Chapter 5 Older adults
1. Discuss the impact of older adults on the healthcare system.
2. Outline the effects of ageism on the care of older adults.
3. Outline the major concepts in adult developmental theories proposed by Erikson, Peck, Havighurst and Levinson.
4. Outline the major biological theories of ageing.
5. Describe clinical manifestations that represent specific age-related physiological changes.
6. Discuss the needs of special populations of older adults.
7. Identify differences in health status and disease manifestation between older and younger adults.
8. Identify the role of the nurse in health screening and promotion and disease prevention for older adults.
9. Explain nursing interventions to assist chronically ill older adults.
10. Discuss common problems of older adults related to hospitalisation and acute illness, and the role of the nurse in assisting them with selected care problems.
11. Discuss challenges and concerns related to the caregiving role.
12. Identify care alternatives to meet patient-specific needs of older adults.
13. Outline the legal and ethical issues related to caring for older adults.
Care of older adults is based on the specialty body of knowledge of gerontological nursing. The nurse approaches the older adult patient from a whole-person perspective (physical, psychological, socioeconomic). This chapter presents specific information about older adults that will assist you in providing care to individuals or groups. Care of older adults presents challenges that require nurses to practise skilled assessment and creative adaptations of nursing interventions.
Demographics of ageing
In the last three decades the older adult population (those aged 65 years and older) has grown twice as fast as the rest of the population. The Australian Census conducted in 2006 found that 2,644,374 people, or 13.3% of the population, were aged 65 or older.1 The proportion of older adults in New Zealand is similar, with 495,600 people, or 12.3% of the population, over the age of 65.2 Several factors have led to an overall increase in the older population worldwide. First, the large post–World War II immigrant population has now grown older. Second, common diseases of the early 1900s that proved fatal for many older adults, such as influenza and diarrhoea, are now less common as they can be prevented and treated more effectively, so people are living longer. Third, drug therapies, including antibiotics and chemotherapy, earlier detection of diseases and improved public health and nutrition have contributed to the increase in life span.
This growth in our older population is expected to continue: by 2021 it is predicted that there will be 4.2 million older adults living in Australia, representing 18% of the population (see Table 5-1),3 and in New Zealand one person in four is expected to be 65 years and older.2 By 2056 there will be a 25% increase in the number of older Australians.4 Within the next 6 years the baby boomers will begin to turn 65 and their life expectancy will rise. In Australia, males and females born in 2001 can expect to live for 83 and 86 years, respectively,5 and in New Zealand males and females can expect to live for 78 and 82.2 years, respectively.6
TABLE 5-1 Population aged 65 and over, by age and sex (projected from 2001)
Source: From Australian Bureau of Statistics (ABS). Table 2.1. Australian demographic statistics. 2003. ABS cat. no. 3101.0. ABS data used with permission from the Australian Bureau of Statistics. Available at www.abs.gov.au.
The most rapidly increasing age group is composed of persons aged 75 years and older. Since the 1960s, in both Australia and New Zealand, this group has increased generally by 250%, although this is not the case for Australia’s Indigenous population.3 While Indigenous people comprise 2.5% of the total Australian population, only 3% of the Indigenous population were aged over 65 years in 2008.5 New Zealand’s Māori and Pacific Islander people over the age of 75 are expected to represent 14% of the total older adult population collectively by 2021.7
The terms young-old adult (65–74 years of age) and old-old adult (75 years of age and older) were introduced in 1978; however, with the increased longevity of the 75+ age group, the old-old group is now considered to be 85 years of age and older. The term frail elderly has been suggested to represent those people aged 85 years and older with a variety of ongoing and accumulating health concerns.8 (Frail older adults are discussed on p 74.) The young-old and the old-old represent chronological ranges that often present different characteristics and needs. The old-old adult is usually a widowed woman who may be dependent on family or kinship support. Many have outlived their spouses, siblings and children, and they are often characterised as hardy, elite survivors. In Australia in 2001, 5.2% of people aged over 65 years were in residential care, although this refers to a particular point in time.9 However, the probability of a person aged 65 entering residential care is 28% for men and 46% for women.10 The total number of Australians aged over 65 with a profound or severe handicap is predicted to increase by 30% by 2011.11 Hospital admissions are also increasing for Australians over 65, currently comprising 45% of all hospital patients.12
Attitudes towards ageing
Who is old? The answer to this question often depends on the age and attitude of the respondent as ageing is a very individual experience. It is important that you maintain the position that ageing is normal and is not related to disease. Age is a date in time and is influenced by many factors, including emotional and physical health, developmental stage, socioeconomic status, culture and ethnicity.
As people age, they are exposed to more and different life experiences. The accumulation of these differences makes older adults more diverse than any other age group. As you assess the older adult, it is important to consider this diversity and assess for perceptions of age. Older adults with poor health report a higher perceived age and lower sense of psychological wellbeing compared with healthy older adults.13 Age is important but it may not be the most relevant factor for determining appropriate care of an individual older adult.
Myths and stereotypes about ageing, found throughout society, are supported by media reports of needy, problematic older adults14,15 and provide the basis of commonly held misconceptions that may lead to errors in assessments and unnecessary limitations to interventions.16–18 For example, if nurses think all old people are rigid in their thinking, new ideas will not be presented to them.19
Ageism is a negative attitude about older people based on their chronological age. It can predispose to discrimination in the care given to the older adult. The reasons for ageism can include: social conditioning, media messages, expectations of the nursing role, inadequate support provided to nurses caring for older people and limited career paths for nurses working in aged care. Ageism is a complex phenomenon and is related to many variables associated with factors such as workforce issues, personal characteristics, social expectations and social conditioning. For instance, nurses who demonstrate negative attitudes towards older people may fear their own ageing process, or be misinformed about ageing and the healthcare needs of the older adult. They may benefit from gaining knowledge about normal ageing and increasing contact with healthy, independent older adults.
Historically, there has not been a high level of demand or interest from nurses to practise or specialise in gerontological nursing. Aged-care nursing generally has a poor image among student nurses, qualified nurses and within the broader community.20 Contributing factors include ageism, the false perception that acute care nursing is not concerned with the older adult, perceived lack of status and/or excitement associated with non-acute nursing, and poor rates of pay and working conditions within the aged-care sector. In addition, while person-centred care is promoted in residential care, the limited funding available to employ skilled nurses does little to encourage students and new graduates to seriously consider a career in aged care. Another key factor is staff strain associated with the growing number of older adults across the care continuum who have associated cognitive impairment, including dementia and delirium.21 The combination of increasing frailty, impaired cognition and acute-on-chronic illness in this older population impacts on nursing resources in particular, resulting in the perception that older people are more difficult, time-consuming and problematic to nurse.
Adult development
Adult development has been approached in several ways. Despite rigorous attempts, no single theory has been universally accepted to explain the process. In fact, there is no way to isolate physical, sociocultural and psychological factors to study adult development. Adulthood reflects the inter-relationship of all factors. Therefore, the best approach towards holistic care incorporates the sociological, psychological, biological and spiritual aspects of the unique person.
Theorists have explained adult development based on the following premises:
1. Adult development continues to occur in definable, predictable and sequential patterns.
2. Critical periods occur throughout the life span when physical growth and psychosocial growth undergo reorganisation.
3. In each stage of development, there are certain normative activities or tasks to be accomplished.
4. Mastering the tasks of the preceding stages is fundamental to a transition and mastery of tasks in future stages.
The adult development models of Erikson, Peck, Levinson and Havighurst are summarised in Table 5-2 and briefly described below.
ERIKSON’S THEORY: PSYCHOSOCIAL DEVELOPMENTAL CONFLICTS
Erikson viewed personality development as resulting from the confrontations between ego and the social milieu.22 He identified points in the life cycle when specific developmental conflicts become paramount because a person’s capacities or experiences dictate that a major self-adjustment and adjustment to the environment must be made. In the process of making this adjustment, the individual moves towards one of two opposing positions, such as towards intimacy or towards isolation. When a person successfully masters a core conflict (such as intimacy), the negative sense (isolation) remains as a dynamic counterpart and may be demonstrated in new situations in which this conflict must be mastered again at a higher level. Although critical times for mastery of each core conflict exist, all conflicts are present throughout the life span.
Intimacy versus isolation
In Erikson’s model, the young adult task is intimacy. This involves fusing self-identity with the identities of others in friendships, for causes or creative efforts, or in close personal relationships, including sexual union. Intimacy requires a degree of commitment that necessitates sacrifice, compromise and self-abandonment for the benefit of others. The young adult who avoids making this commitment to others, fearing the loss of self-identity, will experience a sense of isolation and consequently self-absorption.
Generativity versus stagnation
During middle adulthood, the primary task is generativity. Generative adults are concerned with establishing the next generation by nurturing and guiding either their children or other young people. A sense of productivity in work and creativity in living are also important components of this task. This core conflict probably arises out of an altruistic need to leave some mark that will make the world a better place in which to live. If generativity does not occur, adults experience a sense of stagnation and turn inwards, becoming self-preoccupied and overly concerned with physical and psychological health needs. The focus of self-absorbed people on the physical changes of middle age may result in either invalidism or inappropriate youthfulness in an attempt to stay young.
Ego integrity versus despair
Older adulthood is a time for reviewing the past and rearranging the ‘photo album of life’. This bringing together of all the previous life stages should result in a sense of wholeness, purpose and a life well lived, or a sense of ego integrity, according to Erikson. When a person accepts and approves of a unique life, death also can be accepted as a meaningful part of life. However, if the life review is laden with opportunities missed or wrong directions taken, a sense of despair arises. Death is faced with anxiety. In this last stage of ego integrity versus despair, each person must face adjustments and come to a final conflict resolution that is the product of all previous developmental conflict resolutions.
PECK’S THEORY: DEVELOPMENTAL TASKS
Based on Erikson’s work, Peck further defined psychosocial tasks of middle and older adulthood.23 With a general decline in physical and sexual functioning, the middle-aged adult’s self-esteem can suffer if it is heavily based on such changes. However, judgemental abilities tend to increase with experience, so valuing the use of one’s ‘head’ becomes a positive alternative for maintaining self-esteem. People need flexibility to shift attachments and reinvest emotions in other people and pursuits (see Fig 5-1). People also need the mental flexibility to allow for new solutions to life problems, rather than being dogmatic and governed by past experiences.
HAVIGHURST’S THEORY: DEVELOPMENTAL TASKS
Havighurst also proposed specific developmental tasks for each life stage.24 Like Erikson, he contended that there are optimal points in life to master these tasks and the mastery level depends on the success of previous life stages. Notably, he included family-oriented tasks that are significant to individual development. In addition, Havighurst proposed that ‘successful achievement of a task leads to happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by the society, and difficulty with later tasks’.24
LEVINSON’S THEORY: EVOLUTION OF LIFE STRUCTURES
Levinson’s theory describes the evolution of life structures.25 Although men and women go through similar stages of development, women may have more difficulty planning a life course if the themes of family and career are viewed as mutually exclusive choices. Levinson’s basic concept, individual life structure, is the pattern of a given life at any point in time. Any change in the person’s self-system (e.g. judgements, motives, values) and interactions with other systems (e.g. the social and cultural context of life within the family, ethnicity, religion, occupation and social events), and the particular set of roles the individual assumes, will disrupt the components. Such disruptions call for reorganising of the life structure.25
Life structure is dynamic, with predictable changes occurring as individuals move through life. The four major periods in adult life are early adulthood (21–40 years of age), middle adulthood (41–60 years of age), late adulthood (61–85 years of age) and late-late adulthood (beyond 85 years). Within each of the four stages in adult life, individuals face transitions and stability. Transitions are a time to make changes and redirect growth towards personal goals and objectives. Stable times present opportunities to build and maintain the intact life structures necessary to pursue those goals and objectives.
OTHER THEORIES OF ADULT DEVELOPMENT
Other theorists such as Lowenthal and Neugarten have used life event and transition perspectives to describe adult development. To these theorists major life events are more important than chronological age in assessing and understanding adult behaviours.26 Activities within one’s life, such as being newly married, starting a job, middle-age parenting, divorce, retirement, illness, job-related pressures, adolescent children and parenting one’s parents, provide stresses of varying degrees that are not always associated with a specific age. Another component of development is the individual’s perception of and reaction to the expected or unexpected timing of life events and the ageing process. In this model one’s life experiences are viewed within the appropriate time context: historical time (calendar time), life time (chronological age) and socially defined time (as related to age norms and expectations).27
Courtenay reviewed adult development models and found four characteristics that are common to all models.28 All models focus on self-identity and growth through developmental tasks. Individuals’ psychological identity is closely related to personal growth and the achievement of tasks that extend their capabilities. Another characteristic common among the models is that individuals move through hierarchical stages that range from the simple to the complex, from rigidity to flexibility, and from narrow to comprehensive perspectives. The belief that human development occurs throughout the life span is a third characteristic. The vast variety and complexity of proficiencies faced by adults require constant evolution and lifelong pursuit. Today’s increasing life span offers adults multiple opportunities for continued development. The fourth characteristic of these models is that the ultimate goal of adult development is to achieve autonomy, separateness and independence.
Biological ageing theories
From a biological viewpoint, ageing is defined as the progressive loss of function. This age-related decrease occurs along with decreasing fertility and increased mortality. The exact aetiology or cause of biological ageing remains to be determined. Biological ageing is clearly a multifactorial process involving genetics, the imbalance between oxidation of cells and ability to detoxify and repair the resulting damage, diet and environment. Research efforts are directed at increasing both the average life span and the quality of life of older adults. It is hoped that new anti-ageing therapies will be developed to slow down or reverse age-related changes that result in chronic illness and disability. Reducing energy intake is suggested to increase longevity.29 Some of the anti-ageing strategies that are currently under investigation are presented in Table 5-3.
TABLE 5-3 Current strategies for slowing or reversing ageing
Source: Adapted from vojta CL, Fraga PD, Forciea MA, Lavizzo-Mourey R. Anti-aging therapy: an overview. Hosp Pract 2001; 36(6):43–49.
There has long been an interest in slowing down or reversing the effects of ageing. A number of nutrients have been examined and tested for their potential benefits in reducing the impact of ageing. Examples include vitamin A (retinol), beta-carotene, selenium, ginkgo and chromium.30 However, much research is needed before it is known whether any will delay ageing or enhance the functional ability of older adults.
Several theories regarding biological ageing are currently proposed. One way to categorise theories related to biological ageing is to distinguish between those that propose that ageing is due to chance (a stochastic theory) and those that propose that ageing is not related to chance (non-stochastic). A non-stochastic theory hypothesises that age-related molecular and cellular events are programmed by genes. Proposed theories of ageing are shown in Table 5-4.
STOCHASTIC THEORIES
The somatic mutation and intrinsic mutagenesis theories postulate that ageing is a result of lifelong genetic damage. This damage may include the progressive accumulation of faulty copying in dividing cells or the accumulation of errors in information-containing molecules. According to the somatic mutation theory, body cells develop spontaneous mutations in the same way that germ cells do. Subsequent cell divisions perpetuate the mutations until organs become inefficient and ultimately fail. The intrinsic mutagenesis theory suggests that the increase in mutational cells occurs because of a breakdown in genetic regulatory mechanisms. The basic premise is that the regulatory capacity of the human genetic constitution diminishes throughout life. Thus, more mutations occur with ageing that will ultimately result in functional failure. Although both theories are attractive, little evidence exists to support or deny them.
The free radical theory was initially proposed in 1956 by Harman but in recent years has become the focus of new research.30 A free radical is a highly reactive atom or molecule that carries an unpaired electron and thus seeks to combine with another molecule, causing an oxidative process. This process, also called oxidative stress, can ultimately disrupt cell membranes and alter DNA and protein synthesis. Common diseases, such as atherosclerosis and cancer, are associated with oxidative stress.31 Cellular integrity, function and regeneration mechanisms are injured. Free radicals are natural by-products of many normal cellular processes and are also created by environmental factors, such as smog, tobacco smoke and radiation. There are numerous natural protective mechanisms in place to prevent oxidative damage. Recent research has focused on the roles of various antioxidants, including vitamins C and E, beta-carotene and selenium, in slowing down the oxidative process and ultimately the ageing process.32–34 However, optimal doses of these substances have not been established. These substances are being investigated for their usefulness in preventing diseases related to ageing, such as oral, oesophageal and reproductive cancers, coronary artery disease, cataracts, systemic inflammation and cognitive impairment.
Another stochastic theory is the cross-link theory, which postulates that, over time and as a result of exposure to chemicals and radiation in the environment, cross-links form between lipids, proteins and carbohydrates, as well as nucleic acids. These cross-links result in decreased flexibility and elasticity, and this increases rigidity in tissues (e.g. blood vessels). Such changes in cell structure may explain the observable cosmetic changes associated with ageing, such as wrinkles of the skin and decreased distensibility of arterial blood vessels. However, it is unlikely that such changes account for all of the detrimental physical events associated with ageing.
NON-STOCHASTIC THEORIES
For many years it was believed that cells had the capability to reproduce for an infinite amount of time. However, in the 1950s Hayflick, in a series of classic experiments, demonstrated that cultured skin fibroblasts would reproduce or divide a finite number of times. From these observations rose the theory of programmed cell death. In this theory, it is proposed that there is an impairment in the ability of the cell to continue dividing. A more recent theory of ageing is the telomere–telomerase hypothesis.35 Telomeres are specialised repeated sequences that are present at the ends of DNA strands. Telomerase is the enzyme that synthesises these repeat sequences.36 With ageing there is loss of these strands and a decrease in telomerase activity, both of which affect the number of times a cell can divide.35,36
The neuroendocrine theory proposes that ageing occurs because of functional decrements in neurons and associated hormones.29,31 It suggests that neural and endocrine changes may be pacemakers for many cellular and physiological aspects of ageing. This approach relates ageing to the organism’s loss of responsiveness of neuroendocrine tissue to various signals. In some cases this is a result of a loss of receptors but in others it is caused by changes in neurotransmission beyond the receptors. An important focus of this theory is the functional changes of the hypothalamic–pituitary system. These changes are accompanied by a decline in functional capacity in other endocrine organs, such as the adrenal and thyroid glands, ovaries and testes.37
The immunological theory proposes declining functional capacity of the immune system as the basis for the ageing process.31 It suggests that ageing is not a passive wearing out of systems but an active self-destruction mediated by the immune system. This theory is based on observing an age-associated decline in T cell functioning, accompanied by a decrease in resistance and an increase in autoimmune diseases with ageing.38 Whether the immunological changes are genetically determined, regulated by environment or influenced by endocrine factors remains to be defined. However, some studies of cell division suggest that the cells of the immune system become more diversified with age and demonstrate a progressive loss of self-regulatory patterns. The result is an autoimmune phenomenon in which cells normal to the body are mistaken as foreign and are attacked by the individual’s own immune system.
Age-related physiological changes
Age-related changes affect every body system and it is important that nurses can differentiate between age-related and disease-related changes when caring for older people. Age-related changes are normal and occur as people age. However, the age at which specific changes become evident differs from person to person and within the same person because of the individual nature of ageing. For instance, a person may have grey hair at age 45 but relatively unwrinkled skin at age 80. The nurse should assess for these age-related changes. Table 5-5 presents gerontological differences in assessment based on age-related physiological changes and associated clinical manifestations.
Special older adult populations
OLDER ADULT WOMEN
For the ageing woman, the impact of an ageing body and being a woman is considered a double jeopardy.39 Older women are often discriminated against for being older and female. They are more likely to survive their spouses than are older men. Table 5-6 lists gender differences between older men and women. Gender-based inequities in healthcare have been documented.40
The nurse is in an excellent position to be an advocate for equity for the older woman in the healthcare system and in federal funding of research. While advocacy organisations, such as the Older Women’s Network, and Australian women’s health groups can be helpful in this process their availability is not necessarily known by many women. The contribution to the economy that older women make through voluntary organisations also needs to be acknowledged. Older women are more likely than men to volunteer for fundraising, sales activities and food preparation and serving.41 Many organisations, such as Meals on Wheels and Hospital Auxiliary groups, rely on volunteer older women. Older women also provide the bulk of informal, unpaid healthcare for family and friends and are thus an important, but often hidden, workforce. For example, approximately 19% of older people provide unpaid care for a family member or friend with dementia in their own home and do not access community care services, representing 80% of the value of informal care without compensation, and a significant reduction in the $6 million currently spent by the Australian government on dementia services.
COGNITIVELY IMPAIRED OLDER ADULTS
For the majority of healthy older adults there is no noticeable decline in mental abilities. The older adult may experience a memory lapse or benign forgetfulness, which is significantly different from cognitive impairment. This is often referred to as age-associated memory impairment. Table 5-7 outlines the effects of ageing on adult mental functioning.
The older adult who is forgetful should be encouraged to use memory aids to attempt recall in a calm and quiet environment, and actively engage in memory improvement techniques. Memory aids include clocks, calendars, notes, marked pillboxes, safety alarms on stoves and identity necklaces or bracelets. Memory techniques include word association, mental imaging and mnemonics.
Declining physical health is an important factor that influences cognitive impairment. The older adult who experiences sensory loss, cerebrovascular disease or hypertension may show a decline in cognitive functioning. An Australian longitudinal study of people aged 75 years and older and living in the community found that 56% of participants had at least one neurodegenerative disorder and that the prevalence of neurodegenerative disorders increased with age.42 These neurodegenerative disorders include motor function deterioration, dementia, Parkinson’s disease and syndromes such as age-related cognitive impairment. It has been estimated that the prevalence of dementia in people aged 65 years and over is 6%.3 The prevalence of dementia increases exponentially with age, with the highest prevalence being in those aged 85 years and older.1–3 Dementia and other neurodegenerative diseases are very disabling. Therefore, appropriate cognitive assessment of older people is important and should include functional ability, memory recall, orientation, use of judgement and appropriate emotional state. Standard mental status examinations and behavioural descriptions provide data for determining cognitive status. Cognitive impairment and dementia are discussed in detail in Chapter 59.
RURAL OLDER ADULTS
People over 65 years of age are less likely to live in metropolitan areas than younger people. Approximately one-third of older people live in rural and remote areas of Australia, which is slightly higher than the rest of the population (28%) living in these areas.1,3,43 Also, there has been a steady trend of retirees selling the family home and moving permanently to rural coastal holiday destinations, which are struggling to meet the growing infrastructure demands, such as public transport, community support and healthcare.43 In contrast, New Zealanders aged over 65 are likely to move to larger urban centres after retirement and are highly urbanised. More than two-thirds live in major urban regions and the remainder live in minor urban areas that provide the necessary infrastructure that supports their independence and health needs.7
Rural older adults face special challenges and their health, in general, compares poorly with that of older people in larger metropolitan areas.3,7 Because of geographic isolation and a higher poverty level, the rural older adult is often stressed by changing financial resources and declining self-care abilities.44 With the death of a spouse and the tyranny of distance between the family home and regional centres that offer community support systems, older people living in rural areas are at higher risk of emotional and physical health problems associated with loneliness.43,45 Australians living in rural areas are also more likely to be Indigenous Australians. The health of older people in rural communities is at risk because the rural older adult is less likely to engage in health-promoting activities and the rural community is under-served by healthcare workers as the viability of health services is problematic.44 Research demonstrates the risk of loneliness, chronic conditions and nursing home placement.46
Nurses working with rural older adults must clearly define the lifestyle values and practices of rural life. Healthcare providers should consider transportation as a possible barrier to service. Alternative service approaches, such as computer-based internet sources and chat rooms, videotapes, radio and church social events, can be used to promote healthy practices or to conduct health screening. Flexible multifunctional models for healthcare have been developed in Australia to improve access to services in areas where single function services are not viable. Multipurpose centres and services provide a range of health and aged-care services to rural Australia.43 Within New Zealand, primary health organisations analyse local needs and develop locally driven population health strategies to respond to the needs of the rural population.47
HOMELESS OLDER ADULTS
While most older people live in their own homes or in rented accommodation, homelessness is increasing. The estimate of totally homeless Australians aged over 65 is 5% and growing.3 There is far less homelessness among older New Zealanders.7 Homelessness is a complex issue but system factors contributing to it include: national economic policies; destruction of public and low-cost housing stocks as cities grow and available land diminishes; reduction in government support for charitable and religious organisations; legalised gambling; and privatisation of public utilities (e.g. electricity, water). The older homeless person is less likely to use shelters or meal sites. Personal factors that are associated with homelessness include: (1) having a low income; (2) reduced cognitive capacity; (3) alcohol addiction; and (4) living alone.1,7 Australians of Aboriginal origin constitute 9.1% of the known homeless persons group,48 although they represent only 2.5% of the total Australian population, and are one group where homeless intact families can be found, including older members.49 The majority of older homeless people have mental illness and/or dementia, and they are particularly at risk of threats to their safety and security, and further health deterioration, because many ageing network services are not designed, nor do they have the capacity, to reach out to homeless persons.1,9
Fear of institutionalisation may explain the reason why the older homeless adult does not use shelter and meal site services. Cognitive impairment may preclude regular attendance at community-based services for attention to nutrition, infections or wounds, and management of chronic conditions such as diabetes. The older homeless person needs affordable housing. When cognitively impaired and alone, the older person also needs financial management assistance. Solutions to the problem of homelessness among the older population require more research and intervention studies. In Australia, placement in a residential care facility or supported housing is often an alternative to homelessness.46,49
FRAIL OLDER ADULTS
The term frail elderly is used to identify those older adults who, because of declining physical health and resources, are most vulnerable. Frailty is not directly related to age per se, although age is a risk factor. Old age is just one element of frailty. Frailty depends on functional and cognitive ability and other factors, such as a specific disability and multiple chronic illnesses. The old-old population (85 years of age and older) are the most at risk of frailty, although many in this age group remain healthy and robust.3,7
The frail older adult can have difficulty coping with declining functional abilities and decreasing daily energy. When stressful life events (e.g. the death of a pet) and daily strain (e.g. caring for an ill spouse) occur, the frail individual often cannot cope with the effects of stress and, as a result, may become ill. Common health problems of the frail older adult include mobility limitations, sensory impairment, cognitive decline and falls. This population is especially at risk of falls as the number of risk factors increase, including: poorer cardiac and vascular status; musculoskeletal, sensory and neurological dysfunction; cognitive impairment; and incontinence.50 The frail older adult is at particular risk of malnutrition and problems with hydration status. Malnutrition and dehydration are related to sociopsychological factors, such as living alone, depression and low income. Physical factors, such as declining cognitive status, inadequate dental care, sensory deficits, physical fatigue and limited mobility, also add to the risks of malnutrition and dehydration.51 Because many frail older adults have therapeutic diets and multiple drug regimens, their nutritional state may be altered.52
It is important to monitor the frail older adult for adequate kilojoule, protein, iron, calcium, vitamin D and fluid intake. The acronym SCALES can remind you to assess important nutritional indicators:
Once the older adult’s nutritional needs have been identified, common interventions include home-delivered meals, dietary supplements, dental referrals and vitamin supplements.
Remember that the frail older adult tires easily, has little physical reserve and is at risk of disability, elder abuse and institutionalisation. Approximately 30% of older Australians3 and 47% of older New Zealanders4 live alone and need little support; however, some older adults may be dependent on a network of family, individual and social support that should be respected.
CHRONICALLY ILL OLDER ADULTS
Although the Australian and New Zealand healthcare systems are dominated by an acute illness focus, daily living with chronic illness is a reality for many older adults. Even though persons of all ages can have chronic health problems, the incidence of chronic illness increases as a person ages because advances in medical care have led to people living with chronic disease for longer.53 Eighty-four per cent of persons 85 years of age and older have a disability that commonly relates to a chronic illness.54 The most common chronic conditions present in the older adult are arthritis, visual impairment, diabetes mellitus, cardiovascular disease (including high blood pressure), deafness and hearing impairment, Alzheimer’s disease, osteoporosis, hip fractures, urinary incontinence, stroke, Parkinson’s disease and depression.2,3 There is a particularly high risk for diabetes mellitus, congestive heart failure, cardiopulmonary obstructive disease and hypertension in the Australian Indigenous population.53
Often, chronic illness is composed of multiple health problems that have a protracted, unpredictable course. Diagnosis and the acute phase of a chronic illness are often managed in a hospital. Older people commonly present to hospitals with multiple, complex conditions, accounting for 46% of acute hospital bed days and 33% of hospital discharges.12 All other phases of a chronic illness are usually managed at home. The management of a chronic illness can profoundly affect the lives and identities of the older person, carer and family.53
Although health status refers to acute and chronic illness, it also includes an individual’s level of daily functioning. Functional health includes activities of daily living (ADLs), such as bathing, dressing, eating, toileting and transferring to and from the bed and chair. Instrumental ADLs (IADLs), such as using a telephone, shopping, preparing food, housekeeping, doing laundry, arranging transportation, taking medications and handling finances, are also included in a functional health assessment.
As age increases, a pattern of declining functional health and increasing disability is seen. The nurse caring for the older adult can advocate for accurate, comprehensive assessment in which health and disease states are diagnosed accurately and can actively teach health promotion strategies. Disease in the older adult is often difficult to diagnose accurately. Older adults tend to underreport symptoms and to treat these symptoms by altering functional status. They eat less, sleep more or ‘wait it out’ and often attribute a new symptom to ‘old age’ and will ignore it.
Disease in the older adult may vary greatly. As one disease is treated, another may be affected. For example, the use of a drug with anticholinergic properties, such as a tricyclic antidepressant, may cause urinary retention. In the older adult, disease symptoms are atypical, and complaints of ‘aching in the joint’ may actually be a broken hip. Silent asymptomatic pathology frequently occurs. Cardiac disease may be diagnosed when the adult is being treated for a urinary tract infection. Pathologies with similar symptoms are often confused. Depression and delirium may be mistreated as dementia, as cognition is affected in very similar ways in both conditions, although the onset varies.55 A cascade disease pattern may occur. An example of a cascade disease pattern occurs when a person who experiences insomnia treats the condition with a hypnotic medication, becomes lethargic and confused, falls, breaks a hip and subsequently develops pneumonia.
Tasks required for daily living with chronic illness include: (1) preventing and managing a crisis; (2) carrying out prescribed regimens; (3) controlling symptoms; (4) managing time; (5) adjusting to changes in the course of the disease; (6) preventing social isolation; and (7) attempting to normalise interactions with others. Both the older adult and the nurse must practise behaviours different from those required of persons with an acute illness if the older adult is to accomplish the tasks associated with a chronic disease.
Social support and the older adult
Social support for the older adult occurs at three levels. Family and kinship relations are the first and preferred providers of social support. Second, a semiformal level of support is found in clubs, churches, neighbourhoods and senior citizen centres. Last, the older adult may be linked to a formal system of social welfare agencies, health facilities and government support. Generally the nurse is part of the formal support system.
CARERS
More than 80% of care is provided by a family carer who lives with the older person requiring care.1,56 A carer is someone who provides supervision and direct care, and coordinates services. The tasks include: (1) assisting with ADLs and IADLs; (2) providing emotional and social support; and (3) managing healthcare. A carer is usually a married woman who is often old herself, has chronic diseases and disabilities and is frequently poor. Ethnic background influences the type of caregiving network. Different cultural backgrounds will often determine the use of extended family networks for caring.57
Carer concerns change as the intensity of the caregiving role changes. For example, a carer may need to adjust work schedules to accommodate patient healthcare appointments, or the carer may need to be available to monitor the cognitively impaired patient’s safety 24 hours a day.
Common problems facing the carer include the following: (1) a lack of understanding of the time and energy needed for caring; (2) a lack of information about specific tasks of caring, such as bathing and drug administration; (3) a lack of respite or relief from caring; (4) an inability to meet personal self-care and health needs, such as socialisation and rest; (5) conflict in the family unit related to decisions about caring; and (6) financial depletion of resources as a result of the carer’s inability to work and the increased cost of healthcare.56,57
The intensity and complexity of caring can place the carer at risk of high levels of stress. The carer may develop a sense of being overwhelmed with feelings of inadequacy, powerlessness and depression, particularly when their family member has a mental illness or dementia.58,59 Although most older adults deny loneliness, even when they spend much time alone, carers often lack sufficient social interaction. The primary carer is often at risk of social isolation. The burden of caring separates the individual from others who provide social, emotional and interactional involvement. Time commitments, fatigue and, at times, socially inappropriate behaviours of the dependent older adult contribute to social isolation. Research demonstrates relationships between loneliness, social isolation and chronic conditions, with anxiety, depression, use of health services and increasing risk of nursing home admission.45,46,59
The socially isolated carer needs to be identified and plans should be designed to meet the needs for social support and exchange. The escalating incidence of caring sets the stage for increased incidences of elder abuse. Physical, financial, psychological or sexual abuse and neglect may occur in families that are ill-equipped to handle caring.56–58 The nurse should assess the carer and the patient for the possibility of carer role strain and elder abuse.60
Many family members involved in direct caring activities also identify rewards associated with this role. Positive aspects of caring include: (1) knowing that their loved one is receiving good care (often in a home environment); (2) learning and mastering new tasks; and (3) finding opportunities for intimacy. At the same time the tasks involved in caregiving often provide opportunities for family members to gain greater insights into each other and strengthen their relationships.58 The stress of caring may result in emotional problems, such as depression, anger, resentment and feelings of hopelessness and powerlessness.58–61 It may be appropriate for the nurse to consider the carer as a patient and plan behaviours to reduce carer role strain. It is important for nurses to communicate a sense of empathy to carers while allowing discussion about the burdens and joys of caring. Carers can be taught about age-related changes and diseases and specific caring techniques. Nurses can encourage carers to attend support groups and assist them in seeking help from the formal social support system regarding matters such as the various forms of respite care, housing, health coverage and finances. This is particularly important for non-English-speaking carers and clients.62
CARING AND ELDER ABUSE
The stress associated with ongoing care for an older person can lead to abusive behaviours towards the care recipient, particularly when dementia and/or mental illness is involved.60 The term elder abuse is used to describe the experience of physical harm (battering), verbal abuse, exploitation, denial of rights, forced restraint and neglected needs, usually by an individual responsible for the care of an older adult.8,56,63 It is estimated that elder abuse occurs in approximately 2–3% of the general older adult population.56 The abuse is seldom reported to authorities even though it shows a repetitive pattern. The typical victim is an older woman with at least one limitation in ADLs. Most of these women are widowed, poor, have impaired physical and/or cognitive disability and are dependent on the abuser for some aspect of care.9 Elder abuse is often associated with substance abuse, carer role strain and depression. The lack of reporting of abuse may be related to the older adult’s feeling of vulnerability, lack of self-worth, impaired cognitive functioning and sense of isolation.64
Elder abuse can occur in a variety of forms (see Table 5-8). Australian data suggest that 1–5% of older people may be victims of elder abuse.65 Self-neglect is also a form of elder abuse when the older adult is no longer competent to perform self-care or when the older adult has severe psychological impairments.64 In New Zealand, 75% of self-neglecting adults are women, with 22% being between 80 and 85 years of age.56 In assessing elder abuse nurses must understand the legal limits of practice within their respective government mandates. When caring for an older person, physical assessment should include physical examination, including scrutiny of the musculoskeletal and genitourinary systems; neurological and cognitive testing; and detailed social and sexual histories. Signs and/or symptoms that cannot be explained medically may signal elder abuse. To intervene, clinicians must be familiar with the laws governing reporting procedures and patient privacy.60 With a competent older adult victim, nurses may be limited in intervention because of patient resistance. In some situations healthcare workers are seen as interferers and opportunists. There are several elder abuse assessment instruments, which include basic information, signs of maltreatment, severity of signs and response of abuser. If you suspect abuse,66 an appropriate assessment protocol should be carried out and consultation should be obtained according to agency policy. Follow-up actions may include consultation with adult protective services such as the Office of the Public Guardian, which is located in each state in Australia and in New Zealand. In most situations, nurses are mandated to report abuse.
TABLE 5-8 Types of elder abuse
| Type | Example |
|---|---|
| Violation of individual rights | Lack of privacy; unwanted visitors |
| Exploitation | Taking a social security cheque or property |
| Physical abuse | Shaking or hitting |
| Psychological neglect | Isolating or locking the person in a room |
| Psychological abuse | Swearing at the person; displaying threatening behaviour |
| Physical neglect | Not providing correct medications or proper physical care |
Social services for the older adult
A network of services supports the older adult both in the community and in healthcare facilities. Most older adults are involved in at least one social or governmental service.1,2 To understand the older adult situation, it is necessary to know the government structures that fund and regulate the older adult programs.
The Department of Health and Ageing is the agency responsible for many older adult programs in Australia. In New Zealand the responsibility for community and primary health programs is delegated to the District Health Boards by the Ministry of Health. The general goal of organised bodies, such as the Council on the Ageing (COTA) in Australia and Age Concern in New Zealand, is to include older people wherever programs exist by cooperating and consulting with other agencies or organisations. In Australia, funding from the federal government is funnelled to state and local government agencies for projects on ageing; however, the grant allocation process is often a very competitive one. The Treaty of Waitangi in New Zealand ensures government commitment to equitable distribution of available resources for health and aged-care services.67
In Australia, the complex web of policies of the federal and state governments cannot be easily separated. Policy formulation often results in an intermingling of activities through shared jurisdiction and cost sharing. This shared role has been changing during the last 60 years. Since the 1950s a wide range of federal and state programs have evolved. The role of all levels of government is to regulate and provide funding.68
Funding
Both the Australian and the New Zealand governments provide medical and health funding for citizens older than 65 years of age, and these are supplemented by private healthcare payments and not-for-profit community and religious/charity organisations. New Zealand elders are mainly (78%) supported through the funds allocated to District Health Boards by the central government VOTE Health.67 Australians are covered by the government-initiated Medicare scheme.41 Medicare provides access to free or subsidised treatment by general practitioners and other providers of healthcare, such as specialist doctors and surgeons, and free treatment as a public patient in a public hospital.
In New Zealand the District Health Boards plan, fund and deliver health and community services to geographically defined populations using a weighted population and needs-based formula. Thirty-nine per cent of all VOTE Health funds are used to meet the health needs of adults 65 years and over.67 The Australian Home and Community Care (HACC) program provides support for people living in the community who require rehabilitative services and care.9 There are limitations to the availability of these services as demand often exceeds supply. Hospice care can be covered under Medicare.
In Australian residential aged care, the nursing documentation process is complex yet critical for adequate reimbursement. A new Australian residential aged-care funding system was introduced in 2008. The funding is largely tied to the physical, cognitive, emotional and social function scores derived for each resident through the Aged Care Funding Instrument (ACFI). While the instrument is comprehensive, there are concerns among the aged-care sector that measurement is generally undertaken annually, unless the resident has a significant deterioration in their condition, and it is therefore not well-suited to the dynamic health status of the older person. Another concern is that complex health assessment is not necessarily being undertaken by skilled assessors, especially in the areas of cognitive and mental health status.68 A review of the ACFI by the Department of Health and Ageing is likely to result in a more consistent, efficient and effective residential aged-care system in 2012, one that more accurately identifies the appropriate level of care required for the deteriorating resident, and thus government financial support for the older person requiring residential care placement. In contrast to the centralised Australian funding model, in New Zealand the District Health Boards are responsible for aged-care funding through application of the needs-based principle and guided by the National Service Framework, and are monitored by the Ministry of Health.67
Care alternatives for older adults
HOUSING
Many older adults stay in their place of residence and do not move to a different home or geographic location (see Fig 5-2). However, if New Zealanders do move after retirement they do so to be closer to health and other community services in larger regional areas.7 In contrast, many older Australians move to coastal or rural towns away from the larger cities.1 However, most do not move or return to the geographic location of childhood when health becomes frail. The community becomes important to the older adult as an environment that is safe from crime and accidents. As the older adult needs privacy and companionship, as well as a sense of belonging, the community should be accessible. The older adult may need housing assistance with home repairs and this is provided through some local government support programs. Subsidised, low-income housing arrangements may be available for older adults in some areas.
For the older adult who chooses to remain in the family home as functional abilities decline, home adaptations and modifications can be made. Homes can be made wheelchair accessible. Lighting can be increased and adjusted. Safety devices, such as handrails, grab bars and non-slip surfaces, can be installed in bathrooms and kitchens. Alarms and assistive listening devices can be used.
Retirement villages or over-55s communities may be an option for some older adults. These communities are age-segregated, self-contained developments and provide social activities, security and recreational facilities. Many require an entrance investment fee and other fees if continuing care is necessary. (See Ch 6 for a discussion of community-based care settings.) Independent living facilities provide housing and sometimes congregate meals but have little supervision. Other home maintenance and care services can be purchased from these facilities. Board and care homes provide housing and meals in small congregate home environments.
Assisted-living facilities are designed to provide housing and personalised healthcare. Because over half of community-based older adults require assistance with ADLs or IADLs, this is the most rapidly developing area of long-term care.64 Services vary from state to state, region to region. Nurses provide care to or manage assisted-living facilities and services. Nurses working in this area are challenged by questions related to regulations, use of untrained and unlicensed care workers,5 assessment to ensure safe ‘fit of resident to facility’ and shared resident decision making.
Creative housing options are being developed through home sharing, the use of ‘granny flats’ and apartment rentals in established older homes. Nurses can play a role in meeting the housing needs of older adults by identifying housing preferences and by advocating community housing changes that create a safe, liveable community.
COMMUNITY-BASED OLDER ADULTS WITH SPECIAL NEEDS
Older adults with special care needs include homeless persons, persons who need constant assistance with ADLs, persons who are home-bound and persons who can no longer live at home. The older adult may be served by adult day care, outreach home healthcare or residential care.
Adult day care programs
Adult day care (ADC) programs provide daily supervision, social activities and assistance with ADLs for two major groups of older adults: those who are cognitively impaired and those who have problems undertaking ADLs. The services offered in ADC programs are based on the older adult’s needs. Restorative programs for persons with problems with ADLs offer health monitoring, therapeutic activities, one-to-one ADLs training, individualised care planning and personal care services.64 Programs designed for the cognitively impaired offer therapeutic recreation, support for family, family counselling and social involvement. An increasing number of ethnic-specific day care programs are available to older people with cognitive impairment.69 Patient characteristics in the cognitively impaired group include a high incidence of persons with Alzheimer’s disease and other dementias.59 In this group, incontinence is a common problem. Patient characteristics in the restorative care group include a high level of wheelchair users, problems with incontinence and some depression.
Day care centres can provide relief to the carer, allow continued employment for the carer and delay institutionalisation for the older adult. Centres are regulated and standards are set by state and federal governments; however, costs are not covered by Medicare. Appropriate placement in a day care program that matches the person’s needs is important. Nurses can assist by knowing the available day care services and assessing the older adult’s physical and psychosocial needs. They are then in a position to aid the older adult and family in making a good placement decision. Both carer and care recipient should be informed about day care and its services as an alternative care option.
Home healthcare
In Australia, home health care and the use of Community Aged Care Packages (CAPS) can be a cost-effective care alternative for older adults who are home-bound, have health needs that are intermittent or acute and have supportive carer involvement. These packages are not an alternative for patients in need of 24-hour assistance with ADLs or continuous safety supervision. Extended Aged Care at Home (EACH) packages and dementia-specific packages have recently proved successful in assisting older Australians with higher levels of dependency to remain in their own homes, and are more cost-effective and desirable than assisted care living for some older clients.64,68 Home healthcare services require recommendation by a doctor and, where possible, skilled nurses. (Home healthcare is discussed in Ch 6.)
RESIDENTIAL CARE FACILITIES
Residential care facilities are a placement alternative for older adults who can no longer live alone. This equates to approximately 5% of Australians and New Zealanders over the age of 75.1,2,67 Older people are likely to require residential care when they need continuous supervision, have three or more disabilities with ADLs and are frail or cognitively impaired.3,7 The cost of long-term care facilities is high. Australian aged-care residents contribute most of their personal income to pay their expenses, which for 85% of older Australians is a government aged or disability pension. Approximately 5% of their private income is kept as a personal needs allowance. New Zealanders living in residential care contribute towards the government-subsidised cost of care through private health insurance and personal contributions.2 (Long-term care is discussed in Ch 6.)
Three factors appear to precipitate placement in a residential care facility: (1) rapid patient deterioration, in particular, increases in cognitive impairment; (2) carer inability to continue care as a result of ‘burnout’—too much and too long; and (3) an alteration in or loss of family support system. In both Australia and New Zealand almost half of people over 65 live independently in the family home and receive varying levels of social support.1,2,7 Physical changes of confusion, incontinence or a major health event (e.g. stroke) can accelerate residential care placement.9,56,70 The conflicts and fears faced by the family and older adult make placement a transition time. Common carer concerns include the following: (1) the process of admission will be resisted by the older adult; (2) the level of care given by staff will be insufficient; (3) the care recipient’s relative will be lonely; and (4) financing of nursing care will not be adequate.
This time of disruption is increased by the physical relocation. The process of physical relocation can result in adverse health effects for the older adult, such as delirium.71 The crisis of relocation syndrome can be anticipated by the nurse and appropriate interventions can be used to reduce the effects of relocation. Whenever possible the older adult should be involved in the decision to move and should be fully informed about the location. The carer can share information, pictures or a DVD of the new location. New health personnel can send a welcome message. On arrival the new care recipient (resident) can be greeted by a staff member to orient them. To bridge the relocation the new resident can be ‘buddied’ with a seasoned resident of the home.
Satisfied residents in long-term care facilities tend to show a variety of behaviours indicating adjustment. They are usually assertive and self-reliant; keep active, follow a routine, keep mentally involved and are sociable (see Fig 5-3); maintain family interaction; and show a level of acceptance. They also express a determined, positive perspective. Satisfied residents use coping strategies that increase control and management of their life. The nurse can encourage and enable the use of these strategies.
Relocation of the older adult with a cognitive impairment from their home and familiar routines and people can be very distressing for the person and their carer.59 Nursing care becomes complex and challenging and requires specialised knowledge and skills and an appreciation of the importance of tailoring care to the needs of the individual.72 Early identification of relocation risk in older adults is very important.73 Further details on the management of cognitively impaired older people is presented in Chapter 59.
CASE MANAGEMENT
Matching social support services to the needs of the older adult is complex. For family members who live interstate or in the country and who therefore cannot provide direct caregiving, the use of a case manager may be helpful. This is a new and developing role that nurses are well suited to assume. The case manager supervises and manages care to ensure continuity of care for the older adult. The process of locating and organising older adult services can be time consuming and research is underway to test different case management models that aim to streamline the coordination of care across the health continuum.74
Legal and ethical issues
Legal assistance is a concern for many older adults. Legal concerns centre on advance directives, estate planning, taxation issues and appeals for denied services. Legal aid may be available to low-income older adults by contacting a local government multipurpose senior centre (see Fig 5-4). This service is supported by funds authorised through local government councils in each state or territory.
Figure 5-4 Bulletin board at a senior citizens centre showing times at which legal help is available.
Advance directives and advanced care planning may be arranged, if desired, on admission to a healthcare facility by the person concerned or their guardian. There are primarily two types: a living will and an enduring power of attorney for health. A living will is a directive that permits the individual to direct their healthcare in the event of a terminal or irreversible condition. Most living wills direct that in the event of a terminal illness, extraordinary medical care should not be initiated or should be withdrawn so that the process of dying will not be artificially prolonged. A living will is directive but not legally binding. An enduring power of attorney for health is another form of advance directive that designates another person to voice healthcare decisions when the older adult is unable to do so personally. An enduring power of attorney for health is directive and legally binding. In most states it includes the naming of an individual to carry out directives when the older adult cannot make choices.75 (Advance directives are discussed in Ch 9 and Table 9-3.) Discussion of estate planning, taxation issues and appeals for denied services is beyond the scope of this textbook.
Nurses who work with older adults should identify areas of ethical concern that influence practice. Such issues can include: (1) to restrain or not to restrain; and (2) to evaluate the patient’s ability to make decisions. Other ethical concerns related to (1) resuscitation, (2) treatment of infections, (3) issues of nutrition and hydration and (4) transfer to more intensive treatment units are all a part of long-term care. These situations are often complex and emotionally charged. Nurses can assist older adults, their family members and other healthcare workers by acknowledging when an ethical dilemma is present, by keeping current on the ethical implications of new biotechnology and by advocating for an institutional ethics committee and, if necessary, the Office of the Public Guardian to help in the decision-making process.
Culturally competent care: older adults
The Australian and New Zealand populations aged over 65 are culturally diverse and this has particular significance for nurses in meeting their unique healthcare needs.3,7 Culturally competent healthcare recognises that cultural differences occur across all levels of human diversity and recognises and supports the essential humanity of all persons whatever their cultural background. This is achieved through culturally sensitive administration, policies and procedures, training and professional development, workplace standards, and the inclusion of health consumers’ voices in these domains.67,76 Cultural competence is a dynamic concept: it reflects changing societal values and contexts and is informed by new research.77
The term ethno-geriatrics is used to describe the specialty area of providing culturally competent care to ethnic elders.8 Older adults who identify with certain ethnic groups present a particular challenge to nurses (see Fig 5-5).
In Australia, which is a multicultural society, 22% of older people come from culturally and linguistically diverse (CALD) backgrounds.1 Over the coming decades there will be an increase in the numbers of CALD people represented in the 85 years and over age group. The ageing CALD population presents challenges for nurses providing care for this population.
Cultural diversity in New Zealand is less complex than in Australia. Per head of total population, the major groups of older adults comprise Māori (3%), people from the Pacific regions (3%), Asians (4%) and people of European extraction (22%).2 The Treaty of Waitangi provides nurses with guidelines for safeguarding Māori cultural concepts, values and practices. The Treaty sets out a commitment to fulfilling the special relationship between Māori and the Crown in facilitating an equitable and appropriate health and disability service for all New Zealanders, regardless of ethnic and cultural origin.2,6,7
It is important for nurses to understand which cultural group an older person identifies with. An assessment of this can be made by asking the following questions:
1. Does this person identify with an ethnic or racial group?
2. Do others identify this person with an ethnic or racial group?
3. Does this person show behavioural patterns that are unique to the ethnic group?
Ethnic identity is often found in certain religious groups, nations and minorities. As the demographics of Australian and New Zealand societies change, ethnic institutions and neighbourhoods may alter. For the older adult with strong ethnic roots, the loss of friends who speak the ‘mother tongue’, the loss of religious and cultural institutions that support social ethnic activities and the loss of shops that carry desired ethnic foods may present situational crises that emphasise and diminish a sense of self-worth and personhood. This loss of self is increased when children and others deny or ignore ethnic practices and behaviours. Support for the ethnic older adult is most frequently found among family, in religious practices and in isolated geographic or community ethnic clusters.64 In the old-old population, ethnic group members often live with extended family and continue to speak or revert to speaking their native language.78,79 Consequently, older adults increasingly experience social exclusion when younger family members communicate together in English rather than in their native tongue.
The ethnic older adult is faced with specific problems. Access to healthcare services can be limited if the older person does not speak the language of the mainstream population.78 Over the last decade the Australian government has implemented policies to improve access to aged-care services for the older CALD population. Perceptions of health also differ by ethnic group and people migrating to Australia bring their own unique health profiles. In Australia, data suggest that better health is reported among immigrants and that CALD immigrants tend to have higher life expectancies than English-speaking immigrants and far greater than Indigenous Australians.1 Interestingly, older CALD people are more likely to use home-based services than hospital and residential services.1,69 This may reflect particular cultural values related to the role of family and community in caring for vulnerable and ill family members, but it is also related to the powerlessness they experience because of their inability to communicate with the largely English-speaking health staff. Racism has also been cited as a detriment to their access to health and aged-care services.80
For nurses to be effective with ethnic older adults, a sense of respect and clear communication is critical. You need to identify self-behaviours that could be interpreted as non-caring or disrespectful, such as a refusal to allow a patient to display an item considered important for healing, and particularly to disregard the older patient’s health beliefs.81 Nursing interventions to assist in meeting the needs of ethnic older adults are described in Box 5-1. Questions to ask when assessing ethnic older adults about health-related practices include the following:
2. When do you know someone is sick?
3. What helps people to get better?
BOX 5-1 Culturally competent care: meeting the needs of ethnic older adults
• Identify health practices, rituals and food patterns that are central to an ethnic identity.
• Identify stereotypical attitudes in the ethnic older adult that interfere with multiethnic group participation.
• Inform the ethnic older adult about services available.
• Support the ethnic older adult who is fearful about travelling outside the accepted neighbourhood for services.
• Advocate for the ethnic older adult to receive services that provide special attention to language limitations and cultural health practices.
• Use strategies specific to an ethnic group. For example, Italians may respond to themes such as ‘Do it for your loved ones’. Asians may respond to fear of dependency themes.
• Learn about services and programs that focus on specific ethnic groups. Examples include home-meal services that serve ethnic foods or nursing homes that include specific ethnic or religious preferences.
Australian and New Zealand cultures are changing. For some older adults, ethnic identity is also changing. Do not assume that ethnic identity is or is not of value to the older person and their family. Assess each older adult’s ethnic orientation and individual care expectations and needs. Both the New Zealand and the Australian governments are committed to this approach in healthcare distribution.67,82
NURSING MANAGEMENT: OLDER ADULTS
Nursing assessment
As with all age groups, comprehensive assessment of the older adult provides the database for the rest of the nursing process. It is important to remember that the older adult may face a health problem with fear and anxiety. Healthcare workers may be perceived as helpful but institutions may be perceived as negative, potentially harmful places. Nurses can communicate a sense of concern and care by careful use of direct and simple statements, appropriate eye contact, direct touch and gentle humour. These actions assist the older adult to relax in this stressful situation.
Before beginning the assessment process, the patient’s primary needs should be attended to first, ensuring that they are pain-free, not hungry or thirsty, and do not need to pass urine. All assistive devices, such as glasses and hearing aids, should be in place before the conversation begins. The interview periods should be kept as short as possible so the patient is not fatigued; however, adequate time needs to be allowed to give information as well as to respond to questions. The older adult and carer can be interviewed separately, unless the care recipient is cognitively and/or sensory impaired, or specifically requests the carer’s presence. Medical history may be lengthy, so it may be best to obtain all the required information in several short segments. It needs to be determined what information is relevant. Old medical records should be obtained and available for review.
The focus of a comprehensive geriatric assessment is to determine appropriate interventions to maintain and enhance the functional abilities of the older adult. The comprehensive assessment is interdisciplinary and, at a minimum, includes the medical history, physical examination, functional abilities assessment and identification of social resources (see Table 5-9). The comprehensive geriatric assessment is usually conducted either in the older adult’s home or at a geriatric assessment unit (GAU) by one or more members of an interdisciplinary geriatric assessment team. The interdisciplinary team may include many disciplines but the minimum components include the nurse, the doctor and the social worker. If the patient has a suspected cognitive impairment, specialist health staff must be involved in cognitive assessment. After the assessment is complete, the interdisciplinary team meets with the patient and, ideally, the carer/family to present the team’s findings and recommendations. GAUs are often affiliated with large medical complexes.
TABLE 5-9 Assessment instruments for older people
1 Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189.
2 yesavage JA, Brink TL. Development and validation of a geriatric depression screening scale: a preliminary paper. J Psychiatr Res 1983; 17:41.
3 katz S, Ford AB, Moskowitz RW et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function. JAMA 1963; 185:914.
4 Lawton H, Brody E. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969; 9:179.
5 Isaacs B, kennie AT. The Set Test as an aid to the detection of dementia in old people. Br J Psychiatry 1973; 123:467.
6 Zarit SH. Relatives of impaired elderly: correlates of feelings of burden. Gerontologist 1980; 20:699.
7 Mayfield D, Mcleod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974; 131:10.
8 Gurnedi AM. Older adults’ measure of alcohol, medicines, and other drugs. New york: Springer; 1997.
9 Mathias S, Nayok U, Isaacs B. Balance in elderly patients: the ‘get up and go’ test. Arch Phys Med Rehabil 1986; 67:387.
Elements in a comprehensive nursing assessment include a detailed history using a functional health pattern format (see Ch 3), physical assessment, assessment of ADLs and IADLs, mental status evaluation and a social–environmental assessment. Evaluation of mental status is particularly important for older adults because results of this evaluation often determine their potential for independent living, and can identify the presence of delirium and possible dementia. Evaluation of the results of a comprehensive nursing assessment helps determine the service and placement needs of the older adult patient. A good match between needs and services should be the goal of the assessment. When an older Australian is in need of long-term care, an Aged Care Assessment Team (ACAT) assesses eligibility for residential aged care, CAPS, EACH and dementia-specific care packages. A nurse is usually a member of an ACAT.
The comprehensive nursing assessment should be based on instruments specific to the older adult population (see Table 5-9). Interpretation of laboratory results can be problematic because many values change with age and parameters are not well defined for the older adult, particularly the old-old adult. The healthy adult may have age-related changes that may be considered abnormal in a younger person but are normal for an older adult. An appropriate reference book should be consulted for the correct ranges of laboratory values for the older adult. The nurse is in an important position to recognise and correct inaccurate interpretation of laboratory tests. Cure is often not possible because of the complexity and chronicity of the health problems that commonly affect the older adult. Consequently, the nurse directs the planning and implementation of those actions that assist the older adult in remaining as functionally independent as possible.8
Nursing diagnoses
With few exceptions the same nursing diagnoses apply to the older adult as to a younger person. Often, however, the aetiology and defining characteristics are related to age and are unique to the older adult. Box 5-2 lists nursing diagnoses that are seen in older adults as a result of age-related changes. The identification and management of nursing diagnoses result in improved function and quality care for the older adult.
Planning
When setting goals with the older adult, it is helpful to identify the strengths and abilities that the patient demonstrates, where possible in their own living environment.8 Personal characteristics such as hardiness, persistence and the ability to laugh and learn are positive factors in goal setting. Carers should be included in goal development, particularly in regard to the older adult’s usual self-care abilities and living patterns. The older adult who loses confidence and perceives increasing dependence and learned helplessness as an appropriate response may be resistant to self-care. As behaviour is socially and culturally constructed, priority goals for the older adult will need to be negotiated with them and close family. Depending on cultural relevance, goals may include gaining a sense of control, increasing personal decision making, feeling safe and reducing stress.78,80
Nursing implementation
When carrying out a plan of action, the approach and techniques used may need to be modified based on the physical, cognitive and mental status of the older adult. Small body size, common in the frail older adult, may necessitate the use of paediatric equipment. Bone and joint changes often require transfer assistance, altered positioning, and the use of gait belts and lifting devices. The older adult with declining energy reserves and cognitive impairment requires extra rest periods alternated with short periods of exertion. A slower approach, restricted scheduling and the use of a bedside commode or other adaptive equipment may be necessary.
Cognitive impairment, such as dementia or delirium, if present requires the nurse to listen to the older adult, offer careful explanations and adopt a quiet and calm approach to avoid producing undue anxiety and resistance. Depression can result in apathy and poor cooperation with the treatment plan.
Health promotion
Health promotion and prevention of health problems in older adults are focused on three areas: reduction in diseases and problems; increased participation in health promotion activities (see Fig 5-6); and increased targeted services that reduce health hazards. These goals, together with providing choices for those concerned, are central to major primary healthcare initiatives currently guiding services for older adults in Australia. These initiatives are detailed in publications such as the Australian government directory of services for older people, 2005–2006.69
Nurses place a high value on health promotion and positive health behaviours. Programs have been successfully developed for screening for chronic health conditions, smoking cessation, foot care, vision and hearing screening, stress reduction, exercise programs, drug usage, crime prevention and home hazards assessment. Nurses can carry out and teach older adults about the need for specific preventive services. Health promotion and illness prevention can be included in nursing interventions at any location or level where the nurse and older adult interact. The nurse can use health promotion activities to strengthen self-care, increase personal responsibility for health and increase independent functioning that will enhance the wellbeing of the older adult.
Teaching older adults
Nurses are involved in teaching older adults self-care practices to enhance health and modify disease processes. Older adults present the following challenges to learning: (1) the time needed to learn is increased; (2) new learning must relate to the patient’s actual experience; (3) anxiety and distractions decrease learning; (4) lack of risk-taking and cautiousness decrease motivation to learn; and (5) sensory–perceptual deficits and cognitive decline require modified teaching techniques. Unless older adults perceive the need to change long-held beliefs and self-care approaches, they may be reluctant to learn new self-care skills.83
Specific approaches that increase the level of learning in older adults include the following: (1) present material at a slower rate; (2) use visual aids when possible; (3) use peer educators when appropriate; (4) encourage participation of a spouse or family member; (5) use simple phrases or sentences with repetition if needed; and (6) support the belief that change in behaviour is both helpful and worth the effort of increased learning.83 (Patient teaching is discussed in Ch 4.)
Acute care
Frequently the hospital is the first point of contact for older adults in the formal healthcare system. Australians aged over 65 years currently use 45% of acute hospital bed days and are responsible for 33% of hospital separations, although they represent only 13.3% of the total population.1,12,76 Similar levels of acute care service use occurs with older New Zealanders.2,7 Hospital usage by older adults has seasonal variations, with more older people being admitted to hospital during winter months because of respiratory-related illnesses. The hospitalised older adult is often experiencing multisystem conditions and increasing numbers of older people are admitted to hospital with comorbidities.
Illnesses that most commonly result in hospitalisation include arrhythmias, heart failure, stroke, fluid and electrolyte imbalances (e.g. hyponatraemia, dehydration), chronic respiratory illnesses including pneumonia and hip fractures.12 The complexity of the acute situation often results in a loss of the whole-person perspective and focuses care on the diseased part. Because nurses provide an integrated approach, care that is individualised and helpful to the older adult can be re-established.
When caring for the hospitalised older adult, both the patient and the carer are assisted when the nurse:
1. identifies the frail and old-old person at risk of the unintended, negative (iatrogenic) outcomes of treatment and care during hospitalisation, such as dehydration and malnutrition, falls and associated injuries, and pressure ulcers
2. considers discharge needs early in the hospital stay, especially assistance with ADLs, IADLs and medications
3. encourages the development and use of interdisciplinary teams, special care units and individuals who focus on the special needs of older adults
4. develops standard protocols to screen for at-risk conditions commonly present in the hospitalised older adult, such as urinary tract infection and delirium
5. advocates for referral of the patient to appropriate community-based services (see Ch 6).
The outcome of hospitalisation for the older adult varies. Of particular concern are the problems of high surgical risk, acute confusional state (delirium), hospital-acquired infection, falls and premature discharge with an unstable condition.
High surgical risk
Age-related body changes, chronic illness and declining physical reserve place older adults at an increased surgical risk. Other key factors that increase surgical risk include age older than 75 years, emergency operations, use of spinal anaesthesia and thrombolytic complications.84 Age is an important risk factor for surgery-related mortality. Adults 80 years of age and older are more than twice as likely as adults 65–69 years of age to experience adverse outcomes following elective surgery.12,84 The risk of surgery should be balanced against the benefit and appropriateness of surgery for the older adult person. (See Chs 17–19 Ch 18 Ch 19 for additional surgical considerations for the older adult.)
Acute confusional state (delirium)
The sudden onset of an acute confusional state (delirium) occurs in 18–38% of hospitalised older adults.85 Delirium is a serious condition for the older person and must be reversed quickly as it can be fatal. Delirium has a rapid onset, a course that fluctuates over time and is usually transient. It is often characterised by confusion, disorganised thinking, difficulty concentrating and sensory misperceptions that last from 1 to 7 days. It can also be ‘silent’, with drowsiness being the most common feature. Some delirium symptoms may persist up to and after discharge. Risk factors include fluid, metabolic and nutritional imbalances, medications, hypoxia and infection. It is important to identify the underlying cause of delirium and subsequent management. Delirium is one of the most frequent consequences of unscheduled surgery because the older adult has not been stabilised physically or prepared emotionally. The patient who experiences delirium is likely to exhibit a decline in ability to perform ADLs.85
Hospital-acquired infections
A hospital-acquired infection (HAI) is an infection that develops 3 days after patient admission to a hospital or healthcare facility. These infections occur at higher rates in older adults. For the old-old adult, the rate is two to five times the rate in a younger person. Age-related changes of decreased immunocompetence, the presence of pathological conditions and an increase in disability all contribute to higher infection rates. In addition, 8–9% of all Australians and New Zealanders over the age of 65 have diabetes mellitus, which may predispose them to secondary infections.1,2 Infections common to older adults include pneumonia, urinary tract infections and skin infections. These infections often have atypical presentations showing cognitive and behavioural changes before alterations occur in laboratory values or temperature.8 In addition, age-related changes in immune function, underlying diseases, increased frequency of adverse drug reactions and institutionalisation can all complicate the management of older adults with infection.
Hospital discharge
At the time of hospital discharge, many older adults are considered to be in an unstable condition. This is particularly so for patients attending day surgery. Frail older adults and old-old adults are especially vulnerable at these times. The nurse can use screening inventories to identify those who are at high risk. Because of the high rate of iatrogenic illnesses occurring in older hospital patients in Australia, a comprehensive risk screen has been introduced for all admissions over 65 years of age, which includes assessment of cognition, and potential for falls and pressure ulcers, as well relevant assessment of mental state.12 The post-discharge assistance needed by this high-risk population includes bathing, taking medications, housekeeping, shopping, preparing and eating meals, and making satisfactory transportation arrangements. The risk of unstable discharge increases in the person who experiences a greater length of stay and who is dependent on others for meals, needs assistance with personal care and has experienced one or more falls.86 Early hospital discharge is most successful when older adults have had little change in functional status or are returning to a place with a high level of assistance, such as an aged-care residential facility, or a hospital-in-the-home type follow-up program.86,87 Most of the older adults discharged from an acute or subacute care service require the multidisciplinary care team, in conjunction with the carer/family, to develop a plan for discharge. The discharge plan needs to be commenced as soon as the patient is admitted to hospital and should be periodically reassessed throughout their stay, and carers and families must be counselled to prepare the care recipient for post-hospital care.
Geriatric rehabilitation
Interventions are focused on adapting to or recovering from disability. With proper training, assistive equipment and attendant personal care, patients with disabilities can often live independent lives. Older adults, primarily through health funding bodies or government programs, can receive rehabilitative assistance through inpatient rehabilitation (limited days), and home and community care programs. As the population continues to age the demand for rehabilitation services may exceed the supply of services and a future challenge will be equitable access to such services.
The nurse needs to understand physical disability in the older adult, as occurs commonly in the old-old. Hip fractures, amputations and stroke occur at higher rates in the older adult population. As well, the older person with cerebrovascular disease, arthritis and coronary artery disease has a risk of becoming functionally limited. These disabilities lead to increased mortality rates, decreased life span and increased rates of institutionalisation.76,86 Reducing residual disability through geriatric rehabilitation is important to the quality of life of the older adult.
Often older adults have specific fears and anxieties related to falling and fatigue. They can be limited in the rehabilitation process by sensory–perceptual deficits, other disease states, slowed cognition, poor nutrition and funding problems. One of the greatest inhibitions is the fear of falling88 and thus nurse and carer encouragement, support and acceptance will greatly assist older adults in remaining motivated for the hard work of rehabilitation.
Rehabilitation of the older adult is influenced by several factors. First, the older adult shows greater initial variability in functional capacity than an adult at any other age. Pre-existing problems associated with reaction time, visual acuity, fine motor ability, physical strength, cognitive function and motivation affect the rehabilitation potential of the older adult.
Second, the older adult often loses functioning because of inactivity and immobility. This de-conditioning can occur as a result of unstable acute medical conditions, environmental barriers that limit mobility and a lack of motivation to stay in condition. The effect of inactivity clearly leads to ‘use it or lose it’ consequences. Older adults can improve flexibility, strength and aerobic capacity even into very old age. The nurse needs to encourage passive and active range-of-motion exercises with all older adults to prevent de-conditioning and subsequent functional decline (see the Evidence-based practice box).
Last, the goal of geriatric rehabilitation is to strive for maximal function and physical capabilities considering the individual’s current health status. When a patient demonstrates suboptimal health, the nurse needs to screen and evaluate for risk behaviours. For example, a woman with a history of osteoporosis should be given a fall-risk appraisal, and an older adult patient with diabetes should receive foot assessment and appropriate follow-up care.
Assistive devices
The use of assistive devices can be considered as an intervention for older adults. Using appropriate assistive devices, such as dentures, glasses, hearing aids, walkers, wheelchairs, adult briefs or protectors, adaptive utensils, elevated toilet seats and skin protective devices, can improve ability. These tools and devices need to be included in the patient’s care plan when appropriate. Both the nurse and the carer are critical to the success of these modifications.
Computer technology will continue to affect the evaluation and care of older adults. Electronic monitoring equipment can be used to monitor heart rhythms and blood pressure, as well as to locate a wandering patient in the home or long-term care facility. Computerised assistive devices can be used to help patients with speech difficulties following stroke, pocket-sized devices can serve as memory aids, and intelligent walking aids can help maintain safe mobilisation and transfers.89
Does resistance training in older adults improve physical ability?
EVIDENCE-BASED PRACTICE
Clinical question
For older adults (P), does progressive resistance training (I) improve physical ability (O)?
Critical appraisal and synthesis of evidence
• 121 RCTs (n = 6700) of healthy older adults and patients with health problems or functional limitations. Ability to walk, climb and rise from sitting was measured.
• Resistance training included machines, free weights and elastic bands at least twice per week.
• Patients showed improved physical functioning, muscle strength and carrying out of daily activities.
Safety
Environmental safety is crucial in maintaining the health of older people. With normal sensory changes, slowed reaction time, decreased thermal and pain sensitivity, changes in gait and balance, and medication effects older adults can be prone to accidents. Most accidents occur in or around the home. Falls, motor vehicle accidents and fires are the most common causes of accidental death in older adults. Another environmental problem arises from the older person’s impaired thermo-regulating system, which cannot adapt to extremes in environmental temperatures. The body of an older adult can neither conserve nor dissipate heat as efficiently as that of a younger adult. Therefore, both hypothermia and heat exhaustion occur more readily. This age group accounts for the majority of deaths during severe cold spells and heat waves.
The nurse can provide valuable counsel regarding environmental changes, which may improve safety for the older adult. Measures such as stronger lighting, coloured step strips, bath and toilet grab bars, and stairway handrails can be effective in ‘safety-proofing’ the living quarters of older adults. The nurse can also advocate for home fire and security alarms. Uncluttered floor space, railings, increased lighting and night-lights, and clearly marked stair edges are some of the easiest and most practical adaptations.
Older adults in an inpatient or long-term care setting need a thorough orientation to the environment. The nurse should repeatedly reassure patients that they are safe and attempt to answer all questions. The unit should foster resident orientation by displaying large-print clocks and room signage, avoiding complex or visually confusing wall designs, clearly designating doors of rooms that the resident is able to access, and using simple bed and nurse-call controls. Lighting should be adequate while avoiding glare. Beds should be close to the floor with four side rails that can be modified to individual needs and to prevent serious injury from falling. Environments that are home-like, have visible orientation cues, provide consistent caregiving and have an established daily routine may assist older adult patients to settle in.90
Pain management
Pain is common in older adults. About 85% of adults over the age of 65 experience pain at least once a year and almost 60% have multiple pain complaints.91 Due to cognitive impairment, older adults may not ask for pain relief. When pain is a known complication of a particular condition, the nurse should offer pain-relieving medications at regular intervals, and reassure the patient that pain relief will not cause addiction. Pain assessment in the elderly may be complicated by cognitive decline, sensory–perceptual deficits and age-related changes. The use of verbal and visual pain scales can assist in correct assessment of pain. The Abbey Pain Scale for people with dementia can be very useful in the assessment process.92 It is estimated that 25–50% of community-dwelling older adults experience pain that interferes with their ADLs. For the person with ongoing pain, a pain diary may be helpful in identifying activities that relieve or increase pain. Because older adults may believe that pain is something that must be endured, creative methods may need to be developed to deal with it. The nurse needs to ask the person to describe techniques used to reduce pain.93 Changes in body position, heat, exercise, distraction and rest may help alleviate pain. Mental imaging, positive thinking, and prayer and other spiritual interventions can also be used. Poor pain management may lead to reduced socialisation, limited mobility, impaired posture, sleep disturbances, depression, anxiety, constipation and increased healthcare utilisation.94 (See Ch 8 for an additional discussion of pain.)
Medication use
Medication use in older adults requires thorough and regular assessment and care planning. The use and abuse of medication in older adults is indicated by the following facts:
1. On average, a 70-year-old takes seven different medications.95
2. Individuals aged 85 and over take an average of 12 prescribed medications.
3. The frequency of adverse drug reactions increases as the number of prescribed drugs increases.
4. Approximately 12% of older adult hospital admissions occur because of drug reactions.
5. After discharge from a hospital, even one unnecessary medication may put the older adult at risk of an adverse drug reaction.
Age-related changes alter the pharmacodynamics and pharmacokinetics of drugs.96 Drug–drug, drug–food and drug–disease interactions all influence the absorption, distribution, metabolism and excretion of drugs. Figure 5-7 illustrates the effects of ageing on drug metabolism. The most dramatic changes with ageing are related to drug metabolism and clearance. Overall, by age 75–80 there is a 50% decline in the renal clearance of drugs. Hepatic blood flow decreases markedly with ageing and the enzymes largely responsible for drug metabolism are decreased as well. Thus, the drug half-life is increased in older adults as compared with younger patients.
In addition to changes in the metabolism of drugs, older adults may have difficulty as a result of cognitive decline, altered sensory perceptions, limited hand mobility and the high cost of many prescriptions. Common reasons for drug errors made by older adults are listed in Box 5-3.
BOX 5-3 Common causes of medication errors by older adults
• Forgetting to take medications
• Use of non-prescription over-the-counter drugs
• Use of medications prescribed for someone else
• Use of medications that are out of date (expired)
• Failure to understand instructions or the importance of drug treatment
• Refusal to take medication because of undesirable side effects, such as nausea and impotence
Complications arising from polypharmacy (the use of multiple medications by one person who has more than one health problem), overdose and addiction to prescription drugs are recognised as major causes of illness in the older adult.95
To assess drug use and knowledge accurately, many nurses ask older adult patients to bring all medications (both over-the-counter and prescription) that they take regularly or occasionally to the healthcare appointment. They can then accurately assess all medications being taken, including drugs that the patient may have omitted or thought unimportant. Additional nursing interventions to assist the older adult in following a safe medication routine are listed in Box 5-4.
BOX 5-4 Medication use by older adults
DRUG THERAPY
1. Emphasise medications that are essential.
2. Attempt to reduce medication use that is not essential for minor symptoms.
3. Screen medication use using a standard assessment tool—including over-the-counter drugs, eyedrops and eardrops, antihistamines and cough syrups.
5. Encourage the use of written or medication-reminder systems.
6. Monitor drug dosage strength; normally the strength should be 30–50% less than that for the younger person.
7. Encourage the use of one pharmacy.
8. Work with healthcare providers and pharmacists to establish routine drug profiles for all older adult patients.
9. Advocate (with drug companies) for low-income prescription support services and dosage routines that utilise simple once-a-day time-release forms.
Depression
Depression is the most common mood disorder in older adults. Approximately 15% of the community-dwelling older population has symptoms of depression. Rates of depressive symptoms in institutionalised older adults are higher than in community-dwelling elders.97 Depression is often associated with being female, being divorced or separated, low socioeconomic status, poor social support, and a recent adverse and unexpected event. Depression in older adults tends to arise from a loss of self-esteem and may be related to life situations such as retirement, loss of a spouse and loneliness. In New Zealand’s older males, depression is associated with heavy substance abuse.98 Problems such as hypochondriac complaints, insomnia, lethargy, agitation, decreased memory and inability to concentrate are common. Depression is an under-recognised problem for many older adults.
Late-life depression often occurs together with medical illness, such as heart disease, stroke, diabetes mellitus and cancer. Depression can exacerbate medical conditions by affecting compliance with diet, exercise or drug regimens. It is important that assessment includes physical and mental health examination and laboratory testing for disorders that may have symptoms similar to those of depression. Diseases of concern are thyroid disorders and vitamin deficiencies.99
The older adult who exhibits depressive symptoms should be encouraged to seek treatment. Because a patient often feels unworthy and may withdraw and become isolated, the nurse may need to seek the support of the family to assist in helping the patient to seek treatment. The depressed older adult who is involved in care may need to seek times of respite and be provided with opportunities to re-evaluate their caring role.
Suicide by older people is of particular concern. In Australia, the rate of suicide in men increases with age, reaching a peak rate of 40 per 100,000 at age 85 years and over.76 This rate is second only to that for young men between 20 and 29 (>40 per 100,000). For older women, the suicide rate peaks between ages 75 and 79 (8 per 100,000). Older Australian men from rural areas are a particularly high-risk group. The trend in Australia is similar to that in other countries.100,101 The low-income older man who is divorced or widowed, depressed and has a history of substance abuse is at greatest risk of suicide in New Zealand.98 Residents in long-term care can also experience depression and appropriate assessment and interventions need to be undertaken.102 Nurses should take seriously comments such as ‘ending this life’. Suicide precautions should be followed.
Nutritional therapy
Maintaining adequate nutrition can be a problem for older adults for physical and social reasons. It is estimated that 30–40% of men and women over the age of 75 are at least 10% below ideal body weight. Physiologically, food may be less appealing with the decline in taste and smell, resulting in anorexia or loss of appetite.103 Chewing can be more difficult with dentures or loss of teeth. Swallowing and digestive problems may also result because of a decrease in saliva, gastric motility and enzyme production. Socially, if a person eats alone, snacking on fast foods is easier than preparing meals. Lack of transportation or access to a supermarket, inability to see the merchandise and poverty may be additional factors in poor nutrition. In addition, conditions like dementia may affect a person’s nutritional status as they may forget to eat or the simple task of preparing food becomes too difficult. However, obesity may also be a problem for some older adults. Normally this problem has arisen earlier in adulthood and continues because of difficulty in changing lifelong eating patterns. Problems with urinary incontinence can result in decreased intake of oral liquids, leading to dehydration and urinary tract infection.
The nurse can have the older adult keep a 3-day dietary history. Analysis of this record is helpful in determining dietary adequacy. When appropriate, home delivery of meals, such as Meals on Wheels, can be arranged, although this may not meet the needs of CALD clients.104 Attention to and correction of the many reasons for poor nutrition in the elderly is an important nursing responsibility. Nutritional difficulties are often related to finances, transport, physical ability to get to shops and ability to prepare and cook food. Management of nutritional problems is presented in Chapter 39.
Sleep
Adequacy of sleep is often a concern of older adults because of changed sleep patterns.8 Older people experience a marked decrease in stage IV deep sleep and are easily roused. In individuals aged over 75, the percentage of sleep time spent in rapid eye movement (REM) sleep decreases. Older adults have difficulty maintaining prolonged sleep. Although the demand for sleep decreases with age, older adults may be disturbed by insomnia and complain that they spend more time in bed but still feel tired. Frequently, older people prefer to spread sleep throughout 24 hours with short naps that provide adequate rest. Often, assurance from the nurse that this type of sleep pattern is adequate and normal for the patient’s age will relieve anxiety concerning sleep. Reduced caffeine levels, particularly later in the day, may be conducive to more appropriate sleep patterns. A later bedtime may promote a better night’s sleep and a feeling of being refreshed on awakening.
Behavioural management
When the older adult’s behaviours, such as agitation, resisting care and risky wandering, become problematic for health staff, the nurse needs to plan interventions carefully. Initially the patient’s physical status should be assessed, followed by assessment for changes in vital signs and urinary and bowel patterns that could account for behavioural problems. Behaviours arising from these causes can be interrupted initially by meeting the patient’s physical, emotional and social needs. If distressed behaviour persists, staff can redirect the patient’s attention to pleasurable experiences, such as encouraging participation in individual and group activities of interest to the person—for example, singing, playing or listening to music, sitting with others in a group activity, undertaking simple domestic tasks such as sorting their drawers, exercising or walking with the nurse. If the patient is agitated by the environment, either the patient or the stimulus should be moved. The patient can be assisted to phone and speak with family members if this is reassuring. If the patient resists or pulls tubes or dressings, these items can be covered with stretch tube gauze or removed from the visual field.
The older adult with behavioural problems should be reassured that the nurse is present to keep them safe. Providing physical comfort and reassurance is most effective in settling the person when they are agitated and frightened. The nurse can also orient the person to time, place and person, and ask family members to bring in recognisable personal items such as the patient’s bedspread, photos of family and pets, or a favourite cardigan or shawl, to help them to feel settled and secure. The confused or agitated person should not be asked challenging ‘why’ questions. If they cannot verbalise distress, their mood should be validated, their anticipated and expressed needs should be met and their emotional state should be closely observed. The older person’s statements and questions can be rephrased to validate their meaning, thereby assisting the nurse to provide for stated needs.
When dealing with behavioural disturbance due to cognitive impairment, the nurse’s frustration can be acknowledged. However, the nurse should always try to identify and reduce or eliminate the triggers for the behaviour, which can be caused by delirium, thirst, fear, non-recognition of the context, tiredness, pain, constipation or the urge to use the toilet. The nurse must not threaten to restrain the patient or call the doctor unless they calm down.72 If the older person’s needs cannot be identified and addressed, a close family member or friend can be asked to stay with them until they become calmer. The patient should be monitored frequently and all interventions should be documented. The use of positive nurse actions and person-centred care can reduce the use of physical and chemical (drug therapy) restraints.105
Use of restraints
Physical restraints are devices, materials and equipment that physically prevent an individual from moving freely (by choice) in the environment.8 This includes preventing the person from walking, standing, lying, transferring or sitting. Common devices include seat belts, ‘geri-chairs’, bed rails and jacket vests. Sitting an older person at a table, or placing a fixed tray in front of them that they cannot remove by themselves, also serves as a physical restraint. The restraint device, whether a chair, table, fixed tray, vest or belt, cannot be removed by the individual who is being physically restrained. Chemical and physical restraints should be a last resort in the care of the older person. The use of restraints must follow rigid and explicit criteria. There are regulatory requirements in Australia12 and New Zealand7 for restraint use, including time limits, care during restraint and restraint alternatives. Nurses working in aged care should make themselves familiar with the relevant legislative and professional requirements in relation to the use of restraints in their own country and health service.
The nurse should clearly document a restraint order and use, and the behaviours that require this intervention. It is not appropriate to use restraints on an older adult whom the nurse assumes will fall, or on a person who demonstrates irritating behaviours, such as calling out or interfering with another person’s possessions. The use of restraints makes care more time consuming and complex; restraints do not reduce falls, but they do increase potential patient confusion and the severity of injury when falls occur.88 Restraint alternatives require vigilant, creative nursing care. Restraint alternatives include wedge cushions, low beds, body props and electronic devices (bed alarm signalling). Chemical restraints can be avoided by using early interventions as discussed in the section on behavioural management.106 The use of restraints must follow rigid and explicit criteria. Nurses should be familiar with the regulations regarding the use of restraints set by the relevant legislative and professional nursing authorities. The movement to ‘restraint-free’ environments is resulting in a decline in restraint use.
Evaluation
The evaluation phase of the nursing process is similar for all patients. Evaluation is ongoing throughout the nursing process. The results of evaluation direct the nurse to continue the plan of care or revise it, as indicated. Often the change in health status is not as dramatic in the older adult as it is in the younger person. Because of this, the nurse needs to be cautious in dramatically changing plans prematurely. When evaluating nursing care with the older adult, the focus should be on functional improvement rather than cure. Useful questions to consider when evaluating the plan of care for an older adult are included in Box 5-5.
BOX 5-5 Evaluating nursing care for older adults
Evaluation questions may include the following:
1. Is there an identifiable change in ADLs, IADLs, mental status or disease signs and symptoms?
2. Does the patient identify a better health state?
3. Does the patient think the treatment is helpful?
4. Do the patient and carer think the care is worth the time and cost?
5. Can the nurse document positive changes that support interventions?
6. Does change adequately meet the required mandates for reimbursement?
ADLs, activities of daily living; IADLs, instrumental activities of daily living.
1. The impact that older adults have on the healthcare system is illustrated by the fact that:
2. Ageism is characterised by:
3. A 45-year-old person newly diagnosed with diabetes mellitus responds by telling the nurse that she must re-evaluate what things in life are most important to her and focus her activities around these priorities. This response is most consistent with:
4. When evaluating the blood pressure of an older adult, the nurse needs to know that:
5. An ethnic older adult may experience a loss of self-worth when the nurse:
6. When older adults become ill they are more likely than younger adults to:
7. Nursing interventions directed at health promotion in the older adult are primarily focused on:
8. An important nursing action helpful to a chronically ill older adult is to:
9. Delirium can be defined as:
10. An important fact for the nurse to know about carers is that they:
11. An appropriate care choice for an older adult living with an employed daughter but who requires constant assistance with activities of daily living is:
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