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Ebersole and Hess' Toward Healthy Aging Human Needs and Nursing Response NINTH EDITION Theris A. Touhy, DNP, CNS, DPNAP Emeritus Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida Kathleen Jett, PhD, GNP-BC Gerontological Nurse Practitioner, Senior Care Clinic at Oak Hammock, Department of Aging and Geriatric Research, University of Florida, College of Medicine, Gainesville, Florida Table of Contents Cover image Title page Brief Toc Dedications Copyright About the authors Contributors and reviewers Preface 1. Foundations of Healthy Aging 1. Health and wellness in an aging society The years ahead Aging A wellness-based model Disease prevention and health promotion for older adults Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 2. Gerontological Nursing: Past, Present, and Future Care of Older Adults: A Nursing Imperative Development of Gerontological Nursing Gerontological Nursing Education Organizations Devoted to Gerontology Research and Practice Research on Aging Gerontological Nursing Roles Transitions Across the Continuum: Role of Nursing Promoting Healthy Aging: Implications for Gerontological Nursing Key Concepts Critical Thinking Questions and Activities Research Questions REFERENCES 3. Theories of aging Biological theories of aging Promoting healthy aging: Implications for gerontological nursing Psychosocial theories of aging Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 4. Cross-cultural caring and aging Culture and health care Diversity Health inequities and disparities Obstacles to cross-cultural caring Providing cross-cultural health care Promoting healthy aging: Implications for gerontological nursing Integrating concepts Key concepts Critical thinking questions and activities Research questions References 5. Cognition and learning Adult cognition Promoting healthy aging: Implications for gerontological nursing Learning in later life Promoting healthy aging: Implications for gerontological nursing Health literacy Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 2. Foundations of Caring 6. Communicating with older adults Ageism and communication Therapeutic communication with older adults The life story Promoting healthy aging: Implications for gerontological nursing Communicating with groups of older adults Promoting healthy aging: Implications for gerontological nursing Key concepts Research questions Critical thinking questions and activities References 7. Health assessment The health history Physical assessment Functional assessment Function and cognition Assessment of mood Comprehensive geriatric assessment Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 8. Laboratory values and diagnostics Hematological testing Measures of inflammation Vitamins Blood chemistry studies Uric acid Prostate-specific antigen Laboratory testing for cardiac health Testing for body proteins Laboratory tests of renal health Monitoring for therapeutic blood levels Urine studies Promoting healthy aging: Implications for gerontological nursing Key concepts Research questions Critical thinking questions and activities References 9. Geropharmacology Pharmacokinetics Pharmacodynamics Issues in medication use Promoting healthy aging: Implications for gerontological nursing Safe medication use Key concepts Critical thinking questions and activities Research questions References 10. The use of herbs and supplements Standards in manufacturing Herb forms Select commonly used teas, herbs, and supplements Use of herbs and supplements for select conditions Herb and supplement interactions with standardized drugs Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 3. Wellness and Function 11. Vision Changes in vision with age Visual impairment Diseases and disorders of the eye Promoting healthy aging: Implications for gerontological nurses Key concepts Critical thinking questions and activities Research questions References 12. Hearing Hearing impairment Interventions to enhance hearing Promoting healthy aging: Implications for gerontological nursing Tinnitus Key concepts Critical thinking questions and activities Research questions References 13. Skin care Skin Common skin problems Skin cancers Promoting healthy aging: Implications for gerontological nursing Pressure ulcers Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 14. Nutrition Global nutrition concerns Age-related requirements Obesity (overnutrition) Malnutrition (undernutrition) Factors affecting fulfillment of nutritional needs Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 15. Hydration and oral care Hydration management Dehydration Promoting healthy aging: Implications for gerontological nursing Oral health Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 16. Elimination Age-related changes in the renal and urological systems Urinary incontinence Promoting healthy aging: Implications for gerontological nursing Urinary tract infections Bowel elimination Promoting healthy aging: Implications for gerontological nursing Accidental bowel leakage/fecal incontinence Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Critical thinking questions and activities Research questions References 17. Sleep Biorhythm and sleep Sleep and aging Sleep disorders Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 18. Physical activity and exercise Physical activity and aging Promoting healthy aging: Implications for gerontological nursing Key concepts Research questions Critical thinking questions and activities References 19. Falls and fall risk reduction Mobility and aging Falls Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Restraints and side rails Key concepts Critical thinking questions and activities Research questions References 20. Safety and security Environmental safety Home safety Crimes against older adults Fire safety for elders Vulnerability to environmental temperatures Promoting healthy aging: Implications for gerontological nursing Vulnerability to natural disasters Promoting healthy aging: Implications for gerontological nursing Transportation safety Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Emerging technologies to enhance safety of older adults Elder-friendly communities Key concepts Critical thinking questions and activities Research questions References 4. Wellness and Chronic Illness 21. Living well with chronic illness A model for chronic illness Frailty Key concepts References 22. Cardiovascular and cerebrovascular health and wellness The aging heart Cardiovascular disease (CVD) The aging peripheral vascular system Peripheral vascular disease Cerebrovascular disorders Promoting healthy aging: implications for gerontological nursing: Cardiovascular disease Key concepts Critical thinking questions and activities Research questions References 23. Neurodegenerative disorders Diagnosis Parkinson’s disease Alzheimer’s disease Neurocognitive dementia with lewy bodies Complications Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 24. Endocrine and immune disorders The immune system The endocrine system Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 25. Respiratory health and illness Normal age-related changes Respiratory disorders Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 26. Common musculoskeletal concerns The aging musculoskeletal system Musculoskeletal disorders Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 27. Pain and comfort Pain in the older adult Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 28. Mental health Stress and coping in late life Promoting healthy aging: Implications for gerontological nursing Factors influencing mental health care Mental health disorders Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Schizophrenia Promoting healthy aging: Implications for gerontological nursing Psychotic symptoms in older adults Promoting healthy aging: Implications for gerontological nursing Bipolar disorder (BD) Promoting healthy aging: Implications for gerontological nursing Depression Promoting healthy aging: Implications for gerontological nursing Suicide Promoting healthy aging: Implications for gerontological nursing Substance use disorders Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Critical thinking questions and activities Research questions References 29. Care of individuals with neurocognitive disorders Caring for individuals with neurocognitive disorders Neurocognitive disorder: Delirium Promoting healthy aging: Implications for gerontological nursing Care of individuals with mild and major neurocognitive disorder Communication Promoting healthy aging: Implications for gerontological nursing Behavior concerns and nursing models of care Promoting healthy aging: Implications for gerontological nursing Providing care for activities of daily living Promoting healthy aging: Implications for gerontological nursing Wandering Promoting healthy aging: Implications for gerontological nursing Nutrition Promoting healthy aging: Implications for healthy aging Nursing roles in the care of persons with dementia Key concepts Critical thinking questions and activities Research questions References 5. Healthy Aging for Elders and Their Families 30. Economics and health care in later life Economics in late life Economics and health care Key concepts Critical thinking questions and activities Research questions References 31. Common legal and ethical issues Decision-making Elder mistreatment Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 32. Long-term care Future projections Costs of long-term care LTC and the U.S. health care system Global approaches to LTC Promoting healthy aging: Implications for gerontological nursing Formal long-term care service providers Quality of care in skilled nursing facilities Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 33. Intimacy and sexuality Touch Intimacy Sexuality Sexual health Sexual dysfunction Alternative sexual lifestyles: Lesbian, gay, bisexual, and transgender Promoting healthy aging: Implications for gerontological nursing Intimacy and chronic illness Intimacy and sexuality in long-term care facilities Intimacy, sexuality, and dementia HIV/AIDS and older adults Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 34. Relationships, roles, and transitions Later life transitions Promoting healthy aging: Implications for gerontological nursing Promoting healthy aging: Implications for gerontological nursing Relationships in later life Families Caregiving Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References 35. Loss, death, and palliative care Loss, grief, and bereavement Grief work Promoting healthy aging while grieving: Implications for gerontological nursing Dying and death Promoting a good death: Implications for gerontological nursing Palliative care Decision-making at the end of life Promoting healthy aging: Implications for gerontological nursing Promoting healthy dying while aging: Implications for gerontological nursing Key concepts Research questions Critical thinking questions and activities References 36. Self-actualization, spirituality, and transcendence Self-actualization Wisdom Creativity Recreation Bringing young and old together Promoting healthy aging: Implications for gerontological nursing Spirituality Promoting healthy aging: Implications for gerontological nursing Transcendence Legacies Promoting healthy aging: Implications for gerontological nursing Key concepts Critical thinking questions and activities Research questions References Index Brief toc Part 1 Foundations of healthy aging 1 Health and Wellness in an Aging Society, 1 Kathleen Jett and Theris A. Touhy 2 Gerontological Nursing: Past, Present, and Future, 13 Theris A. Touhy 3 Theories of Aging, 31 Kathleen Jett 4 Cross-Cultural Caring and Aging, 40 Kathleen Jett 5 Cognition and Learning, 54 Theris A. Touhy Part 2 Foundations of caring 6 Communicating with Older Adults, 65 Theris A. Touhy 7 Health Assessment, 74 Kathleen Jett 8 Laboratory Values and Diagnostics, 88 Kathleen Jett 9 Geropharmacology, 101 Kathleen Jett 10 The Use of Herbs and Supplements, 115 Jo Lynne Robins and Lisa Burroughs Phipps Part 3 Wellness and function 11 Vision, 130 Theris A. Touhy 12 Hearing, 142 Theris A. Touhy 13 Skin Care, 152 Theris A. Touhy 14 Nutrition, 170 Theris A. Touhy 15 Hydration and Oral Care, 191 Theris A. Touhy 16 Elimination, 200 Theris A. Touhy 17 Sleep, 221 Theris A. Touhy 18 Physical Activity and Exercise, 233 Theris A. Touhy 19 Falls and Fall Risk Reduction, 244 Theris A. Touhy 20 Safety and Security, 263 Theris A. Touhy Part 4 Wellness and chronic illness 21 Living Well with Chronic Illness, 278 Kathleen Jett 22 Cardiovascular and Cerebrovascular Health and Wellness, 283 Kathleen Jett 23 Neurodegenerative Disorders, 299 Kathleen Jett 24 Endocrine and Immune Disorders, 308 Kathleen Jett 25 Respiratory Health and Illness, 319 Kathleen Jett 26 Common Musculoskeletal Concerns, 327 Kathleen Jett 27 Pain and Comfort, 339 Kathleen Jett 28 Mental Health, 352 Theris A. Touhy 29 Care of Individuals with Neurocognitive Disorders, 381 Debra Hain, María Ordóñez, and Theris A.Touhy Part 5 Healthy aging for elders and their families 30 Economics of Health Care in Later Life, 407 Kathleen Jett 31 Common Legal and Ethical Issues, 417 Kathleen Jett 32 Long-Term Care, 427 Theris A. Touhy 33 Intimacy and Sexuality, 445 Theris A. Touhy 34 Relationships, Roles, and Transitions, 463 Theris A. Touhy 35 Loss, Death, and Palliative Care, 482 Kathleen Jett 36 Self-Actualization, Spirituality, and Transcendence, 502 Priscilla Ebersole and Theris A. Touhy Dedications To my three sons and daughters-in-law, thanks for surrounding me with love and family. To my husband, just thanks for loving me for 47 years even though it’s not always easy! To my beautiful grandchildren, Colin, Molly, and Auden Touhy. Being your Grama TT makes growing older the best time of my life and I love you. To all the students who read this book. I hope each of you will improve the journey toward healthy aging through your competence and compassion. To all of my students who have embraced gerontological nursing as their specialty and are improving the lives of older people through their practice and teaching. To the wise and wonderful older people whom I have been privileged to nurse, and to their caregivers. Thank you for making the words in this book a reality for the elders for whom you care, and for teaching me how to be a gerontological nurse. Theris A. Touhy To my patients and others who teach me every day about the highs and lows of the furthest reaches of age and what really matters the most in life. To my husband Steve, for his patience during the year I worked on this edition, with little time for anything else. To the staff at The Diner where I wrote and re-wrote for many hours in a place with no distractions and a sunny window. They always kept my iced tea glass full, knew what I wanted to eat, and how I liked it cooked! I thank them. And to Dr. Michael Johnson, who pushes me to grow and helps my soul seek peace. Kathleen Jett Copyright 3251 Riverport Lane St. Louis, Missouri 63043 EBERSOLE & HESS’ TOWARD HEALTHY AGING, NINTH EDITION ISBN: 978-0-323-32138-9 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2012, 2008, 2004, 1998, 1994, 1990, 1985, and 1981. Library of Congress Cataloging-in-Publication Data Touhy, Theris A., author. Ebersole & Hess’ toward healthy aging : human needs & nursing response/Theris A. Touhy, Kathleen F. Jett.—Ninth edition. p.; cm. Ebersole and Hess’ toward healthy aging Toward healthy aging Includes bibliographical references and index. ISBN 978-0-323-32138-9 (pbk. : alk. paper) I. Jett, Kathleen Freudenberger, author. II. Title. III. Title: Ebersole and Hess’ toward healthy aging. IV. Title: Toward healthy aging. [DNLM: 1. Geriatric Nursing. 2. Aged. 3. Aging. 4. Health Promotion. WY 152] RC954 618.97’0231—dc23 2015004733 Content Strategist: Sandra Clark Content Development Manager: Laurie Gower Senior Content Development Specialist: Karen C. Turner Publishing Services Manager: Jeffrey Patterson Senior Project Manager: Tracey Schriefer Designer: Amy Buxton Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 About the authors Theris A. Touhy, DNP, CNS, DPNAP, has been a clinical specialist in gerontological nursing and a nurse practitioner for over 35 years. Her expertise is in the care of older adults in nursing homes and those with dementia. The majority of her practice as a clinical nurse specialist and nurse practitioner has been in the long-term care setting. She received her BSN degree from St. Xavier University in Chicago, a master’s degree in care of the aged from Northern Illinois University, and a Doctor of Nursing Practice from Case Western Reserve University. Dr. Touhy is an emeritus professor in the Christine E. Lynn College of Nursing at Florida Atlantic University, where she has served as Assistant Dean of Undergraduate Programs and taught gerontological nursing and long-term, rehabilitation, and palliative care nursing in the undergraduate, graduate, and doctoral programs. Her research is focused on spirituality in aging and at the end of life, caring for persons with dementia, caring in nursing homes, and nursing leadership in long-term care. Dr. Touhy was the recipient of the Geriatric Faculty Member Award from the John A. Hartford Foundation Institute for Geriatric Nursing in 2003, is a two-time recipient of the Distinguished Teacher of the Year in the Christine E. Lynn College of Nursing at Florida Atlantic University, and was awarded the Marie Haug Award for Excellence in Aging Research from Case Western Reserve University. Dr. Touhy was inducted into the National Academies of Practice in 2007. She is co-author with Dr. Kathleen Jett of Gerontological Nursing and Healthy Aging and is co- author with Dr. Priscilla Ebersole of Geriatric Nursing: Growth of a Specialty. Kathleen Jett, PhD, GNP-BC, has been actively engaged in gerontological nursing for over 30 years. Her clinical experience is broad, from her roots in public health to clinical leadership in long- term care, assisted living and hospice, researcher and teacher, and advanced practice as both a clinical nurse specialist and nurse practitioner. Dr. Jett received her bachelor’s, master’s, and doctoral degrees from the University of Florida, where she also holds a graduate certificate in gerontology. In 2000 she was selected as a Summer Scholar by the John A. Hartford Foundation—Institute for Geriatric Nursing. In 2004 she completed a Fellowship in Ethno- Geriatrics through the Stanford Geriatric Education Center. Dr. Jett has received several awards, including recognition as an Inspirational Woman of Pacific Lutheran University in 1998 and 2000 and for her excellence in undergraduate teaching in 2005 and Distinguished Teacher of the year within the Christine E. Lynn College of Nursing at Florida Atlantic University. A board-certified gerontological nurse practitioner, Dr. Jett was inducted into the National Academies of Practice in 2006. She has taught an array of courses including public health nursing, women’s studies, advanced practice gerontological nursing, and undergraduate courses in gerontology. She has coordinated two gerontological nurse practitioner graduate programs and an undergraduate interdisciplinary gerontology certificate program. The majority of her research and practice funding has been in the area of reducing health disparities experienced by older adults. The thread that ties all of her work together has been a belief that nurses can make a difference in the lives of older adults. She is currently employed as a nurse practitioner at Oak Hammock, a life- care community associated with the University of Florida, and provides research consultation for the College of Nursing. In addition to her professional activities, Dr. Jett is actively engaged in the lives of her grandchildren in rural High Springs, Florida. Contributors and reviewers CONTRIBUTORS Debra Hain PhD, ARNP, ANP-BC, GNP-BC, FAANP Associate Professor/Lead Faculty AGNP Program, Christine E. Lynn College of Nursing, Florida Atlantic University Boca Raton, Florida, Nurse Practitioner, Department of Hypertension/Nephrology, Cleveland Clinic Florida, Weston, Florida María de los Ángeles Ordóñez DNP, ARNP/GNP-BC, Director, Louis and Anne Green Memory and Wellness Center, Memory Disorder Clinic Coordinator, Assistant Professor Christine E. Lynn College of Nursing, Assistant Professor of Clinical Biomedical Science (Secondary), Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida Lisa Burroughs Phipps PharmD, PhD, Assistant Professor, Virginia Commonwealth University, Academic Learning Transformation Lab, Richmond, Virginia Jo Lynne Robins PhD, RN, ANP-BC, AHN-C, FAANP, Assistant Professor, Virginia Commonwealth University, School of Nursing, Department of Family and Community Health, Richmond, Virginia REVIEWERS Kathleen Koernig Blais EdD, MSN, RN, Professor Emerita, Florida International University, College of Nursing and Health Sciences, Miami, Florida Sherri Shinn Cozzens MS, RN, GRN, Nursing Faculty, De Anza College Nursing Program, Cupertino, California Gail Potter RN, BScN, M. Div., MN, CGNC(C), Nursing Faculty, Department of Health and Human Services, Selkirk College, Castlegar, British Columbia, Canada P. Janine Ray RN, CRRN, MSN, PhD(c), Assistant Professor of Nursing, Department of Nursing, Angelo State University, Member, Texas Tech University, System San Angelo, Texas Ann Christy Seckman DNP, MSN-FNP, RN, Associate Professor, Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, Missouri JoAnn Swanson MSN, RN-BC, ONC, Assistant Professor, BSN Program Director, Bellin College School of Nursing, Green Bay, Wisconsin Preface Theris A. Touhy, Kathleen Jett In 1981, Dr. Priscilla Ebersole and Dr. Patricia Hess published the first edition of Toward Healthy Aging: Human Needs and Nursing Response, which has been used in nursing schools around the globe. Their foresight in developing a textbook that focuses on health, wholeness, beauty, and potential in aging has made this book an enduring classic and the model for gerontological nursing textbooks. In 1981, few nurses chose this specialty, few schools of nursing included content related to the care of elders, and the focus of care was on illness and problems. Today, gerontological nursing is a strong and evolving specialty with a solid theoretical base and practice grounded in evidence-based research. Dr. Ebersole and Dr. Hess set the standards for the competencies required for gerontological nursing education and the promotion of healthy aging. Many nurses, including us, have been shaped by their words, their wisdom, and their passion for care of elders. We thank these two wonderful pioneers and mentors for the opportunity to build on such a solid foundation in the three editions of this book we have co-authored. We hope that we have kept the heart and spirit of their work, for that is truly what has inspired us, and so many others, to care with competence and compassion. We believe that Toward Healthy Aging is the most comprehensive gerontological nursing text available. Within the covers, the reader will find the latest evidence-based gerontological nursing protocols to be used in providing the highest level of care to adults in settings across the continuum. The content is consistent with the Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults and the Hartford Institute for Geriatric Nursing Best Practices in Nursing Care to Older Adults. The text has been on the list of recommended reading for the ANCC Advanced Practice Exam for many years and is recommended as a core text by gerontological nursing experts. Toward Healthy Aging is an appropriate text for both undergraduate and graduate students and is an excellent reference for nurses’ libraries. This edition makes an ideal supplement to health assessment, medical-surgical, community, and psychiatric and mental health textbooks in programs that do not have a freestanding gerontological nursing course. Information about evidence-based practice is presented where available. A holistic approach, addressing body, mind, and spirit, along a continuum of wellness, and grounded in caring and respect for person, provides the framework for the text. The ninth edition has been totally revised to facilitate student learning. Several new chapters have been added to expand and update content areas from previous editions. We present aging within a cultural and global context in recognition of diversity of all kinds and health inequities which persist. We hope to encourage readers to develop a world view of aging challenges and possibilities and the significant role of nursing in promoting healthy aging. Organization of the text Toward Healthy Aging has 36 chapters, organized into 5 sections. Section 1 introduces the theoretical model on which the text is based and discusses the concepts of health and wellness in aging and the roles and responsibilities of gerontological nurses to provide optimal and informed caring. It includes a discussion of the changing population dynamics around the globe as more and more persons live longer and longer. Section 2 provides the reader with the basic information needed to perform the day-to-day activities of gerontological nursing such as assessment, communication, and interpretation of laboratory tests. Section 3 explores concerns that may affect functional abilities in aging such as vision, hearing, elimination, sleep, physical activity, and safety and security. Nursing interventions to enhance wellness, maintain optimal function, and prevent unnecessary disability are presented. Section 4 goes into more depth regarding the chronic disorders covered in just one chapter in previous editions. Among these are chapters on mental health and neurodegenerative disorders such as Alzheimer’s and Parkinson’s diseases. Section 5 moves beyond illness and functional limitations that may occur in aging and focuses on psychosocial, legal, and ethical issues that affect elders and their families/significant others. Content ranges from the economics of health care to sexuality and palliative care. Aging is presented as a time of accomplishing life’s tasks, developing and sharing unique gifts, and reflecting on the meaning of life. Wisdom, self-actualization, creativity, spirituality, transcendence, and legacies are discussed. The unique and important contributions of elders to society, and to each of us, calls for nurses to foster appreciation of each older person, no matter how frail. Key components of the text A Student Speaks/An Elder Speaks: Introduces every chapter to provide perspectives of older people and nursing students on chapter content Learning Objectives: Presents important chapter content and student outcomes Promoting Healthy Aging: Implications for Gerontological Nursing: Special headings detailing pertinent assessment and interventions for practice applications of chapter content Key Concepts: Concise review of important chapter points Nursing Studies: Practice examples designed to assist students in assessment, planning, interventions, and outcomes to promote healthy aging Critical Thinking Questions and Activities: Assist students in developing critical thinking skills related to chapter and nursing study content and include suggestions for in-classroom activities to enhance learning Research Questions: Suggestions to stimulate thinking about ideas for nursing research related to chapter topics Boxes Safety Alerts: QSEN competencies and safety issues related to care of older adults Research Highlights: Summary of pertinent current research related to chapter topics Resources for Best Practice (New to the ninth edition): Suggestions for further information for chapter topics and tools for practice Tips for Best Practice (New to the ninth edition): Summary of evidence-based nursing interventions for practice Healthy People: Reference to the goals cited in Healthy People 2020 Evolve ancillaries Instructors Test Bank: Hundreds of questions with rationales to use in creating exams PowerPoint: Lecture slides for each chapter, including integrated audience response questions Teach for Nurses Lesson Plans: Detailed listing of resources available to instructors for their lesson planning, and including unique case studies and class activities that can be shared with students Students Student Review Questions: Open-ended study questions covering nearly every element of each chapter Case Studies: Accompanying select chapters, these provide short case studies with questions to help students see content put into practical use Acknowledgements This book would not have been possible without the support and guidance of the staff at Elsevier. Especially Karen C. Turner, who listened to all of our suggestions and concerns and understood how important this work was to us and to nursing students. Special thanks also to Sandra Clark, Content Strategist and Tracey Schriefer, Project Manager. We also acknowledge our reviewers and contributors, because without their efforts this edition would not have been possible. Finally, we acknowledge the past and future readers who, we hope, will provide us with enough feedback to keep us honest in any future writing. PA R T 1 Foundations of Healthy Aging OUTLINE 1. Health and wellness in an aging society 2. Gerontological Nursing: Past, Present, and Future 3. Theories of aging 4. Cross-cultural caring and aging 5. Cognition and learning CHAPTER 1 Health and wellness in an aging society Kathleen Jett, Theris A. Touhy Learning objectives On completion of this chapter, the reader will be able to: 1. Compare and contrast the historical events influencing the health and wellness of those 60 and older. 2. Discuss the implications of the wide range of life expectancies of older adults in different parts of the world. 3. Describe a wellness-based model that can be used to promote the health of an aging, global community. 4. Describe the priorities of the National Prevention Council and suggest how these apply to the aging adult. 5. Discuss the multidimensional nature of wellness and its implications for healthy aging. 6. Define and describe the three levels of prevention. 7. Develop health-promoting strategies at each level of prevention that are consistent with the wellness-based model. 8. Describe the role of the nurse in promoting health in later life. http://evolve.elsevier.com/Touhy/TwdHlthAging A STUDENT SPEAKS I was so surprised when I went to the senior center and saw all those old folks doing tai chi! I feel a bit ashamed that I don’t take better care of my own body. Maggie, age 24 AN ELDER SPEAKS Just a change in perspective! I can choose to be well or ill under all conditions. I think, too often we feel like victims of circumstance. I refuse to be a victim. It is my choice and I have control. Maria, age 86 Herb is an 85-year-old man who considers himself “American.” His great grandfather was born just after the American Civil War. Earlier in Herb’s life he was a business executive but his passion was car racing. Today he works out in the gym and walks 8 miles a day. He no longer races but is active in teaching others to do so. He is talkative and enjoys interacting with those around him. He has mild hypertension and atrial fibrillation. For these conditions he takes a low dose of an antihypertensive and a blood thinner (warfarin), respectively. When asked why he is so healthy and active “at his age,” he replies, “I never thought I would live to be this age, but I have lived life to the fullest. Mostly I think it is having the right genes, staying as active as possible and having a positive attitude.” From a perspective of Western medicine, health was long considered the absence of physical or psychiatric illness. It was measured in terms of the presence of accepted “norms,” such as a specific range of blood pressure readings and results of laboratory testing, and the absence of established signs and symptoms of illness. When any of the parameters negatively affected the ability of the individual to function independently, debility was assumed. The measurement of a population’s health status was usually inferred almost entirely from life expectancy, morbidity, and mortality statistics. The numbers provided information about illness but the health-related quality of life and wellness of the population could not be inferred. Measuring health in terms of illness does not reflect the life of persons with functional limitations, their ability to contribute to the community, or their movement toward self-actualization. Although there had been efforts for many years to recognize that health meant more than the absence of disease, a national effort was not organized in the United States until 1979. At that time initial national goals were set and described in the document The Surgeon General’s Report on Health and Disease Prevention (HealthyPeople, 2009). This has been updated every 10 years with the most current document Healthy People 2020. Many new topical foci have been added to the newest version, which are especially important to aging (HealthyPeople, 2013b). Among these are the dementias and a general area related to older adults. There is now a new area specific to health- related quality of life and wellness (HealthyPeople, 2013a). The importance of social well-being as a part of physical and mental health was recognized by the World Health Organization (WHO) in 1949, and the WHO recognized the importance of measuring social well- being in 2005 (WHO, 2005). A wellness-based model, derived from a holistic paradigm, has reshaped how health is viewed and revolutionized the way health care and health are perceived. Instead of snapshots in time during a person’s illness, a state of wellness can be uniquely defined anywhere along the continuum of health. Age and illness influence the ease at which one moves along the continuum but do not define the individual. Aging is part of the life course. Caring for persons who are aging is a practice that touches nurses in all settings: from pediatrics involving grandparents and great-grandparents, to the residents of skilled nursing facilities and their spouses, partners, and children, to nurses providing relief support in countries outside of their own. Holroyd et al. (2009) have estimated that “by 2020, up to 75% of nurses’ time will be spent with older adults” (p. 374). The core knowledge associated with gerontological nursing affects all of the profession and is not limited to any one subgroup of nurses (Young, 2003). Gerontological nurses can help shape a world in which persons can thrive and grow old, not merely survive. They have unique opportunities to facilitate wellness in those who are recipients of care. As we move forward in the twenty-first century, the manner in which nurses respond to our aging society will determine our character because we are no greater than the health of the country and the world in which we live. This text is written using a wellness-based model to guide the reader in maximizing strengths, minimizing limitations, facilitating adaptation, and encouraging growth even in the presence of chronic illness or an acute health event. It is about helping persons move Toward Healthy Aging. In this ninth edition we appreciate your willingness to join us in this adventure. The years ahead As we look to the future, the world’s population will soon include more persons older than 60 years than ever before. Although highly variable by country, in 2050 the number of persons older than 60 worldwide is expected to more than double from 2010—that is, the number will increase from 10% to 22%, the majority of whom are women (Figure 1-1). (United Nations, Department of Economic and Social Affairs, Population Division [UNDESAPD], 2005). Most of those older than 60 live in what is referred to as “less developed regions” and the percentage is expected to increase from 66% to 79% in this same time period (Figure 1-2) (United Nations [UN], 2012a). These elders are the most likely to be very poor and in need of support to an extent that is not seen in other parts of the world. For example, many grandparents are caring for the estimated 1.3 million Zimbabwean children orphaned by acquired immunodeficiency syndrome (AIDS). They have few, if any, organizations in place to help them (UNICEF, 2010). FIGURE 1-1 Growth in the Number of Persons at Least 60 Across the Globe. Source: (Data from United Nations, Department of Economic and Social Affairs, Population Division: World population prospects: the 2008 revision, New York, 2009, United Nations.) FIGURE 1-2 Distribution of World Population Aged 60 and Older by Development Region: 1950-2050. Source: (From United Nations, Department of Economic and Social Affairs, Population Division: World population ageing 2009, New York, 2009, United Nations.) Many grandparents in Africa must care for their young grandchildren. Source: (©iStock.com/Peeter Viisimaa.) Population growth will change the face of aging as we know it and present many challenges today and in our future. Although healthy aging is now an achievable goal for many in developed and developing regions, it is still only a distant vision for any of those living in less developed areas of the world, where lives are shortened by persistent communicable diseases, inadequate sanitation, and lack of both nutritious food and health care. It is essential that nurses across the globe have the knowledge and skills to help people of all ages achieve the highest level of wellness possible. Some of the questions that must be asked include the following: How can global conditions change for those who are struggling? How can the years of elderhood be maximized and enriched to the extent possible, regardless of the conditions in which one lives? Aging The term geriatrics was coined by American physician, Ignatz Nascher, around 1900 in recognition that the medical care of persons in later life differed from that of other population groups, such as pregnant women or children. Nascher authored the first medical textbook on treatment of the “old” in the United States (Nascher, 1914). Aging was reflected in his eyes as it was in society—a problem that must be reversed, eradicated, or held at bay as long as possible. From the early 1900s, the measurement of the incidence and prevalence of disease and associated morbidity or death was the focus. Although monitoring statistics is still important, the study of later life has been expanded to consideration of the nexus of time and human development, referred to as gerontology. How old is old? Each culture has its own definition of when one is recognized as “old.” A range of terms is used including elderly, senior citizens, elders, granny, older adult, or tribal elder. In some cultures elderhood is defined in functional terms—when one is no longer able to perform one’s usual activities (Jett, 2003). Social aging is often determined by changes in roles, such as retirement from one’s usual occupation, appointment as a wise woman/man of the community, or at the birth of a grandchild. Transitions may be marked by special rituals, such as birthday and retirement parties, invitations to join groups such as the American Association of Retired Persons (AARP, 2014), the qualification for “senior discounts” (Box 1-1), eligibility for age-related pensions, or recognition of special honor. BOX 1-1 The Aging Phenotype A few years ago I stopped coloring my hair, which is almost completely silver now. It was quite a surprise to me the first time the very young clerk in the booth at the movie theater assumed I was 65 and automatically gave me the “senior discount.” My husband’s hair is only fading to a dull brown. When he goes alone they tentatively ask, “Do you have any discounts?” Kathleen, at age 60 Biological aging is a complex and continuous process involving every cell in the body from birth to death (Chapter 3). The physical traits by which we identify one as “older” (e.g., gray hair, wrinkled skin) are referred to as the aging phenotype, that is, an outward expression of one’s individual genetic makeup. The aging phenotype. Source: (©iStock.com/LPETTET; Mlenny.) Chronological aging may be combined with any of the previously mentioned biological aging traits or used alone to define aging. In most developed and developing areas of the world, chronological late life is recognized as beginning sometime between the ages 50 and 65, with the World Health Organization using the age of 60 in their discussions (World Health Organization [WHO], 2013a). These arbitrary numbers have been defined with the expectation that persons are in the last decade or two of their lives. This is no longer applicable to men and women in some developed countries where life expectancies are rising. Japan is most notable. There, women have the longest potential life expectancy in the world—29 additional years at the age of 60 (UN, 2012b). In striking contrast are those living in many West African countries such as Mali, where both men and women can expect to live only 13 more years after 60 (Sanderson and Scherbov, 2008). Women at the age of 60 in the United States can expect to live another 25 years and men another 22 years (UN, 2012b). However, because the population in the United States is quite diverse, so is life expectancy. Although there has been a steady increase overall, this has been slower for those considered non-white when compared with those considered white (racial classification). For example, in 2010 the life expectancy at birth for black American men was 4.7 years less than that for white American men and 3.3 years less than that for black women (Kochanek et al, 2013) (Figure 1-3). FIGURE 1-3 Life Expectancy at Birth, by Race and Sex: United States, 2010. Source: (From Kochanek KD, Arias E, Anderson RN: How did cause of death contribute to racial differences in life expectancy in the United States in 2010? [NCHS data brief no. 125], Hyattsville, MD, 2013, National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db125.htm. Accessed September 11, 2014.) There is an ongoing controversy among demographers and gerontologists regarding the use and accuracy of chronological aging. In 1800 only 25% of men in Western Europe lived to the age of 60, yet today 90% of this same demographic live to the age of 90 (Sanderson and Scherbov, 2008, p. 3). So in 1800, was one “old” at 40? Is “old age” delayed until 70 today? How old is old and can there ever be a universal number? As life expectancy increases how will we define aging? How will these definitions, as well as the meaning and the perception of aging, change as the health and wellness of individuals, communities, and nations improve? How will nursing roles and responsibilities change? How can we promote wellness in those who have a much greater chance of living into their 100s? In the countries where the average life expectancies have expanded most rapidly, the following four generational subgroups have emerged: the super-centenarians, the centenarians, the baby boomers, and those in-between. Elderhood has the potential to span 40 years or more, attributable in a large part to increased access to quality health services and emphasis on improving the health of the public. The super-centenarians The super-centenarians are those who live until at least 110 years of age. As of 2015 they were born in 1905 or earlier (Box 1-2). This elite group emerged in the 1960s as those first documented to have lived so long. According to the New England Super-Centenarian Study at Boston University, there are about 200 to 300 of these exceptionally long-lived persons worldwide and about 60 in the United States (Schoenhofen et al, 2006). BOX 1-2 A Remarkably Long Life: Truth or Fiction? On August 4, 1997, Mme Calment of Arles, France, died a rich woman at reportedly the age of 122 years and 4½ months, a super- centenarian. In 1965, when she was 90 years old, her lawyer recognized the value of the apartment in which she lived and owned and made her, what turned out to be, the deal of a lifetime. In exchange for the deed to the apartment, he would pay her a monthly “pension” for life and she could live in the apartment the rest of her life. Over the next 32 years she was paid three times the apartment’s value. She also outlived the lawyer, his son, her husband of 50 years, her daughter, and her only grandson. An active woman, she took up fencing at 85 and was still riding a bike at 100. She smoked until she was 117 and preferred a diet rich in olive oil. Data from National Institute of Aging (NIA): Aging under the microscope: a biological quest, NIH Pub No. 02-2756, Bethesda, MD, 2003, U.S. Government Printing Office; Nemoto S, Finkel T: Aging and the mystery of Arles, Science 429:149, 2004. Many of the fathers and older siblings of the oldest of this cohort fought and died in World War I (WWI) (1914 to 1918). Too old to fight in WWII, they saw their younger siblings repeat this service to their countries. There are no WWI veterans alive today. American Frank Buckles died at the age of 110 (1901 to 2011) (Duggan, 2011) and British veteran Florence Green died at the age of 111 (1901 to 2012) (Fox, 2012). As teens or young adults the super-centenarians of today survived the influenza pandemic of 1918 to 1919, which killed an estimated 50 million people or one fifth of the world’s population (National Archives, n.d.; U.S. Department of Health and Human Services [USDHHS], n.d.b). Referred to as the “Spanish Flu” or “Le Grippe,” this outbreak began in the United States, Europe, and a small part of Asia. It spread worldwide almost overnight. The virulence was such that the period between exposure and death could be a matter of hours. In 1 year the life expectancy in the United States dropped by 10 to 12 years (National Archives, n.d.). Those alive today have also survived the three subsequent pandemics and three pandemic flu threats (Table 1-1). TABLE 1-1 Pandemic Flu History Since 1918 YEAR(S) HISTORICAL NAME Pandemics 1918 The Spanish flu; Le Grippe (H1N1) 1957-1960 Asian flu (H2N2) 1968-1969 Hong Kong flu (H3N2) 2009-2010 H1N1 (Swine flu) Pandemic Flu Threats* 1946-1947 Pseudopandemic 1976 Swine flu 1977 [Northern China] affecting mostly children 1997 and 1999 H5N1 (avian flu) 1997 Russian flu (Red flu), affecting only those 65 Years of Age) First-generation antihistamines Nitrofurantoin (Macrobid) Alpha1-blockers Antiarrhythmics, especially amiodarone Digoxin (no dose >0.25 mg) Nifedipine, immediate release Tricyclic antidepressants Many of the antipsychotics Barbiturates Benzodiazepines Sliding scale insulin Sulfonylureas, long duration Glyburide Demerol Non–COX-selective NSAIDs* *Concurrent use of a proton pump inhibitor reduces risk, short-term use only. From American Geriatrics Society (AGS) Expert Panel: American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults, J Am Geriatr Soc 60:616–631, 2012. Psychoactive medications Psychoactive medications are those that affect mental function, which in turn affects behavior and how the world is experienced. The gerontological nurse, especially one working in a long-term care setting, is likely to be responsible for older adults who are receiving psychoactive medications, especially those for the treatment of depression, anxiety, and bipolar disorders (Chapter 28). Medications with psychoactive properties have a higher than usual risk for adverse events and must be prescribed and administered, especially in the older population, with an acute awareness of how age-related changes in absorption, distribution, excretion, and hepatic function affect their overall concentration in the serum. Some studies indicate that 35% to 53% of persons living in assisted living facilities were taking at least one psychoactive medication and more than half of older adults admitted from the community into a skilled nursing facility were prescribed at least one such drug within 2 weeks of admission (Lindsey, 2009). In an effort to control the burgeoning use of psychotropic medications in nursing homes, the Centers for Medicare and Medicaid Services issued a clarification of previous instructions, which was issued to guide those who were responsible for monitoring the quality of patient care (usually state surveyors) (CMS, 2013). This classification of medications may never be used as a “quick fix” and should only be used when a thorough assessment had been completed, nonpharmacological approaches had proven ineffective, and the patient would clearly benefit from their use. One specific class of psychoactive medications, antipsychotics, is commonly prescribed to persons with neurodegenerative disorders and behavior disturbances that place those around the person in danger, due to hallucinations and delusions. Persons taking these medications must be monitored with special care. These drugs should never be used for the convenience of the staff or to simply provide sedation; to do so is considered chemical restraint. Antipsychotics Antipsychotic drugs are tranquilizing medications used primarily to treat psychoses, including those associated with the dementias, and are used off-label as mood stabilizers for bipolar disorder. Their mechanism of action centers on blocking dopamine receptor pathways in the brain. Antipsychotics also affect the hypothalamic and thermoregulatory pathways. They are often ranked in relation to their side effects, especially sedation, hypotension, and extrapyramidal (and anticholinergic) side effects (EPSEs). Up to 75% of persons taking typical antipsychotic medications are affected by EPSEs (Lindsey, 2009). Other side effects of these medications include neuroleptic malignant syndrome and movement disorders. The first such medications to be produced (in the 1950s) are now referred to as “typical antipsychotics” (e.g., Haldol, Thorazine), and the newer, second-generation medications (developed since the 1990s) are referred to as “atypicals” (e.g., Risperidone, Seroquel). The dangers associated with the use of the typical antipsychotics require that their use be significantly justified and that a careful cost/benefit analysis be done. Typical antipsychotics can never be used for someone with the diagnosis of dementia with Lewy bodies. When used appropriately and cautiously, antipsychotics can provide a person with relief from what may be frightening and distressing symptoms. Inappropriate use of antipsychotic medications may mask a reversible cause for the psychosis (such as delirium, infection, dehydration, fever, or electrolyte imbalance), an adverse medication effect, or a sudden change in the environment (Medicines and Healthcare Products Regulatory Agency [MHRA], 2014). Because of the seriousness and frequency of the side effects and associated complications, these medications are prescribed at the lowest dose possible and the patient is monitored closely. When antipsychotic medications are prescribed, more caution than usual must be used. SAFETY ALERT Potential complications of antipsychotic medications include stroke (at three times the risk of people not taking the medications), falls, fractures, transient ischemic attacks (TIAs), and death (Hughes and Beizer, 2014). Malignant syndrome Because antipsychotics affect the thermoregulatory pathway, patients taking them cannot tolerate excess environmental heat. Even mild elevations of core temperature can result in liver damage, called neuroleptic malignant syndrome (NMS). Acute NMS is characterized by high fever, rigidity, altered mental status, and other symptoms of autonomic instability such as tachycardia and pallor. The nurse or caregiver must therefore protect the elder affected with hyperthermia by making sure the environment is cool enough at all times. Appropriate interventions include promotion of adequate hydration, relocation to a cooler area away from direct sunlight, and use of a fan or sponge bath. Because the patient may or may not share his or her discomfort about the heat, regular assessment of body temperature is essential. Any circumstance resulting in dehydration greatly increases the risk of heat stroke, which in late life is associated with high death rates. Movement disorders Neuroleptic malignant syndrome is not commonly seen in older adults taking antipsychotics. The more commonly seen significant potential side effects are movement disorders, also referred to as extrapyramidal syndrome (EPS). These include acute dystonia, akathisia, parkinsonian symptoms, and tardive dyskinesia. Although these side effects are much more common with the typical antipsychotics, they can occur with the atypical antipsychotics as well. The prescribing provider should be notified immediately any time such symptoms or signs are seen. Many of these are potentially life-threatening. In most cases the offending medication must be stopped immediately, with implications for the potential need for hospitalization. Acute dystonia. An acute dystonic reaction is an abnormal involuntary movement consisting of a slow and continuous muscular contraction or spasm. Involuntary muscular contractions of the mouth, jaw, face, and neck are common. The jaw may lock (trismus), the tongue may roll back and block the throat, the neck may arch backward (opisthotonos), or the eyes may close. In an oculogyric crisis, the eyes are fixed in one position. Often this creates a feeling of needing to look up constantly without the ability to make the eyes come down. These reactions may occur hours or days after the initiation of a medication or after a dose increase and may continue as long as only a few minutes to many hours. Akathisia. Akathisia is a compulsion to be in motion, a sense of restlessness, being unable to be still, having an unrelenting desire to move, and feeling “like crawling out of my skin.” The patient is seen pacing, fidgeting, and markedly restless. Often this symptom is mistaken for worsening psychosis instead of the adverse medication reaction that it is. It may occur at any time during therapy. Parkinsonian symptoms. The use of antipsychotics may cause a collection of symptoms that are similar to those of Parkinson’s disease: a bilateral tremor (as opposed to a unilateral tremor in true Parkinson’s), bradykinesia, and rigidity that may progress to the inability to move. The patient may have an inflexible facial expression and appear bored and apathetic and thus be mistakenly diagnosed as depressed. These are more common with the higher potency antipsychotics: these side effects may begin within weeks to months of initiation of antipsychotic therapy. Tardive dyskinesia. When antipsychotics have been used continuously for at least 3 to 6 months, patients are at risk for the development of the irreversible movement disorder called tardive dyskinesia (TD). Both low- and high-potency agents have been implicated (Bullock and Saharan, 2002; Goldberg, 2002). TD symptoms usually appear first as wormlike movements of the tongue and other facial movements include grimacing, blinking, and frowning. Slow, maintained, involuntary twisting movements of the limbs, trunk, neck, face, and eyes (involuntary eye closure) have been reported. No treatment reverses the effect of TD. Therefore it is essential that the nurse be attentive for early detection so that the health care provider can make prompt changes to the psychotropic regimen. The scheduled and repeated use of a standardized monitoring instrument is recommended. Promoting healthy aging: Implications for gerontological nursing The gerontological nurse is a key person in ensuring that the medication used is appropriate, effective, and as safe as possible. The knowledgeable nurse is alert for potential medication interactions and for signs or symptoms of adverse medication effects. Nurses in the long-term care setting are responsible for monitoring the overall health of the residents, including fluid and dietary intake, and for being alert to the need for laboratory tests and other measures to ensure correct medication dosage. They are responsible for prompt attention to changes in the patient’s or resident’s condition (such as potassium level) that either are the result of the medication regimen or are affected by the regimen. The nurse is often the person to initiate assessment of medication use, evaluate outcomes, and provide the teaching necessary for safe medication use and self-administration. In all settings, a vital nursing function is to educate patients and to ensure that they understand the purpose and side effects of the medications and assist the patient and family in adapting the medication regimen to functional ability and lifestyle. Assessment The initial step in ensuring that medication use is safe and effective is to conduct a comprehensive medication assessment. Although in some settings clinical pharmacists interview patients about their medication history, more often such reviews are completed through the combined efforts of the licensed nurse and the health care provider (e.g., a physician or a nurse practitioner). The “gold standard” of assessment that is especially important to use with the older adult is the “brown bag approach,” in which the person is asked to show the nurse all of the medications that he or she is taking, including OTCs, herbals, and other dietary supplements. As each product container is removed from the bag, the necessary information can be obtained and compiled. To prevent possible misunderstandings or to determine misuse, it is best to ask the person how he or she actually takes the medicine rather than to depend on how the label is written. By completing the assessment in this manner, the nurse can discover discrepancies between the prescribed dosage and the actual dosage, spot potential interactions, and identify potential or actual ADRs. The basics of the comprehensive medication assessment are the same as those for younger adults (Box 9-8). For details of the information needed in such an assessment that are particularly important for older adults, see Box 9-9. BOX 9-8 Analysis of Assessment Findings Related to Medication Use 1. Is the medication working to improve the patient‘s symptoms? a. What are the therapeutic effects of the medication? (What symptoms are targeted?) b. What is the time frame for the therapeutic effects? c. Have the appropriate medication and dose been prescribed? d. Has the appropriate time been tried for therapeutic effects? 2. Is the medication harming the patient? a. What physiological changes are occurring? b. What laboratory values are changing? c. What mental status changes are occurring? d. What functional changes are occurring? e. Is the patient experiencing side effects? f. Is the medication interacting with any other medication? 3. Does the patient understand the following? a. Why is the patient taking the medication? b. How is the medication supposed to be taken? c. How do you identify side effects and medication interactions? d. How do you reduce or manage side effects? e. What limitations are imposed by taking the medication (e.g., sedative effects)? BOX 9-9 TIPS FOR BEST PRACTICE Components of a Medication Assessment with Special Emphasis for Older Adults Ability to pay for prescription medications Ability to obtain medications and refills Persons involved in decision making regarding medication use Medications obtained from others Recently discontinued medications or “leftover” prescriptions Strategies used to remember when to take medications Recent medication blood levels as appropriate Recent measurement of liver and kidney functioning Ability to remove packaging, manipulate medication, and store supply The analysis by the nurse or the advanced practice nurse (APN) should be centered on identifying unnecessary or inappropriate medications, establishing safe usage, determining the patient’s self- medication management ability, monitoring the effect of current medications and other products (e.g., herbals), and evaluating effectiveness of any education provided. Ideally, the nurse should know what resources are available for teaching about medications, such as the clinical pharmacist. The nurse is well situated to coordinate care, identify the patient’s goals, determine what the patient needs to learn in order to understand his or her medications, and arrange for follow-up care to determine the outcome of medication teaching. Education Patient education is the most common intervention used to promote safe medication use. Because of the complex needs of the older patient, education can be particularly challenging. The following tips may be helpful when the goal of the nurse is to promote healthy aging related to medication use: Key persons: Find out who, if anyone, manages the person’s medications, helps the person, or assists with decision making; and with the elder’s permission, make sure that the helper is present when any teaching is done (Box 9-10). Environment: Minimize distraction, and avoid competition with television, grandchildren, or others demanding the patient’s attention; make sure the person is comfortable and is not hungry, thirsty, tired, too warm or too cold, in pain, or in need of the toilet. Timing: Provide the teaching during the best time of the day for the person, when he or she is most engaged and energetic. Keep the education sessions short and succinct. Communication: Ensure that you will be understood. Make sure the elders have their glasses or hearing aids on, if they are used. Use simple and direct language, and avoid medical or nursing jargon (e.g., “intake”). Speak clearly, facing the person and with light on your face, at head level. Use formal language (e.g., Mr. Jones) unless you have permission to do otherwise. Do not touch the patient unless he or she indicates to you that it is acceptable to do so (e.g., patient lays his or her hand on yours, Chapter 6). If the person is blind, braille instructions may be available from the pharmacy. If the person has limited language proficiency in the country in which care is delivered, a trained medical interpreter is needed. Reinforce teaching: Although there is a wide array of teaching tools and medication reminders available on the market today, many older adults continue to use the strategies they have developed over the years to remember to take their medications. These may be as simple as a using an egg carton as a storage box or turning a bottle upside down once it has been taken for the day, or as intense as having a family member or friend call the person at designated times. Encourage the person to use techniques that have worked in the past or to develop new strategies to ensure correct and timely medication use when needed. All education is supported by written or graphic material in the language that the person (if literate) can read or in the language of the persons who helps. BOX 9-10 Knowing Who You Are Talking To M. François came to the clinic as a new patient with uncontrolled hypertension. The nurse practitioner, through an interpreter, spent a lot of time with him explaining how to take his medications, what they were for, and so on. He and his presumed caregiver sat quietly and appeared to understand. When he returned a month later his blood pressure was still out of control. There was a different person with him who asked all of the questions that were addressed at the first appointment. On further inquiry it was determined that the person who brought M. François the first time was just a neighbor helping out and not involved in his day-to-day life at all! His niece who “takes care of things” had been unavailable during the previous appointment and was now available to take him to his appointment. Safe medication use A safe, optimal, and feasible medication plan is one to which the patient can adhere. Appropriate nursing interventions include those that minimize polypharmacy, avoid adverse medication reactions, and promote adherence to medication regimens that promote healthy aging (or comfort while dying) (Box 9-11). The responsibility of the nurse caring for frail elders is especially challenging because of the physical and social vulnerability and medical complexity common in late life; medication interactions are more likely and adverse reactions more lethal. BOX 9-11 TIPS FOR BEST PRACTICE Reducing Adverse Medication Events By paying attention to the following principles for prescribing and monitoring medications for older adults, the advanced practice nurse can reduce the risk for adverse medication events: Give the lowest dose possible. Discontinue unnecessary therapy. Attempt nonpharmacological interventions first. Give the safest medication possible. Assess renal function. Always consider the risk-to-benefit ratio when adding medications. Assess for new interactions with any new prescription. Avoid the prescribing cascade (i.e., new medications without consideration of those to be discontinued). Avoid inappropriate medications. The promotion of safe medication use requires attention to the potential for misuse, including overuse, underuse, erratic use, and contraindicated use, all of which are referred to as non-adherence. Misuse by patients may be unintentional, such as with misunderstanding, or purposeful, such as when trying to make a prescription last longer because of cost, or believing that it is not appropriate for the believed cause of illness (Box 9-12) (Gould and Mitty, 2010). A person may have considerable difficulty adhering to a medication regimen that is inconsistent with his or her established life patterns or beliefs. For example, the individual cannot follow the instruction to take medication three times per day with meals if he or she eats only two meals each day. In late life adherence is made significantly more complicated when the complexity of a medication regimen is combined with difficulties with self-administration due to normal changes with aging (Table 9-3). TABLE 9-3 Examples of Changes with Aging that May Interfere with Medication Self-Administration CHANGE IN AGING CONSEQUENCE Sensory Decreased visual acuity Greater difficulty in reading instructions Decreased sensation Greater difficulty in manipulating medications Decreased salivation Greater difficulty in swallowing Mechanical Decreased fine motor coordination Greater difficulty in manipulating medications and packaging Stiffening of large joints Greater difficulty in self-administering medications BOX 9-12 A Potentially Lethal Misunderstanding I was making a visit to Mrs. Helena to enroll her in a research study. As we were reviewing her health and current medications she shared that she had not been feeling well and thought it was her heart, and that she had been told to “take the little white pills” until she felt better. When I looked at her pill bottle she had already taken five or more digoxin in the space of about 2 hours. I called an ambulance. All medications have indications, side effects, interactions, and individual patient reactions. The nurse must determine whether side effects are minimal and tolerable or serious (Table 9-4). Asking subjective question and observing the patient’s interactions, behavior, mood, emotional responses, and daily habits can provide essential objective data. By compiling the information obtained in this manner, patient problems can be delineated, nursing diagnoses developed, outcome criteria planned, and interventions initiated. TABLE 9-4 Indications of Toxicity of Medications Commonly Prescribed to Older Adults MEDICATION(S) SIGNS AND SYMPTOMS Benzodiazepines (e.g., Ativan) Ataxia, restlessness, confusion, depression, anticholinergic effect Cimetidine (Tagamet) Confusion, depression Digitalis (Digoxin) Confusion, headache, anorexia, vomiting, arrhythmias, blurred vision or visual changes (halos, frost on objects, color blindness), paresthesia Furosemide (Lasix) Electrolyte imbalance, hepatic changes, pancreatitis, leukopenia, thrombocytopenia Levodopa (L-Dopa) Muscle and eye twitching, disorientation, asterixis, hallucinations, dyskinetic movements, grimacing, depression, delirium, ataxia Nonsteroidal antiinflammatory medications Photosensitivity, fluid retention, anemia, nephrotoxicity, visual changes, (NSAIDs) such as Advil and Naprosyn bleeding, blood pressure elevations Ranitidine (Zantac) Liver dysfunction, blood dyscrasias Sulfonylureas—first generation (e.g., Hypoglycemia, hepatic changes, heart failure, bone marrow depression, Diabinese) jaundice From Lexicomp: Long term-care nursing drug handbook, ed 14, Hudson, OH, 2013, Lexi- Comp. Lastly, it is necessary for the gerontological nurse to monitor and evaluate prescribed treatments for both side effects and efficacy (Planton and Edlund, 2010). Monitoring and evaluation involve making astute observations and documenting those observations, noting changes in physical and functional status (e.g., vital signs, performance of activities of daily living, sleeping, eating, hydrating, eliminating) and mental status (e.g., attention and level of alertness, memory, orientation, behavior, mood, emotional display and affect, content and characteristics of interactions). Monitoring also means ensuring that blood levels are measured when they are needed—for example, regular thyroid-stimulating hormone (TSH) levels for all persons taking thyroid replacement therapy, INRs for all persons taking warfarin, or periodic hemoglobin A1C levels for all persons with diabetes or taking antipsychotics (see Chapter 8). Proper patient care requires nurses to promptly communicate their findings of potential problems to the patient’s nurse practitioner or physician. Accurate monitoring is dependent on the nurse possessing and understanding the relevant information about the treatments and medications that are administered. Medications occupy a central place in the lives of many older persons: cost, acceptability, interactions, untoward side effects, and the need to schedule medications appropriately all combine to create many difficulties. The nurse can promote healthy aging through knowledge of the effect of normal age-related changes on pharmacodynamics and pharmacokinetics, as well as by awareness of the key issues in medication use in older adults in all care settings. Key concepts The therapeutic goal of pharmacological intervention is to reduce the targeted symptoms and disease conditions without undesirable side effects. One must be alert at all times for medication-medication, medication-herb, and medication-food interactions; whereas some are known and anticipated, others are unique. Polypharmacy significantly increases the risk of medication interactions and adverse events. Polypharmacy increases with each prescriber seen. Daily or twice-daily dosing is optimal. Any time there is a change in the patient’s status, it is reasonable to first consider the possibility of a medication effect; this is of paramount importance when caring for an older adult and those who are frail. Many medications have the potential to cause temporary cognitive impairment. Medication misuse may be triggered by prescriber practices, individual self-medication, physiological idiosyncrasies, altered biodegradability, nutritional and fluid states, and inadequate assessment before prescribing. Nurses must investigate medications immediately if a change in mental status is observed in an individual who is normally alert and aware. Patients cannot comply with a prescription or treatment when incompatibilities interfere with the practicalities of life or are distressful to the individual’s well-being or when actual misinformation or disability prevents compliance. The side effects of psychotropic medications vary significantly; thus these medications must be selected with care when prescribed for the older adult. The response of the elder to treatment with psychotropic medications should show reduced distress, clearer thinking, and more appropriate behavior. It is always expected that psychotropic pharmacological approaches augment rather than replace nonpharmacological approaches. Older adults are particularly vulnerable to developing movement disorders (extrapyramidal symptoms, parkinsonian symptoms, akathisia, dystonias) with the use of antipsychotics. The Health Care Financing Administration (HCFA) and the congressional Omnibus Budget Reconciliation Act (OBRA) have severely restricted the use of psychotropic medications for the elderly unless they are truly needed for specific disorders and to maintain or improve function. Careful monitoring and continued justification is required (Table 9-5). Any time a behavior change is noted in a person, reversible causes must be sought and treated before psychotropic medications are used. Antidepressant medications must be tailored to the elder, with careful observation for side effects. TABLE 9-5 Monitoring Parameters and Evaluation of Effectiveness for Medications Commonly Prescribed to Older Adults CLASS OF MEDICATION MONITORING ACTIVITY Antibiotics and Improvement of infection: symptom reduction antivirals Antihyperlipidemics Lipid profile: lipids and triglycerides within normal limits for this person Liver function testing: no changes in function Blood glucose: no elevation Cardiac medications Measurement of heart rate and rhythm: within optimal parameters for that person Anticoagulants Clotting times (international normalized ratio [INR], prothrombin time): no bleeding; if using INR, kept between 2.0 and 3.0 in most cases Antihypertensives Measurement of blood pressure: maintained within normal limits and without the development of orthostatic hypotension Weight: no unexplained weight gain Antihyperglycemics Hemoglobin A1C: maintained between 6.0 and 7.0 (controversy regarding a combination of goal and health status) Antiarthritics Relief from arthritis symptoms such as pain and inflammation Antiparkinsonians Improved functional status Less visible immobility; improved mobility Analgesics Improved symptoms of pain and inflammation NURSING STUDY: AT RISK FOR AN ADVERSE EVENT Rosa was a 78-year-old woman who lived alone in a large city. She had been widowed for 10 years. Her children were grown, and all were successful. She was very proud of them because she and her husband had immigrated to the United States when the children were small and had worked very hard to establish and maintain a home. She had only a few years of primary education and still clung to many of her “old country” ways. She spoke a mixture of English and her native language, and her children were somewhat embarrassed by her. They thought she was somewhat of a hypochondriac because she constantly complained to them about various aches and pains, her knees that “gave out,” her “sugar” and “water” problems, and her heart palpitations. She had been diagnosed with mild diabetes and congestive heart failure. She was a devout Catholic and attended mass each morning. Her treks to church events, to the senior center at church, and to her various physicians (internist; orthopedic, cardiac, and ophthalmic specialists) constituted her social life. One day the recreation director at the senior center noticed her pulling a paper bag of medication bottles from her purse. She sat down to talk with Rosa about them and soon realized that Rosa had only a vague idea of what most of them were for and tended to take them whenever she felt she needed them. What factors about Rosa’s probable medication misuse would be most alarming to you? List two of Rosa’s strengths that you have identified from the information presented in the study. Develop three nursing diagnoses appropriate to this nursing study. These must be stated in concrete and measurable terms. Plan and state one or more interventions for each diagnosed problem. Provide specific documentation of the source used to determine the appropriate intervention and how the effectiveness can be evaluated. Critical thinking questions and activities 1. As a nurse visiting the center for a 6-week student assignment, how would you begin to help someone like Rosa? 2. Who should be responsible for teaching and monitoring medication use in persons such as Rosa? In any case? 3. Mrs. J., a patient of yours in a long-term care setting, is calling out repeatedly for a nurse; other patients are complaining, and you simply cannot be available for long periods to quiet her. Considering the setting and the OBRA guidelines, what would you do to manage the situation? 4. When you are given a prescription for medication, what do you ask about it? 5. Do you think most elders seek adequate information about their medications before taking them? Research questions 1. Where would you obtain sufficient medication information for persons with limited English proficiency (LEP)? 2. What symptoms do elders self-treat with OTC and herbal medicines? 3. What are nursing roles in preventing adverse medication events in elders? 4. Among the following three teaching strategies, which works the best: computer-assisted medication teaching, telephone teaching, or in-person medication teaching? 5. What aspects of Rosa’s situation related to medications do you think are common among isolated elders? References 1. Ajemigbitse AA, Omole MK, Erhun WO. An assessment of the rate, types and severity of prescribing errors in a tertiary hospital in southwestern Nigeria. Afr J Med Sci;2013;42(4):339-346. 2. American Geriatrics Society (AGS) Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc;2012;60:616-631. 3. Beers M. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med;1997;157:1531-1536. 4. Beyth RJ, Shorr RI. Medication use. In: Shorr RI, Hoth AB, Rawls N. Medications for the geriatric patient. St. Louis, MO: Saunders 2007. 5. Bullock R, Saharan A. Atypical antipsychotics experience and use in the elderly. Int J Clin Pract;2002;56:515-525. 6. Burchum JLR. Pharmacologic management. In: Meiner S. Gerontologic nursing ed 4. St. Louis, MO: Elsevier 2011. 7. Centers for Medicare and Medicaid Services (CMS). Dementia care in nursing homes clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309 – Quality of Care and F329 – Unnecessary Drugs (Memorandum S&C13-35 NH). Accessed July 2014 Available at: http://www.cms.gov/medicare/provider-enrollment-and- certification/survey certificationgeninfo/downloads/survey- and-cert-letter-13-35.pdf 2013. 8. Gnjidic D, Hilmer SN, Blyth FM, et al. Polypharmacy cutoff and outcomes five or more medications were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol;2012;65(9):989-995. 9. Goldberg RJ. Tardive dyskinesia in elderly patients an update. J Am Med Dir Assoc;2002;3:152-161. 10. Gould E, Mitty E. Medication adherence is a partnership, medication compliance is not. Geriatr Nurs;2010;31:290-298. 11. Hughes GJ, Beizer JL, et al. Appropriate prescribing. In: Ham RJ, Sloane PD, Warshaw GA. Primary care geriatrics a case-based approach ed 6. Philadelphia: Elsevier 2014;67-76. 12. Kim M, Dam A, Green J. Common GI drug interactions in the elderly. Curr Treat Options Gastroenterol;2014;12(3):292-309. 13. Lindsey PL. Psychotropic medication use among older adults what all nurses need to know. J Gerontol Nurs;2009;35(9):28-38. 14. Lucado J, Paez K, Elixhauser A. Medication-related adverse outcomes in U.S. hospitals and emergency rooms, 2008 (Statistical brief no. 109), Healthcare Cost and Utilization Project. Accessed July 2014 Available at: http://www.hcup- us.ahrq.gov/reports/statbriefs/sb109.jsp 2011. 15. Medicines and Healthcare Products Regulatory Agency (MHRA). Antipsychotic drugs. Accessed July 2014 Available at: http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationand specificinformationandadvice/Product- specificinformationandadvice-A- F/Antipsychoticdrugs/index.htm 2014. 16. Molony S, Greenberg SA. The 2012 American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. Accessed October 31 Available at: http://consultgerirn.org/uploads/File/trythis/try_this_16_1.pdf 2013. New York: Hartford Institute for Geriatric Nursing 2014. 17. Peron EP, Gray SL, Hanlon JT. Medication use and functional status decline in older adults a review. Am J Geriatr Pharmacother;2011;9(6):378-391. 18. Planton J, Edlund BJ. Strategies for reducing polypharmacy in older adults. J Gerontol Nurs;2010;36:8-12. 19. Rochon PA. Drug prescribing for older adults. Accessed July 2014 Available at: http://www.uptodate.com/contents/drug- prescribing-for-older-adults 2014 UpToDate 20. Saxon SV, Etten MJ, Perkins EA. Physical change and aging ed 5. New York: Springer 2010. CHAPTER 10 The use of herbs and supplements Jo Lynne Robins, Lisa Burroughs Phipps Learning objectives On completion of this chapter, the reader will be able to: 1. Identify the legal standards that affect herb and supplement use. 2. Discuss the information that older adults should know about the use of select herbs and supplements. 3. Discuss the role of the gerontological nurse when assisting the older adult who uses herbs and supplements. 4. Describe the effects of selected commonly used herbs and supplements on the older adult. 5. Develop a nursing care plan to prevent adverse reactions related to herb or supplement use. 6. Identify the important aspects of education related to the use of herbs and supplements by older adults. 7. Describe the effects of herbal supplements on the older adult with chronic disease. http://evolve.elsevier.com/Touhy/TwdHlthAging A STUDENT SPEAKS I had no idea how many different things people take. Older adults have so many remedies! All sorts of herbal teas and vitamins... I wonder if they work. Kelly, age 18 AN ELDER SPEAKS I try to take the medicines that the nurse practitioner gives me but I can’t always afford them, so I ask my friend what I should do because she knows a lot about herbs and teas. I take them to supplement my medicines. Sometimes they really help. Jean, age 65 Herbs and other supplements have been used for thousands of years to promote health and treat illness, but during most of the past century, their popularity waned with the availability of prescription and over-the-counter medications. The use of herbs and supplements has resurged over the past two decades. The most recent national data available estimated that 38% of American adults spend $14.8 billion on non-vitamin herbs and supplements, and the highest use rates were for those ages 50 to 59 years (Barnes et al, 2008; Nahin et al, 2009). The most commonly used supplement among adults is fish oil/omega 3 fatty acids, followed by glucosamine, echinacea, flaxseed, ginseng, ginkgo, chondroitin, and garlic (Barnes et al, 2008). In older men and women ages 60 to 99 years, glucosamine was the most frequently used supplement followed by ginkgo, chondroitin, and garlic. Men most commonly use α-lipoic acid, ginkgo, and grape seed extract (Wold et al, 2005).Women favored black cohosh, evening primrose oil, flaxseed oil, chondroitin, ginkgo, glucosamine, grape seed extract, hawthorn, and St. John’s wort. In a survey of 445 community-dwelling older adults 28.3% reported using vitamins and 20.7% used herbal supplements (Cheung et al, 2007). While herb and supplement use occurs across races and ethnicities, a National Health and Nutrition Examination Survey indicated the highest rate of use was in non-Hispanic white, older, normal to underweight, educated females (Radimer et al, 2004). In the United States the increasing use of herbs and dietary supplements by older adults may be related to their hopes of preventing illness, promoting and maintaining health, treating a particular health problem, or replacing some currently missing dietary component (Bruno and Ellis, 2005; Cheung et al, 2007; Yoon and Horne, 2001; Yoon et al, 2004). People perceive that such products will give them more control of their health and bodies. Herbs and supplements are typically used as a complement to, rather than a replacement for, a person’s prescribed therapies (Yoon, 2006). Elders with chronic conditions are more likely to use herbs and supplements with their traditional therapies (Nieva et al, 2012; Ryder et al, 2008). Combining herbs and supplements with prescription and over-the-counter (OTC) medications increases the likelihood of adverse reactions in older adults (Lam and Bradley, 2006; Loya et al, 2009). While historically, patients have not been likely to disclose the use of herbs and supplements to their health care providers (Bruno and Ellis, 2005; Cheung et al, 2007), persons older than 50 years of age may be more likely than younger persons to share information about their use of supplements with their providers (Durante et al, 2001; Israel and Youngkin, 2005; Ryder et al, 2008). Gerontological nurses can anticipate that older adults may use a variety of complementary and alternative therapies, including herbs and supplements, in addition to prescribed and OTC drugs. The nurse has a significant obligation to ask the right questions and obtain specific information related to use—reason, form, frequency, duration, dose, any side/adverse effects, and plans for continuing. Standards in manufacturing Before 1962 all herbs were regarded as medications. In 1962 the U.S. Food and Drug Administration (FDA) required that all products considered “medications” be evaluated for safety, efficacy, and standardization between manufacturers of the same product. The role of the FDA also expanded to that of monitoring these products. In response, herbal manufacturers declared their products as “foods” and therefore not subject to FDA regulations (Youngkin and Israel, 1996). In 1994 some regulation was placed over herbs through the Dietary Supplement Health and Education Act (DSHEA), and they were reclassified as “dietary supplements.” By regulation, herbs and other supplements may not be labeled for prevention, treatment, or cure of a health condition of any kind unless the claim has been substantiated by research and recognized by the FDA (U.S. FDA, 2014). Of all the identified herbs, few are FDA approved as medications: aloe, psyllium, capsicum, witch hazel, cascara, senna, and slippery elm. It is required that all adverse events be reported to the FDA. The World Health Organization and regulatory agencies of individual countries are answering the call for safety and efficacy information based on scientific evaluation of herbs and supplements (Blumenthal et al, 2000; Israel and Youngkin, 2005). Factors that make commercially marketed herbal products difficult to study systematically include the following: differences in plant products used (parts of plant, such as whole plant or extract), different combination products and proprietary blends, and differences in manufacturing processes. To help improve the quality of dietary supplements, the FDA put Good Manufacturing Practices (GMPs) into place in 2007. This set of guidelines for preparation and storage of dietary supplements stipulates that manufacturers are now required to guarantee the identity, purity, strength, and composition of dietary supplements. Many manufacturers today have heeded the call to standardize the production and labeling of herbs and supplements. Some manufacturers are also using standardization to ensure consistency of their products between batches. Honest marketing and the independent testing of products for purity are occurring. Nurses can alert and educate individuals to potential risks and adverse effects, as well as drug-herb and drug-supplement interactions. Risks include the product containing the wrong parts of the herb; containing little or no active ingredient, rendering it ineffective; or being adulterated with one or more unidentified substances that may be dangerous. Mixed herbal supplements, such as some weight loss products, can also have hazardous effects on blood pressure and heart rate and rhythm and can be particularly risky because actually determining what the product contains may be difficult. For example, bitter orange (Citrus aurantium) was used to replace ephedra in many weight loss products after its removal from the general market by the FDA in 2004, but bitter orange has synephrine (epinephrine-like) effects, as did ephedra, that can lead to cardiac arrest and ventricular fibrillation and thus is still unsafe for use in some patients (Swanson, 2007). Nurses must maintain current knowledge about herbs and other supplements so that when they conduct a complete medication review (Chapter 9), potential and actual harmful effects may be recognized. Consideration of each product’s intended use, dose, possible adverse effects, and possible interactions with other substances based on the person’s health or illness conditions is required. Nurses should urge their patients to be aware of these issues and to purchase products from reputable distributors and discuss dietary supplement use with their health care providers and pharmacists. Herb forms Different parts of many herbs have uses and actions that are unrelated. For example, the bulb of the garlic plant contains the active ingredient, whereas the leaf of chamomile is used (Israel and Youngkin, 2005). Herbal products are manufactured in several forms, including teas, capsules, tablets, extracts, oils, tinctures, and salves (Khalsa, 2007). Efficacy varies and depends in part on the form of the herb that is used and how it is prepared. An extract is a concentrated fluid or solid form of the herb that is made by mixing the crude herb with alcohol or other solvents that are then distilled or evaporated (Khalsa, 2007). When an herb is soaked in water, alcohol, vinegar, or glycerin for a specific time and the liquid is then strained to dispose of the plant remains, a tincture is formed. A salve is a type of ointment that is used topically (Khalsa, 2007). Essential oils are aromatic, volatile compounds derived from various parts of the fresh plant. They are commonly used in aromatherapy or massage therapy (Tillett and Ames, 2010). Teas As a beverage, teas are consumed by millions around the world, second only to water. It is considered a food and regulated as such in the United States. It should be noted that the word “tea” is often used to describe preparations that do not contain a tea plant at all. True tea comes from the plant Camellia sinensis, which produces white, green, oolong, black, and pu-erh teas. The difference in these teas is in the processing of the C. sinensis plant. Maté and red teas are from different plants and are not true tea, and many herbal teas contain flowers and herbs but no Camellia sinensis. Some refer to these preparations as tisanes or infusions, and some still refer to them as tea. Newly reported research indicates that some tea

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