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Older Adult Care for Texas Nurses (2 CH)

Online Continuing Education Course

Course Description

MANDATORY CNE FOR TEXAS NURSES. Fulfills Texas Board of Nursing 2 contact hour requirement for older adult care or geriatric care. Course covers goals of care for seniors; physiologic and cognitive changes of aging, elder abuse, palliative and end-of-life care.

Course Price: $20.00

Contact Hours: 2

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This course fulfills the requirement for nurses in Texas whose practice includes older adult or geriatric populations for at least 2 contact hours of continuing education relating to older adult care.

Older Adult Care for Texas Nurses (2 CH)

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will be better prepared to address the needs of older adult patients by understanding aging-related demographic trends, changes in health status, assessment and recommended interventions in older adults, elder abuse, and end-of-life care. Specific learning objectives include:

  • Describe the current demographic characteristics, healthcare conditions, and health disparities in older adults.
  • Summarize the goals of care for the older adult.
  • Discuss the major age-related physiologic and cognitive changes impacting the health of older adults.
  • Review treatment and prevention recommendations related to age-related changes.
  • Review the risk factors and signs of elder abuse.
  • Clarify the principles and goals of end-of-life care.


The graying of America has the attention of many—not only seniors themselves, but public policy makers and health professionals. Caring for the health of people age 65 and older can be complicated and requires specialized knowledge of this demographic group. Older adults are faced with many obstacles, including the challenges of the aging process, societal norms and expectations, changes in financial and caregiving resources, and environmental challenges (Leland et al., 2012).

Age-related changes affect the function of every body system, even in the healthiest older people. Normal age-related changes may be accompanied by chronic health problems such as diabetes or heart disease. Early diagnosis and effective management of chronic conditions can enable older adults to enjoy their later years as functional, active, and independent members of the community.

Demographics of Aging

As the first wave of the 77 million “baby boomers” born between 1946 and 1964 moves beyond their sixtieth birthdays, they are seeking answers to many questions about growing older. Public health professionals and policy makers are seeking ways to prepare for a society in which the number of people over 65 will nearly double in the next twenty years.

This change in the growth in the number and proportion of older adults will make history in the United States. Because of the longer lifespan and aging population of baby boomers, it is estimated that by 2030 one in five Americans and 5.1 million Texans will be over 65 years of age (CDC, 2013a; Proximity, 2014). People in this age group today are the greatest consumers of healthcare services in the United States.

Current data on health-related behaviors among people aged 55 to 64 years do not indicate a positive future for the health of older adults. More than a quarter of all Americans and two out of every three older Americans have multiple chronic conditions, and treatment for this population accounts for 66% of the country’s healthcare budget.

Health Disparities in Aging

Today’s Americans enjoy longer life than previous generations, although life expectancy at age 65 is lower than that of other industrialized countries. The United States’ population ranks forty-second in life expectancy among industrialized countries, with the average life expectancy being 78.1 years (CDC, 2013b). In 2012, the average life expectancy for Texans at birth was 78.3 years, with women having the highest life expectancy of just over 80 years. Hispanic adults in Texas have the highest life expectancy of around 80 years, while Blacks have the lowest life expectancy of just over 74 years (Texas Department of State Health Services, 2014).

Goals of Care for the Older Adult

Overarching goals of healthcare in people over 65 include:

  • Maintaining self-care. This goal is one of the primary objectives for keeping an older adult independent, healthy, and able to manage any chronic conditions in their home environment with relatively few resources.
  • Preventing complications of aging or of existing chronic conditions. The goal for managing chronic conditions is to regularly assess a patient’s current status for any changes or complications that might require new interventions or changes in treatment.
  • Delaying decline. Older adults should be carefully monitored for any decline. Goals may include addressing strength and physical abilities as well as promoting and reinforcing healthy behaviors and appropriate self-care strategies.
  • Achieving the highest possible quality of life. Each individual will have personal goals that are important to their quality of life. These may be based on the values and beliefs of each person.


Aging is both universal and individual. The physiologic changes of aging are universal, but the pace at which they occur is highly individual, depending on genes, age, sex, race, environment, and lifestyle. Some people look and feel old at 60 years or younger, while others remain youthful in health, appearance, and outlook at 70 years and beyond. The challenge for health professionals is to distinguish between normal age-related changes and symptoms of a disease or disorder that requires preventive or therapeutic action.

Musculoskeletal Changes

Beginning by around the fifth decade of life, musculoskeletal changes may significantly alter the posture, overall appearance, and/or function of older adults. Thinning of intervertebral disks can lead to shortening of the trunk of the body, subtly alter the alignment of vertebrae, and slowly diminish height over time.

Calcium is progressively leached (resorbed) from bones, frequently resulting in osteopenia or osteoporosis—both much more common in women than in men—which may increase the risk of fracture. At the same time, muscles and cartilage atrophy and weaken, which may lead to postural deviations such as increased thoracic kyphosis (a pronounced curvature of the thoracic region of the spine), which can further decrease stature and necessitate the adoption of a “chin-up” posture to make eye contact with others.

Loss of muscle mass (sarcopenia) results primarily from disuse of skeletal muscle, as frequently may occur with age-related inactivity (Bonder & Dal Bello-Hass, 2009). Muscle strength continues to be lost at an average rate of 12% to 14% per decade after age 50 years (Milanović et al., 2013).

Wear and tear on cartilage (ligaments, tendons, and joints) reduces flexibility and increases the risk of tears. The synovial fluid that lubricates joints decreases with age, resulting in slower and sometimes painful movement.

Loss of muscle mass and muscle strength can ultimately contribute to a loss of balance and coordination and—if not effectively addressed—to the inability to perform activities of daily living, disability, and eventual loss of independence.


Assessment of musculoskeletal function in an older adult includes general observation of posture, stance, and walking. Observations focus on whether a patient is favoring one side of the body or another while walking.

Osteoporosis can be assessed by additional questioning of the patient regarding any back pain, joint pain, and loss of height. Bone mineral density (BMD) testing can also be completed, with results comparing the patient’s bone mass to individuals in their age range, or previous results if the patient has had a previous baseline BMD test (Mauk, 2014).


Regular exercise such as walking and resistance training as well as doing household chores such as vacuuming, sweeping, gardening, and washing the car help preserve flexibility and strength and delay or prevent musculoskeletal deterioration. Exercise has well-documented musculoskeletal benefits, including increased strength, bone density, flexibility, and endurance, as well as decreasing the risk of falls for older adults (Miller et al., 2010).

Integumentary Changes


Ultraviolet (UV) light from the sun (and from tanning booths) is a major cause of wrinkles because it damages elastin, the fibers in the skin that make it resilient. Gravity also plays a role in wrinkles, causing skin to sag, as does cigarette smoking. Regular exposure to the sun and UV light also places adults at higher risk for skin cancer.

Aging skin becomes more delicate and more easily damaged. Collagen levels and subcutaneous fat diminish, thinning the skin and increasing the risk of tears and bruising. Skin cells take longer to renew themselves, so wound healing takes longer than in younger people.

Skin cancer is the most common form of cancer in the United States. The two most common types of skin cancer—basal cell and squamous cell carcinomas—are highly curable if diagnosed and treated in their early stages. However, melanoma, the third most common skin cancer, is more dangerous (CDC, 2013c).

The vast majority of melanomas are caused by exposure to UV light or sunlight. The U.S. Preventive Service Task Force advises clinicians to be aware that fair-skinned men and women age 65 or older and people with atypical moles or more than 50 moles are at greater risk for developing melanoma.

Hair changes in older adults vary according to race, sex, and hormonal influences. Dark hair turns gray or even white and becomes thinner as melanin production in hair follicles diminishes and growth slows.

Fingernails and toenails tend to harden and thicken with age and may develop vertical striations in the nail plate. Yellowish or dark nails may also indicate a fungal infection.


Skin assessment in older persons is focused on monitoring for dryness, pruritus, signs of skin breakdown such as pressure ulcers, lesions such as bruising that could indicate abuse or unreported falls, and possible skin cancers (basal or squamous cell carcinomas or melanoma).

Clinicians need to be vigilant in inspecting both the hands and feet of older adults, particularly people who have diabetes or vision or mobility problems (including obesity), which may make them unable to trim their nails and properly care for their feet. These individuals need regular care by a podiatrist, who can prevent or treat irritations and infections.

Assessment includes inspecting the skin for brown actinic keratosis precancerous lesions, commonly found on the face, neck, and upper extremities. Untreated, these lesions may progress to squamous cell carcinomas, which are reddish dome-shaped lesions. They may be found around the ear or on the head or neck. Basal cell carcinomas are the most common type of skin cancer, particularly in light-skinned individuals, appearing as a pearly papule with an ulcerated center; as an open sore that bleeds, oozes, or crusts for more than three weeks; or as a reddish patch on the chest, shoulders, arms, or legs. These cancers can be successfully treated if diagnosed early. Dark brown or black lesions may be melanoma, which can metastasize quickly and may prove fatal. Any suspicious lesions should be referred to dermatology for diagnosis.


These ABCDE signs can be followed for assessing suspicious skin lesions:

  • Asymmetry: when one half of a mole is different than the other
  • Border: irregular or uneven
  • Color: irregular, with patches of black, brown, red, blue, or white
  • Diameter: larger than 1/4 inch or 6 mm
  • Evolving: any change in size, shape, color, or texture, or any new symptoms such as itching, bleeding, or crusting

Source: Mayo Clinic, 2014a.


Adequate nutrition and hydration is essential to skin health. Older adults with skin conditions should be encouraged to see a dietitian for recommendations.

Any skin lesions that are larger than 6 mm or those with any of the “ABCDE” signs (see above) should be referred to a dermatologist for potential biopsy. Treatment of skin lesions varies and may include cryotherapy, radiotherapy, surgery, and topical treatment.

Older adults should be taught to inspect their feet on a regular basis. Corns, ingrown toenails, and fungus should be treated by a podiatrist. If existing foot or nail problems are present, a regular inspection by a podiatrist (annually or more frequent if needed) is recommended (Mauk, 2014).


When assisting in strategies for self-care and bathing, patients should avoid hot water and use a mild cleansing agent that minimizes irritation and dryness of the skin. Patients should also use a gentle motion and minimize the force and friction applied to the skin. The frequency of bathing should be individualized according to need and/or patient preference. Patients and caregivers should be taught how to minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage.

Prevention is the best “treatment” for skin cancer. All adults should protect themselves from sun exposure by wearing sunblock and protective clothing (e.g., long sleeves, hat, sunglasses) and by seeking shaded areas when outdoors. Most skin cancers, if detected early, are treatable. Regular full-body skin exams are recommended for all older adults on an annual basis (Mauk, 2014).

Body Composition Changes

Body composition changes over time. Weight and fat mass increase during middle age (the so-called middle-age spread) and continue to do so until about age 74 years. After age 74, seniors generally lose weight, stature, fat-free mass (also called lean body mass), and body cell mass. As lean body mass declines, the proportion of body fat increases. Older adults also experience a decrease in total body water. This means that water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life (Tabloski, 2014).

Cardiovascular Changes

Age-related cardiovascular changes include a slight decrease in maximal heart rate (the number of beats per minute) and a decrease in stroke volume during maximal exercise (amount of blood pumped out of the heart with each beat). These changes reduce cardiac output (the total amount of blood pumped out of the heart each minute). Illness, excitement, activity, or stress may cause rapid heart rate (tachycardia), which in an older person takes longer to return to the baseline level than in a younger person.

Several conditions related to the cardiovascular system are common in older adults. The most common include congestive heart failure (CHF), hypertension, coronary artery disease (CAD), stroke, myocardial infarction (MI), and peripheral vascular disease (Mauk, 2014).


Older adults should have regular assessment of blood pressure and heart function. As people age, the systolic blood pressure may have a tendency to rise. Blood pressure readings of over 160/90 indicate hypertension in older adults and require intervention. A diagnosis of hypertension should be based on several readings at various times of the day (Mauk, 2014).

A cardiac stress test may be necessary to distinguish between normal age-related changes and the presence of cardiovascular disease. Additional testing may include electrocardiogram (ECG) and angiogram or cardiac catheterization to evaluate symptoms or if blockage is suspected.


Lifestyle modifications (see below) may help control blood pressure and improve cardiac function. In addition, medications may be prescribed to treat hypertension and cardiovascular conditions in older adults. For hypertension, the goal of medical treatment for older adults is to lower the blood pressure to 120/80 mm Hg or below (Mauk, 2014).


Lifestyle modifications may help older adults control blood pressure and prevent cardiovascular problems. Strategies may include the following:

  • Limit alcohol to one drink per day
  • Limit sodium intake
  • Stop smoking
  • Maintain a low-fat diet
  • Undertake regular daily aerobic exercise (30 minutes/day)
  • Maintain (or lose) weight (even a 10-pound weight loss can decrease risk)

Older adults are encouraged to work closely with their healthcare providers to achieve good control of their blood pressure, since it is a risk factor and contributes to many other serious cardiovascular conditions such as heart disease and stroke (Mauk, 2014).

Renal Changes

Renal and urologic changes associated with aging have major effects on the physical and psychosocial well-being of older adults. The kidneys are the major organs that regulate red blood cell production, blood pressure, fluid volume (intake and output of fluids), and electrolyte balance throughout the body. In addition, the kidneys filter waste products from the blood, which are then excreted in the urine.

Age-related vascular rigidity and decreased cardiac output reduce renal blood flow and the glomerular filtration rate (GFR), lengthening the time required to excrete waste products such as nitrogen. The biologic half-life of medications is affected by kidney function. This can translate into slower elimination of certain medications (such as streptomycin) and result in toxic effects for older patients.

Aging also reduces the resorption of glucose, leading to increased levels of glucose in the urine (glycosuria). Decreased resorption of bicarbonate and sodium can upset the sodium-potassium ratio, resulting in hyperkalemia (elevated potassium levels). Signs and symptoms of hyperkalemia include muscle weakness or paralysis, tingling of the lips and fingers, restlessness, intestinal cramping, and diarrhea.


Assessment of patient renal function is recommended on a regular basis but is most important to consider when adding new medications or prior to exposure to contrast media for diagnostic tests. Blood pressure should be monitored regularly as well as any medications used in the management of hypertension in older adults. Patients with diabetes are also at increased risk for kidney failure. Creatinine clearance is an important indicator of kidney function and should be assessed prior to making a decision about new medications or drugs that are cleared through the kidneys. Additional blood tests that evaluate kidney function include GFR and blood urea nitrogen (BUN) (Touhy & Jett, 2014).


Treatment of the underlying cause of kidney failure may return kidney function to normal. In older adults especially, efforts to control blood pressure and diabetes may be the best way to prevent chronic kidney disease and progression to kidney failure. Kidney function may gradually decrease over time. If the kidneys fail completely, the only treatment option available for an older adult may be dialysis.


Preservation of kidney function can be maintained by carefully monitoring and treating any chronic condition, such as hypertension and diabetes. Older adults also need to carefully monitor their fluid intake and make adjustments in response to medication effects or other influences on the fluid and electrolyte balance. Patients who are on medications that are excreted by the kidney should have kidney function tests on an annual basis (or more frequently if needed) to monitor any side effects.

Urologic Changes and Incontinence

Urologic changes are closely related to changes in the renal system. Age-related loss of muscle tone and decreased contractibility of the bladder can cause excessive urination at night (nocturia) and increased frequency of urination. Urinary tract infections (UTIs) are more common in women because of their shortened urethra and its proximity to the anus, which increases the risk of fecal contamination.

Some degree of age-related urinary incontinence (any involuntary leakage of urine) is common in older people, particularly among the frail elderly. There are four principal types of incontinence: urge, stress, overflow, and functional (Tabloski, 2014). Incontinence can be transient (potentially reversible) or chronic.

Urinary incontinence also may be caused by factors unrelated to the renal and urologic system. These include delirium, cognitive changes, infections, excess fluid intake, medications, psychological factors, restricted mobility, and stool impaction (Tabloski, 2014). Some of these conditions are reversible.


Urinary incontinence becomes more prevalent among both men and women as they age. Screening for incontinence is essential because non-pharmacologic therapeutic measures can reduce or eliminate the condition, preventing complications such as skin breakdown, urinary tract infections, and withdrawal from social activities, which can lead to isolation.


Research indicates that behavioral modification should be the first-line therapy for incontinence in older patients. Pelvic floor exercises are helpful for stress incontinence, while bladder training is helpful for urge incontinence (Tabloski, 2014). Drug treatment for stress incontinence is limited, although some experts recommend a trial of topical estrogen for women with symptomatic atrophic urethritis.


Preventing incontinence is based on keeping the bladder empty by frequent toileting, bladder retraining, and in some cases, catheterization. However, limiting fluid intake (except in the evening) can cause dehydration, requiring other measures. Review of medications may identify one or more drugs that contribute to incontinence.

Respiratory Changes

Respiratory changes in older adults are not completely understood but include loss of elasticity in the lungs and stiffening of the chest wall. Respiratory muscle strength and endurance also decrease but can be increased with exercise (Huether & McCance, 2008). These changes reduce ventilatory reserves and decrease the older adult’s exercise tolerance. Aging also impairs immune function, increasing asymptomatic low-grade inflammation and the risk of infection. These changes elevate the risk of pneumonia.


Patients with respiratory illnesses such as pneumonia may experience new onset of symptoms such as:

  • Chills
  • Fever
  • Chest pain
  • Sweating
  • Productive cough
  • Dyspnea
  • Confusion/delirium
  • Weakness
  • Shortness of breath

Assessment and diagnosis may be made through chest x-ray, blood tests, and sputum culture. A physical exam, swallow test, lung auscultation, and pulmonary function test are also common assessments for respiratory conditions (Mauk, 2014).


Respiratory conditions such as COPD and pneumonia may be treated with oxygen therapy. In addition, a patient who has difficulty swallowing may need to take precautions when eating. Antibiotics may be needed to treat bacterial pneumonia. Adequate fluid intake is also important when faced with respiratory illnesses. Intravenous fluids may be indicated, depending on the condition of the patient (Mauk, 2014).


Adults over the age of 65 are advised to receive a pneumonia vaccine as well as annual vaccination for influenza. Older adults at risk for aspiration should take precautions when eating to prevent aspiration pneumonia, and caregivers should watch for signs and symptoms of difficulty, including coughing while eating (Mauk, 2014).

Endocrine Changes

The endocrine system undergoes many changes during aging, and these changes affect other body systems and processes. These changes include those to the thyroid gland and the gonadal (sex) hormones.

Hypothyroidism (deficiency in circulating thyroid hormone [TH]) is a common disorder, affecting about 5% of people over 60 (Fitzgerald, 2008). Mild or early hypothyroidism may be underdiagnosed in older people because many of its clinical manifestations are also signs of aging: dry skin, low basal metabolic rate, cold intolerance, slightly lower body temperature, and constipation. Other characteristics of hypothyroidism may include lethargy, fatigue, muscle cramps, headache, anemia, hyponatremia (abnormally low levels of sodium in the circulating blood), and lack of mental alertness. Deficiency in TH increases production of TSH (thyroid-stimulating hormone) and can lead to goiter.

Hyperthyroidism, or thyrotoxicosis (abnormally high levels of T4 or T3), may be caused by Graves’ disease (an autoimmune disease) or by toxic multinodular goiter, thyroid adenomas, thyroid carcinoma, or amiodarone. Hyperthyroidism is characterized by an accelerated metabolic rate, heat intolerance, sweating, protruding eyeballs, irritability, restlessness, anxiety, and tremors.

Androgen and estrogen secretions diminish with aging. Declining estrogen levels result in atrophy of the ovaries, uterus, and vaginal tissue in older women, which may make sexual intercourse painful. Older men may develop firmer testes, hypertrophy of the prostate gland, and erectile dysfunction (ED) (the inability to achieve and sustain a sufficient erection for sexual intercourse) (Mauk, 2014). These changes, together with other physical and psychosocial changes, may decrease sexual capacity. In addition, libido may be affected by nonphysiologic causes including depression, stress, and other emotional concerns. However, libido generally continues in both women and men. Although sexual activity may occur less often, it still can remain satisfying.


Assessment of endocrine function includes a physical exam, patient history, blood tests to check hormonal levels, and assessment of patient symptoms. Sexual function may be assessed with a physical exam and patient-reported signs and symptoms (Mauk, 2014).


Endocrine conditions, such as hypothyroidism, may be treated with medications to replace the hormones that are deficient in the body. Correcting hypothyroidism in people over 60 requires a lower dose of replacement thyroid hormone than in younger people. Replacement should be initiated slowly, particularly in those with coronary artery disease, to prevent angina and myocardial infarction.

Treatment options for ED in men include oral medications, vacuum pump devices, penile implants, and drugs injected into the penis. Many oral medications are contraindicated in patients who have baseline cardiac conditions, since they can increase their risk for myocardial infarction. Women may be helped by using vaginal creams, gels, and lubricants to increase comfort during intercourse (Mauk, 2014).


Patients who are experiencing changes in endocrine function should have regular assessments, especially with existing chronic conditions that involve glandular functions (e.g., diabetes, thyroid problems, and prostate changes). Maintaining a healthy lifestyle, good nutrition, and close monitoring of blood tests to be aware of any changes are important.

For men, causes of ED may be many, including diabetes, hypertension, thyroid disorders, alcoholism, and depression. Lifestyle changes to decrease risk factors for ED include the following:

  • Smoking cessation
  • Exercise
  • Healthy weight
  • Proper nutrition
  • Alcohol in moderation
    (Mauk, 2014)

Gastrointestinal Changes

Gastrointestinal (GI) changes begin in middle age and continue throughout life, affecting not only nutritional intake but also quality of life.

Gastrointestinal function begins in the mouth, where aging takes its toll on teeth, gums, and salivary glands. Gastric motility and volume also decrease with age. Secretion of bicarbonate and gastric mucus decline and the acidity of gastric juices diminishes, leading to insufficient hydrochloric acid and delayed gastric emptying. Nutrients such as proteins, fats, minerals, and carbohydrates (particularly lactose) are absorbed more slowly.

Constipation is often deemed an age-related problem. However, several factors may contribute to constipation in older adults. These factors include long-established bowel habits, inadequate dietary fiber and/or fluid intake, and inactivity or immobility.

The liver, pancreas, gallbladder, and bile ducts are also part of the gastrointestinal system. In healthy older adults, the altered function of these organs generally does not interfere with digestion.


Patients with GI symptoms may be evaluated with a variety of assessment techniques including physical exam, patient history, and blood and diagnostic tests. Upper and lower GI diagnostic exams with endoscopy can evaluate the esophagus, stomach, and duodenum. Patients should be encouraged to report any new GI symptoms to their healthcare team for early assessment and intervention (Mauk, 2014).


Lifestyle and dietary modifications as well as medications may be indicated for treatment of constipation. Adequate fluid intake, routine bowel habits, good nutrition, and regular exercise can all contribute to improvement of constipation. Stool softeners may be indicated for patients who have limited mobility or are at risk for constipation due to medications.


Older adults can prevent GI problems and constipation by maintaining a healthy diet and adequate fluid and fiber intake. Patients who are on medications that put them at higher risk for constipation (e.g., calcium and iron) may need to take countermeasures to prevent constipation (Mauk, 2014).

Sensory Changes

Sensory changes in later life affect how people perceive and experience the world and can have an enormous impact on independence, safety, and quality of life. All five senses—vision, hearing, taste, smell, and touch—diminish in acuity with age.

Vision changes generally begin in middle age, and most adults need glasses or contact lenses for reading because of presbyopia by age 50. The most common eye conditions are age-related macular degeneration (ARMD), glaucoma, cataracts, and diabetic retinopathy (Tabloski, 2014).

Hearing changes related to aging also can have a major impact on independence, safety, and quality of life. More than one third of people over 65 and half of those over 85 suffer some hearing loss (NIDCD, 2011; Tabloski, 2014). In later life the eardrum thickens, decreasing its ability to transmit sounds. Age-related changes in the inner ear can also affect balance.

The number of taste buds declines with age, as does the sense of smell, diluting the intensity of flavors and possibly leading to loss of appetite.

Touch changes during aging decrease an individual’s awareness of vibrations, pain, pressure, and temperature. These changes are caused by both internal (e.g., physiologic) and external factors (e.g., medications) and can affect both physical and mental health.


Anyone with a family history of eye disease or who has diabetes and/or hypertension is at high risk of serious eye diseases. To prevent or delay serious eye disease, the American Academy of Ophthalmology recommends that people age 65 or older have an annual comprehensive eye examination.


Age is the primary risk factor for ARMD. Because women live longer than men, ARMD is more prevalent among women. Aside from age, gender, and race, other risk factors for ARMD include smoking, obesity, increased exposure to ultraviolet light, light-colored eyes, hypertension or cardiovascular disease, poor intake of antioxidants and zinc, and family history (Tabloski, 2014).

Warning signs of ARMD include:

  • Lines or edges that appear wavy or distorted
  • Blurry faces or difficulty seeing colors
  • Dark or empty spaces that block the center of vision
  • Difficulty reading fine print or reading road signs from a moving vehicle
  • Difficulty seeing at a distance or during twilight hours
    (Tabloski, 2014)


Age-related visual impairment (presbyopia) is most often corrected by prescription eyeglasses or by contact lenses. Improved lighting (brighter, but using frosted bulbs and lampshades to reduce glare) can also compensate for visual impairment.

The treatment of low vision can include conditions such as macular degeneration, glaucoma, diabetic retinopathy, and normal age-related vision loss. Dealing with visual loss can make it difficult to complete daily tasks.

Some types of hearing loss can be corrected by hearing aids worn in or behind the ear. These devices amplify sounds but may prove to be a challenge in crowded rooms or public places because it can be difficult to separate what one wants to hear from other sounds. In most cases, hearing aids for both ears are advisable. If hearing loss cannot be corrected with conventional hearing aids, cochlear implants may be indicated for some patients (Tabloski, 2014).


Older adults should continue to practice health habits to preserve their sight and hearing. A few preventive measures include the following:

  • Protecting the eyes from sunlight with sunglasses (wrap-around style)
  • Eating a healthy balanced diet (especially high in fresh fruits, vegetables, and antioxidants)
  • Protecting the ears from loud noises by wearing protective devices
  • Participating in eye and hearing screening exams in order to monitor and detect any changes with early interventions
    (Mauk, 2014)

Sleep Changes

Sleep alterations are common among older adults. Older adults tend to sleep more lightly and for shorter time spans, but they generally need about the same amount of sleep as they needed as a young adult (7 to 8 hours a night). Many older people experience insomnia, which includes difficulty in falling asleep and/or staying asleep, periods of wakefulness during the night, waking very early in the morning, or combinations of any of the above (Tabloski, 2014).


Assessment of sleep is important to the overall care of older adults. Assessment of the onset, duration, and severity of symptoms along with any previous treatments for sleep issues should be determined. Risk factors for sleep disturbances should be identified, including the following:

  • Personal or family history of sleep issues (e.g., sleep apnea)
  • Obesity
  • Smoking
  • Hypertension
  • Depression
  • Medications
  • Caffeine use


A regular nighttime routine is important to maintaining adequate sleep. Healthy sleep hygiene includes keeping a regular sleep and wake schedule, limiting exercise and stimulants in the early evening, and keeping a quiet, comfortable sleep environment.

Medications prescribed to promote sleep (e.g., benzodiazepines) increase sleep time and decrease the time needed to fall asleep and the periods of wakefulness.

Patients diagnosed with sleep apnea may need to sleep with a continuous positive airway pressure (CPAP) device and should keep a regular routine of use. Regular maintenance of the machine and evaluation of its effectiveness are also important considerations.


Adequate sleep can be maintained with good sleep habits and a healthy lifestyle. Attention to new medications and changes in daily routine are important to consider if a patient notices changes or new onset of insomnia. Older adults may want to also explore mind-body techniques such as guided imagery or other relaxation techniques to promote onset of sleep.


In older adults, some forms of confusion may be temporary or reversible, while others may be irreversible or indicative of chronic confusion and dementia, including Alzheimer’s disease.

Reversible Forms of Confusion

Gradual onset of confusion may be reversible if it is related to a treatable or correctible condition such as nutritional deficiency, hypothyroidism, vision or hearing impairment, or depression. Careful assessment is needed to avoid misdiagnosis and thereby perpetuate the confusional state. Health professionals need to assume that confusion may be reversible, particularly confusion of sudden onset, and seek the possible causes (Tabloski, 2014).

Mild Cognitive Impairment (MCI)

Mild cognitive impairment is a transitional state between the normal cognitive changes of aging and the development of Alzheimer’s disease (AD) or other dementias. Two subtypes of MCI have been established: Amnestic MCI is characterized by memory problems. Nonamnestic MCI affects cognitive functions other than memory, such as language, attention, critical thinking, reading, and writing. Experts estimate that MCI may affect more than 18% of the population over age 65. People diagnosed with MCI are at increased risk of developing AD or other dementias (Petersen et al., 2014).

The American Academy of Neurology has established the following criteria for an MCI diagnosis:

  • An individual’s self-report of memory problems, preferably confirmed by another person
  • Measurable, greater-than-normal memory impairment detected with standard memory assessment tests
  • Normal general thinking and reasoning skills
  • Ability to perform normal daily activities

Alzheimer’s Disease (AD)

Alzheimer’s disease is an age-related, irreversible brain disorder that gradually erases memory, thinking, understanding, and sense of self. Over time, as neurons die in widespread areas of the brain’s cerebral cortex, mild sporadic memory loss evolves into severe cognitive dysfunction as well as behavior and personality changes and, eventually, loss of physical function. The course of AD and the rate of decline vary from person to person. On average, clients with AD live for 8 to 10 years after diagnosis but may live as long as 20 years.

Although the risk of developing AD increases with age, AD and other dementia symptoms are not a part of normal aging but the result of diseases that affect the brain. In the absence of disease, the human brain can function well into the tenth decade of life.

Alzheimer’s disease is one of a group of disorders called dementias, which are characterized by progressive cognitive and behavioral changes. Symptoms commonly appear after age 60, beginning with loss of recent memory, followed by faulty judgment and personality changes. People in the early stages of AD often think less clearly and may be easily confused.

In progressive stages of the disease, people with AD may forget how to manage activities of daily living (ADLs). In the late stages, people with AD are unable to function on their own and become completely dependent on others for their everyday care. Finally, they become bedfast and succumb to other illnesses and infections. Pneumonia is the most common cause of death in AD (Touhy & Jett, 2014).


Alzheimer’s disease has no single, clear-cut cause and therefore no sure means of prevention. Scientists believe that AD results from the interaction of genetic, environmental, and lifestyle factors over many years, causing changes in brain structure and function.

Risk factors for AD include the following:

  • Advanced age
  • Family history of dementia
  • Hypertension
  • Diabetes
  • Stroke or transient ischemic attacks (TIAs)
  • Presence of infarcts or white-matter lesions
  • Low mood (depression)
  • Higher body mass index (BMI)
  • Traumatic brain injury
  • Head injury in early adulthood
  • Chronic stress
  • Smoking more than two packs of cigarettes per day
  • Lack of physical activity
  • Dyslipidemia
  • Sleep apnea
  • Low levels of vitamin D
    (Touhy & Jett, 2014; Rusanen et al., 2011)

Factors that protect cognitive function include:

  • Higher levels of education
  • Higher socioeconomic status (SES)
  • Healthy diet
  • Intellectually challenging activities
  • Active social lifestyle
  • Regular physical exercise
    (Touhy & Jett, 2014)


Alzheimer’s disease remains a diagnosis of exclusion, ruling out other conditions that may cause similar symptoms, such as stroke, hypothyroidism, depression, nutritional deficiency, brain tumor, Parkinson’s disease, or inappropriate medications. Conclusive diagnosis of AD is still only possible at autopsy.

However, researchers have reported some success in identifying proteins called biomarkers in the blood and spinal fluid that can provide earlier probable diagnosis of the disease. Combined with more accurate neuropsychological testing and neuroimaging techniques such as positive emission tomography (PET) scans and magnetic resonance imaging (MRI), these advances enable clinicians to more accurately predict who will develop AD.


Care and treatment of the person with AD changes over time as the disease progresses. Care planning should begin at the time of diagnosis and involve the patient and the family. The plan includes:

  • Cholinesterase inhibitor therapy to temporarily improve cognition or slow the rate of cognitive decline
  • Management of comorbid conditions, especially sensory deficits
  • Treatment of behavioral symptoms and mood disorders
  • Support and resources for patient and caregiver
  • Discussion of advance directives
  • Compliance with state-mandated reporting requirements for driving impairment and elder abuse
    (Touhy & Jett, 2014)

The progressively lowered stress model (see box below) presents one option for creating and maintaining a supportive environment when caring for a person who has dementia.

  • Evaluate for any loss of functional abilities and support by assistive devices as needed.
  • Establish a caring and respectful relationship with the patient and family.
  • Assess and respond to patient cues of anxiety and avoidance when faced with stimuli and overwhelming activities.
  • Provide education and feedback to caregivers to understand primary cause of behaviors and to observe for both verbal and nonverbal cues.
  • Identify any triggers related to patient discomfort or stress.
  • Make environmental modifications to address the safety of the patient.
  • Evaluate and make changes to care routines as the patient experiences functional changes.
  • Encourage as much patient control as possible (i.e., offer choices, do not force activities).
  • Maintain a predictable daily routine and stable environment (daily activities and caregivers should be familiar).
  • Provide ongoing support, care, and resources for caregivers and family members.

Source: Adapted from Touhy & Jett, 2014.

Patients receiving collaborative care from an interdisciplinary team including physicians, nurses, social workers, and rehabilitation specialists working with the patient’s family caregiver have been shown to exhibit fewer behavioral and psychological symptoms of dementia than those receiving traditional care. Family caregivers also benefited, showing significant reduction in distress and improvement in depression.


The Reisberg Functional Assessment Staging (FAST) Scale is a 16-item scale designed to parallel the progressive activity limitations associated with AD. Stage 7 identifies the threshold of activity limitation and indicates a life expectancy of 6 months or less.

Stage Function or Activity
Source: Adapted from AGS, 2014.
Stage 1 No difficulty in function reported by patient or others
Stage 2 Complains of forgetting location of objects; subjective work difficulties
Stage 3 Decreased job functioning evident to coworkers; difficulty in traveling to new locations
Stage 4 Decreased ability to perform complex tasks (e.g., following a recipe) or handling finances
Stage 5 Requires assistance in making self-care decisions, (e.g., choosing proper clothing)
Stage 6 Decreased ability in ADLs (e.g., dressing, bathing)
Substage 6a Difficulty understanding how to put on clothing
Substage 6b Unable to bathe properly; may develop fear of bathing
Substage 6c Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)
Substage 6d Urinary incontinence present
Stage 7 Loss of speech, locomotion, and consciousness
Substage 7a Ability to speak only limited vocabulary (1–5 words a day)
Substage 7b All intelligible vocabulary lost
Substage 7c Not able to ambulate
Substage 7d Unable to smile
Substage 7e Unable to hold head up

Other Dementias

Additional forms of dementias include vascular dementia, Parkinson’s dementia, dementia with Lewy bodies, and frontotemporal dementias. The various forms of dementia have different symptom patterns and brain abnormalities. Accurate diagnosis of the type of dementia is important, as each one is treated and managed differently (Touhy & Jett, 2014).


Elder abuse occurs when harm or distress is caused to an older person within the context of a relationship where there is an expectation of trust. Elder abuse is connected with adverse health outcomes as well as an increased risk of mortality. Elder abuse is difficult to track; there is no national reporting system and statistics are unreliable and outdated. In addition, older adults may be hesitant to report abuse out of fear. However, estimates indicate that over one million older adults experience some form of abuse annually (Mauk, 2014).

Elder abuse can take many forms, including physical, sexual, emotional, financial, caregiver neglect, and abandonment. Nurses and other healthcare providers should regularly screen for elder abuse and recognize any unusual symptoms or patient responses that may indicate abuse.

Source: National Institute on Aging, 2011.
Physical Inflicting physical pain or injury on a senior, e.g., slapping, bruising, or restraining by physical or chemical means
Emotional Inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts, e.g., humiliating, intimidating, or threatening
Sexual Non-consensual sexual contact of any kind
Neglect Failure by those responsible to provide food, shelter, healthcare, or protection for a vulnerable elder
Exploitation Illegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else’s benefit
Abandonment Desertion of a vulnerable elder by anyone who has assumed responsibility for care or custody of that person
Self-neglect Failure of a person to perform essential self-care tasks, which failure threatens his/her own health or safety

Most known perpetrators of abuse and neglect are family members, usually an adult child or a spouse. Most abuse happens in the elder’s own home. However, abuse also occurs in long-term care facilities.

Financial exploitation is a serious risk for elders with any degree of cognitive impairment. Unscrupulous individuals, including family members, friends, attorneys, and financial advisors, may take advantage of older people with impaired judgment and financial acumen. Many older adults have lost their homes and their life savings because of financial exploitation. The Internet has increased the opportunity for scam artists to prey on those who may be cognitively impaired.

Risk Factors

Risk factors for elder abuse include:

  • Lack of social support and isolation
  • Cognitive impairment, including Alzheimer’s or other dementias
  • Mental health problems of abusers or victims
  • Physical frailty
  • Abuse of alcohol or other drugs by abusers or victims
  • Polypharmacy or inappropriate use of medications

People with Alzheimer’s disease or other cognitive impairment as well as people with disabilities are at higher risk than other older adults. Caring for a person with AD can cause stress, depression, feelings of isolation, financial worries, and substance abuse, any or all of which can lead to elder abuse. Violent behavior by the patient may also lead to physical abuse by the caregiver.

Respite care for the patient and support group and counseling for the caregiver can help prevent elder abuse. In severe cases, it is usually necessary to separate the patient from the caregiver, initiate legal action, and find a safe facility for the patient.

Assessment and Screening

Health professionals should be alert to any indication of elder abuse. During the physical examination, it is important to look for physical signs of possible abuse or neglect. These may include bruising, malnutrition, burns, scars, and fractures. Signs of sexual abuse may include trauma to the vulva or rectum or any unexplained vaginal or anal bleeding. Clinical findings of neglect may include dehydration, malnutrition, decubitus ulcers, and contractures.

Assessment and interview of the patient separate from the caregiver may be needed to confirm any suspicion of abuse or neglect (Tabloski, 2014). Office or emergency department visits provide a safe and confidential environment. Patients should have the opportunity to respond to the questions in a confidential setting outside the presence of the patient’s family, caregiver, or the person who brings the patient to the appointment.

Screening questions for elder abuse may be used with patients. Questions for routine screening include the following:

  1. Do you feel safe where you live?
  2. Who prepares your food?
  3. Does someone help with your medications?
  4. Who takes care of your checkbook?
  5. Does anyone at home hurt you?
  6. Do they scold or threaten you?
  7. Do they touch you without your consent?
  8. Are you afraid of anyone in your life?
  9. Are you alone a lot?
  10. Are you able to use the telephone any time you want to?
  11. Has anyone forced you to do things you didn’t want to do?
  12. Has anyone taken things or money that belong to you without your permission?
  13. Has anyone ever failed to help you take care of yourself when you needed help?
    (Stanford School of Medicine, 2014)

Reporting Elder Abuse

Nurses, physicians, and other clinical providers in all settings where older people receive care also need to be aware of their legal requirements for reporting abuse to the appropriate government agencies. In Texas, anyone suspecting abuse, neglect, or exploitation is required to report the case to the Texas Department of Family and Protective Services. Reporting can be done anonymously. Those failing to report abuse can be held liable for a misdemeanor or felony.


People are often reluctant to talk about death or to express their wishes about end-of-life care. But avoiding these subjects imposes a costly ignorance, which can mean less than optimal care and diminished quality of life for those who are dying and for their families.

Life ends for everyone; this is a fact. Thus, it is important to prepare older adults—whether they are relatively healthy or dealing with a chronic or incurable illness—and their families to plan and anticipate making decisions regarding end-of-life care and treatment, especially in the event that the older adult is not able to make decisions for themselves.

Older adults should plan and discuss their preferences with significant others, family, and healthcare providers. They can communicate their wishes through planning advance directives, a living will, and appointing a healthcare power of attorney. Advance directives are designed to communicate the type of care patients want when they cannot speak for themselves. A healthcare power of attorney is someone appointed by the patient to make treatment decisions on their behalf.

Palliative Care

Palliative care incorporates multiple strategies to relieve physical and emotional suffering and to enhance quality of life. Palliative care can be requested in the early phases of a life-limiting or debilitating illness and coexist with life-sustaining treatment. For patients with chronic illnesses, palliative care may continue for years.

The Center to Advance Palliative Care (2014) states:

Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

These are quality of life conversations that allow physicians to explore their patients’ values and goals. Patients facing serious illness may live for years. This is why palliative care is necessary for patients with chronic illnesses who want to remain in control of their lives and destiny.

Palliative care for those with life-limiting illness ideally begins at the time of diagnosis. Many people who do not fear death do fear the process of dying, the prospect of pain and suffering, and being a burden to their families. Goals for palliative care support patient and family needs during this time by providing:

  • A way to honor the patient’s wishes
  • Choices among the types of services the patient can receive
  • Pain control tailored to the patient’s wishes
  • Emotional support for the patient and family


Palliative care includes team members from medicine, nursing, social work, pharmacy, chaplaincy, rehabilitation, and other disciplines. The goal of palliative care is to achieve the best possible quality of life for patients and their families. Nursing interventions may include the following:

  • Pain management
  • Symptom management (e.g., oxygen to ease breathing)
  • Spiritual care
  • Emotional support (e.g., mind-body techniques for anxiety)
  • Home equipment needs (e.g., assistive devices, safety features, and other equipment)
  • Home care and medication management
  • Referral to social work, community resources, and other identified needs

Hospice Care

Hospice care is intended for people who are nearing the end of life. The focus of hospice care isn’t to cure or treat the underlying disease but to provide the highest quality of life possible for whatever time remains. Hospice care empowers patients and families to be active participants and make personal decisions about the dying process. Hospice care incorporates physical, emotional, psychosocial, and spiritual needs at the end of life. Bereavement services are also included and may continue for up to a year after the patient’s death.

Many people mistakenly think that hospice refers to a place. Although there are some residential hospice facilities, most hospice care takes place in the patient’s home or the home of a loved one and less frequently in hospitals and nursing homes.

Hospice care services are provided by a team of healthcare professionals who create a holistic plan of care that addresses pain and comfort as well as physical, psychological, social, and spiritual needs of both the patient and the entire family. Many hospice programs employ physicians and nurses with special expertise in pain management and symptom relief. Bereavement and spiritual counselors are also available to help the dying and their families explore their needs and preferences as they come to terms with death. The team develops an individualized care plan to meet each patient’s needs for pain management and symptom control. When the patient is cared for at home, hospice staff is on-call 24 hours a day, 7 days a week.

The hospice team generally includes:

  • Family
  • Physician
  • Nurse, who usually serves as a case manager and coordinates care with other disciplines
  • Physical therapist and/or occupational therapist
  • Counselors, including psychologists and clergy
  • Social worker
  • Home health aides
  • Trained volunteers

For patients and families who are investigating hospice care, helpful questions they may ask include the following:

  • How is the hospice program certified?
  • What services does the program offer to the patient as well as the family?
  • What is the cost? Do benefits cover hospice care (Medicare and private insurance usually do)?
  • What is the process of being accepted into the program?
  • What is the setting (home or facility)?

Talking about hospice care isn’t easy, but it often helps to encourage patients and families to start the discussion early so that choices and initial decisions can be made before a crisis occurs. The fact is that many people enter hospice only in their last few days instead of their last months. Hospice care is designed to give patients the best quality of life during the time when they need it most.


Hospice is not just for people with cancer. Any patient who is diagnosed with a terminal illness is eligible for hospice care. In fact, many patients admitted to hospice have a non-cancer diagnosis, such as heart disease, kidney disease, emphysema, Alzheimer’s or other dementia, HIV/AIDS, and other degenerative conditions.

The Medicare hospice benefit guarantees comprehensive, high-quality care at little or no cost to terminally ill Medicare beneficiaries and their families. To access the Medicare hospice benefit, the patient’s doctor must certify that the patient likely has six months or less of life remaining. If the patient lives more than six months, the benefit can be extended for an unlimited number of 60-day periods based on the physician’s recertification that the patient is likely to die within the next six months (HHS, 2013).

Cancer patients must agree to forgo active treatments such as chemotherapy and radiation. This requirement is one reason some people avoid hospice until the last days or weeks of life and continue with aggressive, expensive treatment, which may make little or no difference in survival time and may diminish the quality of life in the process.


Caring for Texas’s aging population presents unique challenges to nurses and the entire healthcare system. The health care needs of older adults are every bit as specialized as those of children. Given the uncertainty of what the healthcare system will look like over the next decades, it is impossible to predict just how those needs will be met.

Three fourths of Americans over age 65 have two or more chronic illnesses. Graying baby boomers will only intensify this burden. Chronic illness and the high incidence of cancer and diabetes point to exponential escalation in the demand for geriatric care. Knowledge, skills, and tools to assist in the assessment and management of the multiple aspects of caring for older adults are important considerations for the various healthcare provider roles.

As the healthcare system continues to change, self-care and prevention remain paramount in the health of older people. Nurses and other healthcare providers have a critical role in educating patients and their caregivers about what they can do to improve or maintain their health and independence, to ameliorate the complications of aging, and to achieve the highest possible quality of life. This course lays the groundwork for providing competent, compassionate care to older people—the kind of care we all want for ourselves.


NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).

American Geriatrics Society (AGS). (2014). A guide to dementia diagnosis and treatment. Retrieved from

Bonder BR & Dal Bello-Haas V. (2009). Functional performance in older adults (3rd ed.). Philadelphia: F.A. Davis Company.

Center to Advance Palliative Care (CAPC). (2014). Defining palliative care.Retrieved from

Centers for Disease Control and Prevention (CDC). (2013a). The state of aging and health in America 2013. Retrieved from

Centers for Disease Control and Prevention (CDC). (2013b). Deaths: final data for 2010. National Vital Statistics Report, 61, 4. Retrieved from

Centers for Disease Control and Prevention (CDC). (2013c). Skin cancer statistics. Retrieved from

Fitzgerald PA. (2010). Endocrine disorders. In SA McPhee and M Papadakis (eds.), Current medical diagnosis and treatment (49th ed.). New York: McGraw-Hill.

Fox C, Richardson K, Maidment D, et al. (2011). Anticholinergic medication use and cognitive impairment in the older population. Journal of the American Geriatric Society, 59(8), 1477–83.

Huether S & McCance KL. (2008). Understanding pathophysiology (4th ed.). St. Louis: Mosby/Elsevier.

Leland N, Elliott SJ, Johnson KJ. (2012). Occupational therapy practice guidelines for productive aging for community-dwelling older adults. Bethesda, MD: AOTA Press.

Mauk KL. (2014). Gerontological nursing competencies for care (3rd ed.). Burlington: Jones & Bartlett Learning.

Mayo Clinic. (2014a). Melanoma. Retrieved from

Milanović Z, Pantelić S, Trajković N, et al. (2013). Age-related decrease in physical activity and functional fitness among elderly men and women. Clin Interv Aging, 8, 549–56.

Miller KL, Magel JR, Hayes JG. (2010). The effects of a home-based exercise program on balance confidence, balance performance, and gait in debilitated, ambulatory community-dwelling older adults: a pilot study. Journal of Geriatric Physical Therapy, 33, 85–91.

National Institute on Aging. (2011). Age page: elder abuse. Retrieved from

National Institute on Deafness and Other Communication Disorders (NIDCD). (2011). Smell and taste. Retrieved from

Petersen RC, Caracciolo B, Brayne C, et al. (2014). Mild cognitive impairment: a concept in evolution. Journal of Internal Medicine, 275, 214–28.

Proximity. (2014). Population age 65 & over estimates and projections. Retrieved from

Rusanen M, Kivipelto M, Quesenberry CP Jr, Zhou J, Whitmer RA. (2011). Heavy smoking in midlife and long-term risk of Alzheimer’s disease and vascular dementia. Archives of Internal Medicine, 171(4), 333–9.

Stanford School of Medicine. (2014). Elder abuse: how to screen. Retrieved from

Tabloski PA. (2014). Gerontological Nursing (3rd ed.). Upper Saddle River, NJ: Pearson.

Texas Department of State Health Services. (2014). The health status of Texas 2014. Retrieved from

Touhy TA & Jett KF. (2014). Ebersole and Hess’ gerontological nursing & healthy aging (4th ed.). St. Louis: Elsevier Mosby.

U. S. Department of Health and Human Services (HHS). (2013). Centers for Medicare and Medicaid Services: Medicare hospice benefits. Retrieved from

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