Geriatrics

2 Contact Hours

Syllabus

Course Objectives

Upon completion of this activity, participants should be able to:

  1. Describe age related disease processes including chronic conditions
  2. Identify health maintenance and health promotion strategies for older adults
  3. Explain age related memory changes
  4. Define elder abuse
  5. Discuss end of life issues

Introduction

Both in the United States and worldwide, the geriatric or older adult segment of our population is growing. It is projected that by the year 2030, one in five Americans will be over the age of sixty-five. According to the 2017 Profile of Older Americans:  

  • Over the past 10 years, the population age 65 and over increased from 37.2 million in 2006 to 49.2 million in 2016 (a 33% increase) and is projected to almost double to 98 million in 2060.
  • The age 85 and over population is projected to more than double from 6.4 million in 2016 to 14.6 million in 2040 (a 129% increase).
  • Racial and ethnic minority populations have increased from 6.9 million in 2006 (19% of the older adult population) to 11.1 million in 2016 (23% of older adults) and are projected to increase to 21.1 million in 2030 (28% of older adults).
  • About one in every seven, or 15.2%, of the population is an older American.
  • Persons reaching age 65 have an average life expectancy of an additional 19.4 years (20.6 years for females and 18 years for males).
  • Older women outnumber older men at 27.5 million older women to 21.8 million older men.
  • About 28% (13.8 million) of noninstitutionalized older persons lived alone (9.3 million women, 4.5 million men).
  • Almost half of older women (45%) age 75 and over lived alone.
  • The need for caregiving increases with age. In January-June 2017, the percentage of older adults age 85 and over needing help with personal care (22%) was more than twice the percentage for adults ages 75–84 (9%) and more than six times the percentage for adults ages 65–74 (3%).

Life expectancy of older adults, defined as individuals who are sixty-five years of age and above, has increased due to several factors. These factors include: an increased emphasis on healthy lifestyle and health promotion across the lifespan, advances in medical science (including pharmacotherapeutics, genomics, medical and surgical interventions), and an emphasis on the use of best evidence-based practice to provide high quality patient centered care.

Age Related Disease Processes: Chronic Conditions and Geriatric Syndromes

According to the Centers for Disease Control and Prevention (2018) six common chronic diseases are prevalent in older adults:

  • Heart disease
  • Cancer
  • Chronic bronchitis or emphysema
  • Cerebrovascular accident (CVA)
  • Diabetes mellitus
  • Alzheimer’s Disease

Cardiovascular changes that occur with aging include a slight increase in heart size, particularly the left ventricle, a slower heart rate and an increase likelihood of arrhythmias such as atrial fibrillation. Artery walls thicken resulting in an increase in blood pressure. Common cardiovascular conditions seen in older adults include: angina, coronary artery disease, arteriosclerosis, aortic stenosis, heart failure, and hypertension.

Heart disease risk factors include hypertension elevated cholesterol, and obesity Prevention strategies are key to maintaining or improving cardiovascular health in the older adult. These strategies include: a heart healthy diet, regular exercise, and smoking cessation. Exercise can also reduce stress, prevent obesity, and control blood glucose levels (particularly important for older adults with cardiovascular disease and diabetes mellitus),

It is not uncommon for older adults to have two or more coexisting chronic conditions, Individuals who are eighty-five years old or above, also termed the old-old, are the fastest growing part of the older adult population. Older adults age eighty-five and above have more coexisting chronic diseases than individuals between the ages of sixty-five an eighty-four.

Geriatric syndromes are defined as clinical conditions commonly found in older adults that are associated with increased mortality and morbidity. Geriatric syndromes are associated with the aging process and are not a specific disease diagnosis in older adults. Occurrence of one or more geriatric syndrome(s) is associated with decreased functional abilities and increased need for assistance in accomplishing activities of daily living (bathing, dressing, grooming, toileting, mobility, eating, cooking, laundry, housekeeping, managing medications). The presence of one or more geriatric syndromes in an older adult impacts the older adult’s response to treatment, surgical recovery, functional abilities and overall health status. Chang, Goldstein and Dharmarajan (2017) note that the presence of geriatric syndromes impact both the patient’s prognosis and resilience when undergoing cancer treatments. Ulley and Abdelhafiz (2017) note that frailty and geriatric syndromes impact the course of treatment and prognosis for older adults with diabetes.

Geriatric syndromes include: urinary incontinence, cognitive impairment, delirium, falls, pressure ulcers, polypharmacy, and weight loss. According to Brown-O’Hara (2014), recent clinical practice and research have added sarcopenia (muscle atrophy associated with aging) to the list of geriatric syndromes. Sarcopenia impacts older adult’s mobility and susceptibility to falls. Both Maxwell and Wang (2017) and the British Geriatrics Society (2014) discuss the concept of frailty in older adults and its impact on the health status of older adults. Rather than using the term geriatric syndromes, the British Geriatrics Society (2014) identifies five frailty syndromes: falls, immobility, delirium, incontinence, and susceptibility to side effects of medications.

Experts in the field of Geriatrics advocate the use of best evidence-based practices and screening tools to assess for frailty and the presence of geriatric syndromes in older adults. According to Brown-O’Hara (2017) the five most commonly occurring geriatric syndromes are: pressure ulcers, incontinence, falls, functional decline, and delirium. The Braden Scale is one widely used evidence-based assessment tool for pressure ulcers. The Agency for Healthcare research and Quality (2014) has a comprehensive pressure ulcer toolkit for healthcare professionals available at https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool7b.html  This toolkit contains the Braden Scale and other evidence-based resources. The individual older adult’s skin condition needs to be assessed upon admission to a healthcare facility or home health care agency. The Braden Scale should be used in conjunction with prevention measures (turning and repositioning, adequate nutrition and hydration) and a skin inspection and assessment each shift in order to proactively address and treat any skin breakdown.

Lunsford and Wilson (2015) identified the following intrinsic risk factor for falls: low blood pressure or orthostatic hypotension, impaired mobility, limited endurance, foot problems (paresthesia, peripheral neuropathy), and impaired vision. Extrinsic factors that increase risk of falling include: poor lighting, clutter, scatter rugs, uneven or slippery floor surfaces. Lunsford and Wilson (2015) advocate the use of an evidence-based fall risk assessment tool to screen for fall risk in older adults, such as the Morse Fall Risk Assessment or the STRATIFY risk Assessment tool. In healthcare facilities, older adults who are identified as at risk for falls, wear armbands and have fall risk designated in their care plans and posted at their bedside.

Evidence-based screening and assessment tools for functional decline can be found at http://geriatrictoolkit.missouri.edu/funct/index.htm The Katz Index of ADL’s, available via a link at this website, is a six item screening tool which screens for six key aspects of activities of daily living (ADL’s): bathing, dressing, toileting, transfer, continence, and feeding. Deficits in one or more of these ADL’s indicate some degree of functional decline or deficit which must be considered in the interdisciplinary care planning process.

Another resource for current evidence-based geriatric nursing clinical resources, including screening tools, is the Hartford Institute for Geriatric Nursing www.consutgeri.org

The Frailty Index for Elders (FIFE), developed by Tocchi et al (2014), used to assess frailty risk in older adults can be found on the Hartford Institute for Geriatric Nursing website.

Health Maintenance and Health Promotion of the Older Adult

According to the Centers for Disease Control and Prevention (2018) Healthy People 2020 initiative, the overall goal for older adults is to improve the health, function and quality of life of older adults. Evidence has shown that older adults who engage in regular physical activity and strength training have a lower risk of injury than sedentary older adults. Smoking cessation can improve overall health in older adults. Other important health promotion strategies for older adults include regular health screenings for cancer, and receiving immunizations (annual influenza vaccination, pneumococcal vaccine, shingles vaccine, and other vaccines as needed based on chronic health conditions and or travel plans). Refer to the Centers for Disease Control and Prevention (2018) website  https://www.cdc.gov/vaccines/schedule/easy-to-read/adult.html for the current immunization schedules for older adults.

Age Related Memory Changes

Mild forgetfulness, such as misplacing items like glasses or car keys, or taking longer to learn new information, are memory changes that are considered a normal part of the aging process. When forgetfulness interferes with an individual’s ability to successfully manage activities of daily living, nurses who care for older adults need to consider whether the cause is reversible or irreversible.

Reversible causes of forgetfulness and memory change is older adults include memory loss related to a medical condition. Examples of medical conditions that are associated with memory and recall in older adults include: infection, head injury secondary to an accident or a fall, excessive alcohol intake, a poor diet (deficient in essential nutrients, vitamins or minerals), and/or medication side effects (prescription medications, over the counter medications, supplements, herbal remedies) and/or emotional problems.  For example, an older adult who has a urinary tract infection may exhibit signs of confusion and memory deficits which resolve once the urinary tract infection is diagnosed and treated. Emotional problems that can impact memory changes in older adults can be associated with stress, anxiety or depression. Major life changes such as retirement or the death of a spouse may cause an older adult to be more forgetful. Should this forgetfulness significantly impact the older adult’s ability to manage activities of daily living for two weeks or longer, a referral to a healthcare provider is indicated. The provider may prescribe a series of counseling sessions and/or medications for anxiety or depression. Once reversible causes of memory loss are addressed and treated memory improvement is noted.

Some older adults will experience mild cognitive impairment. According to the National Institute on Aging (2017) signs of mild cognitive impairment (MCI) include: losing things often, forgetting to attend events or go to appointments, and having more difficulty coming up with words than other older adults of the same age. Older adults with MCI are still capable of engaging in their normal daily activities. Some, but not all individuals who have mild cognitive impairment may subsequently develop Alzheimer’s Disease. The key point here is should the older adult or his/her family members notice continued decline in the individual’s thinking or memory a health care provider should be seen. It is recommended that older adults with MCI see a health care provider every six to twelve months.

Differences Between Normal Aging And Alzheimer's Disease

Normal Aging SignsSymptoms of Alzheimer's
Making a bad decision once in a whileMaking poor judgements and decisions a lot of the time
Missing a monthly paymentProblems taking care of monthly bills
Forgetting which day it is, and remembering laterLosing track of the date or time of year
Sometimes forgetting which word to useTrouble having conversation
Losing things from time to timeMisplacing things often and being unable to find them

Source: National Institute on Aging from https://www.nia.nih.gov/health/do-memory-problems-always-mean-alzheimers-disease


Elder Abuse

Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. The abuse occurs at the hands of a caregiver or a person the elder trusts. That caregiver may be a trusted family member, significant other or an individual staff member from a home health care agency, assisted living facility or long-term care facility.

Six frequently recognized types of elder abuse include:

  • Physical—This occurs when an elder experiences illness, pain, or injury as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning.
  • Sexual—This involves forced or unwanted sexual interaction of any kind with an older adult. This may include unwanted sexual contact or penetration or non-contact acts such as sexual harassment.
  • Emotional or Psychological—This refers to verbal or nonverbal behaviors that that inflict anguish, mental pain, fear, or distress on an older adult. Examples include name calling, humiliating, destroying property, or not letting the older adult see friends and family.
  • Neglect—This is the failure to meet an older adult’s basic needs. These needs include food, water, shelter, clothing, hygiene, and essential medical care.
  • Financial—This is illegally or improperly using an elder’s money, benefits, belongings, property, or assets for the benefit of someone other than the older adult. Examples include taking money from an older adult’s account without proper authority, unauthorized credit card use, and changing a will without permission.

Source: Centers for Disease Control and Prevention (2016). Understanding Elder Abuse Fact Sheet. Accessed from https://www.cdc.gov/violenceprevention/pdf/em-factsheet-a.pdf

The National Center on Elder Abuse identifies the following red flags for elder abuse:

  • Neglect 
  • Lack of basic hygiene, adequate food, or clean and appropriate clothing 
  • Lack of medical aids (glasses, walker, teeth, hearing aid, medications) 
  • Person with dementia left unsupervised 
  • Person confined to bed is left without care 
  • Home cluttered, filthy, in disrepair, or having fire and safety hazards •
  • Home without adequate facilities (stove, refrigerator, heat, cooling, working plumbing, and 
  • Untreated pressure “bed” sores (pressure ulcers)
  • Financial Abuse/Exploitation 
  • Lack of amenities victim could afford 
  • Vulnerable elder/adult “voluntarily” giving uncharacteristically excessive financial reimbursement/gifts for needed care and companionship 
  • Caregiver has control of elder’s money but is failing to provide for elder’s needs 
  • Vulnerable elder/adult has signed property transfers (Power of Attorney, new will, etc.) but is unable to comprehend the transaction or what it means
  • Psychological/Emotional Abuse 
  • Unexplained or uncharacteristic changes in behavior, such as withdrawal from normal activities, unexplained changes in alertness, other 
  • Caregiver isolates elder (doesn’t let anyone into the home or speak to the elder) 
  • Caregiver is verbally aggressive or demeaning, controlling, overly concerned about spending money, or uncaring
  • Physical/Sexual Abuse 
  • Inadequately explained fractures, bruises, welts, cuts, sores or burns 
  • Unexplained sexually transmitted diseases

Whenever a nurse or a health care provider has a patient encounter in a healthcare setting, including home care, he or she is required by law to report suspected elder abuse. All fifty states have mandatory elder abuse reporting requirements for nurses and healthcare providers. If the older adult victim of suspected abuse is in a life-threatening situation, call 911. To report suspected elder abuse in a nursing home or long-term care setting, contact the local long-term care ombudsman or call the Eldercare Locator at 1 800 677 1116. To report suspected abuse in the community setting, contact the local Adult Protective Services Agency or call the Eldercare Locator at 1 800 677 1116.


End of Life Issues

A key component for older adults dealing with end of life concerns and decisions is having an advanced directive in place. Before completing an advance directive, an individual must make several important health care decisions to specify whether or not he/she wants: CPR (cardiopulmonary resuscitation, a ventilator, artificial nutrition (tube feedings), artificial hydration (intravenous fluids) and/or comfort care (pain medications, medications for anxiety, antiemetic medications, managing dyspnea, emotional or spiritual support).

There are two main elements in an advance directive: a living will and a durable power of attorney for health care. There are also other documents that can supplement the individual’s advance directive. The individual can choose which documents to create, depending on how he or she wants decisions to be made. These documents include:

  • Living will
  • Durable power of attorney for health care
  • Other advance care planning documents

Living will: A living will is a written document that helps you tell doctors how you want to be treated if you are dying or permanently unconscious and cannot make your own decisions about emergency treatment.  

Durable power of attorney for health care:  A durable power of attorney for health care is a legal document naming a healthcare proxy, someone to make medical decisions for you at times when you are unable to do so. Your proxy, also known as a representative, surrogate, or agent, should be familiar with your values and wishes. This means that he or she will be able to decide as you would when treatment decisions need to be made. A proxy can be chosen in addition to or instead of a living will. Having a healthcare proxy helps you plan for situations that cannot be foreseen, like a serious auto accident.

Other advance care planning documents: You might also want to prepare documents to express your wishes about a single medical issue or something not already covered in your advance directive. A living will usually cover only the specific life-sustaining treatments discussed earlier. You might want to give your healthcare proxy specific instructions about other issues, such as blood transfusion or kidney dialysis. This is especially important if your doctor suggests that, given your health condition, such treatments might be needed in the future.  Medical issues that might arise at the end of life include:

  • DNR orders
  • Organ and tissue donation
  • POLST and MOLST forms

A DNR (do not resuscitate) order tells medical staff in a hospital or nursing facility that you do not want them to try to return your heart to a normal rhythm if it stops or is beating unsustainably using CPR or other life-support measures. Sometimes this document is referred to as a DNAR (do not attempt resuscitation) or an AND (allow natural death) order. Even though a living will might say CPR is not wanted, it is helpful to have a DNR order as part of your medical file if you go to a hospital. Posting a DNR next to your bed might avoid confusion in an emergency situation. Without a DNR order, medical staff will make every effort to restore your breathing and the normal rhythm of your heart.

A similar document, called a DNI (do not intubate) order, tells medical staff in a hospital or nursing facility that you do not want to be put on a breathing machine. A non-hospital DNR order will alert emergency medical personnel to your wishes regarding measures to restore your heartbeat or breathing if you are not in the hospital.

Organ and tissue donation allows organs or body parts from a generally healthy person who has died to be transplanted into people who need them. Commonly, the heart, lungs, pancreas, kidneys, corneas, liver, and skin are donated. There is no age limit for organ and tissue donation. You can carry a donation card in your wallet. Some states allow you to add this decision to your driver's license. Some people also include organ donation in their advance care planning documents.

At the time of death, family members may be asked about organ donation. If those close to you, especially your proxy, know how you feel about organ donation they will be ready to respond. There is no cost to the donor's family for this gift of life. If the person has requested a DNR order but wants to donate organs, he or she might have to indicate that the desire to donate supersedes the DNR. That is because it might be necessary to use machines to keep the heart beating until the medical staff is ready to remove the donated organs.

POLST and MOLST forms provide guidance about your medical care preferences in the form of a doctor's orders.  The POLST form (Physician Orders for Life-Sustaining Treatment) or MOLST form (Medical Orders for Life-Sustaining Treatment) is created and implemented when you are near the end of life or critically ill and know the specific decisions that might need to be made on your behalf. These forms serve as a medical order in addition to your advance directive. They make it possible for you to provide guidance that healthcare professionals can act on immediately in an emergency. A number of states use POLST and MOLST forms, which are filled out by your doctor or sometimes by a nurse practitioner or physician's assistant. The doctor fills out a POLST or MOLST after discussing your wishes with you and your family. Once signed by your doctor, this form has the same authority as any other medical order. Check with your state department of health to find out if these forms are available where you live.

Once you have decided what to include in you advanced directive, the appropriate legal forms must be completed. To obtain Advanced Directive forms that are recognized in the state where you (and your older adult patients) live contact your local Area on Aging. You can find your area agency phone number by calling the Eldercare Locator toll-free at 1-800-677-1116 or by accessing their website https://eldercare.acl.gov.

Palliative care uses an interdisciplinary team approach to provide care for older adults diagnosed with one or more chronic diseases; with a focus on disease management and pursuing a cure where possible. Gabbard and McNabney (2018) advocate for dual training in geriatric medicine and palliative care to best meet the health care needs of a growing population of older adults, the majority of whom succumb to death from chronic illness.

The decision to begin hospice care is another important aspect of end of life care. Hospice care provides comfort care and symptom management for patients at the end of life. An interdisciplinary team approach to care is also used by hospice. To qualify for hospice the patient’s health care provider has determined that he/she has a terminal diagnosis with a life expectancy of six months or less. When hospice patients are cared for at home, Medicare guidelines allow for a short-term respite admission to an inpatient hospice or nursing home. This gives the family members a break from the 24-7 care giver responsibilities. A hospice respite admission is typically five days,

The ultimate goal for end of life care is termed the good death. According to Meier et al (2016), there are eleven core themes that constitute a good death. These core themes include: respecting the individual’s specified preferences for the dying process, pain free death. spirituality and religion, emotional well-being, life completion, complying with treatment preferences, death with dignity, including family perspectives and family presence, quality of life, relationship with the health care provider, and other. Of particular concern to patients at the end of life is maintaining independence and not being perceived as a burden to the family.

Powell and Hulkower (2017) express two key components of a good death as: providing adequate pain relief in terms of palliative sedation to assure a pain free death, respecting and implementing the decisions of the dying patient. While respecting the documented wishes of the dying patient, his or her healthcare surrogate, and family members, nurses and other members of the interdisciplinary health care team must be cognizant of family dynamics and the stress that the impending death of a loved one places upon family members. When conflict arises between family member(s) and the dying patient it may be necessary to involve the hospital ethics committee in end of life care decisions. In addition, the ethical obligation for health care professionals to do no harm must ever present in the minds of nurses caring for patients and families at the end of life.


Resources


The websites listed below provide a ready resource for the nurse to access the most current information to provide evidence-based geriatric nursing care. Many of the resources listed below can be accessed by the nurse at the bedside or point of care.

Alzheimer’s Association

https://alz.org

This website provides information on Alzheimer’s Disease diagnosis, treatment. Risk factors and prevention for both the heath care consumer and the health care professional.

American Geriatrics Society

https://www.americangeriatrics.org

This website contains evidence-based resources, including clinical guidelines and eight Geriatrics for Specialty Residents toolkits. Mobile apps, pocket cards and patient resources are also available on this website.

Medline Plus: Health Topics

https://medlineplus.gov/healthtopics.html

This website provides up to date evidence-based resources on health and wellness topics, diseases and disorders. Links to journal article references and abstracts from MEDLINE/PubMed are included.

National Institute on Aging

https://www.nia.nih.gov

This website contains information for health care consumers (older adults, family members, care givers), and for healthcare professionals. Information for health care consumers is available in English and Spanish. Health care professionals can access clinical practice tools, training materials, research resources and patient teaching materials on this website.

Hartford Institute for Geriatric Nursing

https://consultgeri.org

This website contains evidence-based geriatric assessment tools for nurses, e-learning resources, and videos. A mobile app is also available for nurses who want to access these resources on their mobile phones or tablets for use during a patient care encounter.


Conclusion

With a growing population of older adults, many of whom will require health care in a variety of settings, it is critical that nurse’s have the knowledge and resources needed to provide evidence-based geriatric nursing care. An understanding of age related changes, geriatric syndromes, health promotion strategies, elder abuse and end of life care; along with current clinical practice guidelines is essential to the older adult’s ability to maintain an optimal level of functioning and quality of life.



References


Administration for Community Living (April 30, 2018). 2017 Profile of Older Americans

Agency for Healthcare Research and Quality (2014). Preventing Pressure Ulcers in Hospitals.

Balducci, L. (2014). Chapter 63 E. Special Populations - Cancer in the Elderly: Biology, Prevention, and Treatment in Abeloff’s Clinical Oncology Fifth Edition, 904-913

British Geriatrics Society (June 11, 2014). Comprehensive Geriatric Assessment

British Geriatrics Society (June11, 2014), Recognizing Frailty Syndromes

Brown-O'Hara, P. (2014). Geriatric Syndromes and Their Implications for Nursing. Journal of Legal Nurse Consulting, 25(2), 8-11.

Centers for Disease Control and Prevention (2018). Adult Immunization Schedules 

Centers for Disease Control and Prevention (June 1, 2018). Healthy People 2020 Older Adults

Centers for Disease Control and Prevention (2016). Understanding Elder Abuse Fact Sheet

Chang, S., Goldstein, N. E., & Dharmarajan, K. V. (2017). Managing an Older Adult with Cancer: Considerations for Radiation Oncologists. Biomed Research International, 1-13. doi:10.1155/2017/1695101

Gabbard, J., & McNabney, M. (2018). The Case for Dual Training in Geriatric Medicine and Palliative Care: The Time is Now. American Journal of Hospice & Palliative Medicine, 35(2), 364-370. doi:10.1177/1049909117696251

Hartford Institute of Geriatric Nursing (n. d.). Consult Geri a clinical website of the Hartford Institute for Geriatric Nursing.  

Medline Plus (February 1, 2017). Health Topics. 

Jonna, S., Chiang, L., Liu, J., Carroll, M., Flood, K., &  Wildes, T. M. (2016). Geriatric assessment factors are associated with mortality after hospitalization in older adults with cancer. Supportive Care in Cancer, 24(11), 4807-4813. doi:10.1007/s00520-016-3334-8

Kim, J. & Miller, S. (2017). Geriatric Syndromes: Meeting a Growing Challenge. Nursing Clinics of North America, 52 (3): ix-x.

Lunsford, B & Wilson, L. D, (2015). Assessing Your Patient’s Risk for Falling, American Nurse Today, 10 (7)

Martin L, (August 22, 2016). Aging Changes in the Heart and Blood Vessels

Maxwell, C, & Wang, J. (2017). Understanding Frailty: A Nurse’s Guide. In Geriatric Syndromes, Nursing Clinics of North America, 52 (3): 349-361.

Medline Plus (February 1, 2017). Health Topics.

Meier, E. A, et al (2016). Defining a Good Death (Successful Dying): Literature Review and a Call for Public Dialog. American Journal of Geriatric Psychiatry, 24 (4), 261-271.  

Mueller, Y. K. et al (2018). Performance of a brief geriatric evaluation compared to a comprehensive geriatric assessment for detection of geriatric syndromes in family medicine: a prospective diagnostic study.

National Center on Elder Abuse (2015). Red Flags of Abuse

National Institute on Aging (January 15, 2018), Advanced Care Planning: Healthcare Directives.

National Institute on Aging (January 24, 2018). Do Memory Problems Always Mean Alzheimer’s Disease?

National Institute on Aging (May 17, 2017). What is Mild Cognitive Impairment?

Medicare: How Hospice Works (n. d.).

Powell, T & Hulkower, A. (2017). A Good Death. Hastings Center Report 47 (1), 28-29.

Prost, E, (March 19, 2017). Examination toolkit. University of Missouri, School of Health Professions. School of Physical Therapy.

Tocchi, C., Dixon, J., Naylor, M., Sangchoon. J., & McCorkle, R. (2014). Development of a Frailty Index for Older Adults: The Frailty Index for Elders. Journal of Nursing Measurement, 22 (2), 223-240.

Ulley, J. & Abdelhafiz, A. (2017). Frailty Predicts Adverse Outcomes in Older People with Diabetes. The Practitioner, 261 (1), 17-20.




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