Geriatric nursing

Nursing (B.Sc Nursing) · Specialty nursing · free study notes for exams, placements and interviews

In short

Geriatric (gerontological) nursing is the care of people aged 60 years and above — India's statutory definition of a senior citizen — covering normal age-related change, the "geriatric syndromes", chronic disease management, rehabilitation and end-of-life care. It matters because India's elderly population was 10.38 crore (8.6%) in Census 2011 and about 10.5% in 2022, projected to reach roughly 20% by 2050 (UNFPA India Ageing Report, 2023), with falling family-based support. It is examined in INC-prescribed B.Sc Nursing courses (Adult Health Nursing, Community Health Nursing and the geriatric unit), in M.Sc specialities, and in staff-nurse recruitment tests such as AIIMS NORCET, RRB, ESIC, DSSSB, state PSC and Military Nursing Service. On the job it is used in geriatric OPDs and wards under the NPHCE, in ICUs and ortho wards full of elderly patients, in old-age homes, home nursing and palliative care.

Explained

Concepts, demography and the Indian policy framework

Gerontology is the study of ageing; geriatrics is the medical speciality; geriatric/gerontological nursing is the nursing care of older adults. Ageism is prejudice based on age.
Age bands used in practice: young-old 60–74, old-old 75–84, oldest-old 85+. Chronological age differs from biological, psychological and social age.
Senescence: normal, universal, progressive, intrinsic, irreversible decline in functional reserve — not disease. Nursing distinguishes normal ageing from pathology (e.g. forgetfulness of names is normal; disorientation to place is not).
Feminisation of ageing (more elderly women, usually widowed and economically dependent) and ruralisation (about 70% of India's elderly live in rural areas) shape care needs.
National Policy on Older Persons, 1999, and the draft National Policy for Senior Citizens, 2011 — welfare, health care, shelter, protection against abuse.
National Programme for Health Care of the Elderly (NPHCE), from 2010–11: geriatric OPD and ward at district hospitals, rehabilitation units at CHCs, weekly elderly clinics at PHCs, Regional Geriatric Centres in medical colleges, and the National Centre for Ageing at AIIMS, New Delhi. Elderly care is one of the service packages of Ayushman Bharat Health and Wellness Centres / Ayushman Arogya Mandirs.
Maintenance and Welfare of Parents and Senior Citizens Act, 2007: children/relatives are legally bound to maintain parents; application to a Maintenance Tribunal (the Act caps maintenance at ₹10,000 per month — amendment proposals to raise/remove this cap have been debated, so verify the current position); abandonment of a senior citizen is punishable (imprisonment up to three months, or fine, or both); state governments to run at least one old-age home per district.
Other supports: Indira Gandhi National Old Age Pension (NSAP), Rashtriya Vayoshri Yojana (free assistive devices for needy elderly), Atal Vayo Abhyuday Yojana (AVYAY) umbrella scheme of the Ministry of Social Justice and Empowerment, senior-citizen concessions, Elderline 14567 helpline, and PM-JAY cover extended in 2024 to all citizens aged 70+ (Vay Vandana card) — scheme details change, so check the latest circular.

Biological, psychological and social theories of ageing

Biological — programmed: genetic/programmed-senescence theory, telomere shortening, neuroendocrine theory, immunological theory (declining T-cell function).
Biological — stochastic (damage): free radical/oxidative stress theory, wear-and-tear, cross-linkage (glycation of collagen), somatic mutation, error-catastrophe.
Psychosocial: Erikson — integrity versus despair; Havighurst's activity theory (staying active preserves well-being); Cumming and Henry's disengagement theory; continuity theory; Peck's and Newman's developmental tasks; selective optimisation with compensation (Baltes).
Nursing use: activity and continuity theories justify recreation, occupational therapy and day-care in old-age homes; free-radical theory justifies antioxidant-rich diet counselling.

Age-related changes, system by system (and nursing implications)

Skin: thin epidermis, less subcutaneous fat, reduced elasticity and sweating → pressure injury, hypothermia, dry itchy skin, easy bruising. Avoid hot water and strong soap; moisturise; two-hourly turning.
Musculoskeletal: loss of muscle mass (sarcopenia), osteopenia/osteoporosis, degenerated cartilage, kyphosis, loss of height → fracture risk (neck of femur, Colles', vertebral crush). Weight-bearing exercise, calcium 1,000–1,200 mg/day and vitamin D, hip protectors.
Cardiovascular: stiff arteries (rising systolic BP, wide pulse pressure), reduced maximal heart rate and baroreceptor sensitivity → orthostatic hypotension, poor exercise tolerance. Rise slowly, avoid rapid fluid shifts.
Respiratory: reduced elastic recoil and vital capacity, higher residual volume, weak cough, fewer cilia → pneumonia and atelectasis. Deep-breathing exercises, early mobilisation, influenza and pneumococcal vaccination.
Gastrointestinal: reduced saliva, taste and smell, dentition loss, slower peristalsis, atrophic gastritis (reduced B12 absorption) → anorexia, constipation, aspiration. Soft high-fibre diet, fluids, oral care, upright feeding.
Renal and urinary: nephron loss, GFR falls roughly 0.75–1 mL/min/year after 40, weak bladder and pelvic floor, prostate enlargement → nocturia, incontinence, retention, drug accumulation.
Nervous and sensory: reduced neurons and conduction velocity, slower reaction time, mild short-term memory decline, fragmented sleep; presbyopia, cataract, glaucoma, presbycusis (high-frequency hearing loss). Good lighting without glare, face the patient, speak low-pitched and clearly.
Endocrine/metabolic: glucose intolerance, lower basal metabolic rate, menopause/andropause, impaired thermoregulation.
Immune: immunosenescence — blunted fever and leucocytosis, so infection often presents as confusion, falls or incontinence ("atypical presentation").

Comprehensive Geriatric Assessment (CGA) and the tools examined

CGA is a multidimensional, interdisciplinary assessment of medical, functional, psychological, social, environmental and spiritual domains, producing a shared care plan.
Functional status — ADL: Katz Index (6 items: bathing, dressing, toileting, transferring, continence, feeding); Barthel Index (10 items, 0–100). IADL: Lawton–Brody scale (8 items: telephone, shopping, cooking, housekeeping, laundry, transport, medication, finances).
Cognition: MMSE (30 points; <24 suggests impairment, adjust for education and literacy — the Hindi Mental State Examination, HMSE, and vernacular adaptations are used in India), MoCA (<26), Mini-Cog (3-word recall + clock drawing, 0–5), clock-drawing test.
Delirium: Confusion Assessment Method (CAM/CAM-ICU) — acute onset and fluctuating course, inattention, disorganised thinking, altered level of consciousness (features 1 and 2 plus 3 or 4).
Mood: Geriatric Depression Scale (GDS-30 or GDS-15; ≥5 of 15 screens positive).
Nutrition: Mini Nutritional Assessment (MNA/MNA-SF), BMI, mid-upper arm and calf circumference, unintentional weight loss.
Falls: Morse Fall Scale (≥45 high risk), Timed Up and Go (≥12 s suggests risk), Tinetti balance and gait, get-up-and-go, home hazard checklist.
Pressure injury risk: Braden Scale (6 subscales, total 6–23; lower = higher risk) or Norton Scale; Waterlow in some units.
Frailty and sarcopenia: Fried phenotype (weight loss, exhaustion, weakness/grip, slow gait, low activity — 3+ = frail, 1–2 = pre-frail), Clinical Frailty Scale 1–9, AWGS 2019 criteria for sarcopenia (grip strength, gait speed, muscle mass).
Pain: numeric or Wong-Baker scale if communicative; PAINAD or Abbey scale in dementia.
Elder abuse: physical, psychological, financial, sexual, neglect, abandonment; screen with direct private questioning; HelpAge India surveys repeatedly report disrespect and financial abuse as the commonest forms.

Geriatric syndromes and nursing management

The five "I"s (geriatric giants): immobility, instability (falls), incontinence, intellectual impairment, iatrogenesis. The 4Ms framework of age-friendly care: What Matters, Medication, Mentation, Mobility.
Falls: multifactorial — intrinsic (weakness, poor vision, postural hypotension, arrhythmia, neuropathy, sedatives) and extrinsic (wet floor, loose mats, poor light, no grab bars, unsuitable footwear). Nursing: bed in low position, call bell within reach, side rails as indicated, non-slip footwear, assisted ambulation, vitamin D, de-prescribe sedatives, post-fall assessment for injury and cause.
Immobility: complications — pressure injury, DVT, pneumonia, contractures, constipation, hypercalciuria/renal stones, disuse osteoporosis, depression. Nursing: positioning, passive and active range-of-motion exercises, early mobilisation, air/foam mattress, physiotherapy referral.
Pressure injuries (NPIAP staging): Stage 1 non-blanchable erythema, intact skin; Stage 2 partial-thickness loss, exposed dermis; Stage 3 full-thickness, fat visible; Stage 4 exposed bone/tendon/muscle; plus unstageable and deep tissue injury. Prevention: risk scoring, two-hourly turning, pressure-redistributing surface, keep skin clean and dry, no massage over bony prominence, protein and calorie support.
Incontinence types: stress, urge (overactive bladder), overflow (retention, BPH), functional, mixed. Nursing: bladder diary, timed voiding, pelvic floor (Kegel) exercises, treat UTI/constipation, perineal care; indwelling catheter only on clear indication (CAUTI risk).
Delirium vs dementia vs depression (the "3 Ds") — distinguished in almost every exam; see the comparison table below. Delirium is an emergency: find the cause (infection, hypoxia, dehydration, drugs, pain, retention, electrolytes), reorient, keep familiar objects, night light, avoid restraints, involve family, use low-dose antipsychotics only when safety demands.
Dementia: Alzheimer's (commonest), vascular, Lewy body, frontotemporal; stages mild–moderate–severe; progressive memory, language, judgement and behaviour loss with sundowning and wandering. Nursing: fixed routine, simple one-step instructions, validation therapy, reminiscence therapy, orientation cues, safe environment, identity band, feeding assistance, caregiver support and respite. Cholinesterase inhibitors (donepezil, rivastigmine) and memantine are symptomatic.
Depression and suicide: often presents as somatic complaints or pseudodementia; risk factors widowhood, pain, disability, loneliness. Treat, don't dismiss as "just old age".
Malnutrition and dehydration: reduced thirst sensation means dehydration is easily missed; check skin turgor (unreliable in elderly), mucosa, urine output, weight trend, urea/creatinine ratio.
Polypharmacy and iatrogenesis: ≥5 regular drugs; prescribing cascades; Beers Criteria (AGS) and STOPP/START lists potentially inappropriate medicines — e.g. long-acting benzodiazepines, anticholinergics, NSAIDs with renal impairment, glibenclamide. Principle: "start low, go slow", review at every visit, one change at a time.
Sensory deprivation, insomnia, constipation, hypothermia, osteoarthritis, osteoporosis, BPH, cataract, stroke and diabetes are the common day-to-day clinical load; non-pharmacological measures come first.
End of life: advance care discussion, symptom control (pain by WHO ladder, dyspnoea, dry mouth, constipation), mouth and skin care, spiritual support, family presence, grief support. India's National Programme for Palliative Care and the Kerala community palliative model are the usual examples; the Supreme Court has recognised passive euthanasia and advance medical directives (Common Cause, 2018), with simplified procedures issued later.

Care settings, rehabilitation and the nurse's role

Home care/family care (the dominant Indian model), day-care centres, old-age homes (free and paid), assisted living, hospital geriatric wards, rehabilitation units, hospice/palliative units, telemedicine (eSanjeevani).
Nurse's roles: care-giver, assessor, educator, counsellor, advocate, case manager, rehabilitator, researcher, administrator of geriatric services; member of the multidisciplinary team (geriatrician, physiotherapist, occupational therapist, dietician, social worker, psychologist).
Health promotion for elderly: balanced diet, 150 min/week moderate activity plus balance and resistance work, tobacco and alcohol cessation, annual eye/hearing/BP/sugar screening, immunisation (annual influenza, pneumococcal, Td booster, herpes zoster where available), oral and foot care, social engagement, yoga.
Ethical and legal: autonomy and informed consent with capacity assessment, confidentiality, truth-telling, beneficence/non-maleficence, restraint only as last resort with order and documentation, dignity, right to refuse treatment, reporting abuse, will and property rights, and the nurse's accountability under Indian Nursing Council / State Nursing Council registration and the professional code of ethics and conduct.

Key points

Senior citizen (India) - a person aged 60 years and over, per the Maintenance and Welfare of Parents and Senior Citizens Act, 2007.
Gerontology vs geriatrics - study of ageing versus the clinical speciality; nursing covers both.
Senescence - normal loss of functional reserve; disease is not a normal part of ageing.
Atypical presentation - infection or MI in the elderly may show only confusion, a fall, incontinence or anorexia, without fever or chest pain.
Five I's - immobility, instability, incontinence, intellectual impairment, iatrogenesis.
CGA - multidimensional interdisciplinary assessment of medical, functional, cognitive, affective, social and environmental domains.
ADL vs IADL - Katz/Barthel measure basic self-care; Lawton measures complex living skills, which fail first.
Delirium - acute, fluctuating, reversible, inattentive; always look for a physical cause.
Dementia - chronic, progressive, global cognitive decline; Alzheimer's is commonest.
Braden Scale - 6–23; ≤18 indicates pressure-injury risk; reassess with every change in condition.
Polypharmacy - five or more regular drugs; screened with Beers criteria and STOPP/START.
Pharmacokinetics in ageing - less body water and albumin, more fat, reduced hepatic first-pass metabolism and reduced renal clearance → smaller doses, longer intervals.
Osteoporosis prevention - calcium 1,000–1,200 mg/day, vitamin D, weight-bearing exercise, fall-proofing.
Orthostatic hypotension - fall of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing.
NPHCE - national programme giving geriatric OPDs, district geriatric wards and Regional Geriatric Centres.
Elder abuse - physical, psychological, financial, sexual, neglect and abandonment; abandonment is a punishable offence.
Restraints - last resort, time-limited, with a written order, frequent observation and documentation.
Feminisation of ageing - more elderly women, mostly widowed and financially dependent, so care planning must address income and shelter.

Formulas and examples

BMI = weight (kg) ÷ [height (m)]². Asian-Indian cut-offs: <18.5 underweight, 18.5–22.9 normal, 23–24.9 overweight, ≥25 obese.
Creatinine clearance (Cockcroft–Gault) = [(140 − age in years) × weight in kg] ÷ (72 × serum creatinine in mg/dL); × 0.85 for women. Unit: mL/min.
Pulse pressure = systolic − diastolic BP (mmHg). Mean arterial pressure MAP = (2 × diastolic + systolic) ÷ 3 (mmHg).
Maintenance fluid in a stable older adult ≈ 30 mL per kg body weight per day (minimum about 1,500 mL/day unless restricted).
Old-age dependency ratio = (population aged 60+ ÷ population aged 15–59) × 100. Ageing index = (population 60+ ÷ population 0–14) × 100.
Timed Up and Go = seconds taken to rise from a chair, walk 3 m, turn, return and sit; ≥12 s suggests increased fall risk.

Example 1 — drug dose and renal function. A 72-year-old man, 58 kg, serum creatinine 1.3 mg/dL.

CrCl = [(140 − 72) × 58] ÷ (72 × 1.3) = (68 × 58) ÷ 93.6 = 3,944 ÷ 93.6 = 42.1 mL/min.
Serum creatinine looks "near normal" because muscle mass is low, yet clearance is under half of normal → renally excreted drugs (aminoglycosides, metformin, digoxin, NSAIDs, DOACs) need dose reduction or avoidance. For a woman of the same figures: 42.1 × 0.85 = 35.8 mL/min.

Example 2 — nutrition screening. A 68-year-old woman, 46 kg, height 1.52 m, lost 3 kg in 3 months.

BMI = 46 ÷ (1.52 × 1.52) = 46 ÷ 2.3104 = 19.9 kg/m² — within normal by Asian cut-offs.
Weight loss = 3 ÷ 49 × 100 = 6.1% in 3 months, which exceeds the 5%-in-3-months threshold → at nutritional risk despite a "normal" BMI. Do MNA-SF, add 1–1.2 g protein/kg/day (≈46–55 g), small frequent soft feeds, dietician referral.

Example 3 — hydration and postural BP. Same 58 kg man, on no fluid restriction. Requirement = 30 × 58 = 1,740 mL/day. Supine BP 130/80, standing 108/70.

Systolic drop = 130 − 108 = 22 mmHg (≥20) and diastolic drop = 10 mmHg (≥10) → orthostatic hypotension present.
Supine pulse pressure = 130 − 80 = 50 mmHg; MAP = (2 × 80 + 130) ÷ 3 = 290 ÷ 3 = 96.7 mmHg.
Nursing: rise in stages, dangle legs before standing, assist ambulation, review antihypertensives/diuretics/alpha-blockers, increase fluids.

Example 4 — pressure-injury risk. A bed-bound stroke patient scores: sensory perception 2, moisture 2, activity 1, mobility 2, nutrition 2, friction/shear 1.

Total Braden = 2 + 2 + 1 + 2 + 2 + 1 = 10 of 23 → high risk.
Plan: two-hourly turning with a written schedule, pressure-redistributing mattress, heel offloading, 30° lateral tilt, barrier cream, protein-rich diet, daily skin inspection, reassess score every 48 hours or on any change.

Example 5 — community ageing profile. A PHC area of 1,200 people: 156 aged 60+, 720 aged 15–59, 324 aged 0–14.

Proportion elderly = 156 ÷ 1,200 × 100 = 13% (above the national average).
Old-age dependency ratio = 156 ÷ 720 × 100 = 21.7 per 100 working-age adults.
Ageing index = 156 ÷ 324 × 100 = 48.1.
Use: plan a weekly elderly clinic under NPHCE, home visits for the bed-bound, and cataract/BP/diabetes screening camps.

Feature	Delirium	Dementia	Depression
Onset	Hours to days, acute	Months to years, insidious	Weeks to months
Course	Fluctuates, worse at night	Steadily progressive	Often diurnal, worse in morning
Attention	Markedly impaired	Normal until late	Mildly reduced
Consciousness	Clouded, fluctuating	Clear	Clear
Memory complaint	Not reported	Minimised by patient	Emphasised by patient ("I don't know")
Reversible	Usually, if cause treated	No (manageable)	Yes, with treatment
Nursing priority	Find and treat the cause	Safety, routine, caregiver support	Screen with GDS, refer, suicide risk

Pressure injury stage	Finding	Key nursing action
Stage 1	Non-blanchable erythema, skin intact	Offload completely, protect, no massage
Stage 2	Partial-thickness loss, shallow open ulcer or blister	Moist wound dressing (hydrocolloid/film)
Stage 3	Full-thickness, subcutaneous fat visible	Debride slough, fill dead space, nutrition support
Stage 4	Bone, tendon or muscle exposed	Surgical referral, osteomyelitis watch, pain control
Unstageable / DTI	Base obscured by slough or eschar; purple intact skin	Do not stage until base visible; reassess frequently

Where it is used

Government hospitals and district geriatric wards under NPHCE, Regional Geriatric Centres in medical colleges, and the National Centre for Ageing at AIIMS, New Delhi.
Corporate hospitals (Apollo, Fortis, Manipal, Max, Medanta, Narayana) — geriatric OPDs, memory clinics, ortho-geriatric fracture pathways and critical care, where most ICU and ortho patients are elderly.
Home health care and attender services (Portea, Care24, HCAH, Nightingales) — post-stroke and post-hip-fracture home nursing, catheter and tracheostomy care, wound care.
Old-age homes, day-care and NGOs — HelpAge India, Dignity Foundation, Nightingales Medical Trust, charitable homes; roles in nursing supervision, geriatric counselling and dementia day-care.
Community and public health roles — PHC/HWC staff nurse and Community Health Officer running weekly elderly clinics, home visits, NCD screening under NP-NCD, and linking families to pensions and the Maintenance Tribunal.
Palliative and hospice care — Kerala's community palliative network, Cipla Palliative Care Centre, Pallium India; plus teaching posts in B.Sc/M.Sc geriatric nursing and research in ageing (LASI — Longitudinal Ageing Study in India).

Interview questions

Q: Who is a senior citizen in India, and under which law? A: Any person aged 60 years or above, as defined in the Maintenance and Welfare of Parents and Senior Citizens Act, 2007.
Q: What is comprehensive geriatric assessment? A: A multidimensional, interdisciplinary evaluation of medical, functional, cognitive, emotional, social and environmental status that produces a coordinated care and follow-up plan.
Q: How do you distinguish delirium from dementia at the bedside? A: Delirium starts acutely over hours to days, fluctuates, clouds consciousness and destroys attention, and reverses when the cause is treated; dementia is insidious, progressive, and consciousness stays clear until very late.
Q: Why may an elderly patient with pneumonia have no fever or cough? A: Immunosenescence blunts the febrile and inflammatory response and the cough reflex weakens, so presentation is often confusion, a fall, anorexia or incontinence.
Q: Why do older people need smaller drug doses? A: Reduced lean body mass and body water, lower serum albumin, more body fat, reduced hepatic first-pass metabolism and reduced renal clearance raise drug levels and prolong half-life — hence "start low, go slow".
Q: What are the Beers criteria? A: An American Geriatrics Society list of medications that are potentially inappropriate in older adults — such as long-acting benzodiazepines, strong anticholinergics and chronic NSAIDs — used to review prescriptions; STOPP/START serves the same purpose in Europe.
Q: What is the first thing you do when an elderly inpatient falls? A: Do not move them immediately; assess level of consciousness, vital signs, pain and obvious injury or deformity, inform the doctor, document the incident, then investigate the cause and revise the fall-prevention plan.
Q: How often must a bed-bound elderly patient be repositioned, and what else prevents pressure injury? A: Usually every two hours (more often if the Braden score is low), with a pressure-redistributing mattress, 30° lateral tilt, heel offloading, dry clean skin, adequate protein and calories, and daily skin inspection — never massage a reddened bony prominence.
Q: Name the geriatric giants. A: Immobility, instability (falls), incontinence, intellectual impairment and iatrogenesis.
Q: When are physical restraints acceptable? A: Only as a last resort for immediate safety, after non-pharmacological alternatives fail, with a time-limited written order, informed family consent, frequent observation, release and skin checks, and full documentation.
Q: What are the types of urinary incontinence and one nursing measure for each? A: Stress — pelvic floor exercises; urge — timed/bladder training; overflow — relieve retention and treat BPH; functional — accessible toilet, commode and clothing that is easy to remove.
Q: How would you assess a possible case of elder abuse? A: Interview the older person alone, look for unexplained injuries, malnutrition, poor hygiene, missing money or medicines and a controlling caregiver; document objectively, report as per hospital policy and refer to the Maintenance Tribunal, police or Elderline 14567.

Common mistakes

Treating disease as "normal ageing" — dismissing depression, incontinence, hearing loss or memory change instead of assessing and treating them.
Calling every confused older patient "demented" and missing a reversible delirium from infection, dehydration, retention, hypoxia or drugs.
Judging renal function from serum creatinine alone; low muscle mass hides a greatly reduced creatinine clearance, so doses are given too high.
Mixing up ADL and IADL instruments, or quoting MMSE cut-offs without adjusting for education and literacy in Indian patients.
Reading the Braden Scale backwards — a low total means high risk — and scoring once on admission only.
Using restraints or a urinary catheter for staff convenience, and omitting the written order, consent and documentation.
Speaking loudly and in childish terms ("elderspeak"), or talking only to the relative, which breaches dignity, autonomy and consent.