Care Of Older Adults PDF

Care of Older Adults: Demographic and Theoretical Perspectives NURS 8 01 3 DIRECT ENT RY ADULT HEALTH THEORY BOSTON COLLEGE CONNELL SCHOOL OF NURSING STEWART M. BOND, PH D , RN Outline Aging Demographics Definitions and Theories of Aging Challenges to Healthy Aging The “Silve...

Care of Older Adults: Demographic and Theoretical Perspectives NURS 8 01 3 DIRECT ENT RY ADULT HEALTH THEORY BOSTON COLLEGE CONNELL SCHOOL OF NURSING STEWART M. BOND, PH D , RN Outline Aging Demographics Definitions and Theories of Aging Challenges to Healthy Aging The “Silver Tsunami” Older adults are ~16% of U.S. population By 2040 21.7% of population (> 74 million) Living longer More women More racially and ethnically diverse Sub categories of older adults Young old = 65-75 years Old old = 75-85 years Oldest old = 85+ years - fastest growing Administration on Aging. Profile of Older Americans: 2017. https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2017OlderAmericansProfile.pdf U.S. Population “Pyramids” 2000 2020 2040 Increasing Aging Diversity Minority older adults: African Americans, persons of Hispanic origin, Asian or Pacific Islanders, American Indians/Native Alaskans, and more than one race 2006: 19% were minority 2030: 29% will be minority 2050: 42% will be minority Older racial and ethnic minorities have worse health status and receive fewer services (Administration for Community Living, 2020; CDC, 2017) Increasing Aging Diversity 1.75 – 4 million adults > 60 years of age identify as LGBTQIA Many came of age under conditions of intense homophobia and discrimination Non-disclosure of sexual orientation Threats to self-identify and livelihood Experience multiple social and health- related disparities Majority of U.S. Healthcare Provided to Older Adults 57% of all visits to generalist providers 50% of hospital expenditures 80% of home care visits 90% of nursing home care Healthcare costs for older adults are 3-5 times greater than costs for those < 65 years Definitions and Theories of Aging Definitions of Age and Aging Chronologic age ◦ An individual’s age in years Physiologic age ◦ Decline in physiologic or functional reserve capacity ◦ Impaired homeostasis and diminished response to stress ◦ Decline is highly individualized Chronologic age does not adequately predict or reflect physiologic age Theories of Aging Biologic Psychological Sociological Biologic Aging Theories Theory Characteristic Wear and Tear Injury and insults of daily living cause structural and chemical changes resulting in irreversible tissue damage, dysfunction, and/or disease Somatic Mutation Over time molecular damage to DNA results in genetic mutations that cause cells to deteriorate and malfunction Programmed Longevity “Genetic clock”; cells genetically programmed to divide and reproduce only a limited number of times Immunity Diminishing thymus results in impaired immunologic function Psychological Aging Theories Jung’s Theory of Individualism ◦ Positive, life-enhancing approach to aging ◦ Self realization is the goal of personality development ◦ Psychological and spiritual development possible across the life span ◦ To age successfully, older person turns inward and accepts past accomplishments and failures ◦ Continuing creativity and fulfillment, and a deepening spirituality Erikson’s Developmental Task Theory ◦ 8 stages of development throughout the life span ◦ Old age: last stage of development ◦ Task: integrity versus despair ◦ One reflects back on life and views accomplishments as successful or unsuccessful Sociological Aging Theories Disengagement Theory: Older persons and society engage in mutual and reciprocal withdrawal; inevitable and acceptable Activity Theory: Older adults should stay active and engaged. Social involvement = happiness Continuity Theory: Successful aging involves maintaining or continuing previous values, habits, preferences, family ties, and other linkages Challenges to Healthy Aging Challenges to Healthy Aging Biological Lifestyle behaviors Genetic Education Psychological ◦ Literacy Mental health Environment Substance abuse ◦ Social isolation Personality ◦ Transportation Low self-efficacy ◦ Access Socioeconomic Racism Poverty Ageism Chronic Health Conditions Long-term illnesses or conditions that affect well-being and function Contribute to frailty, disability, and death Specific characteristics but often share common symptoms Require ongoing monitoring and treatment Goal to slow progression and prevent exacerbations and complications including hospitalization Chronic Health Conditions Not inevitable 70% of physical decline is modifiable ◦ Smoking cessation ◦ Improved nutrition ◦ Limited alcohol intake ◦ Physical activity ◦ Prevention of injuries from falls ◦ Improved use of Medicare-covered preventive services AGEISM A process of systematic stereotyping or discrimination against people because they are old (Butler, 1969) Robert Butler 1st director of NIA Promote Respect (1975) for "Our Future Selves" What are some examples of ageism? In language? In media? In health care?  Care of Older Adults: Age-Related Physiological Changes NURS 8 013 DIRECT-ENTRY ADULT HEALTH THEORY BOSTON COLLEGE CONNELL SCHOOL OF NURSING STEWART M. BOND, PH D , RN Outline Age-Related Changes and Implications ◦ Musculoskeletal ◦ Neurologic ◦ Cardiovascular ◦ Respiratory ◦ Gastrointestinal ◦ Hepatic ◦ Genitourinary ◦ Integumentary ◦ Sensory ◦ Immune ◦ Thermoregulation Age-Related Physiological Changes Age-Related Physiological Changes Body System Physiologic Changes Implications Musculoskeletal Reduced muscle mass Decreased strength, endurance, Decreased muscle elasticity and coordination Decreased bone mineral density Increased reaction time Shrinking vertebral discs Skeletal instability with increased fracture risk Decreased ligament and tendon strength Loss of height Degenerated joint cartilage Decreased flexibility Joint stiffness, pain, decreased range of motion Age-Related Physiological Changes Body System Physiologic Changes Implications Neurologic Increase neuronal loss Increased risk for cognitive Cortical atrophy impairment Diminished cerebral blood flow Increased risk for delirium Reduced cerebral glucose and oxygen Slowed reaction time metabolism Increased risk for peripheral Altered level of neurotransmitters neuropathy Reduced sensory input Altered gait and balance Delayed speed of nerve conduction Diminished autonomic responsiveness Age-Related Physiological Changes Body System Physiologic Changes Implications Cardiovascular Reduced efficiency of heart muscle Diminished cardiac output Valves thicken and become more rigid Poorer perfusion to organs Decreased intrinsic and maximal heart Peripheral pulses not always rate palpable Altered conduction Decreased response to Slower recover time after exercise physiological stress and changes in blood pressure Decreased elasticity of vessels More ectopic heart beats Increased peripheral vascular resistance Increased blood pressure Venous dilatation Superficial vessels more prominent Age-Related Physiological Changes Body System Physiologic Changes Implications Respiratory Increase rigidity of thorax Poor chest expansion Increased anterior-posterior diameter Shallower breathing Decreased muscle strength Less effective cough Blunted cough reflex Increased risk for infection Decreased ciliary action Decreased exercise tolerance Alveoli thicken and decrease in number and size Increased residual volume Reduced vital capacity Decreased expiratory flow rate Age-Related Physiological Changes Body System Physiologic Changes Implications Gastrointestinal Muscles of mastication weaken Difficulty chewing Decreased taste sensation Increased risk of poor nutrition Decreased saliva production Increased risk of periodontal Decreased sense of thirst disease Decreased gag reflex Increased risk of choking Decreased acid production Increased risk of dehydration Decreased motility Tendency toward constipation and/or diarrhea Mucosal atrophy Altered drug absorption Increased risk of vitamin deficiency Age-Related Physiological Changes Body System Physiologic Changes Implications Hepatic Decreased liver size Decreased drug metabolism Decreased blood flow to liver Increased risk of drug Decreased liver function interactions Decreased production and flow of bile Increased risk of gallstones Bile thicker with higher cholesterol content Age-Related Physiological Changes Body System Physiologic Changes Implications Genitourinary Decreased renal mass Increased accumulation of drugs Decrease in nephrons excreted by kidney Decreased renal blood flow Fluid and electrolyte imbalance Decreased glomerular filtration Urinary frequency & urgency Decrease tubular function Nocturia Reduced bladder capacity Incontinence not a normal part of aging Weaker bladder muscles Prostate enlargement Age-Related Physiological Changes Body System Physiologic Changes Implications Integumentary Decreased subcutaneous fat Thin, wrinkled, dry skin Diminished elastin fibers Diminished secretion of natural Decreased interstitial fluid oils and perspiration Decreased glandular activity Altered sensitivity to heat and Diminished sensation cold Hyperpigmentation Increased risk for injury Capillary fragility Decreased protection from sun exposure and temperature Decreased melanin production extremes Thinning hair on scalp, pubic area, and Lentigines axilla Changes in appearance Increased hair in ears and nose (men) and face (women) Assessing Skin Turgor Do not use back of Assess skin turgor hand in older adult below clavicle Age-Related Physiological Changes Body System Physiologic Changes Implications Sensory Eyes Loss of lid elasticity Increased wrinkles or crow’s feet Decreased lens flexibility Pseudotosis Slowed pupillary response Ectropion of eyelids Change in consistency of vitreous Presbyopia humor Inability to tolerate glare Yellowing of lens Difficulty adjusting to changes in Decreased lacrimal gland secretion light Poor night vision Decreased visual acuity Distortion of color perception Eye dryness and itching Age-Related Physiological Changes Body System Physiologic Changes Implications Sensory Ears Hair cells in inner ear stiffen and Presbycusis atrophy Decreased ability to hear high- Decreased blood supply and pitched sounds degradation of neurons in cochlea Difficulty distinguishing Tympanic membrane thinning consonants Auditory canal narrows Diminished ability to localize Increases cerumen production sound Cerumen impaction Nose Decreased olfactory bulb and cells Decrease ability to smell Decreased taste and appetite Age-Related Physiological Changes Body System Physiologic Changes Implications Immune Depressed immune response Increased risk of infection Thymus gland shrinks Altered response to infection T-cell activity declines Increased risk of cancer Cell-mediated immunity declines Potential reactivation of dormant infections (i.e., varicella zoster, tuberculosis) Age-Related Physiological Changes Body System Physiologic Changes Implications Thermoreguation Lower normal body temperature Baseline oral temperature 97.4◦ F Reduced ability to respond to cold (36.3◦ C) Reduced ability to respond to heat Increased sensitivity to cold Increase risk for heat stroke  Care of Older Adults: Gerontological Nursing Implications NURS 8 01 3 DIRECT ENT RY ADULT HEALTH THEORY BOSTON COLLEGE CONNELL SCHOOL OF NURSING STEWART M. BOND, PH D , RN Outline Implications for Nursing Practice ◦ Assessment of Function ◦ Communication with Older Adults ◦ Atypical Presentation of Illness in Older Adults ◦ Common Geriatric Syndromes Creating age-friendly health care environments Assessment of Function Assessment of Function Three domains: activities of daily living (ADLs), instrumental activities of daily living (IADLs), & mobility Systematic focus on individual needs and abilities Two approaches: asking and observing Basis for care planning, goal setting, and discharge planning Eligibility criterion to obtain services ADLs Bathing Dressing Toileting Mobility Continence Feeding IADLs Ability to use telephone Shopping Food preparation Housekeeping Laundry Transportation Taking medications Managing finances https://consultgeri.org/try-this/general-assessment/issue-23 Communication with Older Adults Communication with Older Adults Introductions Well-lit room Minimize background noise Inquire about hearing deficits Try to be at eye level Speak slowly Do not speak too loudly Communication with Older Adults Use open-ended questions/statements Allow time to respond Listen carefully Use caring responses Avoid “elderspeak” Touch if appropriate and acceptable Communication with Older Adults Avoid complicated explanations Supplement verbal instructions with written material Engage family members Encourage reminiscing Atypical Presentation of Illness in Older Adults Atypical Presentation of Illness Non-specific signs and symptoms: ◦ Change in mental status ◦ Decreased appetite ◦ Incontinence ◦ Falls ◦ Fatigue ◦ Apathy ◦ Self-neglect Atypical Presentation of Illness in Older Adults Illness Atypical Presentation Infectious diseases Absence of fever Sepsis without usual leukocytosis and fever Falls, decreased appetite or fluid intake, confusion, change in functional status Myocardial infarction Absence of chest pain Vague symptoms of fatigue, nausea and a decrease in functional status. Classic presentation: shortness of breath more common complaint than chest pain Medical illnesses that present as Hypothyroid disease that presents as diminished energy and depression apathy Hypoactive delirium Under-Reporting Illness in Older Adults Insidious nature of the onset of the illnesses and the vague symptoms Tendency to regard symptoms as a "normal" part of aging Reluctance to complain about problems because of concerns as to being ignored or generating burdensome tests Communication deficits (hearing impairments, poor vision, speech problems) and cognitive impairment Common Geriatric Syndromes Common Geriatric Syndromes Malnutrition Falls Polypharmacy Delirium Dementia Depression Nutritional Assessment Mini-Nutritional Assessment (MNA) ◦ Most established screening tool for older adults ◦ Identifies patients at risk for malnutrition and those who are malnourished ◦ Not applicable if patients are non- communicable http://www.mna-elderly.com/ Oral Care Often neglected Systemic illness, such as aspiration pneumonia and cardiovascular disease Malnutrition, vitamin deficiencies Pain, halitosis, tooth loss, dental caries, periodontal disease Leukoplakia Denture stomatitis Ability to speak Social isolation, depression, poor self-esteem Falls in Older Adults Prevalence: 1/3-1/2 older adults fall annually (50% in nursing homes) 20-30 percent of older adults who fall suffer moderate to severe injuries (lacerations, hip fractures, head traumas). About 26,000 older adults die from fall injuries Fear of falling may result in activity restriction, which leads to reduced mobility and loss of physical fitness, and in turn increases actual risk of falling Fall Risk Assessment Annual screening for fall risk and upon admission to hospital and long-term care settings Fall risk factors ◦ History of falls ◦ Chronic illness/health problems: sensory, CNS, peripheral nervous system, musculoskeletal, cognition, mood ◦ Medications (use of 4 or more; meds that cause sedation, postural hypotension) ◦ Orthostatic hypotension, pain, incontinence, environmental, fear of falling Fall Prevention & Management Modify risk: lower extremity weakness (physical therapy: strength and resistance training), balance (Tai Chi, proper footwear, use of assistive devices), medication review, investigate incontinence Home safety evaluation: reduce tripping hazards, add grab bars inside/outside tub or shower and next to the toilet, add railings on both sides of stairways, and improve lighting Post-fall evaluation Polypharmacy and Medication Complications Minimize polypharmacy Start low; go slow Avoid starting 2 new meds at same time OTC review Medication reconciliation Monitor hepatic and renal function Consider otoxicity American Geriatrics Society 2019 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Distinguishing Delirium, Dementia, and Depression Delirium Dementia Depression Onset Acute, abrupt Slow, progressive Acute or insidious (hours to days) (months to years) (weeks to months) Course Fluctuates, often diurnal, Stable, progressive May be chronic worse at night Duration Short or variable, resolves Chronic, on-going and Variable, may last months to with treatment progressive years Consciousness Clouded, decreased Alert Clear Attention Impaired, may be either Usually normal except in May be decreased reduced or vigilant advanced dementia Orientation Often impaired, particularly Often impaired Usually normal place, time, and events Perception Hallucinations and delusions May have delusions; Uncommon except in severe common hallucinations uncommon depression Psychomotor Increased or decreased Often normal May be slowed particularly in Behavior severe depression Delirium A potentially reversible condition characterized by the rapid onset of altered arousal and attention, impaired cognitive functioning, and disturbed psychomotor behavior Due to an underlying pathophysiologic disturbance or medical condition Subtypes: hyperactive, hypoactive, mixed Associated with multiple adverse outcomes Delirium Often the first and only indicator of an acute medical problem in older adults Can occur in any setting, often not recognized, increased risk in persons with dementia Delirium is a medical emergency Delirium Risk Factors M Medications : Polypharmacy, anti-cholinergic burden, medication weaning/withdrawal I Infection and advanced illness N Number of co-occurring conditions/comorbidities (e.g. hypertension, heart failure, COPD, OSA, et cetera) D Substance or alcohol use disorders (including withdrawal) S Surgery and/or invasive procedures P Pain (uncontrolled), perfusion problems A Advanced age- BUT may occur at any age, including pediatrics C Cognitive impairment and/or dementia E Emotional or mental illness (e.g. depression, anxiety, etc.) S Sleep disturbances and altered patterns http://www.nursingworld.org/Delirium-Prevention-Strategies Delirium Prevention Identify and treat modifiable risk factors Delirium prevention strategies ◦ Prevent nosocomial infection ◦ Medication management ◦ Promote orientation ◦ Appropriate stimulation ◦ Adequate pain control ◦ Early, aggressive, and progressive mobility ◦ Maintain oxygen saturation ◦ Adequate nutrition and hydration ◦ Prevent and manage constipation ◦ Sleep promotion Delirium Management: Non-Pharmacologic Strategies Supportive Care Strategies Environmental Strategies ◦ Ongoing assessment and monitoring ◦ Provide ongoing reorientation and support ◦ Identify and treat reversible causes ◦ Use calendars, clocks, pictures, and other ◦ Ensure adequate oxygenation, hydration, familiar objects comfort, elimination, and nutrition ◦ Ensure appropriate levels and types of ◦ Promote mobility stimulation ◦ Avoid restraints ◦ Maintain normal schedules and routines ◦ Discontinue all non-essential medications; ◦ Provide adequate and appropriate lighting use lowest dose possible ◦ Use sensory aids Psychosocial Strategies ◦ Provide psychosocial support ◦ Education family about delirium and patient’s condition ◦ Use concrete, simple, face-to-face communication Delirium Management: Pharmacologic Strategies Antipsychotics ◦ haloperidol (Haldol) Atypical Antipsychotics ◦ olanzipine (Zyprexa) ◦ resperidone (Risperdal) ◦ quetiapine (Seroquel) Benzodiazepines (in conjunction with antipsychotic) ◦ lorazepam (Ativan) Use with risk of harm to self and others Dementia A clinical syndrome of cognitive decline Most common forms of dementia ◦ Alzheimer’s disease (~80) ◦ Vascular dementia (~20%) ◦ Dementia with Lewy bodies (1 in 25 cases) ◦ Fronto-temporal dementia (15 per 100,000) Management of Dementia Early identification and treatment Ongoing assessment Pharmacologic interventions ◦ Acetyl cholinesterase inhibitors ◦ donepezil (Aricept) ◦ galantamine (Razadyne) ◦ rivastigmine (Exelon) ◦ NMDA receptor agonists ◦ memantine (Namenda) Non-pharmacologic interventions Depression Highly prevalent in medically ill, functionally impaired, and institutionalized older adults Not a natural consequence of aging or a normal reaction to acute illness and/or hospitalization Associated with poor outcomes Early recognition, intervention, and referral are key Depression Assessment Depression screening tools ◦ Geriatric Depression Scale – Short Form ◦ Patient Health Questionnaire (PHQ-9; PHQ-2) Focused depression assessment noting number of symptoms, onset, frequency/ patterns, duration (> 2 weeks), change in normal mood, behavior, functioning Depression Treatment Depression, even severe depression, can be treated Common treatment strategies ◦ Psychotherapy ◦ Antidepressant medications: SSRIs, buproprion, mirtazapine, venlafaxine ◦ Electroconvulsive therapy ◦ Transcranial magnetic stimulation Creating Age-Friendly Health Care Environments: The 4 M’s What Matters: Know and act on patient specific outcome goals and care preferences Mobility: Maintain mobility and function; prevent and treat complications of immobility Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters Mentation: Focus on delirium and dementia and depression Consider and implement gerontologic nursing principles…… ✓Recognize individual variability and uniqueness of older adults ✓Understand the aging process and how it affects presentation and response to illness and treatment ✓Recognize and mange the complex interaction of multiple comorbid conditions ✓Conduct comprehensive assessments using valid and reliable tools ✓Assess preferences for family involvement in care planning and decision-making ✓ Assess for and implement strategies to avoid geriatric syndromes ✓ Collaborate with interdisciplinary team to provide evidence-based care ✓ Review and assess medication use and adherence ✓ Be aware of and use age-friendly resources and programs (4 M’s)