Care Of The Older Persons PDF

CARE OF THE OLDER PERSONS DEMOGRAPHICS OF AGING  DEFINITION Fa normal developmental process Foccurring throughout the human life span Fcauses a mild progressive decline in body system functioning  CHRONOLOGICAL AGE Ø refers to the number of yea...

CARE OF THE OLDER PERSONS DEMOGRAPHICS OF AGING  DEFINITION Fa normal developmental process Foccurring throughout the human life span Fcauses a mild progressive decline in body system functioning  CHRONOLOGICAL AGE Ø refers to the number of years the person has lived. Ø most commonly used objective method. Ø chronological age serves as a criterion in society for certain activities, such as driving, employment and the collection of retirement benefits. three categories: ü Young old- (ages 65-74) ü Middle-old (ages 75-84) ü Old-old(ages 85 and older)  PHYSIOLOGIC AGE Ø refers to the determination of age by body function  FUNCTIONAL AGE Ø refers to a person’s ability to contribute to society and benefit others and himself. Ø fastest growing segment of the older population - age 75. Ø those who require help - -frail elderly. Ø non-institutionalized adults ages 75-84---25% need help with daily activities. Ø aged 85 and older---one-half need help with daily activities. THEORIES IN AGING  1. SOCIOLOGICAL THEORIES OF AGING o Changing roles, relationships, status, impact the older adult’s ability to adapt. A) ACTIVITY THEORY - remaining occupied and involved is necessary to a satisfying late-life. B) DISENGAGEMENT THEORY - gradual withdrawal from society and relationships serves to maintain social equilibrium and promote internal reflection. C) SUBCULTURE THEORY - the elderly prefer to segregate from society in an aging subculture sharing loss of status and societal negativity regarding the aged. D) CONTINUITY THEORY - personality -influences roles and life satisfaction and remains consistent throughout life. - past coping patterns recur as older adults adjust to physical, financial, and social decline and contemplate death. E) AGE STRATIFICATION - individuals in different generations have different experiences that may cause them to age in different ways. F) PERSON-ENVIRONMENT-FIT - function is affected by ego strength, mobility, health, cognition, sensory perception, and the environment. Competency changes one’s ability to adapt to environmental demands. G) GEROTRANSCENDENCE - the elderly transform from a materialistic/rational perspective toward oneness with the universe. Successful transformation includes an outward focus, accepting impending death, substantive relationships, intergenerational connectedness, and unity with the universe. 2. PSYCHOLOGICAL THEORIES - explain aging in terms of mental processes, emotions attitudes, motivation, and personality development that is characterized by life stage transitions. A) HUMAN NEEDS - five basic needs motivate human behavior in a lifelong process toward need fulfillment. Maslow surmised that a hierarchy of five needs motivates human behavior: physiologic, safety and security, love and belonging, self-esteem, and self- actualization. B) INDIVIDUALISM - personality consist of an ego and a personal and collective unconsciousness that views life from a personal or external perspective. Older adults search for life meaning and adapt to functional and social losses. C) STAGES OF PERSONALITY DEVELOPMENT - personality develops in eight sequential stages with corresponding life tasks. The eighth phase, integrity versus despair, is characterized by evaluating life accomplishments; struggles include letting go, accepting care, detachment, and physical and mental decline. D) LIFE-COURSE/Life Span Development - life stages are predictable and structured by roles, relationships, values, and goals. Persons adapt to changing roles and relationships. Age group norms and characteristics are an important part of the life course. E) SELECTIVE OPTIMIZATION WITH COMPENSATION - Individuals cope with aging losses through activity/role selection, optimization and compensation. Critical life points are morbidity, mortality, and quality of life. Selective optimization with compensation facilitates successful aging.  “ POSITIVE aging means to LOVE, to WORK, to LEARN something we did not know YESTERDAY, and to ENJOY the REMAINING PRECIOUS moments with LOVED ONES “ ( George E. Valiant MD- Aging Well 2002) SOCIOECONOMIC ASPECTS OF AGING 1. AGE COHORTS - Persons who share the experience of a particular event or time in history are grouped together in what is called a cohort. a) AGES 55 TO 64 - persons in this age group are generally healthy and have resources to maintain housing. b) AGES 65-74 - Retirement ordinarily causes income to decrease by about 35% or more. This reduction in income often offset by reduced expenditures associated with working, such as transportation, clothing and meals (away from home).  c) AGES 75-84 - Many persons in this age group live alone, which affects their average household income. d) AGES 85 AND OLDER - this age cohort is at risk for an increase in chronic disease, resulting in decreased ability to perform daily activities of daily living(ADL) and increased expenses for assistance, assistive devices, and medication. - has the lowest average annual income level of all older Americans. 2. POVERTY - inadequate income may affect the quality of life for older adults. - delay seeking medical help. - may not follow through with the prescribed treatment or medications. 3. EDUCATION - has been shown to have a strong relationship to health risk factors. The level of education influences earning ability, information absorption, problem-solving ability, value systems, and lifestyle behaviors 4. HEALTH STATUS - The health status of older adults influences their socioeconomic status. Persons over 65 have an average of 2 chronic conditions (Lorig, 1993). Ø The most common chronic problems in 1994 were arthritis(50%), followed by hypertension (36%), heart disease (32%), hearing impairments (29%), cataracts (17%), orthopedic impairments (16%)16%, sinusitis (15%) and diabetes. Ø Functional Ability - measured by the individual’s ability to perform ADLs and instrumental activities of daily living (IADLs). Ø ADLs include six personal care activities: eating, toileting, bathing, transferring, dressing, and continence. Ø IADLs -refers to the following home-management activities: preparing meals, shopping, managing money, using the telephone, doing light housework, doing laundry, using transportation and taking medications appropriately. ØNurses can work with older adults - prolong independence by encouraging self-management of chronic conditions. ØSelf-management is defined as learning and practicing the skills necessary to carry on an active and emotionally satisfying life 5. INSURANCE COVERAGE - Health insurance is a necessity for older adults because of medical problems- therefore medical expenses- increase with age. - As persons age, they visit the doctor more often(US Census Bureau, 2004). 6. SUPPORT SYSTEMS - throughout life, people make new acquaintances, develop friendships, and form family circles. People identify with schools, churches or synagogues, clubs, neighborhoods, and towns. These are the places and people they turn to when they need advice or help, want to celebrate, or are grieving. THE AGING FAMILY  FAMILY a basic social unit consisting of parents and their children, considered as a group, whether dwelling together or not: the traditional family. a social unit consisting of one or more adults together with the children they care for: a single-parent family. any group of persons closely related by blood, as parents, children, uncles, aunts, and cousins: to marry into a socially prominent family.  EVERYONE COMES FROM A FAMILY J FAMILY MEMBERS - form the nucleus of relationships for the majority of the older adults and the support system if they become dependent. Intergenerational web: sons, daughters, stepchildren, in-laws, nieces, nephews, grand children and great grand children. All these people may play an important part in maintaining satisfaction in later life.  ROLES AND RELATIONSHIPS Roles of members CHANGE. Grandparents may assume parental roles to their grandchildren. Adult children may provide limited or extensive caring to their own parents. This caregiving may be TEMPORARY or LONG-TERM.  The family of the elderly is the support system that renders care and gives LOVE, STRENGTH, and HOPE in the life of an individual chronically ill patient. This family could be the spouse, brothers, sisters and sons/daughters. FAMILIES AS A RESOURCE OR RISK FACTOR qFamilies are generally considered to be a vital resource and integral part of an individual’s social network across the lifespan. Family relationships, like all relationships, vary in positive and negative qualities as they make an individual feel loved and cared for as well as irritated and frustrated.  IMPORTANT ISSUES AND FUTURE DIRECTIONS qThe family --most precious naturally occurring and cost effective resources. Its role in protecting our elders must be supported and augmented. qThe health of our older citizens can best be protected and improved by both supporting and educating the family as the primary vehicle for maintaining the health and well-being of all members of our aging society.  CHANGES IN THE OLDER PERSON AND THEIR IMPLICATIONS TO CARE AGING CHANGES IN CARDIOVASCULAR STRUCTURE Cardiac Aging qEnlargement of heart chambers and coronary cells occurs with age, as does increased thickening of the heart walls., especially in the left ventricle. Ventricles in the heart also begin to thicken and stiffen in correlation with continued steady production of collagen. Vascular Aging qAged arteries become extended and twisted. With age, large arteries begin to dilate and stiffen, leading to hypertension.  AGING OF THE RESPIRATORY SYSTEM Alveoli qThe volume of blood distributed to pulmonary circulation declines with age due to a decreasing number of capillaries per alveolus -impairs efficient passage of oxygen from the alveoli to the blood. Lung Elasticity qWith age, there is a decrease in the lungs’ elasticity, which in turn causes a change in the elastic recoil properties of the lungs. Loss of elastic recoil causes the lung s to close prematurely, trapping air inside and preventing the lungs from emptying completely. The Chest Wall qThe Chest Wall becomes stiffer with advancing age, decreasing the ease with which the thoracic cavity can expand. The stiffness of the chest reduces its ability to expand during inhalation and contract during exhalation.  AGING OF THE GASTROINTESTINAL SYSTEM Pharynx and esophagus qOverall, the gastrointestinal system appears to be relatively preserved in aging with only minor changes. The two gastrointestinal areas most affected by age are the upper tract (pharynx and esophagus) and the colon. Stiffening of the esophageal wall affect the older patient’s ability to swallow. Dysphagia, reflux, heartburn and chest pain are common complaints. The Large Intestine qThe rectum, a colonic structure that is located before the anus, shows age- related increase in fibrous tissue. This increase reduces the rectum’s ability to stretch as feces pass through.  URINARY STRUCTURAL CHANGES WITH AGE Kidneys qWith age, the kidneys shrink in length and width. Changes in renal blood flow and glomerular filtration rate (GFR) account for a majority of functional disability in the kidneys with age. Bladder qWith age, the bladder decreases in size and develops fibrous matter in the bladder wall, changing its overall stretching capacity ad contractibility (Diogiovanna, 2000). Urination qThe amount of urine expelled from the body decreases with age.  REPRODUCTIVE SYSTEM Ovaries qWith age, the ovaries atrophy to such a small size that they can become impalpable during an exam. (Smith, 1998). Uterus qAge-related decreases in uterine endometrial thickening during menstrual cycles occur as the result of decreased estrogen and progesterone levels.--decline in menstrual flow. Vagina qWith age, the vagina becomes shorter and narrower and the vaginal walls tend to thin and weaken. As a result, the vagina can become very dry, causing intercourse to be very painful. Menopause qThe menopause transition is defined by declines in estradiol along with the onset of variable menstrual cycles. Periods of amenorrhea trigger the move into the late stages. Testes qIn aging, the testes decrease in both size and weight, but with high variability among men. Although a decline in sperm production occurs in aging males, the production never ceases, as a result, the older male remains fertile. Glands qThe biggest concern in older males is changes in the prostate gland. The lining and muscle layer of the prostate gland become thinner with age, probably dueto the reduced blood flow to the area. Benign Prostatic Hypertrophy (BPH)-- remains very common among aging males. Penis qThe penis begins to show fibrous changes in erectile tissue around the urethra starting in the 30’s and 40’s. This fibrosis in erectile tissue -- increase in the amount of time it takes to achieve an erection I older males. Andropause q a decline in testosterone levels and eventually deficiency significant enough to cause clinical symptoms (American Society for Reproductive Medicine). Unlike menopause, andropause occurs gradually over time and does not occur in all aging males. Symptoms include: low libido; decreased energy, strength and stamina; increased irritability; and cognitive changes.  NERVOUS SYSTEM The Aging Brain qMemory changes can be observed by the fifth decade, but changes remain variable among individuals. The brain decreases in size and weight as men and women age. The Aging Spinal Cord üNerve Conduction qAccording to Abrams and colleagues(1995), the aging spine may narrow due to pressure on the spinal cord resulting from bone overgrowth. Due to this narrowing, changes in sensation can occur.  THE MUSCLE qA reduction in muscle mass occurs to at least some degree in all elderly persons as compared to young healthy, physically active young adults ---sarcopenia. q Sarcopenia --associated with tremendous increases in functional disability and frailty.  THE SKELETAL SYSTEM Estrogen deficiency qkey contributor to bone loss and bone loss accelerates in women after menopause due to a decline in estrogen levels. Estrogen deficiency q plays a role in bone loss among men--due to a decline in levels of estrogen, not testosterone. Osteoporosis qresults from reductions in bone quantity and strength that are greater than the usual age-related reduction. Bones of those with osteoporosis are very porous-- containing numerous holes or empty pockets--prone to fracture.  THE SENSORY SYSTEM Touch qThe ability to touch and distinguish texture and sensation tends to decline with age due to a decrease in the number and alteration in the structural integrity of touch receptors or Meissener’s corpuscles and pressure receptors or Pacinian corpuscles. Receptors that are elated to the sense of touch are also known as mechanoreceptors. Smell qA decrease in the number of olfactory neurons and weakening of olfactory neural pathways to the brain lead to a reduction in the ability to identify and distinguish aromas. A decrease in the sense of smell is referred to as hyposmia TASTE qAging causes a decrease in taste, also known as hypogeusia, usually more noticeable around the age of 60 with more severe declines occurring after the age of 70. VISION qmost common visual concerns in aging -- presbyopia or the inability to focus on nearby objects, such as newsprint. This is also called farsightedness. HEARING qAge-related hearing loss occurs as a result of changes in the inner ear. Aging changes that cause hearing loss include the alteration and decline in the ability to hear high frequency sounds, and the ability to discern. qAge-related hearing loss, also known as prebycusis--most common sensory deficit in the older population.  THE INTEGUMENTARY SYSTEM qThe greatest changes in aging skin - dermis. There is a general thinning of the dermal layer, with loss of thickness averaging 20% in older persons. This thinning of the dermis is due in large part to a general loss of collagen- approximately 1% loss per year in adulthood.  THE IMMUNE SYSTEM Immunosenescence qrefers to the aging of the immune system. qassociated with increased incidence of infectious disease such as bronchitis and influenza. q It is also implicated in the increased incidence of tumors and cancer that occurs with age.  CULTURAL FACTORS/ETHNICITY Ethnicity qrefers to what some have called race. Ex. African, European, Asian Nationality qrefers to the geographic location of the person’s birth (or the country with which he or she identifies)  DIVERSITY OF ELDERS qWide range of life experiences qLifestyles qHealth status qSocioeconomic status qReligion  PATTERNS OF HEALTH & DISEASE IN THE OLDER ADULT A. Diseases that occur to varying degrees in most older adults 1. cataracts 2. arteriosclerosis 3. benign prostatic hypertrophy [males] B. Diseases with increased incidence with advancing age 1. neoplastic disease 2. diabetes mellitus 3. dementia disorders C. Diseases that have more serious consequences in the elderly 1. pneumonia 2. influenza 3. trauma D. Very common chronic diseases 1. arthritis 2. hypertension 3. heart disease the elderly E. Functional disability 1. 32% of persons over 65 years have some limitation of functions 2. 25% of persons over 65 years require help with at least one ADL or IADL ü “A multidisciplinary diagnostic process intended to determine a frail older person’s medical, functional, and psychosocial status and limitations in order to develop a plan for treatment and long-term follow- up” ü Diagnose and develop an overall plan of care for treatment and long term follow up ü Optimizes independence and prevent future disabilities.  FUNCTIONAL ASSESSMENT Identify an older adult’s ability to : qperform self-care, self-maintenance, and physical activities. Disability qimpact that health problems have on an individual’s ability to perform tasks, roles, and activities  PHYSICAL ASSESSMENT qPhysical assessment with a “systems” approach, reviews each body system first by taking a history—then physical examination. 1. Circulatory Function Øfamily history, current problems with chest pain/discomfort (exertion); current diagnoses and associated medications ; over-the- counter and herbal medicines; sources of stress; adherence to current medical regimens. Øphysical examination, blood pressure, chest sounds, pulse rate. Øexercise stress test, blood and serum tests, electrocardiograms and other tests for imaging and assessing the condition of the heart and blood vessels. 2. Respiratory Function Øcurrent medications /history of smoking behavior and exposure to environmental pollutants. ØAssess: current difficulties and anxieties associated with breathing, decreased energy to complete everyday tasks, frequent coughing, and production of excess sputum. Øobservation of posture and breathlessness, and listening to chest sounds. Øpulmonary function test, chest x-ray, and sputum analysis 3. Gastrointestinal function Øusual diet; appetite and changes in appetite; nausea, vomiting, indigestion, stomach discomforts; problems with bowel function (constipation and diarrhea). Øbarium enemas and x-rays , stool analysis examination of the colon. ØOral health assessment -overlooked with older adults- §oral health practices including brushing, flossing, and regular contact with a dentist. 4. Genitourinary Function (sometimes neglected) Øabnormal bleeding, vaginal discharge, urinary symptoms. Pelvic examinations and Pap smears. ØOlder men- enlarged prostate ØChronic Renal Failure -complication of age-related diseases (diabetes and hypertension). Ø Incontinence - not a normal part of aging. ØHealth history -previous or current difficulties related to the frequency and voluntary flow of urine during either the day or night; medication use Øurine analysis tests for blood, bacteria, and other components. 5. Neurological Function Ømedications , medical diagnosis related to the neurological system (history or family history of stroke) Øprevious and current impairments in speech, expression, swallowing, memory, orientation, energy level, balance, sensation, and motor function. Øsleep disturbance, tremors, and seizures. 6. Musculoskeletal Function Øthe most commonly reported illness among older adults is osteoarthritis(weight-bearing joints-hips/ knees). Ø Observation of posture and walking can assist in asking the appropriate questions: üDoes the older adult favor one side of the body while walking? üAre assistive devices such as canes and walkers being used? vCanes and walkers should be at the appropriate height in relation to body height. 7. Sensory Function Ødiminished vision and hearing-- greatest impact on older adults. -- negative effects on social interaction -- social and psychological health. vThe following two screening procedures are simple tests for functional vision: üAsk the older adult to read a newspaper headline and story üAsk the older adult to read the prescription bottle Øhearing loss is a major concern for many older adults. v The following question is useful in assessing ear and hearing problems: üAre you experiencing a hearing problem or any ear pain, ringing in the ears, or ear discharge? Øolder adults wearing hearing aids--regularly assessed and monitored. 8. Integumentary Function Øskin problems and concerns and inspecting the skin. Øskin injury =close monitoring and treatment Ø rashes, itching, dryness, frequent bruising, and any open sores. Øcolor, hydration, circulation, and intactness. 9. COGNITIVE ASSESSMENT Øattention, memory, language. vThe most extensively used cognitive assessment tool is the Mini Mental State Examination (MMSE) --measures change in cognitive impairment.  PSYCHOLOGICAL ASSESSMENT Ø weighted toward assessment of mental disorders. ØClinical Depression -most common mental health problem among older adults  SOCIAL ASSESSMENT Øsocial network and on the interaction between the older adult and family, friends, neighbors, and community.  SPIRITUAL SUPPORT ØReligiosity -believing in God, organized rituals ØSpirituality -ideas of belief that encompasses personal philosophy and an understanding of meaning and purpose in life.  PROBLEMS RELATED TO THE OLDER PERSONS 1. Physiologic Functioning Ø Urinary Incontinence common problem of the elderly and has tremendous impact on both the morbidity and quality of life of elderly people. a.. Stress Incontinence - involuntary loss of urine during activities that increase intra-abdominal pressure(lifting, coughing, sneezing and laughing). b. Urge Incontinence - associated with a strong , abrupt desire to void and the inability to inhibit leakage in time to reach the toilet. c. Reflex Incontinence - results from uninhibited bladder contractions with no sensation of needing to void or urgency. d. Overflow Incontinence - overdistention of the bladder due to abnormal emptying. e. Functional Incontinence - refers to problems from factors external to the lower urinary tract (cognitive impairments, physical disabilities)  MANAGEMENT OF INCONTINENCE ØManaging Hydration ØPrompted Voiding ØBladder Training ØPharmacological management  SLEEP DISORDER Ømore prevalent with age. Individuals with multiple illnesses rate their sleep as being of poorer quality. vManagement of Sleep Disorder: üSleep Hygiene üEnvironmental Restructuring üMedications- Zolpidem (Ambien), Zaleplon (Sonata) 2. Behavioral qAnxiety Øtachycardia and palpitations, gastrointestinal disorders, insomnia, and tachypnea. vNursing Care: üDecrease environmental stimuli üStay with the patient üMake no demands and do not ask patient to make decisions üSupport current coping mechanism ( crying, talking, etc.) üDon’t confront or argue with the patient üSpeak slowly in a soft, calm voice qDepression ØAlthough depression is the most common mental health disorder in older adults, it is not a normal consequence of aging. vInterventions: üPharmacological therapy- tricyclic anti-depressants üExercise üCounseling qPolypharmacy Øthe act of taking many medications concurrently. ØThe consequences of polypharmacy in the older adult range from mild annoying to life threatening Øadverse drug reactions/drug-drug interaction medication errors Ønon-adherence - not willing to follow the instructions given for prescribed treatments. 3. Safety ØFalls - an event which results in a person unintentionally coming to rest on the ground or another lower level. vInterventions: üModify the environment üEvaluate Gait and balance- assess muscle strength and ability frequently and institute appropriate measures for safe mobility and transfer techniques üReview Medications Thank You!!! J  THE GERONTOLOGICAL NURSE Come to know the family. Monitors progress and manages chronic disorders within the context of the family. Learn their special gifts and talents. Work within the unique culture of his or her family of origin, present family, and support networks, including friends. Assessment: who are the members, usual roles and their strengths, deterrents to function of the family unit; family’s needs, meaning of caregiving. As the needs of the care recipient increase, so often do the formal and informal services. Maintain health and wellness of the entire family structure. Use family’s strengths.  CAREGIVING “GIVE BACK “ to a loved one. Stressful and can be physically and emotionally demanding. Caregivers are “the hidden patient”– their own needs are set aside to meet the needs of the care recipient Takes place at HOME– elders home or that of the caregiver.  CARING FOR PARENTS REVERSE ROLES –-as if the elder becomes a child again. EXPECTED– that children will set aside their own needs in order to meet those of the parent. MAJOR CONCERN–- when the child caregiver is not available or willing to assume the responsibilities  IMPLICATIONS FOR GERONTOLOGICAL NURSING AND HEALTHY AGING Comprehensive assessment of the family– who are the members, their usual roles and their strength contributions, and deterrents to the function of the family unit. Assess the family needs, strengths and stresses, sources of strength, methods of coping, support system,  RESPITE AND INSTITUTIONALIZATION RESPITE provision of temporary relief to the caregiver by temporary stay of the elder in a care facility. INSTITUTIONALIZATION needs exceed, institutional setting may be the solution. -- group homes, nursing homes, assisted living facilities, where CARE is exchanged for a FEE. Personal needs are excluded. --some families are not willing or nor able to provide care to their needy family members. ELDER ABUSE AND NEGLECT  ABUSE PHYSICAL PSYCHOLOGICAL SEXUAL FINANCIAL MEDICAL  NEGLECT IMPLIES… The caregiver has not met his or her OBLIGATION. IN ALL CASES THE VULNERABLE PERSON IS HARMED.  ELDER ABUSE REQUIRES AN ABUSER An ELDER and the CAREGIVER. ESPISODIC AND RECURRENT rather than ISOLATED. The ABUSER is usually the caregiver but may also be the CARE RECIPIENT. The more DEPENDENT the elder, the more VULNERABLE he or she is being abused. Most often victims are unwilling or AFRAID to report the problem because of SHAME, EMBARRASMENT, INTIMIDATION, or FEAR OF RETALIATION.  IMPLICATIONS FOR GERONTOLOGICAL NURSING AND HEALTHY AGING Nurses must be vigilant– for potential abuse, observing signs and symptoms in all their interactions with vulnerable elders. SUBTLE SIGNS. If abuse is suspected: full assessment is done, determination of safety of the victim and the desires of the victim if competent. STOP EXPLOITATION. Protect the victim and society from inappropriate and illegal acts, hold perpetrators, rehabilitate the offender, order restitution of property and payment for expenses incurred. MOST IMPORTANT: KNOW THE REQUIREMENTS FOR MANDATORY REPORTING IN THEIR STATES AND TO PARTICIPATE IN PREVENTION IN THE PROMOTION OF HEALTHY AGING.  PROFILES OF ABUSED AND ABUSERS Abused Elders Abusers Woman age 80 or older Middle-age male sibling or offspring Lives alone or with abuser Mental health and substance abuse problems Mental or physical disability Financially dependent on abused Dependency on abuser History of abuse and being abused PROTECT THEM. RESPECT THEM. LOVE THEM. THANK YOU!!!