Nursing Models of Care and care for The Elderly

Running head: NURSING MODELS OF CARE AND CARE FOR THE ELDERLY
NURSING MODELS OF CARE AND CARE FOR THE ELDERLY
Name of the Student:
Name of the University:
Author note:

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Introduction
The debilitating physiological processes of ageing increase the risk of a number of
chronic and lifestyle complications in the elderly, especially in response to the occurrence of life
limiting health conditions or disease. One such condition is the cardiovascular deficit of ischemic
heart disease and stroke which in turn, increases susceptibility of complications like vascular
dementia, psychological conditions and increased risk of falls in the elderly (Koh, Ahn, Yoo &
Shim, 2018). The purpose of this paper is to first discuss in detail the relevant contributing and
ageing theoretical factors facilitating the concerned disease pathology in Mr. Graham.
Discussion
Pathophysiology: Ischemic Heart Disease, Stroke and resultant Vascular Dementia
Existing cardiovascular conditions, such as atherosclerosis are largely associated with
stroke-inducing pathological mechanisms of thrombosis. High levels of cholesterol in the blood
or hypercholesterolemia results in the deposition of fatty streaks across the endothelial lining of
the blood vessels which in turn, causes irritation and facilitates the functioning of the
immunological system (Kurisu & Yenari, 2018). Such processes activate the production of
macrophages which further stimulate the release of pro-inflammatory substances such as
cytokines and interleukins, which in turn causes oxidation of low density lipoproteins (LDLs) in
the fatty streaks and resultant damage and atrophy of macrophages and endothelial cell lining.
Prolonged action of these inflammatory actions result in continued deposition of atrophied cells,
platelets and oxidized fat particles which coalesce together to form a clot or a thrombus. Such
thrombosis pathologies and associated production of thrombus contributes to thromboembolism
– a condition where these clots may dislodge and travel to cerebral arterial regions causing a

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disturbance in the normal blood circulation of the brain and resultant ischemic stroke (Anrather,
2017).
Inadequate blood flow to the cortex facilitates a range of pathological processes, such as:
decrease in the synthesis of proteins, depleted intracellular stores of energy, depolarization of
cerebral membranes and resultant release of potassium across the extracellular membranes. Such
processes are followed by increased rates of glycolysis and resultant increased rates of acidosis
which enhances the depolarization process and disrupts the regulation of calcium ion channels
(Paquet et al., 2018). The increased rate of circulating calcium across cerebral arteries and
membranes activates the function of protein kinases which in turn, causes phosphorylation and
proteolysis of cerebral proteins and increase in the rates of arachidonic acid production (Kalaria,
2018). High rates of arachidonic acid facilitates the formation of free radicals and nitric oxide
synthase which contributes to increased secretion and facilitation of the vascular-endothelial
damaging effects of nitric oxide resulting disruption of the integrity of the cytoskeleton and
functioning of mitochondria lining the cortex. Such processes thus contribute to the disruptive
loss of neuronal and cognitive functioning of the brain, and are the key ischemic pathologies
underlying the emergence of neurodegenerative conditions like vascular dementia – as
demonstrated by Mr. Graham (Vijayan, Kumar, Bhatti & Reddy, 2017).
Additionally, the increased secretion of calcium ions facilitates the production of
glutamate in the cerebral cortex which in turn stimulates activation of the N-methyl-Daspartate
(NMDA) receptor. Such pathologies contribute to increased permeability of sodium and swelling
of cebral cells paving the way for disruption in the regulation of neurotransmitter secretions like
dopamine, serotonin, norepinephrine and serotonin and gamma amino butyric acid (GABA).
Disruption in such inhibitory and excitatory neurotransmitters as a result of ischemic stroke, is a

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key contributor of mental health conditions like depression and anxiety, as observed in Mr.
Graham (Kalaria, 2018).
Contributing Factors
Nutritional factors are one of the major contributors and facilitators of cardiovascular
deficits like stroke, of which, lipid intake is the most concerning. From the case study, it can be
understood that Mr. Graham has demonstrated hypercholesterolemia or high levels of cholesterol
in the blood. This may be indicative of a high lipid diet consumption and is major contributor
since increased serum lipid accumulation due to diet facilitates fatty streak accumulation in the
endothelial lining and a cascade of atherosclerotic and ischemic pathologies contributing to
stroke (Watanabe et al., 2019). Additionally, vitamin D has been known to ensure maintenance
of regular endovascular functioning via regulation of vascular endothelial processes. Thus its
deficiency, as demonstrated by Mr. Graham, can be considered as a key contributing factor of his
recent ischemic stroke diagnosis (Berghout et al., 2019). Additionally, a deficiency of B
vitamins, namely vitamin B9 and B12 – the latter especially since Mr. Graham has demonstrated
a deficiency – has been linked to high levels of homocysteine in the blood which in turn has been
evidenced to facilitate inflammation and oxidative stress, impairment in the functioning of the
endothelial lining and resultant synthesis of thrombus – the key contributor of ischemic stroke.
Thus, it is likely that vitamin B12 deficiency is a key contributor of ischemic stroke in Mr.
Graham (Ahmed et al., 2019).
Impaired circulation to the cortex and associated neurological changes are not merely
contributed by nutritional, but also due to cardiovascular disease factors. Mr. Graham has
demonstrated a history of cardiovascular complications like atherosclerosis and atrial fibrillation.
Atherosclerosis is largely associated with the progressive accumulation of thrombus within the

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endothelial lining which facilitates the oxidation, inflammation and deposition of atrophied lipid
and immune cell fractions further contributing the hardened and fibrous plaque formation. Such
cardiovascular diseases processes thus contribute to thromboembolism where the developed clot
may dislodge and undergo circulation to the cerebral cortex, thus causing decreased blood
circulation and neurological changes as mentioned above (Bekwelm et al., 2016).
In addition to the above disease and nutritional factors, it is worthwhile to note that the
elderly like Mr. Graham are prone to a range of endocrinal and metabolic changes as a result of
ageing. With ageing, cardiovascular baroreceptors and hormones like vasopressin and
aldosterone lose their functioning which in turn contribute to reduced cardiac output and inability
to regulate high blood pressures, thus facilitating stroke. Additionally ageing is accompanied
with a catabolic loss of lean muscular tissue, cellular atrophy and loss of mitochondrial
functioning which in turn, contributes to reduced metabolic rates and tendency to engage in
decreased levels of physical activity (Coco, Lopez & Corrao, 2016). Coupled with these are age
associated loss of gastrointestinal functioning such as decreased gastric acid and digestive
enzyme secretion. These in turn, hinder the absorption and metabolism of nutrients like sugars
and fats thus contributing to increased circulation of free fatty acids in the blood and resultant
lipid endothelial accumulation. Aging is also associated with a loss of neuronal and sensory
functioning resulting in increased risk of neurocognitive impairments. Thus, it is likely that Mr.
Graham’s age is a major contributor of ischemic heart disease and vascular dementia
(Arvanitakis, Capuano, Leurgans, Bennett & Schneider, 2016).
Theory of Ageing
One of the most significant theories of ageing relevant to Mr. Graham’s medical
condition is the neuroendocrine theory of ageing. According to this theory, the simultaneous

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biochemical reactions induced by hormones coupled with hypothalamic response to the same,
are the major determinants of normal cell, tissue and organ functions in the body. Ageing is
associated with a decreased sensitivity in hormonal functioning and the ability of the
hypothalamus to respond to such functions. This theory can be well related to the case of Mr.
Graham, since an age-associated loss in the functioning of cardiovascular and diuretic hormones
such as vasopressin and aldosterone are largely associated with increased age-associated changes
in reduced cardiac output and inability to regulate high blood pressure (Jagota & Thummadi,
2017)
Additionally, the wear and tear theory of ageing also demonstrates applicability to the
current medical condition of Mr. Graham. According to this theory, the functioning of tissues,
organs and cells in the body encounter degradation as an individual gradually ages. Such
theoretical perspectives can be well related to the case of Mr. Graham, since age associated loss
digestion, lipid metabolism, neuronal cell functioning and sensory abilities of perception and
vision are largely associated with an increased risk of ischemia and vascular dementia in the
elderly (Horvath & Raj, 2018).
Lastly, another theory which holds relevance to the case of Mr. Graham is the free radical
theory of ageing. According to this theory, a number of lifestyle and existing comorbidities are
associated with an increased production of free radicals, increased rate of inflammation and
oxidative stress. These in turn, increase the risk of a variety of disease complications which
progress with ageing (Birch‐Machin & Bowman, 2016). Indeed, the increased accumulation of
lipids in the blood vessels – as evidenced by hypercholesterolemia, atrial fibrillation and
atherosclerosis in Mr. Graham – increase the deposition of inflammatory pigment lipfuscin and
also facilitate the functioning of pro-inflammatory prostaglandins and cytokines. Such

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mechanisms increase oxidative stress and the risk of ischemic heart disease, stroke and vascular
dementia as evidenced by Mr. Graham (Pomatto & Davies, 2018).
Medications: Mechanisms and Side Effects
A key medication which Mr. Graham has been prescribed for regulation of this ischemic
disease and stroke is warfarin. Warfarin is an anti-coagulant and is used commonly for the
regulation of excessive production of blood clots – a key contributor to ischemic heart disease
and stroke. Warfarin exerts its mechanism of action by inhibiting the functioning of vitamin K
epoxide reductase complex 1 (VKORC1) – a key enzyme required for regulating the functioning
of Vitamin K responsible for blood coagulation in the body (Li et al., 2018). This mechanism of
action will in turn, hinder and inhibit the formation of new clots within the body as well as
prevent enlargement in existing clots which may facilitate the pathological mechanism of
atherosclerosis and stroke. These mechanisms in turn, will reduce the risk of Mr. Graham
suffering from another episode of stroke and dementia. The key side effects associated with
warfarin however are: increased bleeding, coughing and vomiting blood, increased head or
stomach aches and joint pains (Li et al., 2017).
Additionally, Mr. Graham has been prescribed with diazepam - a benzodiazepine which
has been used commonly for the treatment of symptoms of anxiety. Diazepam exerts its
mechanism of action by stimulating the production of an inhibitory neurotransmitter gamma
aminobutyric acid (GABA). This in turn, facilitates sedation, anxiolytic and anticonvulsant
effects and thus, inhibition of anxiety and depression symptoms which may be associated with
Mr. Graham’s dementia (Pringle, Warren, Gottwald, Cowen & Harmer, 2016). Additionally, the
sedative effects of benzodiazepines like diazepam have been evidenced to induce myocardial
depression and resultant reduction of hypertension – a key contributing factor of ischemic stroke

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in Mr. Graham. However, prominent side effects include feelings of agitation, depression, mood
swings, sleeplessness, confusion and increased risk of panic attacks (Fogari et al., 2019).
Impact and Ethical/Legal Issues
One of the most significant impacts stroke, dementia and falls in the elderly, is the
gradually loss of ability to engage in ADL which in turn, contributes to a state of disability and
increased dependence. Increased dependence and disability are often perceived negatively by the
elderly where they are likely to feel that they are a liability to their families. This in turn,
translates to increased social isolation, loss of self-esteem and loss of psychological wellbeing –
as demonstrated by Mr. Graham’s depression and anxiety. In addition to the loss of wellbeing,
the inability to engage in ADL due to falls demonstrates a gross inability of the healthcare
organization to facilitate the elderly individual to comply with the ethical need of autonomy
(Hajek & König, 2017). Autonomy is the ability of individuals to exercise control over their lives
in terms of healthcare decision-making and daily life functioning (Hajek & König, 2017). Patient
autonomy is the most important prerequisite of the nursing need to adhere to progression
standard 1 of patient centered care postulated by the Nursing and Midwifery Board of Australia
(NMBA, 2016). These issues In Mr. Graham also raise legal issues in the form of violation of the
Age Discrimination Act 2004 which states that all individuals are entitled to equitable access and
quality of care irrespective of their age (McGann et al., 2016).
Model of Care: Strategies and Resources for Management
Thus, considering the lack of medication compliance and risk of mental health issues,
administrating of a person centered model of care like the Eden alternative would be the most
effective care model of Mr. Graham’s care management. According to the Eden Alternative,
every individual thrives best in habitats suited to their needs and thus, the ability to master

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control in their natural habitats and lives, are closely associated with positive wellbeing. Thus, as
per this model, Mr. Graham’s care plan must aim to support his independence, improve the
quality of his life, empower and enhance his dignity and honor his personal choices (Wahyuni,
Pratiwi & Fidyastria, 2017). A beneficial way to integrate personal needs and goals of Mr.
Graham in his care plan as per is model of care is the inclusion of his favorite sport golf.
Engaging in any form of aerobic, strength or weight bearing activity has been evidenced to
enhance lipid metabolism and cardiovascular functioning and thus risk of stroke in the elderly
(Teixeira et al., 2016). Lack of adequate health literacy is one of the greatest contributors of poor
health across the elderly. Considering Mr. Graham’s love for reading, a beneficial person
centered strategy would involve teaching or providing educational resources on stroke
prevention strategies and consumption of a diet low in fat and rich in B and D vitamins which in
turn, can increase compliance and health literacy (Brooks, Ballinger, Nutbeam, & Adams, 2017).
Establishment of an environment devoid of loneliness and familial contact are the principles of
the Eden alternative and have been evidenced to enhance self-management skills of healthcare in
the elderly. Thus, development of a personal improvement plan in collaboration with his
daughters can prove to be useful in identifying his strengths, setting goals of a medication plan
and exercising desirable therapeutic activities like memory enhancing cross-word puzzles can
assist in the alleviation of dementia, depression and anxiety and long term compliance and
wellbeing in Mr. Graham (Nash, 2019).
Conclusion
Considering the concerns of lack of medication compliance and prevalent psychological
issues, there is a need to enhance Mr. Graham’s skills of empowerment and self-management to
ensure long term wellbeing. To conclude, implementation of patient centered models and

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multidisciplinary approach to care can be beneficial in encouraging long term wellbeing in Mr.
Graham.

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