Adult Health (Chronic Illness and Older Adults)

Age-Related Psychologic Changes

- Age-related changes affect every body system. - These changes are normal and occur as people age. - The age at which specific changes occur differs from person to person and within the same person. > For instance, a person may have gray hair at age 45 but relatively unwrinkled skin at age 80. - It is important for you to assess for age-related changes in patients.

Nursing Implementation Acute Care

- Frequently, the hospital is the first point of contact for older adults and the formal health care system. - Conditions that most commonly result in hospitalization include falls, dysrhythmias, heart failure, stroke, fluid and electrolyte imbalances (e.g., hyponatremia, dehydration), pneumonia, urosepsis, and hip fractures. - Older adults are often hospitalized with multiple system problems. - The outcome of hospitalization for older adults varies. - Of particular concern are problems of high surgical risk, acute confusional state, health care-associated infection (HAI), and premature discharge with an unstable condition.

Nursing Implementation: Acute Care Care Transitions

- Many older adults are considered to be in an unstable condition at the time of a care transition to another setting. > Frail older adults and patients over 85 years of age are particularly vulnerable. > Most of these patients are transitioned under Medicare regulations that require a registered nurse or qualified person to develop a plan for discharge. > Safe, effective, and efficient care transitions are most successful when interdisciplinary team members work together to coordinate care.

Trajectory of Chronic Illness

- Most chronic illnesses may be viewed as a trajectory with overlapping phases, in which an individual moves from a level of optimum functioning, with the illness in good control, to a period of instability where they may need assistance. - Corbin and Strauss identified seven tasks of those who are chronically ill: 1. Managing and preventing crises 2. Controlling symptoms 3. Following the treatment regimen 4. Reordering time 5. Adjusting to disease changes 6. Preventing social isolation 7. Attempting to normalize interactions with others

Trajectory of Chronic Illness .

- Trajectory of Chronic Illness > Controlling symptoms * Onset, duration, severity > Reordering time * Usual schedules may need to be adjusted. - Learning to control symptoms so that desired activities may be continued is an important task for those with chronic illnesses. > Some individuals redesign their lifestyle by learning to plan ahead. > Others redesign their living space. > The patient and family or caregiver need to learn about the pattern of symptoms so that lifestyle can be changed accordingly. - Patients with chronic illness often report having too much or too little time. - Treatment plans that require large amounts of time for the patient, as well as caregivers, may necessitate scheduling changes or eliminating other activities.

Chronic Illness.

- Trajectory of Chronic Illness > Most chronic illnesses have the potential of an acute exacerbation of symptoms. > Preventing and managing a crisis > Most chronic illnesses have the potential of an acute exacerbation of symptoms. > Major task for both the patient and caregiver is to learn to prevent or manage the crisis. 1. The patient and caregiver need to understand the potential for the crisis to occur. 2. They need to know ways to prevent or modify the threat. - Often involves adherence to prescribed treatment - Need to know signs and symptoms of the onset of a crisis which can occur suddenly or slowly - Need to have a plan to manage the crisis that is likely to occur

Chronic Illness

> Illness can be categorized as either acute or chronic. > Chronic illnesses are those that are prolonged, do not resolve spontaneously, and are rarely cured completely. > Chronic diseases account for 70% of all deaths in the United States. > As the population ages, more older adults are living with more than one chronic illness and experience limitations in physical functioning, work productivity, and quality of life. - Almost one out of 10 Americans experiences major limitations in ADLs. - The lives and identities of patients, families, and caregivers can be profoundly affected. - A significant portion of U.S. health care dollars go toward the treatment of chronic illnesses. > Other societal changes contributing to the increase in chronic illnesses include - insufficient physical activity - lack of access to fresh fruits and vegetables - tobacco use - alcohol consumption.

Biologic Aging

> Stress > Cancer > CVD > Diabetes > Obesity VS > Exercise > Good Nutrition > Social Support > Stress management > Coping resources - Aging is defined as a progressive loss of physiologic function. > The exact etiology of biologic aging is unknown. > Genetics, diet, and environment contribute to the process of aging. > Biologic aging is a balance of positive (healthy diet, exercise, social support) and negative (smoking, obesity) factors. - Research is directed at increasing both life span and quality of life. - The hope is for new anti-aging therapies that slow down or reverse changes leading to illness and disability. > Calorie restriction has been shown to significantly extend life span in lab studies with rodents. > Calorie restriction in humans helps decrease issues associated with aging including obesity, diabetes, HTN, and cancer. > Studies of nutrients such as beta-carotene, selenium, vitamin C, and vitamin E are as yet inconclusive.

Social Services for Older Adults

Area Agency on Aging - A network of services supports older adults both in the community and in health care facilities. - In the United States, most older adults are the beneficiaries of at least one social or governmental program. > The Administration on Aging (AoA), which is part of the Department of Health and Human Services, is the federal agency responsible for many older adult programs. > Funding from the AoA is funneled to state and local Area Agencies on Aging. - Social support can involve family, the community, religious organizations, social welfare agencies, health facilities, and government support (Medicaid and Medicare).

Nursing Implementation: Acute Care Medication use

Drug Therapy: Common causes of medication errors by older adults: - Decreased vision - Forgetting to take drugs - Use of non prescribed OTC drug - use of medications prescribed for someone else - lack of financial resources to obtain prescribed medication - failure to understand instructions or importance of drug treatment - refusal to take medication because of undesirable side effects - Medication use in older adults requires thorough and regular assessment, care planning, and evaluation. - Older adults may have difficulty due to cognitive impairment, altered sensory perceptions, limited hand mobility, and the high cost of many prescriptions. - Non-adherence to medication regimens is common. - Four of 10 older adults are unable to read prescription drug labels, and two-thirds are unable to understand the health information that is provided to them. - Polypharmacy, overdose, and addiction to prescription drugs are recognized as major causes of illness in older adults.

Chronic Illness Treatment regimens

Trajectory of Chronic Illness - Carrying out prescribed treatment regimen - Treatment regimens vary in degree of difficulty and the impact that they have on the person's lifestyle.

Nursing Implementation Acute Care-Depression

- Acute Care — Depression > Not a normal part of aging > 20% of suicides > Co-occurs with medical conditions > Geriatric Depression Scale

Acute Care — Use of restraints

- Acute Care — Use of restraints > Physical restraints > Chemical restraints > Used to ensure safety ONLY > Least restrictive approach > Highly regulated

Acute Care-Sleep

- Adequacy of sleep is often a concern for older adults because of altered sleep patterns. - Older people experience a marked decrease in deep sleep and are easily aroused. - Many older adults report difficulty initiating sleep, maintaining prolonged sleep, and feeling 'un-refreshed' following sleep.

Care Alternatives for Older Adults..

- Adult day care centers provide social, recreational, and health-related services to individuals in a safe community-based environment. > Daily supervision, social activities, social interaction, and ADL assistance for cognitively impaired and those unable to independently perform ADLs - Adult day health centers are similar but for people with disabilities who need a higher level of care, such as health monitoring, therapeutic activities, ADLs training, and personal services. - Both centers may provide respite, continued employment for caregivers, and delayed institutionalization. - Centers are regulated by the state. - Costs are not covered by Medicare but are tax-deductible. - Families are often unaware of these services or how to find appropriate placement for their older adult.

Attitudes Toward Aging

- Aging is normal. > Older adults have diverse characteristics. > Care should not be based on age alone. > Myths and stereotypes can lead to poor care. > Ageism leads to discrimination and disparate care.

Older Adults

- Aging population > Surviving acute illness > Living with chronic illness > Becoming more educated and resourceful > More ethnically diverse

Special Older Adult Populations

- Chronically Ill Older Adults > Incidence of chronic illness triples after age 45. - Older Adult Women > Double jeopardy -> An aging body -> Being a woman

Medicaid and Medicare

- Daily documentation is complex and critical and must show that a patient is improving in function. - Four options for coverage under Medicare: > Part A covers inpatient hospital care and partially covers skilled nursing facility care, hospice, and home health care. Funded through payroll taxes, so available to everyone for "free" > Part B partially covers outpatient care, physician's services, home health care, and some preventive services such as mammograms. Has a monthly premium and annual deductible; is optional > Part C or "MA Plans" (Medicare Advantage Plans) are offered by private companies approved by Medicare. > Part D provides a prescription drug benefit. Has a yearly deductible, monthly premium, and copayment Lower-income patients may qualify for extra help. > Medicare does not cover long-term care, custodial ADLs or IADLs care, dental care or dentures, hearing aids, or eyeglasses. > Some older adults pay up to 50% of their health care costs yearly. > Medicare patients may also qualify for Medicaid — called "dual-eligible." > Eligibility and coverage vary by state. > The majority of long-term care in the United States is paid for by Medicaid or private pay.

Social Support and Older Adults.

- Elder Mistreatment/Abuse > From 2-10% of community-dwelling older adults in the United States are abused, neglected, or exploited by trusted others. > Mortality risk is 3 times higher. - Self-Neglect - Elder mistreatment (EM) describes intentional acts of omission or commission by a caregiver or "trusted other" that cause harm or serious risk of harm to a vulnerable older adult and/or neglect meeting the basic needs of the vulnerable older adult. Includes physical and/or mental abuse, sexual abuse, medical abuse, financial exploitation, neglect, and abandonment Its prevalence is unknown but thought to be underreported and widespread. Risk factors include dysfunction that leads to dependence on others for care, psychiatric diagnoses, alcohol abuse, or decreased social support. For every reported case there are five that are not. Victims and health care providers underreport for many reasons. Family members are responsible for up to 90% of EM. - EM usually involves several types; up to 70% involve neglect. Use tools that assist in assessment of abuse. Interview patients alone and tend to inconsistencies or contradictions between behavior, history, and symptoms. - Mandates for reporting elder abuse exist in many states. - Low social support is a risk factor for both self-neglect and mistreatment of vulnerable older adults by trusted others. - Self-neglect is the most common reason for referral to Adult Protective Services. > Live alone, don't meet basic needs, have untreated medical and/or psychiatric conditions, and live in squalor

Nursing Management...

- Evaluation of mental status is particularly important for older adults because these results often determine the potential for independent living. - The goal is to plan and implement actions that help older adults remain as functionally independent as possible. - SPICES, an effective tool for obtaining assessment data in older adults, should be the basis of nursing assessment when working in any setting. - As a nurse caring for the older adult, you can advocate for accurate and comprehensive assessments in which health and disease states are accurately diagnosed and actively teach health promotion strategies. - Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown

Social Support and Older Adults

- Family caregivers > Primary and preferred - Semiformal levels of support > Clubs, faith-based organizations, neighborhoods, senior centers - Formal systems of support > Social welfare agencies, health facilities, government agencies - Social support for older adults occurs at three levels. 1. Family members are the primary and preferred providers of social support but may, themselves, be elderly. 2. A semiformal level of support is found in clubs, religious (or faith-based) organizations, neighborhoods, and senior citizen centers. 3. Older adults may be linked to formal systems of social welfare agencies, health facilities, and government support. - Generally, you, as a nurse, are part of the formal support system.

Nursing Management//

- Gerontological nursing is the care of older adults based on the specialty body of knowledge of gerontology and nursing. - Care of older adults is complex and presents challenges that require skilled assessment and creative nursing interventions that are tailored to older adults. - Diseases and conditions in older adults may be difficult to accurately assess and diagnose. > Older adults may underreport symptoms, attribute a new symptom to "aging" and ignore it, eat less, sleep more, or "wait it out." > Disease symptoms are often atypical. > A cascade disease pattern may occur (a patient who experiences insomnia treats the condition with a hypnotic medication, becomes lethargic and confused, falls, breaks a hip, and subsequently develops pneumonia). > You play a vital role in preventing this downward trajectory. - Older adults may face health problems with fear and anxiety. > Health care workers may be perceived as helpful, but institutions may be perceived as negative and potentially harmful places. Communicate a sense of concern and care by use of direct and simple statements, appropriate eye contact, direct touch, and gentle humor.

Care Alternatives for Older Adults/

- Home Health Care > Homebound > Intermittent or acute health needs > Supportive caregiver involvement - Long-Term Care > Transition may be difficult for patients and families > Relocation stress syndrome

Special Older Adult Populations...

- Homeless Older Adults > Numbers are increasing. > Mortality rates are 3 times higher than for those with housing. > Have more health problems and appear older > Require an interdisciplinary services approach - Homelessness is increasing and associated with low income, reduced cognitive capacity, living alone, and lack of affordable housing. - Homeless older adults have more health problems, appear older, have less access to aging networks, and are less likely to use shelters or meal sites. - Long-term care placement is often the only alternative. > Fear of this keeps some from using existing social services. - An interdisciplinary approach that links shelters with outreach, primary care clinics, Medicare and Medicaid offices, and pharmacies may be required.

Demographics of Aging

- Increasing life expectancy anticipated to continue > 77.8 for men > 80.8 for women - Young old are 65-74. - Old old are 85 and older. - Frail old have some dysfunction. - The U.S. Census Bureau predicts life expectancy to continue to increase for both men and women. - Men and women born in 1950 who reach age 65 can expect, on average, another 12.8 and 15.8 years of life, respectively. - Reason for gender differences are not yet known. - The fastest growing segment of older Americans is people ages 85+. - The two groups of older adults represent different characteristics and needs. - Old old are often widowed, divorced, or single women dependent on family for support. > Often outlived children, spouses, and siblings > Hardy, elite survivors symbolizing family tradition and legacy - About 6% of young old live in nursing homes. - About 25% of old old live in nursing homes. - Frail older adults are usually over 75 and have physical, cognitive, or mental dysfunctions that may interfere with independent ADLs.

Legal and Ethical Issues

- Many complex and emotional situations may arise for older adults. - Decisions may be difficult. - You can help. > Stay informed about concerns. > Be knowledgeable about resources. > Advocate for patients and resolution. - Legal concerns regarding advance directives, end-of-life care, estate planning, taxation, appeals for a denied service, financial decisions, or exploitation by strangers or "trusted others" are concerns for many older adults. - Legal aid is available to low-income older adults by contacting a senior center. - Ethical issues surround care of the older adult and may include using physical or chemical restraints, assessing the patient's ability to make decisions, initiating resuscitation, treating infections, providing nutrition and hydration, and transferring to more intensive treatment units. - These situations are often complex and emotionally charged. - The nurse plays a role in acknowledging when these issues are present, keeping current on the ethical issues, and advocating for an institutional ethics committee to help in the decision-making process.

Care Alternatives for Older Adults

- Many older adults remain in their residence and, if needed, are assisted through community support, religious organizations, living adaptations, and housing assistance. - Other services help older adults stay at home, including respite, personal care, homemaker services, and long-term care. - Continuing care retirement communities, congregate housing, and assisted living facilities are housing options for older adults. - Adult day care and adult day health care centers are available care alternatives for older adults.

Medicare and Medicaid

- Medicare is federally funded insurance for people >65. > Also covers those < 65 with disabilities or end-stage kidney disease - Medicaid is a state-administered, needs-based program to assist eligible low-income people with medical expenses.

Cognitively Impaired Older Adults

- Most healthy older adults experience no noticeable decline in cognitive abilities. - Age-associated memory impairment, such as memory lapse or benign forgetfulness, is significantly different from cognitive impairment. - Memory loss should be evaluated. - Memory aids can be used: > Calm and quiet environments > Memory improvement techniques such as word association, mental imaging, and mnemonics > Use of clocks, calendars, notes, marked pillboxes, safety alarms on stoves, identity necklaces or bracelets. - Declining physical health can influence cognitive functioning.

Nursing Management

- Nurses play a critical role in management of chronic conditions. > Planning care > Teaching patient and family > Implementing strategies > Assessing patient and family outcomes - The course of chronic illness is often unpredictable. - Diagnosis and treatment of the acute phase or acute exacerbations of a chronic illness are sometimes done in a hospital. - Other phases are managed in an ambulatory care setting, at home, in an assisted living facility, or in a skilled nursing facility. - Management of the illness can profoundly affect patient, family, and caregiver's ADLs and lifestyles. - Assessment includes ADLs and perception of relative health/illness: > Bathing, dressing, eating, toileting, transferring > Instrumental ADLs include using a phone, shopping, preparing food, housekeeping, doing laundry, arranging transportation, taking medication, and handling finances. - Self-management is an individual's ability to manage symptoms, treatment, physical and psychosocial consequences, and lifestyle changes in response to living with a long-term disorder: > Even more important in ambulatory care settings. - Ideally, collaboration begins at the time of diagnosis under the direction of the health care team, and then family caregivers learn to work together with the patient. - Situation may be complicated if caregivers are also older and chronically ill.

Nursing Assessment

- Nursing Assessment > Attends to primary needs first > Focuses on functional abilities > Comprehensive > Involves an interdisciplinary team and approach - Before beginning the assessment process, make sure the patient is comfortable, does not need to urinate, has needed assistive devices, and is rested enough to proceed. > Allow enough time. > Interview family and caregivers. > Review records to determine relevant information. - The focus of a comprehensive geriatric assessment is to determine appropriate interventions to maintain and enhance the functional abilities of older adults. - Comprehensive geriatric assessment is interdisciplinary and, at a minimum, includes a thorough medical history, physical examination, functional health pattern assessment, medication review, cognitive and mood evaluation, ADL and instrumental ADL (IADL) evaluation, and social-environmental resources assessment.

Nursing Management/ Diagnosis

- Nursing Diagnoses > Similar to younger adults but defined by age-related changes - Planning > Identify strengths and abilities. * Gain a sense of control. * Feel safe. * Reduce stress.

Nursing Implementation

- Nursing Implementation > Acute Care * Assistive devices can decrease disability when used properly. * Older adults are at higher risk for safety from problems related to illness, disability, and normal aging processes.

Special Older Adult Populations..

- People over 65 > are less likely to live in metropolitan areas > experience barriers to health care access including transportation, limited health care resources, lack of quality health care, social isolation, and financial limitations > are often stressed by declining self-care abilities > are particularly vulnerable when of color > are less likely to engage in health-promoting activities. - Lifestyle and rural life practices need to be recognized and considered. > Transportation is the number 1 barrier. > Alternative service approaches such as Internet resources and chat rooms, radio, community centers, and church social events can be used to promote healthful practices or conduct health screening. > Telehealth devices for monitoring isolated individuals can enhance ability to provide care.

Prevention of Chronic Illness

- Preventive health behaviors —voluntary actions taken by an individual or group to decrease the potential threat of illness > Primary > Secondary > Tertiary - Chronic illnesses are often preventable. - Preventive health behaviors > Primary prevention refers to measures that prevent the occurrence of a specific disease. > Secondary prevention refers to actions aimed at early detection of disease that can lead to interventions to prevent disease progression. > Tertiary prevention refers to activities (e.g., rehabilitation) that limit disease progression or return the patient to optimal functioning.

Care Alternatives for Older Adults.

- Special care needs > Need assistance with ADLs > Cognitively impaired > Homebound > No longer able to live at home > Homeless Older adults with special care needs include people - in need of assistance with ADLs - cognitively impaired - homebound - no longer able to live at home and/or - who are homeless.

Nursing Management/

- Specialty of Gerontological Nursing > Complex, skilled, creative care > Older adult disease symptoms are often atypical and underreported. > Patients may be fearful and anxious about both health problems and institutions of care.

Nursing Implementation Health Promotion

- The approach for older adults must be based on their physical and mental status: > Safety first, as always > Allow for additional time to complete tasks and provide adaptive equipment when indicated > Consider cognitive abilities and mood. - Health promotion and prevention of health problems can be included in nursing interventions at any location or level where nurses and older adults interact. - Health promotion and prevention of health problems for older adults are focused on three areas: (1) reduction in diseases and problems, (2) increased participation in health promotion activities, and (3) increased targeted services that reduce health hazards. - You can use health promotion activities to increase self-care, personal responsibility for health, and independent functioning that will enhance the well-being of older adults.

Evaluating Nursing Care for Older Adults

- The evaluation phase of the nursing process is similar for all patients. - The results of evaluation direct you to continue the plan of care or revise as indicated. - Remember — when evaluating nursing care with older adults, the focus is on functional improvement.

<Nursing Management>

- The goal of rehabilitation is to help older adults in adapting to or recovering from disability. > Rehabilitation may occur in acute inpatient rehabilitation or long-term care settings. - Disabilities from chronic illnesses lead to increased self-care deficits, higher mortality rates, increased rates of institutionalization, and decreased life span. - ADLs, including bathing, dressing, eating, toileting, and transferring, are important for you to assess in the older patient living with chronic illness. - Reducing disability through geriatric rehabilitation is important to the quality of life of older adults. - Rehab can be challenging. > Fear of falling is common. > Preexisting conditions affect reaction time, visual acuity, fine motor ability, physical strength, cognitive function, and motivation. > Inactivity and immobility lead to deconditioning and subsequent functional decline. > Strive for maximal function and physical capabilities considering patient's current health status and limitations.

Culturally Competent Care

- The term ethnogeriatric describes the specialty area of providing culturally competent care to older adults. - Loss of ethnic ties occurs as neighborhoods change, including loss of friends of the same culture and language, loss of religious institutions that support ethnic activities, and loss of stores that carry ethnic foods. - Loss of ethnic support can occur when children or others deny or ignore cultural practices. - Support is most often found within the family, religious practices, and isolated geographic or community clusters. Old old ethnically diverse often live with extended family and continue to speak their native language. - Older neighborhoods can present unique problems such as crime-related security. - Lower incomes result in an inability to afford treatments or medications. - Perceptions of health may vary by ethnic group, with people of color often rating their health lower than older white adults. - Carefully and respectfully assess ethnic and cultural orientation. > Make no assumptions. > Communicate clearly.

Trajectory of Chronic Illness ..

- Trajectory of Chronic Illness > Adjusting to changes in course of disease > Preventing social isolation > Attempting to normalize interactions with others

Frail Older Adults: Special Older Adult Populations

SCALES acronym: S: sadness or mood change C: cholesterol, high A: Albumin, low L: Loss or gain of wt. E: eating problems S: shopping and food preparation problem. - The frail older adult is one who is usually over age 75 years and has physical, cognitive, or mental dysfunctions that may interfere with the ability to independently perform ADLs. - Risk factors include disability, multiple chronic illnesses, and dementia. - People more likely to become frail include those who smoke, have a history of depression or long-term medical health problems, or are underweight. > The old old population is most at risk for frailty. > The frail often become ill when stressed by life events or ongoing daily challenges such as caregiving. > Common health problems include mobility limitations, sensory impairment, cognitive decline, falls, and increasing frailty. > At risk for disability, mistreatment, and institutionalization > Especially at risk for malnutrition and dehydration from factors including living alone, depression, and low income -> Pay special attention to meds, drugs, supplements, herbs, and cultural remedies that may interfere with nutrition. -> Consider home-delivered meals, diet supplements, food stamps, dental referrals, and vitamins.