Healthcare Promotion and Care of the Older Adult PDF

**Chapter 33** **Healthcare Promotion and Care of the Older Adult** Older adulthood begins at about 65 years of age and continues until death older adulthood is split into 4 groups 1. Young-Old: 65 to 74 years old 2. Middle-Old: 75 to 84 years old 3. Old-Old: 85 to 99 years old 4. Elite-Ol...

**Chapter 33** **Healthcare Promotion and Care of the Older Adult** Older adulthood begins at about 65 years of age and continues until death older adulthood is split into 4 groups 1. Young-Old: 65 to 74 years old 2. Middle-Old: 75 to 84 years old 3. Old-Old: 85 to 99 years old 4. Elite-Old: 100 years old and older **Chronologic Age:** An individual expressed as time elapsed since birth (chronologic age may not be an accurate predictor of heath and behavior) **Traits of a Healthy Person** 1. **Self-responsibility**: Is attuned to body messages and knowledgeable about health status and feels empowered to make healthy choices. 2. **Nutritional awareness**: Learns about healthy eating habits that reduce the risk for heart disease, high blood pressure, diabetes, osteoporosis, and cancer and that assist in achieving and maintaining a healthy body weight. 3. **Physical fitness**: Engages in regular physical activity, including aerobics, and activities that improve balance, muscle flexibility, and muscle strength. 4. **Stress management**: Identifies ways of coping with the stresses of life to be able to work productively and connect with others in the community. 5. **Environmental sensitivity**: Designs personal space to include a healthy physical and social environment with opportunities for time with friends, supportive network, giving and receiving affection, and reinforcing wellness behaviors. **Primary prevention** stresses exercise to prevent cardiovascular disease, falls, and depression. Older people who quit smoking can reduce their risk of heart disease and improve lung function and circulation. A well-balanced diet without excessive sugar, fat, or alcohol is another important aspect of primary prevention. Primary prevention also includes recommended vaccinations. Immunizations recommended for older adults include an annual influenza vaccine, a tetanus/ diphtheria (Td) or tetanus/ diphtheria/pertussis booster every 10 years, a zoster (shingles) vaccine for those over the age of 60, and the pneumococcal vaccines (PCV13 and PPSV23) after 65. **Secondary prevention** in older adults focuses on early detection and treatment of disease, including screening for heart disease and hypertension (HTN), cancer, infectious disease, polypharmacy (misuse of multiple medica-tions), nutrition, oral health, osteoporosis, falls, de-pression, and social isolation **Healthy People 2030** **GOAL FOR OLDER ADULTS** Improve the Health, Function, and Quality of Life the Healthy People 2030 objectives for older adults are designed to promote healthy outcomes for this population. Many factors affect the health, function, and quality of life of older adults. Specifically, the focus is on: 1. Individual behaviors that promote health, such as participation in physical activity, self-management of chronic diseases, or use of preventive health services, and can improve health outcomes 2. Social environmental factors that promote health, such as housing and transportation services that affect the ability of older adults to access care; and 3. Health and social services are available to older adults and their caregivers to assist them in managing chronic conditions and long-term care needs effectively. Myths and Realities **THEORIES OF AGING** Our current knowledge about aging and the aging process is limited. To explain aging and an individual\'s response to aging, experts have proposed a number of theories. Biological theories attempt to explain why the body ages; psychosocial **Common Theories of Aging** ***BIOLOGICAL*** **Programmed Aging** Cells in the body can reproduce only 40-60 times. Aging takes place when more and more cells no longer have the capacity to regenerate themselves. **GENETIC FACTORS** People inherit a genetic program that determines their specific life expectancy. **IMMUNOLOGIC** The immune system becomes less effective or less able to distinguish between foreign and host cells, and aging is a result of the consequentially diminished protection from infection or disease, and the immune system destroying body cells that it misreads as defective or foreign. **FREE RADICAL** During the metabolic activity of the body that produces energy, extra electrons are released that build up in the body and combine chemically, damaging cells and interfering with normal body function, resulting in aging. **WEAR AND TEAR** Cells of the body wear out from internal and external stress, including chemical damage, trauma, or dysfunction of body systems, and buildup of waste products. ***PSYCHOSOCIAL*** **Erikson\'s Developmental Stages** In the last stage of life, the task is acceptance of life and one\'s own lifestyle, which potentially results in ego integrity. Inability to achieve a level of acceptance results in anger and despair. **Disengagement Theory** Aging is a process in which older adults and society gradually withdraw from each other to the mutual satisfaction of both. **Exchange Theory** Aging reduces interaction between older adults and society as a result of the decreasing value that the interaction has for both. **Activity Theory** Older adults develop a positive concept of self because of maintaining ongoing social interactions. Well-being in later life is enhanced by substituting new roles in relation to family, recreation, and volunteer services for previous occupational roles. **Continuity Theory** Personality remains the same, and behavior becomes more predictable as people age. **AGEISM** Ageism is a term that describes prejudice against older adults. It reflects a negative response by younger people a personal dread of growing old or becoming disabled, and a fear of powerlessness, uselessness, and death. Ageism systematically stereotypes and discriminates against people because they are old, just as racism and sexism stereotypes and discriminates against people based on skin color and sex. **LEGISLATION THAT AFFECTS OLDER ADULTS** The first major legislation that attempted to provide financial security for older adults was the Social Security Act of 1935. **LOSS, GRIEF, AND DEPRESSION** Significant psychosocial changes experienced by older adults typically include personal, social, and economic losses resulting from role changes, retirement, and the loss of significant others- parents, siblings, children, spouses, and friends. Physical changes often result in loss of independence and space. For some older adults, losses may occur suddenly, concurrently, or within a short period, thus increasing their impact. The ability to cope with grief and the related losses depends on many factors. Successful coping strategies to deal with grief may include avoiding isolation and self-pity, helping others, joining groups, adopting a pet, setting goals, maintaining independence, and retaining a sense of humor **Short-term or long-term depression may result in response to the grief from real and perceived losses.** **Fatigue, sadness, insomnia, anorexia, helplessness, crying, agitation, and hypochondria are frequent symptoms of depression in older adults.** These symptoms are misunderstood commonly as changes that normally occur with aging. Misunderstanding and misdiagnosis too often result in many older adults failing to receive the needed treatment for depression. ***AGING BODY*** **INTEGUMENTARY:** - Age spots called lentigo are tan or brown macules brought on by sun exposure and more common in middle age and older people. - Pruritus dryness and itching of the skin - Bilateral clubbing of fingers indicates possible pulmonary or cardiac disease **GASTROINTESTINAL** - Pernicious Anemia is a decrease in red blood cells when the body cannot absorb vitamin B12 - Decreased tone of the intestine occurs and it is common for peristalsis to become slower leading to increased constipation - Many medications may reduce saliva production - Dysphagia is difficulty swallowing may be caused by stroke, another neurological dysfunction, local trauma and obstruction with tumor **URINARY** - Nocturia is when you must get up twice or more during the night to urinate - Urinary Incontinence - **Stress incontinence** is involuntary loss of small amounts of urine with increase abdominal pressure, such as sneezing and coughing common in older women and women who\'ve had multiple vaginal births and loss of muscle tone - **Urge incontinence** is involuntary urine loss after a sudden urge to void associated with cystitis, tumor stones, & central nervous system disorders like stroke, dementia and Parkinson disease - **Overflow incontinence** occurs when chronically full bladder increases bladder pressure to a higher level than urethral resistance can counter resulting in a loss of a small volume of urine - **Functional incontinence** occurs because of inability or unwillingness to get to the toilet because of physical limitations, depression, or confinement to bed or use of restraints **CARDIOVASCULAR** - Hypertension (HTN)contributes to coronary artery disease (CAD)and stroke it also contributes to the development of heart failure (HF), renal failure and peripheral vascular disease (PVD) - Dysrhythmias changes in the structure of the heart, the blood supply to the heart and the pacemaker system sometimes make the heart susceptible to irregular heart rhythms. The heart is less effective in supplying blood to the body and have potential to lead to heart failure - Peripheral Vascular Disease (PVD) inadequate supply of arterial blood to the lower extremities resulting in a condition known a PVD **RESPIRATORY** - Chronic obstructive pulmonary disease. A common respiratory condition of older adults, chronic obstructive pulmonary disease (COPD) is not a single disease but commonly a combination of chronic bronchitis, chronic asthma, and emphysema in varying degrees because of progressive changes that are seen as individuals become older. A smoking history increases the risk of debilitating COPD. Assessment reveals diminished breath sounds, crackles, and wheezes and a \"barrel chest\" characterized by an increased anteroposterior diameter. - Pneumonia. Age-related changes and decreased resistance to respiratory infections cause more older individuals to contract and die of pneumonia than younger people. Older individuals do not always exhibit the usual signs and symptoms of pneumonia, such as high fever, cough, pain, and headache. In contrast, they often show signs and symptoms only of lethargy, disorientation, anorexia, and low or mild fever. Older adults who show such signs and symptoms should consult their health care provider for diagnosis and treatment, **MUSCULOSKELETAL** - Arthritis. Two forms of arthritis may occur in the older adult. Rheumatoid arthritis, a systemic inflammatory disease thought to be of immune factor origin, has the potential to affect people of any age. - Osteoarthritis, or degenerative joint disease, is a noninflammatory disorder in which the cartilage in the joints deteriorates and new bone forms on the surface. This is the most common type of arthritis in older adults. Because the chronic nature of osteoarthritis affects an individual\'s functional ability and lifestyle, interventions for older individuals with arthritis involve joint protection and energy conservation through a balance between rest and exercise. - Osteoporosis. Osteoporosis, a systemic skeletal disease, is one of the most common conditions in older women. The characteristic low bone mass and deterioration of bone tissue result in a significantly increased risk of fractures. **ENDOCRINE** Type 2 diabetes mellitus. There are two general types of DM: t**ype 1 (formerly called insulin-dependent diabetes mellitus \[IDDM\] or juvenile diabetes), in which the body fails to produce insulin**; and **type 2 (formerly called non-insulin dependent \[NIDDM\] or adult-onset diabetes), which is characterized by the body\'s inability to produce and use insulin appropriately**. Type 2 DM is more common than type 1 DM, and it affects 85% to 90% of adults with diabetes. Hypothyroidism Of people older than 65 years of age 20% have thyroid problems, the most frequent of which is hypothyroidism. Decreased thyroid function often appears in a subclinical form, and the health care provider becomes aware of it through the results of routine serum testing. Almost all cases are inconspicuous and progress slowly toward thyroid failure. Signs frequently linked to hypothyroidism in older adults include unexplained elevation in triglycerides or plasma cholesterol, nonspecific cognitive impairment, slow metabolism, chest pain or atrial fibrillation, constipation, macrocytic anemia, vague arthritic reports, cold intolerance, and depression with underlying apathy and withdrawal. **REPRODUCTIVE** If an older adult indicates that sexual intercourse is difficult or uncomfortable because of vaginal dryness, suggest use of estrogen creams or water-soluble lubricants to relieve the discomfort. **SENSORY** - **Vision** Age-related changes in vision include presbyopia (farsightedness resulting from a loss of elasticity of the lens of the eye), or narrowing of the peripheral field of vision, decreased ability to focus on near objects, and a decrease in visual acuity as the pupil becomes smaller and less responsive to light. - Glaucoma, the second leading cause of blindness in the United States, is caused by an occlusion in the drainage of the fluid in the anterior chamber of the eye, which produces an increase in intraocular pressure. Pressure transfers to the optic nerve, where damage or blindness is a possible result. - Cataracts. Cataracts are the most common disorder found in the aging eye. By the age of 80 an estimated 50% of people either have cataracts or have had surgery to correct them. A cataract is a clouding of the normally clear and transparent lens of the eye. - **Hearing and balance** Hearing loss is not a normal part of aging and is necessary to evaluate. The inner ear is involved in hearing and balance. - Presbycusis is a sensorineural hearing loss and the most common form of loss in older adults. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones and conversational speech. - **Touch** involves tactile information involving pressure, vibration, and temperature. Age-related changes that affect the sense of touch and position include a decrease in the number of receptor cells throughout the skin and joints. Older adults have increasing difficulty sensing temperature and maintaining balance, which places them at risk for burns and falls. The most common disorders to affect tactile ability include stroke, PVD, and diabetic neuropathy. - **Smell and taste** Olfactory receptors decline in number, which tends to reduce or alter a person\'s ability to smell. A decrease is also seen in the number of taste buds, which often influences appetite and causes the person to use more seasoning. **NERVOUS SYSTEM** **Cognition** The process by which information is acquired, stored, shared, and used is called cognitive function. The elements of this process include state of consciousness, general appearance and behavior, orientation, memory, language, intelligence, perception, insight and problem-solving ability, judgment, attention span, and mood and affect. Outcomes from cognitive function are thinking, remembering, perceiving, communicating, and calculating. Many people think that cognitive abilities decline in old age. Only some older people experience some deficits, and the decline occurs at different times in their lives. Generalizations about cognitive decline in older adults are inappropriate. Intelligence and continued ability to learn is possible throughout the lifetime. Teaching strategies may need modification, and learning may require reinforcement because of the age-related changes in the senses and nervous system. **Delirium**. Senility (the state of mental and physical deterioration associated with aging) is a fear and a myth associated with aging. Delirium is a reversible condition of rapid onset. Delirium is not a disease of the nervous system; it is a syndrome that results from one or more causes, including the following: - Fever or infection - Dehydration or malnutrition - Electrolyte imbalances (hyponatremia or hypocalcemia) - Fever or infection - Sleep deprivation - Alcohol or drug use, abuse, or withdrawal - Pain - Medications (analgesics, hypnotics, psychotropics) - Physiological conditions resulting in inadequate oxygenation to the brain **Dementia and Alzheimer disease**. Experts define dementia as a progressive impairment of intellectual (cognitive) function. The reduction in mental performance affects interpersonal relationships and other activities. Aphasia (inability to understand words), agnosia (inability to recognize familiar objects), apraxia (problems manipulating things), and agraphia (difficulty writing and drawing) are symptoms of dementia, as well as noticeable changes in the personality. Alzheimer disease is the most common cause of de-mentia. Dementia of the Alzheimer type is a progressive disorder in which the brain atrophies. It usually arises in individuals older than 60 years of age and includes loss of cortical neurons, enlarged ventricles, and senile plaques and neurofibrillary tangles that appear in the cortex of the brain. The early stage consists of a gradual onset of memory loss and difficulty focusing attention. The middle stage involves difficulty with language, object recognition, and judgment. The terminal (final) stage is characterized by some urinary and fecal incontinence, inability to ambulate or provide self-care, and inability to communicate. **Multinfarct dementia**. Multiinfarct dementia (MID, vascular dementia) is the second most common cause of dementia in older adults. It results from the interruption of blood flow to the brain. As a result, multiple strokes occur. This condition is related to vascular disorders within the brain that possibly result from stroke and severe HTN; characteristics of the condition are periods of remission (absence of symptoms), preservation of person-ality, and mood swings. Risk factors for development of MID include arteriosclerosis, blood dyscrasias, cardiac decompensation, HTN, atrial fibrillation, cardiac valve replacements, systemic emboli arising from other causes, DM, PVD, obesity, smoking, and vasospasms in the brain called transient ischemic attacks (TIAs). **Parkinson disease**. Parkinson disease is the second most common disorder that affects the nervous system in older adults. It is a progressive, degenerative disease whose defining characteristics are muscle rigidity, tremors, and akinesia (an abnormal state of motor and psychic hypoactivity). The individual has a masklike appearance, drooling, and shuffling gait and often experiences emotional instability. In most cases, stress and frustration increase signs and symptoms. **Transient ischemic attacks.** The changes in the vascular system in older adults include thickening of the vessel walls and the presence to some degree of atherosclerosis and arteriosclerosis. Specific medical diagnoses related to arterial conditions common in older adults are TIAs and cerebral vascular accident (CVA), or stroke. TIAs are small spasms or occlusions in the cerebral vessels of the brain. Signs and symptoms of TIA vary, depending on the vessel\'s location in the brain. The most common signs and symptoms are changes in vision, headache, disorientation, ataxia (impaired ability to coordinate movement), and drop attacks (falling without losing consciousness). Symptoms sometimes last for as little as 20 minutes. One in three individuals who experience a TIA has a stroke within 5 years. **Stroke. Cerebrovascular accident** (stroke) is the fifth leading cause of death in the United States and increases in likelihood after 55 years of age. Many of the risk factors for a stroke also are seen with increasing age. These include heart disease, DM, and physical inactivity. Possible symptoms of a stroke include hemiplegia (paralysis of one side of the body), dysarthria (difficult, poorly articulated speech, resulting from interference in the control over the muscles of speech), dysphagia (difficulty in swallowing), sensory changes such as hemianopia (defective vision or blindness in half of the visual field), aphasia (an abnormal neurologic condition in which language function is defective or absent because of an injury to certain areas of the cerebral cortex), and intellectual and emotional changes. **Safety and security issues for older adults** **Falls** **Falls are the leading cause of accidental death in individuals older than age 65. Approximately 25% of adults older than 65 years fall each year.** Prevention begins with exercise that increases strength, balance, endurance, and body awareness. For a reduced risk of falls, an environment that is free of hazards must be maintained. Some adaptations to prevent falls include providing assistive devices such as walkers and canes to aid balance, raised toilet seats, handrails on stairs, grab bars in the bathroom, nonskid shoes, and removal of small scatter rugs. Teach older adults to sit on the side of the bed when they arise and to stand for a minute or so before walking as a technique to cope with orthostatic hypotension (sudden low blood pressure that occurs when an individual assumes the standing posture) that sometimes arises from poor vascular perfusion or medications. **General Fall Prevention Guidelines** **GENERAL CARE** - Assess shoes for safety. - Avoid wearing back-less shoes or flip flops. - Wear leather or rubber-soled shoes. - Illuminate darkened areas. - Avoid storing items in overhead compartments. - Assess assistive walking devices to ensure the tips and wheels are intact and functional. (proper use) - Use caution when standing from a sitting position. Allow time for the body to acclimate to positional changes. - Avoid the use of alcohol. - Do not use ladders or step stools unattended. **STEPS AND FLOOR SURFACES** - Avoid the use of throw rugs. - Assess carpets for holes or frayed areas. - To avoid missing a step count them to ensure placement. - Install banisters in stairways. - Keep walk areas clear. (no clutter) - On landings, use carpeting that has color contrast. **BATHROOM** - Use assistive rails in the bath and shower area. - Use a shower stool as needed **POLYPHARMACY** **Polypharmacy** refers to the use of five or more medications. Medications may be those prescribed by a health care provider or purchased over the counter. Although medications have therapeutic benefits (Make sure it\'s the right person, right medication, right dose, right time, right route, right response to the medication) **Elder Abuse and Neglect** Abuse and neglect of the older adult refer to violence toward individuals older than age 65. **Increasing concern has led the American Medical Association (AMA) to issue guidelines for the identification and treatment of abuse in five classifications: (1) physical or sexual abuse; (2) psychological abuse; (3) misuse of assets;(4) medical abuse (withholding necessary treatment or aids for ADLs); and (5) neglect.** Common reasons for abuse and neglect include frustration and exhaustion of a caregiver; alcoholism; turbulent lifestyles; and lack of financial, emotional, family, and community resources. **The National Center on Elder Abuse identifies the two most important indicators of abuse as: (1) an older person\'s frequent unexplained crying; and (2) an older person\'s unexplained fear of or suspicion of a particular person(s) in the home.** Older adults are often afraid to admit that they are being abused or neglected. **HOSPITALIZATION, SURGERY, AND REHABILATION** Age-related changes place the older adult at risk when faced with illness. Increased risks for the development of complications such as drug reactions, falls, infection, and delayed healing require knowledge of the specialized needs of the older adult. Although responses are individual, older adults have less reserve to cope physically and emotionally with the effects of hospitalization and surgery. They need longer postoperative recovery and convalescent periods. The normal effects of immobility on body systems, including stasis of secretions, orthostatic hypotension, and digestive and perceptual disorders, must be kept to a minimum. When adults in their 80s and 90s undergo surgery, their rehabilitation must begin as soon after surgery as their condition stabilizes. Especially important are measures to prevent complications of immobility and techniques to support coping skills and independence. Turning, deep breathing, coughing, or other techniques for ventilation and removal of respiratory secretions are important with older adults because of the age-related changes in the respiratory tract that increase the risk of atelectasis and pneumonia. Depending on the type of surgery, older individuals are best ambulated within 8 to 24 hours to decrease the risks of stasis in the circulation, kidneys, bladder, and respiratory tract. Getting up, even to stand or take a few steps, usually helps to stimulate peristalsis, peripheral vascular circulation, and muscle activity; expand the lungs; and improve mental outlook Encourage older individuals to perform self-care activities at their own level of tolerance and with rest periods. Remember that the hospitalization and the surgical intervention have the potential to increase signs and symptoms of other chronic conditions, such as arthritis, which sometimes is cause for reports of discomfort or difficulty in ADLS.