Gerontological and Rehabilitation Nursing
This domain tests whether you can distinguish normal ageing from illness, and whether you can organise care around function rather than around the diagnosis. Older adults present atypically, and the exam repeatedly rewards the candidate who investigates a new change instead of explaining it away as age.
Age-related changes that matter clinically
- Reduced glomerular filtration slows drug clearance, so standard adult doses can accumulate.
- Reduced total body water increases the concentration of water-soluble drugs.
- Blunted baroreceptor response causes postural hypotension and falls on standing.
- Reduced cough reflex and swallowing coordination increase aspiration risk.
- Thinning skin and reduced subcutaneous fat increase pressure injury and shear risk.
Atypical presentation
- Serious illness may present as confusion, falls, incontinence, reduced mobility or loss of appetite rather than fever or pain.
- Treat new confusion as delirium until proven otherwise. Screen for infection, medicines, pain, constipation, urinary retention, dehydration, hypoxia and environment. Delirium is acute and fluctuating with altered attention; dementia is chronic and progressive; depression causes low mood with preserved orientation.
Falls and mobility
- Fall risk assessment is multifactorial: medication, vision, footwear, environment, gait, continence, cognition and fear of falling.
- After an unwitnessed fall, do not lift the patient immediately. Check for injury, assess the hip and long bones, take neurological observations if head injury is possible, and document the circumstances.
- Bed rails are restraint, not a falls-prevention device, and may increase injury.
Rehabilitation
- Rehabilitation is goal-directed and functional. Use standard measures such as the Barthel Index to track progress.
- Reposition at least two-hourly to prevent pressure injury and contracture; support limbs in alignment, and avoid pulling on a hemiplegic shoulder to prevent subluxation.
- After stroke, screen swallowing before any oral intake, sit upright at 90 degrees, and use thickened fluids if advised.
- Polypharmacy review matters; sedatives and anticholinergics commonly cause falls and confusion in older adults.
Worked example
An 82-year-old woman admitted with a urinary tract infection becomes acutely confused overnight and tries to climb out of bed. What is the priority? Reasoning: this is delirium superimposed on infection, not dementia. Priority is to identify and treat the precipitating cause, review medications, relieve pain, manage constipation and retention, provide orientation, daylight and familiar cues, involve family, and use the least restrictive safety measures with closer observation. Prescribing a sedative first, or applying bed rails, increases falls and injury risk.
Traps that cost marks
- Labelling new confusion as dementia or as normal ageing.
- Lifting a fallen patient before assessment.
- Assuming reduced food intake is an inevitable part of ageing rather than assessing swallowing, dentition, mood and medication.