Photograph of a woman who has severe arthritis using an adaptive device (fork with large-diameter handle) for eating; photo source: Administration on Aging, DHHS Learning Activities

Adapting Care Competency

Plan, implement, and evaluate care that is adapted to meet the individual functional, physical, cognitive, psychological, social, and endurance capabilities of older adults.


Develop your Adapting Care Competency by completing some or all of these learning activities. Choose the ones that are the most useful and appealing as you prepare to demonstrate your Adapting Care Competency. Please do not become overwhelmed as you look at the length of the material in this document. These learning activities provide you with multiple resources that you can use as you develop several of the older adult competencies and in your practice with older adults. You might want to scan them all now, to see what resources are here for sharing with others in your work setting or community.  Introductory Video for the Adapting Care Competency

If you prefer, you can read a transcript of the video.

This competency builds on previous competencies. It goes beyond the basic content related to physical and functional assessments. Your work here is to become skillful at taking into consideration the complex nature of providing care for older adults.

Overview of Learning Activities:  Learning Activities for the Adapting Care Competency are divided into two major areas of focus:

Learn about Person-Environment Fit

The concept person-environment fit provides a useful framework for adapting care to meet the specific capabilities of individual older adults. 
Photograph of a person holding two shapes whose edges do not fit smoothly together Suboptimal
Person-Environment Fit
Optimal
Person-Environment Fit
Photograph of a person holding two shapes whose edges fit smoothly together
Watch the presentation Person-Environment Fit Model to learn about this important concept. 

Print a Fact Sheet

Assistive technology helps older adults do activities that they otherwise cannot perform. In other words, it helps improve person-environment fit. Learn about assistive technology by printing and reading this Fact Sheet on Assistive Technology that was prepared by the Administration on Aging, U.S. Department of Health and Human Services. The fact sheet provides information for contacting your local Area Agency on Aging. Does your local Area Agency on Aging have services to assist with obtaining low-cost assistive devices?

Picture of the letters http: Find Adaptive Devices on the Internet 

Note: The internet links provided here were active at the time these Older Adult Focus materials were prepared. If a link is no longer active, try searching for the same or similar content using the name of the organization or the title provided.

Abledata

http://www.abledata.com

Consider these questions as you navigate the Abledata site:

Buck and Buck Designs

http://www.buckandbuck.com

Ask yourself this question while you explore the Buck and Buck Designs site:

Silverts, The Easy-Wear Easy-Care Clothing Company

http://www.silverts.com

Explore the Silverts site:

Drawing of a mailbox with a catalog in it Request a free Silverts catalog if you wish.

Sammons Preston

http://www.sammonspreston.com

Here is another site for assistive devices. 

You can request a free Enrichment Catalog from this site. 

Return to top of Learning Activities

Common Geriatric Syndromes

Preventing, recognizing, and managing common geriatric syndromes is an important aspect of adapting care for older adults. Use the following learning activities to become acquainted with these geriatric problems: 

Note: Each link in this box will scroll you rapidly to that specific section in this same web page. To return to this list, do not close the window. Use the Back button or the link titled Return to Geriatric Syndromes Menu Box.

                                  

Photograph of three cans of spices   Look again at the list of problems in the box. 

How many of them can be detected by using the SPICES screening tool that you encountered in the Assessment Competency?

Focus on Delirium and Dementia    

Cartoon of a person looking confused Confusion in older adults may arise acutely or it may be chronic. Confusion may or may not be reversible, depending on its cause and how it is treated or managed. Learn more about this important topic with the following activities.

View a Presentation   

As care providers, we need to be able to differentiate between the three Ds of confusion: Delirium, Depression, and Dementia. Watch this presentation on The Three Ds of Confusion for an introduction. What additional information or clinical examples does a gerontological nursing or other textbook offer about this topic?

Read an Article about Delirium Picture of two journal articles     

Delirium and Poor Functional Recovery

Marcantonio, E.R., Simon, S.E., Bergmann, M.A., Jones, R.N., Murphy, K.M., & Morris, J.N. (2003). Delirium symptoms in post-acute care: prevalent, persistent, and associated with poor functional recovery. Journal of the American Geriatrics Society, 51(1), 4-9.

  • What six symptoms of delirium were assessed? (See Table 1.)
  • Why should staff focus their attention on those older adults who fail to improve or continue to decline? (See page 8, last paragraph of the first column and the first paragraph of the second column.)

Read about management of delirium in a gerontological nursing or other textbook.

Picture of a quill pen writing on an assessment tool Review the Geriatric Depression Scale

In the Assessment Competency, you may have printed the Geriatric Depression Scale. If not, now is the time to do so!

The Geriatric Depression Scale is provided by the Hartford Institute for Geriatric Nursing, Division of Nursing, New York University. Do you need to review the material on screening for depression in the Assessment Competency? What insights does a gerontological nursing or other textbook add regarding depression in older adults?

Dementia: Gain Current Understanding of Alzheimer's Disease

Dementia has many causes, one of which is Alzheimer's disease. Here are three ways to learn what happens in the brain with Alzheimers disease.

Go to the Alzheimers Association website at http://www.alz.org and work with Inside the Brain: An Interactive Tour. The link may be listed as Brain Tour.

Read the online booklet Alzheimer's Disease: Unraveling the Mystery from the National Institute on Aging Alzheimer's Disease Education and Referral Center at http://www.nia.nih.gov/Alzheimers/Publications/Unraveling/. Alternatively, you may access the booklet in PDF form here: Alzheimer's Disease: Unraveling the Mystery.

Watch a 4-minute video Inside the Brain: Unraveling the Mystery of Alzheimer's Disease from the National Institute on Aging Alzheimer's Disease Education and Referral Center at http://www.nia.nih.gov/Alzheimers/ADVideo.

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

Focus on Pressure Ulcers

Drawing of bandages for wound care    Prevention, assessment, and management of pressure ulcers are crucial aspects of care for older adults. 
Drawing of an ear listening to a story Hear a Clinical Story

Listen to this true clinical story, narrated by Catherine Van Son, Ph.D., R.N. If you prefer, you can read a transcript of the story.

Read about Pressure Ulcers      Picture of a stack of books

Read about pressure ulcers in a gerontological nursing or other textbook. Ask yourself these questions as you read:

  • Why are older adults at risk for pressure ulcers?
  • In my clinical setting, how can we identify persons at high risk for developing pressure ulcers?
  • What are some ways to prevent pressure ulcers?
  • In my clinical setting, how can we adapt care to prevent pressure ulcers in the persons we identify as high risk?
  • What are some ways to manage healing of pressure ulcers?
  • In my clinical setting, what resources are available to help manage healing of pressure ulcers?
Picture of a quill pen writing on an assessment tool Find and Use a Pressure Ulcer Risk Assessment Tool

Two assessment tools for determining risk of pressure ulcers are the most well-known:

Find at least one of these assessment tools. Here are places to look:

  • A gerontological nursing textbook
  • Your work place
  • The internet, by using a search engine

Compare the risk factors in the tool you find with the information about pressure ulcers in a gerontological nursing or other textbook. 

If you find both assessment tools, compare them with each other:

  • In what ways are they similar? 
  • In what ways are they different?

Use either the Norton Skin Assessment Scale or the Braden Scale to assess pressure ulcer risk in at least two older adults. Adapt their care to provide some preventive interventions if you identify a high risk. If you work in a clinical area that is apt to have persons at high risk for pressure ulcers, you might want to share one of these assessment tools with your colleagues, if a tool is not already in use.

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

Focus on Polypharmacy

Polypharmacy, the use of multiple medications, causes many adverse effects in older adults. One medication may be prescribed to counteract the side effects of another and a third to manage the effects of the second drug. 

Drawing of many colorful pills of various kinds   Increased numbers of prescribed drugs are associated with nonadherence to drug therapy, adverse drug reactions, drug-drug interactions, medication errors, and increased risk of hospitalization. Polypharmacy can contribute to confusion (delirium), falls, excessive sedation, postural hypotension, and other effects that may trigger a spiral of declining function in older adults. 
Read an Article about Polypharmacy Picture of two journal articles     

Please read at least the first article. The other articles are optional. (Note that the NO TEARS article has only one page!)

Polypharmacy in Home Care

Ellenbecker, C.H., Frazier, S.C., & Verney, S. (2004). Nurses' observations and experiences of problems and adverse effects of medication management in home care. Geriatric Nursing, 25, 164-170.

  • How many of the patients reported on in this study had more than five prescribed medications? 
  • What patient characteristics were associated with medication errors?
  • What reasons were reported for patients taking their medications incorrectly?
  • This study reported that 21% of the patients were discharged from the hospital without understanding how to take their medications. In your clinical setting, how do you address the issue of patient knowledge about drug therapy?
  • What system communication problems have you encountered regarding medications?

Polypharmacy in Dementia

Lau, D.T., Mercaldo, N.D., Harris, A.T., Trittschuh, E., Shega, J., & Weintraub, S. (2010). Polypharmacy and potentially inappropriate medication use among community-dwelling elders with dementia. Alzheimer Disease and Associated Disorders, 24(1), 56-63.

  • What was the association between numbers of prescription medications and potentially inappropriate medications for older adults in this study?
  • How might you use information from this article?
  • This study used the Beers criteria for determining potentially inappropriate medication use. You will learn about the Beers criteria later in this module.

Financial Impact of Polypharmacy

Moss, L., Crane, P.B. (2010). Exploring polypharmacy in elderly women after myocardial infarction. Journal of Women and Aging, 22(1), 22-33.

  • What was average number of medications taken daily by the women in this study?
  • Multiply the average cost of cardiac medications per day by 30 to see the average cost per month for cardiac medications in this study. Note that 52% of the low-income women spent up to $2.66 per day on cardiac medications. How might that impact community-dwelling older women that you know?
  • In the Discussion section, the authors commented on why the women over age 75 on average took fewer daily medications than women aged 65 to 75 years. What was their reasoning?
  • How might you use information from this article?

Medication Review Tool

Lewis, T. (2004). Using the NO TEARS tool for medication review. British Medical Journal, 329, 434.

  • Although the NO TEARS acronym was created for physicians to review their patients' prescriptions, most of these questions are pertinent for nurses who are working with older adults. In your clinical setting, how would you bring these points to the attention of a physician if you saw the need?
  • What is the "prescribing cascade" mentioned in this article? Why is it important?
Picture of a quill pen writing on an assessment tool Take a Medication History

Look for a medication history form in a gerontological nursing textbook, an assessment book, or a pharmacology book. Take a medication history on two older adults. Be sure to ask specifically about thyroid hormones, over-the-counter drugs, vitamins, calcium, laxatives, antacids, herbs, supplements, and home remedies, because many persons do not consider these as medications or may forget to mention them. Are there any potentially dangerous drug interactions? Do you need to provide some teaching? Contact the prescriber? How are the medication histories similar and different for the two persons?

Check the Beers List Picture of a hand with pen writing on a checklist

The "Beers list" is a list of drugs that are potentially inappropriate for older adults because they cause high risk of delirium, falls, or other serious adverse effects. If you are working with an older adult who is prescribed one of the drugs on the Beers list, you might want to contact the prescriber and negotiate a different medication. The drugs on the Beers list can be organized in several ways. We have organized the Beers list by drug therapeutic class, for maximum clinical usefulness. 

Look at the lists of medications that you obtained from the medication histories. Use the Beers list to identify any potentially inappropriate drugs. What follow-up is needed? How do your results compare with the findings in the following article? 

Goulding, M.R. (2004). Inappropriate medication prescribing for elderly ambulatory care patients. Archives of Internal Medicine, 164, 305-312.

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

Focus on Pain in Older Adults

Chronic pain is a huge issue for many older adults. Since pain is a subjective experience, we must obtain information about it from the person who is experiencing it. This poses a challenge in working with older adults who are unable to communicate verbally. Watching for changes in behavior is an important aspect of pain assessment. Pain that is not managed well contributes to decreased physical activity, reduced ability to carry out activities of daily living, sleep disturbance, social isolation, depression, and reduced quality of life. Drawing of jagged lightning bolts coming from a dark cloud
Picture of two compact discs Explore TNEEL Modules

To learn more about pain and older adults, use the TNEEL (Toolkit for Nursing Excellence at End of Life Transition) CD-ROM. If you do not have one, you can order this excellent resource from http://www.tneel.uic.edu. Although the focus of the TNEEL CD is nursing care at the end of life, it covers in detail many of the issues that face older adults. You need the following instructions, so take notes or print this page before you leave these Focus on Older Adults materials.

Using the TNEEL CD, go to the Comfort section and explore the following three modules: 

  • Pain Mechanisms
  • Pain Assessment
  • Pain Management

These directions focus on areas that will be useful in working with older adults, but feel free to explore further if you wish. Here are specific directions:

Load the TNEEL CD into the CD drive in your computer. 

  • If the TNEEL CD opens automatically, you will see a round Navigation Menu. Click on the round Comfort icon in that menu.
  • If the TNEEL CD does not open automatically, open it by double clicking on the CD icon (on a PC computer, look in My Computer for the icon; on a Macintosh computer, look on the desktop for the icon) and you will see a list of folders. Open the folder titled Comfort and double click on the file comfort.htm.

You are now at the Comfort section. Click on Pain Mechanisms. The left column provides a series of links.

  • You can work down through the links, or you can go directly to Instruction Material
  • If you prefer to read text, read the Content section.
  • If you prefer to view slides, click on Lecture Slides. Click on the right screen to advance the slides. These slides present the same material as the Content section.

Now click on Case Studies in the left column. Work through one of the following case studies:

  • Case 2: 86-year-old man
  • Case 3: 67-year-old, B.A.

Think about the questions listed in the case study.

You have now explored the Pain Mechanisms module. It is time to focus on Pain Assessment.

Return to the Comfort section by clicking on Back to Topic at the top of the left column. Click on Pain Assessment. The left column provides a series of links.

  • You can work down through the links, or you can go directly to Instruction Material
  • If you prefer to read text, read the Content section.
  • If you prefer to view slides, click on Lecture Slides. Click on the right screen to advance the slides. These slides present the same material as the Content section.

Now click on Case Studies in the left column. Select one of the following case studies:

  • Case 1: Mr. C
  • Case 4: Mrs. Sando

Think about the questions in the case study.

Now that you have reviewed pain assessment, it is time to focus on Pain Management.

Return to the Comfort menu by clicking on Back to Topic at the top of the left column. 

Click on Pain Mechanisms. The left column provides a series of links.

  • You can work down through the links, or you can go directly to Instruction Material
  • If you prefer to read text, read the Content section.
  • If you prefer to view slides, click on Lecture Slides. Click on the right screen to advance the slides. These slides present the same material as the Content section.

Now click on Case Studies in the left column. Work through one of the following case studies:

  • Case 5: Gypsy
  • Case 8: Mrs. Sando

Think about the questions listed in the case study. 

Think about a clinical situation that you have encountered in which pain management was not optimal. How would you approach that situation now? 

Picture of a quill pen writing on an assessment tool Select and Use a Pain Scale

Look at the pain scales in a gerontological nursing textbook, the Pain Assessment module of the TNEEL CD, and/or the following links.

Assessing Pain in Older Adults (http://consultgerirn.org/uploads/File/trythis/try_this_7.pdf)

Assessing Pain in Older Adults with Dementia (http://consultgerirn.org/uploads/File/trythis/try_this_d2.pdf)

Choose an appropriate pain scale for an older adult in your clinical practice and administer it. Find another older adult for whom another pain scale would be more appropriate and administer that scale. Think about your reasons for selecting the specific pain scale in each situation. How can you adapt the care for these persons to improve pain management?

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

Focus on Urinary Incontinence

Urinary incontinence is a common problem for older adults, many of whom do not mention it to their care providers.  Cartoon of a drop of water grumpily marching off by itself The multiple effects of urinary incontinence in older adults range from social isolation to skin breakdown, from psychological distress to falls. 
Learn about Urinary Incontinence      

Find the material on urinary incontinence in a gerontological nursing or other textbook and scan it briefly. Keep your textbook open as you watch this presentation Managing Urinary Incontinence. We suggest that you refer to your textbook intermittently during the presentation. For example, read it when you reach the slide on Factors that Affect the Pelvic Floor. Some of the slides suggest that you look up a topic. After you finish, you might want to read more of the material about urinary incontinence in your textbook.

Picture of the letters http: Keep an Intake and Voiding Diary

An intake and voiding diary is a useful tool to predict voiding patterns. If voiding patterns can be predicted, toileting can be scheduled to decrease episodes of incontinence.

Go to the website of the American Urogynecologic Society:

http://www.augs.org

Go to Patient Resources and click Tools for Patients. Download the PDF file containing the Bladder Diary. Complete 2 to 4 days of the diary for yourself. What patterns did you observe? 

If you are working in a clinical setting where this would be a useful tool, introduce its use for an appropriate older adult. How could care be adapted to fit this individual's urinary patterns?

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

Focus on Sleep Disturbance

Cartoon of an older man sleeping in bed with a book that he was reading. He is snoring.   Many factors can alter the quality and the patterns of sleep in older adults. Nurses and other care providers can do much to reduce barriers to sleep (e.g., pain) and promote sleep with effective non-pharmacological interventions. 
Read an Article about Sleep Disturbance Picture of two journal articles     

Please read at least one of these articles.

Sleep and Older Adults

Bloom, H.G., Ahmed, I., Alessi, C.A., Ancoli-Israel, S., Buysse, D.J., Kryger, M.H., Phillips, B.A., Thorpy, M. J., Vitiello, M. V., Zee, P. C. (2009). Evidence-based recommendations for assessment and management of sleep disorders in older persons. Journal of the American Geriatrics Society, 57(5), 761-789.

  • Note: This article is a long review of the major issues that influence sleep in older adults. Observe how for each of the issues the authors discuss the review of the current research literature and based on the quality of the research provide the best evidence-based recommendations for clinicians to use. It is a great example of how recommendations are made for clinicians to utilize in practice.
  • What are some behaviors and habits that may impair sleep
  • From the section, Stimulus Control what are some habits that promote good sleep hygiene?

Music to Promote Sleep

Johnson, J.E. (2003). The use of music to promote sleep in older women. Journal of Community Health Nursing, 20(1), 27-35.    

  • How well did music promote sleep in this research study?  Drawing of a music note
  • What type of music did the researcher use?
  • Search the professional literature (using CINAHL) or the internet to find information about the Stanford Sleepiness Scale that was used in this study.
Picture of a quill pen writing on an assessment tool Print and Use a Sleep Assessment Tool

The Pittsburgh Sleep Quality Index, available at http://www.consultgerirn.org/uploads/File/trythis/try_this_6_1.pdf, measures both quality and patterns of sleep. It is based on self-report by the older adult. It is used in research but can also be used in clinical practice. Use this assessment with two older adults. How long did it take to administer? If you identify some sleep problems, what non-pharmacological interventions to promote sleep can you suggest for each person? 

You can learn more about adapting care to promote sleep in older adults by reading a gerontological nursing or other textbook.

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

Focus on Problems with Eating

Cartoon of an older man dunking a doughnut in a cup of coffee. This is his dinner.   Problems with eating can impair nutrition. We shall focus on nutrition screening in the Optimizing Function Competency. Here we shall look briefly at dysphagia, anorexia, and adaptive devices  to make eating easier for persons with limited upper extremity function.
Read about Dysphagia      Picture of a stack of books

Read about dysphagia in a gerontological nursing or other textbook:

  • What is dysphagia?
  • How is it diagnosed?
  • What interventions are important for the person who has dysphagia?
Picture of a stack of books Read about Anorexia

Read about anorexia in a gerontological nursing or other textbook:

  • What are some causes of anorexia?
  • What interventions are important for a person who has anorexia?
  • What interventions have you used for people who have anorexia?
Consider Adaptive Devices

Adaptive devices for persons who have physical difficulty holding or manipulating eating utensils can make the difference between independence in eating or needing to be fed. Watch this short presentation Two Adaptive Devices for Eating, which shows two types of adaptive devices that make it possible for persons with limited upper extremity function to eat independently. If you work with older adults who have limited physical function that makes eating difficult, you might want to search for more adaptive devices for eating, using the internet resources provided earlier in this document. Such adaptive devices improve person-environment fit.

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

Focus on Falls

Cartoon of a man who is falling and a woman who is trying to catch him   Falls and the fear of falling are important considerations for older adults. Our focus here is identification of risk factors for falls. We shall focus on environmental modifications to prevent falls in the Maximizing Function Competency.
Read about Falls Picture of a stack of books     

Read about falls in a gerontological nursing or other textbook. Ask yourself these questions as you read:

  • What age-related physiological changes contribute to falls?
  • What other factors place older adults at risk for falls?
  • What medications can cause postural hypotension?
  • How can I recognize an older adult's fear of falling?
  • In my clinical setting, what has contributed to falls by patients?
  • Have I seen older adults who have limited their activities due to fear of falling?
Picture of the letters http: Find and Use the Morse Fall Scale

The Morse Fall Scale, a falls risk assessment tool, is available from The Department of Veterans Affairs National Center for Patient Safety at http://www.patientsafety.gov/CogAids/FallPrevention/index.html. On this site are multiple system-focused resources for addressing Fall Prevention and Management. Click the Morse Fall Scale link and become familiar with the scale.

  • Use the Morse Fall Scale on two older adults in your clinical setting. Did you identify risk factors that can be modified? Did you identify the need for protection from falling?

If you cannot access the Morse Fall Scale by the above link, look in a gerontological nursing or other textbook, search the internet for it, or obtain it from this classic literature reference:

Morse, J.M., Morse, R.M., & Tylko, S.J. (1989). Development of a scale to identify the fall-prone patient. Canadian Journal on Aging, 8(4), 366-377.

Return to top of Learning Activities

Return to Geriatric Syndromes Menu Box

After you have completed some or all of these Learning Activities, proceed to the Competency Demonstration.

Developed by L. Felver and C. Van Son 2011