an? responses. When HBCP makes
positive efforts to develop good relationships with patients and gain their individual respect and
friendship in difficult situations of personal relationship then resistance to treatment are greatly
reduced and it becomes easier to take care as well as get cooperation from the person.
Confused people may not know their family members and may not know where they are. Some
people are unable to remember how to perform their daily grooming when they become
confused. The person who is confused may become angry, frightened, or withdrawn. Hostile
and aggressive behaviour is intensified if met with aggression and unnecessary restraint. The
HBCP should find out underlying reasons for the patient's anger and frustration. Care of the
Elderly
2) The Approach to the Patient Elderly patients may have difficulty in understanding what is
said to them because of loss of sensory functions. They should be spoken to clearly and face-to
face. It is undignified to discuss the patient's bladder and bowel problems and other personal
matters loudly in the presence of other people. Elderly people will regress and start behaving in
a childish manner if they are treated with indifference towards their feeling and pride.

4. 2)Daily Living Activities
The patient is encouraged to be out of bed as much as possible so as to promote mobility, to
reduce the risk of complication such as pressure sores and stiffness of joint. Independence
encourages self-respect. . Cleanliness and personal tidiness are important to health and safety.
Let the elderly follow their own routine and pattern of daily living. Support in the carrying out of
daily routine like bath, dressing etc.
4) Promotions of Comfort
Physical and mental comfort and relaxation has to be achieved. There are many factors that
contribute to the comfort of the elderly patient. Special points for the elderly care are: • Care of
skin • Care of bony structure • Maintain temperature. • Fluid balance
5) Safety
It is very important part of care to provide safety needs while taking care of elderly at home.
Such as unpolished floors wood help the person against slipping on the floor, good lighting, less
furniture for easy movement and mobility, correct ~eight of beds, chairs and the provision of
walking aids, hand-rails can help towards safety .. of elderly. ' Constant observations and
support has to be provided for elderly especially for those with some degree of confusion and
for the restless patients.
6) Promotion of Independence The patient is encouraged to the maximum possible level of self-
care and decision making. Dressing and undressing, toileting, bathing, walking, planning their
daily activities or their future living pattern are all activities in which elderly should be involved
themselves as much as possible, rather than having done for them with little or no participation.
It is useful for those who are able, to draw their own pension, shop for their own needs, have
trips out with relatives or voluntary helpers, atte~d local services or join in activities oflocal
community groups such as Mahila Mandal for religious activities, yoga, group of elders etc.
7) Promotion of Movement and Mobility The elderly is encouraged to be out of bed as much as
possible, according to capabilities and needs. Movement and mobility should continue
throughout the elderly care. The prevention of further deterioration is an important aspect of
geriatric care and movement and activity is continue even where it is considered unlikely that
the patient will be able to achieve full mobility. Keep movements possible according to
tolerance of the person.
8) Promotion of Mental Activity and Interests
Allow for mental activity. Meet recreational need by allowing music, television, playing with
grandchildren, participating in religious meetings as far as possible.
9) Rehabilitation
Rehabilitation for the elderly includes all those activities which aim at restoring the patient to
the highest possible degree of independent living of which he or she is capable which included
physiotherapy.

5. FALLS
Falls and fractures
Elderly people are often at risk of falling.
Falling may cause fractures of bone easily for the elderly since bones grow weaker with
ageing.
Caregivers should be advised to accompany elderly while walking, going for bathing,
toilet etc.
’ They should also be informed about assistive devices like walking stick, walker etc.
’ If there is any recent fall that has caused a wound or a bruise, you should notify the
CHO.
’ Falls are multifactorial. This may be due to Intrinsic and Extrinsic factors
’ Extrinsic factors include:
ƒ Slippery bath room
ƒ Unsafe floor/stair case
ƒ Poor lighting
ƒ Unsafe kitchen
ƒ Inappropriate use of walkers & crutches
Intrinsic reasons include:
ƒ Acute illness
ƒ Lower limb muscle weakness
ƒ Medications like sedatives etc
ƒ Foot problems
ƒ Problems in vision, hearing.
falls per year with consequences, Such as: 1- Death 2- Injury 3- Hip Fractures 1-2% 4- Fractures in
general 10-15% 5- Reduced Activity due to Fear of Falling
1-Disease: ❖ Dementia ❖ Depression ❖ Drugs ❖ Foot problems ❖ Incontinence
2-Age: ❖ Gait/Balance Disorder ❖ Sarcopenia ❖ Vestibular ❖ Orthostatic Hypotension ❖ Special
Senses –Vision/Hearing
Blackouts
y Syncope
y Seizure
Environmental hazards
y Clutter
y Slippery Floor
y Poor lighting
Mechanical and
Recurrent falls
y Multiple comorbidities
y Risk factors for falls

6. y Gait/balance abnormalities
y Visual impairment
y Arthritis
y Geriatric Giants
Acute Illness
y Infection
y Stroke
y Metabolic disturbance
As the individual’s ability to anticipate danger declines, the potential for a fall increases. There
are also changes in balance and movement that can increase the potential for falls. Although it
is impossible for all hazards to be removed the following are suggestions for prevention and
creating a low risk environment:
Throughout the household check that the following are attended to:
1. Properly fitting footwear with non-skid rubber soles are worn. Ensure shoelaces are properly
tied or Velcro is tightly secured. “Flats” are preferred to shoes with elevated heels. Hip
protectors can be worn to reduce injury for persons who are at higher risk.
2. Flooring and carpeting are in good condition without worn or curled edges that may cause
tripping and falling.
3. Lighting is bright and free of glare.
4. Night-lights are strategically placed throughout the house, especially in stairways and
between bedroom and bathroom. Floor lighting is recommended.
5. Telephones are positioned so the person does not have to hurry to answer a ringing
telephone.
6. Electric cords are not located in walkways. When possible they can be shortened and tacked
down to baseboards.
7. Clutter does not obstruct walkways or stairways.
8. Grab bars are installed in the bathtub and toilet areas.
9. Water drainage is appropriate to prevent the development of slippery floors after bathing.
10. A bath seat is available for use in the tub or shower.
11. Throw rugs are removed from all areas of the home.
12. Bedside table is accessible for placement of glasses, telephone and other important items.
13. A floor to ceiling pole is placed by the bed or favorite chair. (A commode or urinal can be
placed by the bed for easy access at night) _____ 14. The floor has a non-slip surface. _____ 15.
Spills are cleaned up quickly to prevent slipping. _____ 16. Cleaning and cooking supplies are
stored in locations that are not too high (to avoid reaching or standing on a chair) or too low (to
avoid lightheadedness after stooping). Waist height is idea
Throw rugs are not placed over a carpet or scattered in high traffic areas. _____ 18. Furniture is
placed in positions that allow for wide walkways. _____ 19. Chairs and sofas are of a height
sufficient to permit easy sitting and standing. An electric lift chair recliner can help those who
have difficulty getting in and out of a chair. _____ 20. Sturdy railings are provided along both
sides of all stairways. _____ 21. Stairway steps are non-skid. _____ 22. Objects are not placed

7. on stair landings or thresholds. _____ 23. When possible, florescent tape is placed on all steps
to indicate where the steps begin and end. _____ 24. A gate with a complex lock is placed at the
top of the stairway. _____ 25. Outside steps are in good condition. During the winter, sand
and/or salt slippery surfaces to ensure safety. _____ 26. Walkways are shoveled free of ice and
snow in the winter to prevent slips and falls. . For those who have difficulty walking down stairs
or use a wheelchair, installing a ramp at the main door can prevent injury
• Polypharmacy poses risks • ↑ risk of hospitalization • ↑ length of hospital stay • ↑ risk of hospital
mortality • ↑ risk of hospital readmission • ↑ drug-drug interactions • ↑ risk of fallS
These are the typical signs of frailty in the elderly:
Unintentional weight loss
Weakness
Feelings of fatigue
Low levels of physical activity
Slow walking
Healthy Ageing:
Healthy Ageing is “the process of developing and maintaining the functional ability that enables
wellbeing in older age”.
Functional ability is about having the capabilities that enable all people to be and do what they have
reason to value.
This includes a person’s ability to: ’ meet their basic needs ’ to learn, grow and make decisions ’ to be
able to roam around/be mobile ’ to build and maintain relationships ’ to contribute to society
Functional ability of an individual is made up of the interaction between his/her intrinsic capacity and
the environment in which he/she inhabits.
Intrinsic capacity means all the mental and physical capacities that a person can draw on. It is as simple
as their ability to walk, think, see, hear and remember. This capacity changes with the presence of
diseases, injuries and age-related changes. In the elderly, the intrinsic capacity is often reduced.
Environment includes the home, community and broader society, and all the factors within them. The
factors are the environment, people and their relationships, attitudes and values, health and social
policies, the systems that support them and the services that they implement. For elderly, it is important
to have an environment where in they can feel comfortable and accepted. Being able to live in
environments that support and maintain an individual’s intrinsic capacity and functional ability is key to
Healthy Ageing
Age-related changes in human body system

8. It is important for a caregiver to understand the age-related changes in the human body which will
further help in meeting their needs. What are the Signs of Ageing?
’ Vision impairment ’ Hearing impairment ’ Disturbed sleep ’ Loss of teeth ’ Change in taste ’ Decline in
functions of lungs ’ Decline in functions of heart ’ Decline in functions of kidney ’ Wrinkling of skin ’
Decrease in muscle strength ’ Decrease in bone strength Loss of bladder control ’ Loss of appetite ’
Decrease in sexual function ’ Decrease in memory ’ Increase in tiredness
Health risks in elderly Consequences
1 Nutritional deficiencies (Over or under nutrition): Decreased bone mass, immune dysfunction
2 Inadequate consumption of fibers and fruits: Constipation
3 Physical inactivity and sedentary lifestyle: Functional decline, loss of appetite
4 Smoking: Diabetes, cancer, cardiovascular diseases, and lung diseases
5 Excessive alcohol consumption: Decreased rate of metabolism, liver diseases, Cancer
6 Drug reaction and poly pharmacy: Decreased physical functioning, falls, orthostatic hypotension,
delirium, renal failure, gastrointestinal and intracranial bleeding
7 Accidents and injuries: Infections, nosocomial complications, decreased physical functioning
Factors Influencing Ageing
Various hereditary and environmental factors affect ageing:
I) Hereditary: Some families live longer than others. This is related to genetic factors.
II)Environment: Changes in the pattern of climate, pollutants (pollution) and radiation, hygiene,
sanitation/ventilation etc. ,
III) Socio-economic;
• Retirement: For people who are in job or working, the retirement is often a person's first real
experience with ageing. Poor health and medical expenses can make enjoying retired life very difficult.
The family income decreases and day to day life changes.
• Social relationships: Social relationships change throughout life. Children grow up, leave home, and
have their own families. Many live far away from parents. Elderly friends and relatives move away, die
or are disabled. Yet most elderly people maintain regular contact with children, grandchildren, brothers
and sisters. However, many elderly live alone. The person may not have anyone to talk, to discuss his
feelings and problems.
• Death of a spouse: As a couple grows older, chances of death of partner also increase. As a home
based care provider, it is very important to understand the social changes in elderly so that you can
have positive attitude towards the elderly. While taking care of elderly, you may help the elderly to plan
his time when he or she is alone
BODY CHANGES IN AGEING

9. The changes that occur because of ageing are usually permanent.
Ageing is a naturally happening event. It is not a disease, but a normal phase of the human life span.
Due to ageing, the mental functioning such as memory and physical movements decreases.
Ageing affects all the structures and functions of body.
There is a gradual reduction in the number of normally functioning cells as ageing progresses.
The effect of ageing is visible as individuals are not able to function as active as they were in their young
age.
The changes in the body parts due to ageing and measures to be taken to prevent further
deteriorations.
1)Skin;
Wrinkles appear on skin, dryness develops,
Skin breakdown and pressure sores develop in elderly.
Loss of fat under skin increases sensitivity to cold and may complain of cold feet.
Dry skin causes itching.
Nails become thick and tough.
White or grey hair is a common sign of ageing.
Preventive measures:
Elderly persons must be protected from extreme cold. Sweaters, caps, blankets, socks are often
needed for warmth.
Mild soap is used for bathing.
Lotions, oils, and creams prevent drying and itching.
Brushing and shampooing should be done as often as necessary for cleanliness and comfort.
Elderly has more risk of burns as the skin can easily breakdown and is more sensitive to heat.
2) Changes in bones and muscles:
Bones can break easily. Joints become stiff and painful. These changes result in a gradual loss of
height, loss of strength, and decreased mobility (movements).
Activity and diet can help slow down the rate of these changes.
Preventive measures:
Elderly person need to be as active as possible.
Promote bathing, dressing and other daily activities.
The diet should be high in proteins, calcium and vitamins.
Since bones can break easily, the person must be protected from injury. Prevent falls.
Move and turn the person gently and carefully.
A person may need support and help when getting out of bed and during walking.
3)Changes in nervous system

10. Loss of vision and hearing, loss of taste and smell, sense of touch and sensitivity to pain are also
reduced. Heat, cold, and pressure on bony areas may not be felt.
Preventive measures:
The elderly must be protected from injury.
Be careful when applying heat or cold.
Keep the skin clean and give gentle oil massage.
4)Heart and blood vessels: Heart pumps with less force. Hence, during activity, exercise, excitement
and illness, the elderly can have problem.
Preventive measures:
The elderly persons need rest periods during the day. May be encouraged to go for periodical
health check up. Diet should be having less fat and salt.
5)The respiratory system: Respiratory muscles weaken and become less elastic and more rigid.
Difficulty in breathing may occur with activity. The person may not have enough strength to cough
and clear the upper airway of secretions. Respiratory infections may occur and can lead to
complications and even death.
Preventive measures:
Normal breathing must be promoted.
Turning, repositioning, and deep breathing help prevent respiratory complications that may result
from bed rest.
Make the person to stay in a sitting position using extra pillows.
6) The digestive system:
Difficulty and pain in swallowing and loss of teeth and ill-fitting dentures affect chewing. There is
difficulty in digestion and bowel movements decrease. Flatulence and constipation are common.
Preventive measures:
Daily brushing and denture care improve the ability to taste food.
They should be given diet high in fibre, it should be prepared in such a way that patient should not
have difficulty in chewing.
Soft diet, cooked food and vegetables should be given.
High proteins are required for tissue growth and repair.
You should be patience, and kind towards the elderly while working with them.
Food given to elderly should be as per the liking.
small meals can be given more frequently.
7)Urinary system:
Kidney function decreases. Kidney size reduces.
Body wastes can build up in the blood and cause serious health problems.
Bladder muscles also weaken causing the bladder to hold less urine.

11. Persons needs to urinate more frequently and cannot hold at all
Elderly have pain in urination, the need to go more frequently for urination.
Preventive measures:
The doctor may order increased fluid intake to promote kidney function. Intake should include
water, fruit juices, and milk. The most fluid should be given before 8 p.m. This reduces the need to
urinate during the night.
8)Reproductive System:
There are changes in all the reproductive organs. Due to weakening of muscles, uterus may move
from its place and lie lower (prolapse). Vaginal secretions decrease which lead to dry vagina. Sexual
desire remains unchanged in male and female both. In male there may be enlarged prostrate. Men
require to urinate frequently due to prostate enlargement. In men sperm count decreases. In
women size of breast tissue and uterus decreases.
9)The immune system: (Body's Defense) as the ageing progresses, body's defense weakens resulting
in repeated infections. Immunity is the mechanism or state of protection induced by vaccinations or
natural infection.
Supporting the Normal Changes:
Changes in Vision  Decreased peripheral vision  Decreased night vision  Decreased capacity to
distinguish color  Reduced lubrication resulting in dry, itchy eyes
Changes in Hearing  Sensitivity to loud noises  Difficulty locating sound  More prone to wax build up
that can affect hearing
Changes in Smell and Taste  Decreased taste buds and secretions  Decreased sensitivity to smell
Changes in Skin  Decrease in moisture and elasticity  More fragile- tears easily  Decrease in
subcutaneous fat  Decrease in sweat glands -less ability to adjust body temperature.  Tactile sensation
decreases- not as many nerves  May bruise more easily
Changes in Elimination  Bladder atrophy- inability to hold bladder for long periods  Constipation can
become a concern because of slower metabolism  Men can develop prostate problems causing
frequent need to urinate  Incontinence make occur because of lack of sphincter control
Changes in Bones and Joints  Decreased height due to bone changes.  Bones more brittle – risk of
fracture.  Changes of absorption of calcium.  Pain from previous falls or broken bones.  Joints less
lubricated – may develop arthritis.
Changes in Cognitive Ability  Don’t lose overall ability to learn new things but there are changes in the
learning process.  Harder to memorize lists of names and words than for a younger person.  Sensory
and motor changes as well as cognitive ability may affect ability to respond – hard to know which is
which.
Functional Ability: Functional status refers to a person's ability to perform tasks that are required for
living. Two key divisions of functional ability: 1. Activities of daily living (ADL): (Ability to provide self-

12. care) Feeding, dressing, ambulating, toileting, bathing, transfer, continence, grooming, communication
2. Instrumental activities of daily living (IADL): (Higher functions) Cooking, cleaning, shopping, meal
prep, telephone use, laundry, managing money, managing medications, ability to travel
Life expectancy measures the average number of years a person would be expected to live, based on a
set of age-specific death rates in a given observation period.
Health-adjusted life expectancy represents the number of expected years of life equivalent to years
lived in full health, based on the average experience in a population.
Normal Aging
Crow’s feet: wrinkle at the outer corner of a person's eye.
Presbycusis: loss of hearing due to old age
Seborrheic keratosis: loss of skin elasticity
Increase in % body fat.
Benign forgetfulness
Decreased blood vessel compliance
Disease:
Macular degeneration
Tympano-sclerosis.
Basal cell CA
Dementia
Atherosclerosis and HTN
Obesity
Common Geriatric Syndromes:  Dementia and Delerium  Falls.  Polypharmacy.  Pressure Ulcers.
 Urinary Incontinence.
Chronic: diabetes, hypertension and arthritis
Decline in quality of life:
1. Chronic disease.
2. Falls, (more with DM (58%) & HTN (29%)).
3. Sedentary lifestyle (69%; more in joint / bone pain (90%)).
4. Low physical activity (63%).
5. Sleep disturbances.
6. Sensory impairments-depression risk.
7. Decreased self-sufficiency.
Assessment of high risk of elderly is conducted based on mobility.
Mobile elderly
Restricted mobile elderly (mobility only with personal assistance/device) and

13. Bed-bound (assistance required in some form)/home bound elderly for any reason and those
requiring palliative care or end of life care.
Areas of assessment:  Functional assessment  Mobility, gait and balance  Sensory and Language
impairments  Continence  Nutrition  Cognitive/Behavior problems  Depression
Comprehensive geriatric assessment (CGA)  Co-ordinated multidisciplinary assessment.  Identify
medical, functional, social & psychological problems.  The formation of a plan of care including
appropriate rehabilitation.  The ability to directly implement treatment recommendations by the
multidisciplinary team.  Long term follow up.  Targeting (age & frailty). Physician  Social worker
 Nutritionist  Physical therapist  Occupational therapist  Family
Functional ability  Physical health (pharmacy)  Cognition  Mental health  Socio-environmental
Frailty: Frail people suffer from three or more of five of following symptoms:
1. Unintentional weight loss (10 lbs or + in last yr).
2. Muscle loss.
3. A feeling of fatigue.
4. Slow walking speed .
5. Low levels of physical activity.
These people are vulnerable to significant functional decline. They are typically 75 years of age or
older with multiple health conditions; acute and chronic; as well as functional disabilities.
Who is considered as polypharmacy? A: When a patient uses 5 drugs or more for a long period 2-
What are the most common complications of hospitalization? A: falls, immobility, and
deconditioning.

End of life care.
. It’s a critical and advance directive for preventing some ethical dilemmas. 2. Consist of Palliative
care and end-of-life care and they are essential for good Quality of life.
History:
Many elderly patients ignore symptoms they may feel that their symptoms are a normal
concomitant of aging.  The past medical history should include previous surgeries, major illnesses,
and hospitalizations –within the previous 5 years-.  Immunization status and past results of TB
testing.  Review all medications, both prescription and OTC. “brown bag” technique, where the
patient brings all his medications, can be useful.
Physical Examination:  Mini-Mental Status Examination +/- formal cognitive testing.  Blood
pressure should routinely be checked both sitting and standing (orthostatic hypotension). 
Sensory loss is common and hearing and vision screens are important for detecting impairment. 
Careful inspection of the oral cavity is part of the nutritional assessment.  Palpation of the
temporal arteries  screen for temporal arteritis.  The abdominal examination  large aortic

14. aneurysm.  Rectal and genitourinary examination  uterine prolapse, hernias, and testicular
atrophy.  Gait (↑ risk of falls)  correctable causes of unsteadiness  Signs of abuse  trauma,
burns, and weight loss.
Diagnostic Evaluation:  Basic testing such as a CBC, chemistry profile, UA, and TSH. 
Mammography and colon cancer screening (fecal occult blood and/or endoscopy) are
recommended for patients until age 75.  Pap smears can be discontinued at age 65 if there has
been regular testing and a normal Pap smear within the previous 3 years
Prevention and Promotion:  Smoking in middle age is a risk factor  Exercise  Osteoporosis
(Calcium)  Vaccines (influenza)  Treatment of HTN & management of risk factors
As people grow old, there are some degenerative conditions that occur. Elderly people are also
prone to some diseases. Common conditions in older age include hearing loss, blurred
vision/difficulty in reading, back and neck pain, diabetes, depression, and dementia. Furthermore,
as people age, they are more likely to experience several conditions at the same time.
Eye problems
Elderly people often start having issue with their eyesight as their age progresses. However, it is not
necessary that every elderly would have weakened eyesight.
Eye sight for near vision improves and distanced vision weakens.

Blurred/weakened vision can limit mobility of the elderly, affect interpersonal interactions. It may
be a trigger for depression. It often becomes a barrier to accessing information, increases the risk of
falls and accidents, and makes driving dangerous.
Uncontrolled diabetes and increased blood pressure can lead to issues related to eye sight.
Difficulty in seeing the objects nearby: Presbyopia.
This is a common complaint among elderly.
It is a condition that is age related and is commonly starts after the age of 40.
In presbyopia, the person is not able to view near objects properly and finds difficulty in reading.
It can be easily corrected by use of spectacles.
There is ready made spectacles available which provide correction for near vision.
The gradual loss of flexibility of the lens that occurs with age. It results in an inability of the eye to
focus at near distance. Presbyopia generally begins to noticeably affect visual functioning around
age 40, and people often need prescription lenses by age 45. Options for prescription lenses include
glasses for near-distance tasks, bifocals, transition lenses, and monovision contact lenses. Vision
also can be corrected by reshaping the cornea using lasers (LASIK), radio waves (conductive
keratoplasty - CK), or gas bubbles (IntraCor). Other surgical treatments include artificial lens
implants, corneal inlays, and corneal overlays.

15. Presbyopia is a vision condition that makes it difficult to see objects up close. It's caused by the
eye's lens becoming less flexible and harder to focus light onto the retina. 
Presbyopia is the gradual loss of your eyes' ability to focus on nearby objects. It's a natural, often
annoying part of aging. Presbyopia usually becomes noticeable in your early to mid-40s and
continues to worsen until around age 65.
Presbyopia is the medical term for your eye losing the ability to change its focus. This affects how
well you can see close-up objects. It occurs as your eye’s natural lens grows less flexible with aging.
Symptoms 
Difficulty reading small print
Needing to hold reading material farther away
Headaches
Eye strain
Needing brighter light to see clearly
Difficulty reading at night or when tired or stressed
A tendency to hold reading material farther away to make the letters clearer
Blurred vision at normal reading distance
Eyestrain or headaches after reading or doing close-up work
The need for more light when you’re reading.
Blurred vision at a normal reading distance.
The need to hold reading material at arm’s length.
Headaches from doing close work.
Eye strain, which makes your eyes feel sore or tired.
Seek immediate medical care if you:
Have a sudden loss of vision in one eye with or without eye pain
Experience sudden hazy or blurred vision
See flashes of light, black spots or halos around lights
Have double vision
Causes
Aging: The lens of the eye hardens and loses flexibility with age. 
Other medical conditions: Farsightedness, diabetes, multiple sclerosis, and cardiovascular
diseases can increase the risk of developing presbyopia early. 
Medications: Antidepressants, antihistamines, and diuretics can cause premature presbyopia. 
Age-related changes to your eyes cause presbyopia. During the first few decades of life, your
eye’s lens is soft and flexible. It easily changes its shape when you shift your vision from
something far away to something close-up. This ability (accommodation) allows light to land on
your retina so you can see objects clearly.
Risk factors for premature presbyopia include:
Having farsightedness.
Taking certain medications, including antihistamines or antidepressants.
Having certain conditions, including diabetes, multiple sclerosis (MS) or cardiovascular disease.

16. Treatments 
Corrective lenses, such as glasses or contact lenses
Surgical procedures, such as LASIK or refractive lens exchange
Prevention Get regular eye exams, Control chronic health conditions that can contribute to vision
loss, and Wear sunglasses. 
Eyeglasses.
Contact lenses.
Surgeries.
Eye drops.
Hyperopia/hypermetropia
Long-sightedness, also known as hyperopia or hypermetropia, is an eye condition that makes it
difficult to see objects that are close up. It occurs when the eye's lens doesn't bend light properly,
causing light to focus behind the retina. 
Long-sightedness (referred to medically as hyperopia) is a common condition that affects the ability
of the eye to focus. In a long-sighted eye, the light focuses behind the retina, blurring the image. If
it is significant, long-sightedness can cause vision problems, headaches and tiredness.
Glasses, contact lenses and occasionally laser techniques are used to correct long-sightedness.
Symptoms 
Difficulty seeing nearby objects, like words or pictures on a screen
Objects appear fuzzy or out of focus
Tired eyes after close-up work
Headaches
Squinting or narrowing your eyes
Causes
Long-sightedness can affect people of any age, but it often becomes more noticeable as people
get older 
Presbyopia is a type of long-sightedness that occurs with aging 
The exact causes of long-sightedness are not well understood. It is known that the eyeballs of
long-sighted people tend to be smaller than average, with less curved corneas – the main optical
component of the eye. There may also be a hereditary component, as the children of long-
sighted parents can be long-sighted.
Treatment 
Glasses, contact lenses, or laser surgery can correct long-sightedness
An optometrist can provide an eye exam and prescription for glasses
Glasses and contact lenses are the most common method used to correct most refractive errors,
including long-sightedness. The lenses in glasses converge the light rays, moving the focus back
onto the retina.


17. Young people who are slightly long-sighted generally do not have problems in their day to day as
their eye muscles are usually able to compensate. If they do, they may need glasses for close
work such as reading and using computers.

Older people, or young people with significant long-sightedness, often have problems because
focusing requires a lot of effort. Their vision is more likely to be blurred, especially for close
objects, and they usually need glasses for reading and sometimes for distance vision.

For people with significant long-sightedness, contact lenses can be the best form of correction
as they provide better vision and may be preferable to wearing thick glasses. Contact lenses can
be made from different materials and can be disposable or non-disposable.
Safety 
Long-sightedness can make it difficult to complete everyday tasks and can be a safety concern
for activities that require clear, close-up vision
Long-sightedness (also known as hyperopia) is a very common eye problem. It can be hard to
detect. If you are long-sighted close objects can appear blurry.
What causes long-sightedness?
The size and shape of your eye is the main cause of long-sightedness.
When light enters the eye, it's bent by the cornea, the clear layer on the front of the eye, and the
lens. This process is known as refraction.
If you have normal vision, the rays of light are brought into focus on the retina, the layer at the back
of the eye.
In most people, the size and shape of your eyes causes long sightedness. The light rays from close
objects focus behind, rather than on, the retina when your eye is resting.
If you are slightly long-sighted, often the lens of your eye can automatically correct for the
refractive error. Your eye muscles can adjust the focus to get a sharp image.
If you are more long-sighted, or do a lot of near-focus activities such as reading, you may need more
adjustment. This means your eyes can get tired by the end of the day and they might get
headaches.
As you age, the eye's lens becomes less flexible causing long-sightedness. This is why older people
often need reading glasses.
You have a slightly higher chance of being long-sighted if either of your parents is long-sighted.
Mild long-sightedness can be hard to detect because the lens automatically corrects your focus to
make close objects clear. But after periods of close work, you might find that you have:
strained or aching eyes
a headache
tiredness
It becomes harder for your focus to correct as you get older. This is due to the lens in your eye
becoming stiffer.
Treatment of long-sightedness

18. The most common treatment is glasses, especially for reading and other near work. Some people
with long-sightedness also wear their glasses for distance. Your optometrist might recommend eye
exercises.
Laser refraction surgery can correct long-sightedness. Ask your optometrist if it is suitable for you.
Laser surgery is not recommended for children.
Mild long-sightedness, especially in young people, might not need any treatment. However, this
may change as you get older.
Are there any complications of long-sightedness?
If your child has moderate to severe long-sightedness and it's not corrected with glasses, the extra
focusing effort could mean that they are more likely to develop other eye problems. These
include lazy eye (amblyopia) or turned eyes (also called a squint, or strabismus).
Cataract
’ Cataract is most common eye problem in the elderly.
’ It is a leading cause of blindness across the world
’ Cataract usually causes gradual loss of sight.
’ The pupil; black circle of eye shows chalky white or greenish-grey colour.
’ It needs a small surgery where the damaged part (lens) is removed and replaced with new artificial
lens.
’ No other treatment like eye drops/spectacles can cure this condition
Points to remember
Cataract is normally seen in elderly people and can be a result of ageing.
It cannot be cured by putting some eye drops but will require eye surgery.
The surgery commonly involves taking out the affected lens from the eye and replacing it with a
new lens so that vision can be restored normal.
The procedure is done under local anaesthesia so that eye surgery can be done.
The surgery is safe and commonly done. It should be done in a recognized hospital and NOT in the
community or PHC.
Under National Programme for Prevention and Control of Blindness and Visual Impairment,
Government eye hospitals provide free surgeries to affected persons.
Both eyes may get affected due to ageing. The surgery may be required in both the eyes.
A cataract is a cloudy area in the eye's lens that can cause blurry or reduced vision. Cataracts are
common in older people, but they can also affect children.  A cataract is a cloudy area in the lens of
your eye (the clear part of the eye that helps to focus light).
Symptoms 
Faded colors
Blurry or double vision
Halos around lights
Difficulty seeing at night
Sensitivity to light

19. Pupil appears white or gray
Causes
Aging: Cataracts are a natural result of aging and are more common in older people. 
Genetics: Some cataracts are caused by genes passed down through families. 
Risk factors: Other risk factors include smoking, diabetes, exposure to UV light, and long-term
use of corticosteroids. 
Treatment 
Cataracts are usually treated with surgery to remove the cloudy lens.
Surgery is usually performed under local anesthetic.
Prevention 
Reducing cigarette smoking and exposure to UV light may help delay the development of
cataracts.
2. Issues with hearing
’ As a part of ageing, people may start gradually losing their hearing.
’ Many of the elderly could complain about not being able to hear clearly and ask the other person
to speak loudly.
Hearing loss.
This condition could also bring a lot of irritation to the elderly as well as others around them.
Untreated hearing loss affects communication and thus may also contribute to social isolation and
loss of autonomy.
Inability to hear properly is often associated with anxiety, depression.
This may not be understood quickly by the family members and also could be seen as elderly person
“being slow”.
Hints at recognizing a hearing problem
Tilt his or her head to one side. Ask repeated questions. Misinterpret what was said. Withdraw
from social encounters. Appear to have a short attention span. Have a blank stare. Not react to
words or sounds in an expected manner. Experience increased irritability and frustration.
Experience increased anxiety or signs of fearfulness. Act in a way that indicates that he or she is
suspicious.
Psychological problems
As age advances, elderly experience psychological problems and their routine is disturbed as
follows:
’ Forgetfulness
’ Dementia (loss of memory)
’ Depression
’ Age related memory loss
’ Sleep disturbances
’ Mood swings, etc
Signs and symptoms are observed or as informed by the first care giver:

20.  Withdrawal from social activities
 Lack/excessive sleep
Feelings of hopelessness and worthlessness
 Loss of interest in pleasurable things
 Loss of interest in food intake
 Increased confusion
 Neglecting personal care (grooming, bathing, clothing)
Frequent incidents of irritation and agitation leading to anger outburst
Activities to assess memory problems in elderly
ƒ Recall of day, date and time
ƒ Food recall
ƒ Practice button up shirt, calculation of money and coins in purse
ƒ Encourage them to describe “how do they dress up”
ƒ If literate, they may also be engaged in grocery calculation
6. Oral Health Problems
’ Majority of elderly groups suffer from poor oral health issues.
’ Traditional methods are practiced more often by elderly for cleaning of teeth which may
be inadequate to maintain oral hygiene
’ Diseases of other parts of the body may also lead to increased risk of oral disease.
’ Adverse side effects of some treatment may also lead to dry mouth, altered sense of
taste and smell.
’ Poor oral health results in impaired nutritional status and general health, reduced selfesteem,
wellbeing and quality of life
Signs and symptoms are observed or as informed by the first care giver:
 Dry mouth
 Tooth pain
 Tooth infection
 Discoloration of tooth
 Swelling/infection of gums
 Bleeding of gums
 Inability to open mouth
Hypertension
’ High Blood Pressure, also known as “silent killer” remains silent and undetected unless
specifically checked among the elderly.
’ Normal range of Blood Pressure among the elderly is 140/90 mm of Hg.
’ If undetected, high blood pressure may damage the heart, brain, kidneys and blood
vessels
ASHA should notify CHO if any of the following signs and symptoms are observed or as informed
by the first care giver:
 Complaints of headache

21.  Increased attacks of sweating, headache and palpitations
 Breathlessness
 Bleeding from nose
. Diabetes
’ Similar to hypertension, diabetes is also termed as “silent killer” which gets detected
only when it is specifically checked.
’ Diabetes can also lead to complications like heart attack or stroke
Signs and symptoms are observed or as informed by the first care giver:
 Frequent urination
 Increased hunger
Excessive thirst
 Unexplained weight loss
 Lack of energy
 Extreme tiredness
 Lack of interest
 Lack of concentration
 Blurred vision
 Repeated or severe infection like vaginal infections
 Slow healing of wounds
 Impotence in men
 Tingling and numbness in hands and/or feet
 Foot ulcers
 Pressure ulcers
Musculoskeletal Disorders
Musculoskeletal disorders are injuries or disorders of muscles, nerves, joints, tendons, cartilages
and spinal discs impairing the movement.
’ Accounts for increased morbidity among the elderly population
’ Timely recognition may prevent complications including falls and deformities
Signs and symptoms are observed or as informed by the first care giver:
 Joint Pain
 Difficulty in walking/squatting
 Swelling in joints
 Neck pain
 Back ache
a)Constipation: It is the passage of hard, dry stool. The person usually strains during passing stool.
Large stool causes pain. Increase fluid intake, give food having fibre like salad, increase physical
movements, sometimes medicines are required.

22. b)Diarrhoea: When elderly persons are not able to chew or have regular meals it may lead to the
frequent passage of liquid stool. Some people cannot control elimination until getting to a
bathroom. Abdominal cramping (pains), nausea and vomiting may also occur. As a home based
care provider - you have to help the person to the bathroom or provide the bed-pan quickly.
You also have to keep in mind that stool needs to be disposed off immediately to reduce bad
smell and prevent the spread of micro-organisms. Good skin care is also important.
c)Flatulence: Gas and air passed through the anus is called flatus. Flatulence is the excessive
formation of gas or air in the stomach. "Bloating" is the common complaint. Bloating is the
sensation of fullness of abdomen with gas. Give small food and simple food without spices,
physical activity like walking after meals may help. Avoid gas forming food such as cabbage,
spinach, beans, peas, fried food.
Geriatric Syndromes
’ Geriatric syndrome is unique to older persons with multi factorial pathophysiology
’ It leads to high morbidity and mortality
Major geriatric syndromes include:
1. Delirium
2. Dementia
3. Falls
4. Incontinence
5. Pressure ulcers
6. Immobility
7. Fragility
Things to keep in mind while interacting with elderly:
1. Be patient with them. Understand that they might have lost some of their ability to hear or see.
Raise your voice accordingly but do not shout at them.
2. They might not accept your suggestions immediately. Pursue them slowly for seeking care. Try
to pursue the family members and caregivers as well.
3. Encourage them for doing mild physical activity wherever feasible.
4. Respect their autonomy. Ask them whether they need assistance. They might not like to be
assumed as weak individuals.
5. Be gentle with them while helping them around.
Counselling an older person
Providing counselling for elderly helps them to deal with the problems of old age, and can also
provide the opportunity for enrichment, personal growth, and satisfaction. ’ Good counselling
approaches build upon a foundation of respect, empathy, and support. ’ A high degree of
sensitivity, awareness, and acceptance among health care workers is required for giving care and
counselling to elderly. ’ Counselling the elderly should address issues of anxiety and stress, related

23. to the losses of their life, particularly the sense of losing control over one`s life. ’ It should also help
them in understanding and accepting the value and reality of their life, help in decision making and
increasing autonomy as well as deal with depression and demoralization.
The objectives of elderly counselling ’ To understand the psycho-social and biological problems of
old people ’ To help them to solve their problems ’ To enhance wellness in their life
Key messages for community regarding elderly care:
’ Elderly individuals have different health needs. They need to be looked after with care. ’ They
commonly face loss of sensory functions, commonly sight and hearing. One needs to keep it in mind
while interacting with them. ’ Everyone in the community should be responsible towards the
elderly. As a community we should support and help them around if they need any help. ’ If you
come across any destitute or single elderly, you should enquire about them, their health and
whether they require any support. You should also notify the ASHA/MPW about them. ’ Speak to
ASHA if you need any support in helping or taking care of elderly in your household. She will be able
to help you and also connect you to the health and wellness center.
Key messages for families with elderly individuals:
’ Be patient with them! Family members should understand that elderly need to be cared with
patience and compassion. ’ Elderly may also feel isolated because of reduced hearing and vision.
Family members should try and make them feel included in the family functions. ’ Speak to ASHA if
you need any support in helping or taking care of elderly in your house. She will be able to help you
and also connect you to the health and wellness center.
You might not be skilled at nursing needs of the elderly (in case of bed bound or restricted elderly).
If there is any nursing task like wound care/catheterization/changing diapers, contact the ASHA of
the village. She will connect the MPW F/M and Health and wellness center team to your household.
They will also train you regarding these tasks. ’ Elderly individuals may have many health concerns
at the same time. Most of them could be because of ageing. You should accompany them to the
health and wellness center for check-ups. ’ In case the elderly is restricted, or bed bound, notify the
ASHA about health concerns. She will connect the health and wellness team for home visits. ’
Elderly are at higher risk for falls and since their bones are weak even slight injury may result in
fracture. Family members need to take care that there are no wet floors, slippery stairs in the
house. Elderly should be having proper footwear. They should be accompanied whenever possible. ’
Support groups for elderly are created by MPW(F/M) of the village. They will help you with
interacting with others who also have elderly in their house. These groups will help you regarding
taking care of elderly. Such sharing helps with the stress that may come from having to take care of
a dependent person. Do join these groups and be a supporter for others as well! ’ It could be often
exhausting for one person to take care of the elderly constantly. Family members are suggested to
take turns to take care of the elderly.
Key messages for diet in elderly
Include foods like cereals, millets, pulses, nuts and oilseeds, eggs, poultry and fish (if non
vegetarian) low fat milk and milk products and seasonal fruits and vegetables in the daily diet to
ensure dietary diversity.

24. Small portion sizes consumed frequently throughout the day are recommended and the plate
should be colourful (natural colours only).
Choose healthy, easy to prepare, easily digestible dietary options.
The daily intake of oil should not exceed 20 grams (4 teaspoons).
Adequate water (at least 8 glasses) should be consumed as the thirst perception in the elderly may
be diminished.
A balanced antioxidant rich and nutrient dense diet, with 4-5 servings of fruits and vegetables, six
servings of whole grain cereal, 2-4 serving of low-fat dairy products, 2 servings of legumes is
recommended.
To stimulate appetite and promote digestion add herbs, spices and condiments in the diet like
fenugreek seeds (Methi), carom seeds (Ajwan), aniseed (saunf), asafetida (hing), clove (laung),
garlic, ginger, onion, turmeric (Haldi), cumin (zeera), cardamom (elaichi), black pepper (kali mirch).
Some of these will also boost your immunity.
Elderly with chewing difficulties can include soft cooked foods:
 Soft cooked foods like vegetable pulao/upma/seviyan/poha/khichdi/vegetable idli/cheela/uttapam
 Ragi/semolina/amaranth kheer/makhana porridge, dhokla, etc., dals,paneer, curd, eggs  Soft fruits
like banana, papaya, mango, cooked apples and soft cooked vegetables and soups (bottle gourd,
tomato, drumstick, carrot etc) can be included.
 Boiling/steaming as cooking methods can be opted rather than frying.  Avoid dry meals as
swallowing becomes difficulT
Physical exercise is good for physical and mental health and helps in the prevention and control of
many diseases like diabetes, osteoporosis and falls, obesity, heart disease and even certain cancers.
’ Exercise also enhances sleep and quality of life. Physical work can be occupation related,
household related and transport related. ’ Exercises can be of aerobic and weight bearing types. 
Engage in regular physical activity for at least 30 minutes a day at home with customized light
exercises, yoga, stretching, walking, gardening etc.  Encourage them to sleep for 7- 8 hours daily to
improve your immunity and mental health.  Encourage them to take daily dose of sunlight by sitting
in verandah/balcony/terrace for at least 30-40 minutes between 11:00 to 1:00 pm (urban setup)
Exercises in elderly people may assist in- ’ greater survival ’ protection against cardiovascular
disease ’ weight reduction ’ control of high blood sugar in diabetes ’ protection against osteoporosis
and fracture ’ improvement of muscle strength, balance, and functional capacity and ’ improvement
in psychological well-being, better sleep, and bowel habits
Safety measures in elderly: Assessment of sense of hearing, balance, vision and sense of smell in
elderly and there by modifying environment for specific sensory deficits ’ Avoid pollution, smoke
and dust, extreme of weather. ’ Avoid driving in cases of low vision, slow reflexes or after taking
medications that cause drowsiness. ’ Presence of assistance devices like cane, walker etc
Accidents and falls should be prevented by adopting safety measures ƒ Elderly should ensure
carrying identity cards
Safe home environment ’ Adequate lighting in the house ’ Guards or side rails should be present at
bed, window, stairways and bathroom ’ Non slippery floor in bathroom ’ Coloring of house should

25. be helpful in defining doors, stairs etc. ’ Floor should not be very smooth, floor coverings are
preferred ’ Furniture should be comfortable and sturdy to allow weight ’ Noise should be controlled
’ Proper cleanliness should be maintained ’ Electric appliances should be shock proof ’ Home should
be free from pests ’ Drugs, pesticides, insecticides etc. should be kept in isolation. ’ Use of call bells.
Manage stress and anxiety to ensure mental well-being and overall health ’ Cut down on watching,
reading, or listening to anxiety inducing news. Watch the news from relevant sources only
once/twice in a day. ’ Keep yourself engaged in daily activities like cleaning, cooking, gardening,
meditation etc. and try to do other activities that you enjoy like painting, listening to music, reading,
playing board games etc. ’ If religious practices have been the norm in your daily activities, practice
them at home. ’ Jot down recipes of traditional cuisines for your young family members. Take
pictures, make videos, file and document. ’ Connect with others. Talk to people you trust regarding
your concerns and how you are feeling. ’ Have a plan, in case you get sick, determine who can care
for you, if you need any help. ’ Do not isolate yourself in one room. Sit with family members and
share your thoughts.
Genitourinary problems
Most of elderly suffer from genitourinary problems.
In case of men, genitourinary problems are commonly due to enlargement of the prostate gland
in old age and in women it is mainly due to weak muscles.
This leads to symptoms like frequent and urgent need to urinate, difficulty in starting
urination, weak urine stream, dribbling of urine and inability to completely empty the
bladder.
’ This may cause significant distress to them. These individuals must be referred to the
Medical Officer for treatment.
A urinary tract infection is a very common type of infection in your urinary system. It can involve
any part of your urinary system. Bacteria — especially E. coli — are the most common cause of
UTIs. Symptoms include needing to pee often, pain while peeing and pain in your side or lower
back. Antibiotics can treat most UTIs.
A urinary tract infection (UTI) is an infection of your urinary system. This type of infection can
involve your:
Urethra (urethritis).
Kidneys (pyelonephritis).
Bladder (cystitis).
Urine (pee) is a byproduct of your blood-filtering system, which your kidneys perform. Your
kidneys create pee when they remove waste products and excess water from your blood. Pee
usually moves through your urinary system without any contamination. However, bacteria can
get into your urinary system, which can cause UTIs.
A UTI causes inflammation in the lining of your urinary tract. The inflammation may cause the
following problems:
Pain in your flank, abdomen, pelvic area or lower back.

26. Pressure in the lower part of your pelvis.
Cloudy, foul-smelling pee.
Urinary incontinence .
Frequent urination .
Urge incontinence .
Pain when you pee (dysuria).
Blood in your pee (hematuria).
Other UTI-associated symptoms may include:
Pain in your penis.
Feeling extremely tired (fatigue).
Fever .
Chills .
Nausea and vomiting .
Mental changes or confusion.
Pain or burning when urinating
Frequent urination
Cloudy or strong-smelling urine
Blood in the urine
Pressure or cramping in the lower abdomen or groin
Fever
Lower back pain
Treatment 
Antibiotics, usually taken in a short course
Pain relievers
Drinking lots of fluid
Prevention
 Washing your hands before using the toilet or showering, Emptying your bladder often, Wiping
from front to back after using the toilet, Drinking lots of water, and Practicing good genital
hygiene. 
INCONTINENCE
The inability to hold one’s urine is not a normal part of aging. It is caused by a physical condition of
the bladder and the muscles around it or another medical condition such as diabetes, and is
common among individuals with dementia. It can also result as the side effect of medications
commonly prescribed for conditions in older persons. The most common medications are diuretics
(water pills), narcotic analgesics (pain pills), ACE inhibitors (blood pressure pills), and antiseizure
medications. The cause and type of incontinence require an evaluation by a urologist, who will
recommend the appropriate treatment throw rugs should be removed.
INCONTINENCE
.The three types of incontinence are stress, urge, and overflow.
Stress incontinence is involuntary loss of urine when coughing, laughing, or exercising.

27. Urge incontinence is the inability to delay urination after feeling the sensation that the bladder is
full.
Overflow incontinence is leakage of urine resulting from bladder contractions from an over
distended bladder.
Treatment can be a prescription medication, minor surgery, or Kegel exercises (tightening and
releasing of the muscles around the bladder. Other interventions that may be helpful are
establishing a routine schedule for urinating, limiting fluids after dinnertime, and wearing adult
briefs. Incontinence can lead to rashes and skin breakdown from urine burning the sensitive skin, so
briefs should be changed as soon as they become moist, and the use of a skin barrier cream can
help to prevent this problem. Overactive bladder syndrome is not the same as urinary incontinence.
With this condition there is no leakage of urine but instead a feeling of extreme urgency with
frequent urination, and treatment is the use of prescription medication to decrease bladder spasms
and urgency.
The privacy and dignity of the person who may be experiencing problems with incontinence is of
the utmost importance. Caregivers must be sensitive to the feelings of humiliation and
embarrassment experienced by the individual who is losing control of their bodily functions. It is
important to make every effort to preserve the person’s self-esteem as individuals with dementia
have some degree of awareness of the functions they have lost. Family members and other
caregivers may also feel embarrassed or awkward when assisting with toileting. These feelings are
normal under these circumstances and it is helpful for caregivers to discuss these feelings with
other family members, physicians, nurses, Home Support workers, or friends. At times caregivers
may find the experience of assisting an individual to clean up to be a very difficult and unpleasant
task. Try to remain calm and reassuring and recognize that both of you will probably feel quite
uncomfortable in this new situation. Talk through the steps slowly and simply while having the
individual assist as much as possible and remember to praise the person for their efforts. It is
important to communicate with the person so that you may establish a routine that is comfortable
for everyone. Persons with a progressive dementia may begin to wet themselves or have bowel
movements in their clothing in the latter stages of the disease. This problem can be devastating and
embarrassing for the individual as well as distressing for the caregiver. It is important for family
members and professional caregivers alike to be aware of the strong feelings evoked by this
behaviour and approach the problem in a sensitive, caring manner. There are many possible causes
of urinary and bowel incontinence, therefore it is important to rule out any treatable causes of this
behaviour. Some possible causes include
Infections such as urinary tract infection and urethritis.
Male Prostate surgery may cause infection or urinary retention that leads to overflow
Females Vaginitis can cause loss of urine control Constipation or fecal impaction can block the
bladder so that urine leaks past the blockage point In older women weak pelvic muscles can
sometimes cause “stress incontinence” or “leaking”, this may occur if a person sneezes, coughs or
laughs.
Chronic illnesses that limit physical mobility such as stroke, Parkinson’s disease, arthritis or chronic
pain can hamper attempts to reach the bathroom. Changes to vision associated with normal aging

28. or physiological conditions can hamper visibility and make it difficult to find the bathroom. Not
drinking enough fluids may cause irritation of the bladder; if the person becomes dehydrated they
may become incontinent because the physical signal or urge to use the bathroom may be lessened
or no longer be understood. Promote hydration, as reducing fluids will not stop incontinence.
Fluids such as coffee, tea, cocoa, alcohol and colas can have a diuretic (promotes the formation and
excretion of urine) effect. Medications such as tranquillizers, sedatives, hypnotics, antidepressants
and diuretics can affect bladder muscle function and/or reduce the person’s sensitivity to body
signals.
ENVIRONMENTAL CAUSES
The bed may be too low to the floor making it difficult for the person to get up and use the toilet.
The distance to the bathroom may be too far as older adults are not always able to hold urine for
extended periods of time. The person may be afraid of falling, particularly when walking during the
night, and resist the need to walk to the bathroom. The person may have difficulty undressing to
use the toilet. If the floor and the toilet seat are similar in colour it may make it difficult for a
person with visual difficulties to find the toilet. Poor lighting may make it difficult for the person to
find the bathroom or locate the toilet once they are inside the bathroom. The person may require
cues or signs that orient them to the location of the bathroom.
OTHER CAUSES
The task of using the toilet may have become too complicated for the person. The person may not
remember what to do once they are in the bathroom. The person may require assistance to
undress, sit on the toilet, wipe themselves, and/or get up from the toilet. The verbal instructions
the person receives may not be simple or clear enough for them to understand. The person may
feel they are being rushed which can cause confusion and lead to difficulties in using the toilet. The
person may SENSE the need to go to the toilet but may no longer be able to EXPRESS the need to go
to the toilet.
Management.
Use a written diary or journal to assist you in understanding the nature of incontinence. Document
routine patterns of behaviour associated with bathroom activities so that alternate caregivers may
also be of assistance. Write down any observations about the incontinent behaviour over several
days. Do accidents happen only at certain times of day or just at night? How often does the person
use the toilet? Did the incontinence begin suddenly? Is the person urinating in improper places,
such as flowerpots, wastepaper baskets, closets, the bathtub, or in the kitchen sink? Do accidents
happen on the way to the bathroom?
Ensure that the person is given a thorough medical examination to rule out any possible infections
or medical conditions that may be contributing to the incontinence. A urinary tract infection can
often be accompanied by a fever or a sudden change in the person’s behaviour. If a fever persists
for more than 24 hours and/or behaviour changes are sudden with an increase in confusion and
speech problems it is important to contact your physician, as this might be a delirium.

29. A delirium is a serious medical condition that should be addressed immediately. Discuss with your
physician medications that can be used to treat incontinence. Remember that all medications have
side effects and if drugs are used the person must be carefully observed. Talk with your doctor
about a Home Care Nursing assessment and non-medical recommendations. After carefully
observing the individual’s toileting pattern during the day and night attempt to toilet the person just
prior to expected the time you have documented. Consistently toilet the person before and after
meals, before going to bed and immediately upon arising. An adequate water intake of 5-8 glasses
daily is the minimum daily requirement for a healthy adult. At times it may be difficult for the
person with dementia to remember to drink or they may have lost the recognition of the sensation
of thirst. Caregivers can provide a great variety of substitutes for fluids such as; jello, popsicles, ice
cream, or ice cubes. A regular routine schedule for providing fluids will be helpful
Watch for any visible clues that the person needs to use the toilet; such as reaching for a belt,
tugging at a zipper, holding onto themselves, or taking down pants. Often time’s restless behaviour
or facial expression may signal a need to use the toilet. *Consider the person’s use of slang or
alternate expressions around using the bathroom. Ensure that alternate caregivers are familiar with
the behaviour and words the individual uses when needing to use the toilet. Listen carefully, as the
person with dementia may substitute a different word in his attempts to express his/her need to
use the toilet. Individuals with dementia, no matter how severe, have some degree of awareness of
their inabilities. It is important to not focus on the incontinence itself but to focus more on
providing assistance in a way that is reassuring and not reprimanding or punitive.
It is sometimes helpful to use signs to assist the person in locating the bathroom, for example, the
word “toilet” with letters that are boldly printed, in capital letters, and large enough to be easily
read. If the person is no longer able to read, placing a picture of a toilet at eye level on the
bathroom door can be helpful.
CLOTHING FOR INCONTINENCE
Simplify clothing as much as possible by using pants with elastic waistbands or skirts. Velcro may
be used instead of zippers or buttons. Select clothing that is washable and does not need ironing.
Shoes that are also washable such as tennis shoes or good fitting slippers are much easier to keep
clean. Clothing should be changed when wet to avoid the person becoming accustomed to wet
clothing, as well as to avoid irritability and confusion. Adult briefs or “undergarments” are readily
available in stores. These briefs are washable or disposable and are recognizable to the individual as
an undergarment
SKIN CARE
It is important to provide good skin care to prevent rashes or skin breakdown that can lead to
irritability, discomfort, pain and medical complications. Allow the individual to participate as much
as possible in his/her hygiene; giving the person a cloth to wash with is often a good distraction
when assisting with changes of clothes and cleanup during periods of incontinence. This can also
make the person feel like they are participating in his/her own care. Local drug stores supply
products that act as both soap and skin conditioners to lessen the steps involved in assisting the
individual as well as keeping the skin clean and dry.

30. Bathroom aids.
A raised toilet seat with grab bars can make it easier for a person to safely get on and off the toilet.
Ensure that the toilet seat is fastened securely to the toilet so that it does not slip when the person
sits on it. A padded toilet seat is more comfortable for the person who may need to sit for a longer
period of time. If the person is having difficulty getting to the bathroom because of stairs or
distance, a commode chair placed near the person’s bed or in a private area can be helpful. The
commode should be stable so that it does not easily slide or topple over and the toilet top should
be left off or raised so the individual can easily identify it as a toilet. For an individual who is restless
and has difficulty sitting for extended periods of time, it is often helpful to give them something to
do with their hands when they are using the toilet. Giving them face cloths to fold, a book or
magazine with meaningful pictures to look at, or playing music are a few examples of activities that
may be of assistance. It is important to know the individual well and give them an activity that will
both hold their attention and is meaningful to them. Urinals and bedpans are readily available
through medical supply stores and for men there are spill proof urinals, which can be kept in the
bed.
CANCER
Cancer is a complex disease process caused by cumulative DNA damage.(24) It is characterized by an
uncontrolled growth and spread of abnormal cells anywhere in the body. There are more than 100
different types of cancer, but the four most common types (lung, colorectal, breast and prostate cancer)
account for about half of all cases diagnosed in Canada.(25) Cancer is a leading cause of morbidity and
the most common cause of death in Canada—nearly 1 in 2 Canadians will develop cancer in their
lifetime and about 1 in 4 will die of the disease.(25) Since DNA damage accumulates with age, the risk of
developing and dying from most types of cancer increases with age. Despite this, the risk levels off in the
oldest age groups. Reasons for this decline are unclear, but it is hypothesized that oldest individuals may
be asymptomatic or even less susceptible to cancer growth. Further, cancers may be undiagnosed in the
very old due to reduced frequency of diagnostic testing and screening.(26) Modifiable behavioural risk
factors associated with the development of cancer include:(25,27) { Smoking; { Physical inactivity;
{ Harmful use of alcohol; { Diet low in fruits and vegetables and high in red and processed meat; and
{ Overweight and obesity. Cancer risk can also be reduced by practising sun safety and avoiding indoor
tanning; getting vaccinated against cancer-causing infections; participating in cancer screening programs
and getting treated for precancerous conditions; ensuring household radon levels are safe; and wearing
appropriate protective equipment when exposed to carcinogens
BRAIN TUMOR/CANCER.
Brain turnor is one of the most common form of neurological illness. Without treatment these tumors
may be fatal. Two effects of intracranial tumors can be described as localized or generalized, and
outcomes range from full neurologic recovery to disability or death-depending on the tumor size, and
site.
Definition A brain tumor is a localized brain growth that occupies space within the skull.
Sign and symptoms: Part of the brain may cause few symptoms like: • Headache: The area affected by
heada~he can be generalized or localized region, and it is worse in the morning. • Vomiting: in patients

31. with tumors at the back of the br~. -. • Visual disturbances: Like haziness in vision and decreased visual
power. • Memory deficits: Difficulty in concentration, slowing reaction time and difficulty in calculation.
• Knowledge deficlts. A short and long term memory loss, difficulty in concentration and vigilance,
slowing reaction time and difficulty in calculation, • Vital signs: Slow pulse rate, irregular respiration,
lowblood pressure. • Seizures: Convulsions or epileptic fits. • Muscles weakness; Patient is not able to
move, stand; walk, and sit her! himself
Lung Cancer
Lung cancer usually affects people who are smokers. As the tumor grows, it becomes harder to breathe.
Lung cancer often spreads to otller parts of the.body. Since lung cancer tends to spread very early to
other parts of the body. It is life threatening cancer and one of the most difficult cancer to treat.
Signs and Symptoms • These patients with small single mass may often report no symptoms till the
cancer is discovered. • Cough, shortness of breath, wheezing or chest pain and sometimes coughing of
blood. • If cancer has affected the nerves it may cause shoulder pain that travels down the arms. .•
Paralysis of vocal cords leading to hoarseness of voice. • Esophagus be effected leading to difficulty in
swallowing. • If large air passage is obstructed collapse of a portion of lung may occur and cause
infection (abscess pneumonia) in the obstructed area.
Other symptoms seen with lung cancer include: • Weight loss • Weakness • Fatigue • Psychological
symptoms such as depression and mood changes.
Treatment of lung cancer Lung cancer treatment can involve • Surgical removal of the affected area of
lungs • Chemotherapy Radiation therapy • Combination of all these
Surgery for lung cancer is a major surgical procedure that requires general anesthesia, hospitalization
and follow up care from weeks to months. Following the surgical procedure patient may experience
difficulty in breathing, shortness of breath, pain and weakness. The risk of surgery includes
complications due to bleeding, infection and complication of general anesthesia.
Surgery - if the cancer is contained to one area and has not spread, surgery may remove all or part of
the cancer.
Medications - used to treat the symptoms of cancer and side effects of treatment (e.g. pain, fever,
infection, and/or nausea).
Alternative therapies - either alone or in combination with the other options listed above, including:-
acupuncture;- vitamins, minerals, and herbs;- nutrition;- meditation; and- faith healing
Radiation therapy uses high energy x-rays or other types of radiation to kill the dividing cancer cells.
Radiation therapy can be given if patient refuses surgery or tumor has spread to area such as lymph
nodes or trachea making surgical removal impossible or if a person has other condition that makes them
too sick to undergo major surgery. Radiation therapy does not carry the risk of major surgery but it can
have unpleasant side effect including fatigue and lack of energy and even can reduce white blood cell
count and low blood platelet level. If digestive organs are in the field exposed to radiation, patient may
experience nausea, vomiting, diarrhoea. Radiation therapy can also irritate the skin in the area that is
treated but this irritation generally improves with the time after the treatment has ended.

32. Radiation therapy - targets and kills cancer cells in a certain area of the body. Radiation can also affect
normal cells.
Chemotherapy - a course of drugs that kill cells throughout the body, both cancerous and normal cells.
Chemotherapy refers to the administration of drugs that stop the growth of cancer cells by killing them
or preventing them from dividing. Chemotherapy also helps in prolonging survival. Chemotherapy is
given at regular intervals over a period of weeks to months. Side effects during chemotherapy include
fatigue, weight loss, hair loss, nausea, vomiting, diarrhoea and mouth sores. Medicines are available that
can prevent and treat many side effects of chemotherapy. Side effects generally disappear during the
recovery phase of the treatment or after the treatment.
Signs.
A new persistent cough or wheezing chronic cough. • Blood in the sputum • Persistent bronchitis. •
Repeated respiratory infections. • Chest pain. • Unexplained weight loss and or fatigue. • Breathing
difficulty or shortness of breath.
Care of the patient with lung cancer
• Give comprehensive supportive care and provide patient's teaching to minimize complication and
speed the patient's recovery from surgery. • Encourage patient to have soft, non-irritating protein rich
food. • Teach the patient about prevention of infection. • Educate the high-risk patient to reduce
chances of lung cancer or recurrent cancer. Educate heavy smoker over the age of 40 years to have
chest x-ray·· annually and sputum analysis every six-month. • Encourage patients who ha-: rnrring or
chronic respiratory tract infection, . chronic lung disease or cough to seek. pt vu1pt medical advice.
Leukemia (Blood Cancer)
It is referred to the cancer of blood. In leukemia normal control mechanisms breakdown, the bone
marrow starts to produce large number of abnormal cells. This disrupts the normal production of blood
cells leading to anemia and low platelet count; the abnormal cells cannot fight infections like normal
white blood cells. It is not an infectious condition.
Causes
Leukemia and related diseases of blood arise as a result of changes in or damage to the genes which
control cell growth development and division. In most cases no specific cause can be identified. There
are certain factors which are known to increase the risk of developing leukemia.
Sighs and Symptoms of Leukemia
• .Patients' history may usually show sudden onset of high fever and abnormal bleedings such as
brushing after minor trauma, nose bleeds, gingival bleeding, purpura bluish patches and prolonged
menses in girls. • May report fatigue and night 'sweats. •. Weakness and lazyness. • Recurrent infection
and chills. • Abdominal and back pain. • Tachycardia (fast pulse) may be observed during auscultation,
shortness of breath, palpitations .. • Pallor. • Liver or spleen enlargement. • Weight loss and anorexia. •
Chronic condition may result into retinal haemorrhage.
Care of patient with Leukemia

33. Develop a plan of care that emphasizes on: • Provision of comfort. • Minimizing the adverse effect of
chemotherapy. • Promoting the preservation of veins. • Because so many patients with leukemia are
children, you may need to be especially sensitive to their emotional needs and to those of their families
when developing plan of care. ' • After chemotherapy make sure that patient receives enough fluid
intake as advised by the doctor. . , • To control infection keep patient in separate room and adopt
isolation precaution. Refer Practical Manual I , Skill 2. • Keep the pati,ent skin and ~':"l';~: 1 «rea clean.
Apply mild lotions or creams to keep the skin from drying and cracking. • Use strict aseptic technique for
doing any procedure. • If bleeding occurs apply ice compression and pressure and elevate the extremity
effected . .'. Frequent blood transfusion is given, encourage to arrange safe blood .. • Administer pain
medication as prescribed. • Provide comfort measures such as position change and distraction, to
reduce patient's discomfort. • Ensure frequent mouth care and saline gargles. • Reduce stress by
providing calm and quite atmosphere that is needed for rest and relaxation. • .Monitor the required
blood counts for signs of improvements. • Monitor the patient's temperature and take doctor's advice
when needed. • Check the patient's oral cavity daily for ulceration.and Qisrectal area daily for
indurations, swelling, erythemia, skin discoloration. ' • . Teach the patient and his family to recognize
signs and symptoms of infection, . +such as fever, cJ:ills, cough and sore throat and take doctor's advice.
• Explain to the patient that his blood may not have enough platelet for proper clotting and teachhim
the signs-of abnormal bleeding. Explain the patient to apply ice tothe area to stop such bleeding. • Tell
him to report excessive bleeding or bruising to the doctor. • .- Explain if chemotherapy causes weight
loss and anorexia the patient will need to eat and drink high calorie and high protein food. • If he losses
his appetite advise him to take small and frequent meals. '. Advise the patient to use soft tooth brush
and to avoid lot of spicy foods, which can irritate the mouth ulcer that results from chemotherapy.
Cancer of Larynx
Cancer can develop in any region of larynx, for example glottis the area above the vocal cords or the
area that connects the larynx to the trachea. It can spread in the neck, back of tongue and other parts of
the throat and the neck, the lungs and other parts of body. When the cancer of larynx spreads it is called
metastatic laryngeal cancer. We had discussed larynx as organ of respiratory system. Let us revise once
more. Larynx is also called the voice box and is 2" long tube shaped organ in the neck. We, use larynx
when we breathe, talk or swallow. The larynx is at the top of (wind pipe) trachea.
Signs and Symptoms • Hoarseness of voice (heaviness in voice while talking) • Feeling of lump in throat
• Cough which constantly remains • As the tumor grows it may cause pain, weight loss, bad breath and
frequent chocking during eating • Difficulty in breathing or noisy breathing
Care of the patient with larynx cancer • Encourage the patient to select the alternative way to
communicate such as writing, using sign language or alphabet boards. \ • Keeping Tracheostomy tube
(inserted during surgery) in place until tissue odema subsides. • Provide frequent mouth care, clean the
patient's mouth with soft toothbrush or soft cloth. • Rinse mouth with mouth wash. • Give analgesics as
ordered.
If nasogastric tube or Ryles tube feeding, check tube placement and elevate the patient head to prevent
aspiration. Refer Practical Manual 2-, • Monitor vital signs for fever, which indicates infection, record
fluid intake and output and watch for dehydration. • Reassure that speech rehabilitation measure may
help him communicate again with hell' of mechanical devices. • Ask the family provide pleas~t and

34. relaxed meals. • Encourage the patient to have food with other family members or friends. • Select food
that are of patient's choice or as'l'er his taste. • After patient's discharge from the hospital, the health
care provider needs to follow the care at home. You needs to understand the psychological care and get
the help of the family to provide both physical and psychological care to the patient
Cancer of Colon
Cancer colon is the commonest cause. It is common in middle aged or elderly person but it may occur
among young also.
Signs and symptoms: • Change in bowel habit, constipation followed by diarrhoea. • Bleeding per
rectum. • Abdominal pain .. • Weight loss. • Lack of appetite. • Hard mass felt in abdomen.
Cancer of Stomach
Cancer of the stomach is very common among middle aged people, Causes • Spicy food • Stress •
Malnutrition • Chronic gastric ulcer \
Signs and symptoms; • Abdominal pain while taking food. • Loss of weight. • Anemia, paleness. • Loss,
of appetite (lack of interest in food). • A solid mass is felt in abdomen.
CARDIOVASCULAR DISEASES ISCHEMIC HEART DISEASE
Ischemic heart disease (IHD), also known as coronary artery disease and coronary heart disease, is a
condition in which the heart muscle is damaged or does not function effectively. IHD develops over
decades. Plaque, which is composed of fat, cholesterol, calcium and other substances, builds up on the
inner walls of coronary arteries, leading to narrowed arteries. As a result, less blood and therefore
oxygen reaches the heart muscle, which can lead to heart attack or stroke.(28)
Modifiable behavioural and metabolic risk factors associated with the development of IHD include:(29)
Abdominal obesity; { Smoking; { Physical inactivity; { Harmful use of alcohol; { Unhealthy diet;
{ Hypertension; { Diabetes (type 2); { High blood cholesterol; and { Psychosocial factors.
Other risk factors associated with the development of IHD include:
(30–36) { Age—the risk of IHD increases with age; { Sex—men in all age groups are more likely to be
diagnosed with IHD than women, although outcomes are often worse in women; { Ethnic or cultural
origin—Indigenous populations, as well as Canadians of South Asian descent, are at increased risk of
IHD; and { Family history of IHD.
HEART FAILURE
Improvements in treatment and control of hypertension as well as advances in cardiac care have led to
an increase in the number of individuals with cardiovascular disease surviving into older age. While
aging however, these individuals remain at risk of developing heart failure and as a result, the
prevalence of heart failure increases drastically with age.(37,38)
Heart failure is chronic and progressive. Heart failure occurs when the pumping action of the heart
cannot provide enough blood to the rest of the body(38) due to damage to and progressive weakening
of the heart muscle. IHD is the most common cause of heart failure.

35. Other modifiable metabolic and behavioural risk factors of heart failure include:
Hypertension; { Diabetes (type 2); { High blood cholesterol; { Obesity; { Smoking; { Physical inactivity; and
{ Harmful use of alcohol.
Other risk factors for heart failure include:
{ Age—the risk of heart failure increases with age; { Sex—men are more likely than women to have heart
failure, but this difference between the sexes diminishes with age; { Ethnic or cultural origin—Black
populations have been shown to be at increased risk of heart failure compared to other ethnic groups;
and { Family history of cardiovascular disease.
STROKE
Stroke is a sudden loss of brain function when blood flow to part of the brain is stopped.(43) The
severity of stroke depends on the type (ischemic stroke or hemorrhagic stroke); the part of the brain
damaged; and the amount of damage sustained.(44) Ischemic stroke happens when a blockage or clot
forms in a blood vessel in the brain. The blockage can be caused when plaque builds up on the inner wall
of an artery, leading to a narrowed artery.(44) Hemorrhagic stroke occurs when an artery in the brain
ruptures.(44) This interruption in blood flow damages brain cells. A major cause of hemorrhagic stroke is
elevated blood pressure (hypertension), which weakens arteries over time.(44)
The leading modifiable metabolic and behavioural risk factors associated with the development of
stroke are:
Hypertension; { Physical inactivity; { Smoking; { Harmful use of alcohol; { Abdominal obesity; { Unhealthy
diet; { Diabetes (type 2); { High blood cholesterol; and { Psychosocial factors
Other risk factors associated with the development of stroke include:
{ Age—the risk of stroke increases with age; { Sex—although men have higher rates of stroke overall,
women aged 80+ are more likely to have a stroke, in part due to their longer life expectancy; { Ethnic or
cultural origin—Indigenous peoples as well as South Asian and Black populations are at increased risk of
stroke; and { Family history of stroke.
HYPERTENSION
Blood pressure is the force of the blood against the walls of the arteries. It is expressed as two numbers:
systolic blood pressure (the top or higher number) is the pressure in the artery when the heart
contracts, and diastolic blood pressure (the bottom or lower number) is the pressure in the artery when
the heart relaxes between beats. A systolic blood pressure below 120 mmHg or a diastolic blood
pressure below 80 mmHg is considered normal.(54) Hypertension, or high blood pressure, occurs when
blood pressure is too high for long periods of time. The risk of developing hypertension can be reduced
by adopting a healthy lifestyle. For individuals diagnosed with hypertension, lifestyle modifications
and/or use of blood pressure lowering medication can help maintain their blood pressure in a healthy
range. When left uncontrolled, hypertension can lead to damage to the artery walls and decreased
blood flow to the heart and other organs and lead to heart disease or stroke.(55,56)
Modifiable metabolic and behavioural risk factors associated with the development of hypertension
include:

36. { Physical inactivity; { Overweight and obesity; { Unhealthy diet; { High sodium intake; { Harmful use of
alcohol; { Inadequate potassium intake; and { Diabetes (type 2).
Other risk factors associated with the development of hypertension include:
{ Age—the risk of hypertension increases with age; { Sex—men are more likely than women to suffer
hypertension in early to mid-adulthood, however, hypertension is more prevalent in women after
menopause; { Ethnic or cultural origin—the prevalence of hypertension is higher in South Asian and
Black populations; and { Family history of hypertension
DIABETES
Diabetes occurs when the body is unable to produce and/or use insulin. Insulin is a hormone that
regulates blood glucose. There are three main types of diabetes: type 1 diabetes, type 2 diabetes and
gestational diabetes. About 90% of diabetes cases among Canadian adults are type 2; 9% are type 1 and
less than 1% are of a different type.(48) Children and youth generally have type 1 diabetes.(49) About 1
in 10 women have gestational diabetes, that is, diabetes while pregnant.(50) Type 1 diabetes, which
usually begins in childhood, is an autoimmune disease. The risk factors for type 1 diabetes are not fully
understood, but interactions between genetic and environmental factors are likely involved.(51) Type 2
diabetes is caused by a wide range of social, environmental and genetic factors.
Some common modifiable metabolic and behavioural risk factors include
{ Obesity; { Physical inactivity; { Unhealthy diet; and { Smoking.
Other risk factors include:
{ Age—the risk of diabetes increases with age. { Ethnic or cultural origin—In 2010–2013, diabetes was
2.3 and 2.1 times more common among South Asian and Black adults, respectively, than among White
adults. Over the same period, the prevalence of diabetes among First Nations adults living off reserve
and Métis adults was, respectively, 1.9 and 1.5 times higher than the prevalence among non-Indigenous
adults. { Family history of type 2 diabetes
Diabetes
Definition It is very common disease in which blood glucose become more than normal (Normal blood
sugar level is 80-120mg/l OOc.cof blood).
Causes: • Enough insulin is not produced as a result sugar level rises in the blood. Sugar is excreted
through kidney. Action of insulin is to lower the levels of sugar in blood. • Obesity • Genetic • Stress
Signs and symptoms: • Polyuria (excessive output of urine) or increased frequency of urination. , • Thirst
(constant desire to drink water). • Increased hunger • Loss of energy, lack of interest. • Leg cramps. •
Non-healing of wounds. • Repeated infection. • Vision disturbarices.
Chronic Liver Failure or Cirrhosis of Liver
Definition

37. This is a disease of liver. The liver becomes hard and liver cells die and unable to carry out the normal
function of liver.
Cause • VIral hepatitis • Excessive intake of alcohol • Infection, malnutrition or protein deficiency ',
Signs and symptoms. • Bleeding from stomach. • Loss of appetite (loss of interest for the food). •
Prominent vein on the abdomen. • Low grade fever; • Enlarged abdomen. • Prone to infection. • Yellow
colour of eye, nail and skin
Pancreatitis
Definition In pancreatitis there is inflammation of the pancreas. The enzymes which are secreted by the
pancreas become more active. Causes • Gallbladder Stones. • Excessive alcohol. Signs and symptoms • .
Sudden onset of severe abdominal pain, which shifts to the back. • Shock. • Vomiting Pulse becomes
rapid. • Low blood pressure.
MENTAL ILLNESS AND SUICIDE MOOD AND ANXIETY DISORDERS
The most common mental illnesses among Canadian seniors are mood and anxiety disorders,(62)
cognitive and mental disorders due to a medical condition (including dementia and delirium), substance
misuse (including prescription drugs and alcohol) and psychotic disorders. Dementia is discussed in
section 3.7 “Neurological diseases”. Mood disorders are characterized by prolonged periods of excessive
elevation or depression of mood or of both.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5),(63) mood
disorders include
Major depressive disorder; { Bipolar disorder; { Dysthymic disorder; and { Perinatal/postpartum
depression.
Anxiety disorders are characterized by excessive and persistent feelings of apprehension, worry and
fear. According to the DSM-5, anxiety disorders include but are not limited to:
{ Generalized anxiety disorder; { Social phobia / social anxiety disorder; { Specific phobias; { Post-
traumatic stress disorder; { Obsessive-compulsive disorder; { Panic disorder; and { Agoraphobia.
Both mood and anxiety disorders impact an individual’s everyday life for an extended time. This may
lead to difficulties fulfilling professional, family and/or social obligations.(64,65) Mood and anxiety
disorders and other mental illnesses (e.g. substance abuse disorder) often co-occur.(66) Due to the
complex interplay of various biological, genetic, socioeconomic, social and psychological factors that
contribute to the development of mood and anxiety disorders, individuals often need lengthy treatment
and health service use.(65,67,68) Professional care with active engagement in self-management
strategies can foster recovery and improve the wellbeing of affected individuals
SUICIDE

38. Suicide is death caused by self-inflicted injury where the intent is to die.(71) Suicide-related behaviours
include:
{ Deliberate self-inflicted injury, or intentional self-poisoning(72) with or without the intention to die;
{ Suicidal thoughts or ideation (seriously considering suicide); { Suicidal plans; and { Suicidal attempts.
Preventing suicide is complex. Many risk factors are involved, for example, low socioeconomic status,
having a mental illness, substance use and previous suicide attempts.(71,73–75) Protective factors that
may have a critical role in preventing suicide-related behaviours include: (74,75)
{ A sense of community belonging; { Satisfaction with frequency of communication with friends and
family; { Social, familial and cultural connections (religious, spiritual, cultural or social groups); { Positive
psychological factors, for example, a sense of meaning in life and having reasons for living; and { Access
to appropriate community-based mental health education, screening and outreach services.
MUSCULOSKELETAL DISORDERS
Fractures.
Fractures account for a high percentage of traumatic injuries. They create changes in one's quality of life
by causing restriction in activity, disability and loss of wages because patient is not able to go for work. A
fracture is breakage (gap) in the normal continuity of a bone. We have also discussed about types of
fractures in Block 1, Unit 4. One of the most common fracture among older adults is fracture of the hip
also. Let us learn about its causes, sign and symptoms and measures to relieve the symptoms. Hip
fractures are one of many events that may permanently change your patient's level of functioning and
independence. Fractures in an older person are related to falls, cancer, osteoporosis, and other skeletal
diseases. The most common fracture site is the head of the femur, with women having a higher
incidence than men. Older adults' bones fracture more easily because they're more' brittle. They also
heal more slowly, increasing the risk of immobility complications.
Causes • Falls are the most common cause of fractures • Slippery surfaces • Cancer of bone • Severe
osteoporosis can lead to fracture of hip by twisting in bed.
Signs and Symptoms • Swelling around and in the hip area • Bluish discoloration at the pelvic area ".
Inward or outward rotation of the leg on the side with the affected hip • Limited movement of the limbs
(arm or legs)· • Anxiety increased heart rate . I • Pain
Measure to relieve symptoms • Early recognition of pain allows for quick measures before the pain . .
becomes unnianageable. • Encourage the patient to have scheduled rest periods because fatigue
increases pain. • Help the patient with pain relief measures such as massage, meditation, relaxation
exercises. • Turn the patient every 2 hours to promote patient comfort and to reduce the risk of
developing immobility (stiffness of the joints). • Check for foul-smelling discharge from the dressing, it
can be due to pus at the site of wound. • Help in doing sterile dressing if doctor comes for check up at
home. • Change the dressing using sterile technique as per guidelines given in Practical Manual 2 under
dressing. • Encourage well balanced nutritious diet which is easily digestible and record the intake and
output.

39. Bone tumor.
Bone tumor may remairi undiagnosed because they often cause no pain initially but later on severe pain.
They may be noted as on incident, x-ray finding when the client is being evaluated for another
compliant, such as fracture. Causes • Exact cause is unknown. • Past trauma (accident). • Family history
of cancer.
Signs and Symptoms • -Pain which is severe r- • Immobility • Inability to hold heavy objects • Weight
loss " • .Localized Swelling .". • Anaemia • Frequen~ infections, chills, fever.
D) Measure to relieve symptoms 74 • Surgical removing of the affected part (amputation). It is a
psychological trauma for the patient and family members. Hence, you should prepare the patient and
family members to accept the surgery; alternative as artificial limb for the patient. ' • Teach the patient
about phantom limb sensations. • Phantom limb cause unpleasant feeling thatthe limb is still there.
Patient may feel pain, you should explain that this sensation may be.constant, hence, distract 'the
patient to relieve phantom limb sensations. Have him look at the stump or close eye and put the stump
in sense of motion as if the full limb were still be there. • Allow the patient to express his emotional
reactions. • Patient with total hip replacement (THR) and total knee replacement (TKR) mostly needs
devices such as walker or crutches and bathroom equipment to be available at home. Refer Practical
Manual 2 under use of devices for ambulation for further details in skill 15. ,. • Advise patient to avoid
tub bath in case ofTHR,.TKR.
GOUT AND OTHER CRYSTAL ARTHROPATHIES
Gout is disease related to joints. Gout also called gouty arthritis, is a metabolic disease marked by urate
deposits, which cause painfully arthritic joints. It can cause chronic disability (inability to carry out
activity).
Crystal arthropathies are caused by small crystals that accumulate in the joints.(76) Gout and
pseudogout are the two most common types of crystal arthropathies. Gout is characterized by the
crystallization of uric acid within the joints. It is often associated with an excess of uric acid in the blood,
or hyperuricemia. Pseudogout results from deposits of calcium pyrophosphate crystals in the joints. The
body’s immune system is triggered by these crystals, and the immune system activity can lead to pain,
swelling and redness in the joint and surrounding tissues. While gout can occur in any joint, it most often
occurs at the base of the big toe.(77) Other joints commonly involved include the knees, ankles, elbows,
wrists and fingers. Both gout and pseudogout are episodic in nature, with active and inactive periods.
Active periods or “attacks” vary in length and severity. Repeated attacks of these conditions may
become more frequent, last longer and affect more joints and can cause permanent joint damage.
Although hyperuricemia is the primary risk factor for gout, only a minority of people with hyperuricemia
develop gout and other crystal arthropathies because other factors affect risk.(78)
Modifiable metabolic and behavioural risk factors associated with the development of gout and other
crystal arthropathies include
{ Obesity; { A diet high in purines (e.g. red meat, organ meats, certain types of seafood); { Consumption
of alcohol (especially beer); and { Consumption of beverages sweetened with fructose.

40. Diabetes mellitus, hypertension, renal disease
Other risk factors associated with the development of gout and other crystal arthropathies include:
77–80) { Age—the risk increases with age; { Sex—gout is more prevalent in men; { Ethnic and cultural
origin—gout and other crystal arthropathies are more prevalent among Black adults, particularly men,
than their White counterparts; and { Family history of gout and other crystal arthropathies.
Signs and symptoms.
Extreme pain in the joints such as ankle, heel, knee, or wrist joints. Recent increase in exercise and
activity level. • History of diabetes, hypertension, or sickle cell anemia. • Extreme joint tenderness. •
Shiny red, purple or cyanotic skin over the inflamed joint. • Low-grade fever. • Loss of movements of
joints or immobility.
Measures to relieve pain.
Encourage the patient with gout to rest frequently and keep the affected limb elevated or in a splint. •
Rest is the most important treatment for inflammation. Not to move the joint too much can improve the
effect of medicines given for relieving pain and infection. • Plan undisturbed rest periods for the patient
to reduce fatigue. • Educate the patient on how to perform range of motion exercises to maintain
jointmobility. Refer Practical Manuall for more details under skill 7. • Apply ice packs to joints because
cold effectively reduces acute pain, give medication. Refer Practical Manual 2, skilll4 for more details. •
Provide other comfort measures such as massage, turning and repositioning as often as possible to
promote comfort and distract the patient from pain. • Encourage the patient to drink 6 to 8.glasses of
fluid each day because adequate hydration minimizes the risk of kidney stone formation. • Tell the
patient to avoid foods such as beans, peas, whole grain cereals, pulses, rajmah, spinach, red meat, milk
and milk product because these food stuffs are gas forming
Joint conditions.
Bones are joined to one another that perinits a variety of movements such as free movements in which
arms and legs provide full range of motion in all directions with the help of ball and socket joints such as
shoulder joint and hip joint. • Other joints which provide slight movements - joint between right and left
pelvis. • Joint which provide little or no movement at all, bones of skull are joined with the help of
sutures e.g. suture in skull.
OSTEOARTHRITIS
Osteoarthritis: The most common arthritis causes destruction of joint cartilage , and the formation of
new bone at the margins of joints. Osteoarthritis occurs commonly in weight-bearing joints, especially
the hips and knees. Dependingon the site and severity ofjoint involvement, disability can range from
minor limitation of the fingers to near immobility in some people with hip or knee disease.
Osteoarthritis is the most common form of arthritis and a significant cause of disability.(81) Although
once thought to be caused by the wear and tear of aging, we now know that osteoarthritis is a
progressive disease of the synovial joints resulting from a failed attempt by the body to repair joint
tissues that are damaged due to abnormal joint loading (from obesity and joint injury) with the influence
of systemic factors (for example, genetic factors, inflammation, aging and sex).(82) All of these factors

41. cause abnormal joint tissue metabolism, which is followed by the breakdown of the joint cartilage and
underlying bone. Osteoarthritis usually affects the joints of the hands, feet, hips, knees and spine. Signs
and symptoms include joint stiffness, swelling, pain and loss of mobility. Although there is no cure for
osteoarthritis, interventions (including lifestyle modifications) can reduce pain, improve function and, in
some instances, delay disease progression.(83)
Modifiable risk factors associated with the development of osteoarthritis include:
Overweight and obesity; { Joint injury; and { Mechanical stress.
Other risk factors associated with the development of osteoarthritis include:
{ Age—although osteoarthritis is not an inevitable part of aging, the chance of developing this disease
increases with age; { Female sex (particularly post menopause); and { Family history of osteoarthritis.
Causes • 'Osteoarthritis may be related to aging. Wear mid tear on the joints due to . '. agmg process. •
Obesity • Repetitive overuse of ajoint,
Signs and Symptoms • Decreased movements of joints • Inflammation of the joint e.g, warmness,
swelling and joint ispainful to touch. Fever • Depression, Anxiety
• Joint enlargement (increase) and deformities (defect) .• Stiffness of muscles \. . Leg ulcersIwound)
RHEUMATOID ARTHRITIS
chronic autoimmune disease characterized by the unresolved synovial inflammation for tissues-
destructive consequence, which remains one of significant causes of disability
Rheumatoid arthritis is a chronic disease that attacks peripheral joints and surrounding muscles,
tendons, ligaments, and blood vessels.
Rheumatoid arthritis, a common type of inflammatory arthritis, is an autoimmune disease where the
body’s immune system mistakenly attacks the lining of the joints and other tissues.(86,87) Inflammation
in the joints causes swelling, pain and stiffness. Left untreated, such inflammation can lead to joint
damage. Rheumatoid arthritis can affect multiple joints in the body and most commonly the joints of the
hands, wrists and feet. The inflammation may also affect other organs, such as the eyes, skin, lungs or
heart. While there is no cure for rheumatoid arthritis, effective treatment options can alleviate
symptoms and improve function of the joints. Medication is often prescribed as a first line of treatment.
Other treatments include physical therapy, occupational therapy and lifestyle modification.(88)
Individuals who are diagnosed and treated early are less likely to have severe symptoms, joint damage
and functional impairments
The specific causes of rheumatoid arthritis are unknown, but a number of factors are associated with
the increased risk of developing the disease. Modifiable risk factors that may play a role in the
development of rheumatoid arthritis include:
{ Smoking; { Obesity; { Occupational exposures; and { Infection.
Other risk factors associated with the development of rheumatoid arthritis include:(91)

42. { Age—the risk increases with age; { Sex—rheumatoid arthritis is more prevalent in women; { Ethnic or
cultural origin—the prevalence of rheumatoid arthritis is higher among Indigenous people (First Nations,
Métis and Inuit populations); and { Family history of rheumatoid arthritis.
) Measures to relieve symptoms: • Check for pain, by seeing facial expression, and increased heart rate.
• Apply ice packs in case of hot, inflamed joints. • Apply heat to joints in case of contractures (stiffness).
Refer Practical Manual 2 for the procedure of hot and cold applications. • Give medicines as ordered by
the doctor. • Encourage the patientto take rest frequently. • Keep the affected limb raised in a splint as
per doctor's order. • Help the patient to perform exercises according to tolerance of the patient. • Help
the patient to use assistive devices, such as a cane, crutches, or a walker to provide stability and
increase mobility. Refer Practical Manual 2 for more details. • Instruct the patient to wear proper
footwear. • Tell the patient to avoid walking down stairs, which increases stress en weight-bearingjoints.
• Encourage the patient to express his feeling. • Provide opportunities for the patient to wear make-up
or different clothing. Allowing the patient to enhance her/his appearance which helps to boost morale. •
Check for the patient's ability to feed, bathe, and dress himself to find out how much help the patient
needs. • Maintain proper body weight. • Sit on cushions and use an elevated toilet seat. • Have safety
devices installed in the patient's home such as grab bars in the bathroom.
OSTEOPOROSIS
Osteoporosis is a disorder in which bone formation decreases. As the bones lose more calcium and
phosphate than they replace, they become porous and easily breakable and vulnerable (at high risk) to
fracture. Osteoporosis usually affects women aged 51 to 75 years.
Osteoporosis is a metabolic bone disease characterized by low bone density and an elevated risk of
fracture. Although more common among older individuals and among women, osteoporosis can affect
people of all ages.(92) Many people are not aware they have osteoporosis until they have a fracture,
often the consequence of a fall. The most common fracture sites are the wrist, shoulder, spine, pelvis
and hip.(93,94) Hip fractures are the most serious due to the life-threatening complications. Several
factors play a role in the development of osteoporosis. The more risk factors individuals have, the
greater their risk. Modifiable risk factors associated with development of osteoporosis include
Physical inactivity; { A diet low in calcium, vitamin D and other important nutrients related to bone
health; { Low body weight (10% of body weight at age 25); { Harmful use of alcohol; and { Smoking.
) Causes • Lack of calcium in diet • Estrogen (hormone) deficiency • Faulty protein metabolism •
Sedentary lifestyle
Other risk factors associated with the development of osteoporosis include:(95) { Age—the risk of
osteoporosis increases with age; { Sex—osteoporosis is more prevalent in women; { A family history of
osteoporosis or fracture (parental hip fracture); { Hormonal deficits, for example, in the case of
hypogonadism or premature menopause (less than 45) Specific medications (e.g. glucocorticoids); and
{ Certain medical conditions (e.g. primary hypothyroidism, chronic inflammatory conditions,
malabsorption syndromes).
osteoporosis-related fractures, most commonly in the forearm, hip, spine, humerus and pelvis. Among
those aged 80+ years, hip fractures were the most common type. These also resulted in the most serious

43. complications. Women were more likely to fracture a hip than men, but men with a hip fracture were
more likely to die of any cause within the following year
Signs and symptoms: •• Chronic back pain • Joint discomfort while sitting or standing • Decreased
mobility • Early menopause (end of menstrual cycle) • Loss of appetite • Cigarette smoking and
alcoholism • Muscle spasm, especially in the back • Muscle weakness • Self-care deficit (inability of the
patient to care for himself)
Measure to relieve symptoms: ,. Prevent injury and falls. • Encourage the patient to exercise regularly,
especially weight-bearing exercises, such as walking, lifting heavy weight. .• Educate the patient on
maintaining good posture while sitting on chair or at work place. ~ Encourage the patient to avoid
coffee' and stop taking alcohol and cigarette smoking '0 Cheek the patient's home for pets, small toys,
loose rugs, and other objects to identify environmental hazards that may cause him to fall. • Tell the
patient to increase calcium intake with foods high in calcium, such as milk and milk products, fish and
give medications as prescribed by doctor.
NEUROLOGICAL DISEASES
DEMENTIA (including Alzheimer disease)
Dementia is an umbrella term used to describe a set of symptoms affecting brain function that are
caused by neurodegenerative and vascular diseases or injuries. Alzheimer disease is the most common
cause of the condition. Dementia is characterized by a decline in cognitive abilities (including memory;
awareness of person, place, and time; language, basic math skills; judgment; and planning) and can
affect mood and behaviour. Over time, it reduces the ability to independently maintain activities of daily
life, such as eating, bathing, toileting and dressing.(96)
Pseudo-Dementia
An older person may appear to be experiencing dementia, but may in fact be suffering from a reversible
condition such as depression, delirium from acute infection, side effects of drugs, thyroid condition, B12
deficiency
Although all the causes of dementia are not known, research suggests the following possible modifiable
risk factors
Physical inactivity; { Obesity; { Unhealthy diet; { Smoking; { Harmful use of alcohol; { Social isolation;
{ Lack of cognitively stimulating activities; and { Diabetes (type 2), hypertension and/or depression.
Other risk factors for dementia include:
{ Age—although not a normal part of aging, age is a key risk factor for dementia. However, early onset
dementia can develop at younger ages; and { Sex—women are at an increased risk of developing
dementia.
Dementia is an umbrella term used to describe a range of cognitive impairments that affect memory,
thinking, behavior, and the ability to perform daily activities. It is not a single disease but rather a set of
symptoms caused by various conditions that damage the brain. The condition typically worsens over
time and can significantly interfere with a person's ability to live independently.

44. Key Features of Dementia:
Memory loss: Difficulty remembering recent events, conversations, or appointments.
Cognitive decline: Impairment in other areas of cognitive function, such as attention, problem-
solving, language, and executive functioning.
Behavioral changes: Individuals may exhibit changes in mood, personality, or behavior, such as
increased irritability, confusion, anxiety, or aggression.
Difficulty with daily tasks: Problems performing routine tasks like cooking, dressing, or
managing finances.
Disorientation: Individuals with dementia may become lost in familiar places or have difficulty
recognizing people they know.
Causes of Dementia:
Dementia is caused by damage to brain cells, which disrupts communication between brain cells and
impairs cognitive functions. The causes of dementia vary depending on the specific type, and the most
common causes include:
1.Alzheimer's Disease:
oThe most common cause of dementia, accounting for around 60-70% of cases.
oInvolves the buildup of amyloid plaques and tau tangles in the brain, which interfere
with normal brain cell function.
oSymptoms typically begin with mild memory loss and gradually progress to severe
cognitive decline, including difficulty recognizing loved ones, severe memory
impairment, and a loss of independence.
2.Vascular Dementia:
oCaused by reduced blood flow to the brain, often due to stroke or other blood vessel-
related problems.
oSymptoms can vary, depending on which areas of the brain are affected, but they often
include difficulties with memory, problem-solving, and attention.
oIndividuals may experience a more "stepwise" decline in function due to strokes or
other vascular events.
3.Lewy Body Dementia (LBD):
oCaused by abnormal deposits of a protein called alpha-synuclein, which forms clumps
known as Lewy bodies in brain cells.
oSymptoms can include fluctuating cognitive abilities, visual hallucinations, Parkinsonism
(tremors, stiffness), and difficulty with motor control.
oLBD shares some features with both Alzheimer's disease and Parkinson's disease.

45. 4.Frontotemporal Dementia (FTD):
oCaused by progressive damage to the frontal and temporal lobes of the brain, which
control behavior, language, and judgment.
oSymptoms often involve significant changes in personality and behavior, such as
impulsivity, inappropriate behavior, and difficulty with speech or understanding
language.
oUnlike Alzheimer’s, memory may not be as significantly affected in the early stages.
5.Other Causes:
oParkinson's Disease Dementia: Some individuals with Parkinson’s disease develop
dementia as the disease progresses.
oMixed Dementia: A combination of different types of dementia, such as Alzheimer's
disease and vascular dementia, can occur simultaneously.
oTraumatic Brain Injury: Repeated head injuries (e.g., from sports, accidents) can lead to
a form of dementia called chronic traumatic encephalopathy (CTE).
oInfections or diseases: Infections like HIV, or conditions like Creutzfeldt-Jakob disease or
Huntington's disease, can cause dementia in some cases.
Symptoms of Dementia:
The symptoms of dementia can vary widely depending on the underlying cause, but they generally
involve two main categories:
1.Cognitive Symptoms:
oMemory loss: Forgetting recent events or repeating the same questions or stories.
oLanguage difficulties: Trouble finding the right words, or understanding complex
sentences.
oAttention and concentration problems: Difficulty focusing or keeping track of
conversations, tasks, or directions.
oExecutive dysfunction: Impairments in reasoning, judgment, planning, and problem-
solving.
oVisuospatial problems: Difficulty with tasks that require visual-spatial skills, such as
reading, navigating familiar environments, or recognizing objects.
2.Behavioral and Psychological Symptoms:
oMood swings: Feelings of sadness, anxiety, or irritability.
oDepression: Feelings of hopelessness or a lack of interest in things that were previously
enjoyed.

46. oDelusions or hallucinations: In some types of dementia, individuals may believe things
that are not true (delusions) or see/hear things that aren’t there (hallucinations).
oSleep disturbances: Changes in sleep patterns, including insomnia or excessive
sleepiness.
oApathy or withdrawal: Lack of motivation or interest in socializing or participating in
activities.
Diagnosis of Dementia:
Diagnosing dementia involves a comprehensive evaluation that includes:
1.Medical history: Reviewing symptoms, family history, and any potential underlying health
conditions.
2.Physical and neurological exams: Assessing reflexes, motor skills, coordination, and cognitive
function.
3.Cognitive testing: Specific tests to evaluate memory, attention, problem-solving, and language
skills.
4.Brain imaging: MRI or CT scans to identify changes in the brain, such as shrinkage or damage
from strokes, tumors, or other conditions.
5.Blood tests: To rule out other conditions that might cause cognitive impairment (e.g., vitamin
deficiencies, thyroid problems, infections).
Treatment and Management:
Currently, there is no cure for most types of dementia, but there are treatments and strategies to
manage symptoms and improve quality of life:
1.Medications:
oCholinesterase inhibitors (e.g., Donepezil, Rivastigmine) may be prescribed for
Alzheimer's disease to help improve communication between brain cells and slow
cognitive decline.
oGlutamate regulators (e.g., Memantine) can help regulate brain activity and improve
symptoms in moderate to severe Alzheimer's disease.
oFor other types of dementia, there may be specific medications to address symptoms
such as depression, anxiety, or agitation.
2.Non-Pharmacological Interventions:
oCognitive stimulation therapy (CST): Engaging activities that stimulate thinking and
memory, such as puzzles or word games.
oBehavioral therapy: To manage problematic behaviors such as aggression, anxiety, or
repetitive actions.

47. oEnvironmental modifications: Creating a safe, supportive environment that reduces
confusion and enhances independence (e.g., using clear signs, reducing clutter).
oSocial engagement: Encouraging participation in social activities can help improve mood
and reduce feelings of isolation.
3.Supportive Care:
oCaregivers: As dementia progresses, individuals often need support with daily activities.
Caregivers may need to assist with tasks like cooking, cleaning, and medication
management.
oSupport groups and counseling: Both patients and caregivers can benefit from
connecting with others facing similar challenges to share experiences, gain emotional
support, and learn coping strategies.
Prevention and Risk Factors:
While there is no guaranteed way to prevent dementia, certain lifestyle changes may reduce the risk:
Physical exercise: Regular activity helps maintain brain health.
Healthy diet: A diet rich in fruits, vegetables, whole grains, and healthy fats (e.g., Mediterranean
diet) may reduce the risk of cognitive decline.
Mental stimulation: Engaging in activities that challenge the brain, such as reading, learning
new skills, or puzzles, may help maintain cognitive function.
Social engagement: Maintaining social connections and staying active in social settings may
reduce dementia risk.
Managing health conditions: Controlling risk factors like high blood pressure, diabetes, and
cholesterol may help prevent vascular dementia.
Prognosis:
The progression of dementia varies depending on the cause and the individual. While dementia is a
progressive condition that worsens over time, the rate at which it progresses can differ widely from
person to person. Some people live with dementia for many years, while others may experience a more
rapid decline.
Overall, while there is no cure for dementia, early diagnosis, appropriate treatment, and supportive care
can help manage symptoms and improve the quality of life for both individuals with dementia and their
caregivers.
MEMORY LOSS:
Occasional forgetfulness of such things as dates, names, and information is a normal part of aging.
These are sometimes referred to as senior moments, and these brain glitches occur more frequently as
age increases. There are two types of memory: short-term and long-term. Short-term memory is new

48. information, recent occurrences, and what is happening in the here and now. Long-term memory is the
distant and recent past, and includes occurrences and education. As one ages, long-term memory stays
intact, but short-term memory may take more time and effort to store information. The aging brain can
store and remember new information. Its ability is enhanced by the use of all the body senses to take in
the information. In other words, hearing a new piece of information while seeing it, reading it, or writing
it can dramatically increase the chances of retention. Therefore, working puzzles, playing brain games,
and reading or taking classes all help to keep the brain sharp.
diet and medical conditions play a big role in maintaining brain function. A diet that is high in trans fat
and cholesterol causes narrowing of the blood vessels and can decrease blood flow to the brain.
Untreated or poorly controlled diabetes, high blood pressure, and hear t disease can cause strokes and
vascular dementia. Maintaining a healthy weight, following a low-fat diet, and getting yearly checkups all
play a par t in maintaining memory
Alzheimer’s disease—This is the most widely recognized form of dementia. It is characterized by the
formation of plaques and tangles of nerve fibers in the brain. The decline that occurs as the condition
progresses follows a distinct pattern of stages. Each stage marks a specific decline in memory and brain
function. Persons with a dementing illness such as Alzheimer’s Disease best remember
events/places/and people during the early years of their lives. The years that hold the most vivid
memories are between 12-24 years of age.
Alzheimer's disease (AD) is a degenerative brain syndrome characterised by a progressive decline in
memory, thinking, comprehension, calculation, language, learning capacity and judgment sufficient to
deteriorate personal activities of daily living. Exact cause is not known. Long standing history of
hypertension, history of head injury, history of heart attack, Diabetes Mellitus etc
Warning signs of Alzheimer's disease are: • Asking the same question over and over again. • Repeating
the same story, word for word, again and again. • Forgetting how to cook, or how to make repairs, or
how to play cards - activities that were previously done with ease and regularity. • Losing one's ability to
pay bills or balance one's cheque book. • Getting lost in familiar surroundings, or misplacing household
objects. •• Neglecting to bathe, or wearing the same clothes over and over again, while insisting that
they have taken bath or that their clothes are still clean. • Relying on someone' else, such as a spouse, to
make decisions or answer questions they previously would have handled themselves • Difficulty in
learning new material.
As the disease progresses the patient develops: Aphasia - Difficulty in speaking/inability to speak or
communicate Apraxia - Inability to perform correct movement. Agnosia - The inability to recognize
common objects through the senses. • Activities of daily living are impaired. • Personality
changes :irritability.
Supportive Care of Patient with Alzhemier's Disease There is no cure for Alzhernier's disease. Generally
treatment is supportive only and palliative in nature: • Patient is given medicines to treat symptoms •
Antipsychotic drugs are given to control agitation and confusion. • Hormone replacement therapy may
Prevent injury • Keep neces~ary items - water, phone, call bell within easy reach. • Remove extra
furniture and equipment from the room._ • Instruct him to use non-slippery shoes. • Ensure adequate

49. lighting to prevent falls. • Assess for ataxia (difficulty in walking) and assist with walking. • . Patient
should be restricted from dri ving.
Selfcare deficit: Related to memory loss and coordination problem. • Maintain a routi ne, decrease the
number of choices available to the patient, use picture to identify activities. • Ask patient to perform
one task at a time. Do not hurry the patient.
Imbalance Nutritional . • . Provide foods familiar to the patient. • Provide foods higher in calories and
fibers. • Encourage fluids. . , • Ensure that dental care is maintained and dentures are well fitting. •
Tolerate spills without scolding and obtain unbreakable plates and nospill cups when needed. play a role
in slowing diseases progression. • Antianxiety agents to reduce anxiety and restlessness.' • Antiepileptic
drugs to control fits. • Laxative or stool softeners for constipation
Impaired verbal communication Introduction to Health ConditionslProblems Related to Brain (Nervous
System) • Maintain a calm, positive attitude, eliminate distracting noises such asradio or television. •
Call patient's name or gently touch patient to get himlher attention. • Speak slowly and calmly, using a
clear, low-pitched voice.
Disturbed sleep pattern • Prevent patient from falling asleep during the day through such measures as
periodic short walks, planned activities and keeping patient upright as needs as possible. • Adhere to
regular bedtime schedules and rituals such as bed time snacks and ,toileting.
Vascular or multi-infarct—This form is caused by mini-strokes, which disrupt the blood flow to specific
b
parts of the brain, rendering them useless.This condition may present more subtly and does not follow
prescribed stages.
Lewy body—This disease is characterized by signs of dementia and Parkinson’s disease. In addition to
b
cognitive and memory problems, Lewy body patients often have trouble maintaining balance and
experience a shuffling gait, tremors, and stiffness in the arms and legs.This condition is also associated
with mood and personality changes.
Unfortunately, there is no cure for dementia. Treatment is focused on slowing the progression of the
disease and treating symptoms
COMMUNICATION
Avoid asking questions that rely on memory alone. The person may be persistent in expressing an
irrational thought or idea. Try not to reason with the person as he/she may no longer have the ability to
rationalize. Reasoning or rationalizing with the person frequently leads to frustration and anger. Try not
to express your anger or impatience verbally or with physical movements such as shaking your head,
pointing your finger, etc. These responses are easily sensed and will likely increase confusion and
agitation. Approach the person slowly from the front to avoid startling him/her. Make sure you have
the person’s attention before speaking or touching him/her and speak slowly and clearly using short,
simple sentences. A person with dementia can often have a low frustration tolerance and can become
agitated quite quickly if they feel confused or feel threatened. When communicating to the person
around tasks or activities, try to:
Give clearly stated directions for each step. • Complete one step at a time. • Limit the number of choices
presented at one time (e.g. food, activities, or clothing). The person may no longer have the ability to

50. think of several things at once and may be too overwhelmed to keep track of multiple events,
statements, questions or directions. Decision-making may be overwhelming to the person and result in
an agitated response. Offer activities and events that the person is capable of doing. You will need to
regularly assess the person’s capabilities and adjust your expectations accordingly.
Always talk to the person as a fellow human being. Avoid talking over the person as if he/she were not
there. Avoid the use of medical terms with the person. Provide the person with verbal, factual help.
Clocks and calendars should be placed at eye level, and numbers and letters should be large enough to
read clearly. Mirrors should be placed at eye level. Write down information to help the person
remember things. Use non-glare, light yellow tinted paper to write information/messages for the
person. Write down regularly scheduled activities clearly on a calendar. If you leave the house to go
outside or to go to the garage, leave a message with the person or on the table or fridge
Wandering is a common and often times serious problem that affects both the individual and the
caregiver. As there are different kinds of wandering behaviour and different reasons attributing to this
behaviour, the most important approach to management is identifying the causes of the behaviour
itself. Some possible causes include:
PHYSICAL OR MEDICAL CAUSES
Direct result of changes to the brain from the disease. Unable to identify or express hunger/thirst.
Reaction to medications such as sedatives, tranquillizers, or the interaction of several medications in
combination. Physical discomfort due to pain, infection, constipation (urinary tract infection and chest
infection are common causes of wandering, agitated behaviour). Need to use the bathroom. Need to
exercise and be active (wandering can become an expression of the person’s need for sensory
stimulation and socialization). Need for companionship and socialization (i.e. feeling lonely and
isolated).
ENVIRONMENTAL CAUSES
The person:
May want to escape from a noise or a crowd. May be afraid (possibly from new and strange
surroundings, hallucinations or delusions). May be misinterpreting their environment (shadows can be
interpreted as people or animals and can be quite frightening; noises can be misinterpreted and also
lead to feelings of fear; smells are often misinterpreted and trigger old memories that induce fear or
confusion). May be trying to make sense of a new environment (e.g., recent relocation, new daycare,
facility placement, move to a new neighbourhood or city). Changes in the immediate environment: such
as a new decorating scheme or moving furniture to a different spot can also create confusion and
wandering behaviour. May be uncomfortable, (e.g., too hot or too cold, clothing too tight). May be
triggered to want to leave by seeing outdoor clothing such as a coat, hat or shoes. May be acting out
his/her past/old routines such as leaving for work, school, going to feed the cows, etc. May be looking
for a friend or family member who is out of sight. May get lost while taking a walk even if surroundings
were at one time familiar. May be searching for his/her past home or searching for people from the
distant past.
NIGHT TIME WANDERING

51. May be caused by:
Inability of the person to separate dreams from reality. Inactivity during daytime hours. Too much
sleep during daytime. Delirium which can cause sleep disturbances. Adverse reactions to medication
such as sedatives and tranquilizers. Person may be cold as core body temperature is at it’s lowest 30
minutes after a person falls asleep. Inability of the person to appreciate time; when they awaken in the
night they may believe that it is time to get up and dress.
TO PREVENT WANDERING
Wandering may be due to the person searching for a person, place or object from the past. Reminiscing
about things from the past may be comforting. Photo albums, travel books and magazines are ways of
introducing a reminiscence activity. For some people with dementia, wandering is a coping mechanism
to release energy or reduce stress and tension. Trying to stop the wandering may increase agitation and
cause anger and frustration. Anticipating an event such as a visit to or from a relative may contribute to
wandering. Consider if the person needs to be advised of plans ahead of time and what amount of
advanced notice is necessary without causing undue anxiety or restlessness. Wandering may occur
when a change in location is anticipated. In the event of relocation slowly introduce the person to the
idea of change. If possible, visit the new location several times prior to moving to help orient the person
to new surroundings. Involve the person in the actual move if possible, by allowing them to pack and
transport boxes. A person who wanders at the same time every day may be returning to a former
schedule or routine. For example, a person may be trying to get back to work after lunch or fixing a
snack for children coming home after school. Think of ways to accommodate this by going for a walk or a
drive or provide other distractions during this time of day. Have the individual see a physician for a
thorough medical examination to rule out medical causes contributing to the wandering behaviour.
Avoid or limit daytime napping. Plan daily activities during the time a person tends to wander. This
could include an exercise regime, participation in household activities, participation in gardening
activities, walks to the store, etc. Decrease noise levels in the environment and the number of people
interacting with the individual to prevent over stimulation. Remove items from view that may trigger a
desire to wander such as shoes, boots, purse, coat rack. Make sure the person is not wandering because
of a need to use the bathroom. Look for obvious signs such as fidgeting with clothes or holding onto
themselves. At night time be sure the bathroom or a commode is easily accessible and visible.
Use night-lights, floor lighting, signs and familiar objects to assist the person to move around an area
safely, particularly for finding the bathroom at night. Place an extra blanket over the person after they
are asleep to ensure they stay warm and comfortable. Reflector tape is useful around a bathroom door
to assist in finding the bathroom. Put fences or hedges around your patio or yard; install gates on
stairwells; consider electronic buzzers, motion sensor lights, chimes/bells on doors and windows, or a
sound monitor with a transmitter or receiver. Camouflage some doors with a screen, curtain or a
painted mural. Put a two foot square dark color in front of a door knob, or place a decorative plant stand
at the level of the door knob. Install locks that are difficult to operate and higher up on doorframe, out
of field of vision or the person’s reach. Frequently reassure the person who may be feeling lost or
abandoned. Try communication techniques such as reassuring the person frequently about where
he/she is and why. Speak in a calm, normal tone of voice. Try to follow the person or offer to walk with
him/her until they are ready to be redirected towards home. Offer proper nutrition with frequent meals
to accommodate for calories burned with increased activity. Finger foods such as sandwiches, cheese

52. and fruit offer good nutrition for persons unable to always sit for a meal. On occasion, a successful
substitute for wandering behaviour is a rocking chair.
To ensure safety: limit the person’s access to: Bodies of water Tunnels High balconies Bus stops Steep
stairways Obstacles that might cause falls, such as loose scatter rugs, cluttered rooms Swimming pools
Roadways where traffic tends to be heavy Dense foliage Deep ditches or hills Other things that could
present hazards if this person wanders Make sure the house is accident proof by keeping medications,
toxic substances such as cleaning supplies, sharp objects, alcohol and matches in locked cupboards or
closets. Put locks on outside gates. Fenced in backyards allow people to wander safely and provide
positive exercise and activity. Use a safety gate across doors and at the top of stairs. This may help keep
the wanderer in a limited area where he/she can explore safely. Provide comfortable clothing such as
jogging suits and tennis shoes. Give frequent drinks of water or juice or juice pops to prevent
dehydration. The person with dementia will often forget to drink or will not recognize thirst.
Dehydration can be dangerous and increase confusion, leading to delirium and increased potential for
falls.
Have a current picture of the individual available with a matching description including name, age,
address, any medical or physical conditions and a description of distinguishing characteristics such as
scars, moles, glasses, etc. Provide the individual with a medic alert bracelet or necklace. Provide the
individual with an ID card in a wallet or purse that indicates that the individual has memory impairment
and gives a list of names and phone numbers of several contact persons. Label clothing with a name
and phone number. Whenever the person leaves the home place a pocket instruction card on their
person with a quarter taped to the card. The card should carry a message to call home with a phone
number as well as a message to stay calm and not to walk away. The information on the card should be
individualized to the person and should be provided by a family member or friend who is aware of what
the person may respond to. Alert neighbours and police that a memory impaired person lives at this
particular residence and keep a list of important phone numbers close to the telephone such as
neighbours, police, physician, and family members. Use brightly coloured outdoor clothing such as a
jacket, coat and pants when they are leaving the house. Reflectors can be sewn onto sleeves or pant
legs, which may help motorists, identify a person in the night or assist police involved in searching for a
missing person.
If the person’s behaviour is not jeopardizing his/her or others safety, or disrupting the lives of others,
the best approach is to try to identify the cause(s) and try to mange the behaviour. Medications to
induce sleep in an attempt to prevent wandering can create a whole new set of problems, such as:
falling, increased confusion, incontinence, constipation, irritability, and depression.
Persons with a progressive dementia may begin to wet themselves or have bowel movements in their
clothing in the latter stages of the disease. This problem can be devastating and embarrassing for the
individual as well as distressing for the caregiver. It is important for family members and professional
caregivers alike to be aware of the strong feelings evoked by this behaviour and approach the problem
in a sensitive, caring manner.
Anger and irritability are often signs that a person is feeling a loss of control over his or her life. Calmly
acknowledging these feelings even when you do not understand what it is that has upset the person can
be helpful in reducing the behaviour. As it is often difficult to predict these episodes, it is useful to keep
a diary or a journal to help identify situations when a person may become upset. Write down everything

53. that happens each time a person reacts this way. Write down what time of day it was, who was present,
whether noise or over stimulation was a factor and what immediately preceded the outburst. As a
caregiver, you will often see a pattern emerge that can help you think about how to alter the
environment and prevent an angry outburst from occurring.
Persons with dementia will often sense a caregiver’s frustration or anger and become anxious or angry
themselves. A gentle, supportive, simple approach will almost always be more successful than lengthy
explanations or rationalizing.
After the episode is past, try not to remind the person of the incident. He or she will probably soon
forget that it occurred. Caregivers should carefully consider what could be changed to avoid a
reoccurrence.
Work out an emergency procedure for yourself in the event that you feel your physical safety is
threatened. Stand out of reach of the person. o Leave the room to prevent injury to yourself. o Leave
the house and return in a few minutes. o Call for help from family members, friends, a family physician
Causes.
Physical
Fatigue at the time of a request, activity or event. Disruption of the sleep pattern, sleepless nights or
day and night reversal, which can cause sleep deprivation. This can lead to a delirium and will increase
confusion and decrease function. Physical discomfort, such as pain, fever, illness or constipation is often
expressed as agitation and can lead to delirium if not treated.
Side effects from medications, especially tranquilizers, sedatives, and antidepressant medications and
can lead to delirium if not brought to the physician’s immediate attention.
Impairment to vision or hearing which can cause a person to misinterpret sights and sounds in his/her
environment. Expectations that are too difficult for the person’s current level of understanding and
function
Environmental
Sensory overload – too much noise, activity, clutter or too many people in the environment at one time.
Unfamiliar people, place or sounds. Sudden movements or startling, unexpected noises. Feeling lost,
insecure, or forgotten. When the familiar family caregiver is out of sight the impaired person may feel
abandoned and frightened. Difficulty adjusting to darkness from a well-lighted area and visa versa can
cause confusion and agitation. Poor lighting, dark hallways, which may cause misinterpretations of
surroundings.
Other Causes
Being asked to respond to several questions or statements at once. An emotional reaction to
arguments, stress, irritability, or frustration of others. Being scolded, confronted, or contradicted.
Feeling embarrassed. Being surprised or startled by unexpected physical contact. The frustration of
being unable to perform what was once a simple task. Unable to understand what they are expected to
do. Instructions that are unclear or too complicated. Any change in schedule or routine. Attention

54. might be too short for the task that is expected of them. The activity is perceived as too child-like or
insulting.
Management.
Discuss possible side effects of the person’s current medications with the physician. Have vision and
hearing checked and optimize using clean glasses and properly working hearing aids. Alternate quiet
times with more active periods during the day. Plan outings and activities when the person is well
rested. Make sure that the person is comfortable, that clothes are not too tight, that the person is not
too hot or too cold, and that the person is not experiencing any pain. Keep the environment simple by
reducing noise level, the number of people in the person’s immediate surroundings and unnecessary
clutter. Daily routine should be as consistent as possible; persons with dementia become quickly
disoriented and confused if there are any changes or surprises in their daily routine. Try scheduling
meals, bathing, socialization and other activities at the same time everyday.
If change in routine is necessary (this may be especially important for caregiver respite or daycare relief)
the person should be introduced to the new caregiver or new place as gradually as possible. Ensure that
the person is protected from hurting him or herself. Remove sharp utensils, tools, and other dangerous
objects from the person’s environment. Regular exercise, including daily walks, helps in reducing stress
and promoting relaxation. Gentle distraction with a favorite food, topic of conversation, or meaningful
activity is useful approaches in reducing anxiety or agitation. Music, massage, quiet reading, or gentle
physical touch such as holding hands and hugging may be comforting and help to calm the person. A
heated beanbag placed over the back of the neck and shoulders can help promote relaxation.
TECHNOLOGY ADVANCEMENTS TO AID THE ELDERLY.
An app that allows a loved one to monitor the live video feeds if video cameras have been placed in
strategic places throughout the house
A GPS locator app that acts as a monitoring system for those with memory loss
Tiny sensors that can be attached to key chains, cabinets, refrigerator doors, and pillboxes to aler t a
family member when an individual has left the house or taken food or medications—The system also
provides a watch with a one-touch button for emergencies.
A ready-made computer that requires no experience to use, as it has touch-screen buttons that link to
video chat and e-mail, as well as a large display screen For the individual who cannot speak, an app that
has preloaded statements and questions that the person can choose, and the phone or device speaks
the selected statement
An app that enhances available light to make reading easier, such as for pill bottles and small-print
items
DEPRESSION, DELIRIUM AND DEMENTIA

55. Sometimes referred to as the three D’s in geriatric psychiatry, depression, delirium and dementia are
three diseases that often co-occur in geriatric populations
Depression is characterized by lowered mood or diminished pleasure in activities, as well as somatic
symptoms such as diminished ability to concentrate and suicidal thoughts or plans.(63) Depression can
reduce quality of life and life expectancy.
The most common health issue experienced by elderly patients is depression. Unfortunately, depression
usually goes undetected and untreated. Many-older people and their families don'trecognize the
symptoms of depression, commonly mistaking them for a "physical" disorder. Depression is the most
psychological disorder in the older adult; however, it . isn't a normal part of aging. "Depression is a
mood disorder in which the person feels sad, has decrea~ed ) energy, social withdrawal and negative
thoughts.
Causes. • A major illness such as cancer • Loss in the life of near and dear ones . • Lossofproperty
Signs and symptoms.
Decreased interest in daily activities• Avoids friends and relatives. • Sleep disturbances • Lack of interest
in daily routine activities such as poor personal hygiene • Feelings of hopelessness • Weight loss •
Anxiety • Sad depressed mood • Suicidal thoughts (tendency to kill self) • Injury marks on the body •
Tiredness • Decreased pain tolerance • Headaches • Inability to recall things/events, • Social isolation
(does not mix up with people easily)
Measures to relieve symptoms.
Listen patiently to the patient's feelings. • Help the client in getting involved in activities of his/her
interest. • Include the client mplans for current and future treatment. This allows the patient to feel that
he has some say and control. Involve family members in daily care of patient. • Find out the patient's
present physical capabilities, do not expect beyond his/her abilities. • Make sureall supplies needed for
self-care are readily available to avoi:1 giving the patient excuses for putting off the activity. • Encourage
daily exercise. Exercise promotes better sleep patterns and increases energy.levels. • Administer
medications as prescribed.
Dementia is an umbrella term used to describe a set of symptoms affecting brain function that are
caused by neurodegenerative and vascular diseases or injuries. Alzheimer disease is the most common
cause of the condition. Dementia is characterized by a decline in cognitive abilities (including memory;
awareness of person, place, and time; language, basic math skills; judgment; and planning) and can
affect mood and behaviour. Over time, it reduces the ability to independently maintain activities of daily
life, such as eating, bathing, toileting and dressing
Delirium has an acute onset (with changes occurring over hours or days) and is characterized by
inattention, disorganized thinking and altered level of consciousness. It usually resolves within days or
weeks. It is often unrecognized and can be misdiagnosed as dementia. Although the prevalence of
delirium in the community is low, between 4% and 12%, it varies between approximately 7% and 73%
on admission to palliative care.(103) Cognitive impairment, including dementia, is one of the most
important risk factors for delirium. Other important factors include functional impairment, vision
impairment, history of alcohol abuse and older age.(104) Vulnerable patients exposed to certain

56. precipitating factors (e.g. major surgery, hip fracture, medication) are at increased risk of developing
delirium and increased risk of morbidity and mortality.(104) Non pharmalogical interventions targeting
specific risk factors have been shown to be successful in the primary prevention of delirium
Disruptive and Aggressive Behaviour
Disruptive behaviours include shouting, walking fast steps, acts of aggression or violence directed 'at
others or oneself, and lack of respect for others' property like destroying furniture etc.
Causes: • Trauma • Environmental factors • Psychotic disorders • Chronic alcoholism • History of suicide
attempts or mental illnesses • History of drug or alcohol abuse • History of head injury
Signs and Symptoms: • Progressive forgetfulness • Social withdrawal • Increased irritability • Searching
behaviours • Making stories • Suspicion • Confusion • Anxiety • Mood does not match with the words
he says • TIredness (fatigue) • Increased complaints of pain • Gait or postural abnormalities • Decreased
recall • Inability in completing a sentence • Self-neglect • Increased risk for injuries (falls) • Increased
risk of caregiver abuse • Malnutrition • Depression • Sleep-pattern disturbance
Measures to relieve symptoms: • Observe for changes in behaviour • Reduce or eliminate things or
events that cause the agitated behaviour. r • Identify and ensure safety risks to prevent the patient from
harming himself during confusion. Avoid physical restraints or tying the patient if possible. • Involve
physical and occupationaltherapy that will help to distract and occupy the patient in some or the other
activity. • Involve recreational therapy __.. • Assess for signs of pains. . • Listen to the patient. Remain
calm and.be honest while interacting with the patient. • Sit near him .and maintain eye contact because
this makes sense of trust. • . Listening attentively conveys concern and helps effective communication. •
. Maintain a stable physical environment having no noise because over stimulation can increase
agitation and confusion. • Maintain a safe environment by-removing harmful items from patient's reach.
• Establish familiar routines and encourage the patient to do as much she can for himself. • Promote
exercise such as walking whichprevents wandering and channels the patient's energy
Insomnia.
Sleep disorders are common in the older population. An older person gets less sleep. Insomnia is a sleep
disorder characterized by marked difficulty in falling asleep or difficulty to continue to sleep for a
considerable period.
Causes • Lifestyle stresses • Alterations in the sleep schedule - . • Environmental factors like noise and
lights
Signs and Symptoms • Decreased sleep and sleeping time (. Anxiety , • Changes in appetite • Headaches
• .Frequent awakenings • Fatigue • Mood alterations • IrritabilityHostility • Muscle and joint pain •
Confusion • Patient having disorders of urination e.g. passing urine in bed or excessive urination in night.
Measures to relieve symptoms: • Assess patient's normal bedtime rituals, preferred night time
environment (light bedding etc.), way of sleeping and normal daytime activities. • Encourage the patient
to use relaxation techniques like deep breathing, meditation etc. which will help to promote sleep. •
Teach the patient not to lie or sit on the bed for purposes other than sleep or to get out of bed and read
or watch television if he is not asleep in 30 minutes. • Give medicines during waking hours to avoid
waking the patient if he is sleeping just to give medicines because patient may not sleep once wake up.

57. • Promote bedtime comfort measures like reading, warm bath, massage etc. • Try to perform activities
through out the day to reduce sleeping during .daytime. • Avoid medications for sleep or follow the
doctor's written order for giving medicines. • Keep noise to a minimum during sleep. • Encourage
patient to ambulate during the day. • Relax after dinner and avoid exercising 2 hours before bedtime,
which may interferewith the patient's ability to fall asleep. • Tell the patient to take less fluid in the
evening and urinate before going to bed. • Provide a consistent bedtime and awakening time because a
proper sleep pattern promotes sleep.
PARKINSONISM (including Parkinson disease)
Parkinsonism is an umbrella term that includes Parkinson disease, secondary parkinsonism and atypical
parkinsonism. While the majority of parkinsonism cases are due to Parkinson disease, cases also arise
due to other neurological disorders, medication side effects or toxins.(105–107) Rates are higher among
men than women, and the risk of developing parkinsonism increases with age. Parkinsonism refers to a
set of signs and symptoms usually characterized by: rigidity, tremors, bradykinesia (abnormal slowness
of movement) and/or postural instability.(105–107) Individuals with parkinsonism also often experience
non-motor symptoms such as pain, mood disorders, sleep problems, cognitive impairment or dementia,
constipation, urinary incontinence, sexual dysfunction and/or reduced sense of smell
A disease that gets worse over a period of time and causes the muscle to become weak and the arms
and legs to shake. Parkinson's disease affects the brain centers that are responsible for control and
regulation of movement that eventually leads to disability. Mostly cause is not known. Less common
causes are genetic, toxins, head injury etc.
Signs and Symptoms • Tremors: or shaking of the limbs, slowness, stiffness of the limb movements. •
Increased muscle rigidity: Limb muscles become rigid on passive motion, this rigidity results ,injerky
motions steady resistance to an movements. • Pain in muscles and joints. • Posture is stooped, leaning
forward and short steps taken while walking. (Fig. 2.1). • Sleep disturbances: Patient usually sleeps more
in day time and less in night. • Low blood pressure • Excessive sweating • Loss of control over passing
urine • Weight loss
Drug Therapy Medicines are given for maintaining vital signs at nomal rangys, to reduce involuntary
movements, to decrease tremors, and to prevent constipation.
Supportive Care: There is no treatment, drugs help in relieving many symptoms of diseases.
Impaired physical mobility related to muscle weakness: • Provide range of motion exercise. •
Progressive programme of daily exercise. • Warm bath and massage. • Encourage to practice walk to
marching music etc. • Encourage deep breathing exercise while walking. • Frequent rest periods. •
Provide assistive devices to support mobility (for more details refer Practical Manual 2 skill 15) . •
Remove environmental objects that could cause fall. • Develop a trusting relationship with patient. •
Promote social interaction. • Provide necessary information to adjust to changes brought about by the
disease. • Speech can be improved by reading aloud, singing and rasing voice. -- Tell patient to speak in
short sentences. • Ask him to take two deep breathes before speaking. • For writing difficulty, develop
an alternative method of communication. • Establish regular bowel routine. • Increase fluid intake. •
Encourage him to take food moderately rich in fiber content.

58. To prevent rigidity ericourage to do: • Range of motion exercises to prevent stiffness and contractures in
accordance with meditation time. • Stand up straight with the head over hips and the feet 8 to )0 inches
part. • Wear good pair of walking. shoes. - • Practice taking long steps and swing arms. • In case of
freezing rockgently from side to side.
To avoiding falls encourage exercise that improve balance: • Practice taking long steps. • Teach head
and neck exercises, maintain upright posture and look up while walking • Wear rubber soled shoes. •
Remove objects that can be obstacles to patient.
Maintain wide based gait and move out of bed with the help of walker. • Help him in wearing clothes
and dressing up.
ORAL DISEASES
The primary types of oral diseases are tooth decay (cavities), gum (periodontal) disease, and oral
cancer. These diseases are largely preventable and although usually considered in isolation from other
chronic conditions, are often inter-related. Poor oral hygiene, a diet low in fruits and vegetables and
high in sugars, smoking and harmful use of alcohol can increase a person’s risk of developing an oral
disease. Oral diseases can affect the mouth and other parts of the body
RESPIRATORY DISEASES
ASTHMA
Asthma is a complex chronic lung disease characterized by the inflammation and narrowing of the
airways. Symptoms of asthma include cough, shortness of breath, chest tightness and wheezing.(118)
Asthma symptoms and attacks can be triggered by exercise, exposure to allergens or irritants, changes in
the weather or viral respiratory infections. Although the causes of asthma are not well understood and
there is no cure, asthma can be easily controlled with medication as well as by eliminating or minimizing
risk factors and triggers
Modifiable risk factors associated with the development of asthma include:
Smoking and/or exposure to tobacco smoke; { Occupational exposures; { Environmental exposure (e.g.
air pollution); { Viral infection; { Obesity; and { Sedentary lifestyle.
Other risk factors associated with asthma include:
{ Age—prevalence is higher among younger people; { Sex—in children, asthma is more prevalent in
boys than in girls, but in adults, women have a higher prevalence of asthma than men; and { Family
history of asthma.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung disease that causes
limitations in airflow. It is a common, often preventable and treatable disease associated with an
enhanced chronic inflammatory response in the airways. This inflammatory response results in
structural changes and the narrowing of small airways in the lungs. Symptoms of COPD include
shortness of breath, cough and/or sputum production. The development and progression of COPD is a

59. complex interaction between various risk factors. Modifiable risk factors associated with the
development and progression of COPD include
Smoking—cigarette smoking is the leading modifiable risk factor for COPD;
Occupational exposure to dust, vapor and fumes;
Indoor or outdoor air pollutants;
Infection;
Asthma
Other risk factors associated with the development and progression of COPD include:
{ Age—lung function declines with age, leaving older adults more susceptible to developing lung
disorders such as COPD; { Sex—COPD is more common in men than women, although this gap narrows
with age; and { Family history of COPD.
FALLS
Falls are preventable but require multifactorial and evidence-based interventions.(137) Data from the
2009 CCHS—Healthy Aging indicate that 19.8% of seniors reported falling in the previous year. Of these,
63.3% reported falling once while 36.7% reported falling more than once in the previous year.(138) Fall-
related injuries may affect quality of life and lead to loss of independence, hospitalization and
sometimes death.(139) Seniors who are hospitalized for a fall stay in hospital an average of 14.3 days
compared to 7.5 days for those hospitalized for any other cause.(140) Falls and injuries are influenced by
several risk factors that are a combination of both intrinsic and extrinsic factors. Intrinsic risk factors for
falls include older age, having a chronic disease, medication use, impaired mobility, fear of falling and
prior falls. A history of falls is a strong predictor of future falls.(137,141–143) Seniors who have had a fall
are 3 times more likely than those who never fell to have another fall within the following year.(137) The
presence of multiple chronic conditions is also an important predictor of falls among community-
dwelling seniors. Data from the 2009 CCHS—Healthy Aging reveal that risk of falling increases with
number of chronic conditions, with risk of falling at least 2 times higher in seniors with four or more
chronic conditions.(138) Extrinsic risk factors for falls include factors in the community (e.g. hazards
related to design standards and building codes), factors in the living environment, and weather and
climate. Other factors are unfitting footwear and clothing and inappropriate assistive devices.
(137,141,142) Social isolation and low socioeconomic status have also been shown to increase the risk
of falls
HEALTH DETERMINANTS.
, exercising regularly and having a healthy, balanced diet, are important protective factors for type 2
diabetes, dementia and stroke. regular physical activity can improve blood glucose control, reduce
cardiovascular risk factors and result in weight loss among people with type 2 diabetes. It can also
improve cognition among those with dementia(163), aid in the functional recovery of people who have
had a stroke and help reduce the risk of future stroke.(164) Smoking cessation also has many health
benefits, including for cancer patients and survivors.(165) Similarly, reducing alcohol drinking or

60. complete cessation have been shown to improve outcomes in those with established cardiovascular
diseases
Physical activity also plays a vital role in reducing depression, anxiety and chronic stress while enhancing
cognitive functions.(173) Physical activity is not only protective for those who were active throughout
their lives, but is also beneficial for those who become active later in life.(176) It has been shown to
delay functional loss and improve survival and help improve outcomes in those living with chronic
diseases.
Nutritional risk refers to the risk of developing nutritional deficits as a result of poor nutrient intake.
Nutrient intake may be poor due to either under-nutrition or over-nutrition. Physiological changes
associated with aging that affect dietary intake include, for example, changes in body composition which
may result in a reduced metabolic rate, oral health problems, diminished sense of taste and smell and
having chronic diseases. Social, socioeconomic and psychosocial factors may also contribute to the
development of nutritional risk. These factors include (but are not limited to) social isolation, loneliness,
economic constraints and lack of social support, including help with activities of daily living such as
shopping and cooking. 4) A diet low in fruit and/or vegetables increases the risk of developing several
major chronic diseases including ischemic heart disease (IHD), stroke, type 2 diabetes, esophageal
cancer and lung cancer.(167) In contrast, a diet high in fruit and/or vegetables is associated with a
decrease in waist circumference and in BMI, and an overall lower weight gain
Excess alcohol use increases the risk of developing many cancers (e.g. oral cavity and pharynx, oral
esophagus, colon, rectum, liver, larynx), digestive diseases (e.g. liver cirrhosis), pancreatitis, diabetes,
cardiovascular diseases and injuries The toxic effects of alcohol may be more pronounced in seniors
since the body’s ability to metabolize and eliminate alcohol slows down with age.(191) Alcohol intake
can sometimes adversely interact with medications. seniors are often prescribed multiple drugs to
manage their chronic health conditions, those who drink alcohol are at increased risk of adverse effects.
Alcohol consumption alone or in conjunction with medications has also been linked to falls. Moderate-
to-heavy drinking has also been associated with an increased risk of motor vehicle accidents and suicide
among seniors
Body mass index (BMI), an indirect measure of an individual’s body fat, is used to classify people
according to potential health risks associated with underweight and overweight. BMI is calculated as a
person’s weight in kilograms divided by their height in metres squared—kg/m2 .
Obese are at increased risk of developing type 2 diabetes, ischemic heart disease, stroke, osteoarthritis,
colorectal cancer, breast cancer and other chronic diseases or conditions
Sleep is important for overall health and well-being, including cognitive, emotional well-being and
physical health.(202) Sleep disturbances such as sleep apnea, insomnia, fragmented sleep and early
awakening are common in seniors.(203) Sleep quality can be improved by having healthy sleep habits,
including having regular meals and exercise, avoiding caffeine, nicotine and alcohol before bedtime, and
reducing noise and light in the sleeping environment. people aged 65+ get 7 to 8 hours of sleep per day
for a better cognitive functioning, lower rates of mental illness and chronic diseases and conditions, and
improved quality of life. Exceeding the recommended sleep guidelines is associated with increased risk
of mortality and morbidity including hypertension, type 2 diabetes, and atrial fibrillation

61. High levels of social support have been shown to be protective against mortality and predictive of
healthy aging. Seniors also enjoy social networks of family and friends. Social participation, including
engagement in work, voluntary activities and leisure activities, are all associated with better health
among older adults
Age-friendly environments are designed to foster health and well-being and the participation of people
as they age. Such environments are accessible, equitable, inclusive, safe and secure, and supportive.
They promote health and prevent or delay the onset of disease and functional decline. Creating age-
friendly environments can be an effective way to address the social, economic and physical needs that
help determine health.
Social isolation can occur as a result of low quantity and quality of contact with others, few social roles
and few or no mutually rewarding relationships. Social isolation is associated with poor physical and
mental health, including increased emotional distress and prevalence of depression, increased number
of falls and use of health and support services, and premature death. Numerous factors may place
seniors at risk of social isolation and loneliness including living alone, being age 80+, having
compromised health status or multiple chronic health problems, having no children or contact with
family, lacking access to transportation and living in low income. In addition, women are more likely
than men to be socially isolated
The physical environment is also related to health outcomes as seniors can be particularly vulnerable to
any hazards in the built environment. Mobility limitations, which can be a consequence of living with
chronic diseases, can create unique challenges in crossing a busy intersection and entering a building
that can only be accessed by steps. Older people with chronic diseases may also be vulnerable to the
effects of heat waves and develop heat-related illness or injury
Warning Signs That an Elder Needs Help
The first is unexpected weight loss. Older persons are prone to losing weight for many reasons, including
chronic illness, difficulty eating, mouth pain due to broken and missing teeth or loosely fitting dentures,
inability to afford food, taking multiple medications, and the need for assistance in eating.
frozen prepared dinners may be an option. If the reason is that the individual can longer go grocery
shopping, many local grocery stores now offer delivery services
falls or unexplained injuries may be a sign of decline in function or a medical problem. As an older
person loses mobility and becomes less active, the muscles begin to weaken, increasing the risk for
falls.The individual may not be able to support his or her weight when standing, walking, or getting up
from bed or a chair. Unexplained bruises, open areas on the skin, and redness of the skin over the hips,
elbows, and shoulder blades
memory problems, he or she may get lost in familiar surroundings, leave home without a destination, or
become confused while driving
fainting or dizziness could be a sign of one’s blood pressure lowering rapidly when standing up.
Missing teeth or ill-fitting dentures make it difficult to eat and lead to weight loss.

62. Swelling in the lower legs or feet is usually a sign of heart problems. Normal treatment for these
symptoms can prevent falls, injuries, and illness
Anatomical differences in pediatrics.
The mouth and nose are smaller and more easily obstructed than in adults.
The tongue takes up more space in the mouth compared to adults.
The trachea is softer and more flexible.
Trachea is narrower and easily obstructed by swelling.
Chest wall is softer and depend on the diaphragm for breathing.