Objective 6 2023.pdf

Objective 6: Chronic Illness Affecting Older Adults Chronic Illness & Aging A condition that lasts a year or more and requires ongoing medical attention, limits activities of daily living, or both Rising prevalence and associated costs make chronic illness a global health concern. Up to 60% of old...

Objective 6: Chronic Illness Affecting Older Adults Chronic Illness & Aging A condition that lasts a year or more and requires ongoing medical attention, limits activities of daily living, or both Rising prevalence and associated costs make chronic illness a global health concern. Up to 60% of older-person Canadians living in the community live with 2 or more chronic conditions. Nonfatal chronic illness: conditions such as osteoarthritis or hearing or vision problems Serious, eventually fatal chronic conditions: cancers, organ system failures, dementia, strokes Frailty: a fatal, chronic condition in which the body has few reserves left, and any disturbance can cause multiple health conditions and costs Chronic Illness Is not cured. Can be managed so that an individual can have a quality of life. Can affect any body system & can start with one particular system & then move to another system. Acute vs. Chronic Illness Acute Illness • Occurs suddenly & often without warning e.g. Stroke, myocardial infarction, hip fracture, infection Chronic Illness • Managed rather than cured • Always present, but may not always be visible e.g. Diabetes, Arthritis Blurred Lines • Those with chronic illnesses can have acute exacerbations (flare ups) of their illness e.g. arthritis. • Acute illness may surface from long term chronic illness, maybe unknown to the person e.g. MI, CVA (Cerebral Vascular Accident – stroke). Chronic Illness & Aging Prevalence increases with age. Difficult to determine the impact that normal aging changes have on the development of chronic illness. High % of older adults are diagnosed with chronic illness due to increase life expectancy and advances in treatment. Research supports that chronic illness & poor health are not inevitable consequences of aging. Many chronic illnesses are preventable through lifestyle choices or early detection & management of risk factors. Risk factors for Chronic Illness: poor diet, inactivity, smoking. *Modifiable Chronic Illness & Aging: Implications Can involve multiple diseases Long term implications (quality of life) Unpredictable patterns Affect self-concept Often results in chronic residual disability Treatments can lead to iatrogenic complications • Iatrogenesis: A complication or by-product of the health care intervention or the environment itself. • Ex: Loss of mobility because insufficient ambulation, functional incontinence, adverse effects of meds. • Box 15-6: Iatrogenic problems associated with hospitalization Frailty Syndrome A term referring to older adults having multiple co-morbidities / chronic illnesses. A condition including both mental & physical decline. Associated with: sarcopenia (muscle wasting), atherosclerosis, cognitive impairment & malnutrition Signs & Symptoms (s/s): weight loss, fatigue, weakness, unsteady gait & decrease in activity. Chronic Illness: Common Psychological Issues Fear of incapacitation, pain, abandonment, isolation & death. A desire to fit into family system again. Low self-esteem & loss of confidence. Feelings of helplessness, uselessness, burden. Willingness to redefine role relationships. A desire to face & handle public situations free of embarrassment or fear. Coping with Chronic Illness: Factors to Consider Gender Accessing continuing care, relocation Sexuality Fatigue / Pain Multiple losses Iatrogenic complications Self-care (selfmanagement programs) Availability & use of assistive devices Support (family, spouse & friends) Promoting Wellness: Chronic Illness • Adaptation is key • Health care providers often view chronic illness as negative. • People living with it focus on hope, moving forward & living with it. • Self-management programs are positive • Each individual is encouraged to work towards the highest (optimal) level of functioning – to achieve a sense of well-being. • This is attainable with chronic illness. • Positive approach to care, working towards improved wellness. • Regression is viewed as opportunity for growth. Common Chronic Illnesses High blood pressure (B/P) Arthritis Glaucoma Heart disease Diabetes Chronic Illness: Arthritis The term used to refer to more than 100 diseases that affect 4.2 million individuals of all ages in Canada. #1 reason for activity limitations in older adults. Most common: osteoarthritis, polymyalgia rheumatica, rheumatoid arthritis & gout (in descending order). Osteoarthritis (OA) • Degenerative joint disease. • Affect 1 in 10 Canadians. • Risk factors: age, obesity, family history, repetitive use, trauma. • Joint cartilage becomes thin and damaged, joint spaces narrows. Osteoarthritis (OA) S/S: • Stiffness (relieved by activity) • Pain (related to activity) relieved by rest. • As disease progresses, pain increases, even at rest. • Can have joint instability / crepitus. • Most common in knees, hips, neck, lower back, fingers and thumbs. Polymyalgia Rheumatica (PMR) • Common form of arthritis in older adults. • Acute onset with pain in neck, upper arms, shoulders, lower back, buttocks & thighs. • Assoc. with inflammation of blood vessels. • More common in women. • Seems to be genetic. • Other S/S: low grade fever, fatigue & pain and stiffness at night / early a.m. • Treatment (Rx): small doses of corticosteroids (prednisone). • Can resolve in one or two years. Rheumatoid Arthritis (RA) • Chronic systemic inflammatory joint disorder • Autoimmune disease • Inflamed joints begin to destroy lining of joint (synovial lining), joint destruction. • Can be debilitating Rheumatoid Arthritis S/S Treatment (Rx) • Pain & swelling in multiple joints • Hands, wrist, ankle, knees and hips • Usually smaller joints, symmetrical • Morning stiffness > 30 mins • Experience with disease is variable • NSAIDS (nonsteroidal anti-inflammatory drugs) e.g. Indocid, Ibprophen. • DMARDS (disease modifying antirheumatic drugs). • Corticosteroids (prednisone) • Joint replacements (OA & RA) Non-pharmacological • • • • • • Heat & cold applications Ultrasound Music therapy Acupuncture Massage Glucosamine Gout • Common form resulting from an accumulation of uric acid crystals in the joint. • Acute attack, very painful. • Joint is bright purple red, painful to touch. • Most common location – proximal joint of great toe. Gout Risk Factors: • Diet high in purines (Asparagus, steak, organ meats, seafood, sweet bread, gravy, alcohol, etc.) See Box 18-3 • High BP • Certain medications: Thiazide diuretics, aspirin Treatment: • Allopurinol • Increase fluid intake • Decrease alcohol, purines Arthritis: Nursing Implications Educate Appropriate use of heat and cold Recommend SelfManagement programs ROM (Range of Motion exercises) Arthritis Society (community resource) Conserving energy Be knowledgeable – alternative therapies Chronic Illness: Hypertension (HTN) Hypertension (High Blood Pressure): • *Systolic > 140 & Diastolic > 90 • (on 2 separate occasions). Classification: (Table 20-2) • Normal: systolic < 120; diastolic < 80 • Prehypertension: S 120-139; D 80-89 • Stage 1 HTN: S 140-159; D 90-99 • Stage 2 HTN: S > 160; D >100 Hypertension Often onset is often asymptomatic Other S/S: Headache, blurred vision, etc. Organ damage is likely (if not treated) “White coat syndrome” Postural hypotension (orthostatic) often an adverse effect of medications. Hypertension: Modifiable Risk Factors Cigarette smoking or tobacco use Excessive alcohol intake Sedentary lifestyle Inadequate stress management, anger management, or both. High-sodium diet High-fat diet Chronic Illness: Coronary Heart Disease (CHD) • Result of untreated hypertension, narrowing of the arteries (arteriosclerosis), may lead to a blockage & Myocardial Infarction (MI) or heart attack. • Diabetes – significant risk factor. Coronary Heart Disease S/S of a MI / Heart Attack: • In older adults ‘heartburn’ may be the only symptom (Gastrointestinal distress similar to reflux). • Not usually a typical presentation like gripping chest pain. • May present as localized pain to the back, abdomen, shoulders & both arms. • Nausea & Vomiting (N & V) may also be a symptom. Chronic Illness: Heart Failure (HF) Also called Congestive Heart Failure (CHF). Damage to the heart caused by CHD / MI. Other causes: hypertension, excessive use of drugs & alcohol, diabetes, obesity, infection, high cholesterol & other medical conditions. Most frequent cause of hospitalization of older adults. Heart can no longer pump enough blood efficiently to meet the needs of body. Heart Failure (HF) S/S of Heart Failure: • Shortness of Breath (SOB), dyspnea with exertion or at rest. • Orthopnea (can’t lie flat), *elevate bed to help • Fatigue • Swelling in lower extremities • Weight gain • Type 1 & 2 • 2.7 million Canadians over 20 have diabetes. • NIDDM (Type 2) diagnosed in later life. • Pancreas make insulin, not enough for needs. • Insulin resistance (metabolic syndrome). • Many go undiagnosed /serious complications develop. • Death likely due to MI (heart attack) or stroke. Chronic Illness: Diabetes Diabetes Symptoms (s/s): Complications: • Polydipsia (thirsty), polyuria (voiding frequently), polyphagia (hungry) and weight loss • *Classic s/s of diabetes rarely seen in older adults • Older adults’ presentation: fatigue, change in weight, recurrent infections. • Microvascular • Loss of vision (Diabetic retinopathy), End-stage renal failure (Diabetic nephropathy) • Macrovascular • MI, Stroke, Peripheral vascular disease, Neuropathy Diabetes Management: • Important to learn self-care skills. • Understand treatment: hypoglycemic medications (lower blood sugar) e.g. Metformin, glyburide, insulin (injection) to balance Blood Glucose (BG) levels. • Need to understand drug interactions • *Box 17-4 Meds affecting Blood sugar Nursing Considerations: • Monitor BG levels (glucometers). • Educate clients on how to manage disease including: appropriate diet, weight management, glucometers, exercise, prevention of infections, foot care. • Medications • Regular health monitoring / assessment. Diabetes Management Challenges: • Self-monitoring / self-management / level of support • Affordability e.g. costs of medications, transportation to health clinics. • Comprehension e.g. cognitive and sensory. *Goal: manage blood glucose levels to prevent serious complications *Caution: Hypoglycemic medications may lower BG levels too low & cause Hypoglycemia. • S/S: the person feels clammy or cold, sweaty, shaky & confused. May precipitate a medical emergency if not treated immediately. • Nursing Action: provide client with orange / apple juice (Check agency policy). May need Intravenous glucose. Chronic Illness: Cerebral Vascular Accident (CVA) • Risk increases with uncontrolled high B/P & diabetes. • Residual effects of a stroke: balance, spatial awareness, sensation, range of motion control. • Risk for depression increases when recovery not favorable. • Hazards of immobility & safety issues become priority in care. • Rehabilitation important to optimize level of function. Transient Ischemic Attack (TIA) Transient strokes that last only a few minutes Usually when the blood supply to part of the brain is briefly interrupted Symptoms usually occur suddenly and are similar to those of stroke but do not last as long. Often warning signs that a person may be at risk for a more serious and debilitating stroke This Photo by Unknown Author is licensed under CC BY-SA-NC Chronic Illness: Chronic Obstructive Pulmonary Disease (COPD) • Involves all conditions that affect airflow • e.g. asthma, bronchitis, emphysema. • 4th leading cause of death in older adults • Caused by tobacco use & exposure to pollutants COPD: S/S Emphysema: • Little sputum production & patients appear pink because they are receiving adequate oxygen Bronchitis: • Chronic sputum production, frequent cough, pale and somewhat cyanotic (bluish color) Acute episode of COPD: • Characterized by significantly worsened dyspnea and increased volume and purulence of sputum COPD: Treatment Smoking cessation Nutritious diet Educate re signs of lung infection Exercise as tolerated Medications / RX: bronchodilators, corticosteroids, antibiotics (infection), oxygen therapy. Chronic Illness: Cancer Older adults have increased risk, (advancing age is a risk factor). When treatment options are explored, should consider overall health & function NOT just age. Treating cancer in older adults is complex because of multiple co-existing or comorbid conditions. Cancer in older people is often under treated. Important to have shared decision making between client & healthcare providers to ensure that the best decision around treatment is arrived at for the individual. Cancer Concerns in Older Adult Population: • Maintaining independence • Feelings of social isolation • Spiritual concerns • Financial concerns • Physical limitations • Transportation Screening over 50: • Breast CA: BSE, Mammogram • Cervical CA: Pap test, Pelvic exam • Colon CA: Fecal Occult Blood Test, Colonoscopy • Mouth, tongue, throat CA: Oral exam • Prostate CA: Digital rectal exam, PSA • Skin CA: Skin Exams Cancer: Prevention Not Smoking Watch sun exposure and burning (Box 11.4) Keeping active Healthy diet No more than 1 drink of alcohol per day Healthy weight Ensure work environment safety Chronic Illness Trajectory (CIT) Preventive phase (pretrajectory) Definitive phase (trajectory onset) Crisis phase Acute phase Dying phase Downward phase Unstable phase Stable phase CIT Applied to Diabetes • Pre-trajectory - before illness begins, (preventive), may be a family history; follow positive lifestyle measures. • Trajectory onset - includes diagnosis (s/s are present), may take days / weeks /months. • Crisis – maybe life threatening, one of more systems fails to function (hyperglycemia). • Acute - active illness / determining course of active treatment. • Stable - course of treatment working • Unstable - treatment not working, not necessary for hospitalization. • Downward - progressive worsening effects on other body systems. • Dying - immediate weeks, days , hours to death; cause of death results from impact of comorbidities, ability of other systems to function. CIT: Goals for Clients • After a person’s condition stabilizes (plateaus), the nurse can help the patient by encouraging adherence to the treatment regimen so that the person may reach the highest level of function within the limits of his disability. • Example: adhering to a diabetic diet, or an exercise program. • Helping & Educating clients: • To adopt attitudes & lifestyle changes to promote health & prevent disease (manage illness). • To adapt to changes when the illness is in the downward trajectory. • To gain greater control over symptoms when a patient is in the ‘unstable phase’. • To establish illness stability, integrating / balancing illness management activities with everyday life. • Goals can be made more specific for every person. Key Points in CIT Framework Chronic illness management designed to maximize & extend period of stability in home with help from family, augmented by visits to and from health care providers. Maintaining stable phases is central in managing chronic illness. Nurse is involved with coordinating multiple disciplines / resources needed to promote quality of life along the trajectory. Goals are multi-dimensional, ranging from symptom relief & comfort, to psychological adaptations & stress reduction, and the prevention of complications. Orem’s Self-care Theory Individuals have universal self-care requisites, that is the need to retain control over meeting one’s needs. Needs are met by the individual (self-care), the nurse or both the individual + nurse. Individual moves from self-care to dependent care to semi-dependent care as condition changes (depends on stage of illness). Orem’s theory allows older adults to retain control & physical functioning (as realistic). (Chp. 15, p. 250) Restorative & Rehabilitative Care Restorative: • Capability of an individual to be ‘restored’ to as near normal functions as possible. • Focuses on improvement rather than maintenance. Rehabilitative: • Focuses on improving a person’s quality of life in any way • Multi-disciplinary involvement e.g. speech therapy, physiotherapy, psychology or psychiatry etc. Both focus on determining a person’s strengths / needs & working with him/her to obtain the highest level of function. • Both enhance quality of life.