Gerontology Nursing Guide

Physiological Changes with Ageing

Cardiovascular

Myocardial stiffening — reduced diastolic filling
Increased systolic BP; widened pulse pressure
Decreased maximum heart rate (220 − age)
Baroreceptor sensitivity reduced → orthostatic hypotension risk
Conduction system fibrosis → atrial fibrillation risk
Decreased cardiac output reserve on exertion

Respiratory

Chest wall stiffness → increased work of breathing
Reduced FEV1 and FVC; increased residual volume
Blunted hypoxic / hypercapnic ventilatory response
Decreased mucociliary clearance → infection risk
Reduced cough reflex → aspiration pneumonia risk
SpO2 may be lower (93–96% acceptable in many elderly)

Renal

GFR declines ~1 mL/min/yr after age 40
Reduced tubular secretion and reabsorption
Serum creatinine may be normal despite low GFR (less muscle mass)
Use CKD-EPI or Cockcroft-Gault for true eGFR
Decreased ability to concentrate/dilute urine
Salt-wasting tendency → dehydration risk

Hepatic

Liver mass and blood flow decrease 20–40%
Phase I metabolism (CYP enzymes) reduced
Phase II (conjugation) relatively preserved
Reduced first-pass metabolism → higher drug bioavailability
Albumin synthesis decreases → altered protein binding

Neurological

Brain volume decreases ~5% per decade after 40
Reduced dopamine, acetylcholine, serotonin
Slowed nerve conduction velocity
Increased blood-brain barrier permeability
Sleep architecture changes (less deep sleep)
Thermoregulation impaired → hypo/hyperthermia risk

Musculoskeletal & Skin

Sarcopenia: muscle mass loss from ~50 yrs (3–5%/decade)
Bone density loss → osteoporosis, fracture risk
Cartilage thinning → osteoarthritis
Skin: reduced collagen, elastin, subcutaneous fat
Decreased skin turgor; pressure injury risk
Impaired wound healing; reduced sweating

Pharmacokinetic Changes

Parameter	Change	Clinical Impact
Absorption	Gastric pH ↑, motility ↓	Delayed drug absorption; calcium, iron less well absorbed
Distribution (Vd)	Body fat ↑, lean mass ↓, TBW ↓	Lipid-soluble drugs (diazepam) accumulate; water-soluble drugs (digoxin) have higher plasma levels
Protein binding	Albumin ↓	More free (active) drug for highly protein-bound drugs (warfarin, phenytoin)
Hepatic metabolism	CYP activity ↓, blood flow ↓	Longer half-lives for CYP-metabolised drugs; watch for accumulation
Renal clearance	GFR ↓, tubular secretion ↓	Renally cleared drugs (metformin, digoxin, antibiotics) require dose reduction

Atypical Disease Presentation in the Elderly

Warning: Classic symptoms are often absent in older adults. A high index of suspicion is essential.

Common Atypical Presentations

MI: No chest pain — presents as fatigue, confusion, dyspnoea, nausea
UTI: No dysuria — presents as acute confusion, falls, incontinence
Pneumonia: No fever — tachypnoea, confusion, reduced appetite
Appendicitis: Minimal localised pain; peritonism signs blunted
Hyperthyroidism: "Apathetic" thyrotoxicosis — weight loss, AF, depression
Depression: Somatic complaints, memory issues, not sadness

The "I WATCH DEATH" Mnemonic (Delirium Causes)

I Infection
W Withdrawal (alcohol, sedatives)
A Acute metabolic disturbance
T Trauma / pain
C CNS pathology
H Hypoxia
D Deficiencies (B12, thiamine)
E Endocrine (thyroid, glucose)
A Acute vascular (stroke, MI)
T Toxins / medications
H Heavy metals

Clinical Frailty Scale (CFS) — Interactive

Click a score to see the description and care implications.

Very Fit

Well

Managing Well

Vulnerable

Mildly Frail

Moderately Frail

Severely Frail

Very Severely Frail

Terminally Ill

MUST Nutritional Screening

Malnutrition Universal Screening Tool (MUST)

Step	Criterion	Score
1 — BMI	BMI >20: 0 \| BMI 18.5–20: 1 \| BMI <18.5: 2	0–2
2 — Weight loss	<5% loss: 0 \| 5–10%: 1 \| >10%: 2	0–2
3 — Acute disease	Acutely ill, no nutritional intake >5 days: +2	0–2
Total 0: Low risk — routine care \| 1: Medium risk — monitor \| ≥2: High risk — treat & refer dietitian

ADL Assessment

Basic ADL — Barthel Index (0–100)

Feeding (0/5/10)
Bathing (0/5)
Grooming (0/5)
Dressing (0/5/10)
Bowel control (0/5/10)
Bladder control (0/5/10)
Toilet use (0/5/10)
Transfers bed↔chair (0/5/10/15)
Mobility on level surface (0/5/10/15)
Stairs (0/5/10)

Score <20: Total dependence | 20–60: Severe | 61–90: Moderate | 91–99: Slight | 100: Independent

Instrumental ADL — Lawton Scale (0–8)

Telephone use
Shopping
Food preparation
Housekeeping
Laundry
Transportation
Medications management
Finances

Score 0–1 = dependent; scored for ability not performance. IADL lost before basic ADL in dementia.

Timed Up and Go (TUG) Test

Procedure

Patient seated in standard chair (45 cm height)
On command: stand, walk 3 metres, turn, walk back, sit
Time the complete task; no assistance unless required

<12 seconds: Normal mobility — low falls risk

12–20 seconds: Moderate risk — assess further

>20 seconds: High falls risk — multifactorial intervention

Falls Risk Factors:

Previous fallsPolypharmacyVisual impairmentCognitive impairmentOrthostatic hypotensionEnvironmental hazardsVitamin D deficiencyFootwear issues

Dementia Types

Type	Features	Onset	Key Points
Alzheimer's	Memory, language, orientation, behaviour	Insidious, gradual	60–70% of dementia cases; amyloid plaques & neurofibrillary tangles; cholinesterase inhibitors
Vascular	Executive function, stepwise decline, focal signs	Stepwise after strokes	CV risk factor control is key; may co-exist with Alzheimer's
Lewy Body	Fluctuating cognition, visual hallucinations, parkinsonism	After 65, fluctuating	Avoid antipsychotics (severe sensitivity reaction); REM sleep disorder
Frontotemporal	Personality change, disinhibition, language problems	50–70 yrs, younger onset	Memory preserved early; Pick's disease subset; executive dysfunction

Cognitive Screening Tools

MMSE (Mini Mental State Examination)

Max score: 30 | Time: ~10 min
Domains: orientation, registration, attention, recall, language, visuospatial
Mild impairment: 21–25 | Moderate: 10–20 | Severe: <10
Limitation: literacy dependent; misses early MCI; copyright issues
Adjusted for age/education in interpretation

MoCA (Montreal Cognitive Assessment)

Max score: 30 | Time: ~10 min | Free online
Better for Mild Cognitive Impairment (MCI) detection
Domains: visuospatial, naming, memory, attention, language, abstraction, recall, orientation
Score <26 = impairment; +1 if education ≤12 yrs
Arabic version validated for GCC use

The 3 D's: Differential Diagnosis

Feature	Delirium	Dementia	Depression
Onset	Hours–days (acute)	Months–years (insidious)	Weeks–months
Consciousness	Fluctuating, impaired	Usually alert until late	Alert
Attention	Markedly impaired	May be intact early	Mildly reduced
Course	Fluctuating (worse at night)	Progressive, stable daily	Persistent
Reversibility	Usually reversible	Progressive (irreversible)	Treatable
Hallucinations	Common (visual)	Late stage	Rare (mood congruent)
CAM criteria	Positive	Negative	Negative

Delirium is a medical emergency — always investigate the underlying cause. Use CAM (Confusion Assessment Method) for rapid diagnosis.

BPSD Management — Non-pharmacological First

Non-pharmacological (First Line)

Structured daily routine and activities
Music therapy and reminiscence therapy
Maintain familiar environment and personal objects
Ensure adequate lighting (reduce sundowning)
Treat pain, constipation, urinary retention
Caregiver education and support
Validation therapy — meet patient in their reality

Pharmacological (Last Resort)

Low-dose haloperidol if severe agitation with risk to self/others
Avoid in Lewy body dementia (severe sensitivity)
Quetiapine: fewer EPS, preferred if Parkinsonism
Short-term only — reassess every 4–6 weeks
Antidepressants for depression/anxiety in dementia
Benzodiazepines generally avoided (increase fall risk)

Black box warning: Antipsychotics increase stroke and mortality risk in elderly with dementia

Mental Capacity Assessment (MCA)

Four Functional Criteria (all must be present)

Understand the information given
Retain the information long enough to decide

Weigh up information to reach a decision
Communicate the decision

Capacity is decision-specific and time-specific. Always assume capacity until proven otherwise. Document assessment thoroughly.

Beers Criteria — Drug Checker

Select a drug category to check appropriateness in elderly patients.

STOPP / START Criteria Overview

STOPP — Drugs to Consider Stopping

Benzodiazepines — fall & fracture risk
Antipsychotics — stroke risk in dementia
NSAIDs — GI bleed, renal impairment, fluid retention
Long-acting sulphonylureas — hypoglycaemia
Antimuscarinics for urge incontinence if eGFR <30
Digoxin >0.125 mg/day with normal renal function
Alpha-blockers in men with frequent incontinence

START — Drugs to Consider Starting

ACE inhibitor / ARB in heart failure with reduced EF
Statin for established cardiovascular disease
Aspirin/antiplatelet for secondary CV prevention
Bisphosphonate + Vitamin D in osteoporosis with fracture
SSRIs for persistent depression
Cholinesterase inhibitors in Alzheimer's disease
Vitamin B12 supplement if deficient

Renal Dose Adjustment — Common Drugs

Drug	eGFR 30–60	eGFR 15–30	eGFR <15 / Dialysis
Metformin	Caution, monitor	Stop	Contraindicated
Digoxin	Reduce dose, monitor levels	Significant accumulation risk	Avoid if possible
Amoxicillin	Normal	Reduce interval	Max 500 mg 3×/day
Ciprofloxacin	Normal	250–500 mg BD	250–500 mg once daily
Enoxaparin	Monitor anti-Xa	0.5 mg/kg once daily	Unfractionated heparin preferred
Gabapentin	Reduce dose	Significant reduction	Dialysis dose protocols
Atenolol	Normal	50 mg once daily	25 mg once daily

Medication Reconciliation & Pill Burden

Reconciliation Steps

Best Possible Medication History (BPMH) — patient, carer, community pharmacy
Compare admission orders vs pre-admission medications
Identify omissions, duplications, dose changes
Document intentional and unintentional discrepancies
Communicate changes at every care transition
Discharge medicines counselling + written list

GCC Formulary Considerations

UAE MOH Essential Medicines List — verify availability
Saudi SFDA approved formulary — generic substitution common
Some geriatric medications not routinely stocked in primary care
Cholinesterase inhibitors require specialist initiation in many GCC states
Polypharmacy common — average elderly GCC patient takes 6–10 drugs
Drug storage in extreme heat — patient education essential

Pressure Injuries

NPUAP / EPUAP Staging

Stage	Description	Action
Stage 1	Non-blanchable erythema of intact skin	Reposition 2-hourly, moisture barrier
Stage 2	Partial thickness — open blister/shallow ulcer	Wound dressing, pressure relief, nutrition
Stage 3	Full thickness — subcutaneous tissue visible	Wound nurse referral, debridement if needed
Stage 4	Full thickness — bone, tendon, muscle exposed	Urgent surgical review, advanced wound management
Unstageable	Full thickness, base covered by slough/eschar	Cannot stage until debrided
DTI	Deep Tissue Injury — purple/maroon discoloration	Monitor closely; may evolve to deep wound

High-risk sites: SacrumHeelsGreater trochanterIschial tuberositiesOcciputMalleoli

Urinary Incontinence

Types

Stress: Leakage on coughing/sneezing — weak pelvic floor; Rx: pelvic floor exercises
Urge: Sudden urge, can't defer — overactive bladder; Rx: bladder training, antimuscarinics (caution in elderly)
Overflow: Dribbling, retention — BPH/neurogenic; Rx: catheterisation, alpha-blockers
Mixed: Combination of stress + urge
Functional: Unable to reach toilet in time — mobility/cognitive issues

Management Principles

Bladder diary — frequency, volume, triggers
Fluid management — adequate hydration, avoid caffeine
Timed voiding and prompted voiding
Pelvic floor muscle training (stress)
Bladder retraining (urge)
Review medications — diuretics, ACE inhibitors, alpha-blockers
Manage constipation (pelvic pressure)

Dysphagia — IDDSI Framework

Level	Name	Description
0	Thin	Normal liquids — water, juice
1	Slightly thick	Flows slower than water
2	Mildly thick	Sipable, slight effort needed
3	Liquidised	Smooth, no lumps
4	Puréed	Cohesive, easily mashed
5	Minced & Moist	Small soft lumps, particle size ≤4 mm
6	Soft & Bite-Sized	Soft, moist; particle size ≤15 mm
7	Regular	Normal diet

Refer to speech and language therapy (SLT) for formal assessment. Silent aspiration is common in elderly — watch for repeated chest infections.

Sarcopenia & Osteoporosis

Sarcopenia (EWGSOP2 Criteria)

Low muscle strength (handgrip <27 kg men, <16 kg women)
Low muscle quantity/quality on DXA/BIA
Low physical performance (gait speed <0.8 m/s)
Probable sarcopenia: low strength alone
Confirmed: low strength + low muscle mass
Severe: + low physical performance
Management: resistance exercise, adequate protein (1.2–1.5 g/kg/day)

Osteoporosis & FRAX

FRAX tool: 10-year fracture probability (WHO)
Input: age, sex, BMI, clinical risk factors, BMD (optional)
GCC-specific FRAX models available for UAE, Saudi Arabia
DXA scan: T-score ≤ −2.5 = osteoporosis
Treatment: bisphosphonates (alendronate, zoledronate)
Calcium + Vitamin D supplementation
Falls prevention equally important as pharmacotherapy

Temperature Dysregulation

Hypothermia (<35°C core)

Risk factors: thin patients, poor nutrition, sedatives, hypothyroidism
Signs: confusion, slurred speech, slow pulse, shivering (may be absent)
GCC risk: air-conditioned environments, cold IV fluids
Management: passive rewarming first, monitor cardiac rhythm

Hyperthermia / Heat Stroke

High risk in GCC summers (ambient 45–50°C)
Elderly have impaired sweating and thirst perception
Classic heat stroke: core temp >40°C, confusion, no sweating
Management: rapid cooling, IV fluids, ICU if severe
Prevention: adequate hydration, cool environments, avoid peak heat hours

GCC Demographic Context

Rapidly Ageing Population

GCC elderly population projected to triple by 2050
Unique dual population: local nationals + large ageing expat workforce
Expat retirees often remain in GCC — limited return migration
South Asian expat workers (India, Pakistan, Bangladesh) form large elderly cohort
Non-communicable disease burden high: DM, HTN, CAD prevalent
Low traditional geriatric specialist workforce — nurses play central role

Cultural Caregiving Norms

Family-centred care model — eldest son traditionally leads decisions
Women of household primary informal caregivers
Nursing home placement carries stigma in GCC culture
High caregiver burden — assess and support family members
Elder care seen as religious duty (Islamic values of filial piety)
Patient may defer all decisions to family — assess capacity sensitively

GCC Policy Frameworks

UAE MOH Elderly Care Policy

National Policy for Elderly 2021–2031: active ageing, dignity, independence
Dubai Ageing Strategy — age-friendly city initiatives
Home healthcare services expansion (SEHA, DHA)
Geriatric outpatient clinics established in major hospitals
DHA: National Mental Health Programme includes dementia pathway
Abu Dhabi: HAAD/DoH standards for elderly care homes

Saudi Arabia Vision 2030

Health Transformation Program — elderly care a priority sector
National Centre for Aging established (NCA)
Expansion of home health and long-term care services
Geriatric medicine recognised as separate specialty (SCFHS)
Integration of elderly care into primary health centres (PHC)
Digital health tools for elderly monitoring (wearables, telehealth)

Ramadan in Elderly Patients

Always conduct a pre-Ramadan medical review for elderly patients with chronic conditions at least 4–6 weeks before Ramadan begins.

High-Risk Elderly for Fasting

Uncontrolled DM (especially on insulin or sulphonylureas)
Renal impairment — dehydration significantly worsens eGFR
Advanced heart failure — fluid status management difficult
Dementia — may forget they are fasting; double-dosing risk
Frail patients (CFS 5+) — fatigue, dehydration, falls risk
Patients on critical time-dependent medications (warfarin, anti-epileptics)

Medication Timing During Ramadan

Once-daily medications: move to Iftar (break-fast) time
Twice-daily: Suhoor (pre-dawn) + Iftar
Insulin: basal-bolus regimens require specialist review and adjustment
Diuretics: morning dose can cause excessive dehydration — consider Iftar dosing
Antihypertensives: long-acting agents preferred; review BP pattern
NSAIDs: avoid — GI risk with large Iftar meal and dehydration

Islamic ruling (fatwa): elderly with serious illness are exempt from fasting (rukhsa). Nurses should support informed decision-making without coercion.

Long-Term Care Landscape

Key fact: Unlike Western countries, the majority of elderly care in GCC is provided at home by family members, often with minimal formal support. Nursing home provision is limited and institutionalisation rates remain very low (<1% of elderly population in most GCC states). This places unique responsibilities on community and home health nurses.

Home-Based Care Assessment

Environmental safety assessment (fall hazards, temperature)
Caregiver capacity and burden assessment
Medical equipment needs (wheelchair, hospital bed, suction)
Medication management and storage in heat
Social isolation screening — particularly male expat patients
Refer to community social work, voluntary organisations

Nurse's Advocacy Role

Identify elder abuse — physical, financial, neglect (culturally sensitive approach)
Support advance care planning discussions with patient and family
Liaise with geriatrician for specialist input
Facilitate respite care for overburdened caregivers
Document and escalate concerns via hospital safeguarding pathways
Patient education in culturally appropriate language (Arabic materials)

Gerontology Nursing

Comprehensive Gerontology Nursing Guide