Understanding the Aging Demographic

Demographics

• Nearly 1 in 7 US residents was 65+ in 2018
• Over 52 million people were 65+ in 2018, expected to reach 95 million in 2060
• By 2060, life expectancy is predicted to increase for men to 83.9 years and for women to 87.3 years
• The fastest-growing age group is 85+
• The 85+ age group is projected to increase from 6.5 million in 2017 to 14.4 million in 2040
• There is a greater emphasis on health promotion, disease prevention, and early detection
• Better care management correlates with the increasing age demographic
• The demographic is also becoming more diverse
• Young-old adults are 65 to 74 years old, typically healthier with good cognitive function and independent
• Old-old adults are 85 and older, often widowed, divorced, single females dependent on family for support or care, and who outlived children, partners, and siblings
• Frail older adults often have conditions that interfere with living independently

Attitudes Toward Aging

• Aging is normal and influenced by many factors
• Older adults have diverse characteristics and it is impotant to value their diverse life experiences and history
• Assess their perceptions of age and health
• Providing care should not be based on age alone
• Myths and stereotypes can lead to poor care
• "Ageism" is a negative attitude and leads to discrimination and disparities in care

Chronically Ill Older Adults

• The incidence of chronic illness triples after age 45
• Most people over age 65 have at least one chronic condition; HTN, arthritis, heart disease, diabetes, cancer, stoke, COPD, and often have multiple comorbidities

Specific Older Adult Populations

• Rural older adults face five barriers to health care access, including: transportation, limited access to healthcare agencies/workers, a lack of quality healthcare, social isolation, and financial limits
• Homeless older adult: numbers are increasing due to health, economic, or social status crises
• Homeless older adult: there is a higher risk of health problems and mortality
• Homeless older adult: they are less likely to use shelters and meal sites and require an interprofessional approach to provide access to health care resources
• Frail older adults manifest frailty with three or more of unintentional weight loss/muscle loss, self-reported exhaustion, weakness, slow walking speed, and low levels of physical activity
• Stress and strain may lead to ineffective coping, mobility limitations, sensory impairment, cognitive decline, and falls

Nutrition Assessment: SCALES

• SCALES acronym: Sadness, Cholesterol (high), Albumin (low), Loss or gain of weight, Eating problems, and Shopping and food preparation problems

Elder Mistreatment

• Mistreatment is intentional acts of omission or commission by a caregiver or trusted other and cause harm or serious risk for harm to a vulnerable older adult.
• Mistreatment may occur at home, in assisted-living facilities, or institutions
• It is underreported by victims and HCP
• 90% of domestic elder mistreatment is by family members
• Adult children who are dependent on housing and/or finances, have a history of violence, substance use, or mental illness, or are unemployed can be perpetrators
• Spouses/partners that begin or continue violence can be perpetrators
• Risk factors for elder mistreatment include physical or cognitive limitations, psychiatric disorders, alcohol use, a lack of social support, larger households, and inadequate income
• Types of elder mistreatment: physical, psychologic, sexual, or financial abuse; neglect, abandonment, and violation of personal rights
• Types of elder mistreatment in institutions: failure to follow the plan of care, the use of physical or chemical restraints, over or under medicating, and/or punishment by isolation
• Elder mistreatment must be assessed with a nursing history and physical assessment, screening, and safety plan
• Evidence of elder mistreatment; photos with consent should be documented and reported
• Mandatory reporting exists in most states with adult protective services (APS) and law enforcement

Self Neglect

• Inability to meet basic needs; refuse help
• Have multiple, untreated medical or psychiatric conditions
• Live alone, often in squalor
• Experience higher rates of mortality
• Nursing intervention: refer to long-term case management, and APS as needed

Social Services for Older Adults

• Administration on Aging (AoA): part of the Departments of Health and Human Services and is a federal agency responsible for many older adult programs
• Area agency on aging: State and local agencies funded from the AoA
• Medicare is a federally funded insurance program for people ages 65 or older and covers those less than 65 with disabilities or end-stage renal disease (dialysis or transplant)
• Medicare coverage is limited and out-of-pocket expenditures continue to rise
• Medicaid is a state-administered, needs-based program to assist eligible low-income people with medical expenses, and covers most long-term care in the US if not privately paid

Assessment Tool- SPICES

• SPICES, Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin Breakdown

Care Alternatives Older Adults

• Adult day care: Provide social and recreational services and ADL and assistance in a supervised setting for cognitively impaired adults and those unable to perform ADLs independently
• Home health care (HHC) includes those who are homebound 1-2x a week, have intermittent or acute health needs, a supportive caregiver involvement, a physician’s order, and require skilled nursing care for Medicare reimbursement
• Long-term care facilities: Placement factors include rapid patient deterioration or function, caregiver stress, and burnout, and/or alteration in or loss of a family support system
• Caregiver concerns: resistance, insufficient care, loneliness and cost
• Relocation stress syndrome: disruption, confusion, anxiety, depression, and disorientation

Legal and Ethical Issues

• Legal: Advance directives, estate planning, taxes, denied services, finances, and exploitation
• Ethical: Resuscitation, treatment of infections, nutrition, hydration, and transfer to a higher level of care
• Nursing responsibilities: stay current on ethical issues, identify when ethical issues occur, and advocate/ethics committee guidance

Nursing Management of the Older Adult

• Fall risk factors: medications; infections; orthostatic hypotension; dehydration; electrolyte imbalance, arthritis, changes in gait, balance and mobility, neurologic problems, and decreased muscle strength, reduced visual acuity
• Other fall risk factors: environmental hazards (clutter, rugs, slippery floors, bed too high, poor lighting, and uneven pavement), improper footwear, or assistive devices
• Health promotion: population health through vaccines, reducing hazards in the environment, drink liquids and reduce sugar and salt, 150 minutes of moderate intensity exercise weekly, nutrition for a healthy weight, and meds, herbs and supplements as ordered.
• Care transitions can be challenging and need to be prepared for
• Rehospitalization is a risk
• Transitional care model: evidence-based and innovate care coordination and management model
• Rehabilitation goal: adapt to/recover from disability or functional decline, strive for maximal function and physical capabilities
• Impaired by existing conditions, immobility, falls, nutrition, and finances
• Encouragement, support, and acceptance can help with motivation for rehab

Nursing Management of the Older Client

• Medication use is more difficult due to cognitive impairment, sensory perception changes, limited hand mobility, and cost
• The inability to read labels and understand health information can contribute to nonadherence due to multiple comorbidities
• Polypharmacy, overdose, and addiction are major causes of illness
• Medication errors can be prevented by regular review of the regimen by a pharmacist
• Depression is not a normal part of aging
• 2nd highest rate of suicide is in those over 75
• Often occurs together with medical conditions and affects adherence with treatment
• Encourage older adults and caregivers with depression to seek medical attention and support
• The current standard for restraint is to provide safe care without restraints of any form
• Physical restraints and chemical restraints: only used to ensure safety and as a last resort with careful documentation, assess need for restraint with an physician's order, determine unmet physiological or psychosocial needs
• Least restrictive approach with time limits, observations and care, alternatives tried and ability to discontinue should be standard practice

Health Disparities and Older Adult Women

• Women have fewer financial resources than men

Demographic Trends Among Older Americans

• A growth in racial and ethnically diverse populations

Elder Mistreatment

• Sacral pressure injury on a patient who lives at home

M.S. Case Study #A

• M.S. is an 85-year-old woman who fell in the bathroom and broke her left hip; she is three days post-op
• She lives in a two-story home and does not drive with MD insurance through medicare. A friend takes her places.
• She is alert and oriented to person and place and occasionally disoriented to time and situation
• Requires moderate assistance with transfers and ADLs and takes hydrocodone with acetaminophen every six hours as needed for pain control

C.L. Case Study #B

76-year-old Filipino woman, was admitted with confusion and found to have a UTI. Her medical history includes HTN, diabetes, lung cancer, mild renal insufficiency, depression, macular degeneration, and significant hearing loss.

• A stroke occurred 5 years ago and has residual right-sided weakness; 100-pack-year history of tobacco use
• Unplanned weight loss of 15 pounds in the past year
• Confusion and urinary incontinence for the past 3 days
• Came to the United States 35 years ago from Manila and speaks Tagalog with limited English proficiency
• Lives with her unemployed adult son, who provides help with ADLs and IADLs
• Has three daughters who live within a 2-hour drive and limited financial resources but has Medicare benefits
• Daughters raise concerns about their mother's care and safety at home, given their brother's history of anger issues and gambling addiction. The brother’s response is "I'm doing the best I can. She refuses to help. She refuses to go to the doctor. What do you want me to do? She's old. She's crazy. She's going to die anyway.”
• Daughters state that their mother does not want to go to a nursing home
• Presents with unwashed, matted hair, poor oral hygiene, overgrown toenails with 2 - stage 3 sacral pressure ulcers, unstageable right heel pressure ulcer, multiple small bruises on her forearms and shins, and a 5 x 10 cm bruise in the middle of her back
• Labs reveal: serum albumin 2.4 g/dL, creatinine 1.3 mg/dL, BUN 26 mg/dL and Urinalysis reveals +leukocytes, + nitrites, 3+ blood, + bacteria