Normal ageing versus pathology
The exam expects you to distinguish expected age-related change from findings that require intervention, because mislabelling pathology as normal ageing is a genuine patient safety failure. Normal changes include reduced skin elasticity, decreased subcutaneous fat, slower gastric emptying, reduced renal filtration, decreased visual accommodation, high-frequency hearing loss and slower but intact information processing.
Findings that are not normal ageing include confusion of new onset, weight loss without explanation, incontinence, depression, persistent pain and functional decline. Each of these deserves assessment rather than acceptance, and exam items frequently offer reassurance as an attractive but incorrect option.
Practical implications follow from the physiology. Reduced renal clearance and hepatic metabolism mean drugs accumulate, so older adults are more sensitive to sedatives, opioids, anticholinergics and benzodiazepines. Reduced thirst sensation raises dehydration risk. Thinner skin and reduced sensation raise pressure injury and burn risk from heating pads and hot water.
- •Expected: presbyopia, presbycusis, slower reaction time, drier skin
- •Not expected: acute confusion, incontinence, depression, unexplained weight loss
- •Sensitivity to sedatives and anticholinergics increases with age
- •Reduced thirst sensation makes dehydration easy to miss
Delirium, dementia and depression
Delirium is an acute, fluctuating disturbance of attention and cognition caused by an underlying physiological problem. The classic exam triggers are infection, especially urinary tract infection and pneumonia, hypoxia, dehydration, electrolyte disturbance, uncontrolled pain, medication effects and alcohol withdrawal. Because delirium is reversible when the cause is treated, identifying and reporting the change quickly is the priority.
Dementia develops gradually over months to years, is progressive and irreversible, and attention is relatively preserved until late stages. Care focuses on consistent routine, simple one-step directions, environmental cues, safety measures for wandering, and support for caregivers rather than reorientation arguments that increase distress.
Depression in older adults can mimic dementia, sometimes described as pseudodementia. It has a more definable onset, the client often complains about memory rather than concealing difficulty, and effort on testing is poor rather than performance being genuinely impaired. Screening and referral are appropriate exam answers.
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Hours to days | Months to years | Weeks to months |
| Course | Fluctuates, worse at night | Steadily progressive | Fairly constant |
| Attention | Markedly impaired | Preserved until late | Variable |
| Reversibility | Reversible with treatment | Irreversible | Treatable |
| Nursing priority | Find and report the cause | Safety and routine | Screen and refer |
Fall prevention and restraint rules
Fall risk assessment considers history of falls, gait and balance, muscle weakness, cognitive impairment, urinary urgency, visual impairment, orthostatic hypotension, footwear and medications including sedatives, antihypertensives and diuretics. Prevention is overwhelmingly environmental and behavioural: bed in the lowest position, brakes locked, call bell within reach, clutter and cords removed, adequate lighting including at night, non-slip footwear and scheduled toileting.
Restraints are a last resort with strict rules. Less restrictive alternatives must be attempted first and documented. A provider order is required, is time-limited, and cannot be written as a standing or as-needed order. The client is monitored frequently, the restraint is released regularly for circulation checks, range of motion, toileting and nutrition, and the knot must be a quick-release type secured to the movable part of the bed frame rather than to the side rail.
Side rails deserve special mention because four raised side rails may constitute a restraint and, in a confused client attempting to climb out, they increase the height and severity of a fall. Bed alarms, closer observation and moving the client nearer the nurses' station are usually the preferred answers.
- •Try less restrictive measures first and document them
- •Restraint orders are time-limited and never PRN
- •Secure ties to the movable bed frame with a quick-release knot
- •Four raised side rails can legally constitute a restraint
Pressure injuries, polypharmacy and functional care
Pressure injury prevention is a nursing-sensitive outcome the exam takes seriously. Reposition at-risk clients at least every two hours, use pressure-redistributing surfaces, keep skin clean and dry, manage incontinence promptly, maintain adequate protein and hydration, and avoid massaging reddened bony prominences. Inspect heels, sacrum, trochanters, elbows and the occiput in bedbound clients.
Polypharmacy compounds every other risk. A medication review at each transition of care is a legitimate intervention: look for duplicate therapy, anticholinergic burden, benzodiazepines, sedating antihistamines and medications no longer indicated. Teaching should include bringing all medications, including over-the-counter products and supplements, to every appointment.
Functional care means preserving independence rather than simply preventing harm. Encourage mobility, use assistive devices correctly, allow adequate time for tasks, protect dignity during personal care, and involve the client in decisions. Exam items rewarding autonomy-preserving answers are common, provided safety is not compromised.