Mental Chapter 25- The Aging Individual

Sensory systems

-vision -hearing -taste -smell -touch -pain

Touch and Pain

Although the primary sensory changes that occur specifically related to aging are in hearing and vision, sensitivity to touch and pain may also decline or change with age related to less blood flow to nerve endings, in the spinal cord, or to the brain. These changes have critical implications for the elderly in their potential inability to use sensory warnings to escape serious injury.

Learned Violence

Children who have been abused or have witnessed abusive and violent parents are more likely to evolve into abusive adults. In some families, abusive behavior is the normal response to tension or conflict, and this type of behavior can be transmitted from one generation to another. There may be some unresolved family conflicts or retaliation for previous maltreatment that foster and promote abuse of the elderly person.

Dependency

Dependency appears to be the most common precondition in domestic abuse. Changes associated with normal aging or induced by chronic illness often result in loss of self-sufficiency in the elderly person, requiring that he or she become dependent on another for assistance with daily functioning. Long life may also consume finances to the point that the elderly individual becomes financially dependent on another as well. This type of dependency also increases the elderly person's vulnerability to abuse.

Marital Status

In 2014, of individuals aged 65 and older, 72 percent of men and 46 percent of women were married. Thirty-five percent of all women in this age group were widowed. There were three times as many widows as widowers, which is consistent with the longer life expectancy for women.

Population

In 1980, Americans 65 years of age or older numbered 25.5 million. By 2013, these numbers had increased to 44.7 million, and this number is expected to double by 2060 to 98 million. In 2013, that number represented 14.1 percent of the population, and it is projected that by 2040, the number of Americans over 65 will reach 21.7 percent of the population.

Maintenance of Self-Identity

Maintaining a positive self-concept and identity is important in successful aging. Individuals who tend toward a rigid self-identity and a negative self-concept will no doubt struggle with any changes and adaptations faced in the process of aging. For example, individuals whose identity centers entirely around their job may struggle more with their identity in retirement than those whose identity includes job, family, travel, and so on. Researchers in one study found that maintaining a youthful age identity and positive perceptions and experiences related to aging had a self-enhancing function for self-esteem and identity. The authors compared citizens in the United States with citizens in the Netherlands and found that this self-enhancing function was stronger for Americans than for Netherlanders. Their conclusion was that factors influencing self-identity and self-concept in older age need to be considered within the cultural context.

Mental Health Status

Mental health problems are risk factors in assessing need for long-term care. Many of the symptoms associated with certain mental disorders (especially NCDs) such as memory loss, impaired judgment, impaired intellect, and disorientation would render the individual incapable of meeting the demands of daily living independently.

Later Life-Anxiety Disorders

Most anxiety disorders begin in early to middle adulthood, but some appear for the first time after age 60. Because the autonomic nervous system is more fragile in older persons, the response to a major stressor is often quite intense. The presence of physical disability frequently compounds the situation, resulting in a more severe posttraumatic stress response than is commonly observed in younger persons. In older adults, symptoms of anxiety and depression often accompany each other, making it difficult to determine which disorder is dominant.

Common psychosocial changes associated with aging include the following:

Prolonged and exaggerated grief, resulting in depression Physical changes, resulting in disturbed body image Changes in status, resulting in loss of self-worth

Later Life-Personality Disorders

Personality disorders are uncommon in the elderly population. The incidence of personality disorders among individuals over 65 is less than 5 percent. Most elderly people with personality disorder have likely manifested the symptomatology for many years.

Psychosocial Theories

Psychosocial theories focus on social and psychological changes that accompany advancing age rather than on the biological implications of anatomic deterioration. Several theories have attempted to describe how attitudes and behavior in the early phases of life affect people's reactions during the late phase. This work is called the process of "successful aging."

Later Life-Schizophrenia

Schizophrenia is an illness that typically begins in young adulthood. In most instances, individuals who manifest psychotic disorders early in life show a decline in psychopathology as they age. Late-onset schizophrenia (after age 60) is rare, and when it does occur, it is more common in women and is often characterized by paranoid delusions or hallucinations. Antipsychotic agents may be beneficial but should be used judiciously and at lower than usual doses.

Changes in Men

Testosterone production declines gradually over the years, beginning between ages 40 and 60. A major change resulting from this hormone reduction is that erections occur more slowly and require more direct genital stimulation to achieve. There may also be a modest decrease in the firmness of the erection in men older than age 60. The refractory period lengthens with age, increasing the amount of time following orgasm before the man may achieve another erection. The volume of ejaculate gradually decreases, and the force of ejaculation lessens. The testes become somewhat smaller, but most men continue to produce viable sperm well into old age. Prolonged control over ejaculation in middle-aged and elderly men may bring increased sexual satisfaction for both partners.

Cardiovascular System

The age-related decline in the cardiovascular system is thought to be the major determinant of decreased tolerance for exercise and loss of conditioning and the overall decline in energy reserve. The aging heart is characterized by modest hypertrophy and loss of pacemaker cells, resulting in a decrease in maximal heart rate and diminished cardiac output (Blair, 2012). This results in a decrease in response to work demands and some diminishment of blood flow to the brain, kidneys, liver, and muscles. Heart rate also slows with time. If arteriosclerosis is present, cardiac function is further compromised.

Living Arrangements

The majority of individuals aged 65 or older live alone, with a spouse, or with relatives. In 2013, 2.2 million adults over 65 were living in a household with a grandchild present, and 536,000 of these grandparents had primary responsibility for the grandchild living with them. At any one time, fewer than 5 percent of people in this age group live in institutions. This percentage increases dramatically with age, ranging from 1 percent for persons 65 to 74 years to 3 percent for persons 75 to 84 years, and 10 percent for persons 85 and older.

Neuroendocrine Theory

The neuroendocrine theory was first developed in 1954 by Vladimir Dilman, MD. Dilman subsequently worked with another physician, Ward Dean, to update this theory in the early 1990s. The theory suggests that as humans age, the hypothalamus declines in its ability to regulate hormones and becomes less sensitive to them. Consequently, hormone secretion and hormone effectiveness decline. Dilman identified several hypotheses to explain why the hypothalamus becomes less sensitive, including reduced neurotransmitter levels (serotonin in particular), decline in the secretion of pineal gland hormones, reduced glucose utilization and fat accumulation, neuronal lesions caused by chronically elevated cortisol levels secondary to stress, and accumulation of cholesterol in plasma membranes of neurons. Some believe that hormone replacements impacted by the hypothalamus may be a future treatment to counter the effects of aging, but more research is needed.

Stress

The stress inherent in the caregiver role is a factor in most abuse cases. Some clinicians believe that elder abuse results from individual or family psychopathology. Others suggest that even psychologically healthy family members can become abusive as the result of the exhaustion and acute stress caused by overwhelming caregiving responsibilities. This is compounded in an age group that has been dubbed the "sandwich generation"—those individuals who elected to delay childbearing so that they are now at a point in their lives when they are "sandwiched" between providing care for their children and providing care for their aging parents.

Respiratory System

Thoracic expansion is diminished by an increase in fibrous tissue and loss of elastin. Pulmonary vital capacity decreases, and the amount of residual air increases. Scattered areas of fibrosis in the alveolar septa interfere with exchange of oxygen and carbon dioxide. These changes are accelerated by the use of cigarettes or other inhaled substances. Cough and laryngeal reflexes are reduced, causing decreased ability to defend the airway. Decreased pulmonary blood flow and diffusion ability result in reduced efficiency in responding to sudden respiratory demands.

Employment

With the passage of the Age Discrimination in Employment Act in 1967, forced retirement has been virtually eliminated in the workplace. It is well accepted that involvement in purposeful activity is vital to successful adaptation and perhaps even to survival at any age. Increasing numbers of adults over 65 are remaining active in employment environments. In 2014, 8.4 million Americans aged 65 and older were in the labor force (working or actively seeking work), and that number represents a steady increase for both men and women since around the year 2000. The data does not clarify whether this tendency to remain in the workforce during older adulthood is related to the desire to remain active and productive through the labor force or whether it is based in necessity for income.

Endocrine System

-A decreased level of thyroid hormones causes a lowered basal metabolic rate. Decreased amounts of adrenocorticotropic hormone may result in less efficient stress response. -Impairments in glucose tolerance are evident in aging individuals. Studies of glucose challenges show that insulin levels are equivalent to or slightly higher than those from younger challenged individuals, although peripheral insulin resistance appears to play a significant role in carbohydrate intolerance. The observed glucose clearance abnormalities and insulin resistance in older people may be related to many factors other than biological aging (obesity, family history of diabetes) and may be influenced substantially by diet or exercise.

Elder Abuse

-Abuse of elderly individuals is a serious form of family violence. Statistics regarding the prevalence of elder abuse are difficult to determine. It is estimated that annually up to 2 million older adults in the United States are victims of abuse. 84 percent of these cases are reported to authorities. The abuser is often a relative who lives with the elderly person and may be the assigned caregiver. Typical caregivers who are likely to be abusers of the elderly were described as being under economic stress, substance abusers, themselves the victims of previous family violence, and exhausted and frustrated by the caregiver role. Identified risk factors for victims of abuse included being a white female age 70 or older, being mentally or physically impaired, being unable to meet daily self-care needs, and having care needs that exceeded the caretaker's ability. -Abuse of elderly individuals may be psychological, physical, or financial. -Neglect may be intentional or unintentional. -Psychological abuse includes yelling, insulting, harsh commands, threats, silence, and social isolation. -Physical abuse is described as striking, shoving, beating, or restraint. Financial abuse refers to misuse or theft of finances, property, or material possessions. -Neglect implies failure to fulfill the physical needs of an individual who cannot do so independently. -Unintentional neglect is inadvertent, whereas intentional neglect is deliberate. -In addition, elderly individuals may be the victims of sexual abuse, which is sexual intimacy between two persons that occurs without the consent of one of the persons involved. -"Granny-dumping" by the media, involves abandoning elderly individuals at emergency departments, nursing homes, or other facilities—literally leaving them in the hands of others when the strain of caregiving becomes intolerable. -Elder victims often minimize the abuse or deny that it has occurred. The elderly person may be unwilling to disclose information because of fear of retaliation, embarrassment about the existence of abuse in the family, protectiveness toward a family member, or unwillingness to institute legal action. Adding to this unwillingness to report is the fact that infirm elders are often isolated, so their mistreatment is less likely to be noticed by those who might be alert to symptoms of abuse. For these reasons, detection of abuse in the elderly is difficult at best.

Genitourinary System

-Age-related declines in renal function occur because of a steady attrition of nephrons and sclerosis within the glomeruli over time. Vascular changes affect blood flow to the kidneys, which results in reduced glomerular filtration and tubular function. Elderly people are prone to develop the syndrome of inappropriate antidiuretic hormone secretion, and levels of blood urea nitrogen and creatinine may be elevated slightly. The overall decline in renal functioning has serious implications for physicians who prescribe medications for elderly individuals. -In men, enlargement of the prostate gland is common as aging occurs. Prostatic hypertrophy is associated with an increased risk for urinary retention and may also be a cause of urinary incontinence. Loss of muscle and sphincter control, as well as the use of some medications, may cause urinary incontinence in women. Not only is this problem a cause of social stigma, but also, if left untreated, it increases the risk of urinary tract infection and local skin irritation. Normal changes in the genitalia are discussed in the section "Sexual Aspects of Aging."

Genetic Theory

-Aging is an involuntarily inherited process that operates over time to alter cellular or tissue structures. This theory suggests that life-span and longevity changes are predetermined. The theory is supported by the finding that there are similar life spans among identical twins and children of parents with a long life span. -A second genetic theory identifies aging as a process of genetic mutations that essentially create "errors" in transmission of information with the outcome being molecules that no longer function properly. Epigenetics, which involves the study of changes in the way genes are expressed in the absence of changes in the sequence of nucleic acids, has confirmed some fascinating findings that have implications for aging and illness. First, it was discovered that DNA methylation (the addition of a methyl group to a DNA base) is a mechanism responsible for gene regulation. Genome studies of aging cells and tissues have shown a variable "DNA methylation drift," which creates changes in aging stem cells that culminate in reduced stem cell plasticity, stem cell exhaustion, and focal defects that can lead to illnesses such as cancer. Issa describes that "aging pathologies in turn accelerate methylation drift by promoting chronic inflammation and uncontrolled proliferation which creates a vicious cycle that may explain why some illnesses increase ... exponentially ... with age." It is possible, with ongoing research, that we may discover what aging will look like for an individual and what his or her disease risks are. If epigenetic drift can be prevented, it may be possible to prevent diseases associated with aging.

Immune System

-Aging results in changes in both cell-mediated and antibody-mediated immune responses. The size of the thymus gland declines continuously from just beyond puberty to about 15 percent of its original size by age 50. The consequences of these changes include a greater susceptibility to infections and a diminished inflammatory response that results in delayed healing. There is also evidence of an increase in various autoantibodies as a person ages, increasing the risk of autoimmune disorders, such as rheumatoid arthritis. -Because of the overall decrease in efficiency of the immune system, the proliferation of abnormal cells is facilitated in the elderly individual. Cancer is the best example of aberrant cells allowed to proliferate due to the ineffectiveness of the immune system.

Suicide

-Although persons aged 65 and older comprise only 14.1 percent of the population, they represent a disproportionately high percentage of individuals who commit suicide. The highest number of suicides (19.3%) occurred among those 85 years of age and older. The group especially at risk appears to be white men over the age of 65 who are at five times greater risk for suicide than the general population. -Predisposing factors include loneliness, financial problems, physical illness, loss, and depression. It has been suggested that increased social isolation may be a contributing factor to suicide among the elderly. -The number of elderly individuals who are divorced, widowed, or otherwise living alone has increased, and being a widow is associated with higher risk for depression and suicide. -Many elderly individuals express symptoms associated with depression that are never recognized as such, particularly somatic symptoms. -Components of intervention with a suicidal elderly person should include demonstrations of genuine concern, interest, and caring; indications of empathy for their fears and concerns; and help in identifying, clarifying, and formulating a plan of action to deal with the unresolved issue. If the elderly person's behavior seems particularly lethal, additional family or staff coverage and contact should be arranged to prevent isolation.

Assessment

-Assessment of the elderly individual may follow the same framework used for all adults, but with consideration of the possible biological, psychological, sociocultural, and sexual changes that occur in the normal aging process described previously in this chapter. -In no other area of nursing is it more important for nurses to practice holistic nursing than with the elderly. -Older adults are likely to have multiple physical problems that contribute to problems in other areas of their lives. Obviously, these components cannot be addressed as separate entities. -Nursing the elderly is a multifaceted, challenging process because of the multiple changes occurring at this time in the life cycle and the way in which each change affects every aspect of the individual. -Several considerations are unique to assessment of the elderly. Assessment of the older person's thought processes is a primary responsibility. Knowledge about the presence and extent of disorientation or confusion will influence the way in which the nurse approaches elder care. -Information about sensory capabilities is also extremely important. Because hearing loss is common, the nurse should lower the pitch and loudness of his or her voice when addressing the older person. Looking directly into the face of the older person when talking facilitates communication. -Questions that require a declarative sentence in response should be asked; in this way, the nurse is able to assess the client's ability to use words correctly. -Visual acuity can be determined by assessing adaptation to the dark, color matching, and the perception of color contrast. Knowledge about these aspects of sensory functioning is essential in the development of an effective care plan. -Knowledge of the client's functional capabilities is essential for determining the physiological, psychological, and sociological needs of the elderly individual. Age alone does not preclude the occurrence of all these changes. The aging process progresses at a wide range of variance, and each client must be assessed as a unique individual.

Economic Implications

-Because retirement is generally associated with 20 to 40 percent reduction in personal income, the standard of living after retirement may be adversely affected. Most older adults derive post-retirement income from a combination of Social Security benefits, public and private pensions, and income from savings or investments. -The Social Security Act of 1935 promised assistance with financial security for the elderly. Since then, the original legislation has been modified, yet the basic philosophy remains intact. Its effectiveness, however, is now being questioned. Faced with deficits, the program is forced to pay benefits to those currently retired from both the reserve funds and monies being collected at present. There is genuine concern about paying Social Security benefits to future generations, when there may be no reserve funds from which to draw. Because many of the programs that benefit older adults depend on contributions from the younger population, the growing ratio of older Americans to younger people may affect society's ability to supply the goods and services necessary to meet this expanding demand. -Medicare and Medicaid were established by the government to provide medical care benefits for elderly and indigent Americans. The Medicaid program is jointly funded by state and federal governments, and coverage varies significantly from state to state. Medicare covers only a percentage of health-care costs; therefore, to reduce risk related to out-of-pocket expenditures, many older adults purchase private "medigap" policies designed to cover charges in excess of those approved by Medicare. -The magnitude of retirement earnings depends almost entirely on pre-retirement income. The poor will remain poor and the wealthy are unlikely to lower their status during retirement; however, for many in the middle classes, the relatively fixed income sources may be inadequate, possibly forcing them to face financial hardship for the first time in their lives.

Taste and Smell

-Beyond 70 years of age, taste sensitivity begins to decline related to atrophy and loss of taste buds . Taste discrimination decreases, and bitter taste sensations predominate. Sensitivity to sweet and salty tastes is diminished. -The deterioration of the olfactory bulbs is accompanied by loss of smell acuity. The effect of aging on the sense of smell has not been precisely identified, though, and is difficult to evaluate because so many environmental factors influence sensitivity to smell. However, some decreased sensitivity may be related to loss of nerve endings in the nose and less mucous production.

Dealing with Death

-Death anxiety is a universal phenomenon, and attitudes about death are a result of cumulative life experiences. As more people are living longer there has been a resurgence of interest in research about death anxiety. Lehto and Stein conducted an extensive review of the research to lay a foundation for an emerging understanding of this concept. Kubler-Ross's (1969) pioneering research on attitudes about death and the experience of dying paved the way for discussions of this issue, but as Lehto and Stein (2009) identify in their review of literature, death anxiety is largely denied or repressed. They cited several studies confirming that religious beliefs reduced death anxiety and suggest that these were beneficial because they provide a context for meaning about life and death. Positive self-esteem mediates death anxiety or at least "assists in preventing overt manifestations of death anxiety." Other researchers found similarly that fear of the dying process among elderly individuals in care institutions was correlated with low self-esteem, purposelessness, and poor mental health. These authors also found that, in their sample, death anxiety was more correlated with fears for significant others than fear of the unknown. -Interestingly, death anxiety seems to be the highest during middle age and, by later adulthood, stabilizes. Maladaptive consequences of death anxiety include mental illnesses such as depression and anxiety disorders, so assessing and intervening with regard to death anxiety may be beneficial in preventing longer-term consequences. Self-esteem interventions, for example, may be beneficial in preventing older adult depression secondary to death anxiety. Some research has shown that death education is beneficial in reducing anxiety associated with fear of death. Addressing these issues with middle-aged clients may be in the interest of primary or secondary prevention in the aging process.

Depression: Is it Depression, Dementia, or Pseudodementia?

-Depressed affect -Apathy or Anhedonia -Difficulty doing normal tasks -Memory changes -Decreased ability to focus

Disengagement Theory

-Disengagement theory describes the process of withdrawal by older adults from societal roles and responsibilities. According to the theory, this withdrawal process is predictable, systematic, inevitable, and necessary for the proper functioning of a growing society. Older adults were said to be happy when social contacts diminished and responsibilities were assumed by a younger generation. The benefit to the older adult is thought to be in providing time for reflecting on life's accomplishments and for coming to terms with unfulfilled expectations. The benefit to society is thought to be an orderly transfer of power from old to young. -There have been many critics of this theory, and the postulates have been challenged. For many healthy and productive older individuals, the prospect of a slower pace and fewer responsibilities is undesirable.

Growing Old

-Growing old has not been popular among the youth-oriented American culture. -With 66 million baby boomers reaching their 65th birthdays by the year 2030, greater emphasis is being placed on the needs of an aging population. -The disciplines of gerontology (the study of the aging process), geriatrics (the branch of clinical medicine specializing in problems of the elderly), and geropsychiatry (the branch of clinical medicine specializing in psychopathology of the elderly population) are expanding rapidly in response to this predictable demand. -Growing old in a society that has been obsessed with youth may have a critical impact on the mental health of many people.

Evaluation

-Has the client escaped injury from falls, burns, or other means to which he or she is vulnerable because of age? -Can caregivers verbalize means of providing a safe environment for the client? -reality orientation at an optimum for his or her cognitive functioning? -Can the client distinguish between reality-based and non-reality-based thinking? -Can caregivers verbalize -Is the client able to accomplish self-care activities independently to his or her optimum level of -Does the client seek assistance for aspects of self-care that he or she is unable to perform independently? -Does the client express positive feelings about -Does the client reminisce about accomplishments that have occurred in his or her life? -Does the client express some hope for the future? -Does the client wear eyeglasses or a hearing aid, if needed, to compensate for sensory deficits? -Does the client consistently look at others in the face to facilitate hearing when they are talking to him -Does the client use helpful aids, such as signs identifying various rooms, to help maintain orientation? -Can the caregivers work through problems and make decisions regarding care of the elderly client? -Do the caregivers include the elderly client in the decision-making process, if appropriate? -Can the caregivers demonstrate adaptive coping strategies for dealing with the strain of long-term caregiving? -Are the caregivers open and honest in expression of feelings? -Can the caregivers verbalize community resources to which they can go for assistance with their caregiving responsibilities? -Have the caregivers joined a support group?

Any sign of helplessness or hopelessness should prompt an assessment for suicide risk using clear and, often, closed-ended questions to elicit a specific response, such as the following:

-Have you thought of hurting yourself or taking your own life? -Do you have a plan for hurting yourself? -Have you ever acted on that plan? -Have you ever attempted suicide?

Health Care-Identifying Elder Abuse

-Health-care workers often feel intimidated when confronted with cases of elder abuse. In these instances, referral to an individual experienced in management of victims of such abuse may be the most effective approach to evaluation and intervention. Health-care workers are responsible for reporting any suspicions of elder abuse. An investigation is then conducted by regulatory agencies, whose job it is to determine if the suspicions are corroborated. Every effort must be made to ensure the client's safety, but it is important to remember that a competent elderly person has the right to choose his or her health-care options. As inappropriate as it may seem, some elderly individuals choose to return to the abusive situation. In this instance, he or she should be provided with names and phone numbers to call for assistance if needed. A follow-up visit by an adult protective services representative should be conducted. -Increased efforts need to be made to ensure that health-care providers have comprehensive training in the detection of and intervention in elder abuse. More research is needed to increase knowledge and understanding of the phenomenon of elder abuse and ultimately to effect more sophisticated strategies for prevention, intervention, and treatment.

Hearing

-Hearing changes significantly with the aging process. Gradually over time, the ear loses its sensitivity to discriminate sounds because of damage to the hair cells of the cochlea. The most dramatic decline appears to be in perception of high-frequency sounds. -Age-related hearing loss, called presbycusis, is common and affects more than half of all adults by age 75 years. It is more common in men than it is in women, a fact that may be related to differences in levels of lifetime noise exposure.

Developmental Task Theroy

-In contrast to the personality trait theories of aging, which discuss a largely stable process that continues into old age, developmental task theory holds that there are activities and challenges that one must accomplish at predictable, changing stages in life to achieve successful aging. The primary task of old age as being able to see one's life as having been lived with integrity. In the absence of achieving that sense of having lived well, the older adult is at risk for becoming preoccupied with feelings of regret or despair. As noted previously, the life span was significantly different when Erikson's developmental tasks and stages were first identified, and in the late 1990s, Erikson expanded the concept of transcendence as an additional stage that occurs after the stage of integrity versus despair -Transcendence as a concept within the spiritual domain -Transcendence [is] an inherent developmental process, resulting in a shift from a rational, materialistic view to a wider world view characterized by broadened personal boundaries, within interpersonal, intrapersonal, transpersonal, and temporal dimensions resulting in an increased sense of meaning in life, well-being, and life satisfaction. -transcendence is a significant contributor to successful aging

Activity Theory

-In direct opposition to the disengagement theory is the activity theory of aging, which holds that the way to age successfully is to stay active. -Growing evidence supports the importance of remaining socially active for both physical and emotional well-being. Cultural expectations are influential, and as more older Americans are identified as reaping the benefits of physical and social activity, cultural expectations begin to shift. Many fitness classes, for example, are now finding a membership of people in their 80s and beyond.

Gastrointestinal System

-In the oral cavity, the teeth show a reduction in dentine production, shrinkage and fibrosis of root pulp, gingival retraction, and loss of bone density in the alveolar ridges. There is some loss of peristalsis in the stomach and intestines, and gastric acid production decreases. Levels of intrinsic factor may also decrease, resulting in vitamin B12 malabsorption in some aging individuals. A significant decrease in absorptive surface area of the small intestine may be associated with some decline in nutrient absorption. Motility slowdown of the large intestine, combined with poor dietary habits, dehydration, lack of exercise, and some medications, may give rise to problems with constipation. -There is a modest decrease in size and weight of the liver resulting in losses in enzyme activity required to deactivate certain medications by the liver. These age-related changes can influence the metabolism and excretion of these medications. These changes, along with the pharmacokinetics of the drug, must be considered when giving medications to aging individuals.

Identifying Elder Abuse-individuals are reluctant to report personal abuse, health-care workers need to be able to detect signs of mistreatment when they are in a position to do so. Manifestions:

-Indicators of psychological abuse include a broad range of behaviors such as the symptoms associated with depression, withdrawal, anxiety, sleep disorders, and increased confusion or agitation. -Indicators of physical abuse may include bruises, welts, lacerations, burns, punctures, evidence of hair pulling, and skeletal dislocations and fractures. -Neglect may be manifested as consistent hunger, poor hygiene, inappropriate dress, consistent lack of supervision, consistent fatigue or listlessness, unattended physical problems or medical needs, or abandonment. -Sexual abuse may be suspected when the elderly person is presented with pain or itching in the genital area; bruising or bleeding in external genitalia, vaginal, or anal areas; or unexplained sexually transmitted disease. -Financial abuse may be occurring when there is an obvious disparity between assets and satisfactory living conditions or when the elderly person complains of a sudden lack of sufficient funds for daily living expenses.

Long-Term Care

-Long-term care facilities are defined by the level of care they provide. They may be skilled nursing facilities, intermediate care facilities, or a combination of the two. Some institutions provide convalescent care for individuals recovering from acute illness or injury, some provide long-term care for individuals with chronic illness or disabilities, and still others provide both types of assistance. -Most elderly individuals prefer to remain in their own homes or in the homes of family members for as long as this arrangement can meet their needs without deterioration of family or social patterns. Many elderly individuals are placed in institutions as a last resort only after heroic efforts have been made to keep them in their own or a relative's home. The increasing emphasis on home health care has extended the period of independence for aging individuals. -Fewer than 4 percent of the population aged 65 and older live in nursing homes. The percentage increases dramatically with age, ranging from 1 percent for persons aged 65 to 74, 3 percent for persons aged 75 to 84, to 10 percent for persons aged 85 and older. A profile of the "typical" elderly nursing home resident is about 80 years of age, white, female, widowed, with multiple chronic health conditions.

Socioeconomic and Demographic Factors

-Low income generally is associated with greater physical and mental health problems among the elderly. Because many elderly individuals have limited finances, they are less able to purchase care resources available outside of institutions (home health care), although Medicare and Medicaid now contribute a limited amount to this type of noninstitutionalized care. -Women are at greater risk of being institutionalized than men, not because they are less healthy but because they tend to live longer and thus reach the age at which more functional and cognitive impairments occur. They are also more likely to be widowed. Whites have a higher rate of institutionalization than nonwhites, which may be related to cultural and financial influences.

Attitudinal Factors

-Many people dread the thought of even visiting a nursing home, let alone moving to one or placing a relative in one. Negative perceptions exist of nursing homes as "places to go to die." The media picture and subsequent reputation of nursing homes has not been positive. Stories of substandard care and patient abuse have scarred the industry, making it difficult for those facilities that are clean and well-managed and that provide innovative, quality care to their residents to rise above the stigma. -State and national licensing boards perform periodic inspections to ensure that standards set forth by the federal government are being met. These standards address quality of patient care as well as adequacy of the nursing home facility. Yet, many elderly individuals and their families perceive nursing homes as a place to go to die, and the fact that many of these institutions are poorly equipped, understaffed, and disorganized keeps this societal perception alive. There are, however, many excellent nursing homes that strive to go beyond the minimum federal regulations for Medicaid and Medicare reimbursement. In addition to medical, nursing, rehabilitation, and dental services, social and recreational services are provided to increase the quality of life for elderly people living in nursing homes. These activities include playing cards, bingo, and other games; parties; church activities; books; television; movies; and arts, crafts, and other classes. Some nursing homes provide occupational and professional counseling. These facilities strive to enhance opportunities for improving quality of life and for becoming places to live rather than to die.

Changes in Women

-Menopause may begin anytime during the 40s or early 50s. -Gradual decline in the functioning of the ovaries and the subsequent production of estrogen, which results in a number of changes. -The walls of the vagina become thin and inelastic, the vagina itself shrinks in both width and length, and the amount of vaginal lubrication decreases noticeably. -Orgastic uterine contractions may become spastic. -All of these changes can result in painful penetration, vaginal burning, pelvic aching, or irritation on urination. -Discomfort may be severe enough to result in an avoidance of intercourse. -More likely to occur with infrequent intercourse of only one time a month or less. -Regular and more frequent sexual activity results in a greater capacity for sexual performance. -Other symptoms that are associated with menopause in some women include hot flashes, night sweats, sleeplessness, irritability, mood swings, migraine headaches, urinary incontinence, and weight gain. -Some menopausal women elect to take hormone replacement therapy (HRT) for relief of these changes and symptoms. -With estrogen therapy, the symptoms of menopause are minimized or do not occur at all. However, some women choose not to take the hormone because of an increased risk of breast cancer, and when given alone, an increased risk of endometrial cancer. To combat this latter effect, many women also take a second hormone, progesterone. Taken for 7 to 10 days during the month, progesterone decreases the risk of estrogen-induced endometrial cancer. Some physicians prescribe a low dose of progesterone that is taken, along with estrogen, for the entire month. A combination pill, taken in this manner, is also available. Results of the Women's Health Initiative (WHI), as reported in the Journal of the American Medical Association, indicated that the combination pill is associated with an increased risk of cardiovascular disease and breast cancer. -Benefits related to colon cancer and osteoporosis were reported; however, investigators stopped this arm of the study and suggested discontinuation of this type of therapy. 0In a 3-year follow-up study of the participants, the results showed that the increased risk for cardiovascular disease dissipated with discontinuation of the hormone therapy. -HRT may have a cardioprotective effect, but review of the literature did not substantiate that finding. Their review cites other studies that suggest that the cardiovascular risks versus benefits may be associated with the age at which HRT is initiated. -A more recent WHI study reported that their findings do not support use of HRT for chronic disease prevention but that it may be beneficial in some management of menopause symptoms. Controversies about HRT and conflicting study findings continue to highlight the need for ongoing research on this topic.

Financial Abuse or Exploitation

-Misuse of the elderly person's income by the caregiver -Forcing the elderly person to sign over financial affairs to another person against his or her will or without sufficient knowledge about the transaction

Economic Status

-More than 4.2 million (9.5%) persons aged 65 or older were below the poverty level in 2013, and when the U.S Census Bureau figures adjusted for regional variations in cost of housing, other benefits, and out-of-pocket expenses for needs such as medical care, the percentage of those living below the poverty level rose to 14.6 percent. These statistics are higher than those from 2012, suggesting a trend toward increasing numbers of older adults living below the poverty level. Older women had a higher poverty rate than older men, and older Hispanic women living alone had the highest poverty rate. Poor people who have worked all their lives can expect to become poorer in old age, and others will become poor only after becoming old. However, there are a substantial number of affluent and middle-income older persons. -Of individuals in this age group, 81 percent owned their own homes in 2013. However, the housing of this population of Americans is usually older and less adequate than that of the younger population; therefore, a higher percentage of income must be spent on maintenance and repairs. The AoA reports that in 2013, 45 percent of older adults living in houses spent more than 25 percent of their income on housing costs.

Sociocultural Aspects of Aging

-Old age brings many important socially induced changes, some of which have the potential for negative effect on both the physical and mental well-being of older persons. In American society, old age is defined arbitrarily as being 65 years or older because that is the age when most people have been able to retire with full Social Security and other pension benefits. Recent legislation has increased the age beyond 65 years for full Social Security benefits. Currently, the age increases yearly (based on year of birth) until 2027, when the age for full benefits will be 67 years for all individuals. -Elderly people in virtually all cultures share some basic needs and interests. There is little doubt that most individuals choose to live the most satisfying life possible for as long as possible. They want protection from hazards and release from the weariness of everyday tasks. They want to be treated with the respect and dignity they deserve as individuals who have reached this pinnacle in life; and they want to die with the same respect and dignity. -Historically, the aged have had a special status in society. Even today, in some cultures, the aged are the most powerful, the most engaged, and the most respected members of the society. This has not been the case in the modern industrial societies, although trends in the status of the aged differ widely among industrialized countries. For example, the status and integration of the aged in Japan have remained relatively high when compared with other industrialized nations, such as the United States. There are subcultures in the United States, however, in which the elderly are afforded a higher degree of status than they receive in the mainstream population. Examples include Latino Americans, Asian Americans, and African Americans. The aged are awarded a position of honor in cultures that place emphasis on family cohesiveness. In these cultures, the aged are revered for their knowledge and wisdom gained through their years of life experiences. -Many negative stereotypes color the perspective on aging in the United States. Ideas that elderly individuals are always tired or sick, slow and forgetful, isolated and lonely, unproductive, and angry determine the way younger individuals relate to the elderly in this society. Increasing disregard for the elderly has resulted in a type of segregation, as aging individuals voluntarily seek out or are involuntarily placed in special residences for the aged. -Assisted living centers, retirement apartment complexes, and even entire retirement communities intended solely for individuals over age 50, are becoming increasingly common. In 2013, more than half (61%) of persons aged 65 and older lived in 13 states, with the largest numbers in California, Florida, Texas, New York, and Pennsylvania. It is important for elderly individuals to feel part of an integrated group, and they are migrating to these areas in an effort to achieve this integration. This phenomenon provides additional corroboration for the activity theory of aging and the importance of attachment to others. -Employment is another area in which the elderly experience discrimination. Although compulsory retirement has been virtually eliminated, discrimination still exists in hiring and promotion practices. Many employers are not eager to retain or hire older workers. It is difficult to determine how much of the failure to hire and promote results from discrimination based on age alone and how much of it is related to a realistic and fair appraisal of the aged employee's ability and efficiency. It is true that some elderly individuals are no longer capable of doing as good a job as a younger worker; however, there are many who likely can do a better job than their younger counterparts if given the opportunity. Nevertheless, surveys have shown that some employers accept the negative stereotypes about elderly individuals and believe that older workers are hard to please, set in their ways, less productive, frequently absent, and involved in more accidents. -The status of the elderly may improve with time and as their numbers increase with the aging of the baby boomers. As older individuals gain political power, the benefits and privileges designed for the elderly will increase. There is power in numbers, and the 21st century promises power for people aged 65 and older.

Older Americans

-Older: 55-64 -Elderly: 65-74 -Aged: 75-84 -Very Old: 85 and older -Young old: 60-74 -Middle old: 75-84 -Old old: 85 and older

Skin

-One of the most dramatic changes that occurs in aging is the loss of elastin in the skin. This effect, as well as changes in collagen, causes aged skin to wrinkle and sag. Excessive exposure to sunlight compounds these changes and increases the risk of developing skin cancer. -Fat redistribution results in a loss of the subcutaneous cushion of adipose tissue. Thus, older people lose "insulation," their skin appears thinner, and they are more sensitive to extremes of ambient temperature than are younger people. A diminished supply of blood vessels to the skin results in a slower rate of healing.

Social Implications

-Retirement is often anticipated as an achievement in principle but met with a great deal of ambiguity when it actually occurs. Our society places a great deal of importance on productivity, making as much money as possible, and doing it at as young an age as possible. These types of values contribute to the ambiguity associated with retirement. Although leisure has been acknowledged as a legitimate reward for workers, leisure during retirement historically has lacked the same social value. Adjustment to this life-cycle event becomes more difficult in the face of societal values that are in direct conflict with the new lifestyle. -Historically, many women have derived a good deal of their self-esteem from their families—birthing them, rearing them, and being a "good mother." Likewise, many men have achieved self-esteem through work-related activities—creativity, productivity, and earning money. With the termination of these activities may come a loss of self-worth, resulting in depression in some individuals who are unable to adapt satisfactorily. Well-being in retirement is linked to factors such as stable health status and access to health-care services, adequate income, the ability to pursue new goals or activities, extended social network of family and friends, and satisfaction with current living arrangements. -American society often identifies an individual by his or her occupation. This is reflected in the conversation of people who are meeting each other for the first time. Undoubtedly, most people have either asked or been asked at some point in time, "What do you do?" or "Where do you work?" Occupation determines status, and retirement represents a significant change in status. The basic ambiguity of retirement occurs in an individual's or society's definition of this change. Is it undertaken voluntarily or involuntarily? Is it desirable or undesirable? Is one's status made better or worse by the change? -In looking at the trend of the past two decades, we may presume that retirement is becoming, and will continue to become, more accepted by societal standards. With many individuals retiring earlier and living longer, a growing number of aging people will spend a significantly longer time in retirement. It is a major life event that requires planning and realistic expectations of life changes.

Sexual Abuse

-Sexual molestation; rape -Any type of sexual intimacy against the elderly person's will

Sexual Aspects of Aging

-Sexuality and the sexual needs of elderly people are frequently misunderstood, condemned, stereotyped, ridiculed, repressed, and ignored. Americans have grown up in a society that has liberated sexual expression for all other age groups but still retains certain Victorian standards regarding sexual expression by the elderly. Negative stereotyped notions concerning sexual interest and activity of the elderly are common. Some of these include ideas that older people have no sexual interests or desires, that they are sexually undesirable, or that they are too fragile or too ill to engage in sexual activity. Some people even believe it is disgusting or comical to consider elderly individuals as sexual beings. -These cultural stereotypes undoubtedly play a large part in the misperception many people hold regarding sexuality of the aged, and they may be reinforced by the common tendency of the young to deny the inevitability of aging. With reasonable good health and an interesting and interested partner, there is no inherent reason that individuals should not enjoy an active sexual life well into late adulthood.

Musculoskeletal System

-Skeletal aging involving the bones, muscles, ligaments, and tendons probably generates the most frequent limitations on activities of daily living experienced by aging individuals. Loss of muscle mass is significant, although this occurs more slowly in men than in women. Demineralization of the bones occurs at a rate of about 1 percent per year throughout the life span in both men and women. However, this increases to approximately 10 percent in women around menopause, making them particularly vulnerable to osteoporosis. -Individual muscle fibers become thinner and less elastic with age. Muscles become less flexible following disuse. There is diminished storage of muscle glycogen, resulting in loss of energy reserve for increased activity. These changes are accelerated by nutritional deficiencies and inactivity.

Retirement

-Statistics reflect that a larger percentage of Americans are living longer and that many of them are retiring earlier. Reasons often given for the increasing pattern of early retirement include health problems, Social Security and other pension benefits, attractive "early out" packages offered by companies, and long-held plans (turning a hobby into a money-making situation). -Studies show that about 10 to 20 percent of individuals reenter the workforce following retirement. Reentry is more common among men than women and among those individuals who are at a younger age and in good health at the time of their retirement. Some reasons people give for returning to work following retirement include negative reactions to being retired, feelings of being unproductive, economic hardship, and loneliness. Recent downturns in economic conditions have forced many retired people to seek employment to augment dwindling retirement resources. -Retirement has both social and economic implications for elderly individuals. The role is fraught with a great deal of ambiguity and is one that requires many adaptations on the part of those involved.

Physical Abuse

-Striking, hitting, beating -Shoving -Bruising -Cutting -Restraining

Reminiscene Therapy

-Studies have indicated that reminiscence, or thinking about the past and reflecting on it, may promote better mental health in old age. Life review is related to reminiscence but differs from it in that it is a more guided or directed cognitive process that constructs a history or story in an autobiographical way. -Elderly individuals who spend time thinking about the past experience an increase in self-esteem and are less likely to suffer depression. Some psychologists believe that life review may help some people adjust to memories of an unhappy past. Others view reminiscence and life review as ways to bolster feelings of well-being, particularly in older people who can no longer remain active. -Reminiscence therapy can take place on a one-to-one basis or in a group setting. In reminiscence groups, elderly individuals share significant past events with peers. The nurse leader facilitates the discussion of topics that deal with specific life transitions, such as childhood, adolescence, marriage, childbearing, grandparenthood, and retirement. Members share both positive and negative aspects, including personal feelings, about these life-cycle events. -Reminiscence on a one-to-one basis can provide a way for elderly individuals to work through unresolved issues from the past. Painful issues may be too difficult to discuss in the group setting. As the individual reviews his or her life process, the nurse can validate feelings and help the elderly client come to terms with painful issues that may have been long suppressed. This process is necessary if the elderly individual is to maintain (or attain) a sense of positive identity and self-esteem and ultimately achieve the goal of ego integrity, as described by Erikson (1963). -A number of creative measures can be used to facilitate life review with the elderly individual. Having the client keep a journal for sharing may be a way to stimulate discussion (as well as provide a permanent record of past events for significant others). Pets, music, and special foods have a way of provoking memories from the client's past. Photographs of family members and past significant events are an excellent way of guiding the elderly client through his or her autobiographical review. -Care must be taken in the life review to assist clients to work through unresolved issues. Anxiety, guilt, depression, and despair may result if the individual is unable to work through the problems and accept them. Life review can work in a negative way if the individual comes to believe that his or her life was meaningless. However, it can be a very positive experience for the person who can take pride in past accomplishments and feel satisfied with his or her life, resulting in a sense of serenity and inner peace in the older adult.

How old is old?

-The concept of "old" has changed drastically over the years. -Our prehistoric ancestors probably had a life span of 40 years, with the average individual living around 18 years. -As civilization developed, mortality rates remained high as a result of periodic famine and frequent malnutrition. -An improvement in the standard of living was not truly evident until about the middle of the 17th century. Since that time, assured food supply, changes in food production, better housing conditions, and more progressive medical and sanitation facilities have contributed to population growth, declining mortality rates, and substantial increases in longevity. -In 1900, the average life expectancy in the United States was 47 years, and only 4 percent of the population was aged 65 or over. By 2013, the average life expectancy at birth was 78.8 years (76.4 years for men and 81.2 years for women) -Ideas that all elderly individuals are sick, depressed, obsessed with death, senile, and incapable of change affect the way elderly people are treated. They even shape the pattern of aging of the people who believe them. They can become self-fulfilling prophecies—people start to believe they should behave in certain ways and therefore act according to those beliefs. Generalized assumptions can be demeaning and interfere with the quality of life for older individuals. -the mentally healthy older person possesses a sense of ego integrity and self-acceptance that will help in adapting to the ambiguities of the future with a sense of security and optimism -[Having accomplished the earlier developmental tasks], the person accepts life as his or her own and as the only life for the self. He or she would wish for none other and would defend the meaning and the dignity of the lifestyle. The person has further refined the characteristics of maturity described for the middle-aged adult, achieving both wisdom and an enriched perspective about life and people. -Everyone, particularly health-care workers, should see aging people as individuals, each with specific needs and abilities, rather than as a stereotypical group. Some individuals may seem old at 40, whereas others may not seem old at 70. Variables such as attitude, mental health, physical health, and degree of independence strongly influence how an individual perceives himself or herself. Surely, in the final analysis, whether one is considered old must be self-determined.

Health Status

-The number of days in which usual activities are restricted because of illness or injury increases with age. Approximately 80 percent of older adults have at least one chronic condition, and 50 percent have two or more. The most commonly occurring conditions among the elderly population are hypertension (71%), arthritis (49%), heart disease (31%), cancer (25%), and diabetes (21%). -Emotional and mental illnesses increase over the life cycle. Depression is particularly prevalent, and suicide is a serious problem among elderly Americans. Prevalence of major depression is estimated at between 1 and 5 percent for the general population of older adults but that may rise to as high as 13.5 percent for older adults requiring hospitalization or home health care. Depression in this age group is particularly underdiagnosed and undertreated by both health-care providers and older adults themselves, perhaps related to a misperception that this is a normal part of aging or a natural reaction to illnesses. Neurocognitive disorders increase dramatically in old age.

Continuity Theory

-This theory, also known as the developmental theory, is a follow-up to the disengagement and activity theories. It emphasizes the individual's previously established coping abilities and personal character traits as a basis for predicting how the person will adjust to the changes of aging. Basic lifestyle characteristics are likely to remain stable in old age, barring physical or other types of complications that necessitate change. A person who has enjoyed the company of others and an active social life will continue to enjoy this lifestyle into old age. One who has preferred solitude and a limited number of activities will probably find satisfaction in a continuation of this lifestyle. -Maintenance of internal continuity is motivated by the need for preservation of self-esteem, ego integrity, cognitive function, and social support. As they age, individuals maintain their self-concept by reinterpreting their current experiences so that old values can take on new meanings in keeping with present circumstances. Internal self-concepts and beliefs are not readily vulnerable to environmental change, and external continuity in skills, activities, roles, and relationship styles can remain remarkably stable into the 70s and beyond.

Vision

-Visual acuity begins to decrease in midlife. Presbyopia (blurred near vision) is the standard marker of aging of the eye. It is caused by a loss of elasticity of the crystalline lens and results in compromised accommodation. -Cataract development is inevitable if the individual lives long enough for the changes to occur. Cataracts occur when the lens of the eye becomes less resilient (due to compression of fibers) and increasingly opaque (as proteins lump together), ultimately resulting in a loss of visual acuity. -The color in the iris may fade, and the pupil may become irregular in shape. A decrease in production of secretions by the lacrimal glands may cause dryness and result in increased irritation and infection. The pupil may become constricted, requiring an increase in the amount of light needed for reading.

Nervous System

-With aging, there is an absolute loss of neurons, which correlates with decreases in brain weight of about 10 percent by age 90 Gross morphological examination reveals gyral atrophy in the frontal, temporal, and parietal lobes; widening of the sulci; and ventricular enlargement. However, it must be remembered that these changes have been identified in careful study of adults with normal intellectual function. -The brain has enormous reserve, and little cerebral function is lost over time, although greater functional decline is noted in the periphery. There appears to be a disproportionately greater loss of cells in the cerebellum, the locus ceruleus, the substantia nigra, and olfactory bulbs, accounting for some of the more characteristic aging behaviors such as mild gait disturbances, sleep disruptions, and decreased smell and taste perception. -Some of the age-related changes within the nervous system may be due to alterations in neurotransmitter release, uptake, turnover, catabolism, or receptor functions. A great deal of attention is being given to brain biochemistry and, in particular, to the neurotransmitters acetylcholine, dopamine, norepinephrine, and epinephrine. These biochemical changes may be responsible for the altered responses of many older persons to stressful events and some biological treatments.

Neglect (Intentional or Unintentional)

-Withholding food and water -Inadequate heating -Unclean clothes and bedding -Lack of needed medication -Lack of eyeglasses, hearing aids, false teeth

Psychological Abuse

-Yelling -Insulting, name-calling -Harsh commands -Threats -Ignoring, silence, social isolation -Withholding of affection

Attachment to Others

-[Social networks] contribute to well-being of the elder by (a) promoting socialization and companionship, (b) elevating morale and life satisfaction, (c) buffering the effects of stressful events, (d) providing a confidant, and (e) facilitating coping skills and mastery. -This need for attachment is consistent with the activity theory of aging that correlates the importance of social integration with successful adaptation in later life.

Personality Theory

-address aspects of psychological growth without delineating specific tasks or expectations of older adults. -highly correlated with early life characteristics. -No specific personality changes occur as a result of aging. The older person becomes more of what he or she was. The older person continues to develop emotionally and in personality and adds on characteristics instead of making drastic changes. -In extreme old age, however, people show greater similarity in certain characteristics, probably because of similar declines in biological functioning and societal opportunities. -big five personality traits (conscientiousness, agreeableness, neuroticism, openness, and extraversion) determine how personality changes over the life span. -Age range of the participants was 21 to 60 years. -conscientiousness (being organized and disciplined) increased throughout the age range studied, with the biggest increases during the 20s. -Agreeableness (being warm, generous, and helpful) increased most during a person's 30s. -Neuroticism (being anxious and emotionally labile) declined with age for women but did not decline for men. -Openness (being acceptable to new experiences) showed small declines with age for both men and women. -Extroversion (being outwardly expressive and interested in the environment) declined for women but did not show changes in men. -This study contradicts the view that personality traits tend to stop changing in early adulthood. These researchers suggest that personality traits change gradually but systematically throughout the life span. Their research was foundational in understanding the adult population, though; the elderly were not evaluated in that study. -People over 60 and up to 80 years of age, identify support for the premise that personality traits are relatively stable but do change somewhat over the long term related to aging and possibly in response to intervention. -The personality trait of conscientiousness, for example, when viewed over the course of a lifetime, was found to be relatively stable. -As the population of older adults continues to grow, research has focused not only on what constitutes aging but more specifically on what constitutes successful aging. -Personality is undeniably influential in successful aging (they note that the term successful aging is often used but is controversial to some). -The classic paradigm for successful aging, identifying three criteria which must be met: (1) absence of disease, disability, and risk factors; (2) maintaining physical and mental functioning, and; (3) active engagement in life. -What role do personality factors play in these aspects of successful aging? -Personality trait of conscientiousness as most linked to health-promoting behaviors. -Genetic underpinnings of each of the big five personality traits and, among other findings, identified a gene associated with the trait of conscientiousness. They found that this personality trait gene was associated with the same gene that has been linked to some neurodegenerative diseases, including Alzheimer's disease. -Could personality traits unravel the mysteries of aging and age-related illnesses? What all of this means for intervening in and possibly improving the aging process is still unknown. -Future research may begin to unfold the intricate interaction between genetic and environmental influences such that personality traits might become alterable to promote healthier, more successful aging.

Adaptation to the Tasks of Aging

-loss and grief -attachment to others -maintenance of self-identity -dealing with death

Caregiver outcomes

1. Can problem-solve effectively regarding care of the elderly client. 2. Demonstrate adaptive coping strategies for dealing with stress of caregiver role. 3. Openly express feelings. 4. Express desire to join a support group of other caregivers.

Client outcomes

1. Has not experienced injury. 2. Maintains reality orientation consistent with cognitive level of functioning. 3. Manages own self-care with assistance. 4. Expresses positive feelings about self, past accomplishments, and hope for the future. 5. Compensates adaptively for diminished sensory perception.

Memory Functioning

Age-related memory deficiencies and slower response times have been extensively reported in the literature. Although short-term memory seems to deteriorate with age, perhaps because of poorer sorting strategies, long-term memory does not show similar changes. However, in nearly every instance, well-educated, mentally active people do not exhibit the same decline in memory functioning as their age peers who lack similar opportunities to flex their minds. Nevertheless, with few exceptions, the time required for memory scanning is longer for both recent and remote recall among older people. This can sometimes be attributed to social or health factors (stress, fatigue, illness), but it can also occur because of certain normal physical changes associated with aging (decreased blood flow to the brain).

Age

Because people grow older in very different ways, and the range of differences becomes greater with the passage of time, age is becoming a less relevant characteristic than it was historically. However, because of the high prevalence of chronic health conditions and disabilities, as well as the greater chance of diminishing social supports associated with advancing age, the 65-and-older population is often viewed as an important long-term care target group.

Biological Theories

Biological theories attempt to explain the physical process of aging, including molecular and cellular changes in the major organ systems and the body's ability to function adequately and resist disease. They also attempt to explain why people age differently and what factors affect longevity and the body's ability to resist disease.

Psychiatric Disorders in Later Life

Cognitive disorders, depressive disorders, phobias, and alcohol use disorders are among the most common psychiatric illnesses in later life. Many factors, including medical conditions and medications, may influence symptomatology. One should never assume that psychiatric symptoms are a usual part of aging. Age itself is not a risk factor for depression, but being widowed and having a chronic medical illness are associated with vulnerability to depressive disorders. A thorough assessment is essential to distinguish the multiple factors that may concurrently influence symptomatology.

Sexual Behavior in the Elderly

Coital frequency in early marriage and the overall quantity of sexual activity between ages 20 and 40 correlate significantly with frequency patterns of sexual activity during aging. Although sexual interest and behavior do appear to decline somewhat with age, studies show that significant numbers of elderly men and women have active and satisfying sex lives well into their 80s. Sexual activity can and does continue well past the 70s for healthy, active individuals who have regular opportunities for sexual expression. If an individual has healthy attitudes about sexuality and healthy sexual relationships in younger adulthood, those will probably continue into older adulthood.

Later Life-Delirium

Delirium is one of the most common and critical forms of psychopathology in later life. A number of factors have been identified that predispose elderly people to delirium, including structural brain disease, reduced capacity for homeostatic regulation, impaired vision and hearing, a high prevalence of chronic disease, reduced resistance to acute stress, and age-related changes in the pharmacokinetic and pharmacodynamics of drugs. Delirium needs to be recognized and the underlying condition treated as soon as possible. A high mortality rate is associated with this condition.

Later Life-Depression

Depressive disorders are the most common affective illnesses occurring after the middle years. The incidence of increased depression among elderly people is influenced by the variables of physical illness, functional disability, cognitive impairment, and loss of a spouse. Somatic symptoms are common in the depressed elderly. Symptomatology often mimics that of NCD, a condition that is referred to as pseudodementia. Suicide is prevalent in the elderly, with declining health and decreased economic status being considered important influencing factors. Treatment of depression in the elderly individual may include psychotropic medications or electroconvulsive therapy. Tricyclic antidepressants pose a risk for orthostatic hypotension and other anticholinergic effects, and selective serotonin reuptake inhibitors (SSRIs) pose a higher risk for hyponatremia in the elderly, so risks and benefits of medication use should be carefully reviewed.

Psychosocially Related Diagnoses

Disturbed thought processes related to age-related changes that result in cerebral anoxia, evidenced by short-term memory loss, confusion, or disorientation (This diagnosis has been retired by NANDA-I but retained in this text because of its appropriateness to the specific behaviors described.) Complicated grieving related to bereavement overload, evidenced by symptoms of depression Risk for suicide related to depressed mood and feelings of low self-worth Powerlessness related to lifestyle of helplessness and dependency on others, evidenced by depressed mood, apathy, or verbal expressions of having no control or influence over life situation Low self-esteem related to loss of pre-retirement status, evidenced by verbalization of negative feelings about self and life Fear related to nursing home placement, evidenced by symptoms of severe anxiety and statements such as "Nursing homes are places to go to die" Disturbed body image related to age-related changes in skin, hair, and fat distribution, evidenced by verbalization of negative feelings about body Ineffective sexuality pattern related to pain associated with vaginal dryness, evidenced by reported dissatisfaction with decrease in frequency of sexual intercourse Sexual dysfunction related to medications (e.g., antihypertensives) evidenced by inability to achieve an erection Social isolation related to total dependence on others, evidenced by expression of inadequacy in or absence of significant purpose in life Risk for trauma (elder abuse) related to caregiver role strain Caregiver role strain related to severity and duration of the care receiver's illness; lack of respite and recreation for the caregiver, evidenced by feelings of stress in relationship with care receiver; feelings of depression and anger; or family conflict around issues of providing care

Environmental Theory

Factors in the environment (industrial carcinogens, sunlight, trauma, and infection) bring about changes in the aging process. Although these factors are known to accelerate aging, the impact of the environment is a secondary rather than a primary factor in aging. Science is only beginning to uncover the many environmental factors that affect aging.

The Normal Aging Process-Biological Aspects of Aging

Individuals are unique in their physical and psychological aging processes, as influenced by their predisposition or resistance to illness; the effects of their external environment and behaviors; their exposure to trauma, infections, and past diseases; and the health and illness practices they have adopted during their life span. As the individual ages, there is a quantitative loss of cells and changes in many of the enzymatic activities within cells, resulting in a diminished responsiveness to biological demands made on the body. Age-related changes occur at different rates for different individuals, although in actuality, when growth stops, aging begins. This section presents a brief overview of the normal biological changes that occur with the aging process.

Loss and Grief

Individuals experience losses from the very beginning of life. By the time individuals reach their 60s and 70s, they have experienced numerous losses, and mourning has become a lifelong process. Unfortunately, with the aging process comes a convergence of losses, the timing of which makes it impossible for the aging individual to complete the grief process in response to one loss before another occurs. Because grief is cumulative, this can result in bereavement overload, which has been implicated in the predisposition to depression in the elderly.

Marital Status, Living Arrangement, and the Informal Support Network

Individuals who are married and live with a spouse are the least likely of all disabled people to be institutionalized. Those who live alone without resources for home care and with few or no relatives living nearby to provide informal care are at higher risk for institutionalization.

The nurse should be familiar with the normal physical changes associated with the aging process. Examples of some of these changes include the following:

Less effective response to changes in environmental temperature, resulting in hypothermia Decreases in oxygen use and the amount of blood pumped by the heart, resulting in cerebral anoxia or hypoxia Skeletal muscle wasting and weakness, resulting in difficulty in physical mobility Limited cough and laryngeal reflexes, resulting in risk of aspiration Demineralization of bones, resulting in spontaneous fracturing Decrease in gastrointestinal motility, resulting in constipation Decrease in the ability to interpret painful stimuli, resulting in risk of injury

Health

Level of functioning, as determined by ability to perform various behaviors or activities—such as bathing, eating, mobility, meal preparation, handling finances, judgment, and memory—is a measurable risk factor. The need for ongoing assistance from another person is critical in determining the need for long-term care.

Later Life-Neurocognitive Disorder

Neurocognitive disorders (NCDs) are the most common causes of psychopathology in the elderly. About half of these disorders are of the Alzheimer's type, which is characterized by an insidious onset and a gradually progressive course of cognitive impairment. No curative treatment is currently available. Symptomatic treatments, including pharmacological interventions, attention to the environment, and family support, can help to maximize the client's level of functioning.

Wear-and-Tear Theory

Proponents of this theory believe that the body wears out on a scheduled basis. Since animals have some ability to repair themselves, it would seem that this theory does not fit what we know about biological systems. A related theory suggests that free radicals, which are the waste products of metabolism, accumulate and cause damage to important biological structures. Free radicals are molecules with unpaired electrons that exist normally in the body; they also are produced by ionizing radiation, ozone, and chemical toxins. According to this theory, these free radicals cause DNA damage, cross-linkage of collagen, and the accumulation of age pigments.

Physiologically Related Diagnoses

Risk for trauma related to confusion, disorientation, muscular weakness, spontaneous fractures, falls Hypothermia related to loss of adipose tissue under the skin, evidenced by increased sensitivity to cold and body temperature below 98.6°F Decreased cardiac output related to decreased myocardial efficiency secondary to age-related changes, evidenced by decreased tolerance for activity and decline in energy reserve Ineffective breathing pattern related to increase in fibrous tissue and loss of elasticity in lung tissue, evidenced by dyspnea and activity intolerance Risk for aspiration related to diminished cough and laryngeal reflexes Impaired physical mobility related to muscular wasting and weakness, evidenced by need for assistance in ambulation Imbalanced nutrition, less than body requirements, related to inefficient absorption from gastrointestinal tract, difficulty chewing and swallowing, anorexia, difficulty in feeding self, evidenced by wasting syndrome, anemia, weight loss Constipation related to decreased motility; inadequate diet; insufficient activity or exercise, evidenced by decreased bowel sounds; hard, formed stools; or straining at stool Stress urinary incontinence related to degenerative changes in pelvic muscles and structural supports associated with increased age, evidenced by reported or observed dribbling with increased abdominal pressure or urinary frequency Urinary retention related to prostatic enlargement, evidenced by bladder distention, frequent voiding of small amounts, dribbling, or overflow incontinence Disturbed sensory perception related to age-related alterations in sensory transmission, evidenced by decreased visual acuity, hearing loss, diminished sensitivity to taste and smell, or increased touch threshold (This diagnosis has been retired by NANDA-I but retained in this text because of its appropriateness to the specific behaviors described.) Insomnia related to age-related cognitive decline, decrease in ability to sleep ("sleep decay"), or medications, evidenced by interrupted sleep, early awakening, or falling asleep during the day Chronic pain related to degenerative changes in joints, evidenced by verbalization of pain or hesitation to use weight-bearing joints Self-care deficit (specify) related to weakness, confusion, or disorientation, evidenced by inability to feed self, maintain hygiene, dress/groom self, or toilet self without assistance Risk for impaired skin integrity related to alterations in nutritional state, circulation, sensation, or mobility

Later Life-Sleep Disorders

Sleep disorders are very common in the aging individual. Roughly 50 percent of older adults report difficulty initiating or maintaining sleep, and these disorders may contribute to cognitive changes. Contributing factors include medical conditions, medications, age-related changes in circadian rhythms, sleep disordered breathing, and restless leg syndrome. Sedative-hypnotics, along with nonpharmacological approaches, are often used as sleep aids with the elderly. Changes in aging associated with metabolism and elimination must be considered when maintenance medications are administered for chronic insomnia in the aging client.

Longer Life

The 65-and-older age group has become the fastest-growing segment of the population. Within this segment, the number of elderly older than age 75 has increased most rapidly. This trend is expected to continue well into the 21st century. The 75-and-older age group is the one most likely to be physically or mentally impaired, requiring assistance and care from family members. This group also is the most vulnerable to abuse from caregivers.

Learning Ability

The ability to learn is not diminished by age. Studies, however, have shown that some aspects of learning do change with age. The ordinary slowing of reaction time with age for nearly all tasks or the overarousal of the central nervous system may account for lower performance levels on tests requiring rapid responses. Under conditions that allow for self-pacing by the participant, differences in accuracy of performance diminish. Ability to learn continues throughout life, although it is strongly influenced by interests, activity, motivation, health, and experience. Adjustments need to be made in teaching methodology and time allowed for learning.

Autoimmune Theory

The autoimmune theory describes an age-related decline in the immune system. As people age, their ability to defend against foreign organisms decreases, resulting in susceptibility to diseases such as cancer and infection. These aging cells become unable to distinguish between themselves and foreign proteins and begin to attack themselves. A rise in the body's autoimmune response occurs, leading to the development of autoimmune diseases such as rheumatoid arthritis and allergies to food and environmental agents. This theory, though, is based on clinical rather than experimental evidence.

Intellectual Functioning

There appears to be a high degree of regularity in intellectual functioning across the adult age span. Crystallized abilities, or knowledge acquired in the course of the socialization process, tend to remain stable over the adult life span. Fluid abilities, or abilities involved in solving novel problems, tend to decline gradually from young to old adulthood. In other words, intellectual abilities of older people do not decline but do become obsolete. The age of their formal educational experiences is reflected in their intelligence scoring.