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Intro gerontological nursing_fall 2013 abridged
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  • Process of maturing or aging Aging is not a disease Aging brings the opportunity for usefulness, fulfillment, and joy Need for a realistic understanding of the aging process
  • What is aging or old age? Difficult to define. Aging = Any time related process beginning at conception. Chronological age – Exact age from birth; Chronological age is a marker of where we are on life’s path. Easy to measure Poor marker of health status Does not necessarily determine state of health, attitude toward daily life, or beliefs about living Chronologic age, the number of years since birth, is the simplest method of evaluating age. Although the easiest method, it is not the most effective method. For example, two people the same chronological age can function quite differently. One can be alert and independent, whereas the other is dependent and confused. Biological age - Age determined by physiology rather than chronology Changes in body’s physical structure Changes in performance of motor skills & sensory awareness Whereas the CHRONOLOGICAL AGE is the number of years a person has been alive, the BIOLOGICAL AGE is the age that most normal people would be according to certain criteria. Biological Age is calculated by asking about various health factors including hereditary disease, personal habits (smoking, overeating, alcohol), and some other basics. Then, an age is arrived at that is relevant by comparison with the chronological age. That is, if you're 44 and your biological age is 57, your health could stand improvement, because you would be a 44-year-old with the body of a 57-year-old.Of course, it can go the other way as well. Functional age – Age in terms of functional performance, ability to care for oneself (independent vs. dependent) Functional age – evaluates age in terms of functional performance. Our functional status, defined as how well we accomplish the desired tasks of daily living, is better indicative of health in older adults than chronological age. Rather than ask, “How old are you?” we should ask, “What can you do?” The functional ability of the elderly person is compared with the standard adult performance. Adults who fail to met the criteria for standard adult performance are considered “old.” Functional Assessment - A comprehensive evaluation of physical and cognitive abilities required to maintain independence; includes objective measures of physical health, activities of daily living (ADL's), instrumental activities of daily living (IADL's), and psychological and social function. Assessment of biological & functional age is preferred when assessing potential benefits from health care interactions.
  • Basic activities of daily living – Basic care activities that include: Bathing, dressing, eating, toileting, and transferring = INDEPENDENCE! Inability to perform ADLs = severe functional impairment Instrumental activities of daily living are not necessary for fundamental functioning, but enable the individual to live independently within a community: Light housework Preparing meals Taking medications Shopping for groceries or clothes Using the telephone Managing money Inability to perform IADLs = MODERATE functional impairment
  • There is no “typical” older person. Each older adult is as different as the experiences that person has encountered over a lifetime. Age 65 has long been considered the most suitable age for retirement and therefore the beginning of “old age.” In reality, age 65 is nothing more than an arbitrary age set by government for retirement with no real scientific data to support the decision. In our society, most adults are active and healthy at age 65. Rather than conforming to the stereotypical image of sitting in a rocking chair and watching the world go by, older adults are energetic, vibrant, and influential members of society. They represent a very diverse group influenced by their past experiences. For example, those of the 85 and older group are veterans of World War II and lived through the Great Depression. These individuals have little in common with those of the younger members of the aging population who were influenced by the Vietnam War, the Civil Rights Movement, and economic growth. Although older adults are diverse and dissimilar in many ways, certain common characteristics and problems are associated with aging. This and subsequent chapters seek to identify those common characteristics, problems, disease processes, and concerns of aging population. Still, when planning and implementing care for the older adult, the nurse must consider individual differences and characteristics.
  • In the 1950s and 1960s, little was known about aging. Much of the knowledge resulted form the study of diseases associated with aging. This practice resulted in the widespread idea that decline and illness were inevitable in old age. The focus of gerontology and gerontological nursing was to study, diagnose, and treat disease. However, in the last several years, the study of gerontology has moved beyond the disease focus to the improvement of health holistically, including physical, mental, emotional, and spiritual well-being. The study of aging and health is imperative if older people are to enjoy quality of life in final years. The enlightened nurse now knows that growing older is a privilege and the older person is biologically elite. Those who suffer from inherited illnesses, weak immune systems, and the inevitable damage from devastating poverty and substance abuse do not usually live to be old. Growing older is a reward and a time to be treasured and enjoyed.
  • Aging - Any time related process beginning at conception. Gerontology is holistic, encompassing more than the medical model, and involves all aspects of an older person’s life. Senescence - The period in life after reproductive activity has ceased when common, degenerative features associated with the passage of time are recognizable. Age-associated functional deficits are manifested.
  • Prevention is any activity which reduces the burden of mortality or morbidity from disease. This takes place at primary, secondary and tertiary prevention levels. Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms. Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications. A prevention or preventive measure is a way to avoid an injury, sickness, or disease in the first place, and generally it will not help someone who is already ill (though there are exceptions). For instance, many American babies are given a polio vaccination soon after they are born, which prevents them from contracting polio. But the vaccination does not work on patients who already have polio. A treatment or cure is applied after a medical problem has already started. A treatment treats a problem, and may lead to its cure, but treatments more often ameliorate a problem only for as long as the treatment is continued. For example, there is no cure for AIDS, but treatments are available to slow down the harm done by HIV and delay the fatality of the disease. Treatments don't always work. For example, chemotherapy is a treatment for cancer which may cure the disease sometimes - it does not have a 100% cure rate. Therefore, chemotherapy isn't considered a bonafide cure for cancer. Cures are a subset of treatments that reverse illnesses completely or end medical problems permanently.
  • Considered nursing’s newest and youngest specialty, geriatric or gerontological nursing has been referred to as nursing’s forgotten or little understood specialty. Care of the aged demands all the best skills known to nursing, yet gerontological nursing is a relatively new specialty. Geriatric nursing emerged as a defined area of practice only within the past 5 decades. Prior to 1950, geriatric nursing care was seen as the application of general principles of nursing to the aged client with little recognition to this area as a specialty similar to obstetric, pediatric, or surgical nursing. Content on geriatric nursing is not found in any early nursing text. In just over 50 years, gerontological care has emerged from a disregarded aspect of nursing and medicine into the foremost concern of health care in the U.S. Because there is little awareness of the breadth and depth of gerontological nursing, many nurses still mistakenly believe it to be simply a kindly attention to the bedfast old. Because of this mistaken belief, they foster a passive acceptance for some of the most complex care problems in nursing, such as mental disorientation, incontinence, and pressure sores.
  • The care of older adults is intricate and complex, encompassing three levels of complexity. The majority of older patients have two or more coexisting chronic conditions (comorbidity) and as a result, often require much more intervention and care while hospitalized than younger patients.
  • The study of geriatrics/ gerontology is a relatively new science. The first significant step in improving the lives of older adults was the passage of the Federal Old Age Insurance Law under the Social Security Act in 1935. In the 1950s and 1960s, the study of aging was based on diseases associated with aging. The emphasis, even in nursing, was on the diseases of aging and the medical model of care. The first geriatric nursing textbook was published in 1950, and with its publication came the recognition of geriatrics as a specialization within nursing. American Geriatric Society – 1942 Gerontological Society of America – 1945 American Society on Aging – 1954 In 1958, ANA issued Statement of Standards for Nursing Care in Nursing Homes.
  • In 1958, ANA issued Statement of Standards for Nursing Care in Nursing Homes. In 1966, ANA created the Division of Geriatric Nursing Practice. Nursing care of the aged  specialty status along with maternal-child, medical-surgical, psychiatric, & community health 1974 – Congress created the National Institute on Aging (NIA) as part of the National Institutes of Health. 1976 – ANA renames Geriatric Division “Gerontological” to reflect a health promotion emphasis. This is the same year that ANA publishes standards for Gerontological Nursing Practice.
  • In the past several years, the study of gerontology has moved beyond the disease focus to the improvement of health holistically. 2003 – Nurse Competence in Aging Initiative to improve the quality of health care to older adults by enhancing the geriatric competence of nurses. 2004 – ANA Scope and Standards of Practice for all registered nurses referenced to include care of older adults.
  • Advanced practice nurses make a significant difference in the care of the older adult: Improvement in quality of care Reduction in cost of care Acute care: reduction in complications, length of stay, and need for readmission
  • The older adult population is increasing more rapidly than any other age group, making gerontologic nursing an integral component of medical-surgical nursing practice.
  • Population of older Americans is exploding, increasing more rapidly than any other age group More than half the people in hospitals are 65 years or older In most nursing specialties, majority of patients  age 65 Geriatric pts are not one sub-group of pts but rather the core business of health systems. Most nurses will be involved in caring for older people. Unfortunately, less than 1% of registered nurses are certified in gerontological nursing and only 3% of advanced practice nurses (APNs) have specialized training in this area. The majority of nurses are still being educated without any specified content in geriatric nursing. There are not enough nurses in general, geriatric clinical nurse specialists, or gerontological nurse practitioners to care for the burgeoning older adult population. As the baby boomers reach their 60s, 70s, and beyond, there will be a dramatic increase in the demand for nurses. Sadly, only 1.9% of undergraduate student nurses identify working with older adults as their first career choice. Of nine nursing specialties, gerontological nursing ranks last as a career choice. Gerontological nursing in an integral component of medical-surgical nursing practice, and in most nursing specialties the majority of patients are age 65 and older. This proportion will only increase as the population continues to age.
  • In 1900, 3.1 million people, or 4 percent of the population, were 65 years or older. By 2000, the number had increased to 35 million people, an increase of more than tenfold. Presently, there are 41.4 million older Americans (65 and above) – 13.3% of the population. This is an increase of 6.3 million or 18% since 2000. Over one in every eight persons is an older American. By the year 2030, the number of older adults will grow to 72 million, which is 20% of the population. (One in FIVE!) By 2040, projected to increase to 79.7 million. By 2050, it is projected that there will be 88.5 million older adults in the U.S. Among the older population, 18.3 million people were aged 65 to 74, 12.9 million were aged 75 to 84, and 5.7 million were 85 and older. The fastest growing age group in terms of percentage of total population are those 85 and over. This is of great concern, since this demographic group is the heaviest consumer of healthcare resources. By the year 2050, the 85+ population will number 19 million. (Triple in size!)
  • Although normal aging does not imply disease, the incidence of certain diseases increases with increasing age. These conditions are termed ‘aging-associated diseases.’ Examples are cardiovascular disease, cancer, arthritis, cataracts, age-related macular degeneration, osteoporosis, type 2 diabetes, hypertension, and Alzheimer’s disease. Older adults, those at least 65 years of age, are more likely to suffer from chronic illness and impairments in function, are more likely to take multiple medicines, and, on average, are more likely to die than younger adults. Older adults (13% population) presently account for: * 60% of primary care provider office visits * 50% of hospital days * 34% of prescriptions * 38% of emergency-medical-service responses * 90% of all nursing-home use The vast baby boom generation -- the 78 million people born from 1946 to 1964, are rapidly approaching retirement age. The oldest, 2011; the youngest by 2026. As they reach old age, our retirement system and health care institutions will be strained. As the population has aged, understanding the meaning of “old age” and it’s potential consequences is critical for all nurses. Few of our nation’s current 2.2 million practicing registered nurses have received any preparation in geriatric nursing. According to a new study released by the health policy journal Health Affairs, an estimated 260,000 new and replacement nurses will be needed to take care of the burgeoning elderly population by the year 2025. Decades in have been added to peoples’ lives (in some cases 25, 30, or 40 years). We now have people commonly living into their nineties (but when they were born, the life expectancy was 50). We don’t have the healthcare workers to keep up with this increase in life expectancy.
  • Although older adults constitute the most diverse and individualized age group in the population, they continue to be stereotyped by many misconceptions that are not based on facts.
  • Ageism is a negative attitude based on age; it is the process of stereotyping and of discriminating against people because of their age. We live in a society that favors youth. Over the years, anti-aging has become a multi-billion dollar industry offering everything from creams and surgeries, to products such as Botox® and Rogaine®, and other so-called wonder treatments. Aging anxiety is related to negative stereotypes of older adults, perceptions of younger adults that these problems are likely to happen in their own future. Indicators of aging anxiety includes worrying about: Declining health, physical function, social losses and connectedness Changing physical appearance including wrinkles, receding hair lines and grey hair Declining cognitive ability Depleting financial resources While many of us make personal choices to enhance our appearance (e.g., hair coloring), that is not the issue. Our concern is when people equate aging to disease and pathology as that is incorrect. Many segments of our society hold negative attitudes toward older adults. Even many older adults have negative stereotypes about other older adults Literature suggests that negative attitudes toward the aging process and older adults themselves adversely affect the care and support provided to older people. It leads to discrimination and disparities in the care given to the older adults. Nurses need to be aware of myths/ stereotypes & to separate them from realities of aging process
  • There is a fear of aging because of the perception that disease, disability, and decline are inevitable. Myths of aging result in perpetuating negative stereotypes of aging, difficulty in recruiting good nurses, limited opportunities for rehabilitation and health promotion services to older people, and segregation of older people from mainstream society.
  • Myth: Being old means being sick Fact: Only 5% of older people live in nursing homes. Fact: Some elderly people have chronic diseases but still function quite well. Myth: Older people are set in their ways and cannot learn new things. Fact: Older people should be challenged to stay mentally active. Fact: Older people who learn to play an instrument or learn a new language are less likely to get Alzheimer’s disease. Myth: Health promotion is wasted on older people Fact: It is never too late to start good healthy lifestyle habits like eating a healthy diet and engaging in exercise. Fact: It is never too late to stop bad habits like smoking cigarettes or drinking too much alcohol. Myth: The elderly do not pull their own weight. Fact: Older people contribute greatly to society by supporting the arts, doing volunteer work, and helping with grandchildren. Fact: Pain employment is not the only measure of value and productivity.
  • The profile, interests, and health challenges of each of these subsets can be vastly different. The population over age 85 represents approximately 40% of the older population, and the number of centenarians is steadily growing.
  • The population age 85 and older is currently the fastest growing segment of the older population. In 2000, an estimated 2 percent of the population is age 85 and older. By 2050, the percentage in this age group is projected to increase to almost 5 percent of the U.S. population. The size of this age group is especially important for the future of our health care system, because these individuals tend to be in poorer health and require more services than the younger old. Projections by the U.S. Census Bureau suggest that the population age 85 and older could grow from about 4 million in 2000 to 19 million by 2050. Some researchers predict that death rates at older ages will decline more rapidly than reflected in the Census Bureau’s projections, which could result in faster growth of this population
  • U.S. population is rapidly aging Life expectancy: the length of time that a person can be predicted to live Adults over age 65 fastest growing segment of population In 1900, average life expectancy, 47.3 yrs. In 1990, life expectancy at birth was 79 years for women, and 72.1 years for men. In 2010, life expectancy of both sexes and all races 78.7 – 81.1 yrs for women, 76.2 yrs for men. Life expectancy increased by 0.1 year from 78.6 in 2009 to 78.7 in 2010. Persons reaching age 65 have an average life expectancy of an additional 20 years for females and 17 years for males. With technological advances in medicine, improved nutrition, and an emphasis on disease prevention and health promotion, and increasingly high quality of health and a longer lifespan can be attained.
  • 2.7 million turned 65 during 2011; peaks around 2025, with 4.2 million Boomers turning 65 per year. In 2011, 10,000 people turned 65 every day—and will continue to do so for the next for 20 years. By 2030, almost one out of every five Americans—some 72 million people—will be 65 years or older. By 2050, the 65+ population is projected to be between 80 and 90 million, with those 85 and older close to 21 million. Not only will there be many more senior Americans, but they’ll be living longer: individual life expectancy is increasing.
  • Public health measures are credited with much of the increase in life expectancy during the last century. A cleaner environment, in terms of improved water supplies and improved sewage disposal, together with the discovery and use of vaccines and antibiotics, contributed to the spectacular fall of infectious diseases as causes of death. Also, improvements in the transport of fruits, vegetables, and other foods led to the elimination of seasonal dietary deficiencies . General improvements in diets also contributed to the improvement in life expectancy.
  • Gender and Race Differences in Life Expectancy (in Years) Gap in life expectancy is narrowing between the sexes. Gap in life expectancy has narrowed among the races. White women 81.3 White men 76.5 Black women 78 Black men 7 Overall life expectancy: 78.7 Females: 81.1 Males: 76.2 Whites: 79 Blacks: 75.1
  • The higher survival rates of women, along with the practice of women marrying men older than themselves, make it no surprise that more than half of women older than 65 years of age are widowed, and a majority of their male contemporaries are married. Twice the number of women than men live alone in later life Most older adults live in a household with a spouse or other family member, although more than twice the number of women than men live alone in later life. The likelihood of living alone increases with age for both sexes. Most older people have contact with their families and are not forgotten or neglected.
  • Life expectancy of females has increased more rapidly than males, woman can expect to outlive men by 6-7 more years. In year 2005, life expectancy for women 80.4 yrs, as opposed to 75.2 yrs for men. In 2011, there were approximately 23.4 million women to 17.9 million men who are 65 years of age or older. Older women outnumber older men 4 to 3. As age increases, this ratio increases as well. The trend for a greater number of aging women continues and will no doubt increase in future years. The term feminization of later life describes how women predominate at older ages and how the proportions increase with advancing age. Older women greatly outnumber older men in most nations. Therefore, the study of gerontology is closely linked to the study of women’s health . These statistics bring with them potential problems: Widowhood Living alone – About 30% of older persons who reside outside of institutions live alone. 70% of these are older women. Almost half of women over the age of 75 live alone. Coping with the loss of a mate Difficulty finding another life companion Lack of a caregiver Financial problems The median income of older persons in 2011 was $27,707 for males and $15,362 for females. Households containing families headed by persons 65+ reported a median income in 2011 of $48,538. Almost 3.6 million elderly persons (8.7%) were below the poverty level in 2011. Older women who are widows are more likely to live below the poverty level. Minority women living alone have the most difficult time. Poverty rates are highest among elderly black women. Approximately 61% of elderly black women live in poverty. Hispanic women have the lowest median income. Worldwide, in most countries, females outnumber men (“female advantage”). However, India is an exception. By 2025, nearly three quarters of the world’s older women are expected to reside in what is know today as the developing world. Elderly women greatly outnumber elderly men in most nations. Therefore, the health and socioeconomic problems of the elderly are, to a large extent, the problems of elderly women.
  • Men in our society have a shorter life expectancy and die at a younger age than women. Men 75.3 – as opposed to women, 80.4 Men have higher rates of smoking, alcohol abuse, occupational hazardous exposures and violent deaths. Older men are more likely to remarry if widowed. 72% of men versus 45% of women. Only 30% of older people who live alone in the community are men – the rest are women. Widows outnumber widowers 5 to 1. Men who are widowers face problems similar to women who lose their husbands (I.e., loneliness, lack of a caregiver, and living alone). However, men often remarry and have fewer financial problems than women. Men are more likely than women to have worked 30 years or longer and to qualify for full Social Security benefits.
  • The median income of older persons in 2011 was $27,707 for males and $15,362 for females. Households containing families headed by persons 65+ reported a median income in 2011 of $48,538. Almost 3.6 million elderly persons (8.7%) were below the poverty level in 2011. Fixed income is a person's income that does not vary materially over time. This can include income derived from fixed-income investments such as bonds and preferred stocks or pensions that guarantee a fixed income. When pensioners or retirees are dependent on their pension as their dominant source of income, the term "fixed income" can also carry the implication that they have relatively limited discretionary income or have little financial freedom to make large or discretionary expenditures. As many of the elderly are finding, without a significant fixed income, living can get very challenging. The income doesn’t rise to accommodate rising prices. With people now living longer than ever before, a small fixed income can make for a person gradually sinking into poverty and being unable to live in manner they're accustomed to. Simple things like the rise in the price of gasoline can significantly affect the person with a small fixed income, making it impossible or challenging to travel, or to even take small necessary trips to grocery stores or to doctor’s offices. Asset rich and cash poor –Homes are paid for but there is not enough money available for monthly expenses. All your money is tied up in things that are not easy to convert to cash. The assets of a person are all the things that he or she owns. Too much wealth is tied up in a house, real estate property, etc. Cash poor means the person doesn’t have a lot of cash flow. All the money is tied up in things that don’t produce an income. Median net worth of older households is nearly twice the national average because of the high prevalence of home ownership, but many older adults are “asset rich and cash poor”−they live in a house that has appreciated in value over the years, but they barely have sufficient monthly income to meet basic expenses. Social Security constituted 90% or more of the income received by 36% of beneficiaries in 2010. (23% of married couples and 46% of non-married beneficiaries). Social Security replaces about 40% of an average wage earner’s income after retiring, and most financial advisors say retirees will need 70% or more of pre-retirement earnings to live comfortably. To have a comfortable retirement, Americans need much more than just Social Security. They also need income from private pensions, savings, investments, or continued part-time employment. For nearly 40% of older adults, Social Security provides the main source of their income. The large majority of beneficiaries have other income from a pension, savings, or continued part-time employment. The major sources of income as reported by older persons in 2010 were Social Security (reported by 86% of older persons), income from assets (reported by 52%), private pensions (reported by 27%), government employee pensions (reported by 15%), and earnings (reported by 26%). Older women who are widows are more likely to live below the poverty level. Minority women living alone have the most difficult time. Poverty rates are highest among elderly black women. Approximately 61% of elderly black women live in poverty. Hispanic women have the lowest median income.
  • 65 years of age and older population in North Carolina: 1,278,786 (13.2% of the population). Older population grew by 31.67% from 2000 to 2011. North Carolina's senior population is growing faster compared with other states, and is expected to reach more than 1.6 million in the year 2020. The state is estimated to rise in ranks, in terms of states with the highest percentage of senior adults, from 31st to 11th by 2025.
  • North Carolina: Increase in senior population 31.67% from year 2000 to 2011
  • The older population experiences fewer acute illnesses (mainly infectious diseases) than younger age groups and a lower death rate from these problems. However, older people who do develop acute illnesses usually require longer periods of recovery and have more complications from these conditions.
  • Although normal aging does not imply disease, the incidence of chronic diseases increases with increasing age. Chronic diseases are more common than acute illnesses in the older age group. Older adults, those at least 65 years of age, are more likely to suffer from chronic illness and impairments in function, are more likely to take multiple medicines, and, on average, are more likely to die than younger adults. Chronic illness (I.e., sickness of a long duration showing little change or slow progression) is a major concern for the older adult. Approximately 80% of older adults have at least one chronic illness, such as heart disease, cancer, diabetes, arthritis, hypertension, or Alzheimer’s. The majority suffer from two or more chronic illnesses (comorbid). The incidence of chronic illness complicates care and makes nursing care an integral part of the health care of the older adult. Chronic illnesses are likely to cause disabilities, robbing the elderly of quality of life, rendering them less productive and running up huge bills for medical care. More than 80 percent of health care spending is for people with chronic conditions. Health expenditures are already skyrocketing and are expected to reach $16 trillion by 2030. To combat the effects of chronic illness, the elderly are challenged to reach their highest functional capacity. An emphasis on developing healthy lifestyles and the presence of health maintenance programs assist the elderly to deal with the impact of chronic illness. The only current defense between this growing “age wave” and an already overburdened health care system is the hope that medical research breakthroughs and new technologies can remake the experience of chronic disease—and remake it quickly. ,
  • Chronic illness is a major problem for the older population. Chronic disease is not caused by aging, but the incidence increases with increasing age. Most older adults have at least one chronic medical conditions, and typically they have several chronic conditions that must be managed simultaneously. Infectious diseases were the major cause of death early in the 20 th century. Medical technology has helped many people survive illnesses that once would have killed them; greater numbers of people are reaching old age, in which the incidence of chronic disease is higher. The chronic disorders most prevalent in the older population are ones that can have a significant impact on independence and the quality of daily life. The manner in which a chronic condition is managed can make the difference between a high-quality satisfying life and one in which the person is prisoner to a disease.
  • Chronic conditions most prevalent in older adults are those that can impact independence and quality of life.
  • “ A” The ten leading chronic conditions affecting the population age 65 and older are: arthritis, high blood pressure, hearing impairments, heart conditions, visual impairments, deformities or orthopedic impairments, diabetes, chronic sinusitis, allergic rhinitis, and varicose veins.
  • True. Chronic illness is a major problem for the older population and results in limitations in ADLs, IADLs, and quality of life.
  • 7 out of 10 deaths among Americans each year are from chronic diseases. Heart disease, cancer and stroke account for more than 50% of all deaths each year. In 2005, 133 million Americans – almost 1 out of every 2 adults – had at least one chronic illness. Obesity has become a major health concern. 1 in every 3 adults is obese3 and almost 1 in 5 youth between the ages of 6 and 19 is obese (BMI ≥ 95th percentile of the CDC growth chart). About one-fourth of people with chronic conditions have one or more daily activity limitations. Arthritis is the most common cause of disability, with nearly 19 million Americans reporting activity limitations. Diabetes continues to be the leading cause of kidney failure, nontraumatic lower-extremity amputations, and blindness among adults, aged 20-74. Excessive alcohol consumption is the third leading preventable cause of death in the U.S., behind diet and physical activity and tobacco.
  • Chronic diseases are not only major sources of disability, but they are the leading causes of death. Discuss three levels of complexity – acute exacerbations of chronic age-related conditions are major cause of death in the older adult population. In 1900 the five major causes of death were: (1) pneumonia and in fluenza , (2) tuberculosis , (3) diarrhea and intestinal disease, (4) heart disease , and (5) stroke. How things have changed in a century! A cleaner environment, in terms of improved water supplies and improved sewage disposal, together with the discovery and use of vaccines and antibiotics, contributed to the spectacular fall of infectious diseases as causes of death. Also, improvements in the transport of fruits, vegetables, and other foods led to the elimination of seasonal dietary deficiencies . General improvements in diets also contributed to the improvement in life expectancy. Due to these spectacular improvements in public health etc, the major causes of death have changed from acute illness to chronic illness.
  • “ A”
  • Health promotion activities are actions taken to enhance the quality of life. It is an interactive and multidimensional process. Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health.  Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health, along the illness-wellness continuum.  Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices.  According to Mark Twain, the 19th century American novelist and social observer, "The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not." This is certainly as succinct a view of most of our patients' feelings about health promotion. The nurse needs to diligently work to overcome this unproductive perception. A lot of healthcare workers also believe that health promotion activities are wasted on the elderly. This is a form of ageism. Functional health in the elderly, for instance, can be greatly enhanced by health promotion activities. Health promotion interventions are important to help older adults achieve a sense of well-being. The purpose of health promotion and disease prevention is to reduce the years of life lost to premature mortality and ensure better quality of remaining life. As Americans live longer, it is suggested that health promotion activities are all the more important because these individuals will have more years to benefit from preventive services. Americans can improve their chances for a healthy old age (long life AND good life) by simply taking advantage or recommended preventive health services and by making healthy lifestyle changes.
  • The vision, mission, and overarching goals provide structure and guidance for achieving the Healthy People 2020 objectives. While general in nature, they offer specific, important areas of emphasis where action must be taken if the United States is to achieve better health by the year 2020. Developed under the leadership of a Federal Interagency Workgroup, the Healthy People 2020 framework is the product of an exhaustive collaborative process among HHS and other Federal agencies, public stakeholders, and the Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Vision A society in which all people live long, healthy lives. Mission Healthy People 2020 strives to: Identify nationwide health improvement priorities; Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; Provide measurable objectives and goals that are applicable at the national, state, and local levels; Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; Identify critical research, evaluation and data collection needs. Overarching Goals Attain high quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development and healthy behaviors across all life stages.
  • Healthy People 2010 is a prevention agenda for the nation with the following major goals: to increase quality and years of healthy life and to eliminate health disparities. Healthy People 2010 is the nation’s comprehensive health promotion agenda for the first decade of the twenty-first century.  It identifies the most significant preventable threats to health and establishes national benchmarks to reduce these risks.  It consists of two major goals, 28 focus areas, and 467 broad-reaching health objectives to serve as a road map for improving the health of all people in the United States (US). The major goals of Healthy People 2010 are to increase years and quality of healthy life, and to eliminate health disparities, including differences that occur by race or ethnicity. In 2010, the Healthy People 2020 objectives will be released along with guidance for achieving the new 10-year targets.
  • Healthy People 2010 is a prevention agenda for the nation with the following major goals: to increase quality and years of healthy life and to eliminate health disparities. Healthy People 2010 is the nation’s comprehensive health promotion agenda for the first decade of the twenty-first century.  It identifies the most significant preventable threats to health and establishes national benchmarks to reduce these risks.  It consists of two major goals, 28 focus areas, and 467 broad-reaching health objectives to serve as a road map for improving the health of all people in the United States (US). The major goals of Healthy People 2010 are to increase years and quality of healthy life, and to eliminate health disparities, including differences that occur by race or ethnicity. In 2010, the Healthy People 2020 objectives will be released along with guidance for achieving the new 10-year targets.
  • About 70% of the physical decline that occurs with aging is related to modifiable factors: smoking, poor nutrition, physical inactivity, and failure to use preventive and screening services. Chronic illnesses most commonly experienced by older persons in US – arthritis, hypertension, heart disease, cancer, COPD, stroke, diabetes Although they are treatable, the leading chronic diseases are not curable and result in a great burden from disability and diminished quality of life. They cause major limitations in activity for many millions of people. The government insurance program that covers almost all older adults in the United States -- Medicare -- did not recognize the value of preventive interventions until recently. Medicare coverage of preventive services has expanded dramatically over the past few years with passage of the Affordable Care Act. Non-modifiable risk factors? Heredity, gender
  • About 70% of the physical decline is modifiable through healthy lifestyle changes. The challenge for nurses is to encourage healthy lifestyles. What sorts of conditions can be affected through healthy lifestyle changes? Decreases in blood pressure, serum cholesterol & lipids, normalization of blood glucose, loss of weight CDC: Four Common Causes of Chronic Disease Four modifiable health risk behaviors—lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption—are responsible for much of the illness, suffering, and early death related to chronic diseases. More than one-third of all adults do not meet recommendations for aerobic physical activity In 2007, less than 22% of high school students 10 and only 24% of adults 11 reported eating 5 or more servings of fruits and vegetables per day. More than 43 million American adults (approximately 1 in 5) smoke. 12 Lung cancer is the leading cause of cancer death, and cigarette smoking causes almost all cases. Compared to nonsmokers, men who smoke are about 23 times more likely to develop lung cancer and women who smoke are about 13 times more likely. Smoking causes about 90% of lung cancer deaths in men and almost 80% in women. Smoking also causes cancer of the voicebox (larynx), mouth and throat, esophagus, bladder, kidney, pancreas, cervix, and stomach, and causes acute myeloid leukemia. 14 Excessive alcohol consumption contributes to over 54 different diseases and injuries, including cancer of the mouth, throat, esophagus, liver, colon, and breast, liver diseases, and other cardiovascular, neurological, psychiatric, and gastrointestinal health problems. 15
  • Modifiable: Overweight and obesity High blood glucose High blood pressure Unhealthy cholesterol and lipid levels Physical inactivity Smoking Non-modifiable: Age Race & ethnicity Gender Family history
  • Chronic conditions usually develop over long periods of time and can even start at about age 20. Thus nurses and other health professionals have ample opportunity to screen, detect, educate, and intervene. The disease process may be altered or change course with a resultant increase or decrease in symptoms. The actions that older persons, families, and healthcare professionals take can alter and change the course of chronic illness. Nurses should encourage older adults to make healthy lifestyle changes, and take advantage of preventive health services. Nurses have the opportunity to intervene using the three levels of prevention designated as Primary, Secondary, and Tertiary. Primary prevention – Activities directed toward the protection from or avoidance of potential health risks Secondary prevention – Activities designed for early diagnosis and treatment of disease or illness Tertiary prevention – Activities designed to restore disabled individuals to their optimal level of functioning. Reduces degree and quality of injury, disability, and damage following a disease, illness, disaster, or crisis.
  • Women who reach the age of 65 can expect to live another 19 years, while men can expect to live another 16. This increase in life expectancy has been attributed to improved healthcare, increased use of preventive services, and healthier lifestyles. Nurses should be aggressive in health promotion efforts and rehabilitation after surgery or illness, because the 65-year-old man or woman has the potential for 16 to 19 years of additional life. It can be a time of significant health or significant disability. The challenge for nurses and other healthcare professionals is to encourage people at all stages of life to reduce their chances of disability and chronic illness by undertaking healthy lifestyle changes. This strategy will improve quality of life, delay disability, and increase the number of healthy years an older person is expected to live. Older adults are more likely to suffer from chronic illness and impairments in function, are more likely to take multiple medicines, and, on average, are more likely to die than younger adults. Because of these factors, health promotion and disease prevention activities often are forgotten or overlooked. Promoting the health of older adults is not simply a matter of taking existing adult guidelines and blindly using them. Recommendations should be specific to the geriatric population. Americans can improve their chances for a healthy old age by simply taking advantage of recommended preventive health services and by making healthy lifestyle changes. 70% of physical decline that occurs with aging is related to modifiable factors such as smoking, poor nutrition, lack of physical activity, injuries from falls, and failure to use Medicare-covered preventive services. Older people should be educated regarding the need to start exercise programs, stop smoking, and engage in other healthy behaviors. This strategy will improve quality of life, delay disability, and increase the number of healthy years an older person is expected to live – Healthy People 2010 goal of increase quality & quantity of healthy life.
  • Primary prevention focuses on keeping an illness, disease, crisis, or disaster from happening. The nurse promotes health in the older adult by teaching healthy behaviors. Older adults get the same benefits from health teaching as young adults and middle adults; they should never be viewed as “too old” for healthy living practices. However, nurses should structure teaching activities to meet age-related physiologic changes, such as using charts and literature with large print. Health education for the older adult is provided in hospitals, long-term care facilities, retirement centers, outpatient clinics, senior citizen centers, and other community settings. Examples: Educational seminars about accident prevention in the home, in automobiles, and when taking public transportation. Community programs provide immunization for influenza and pneumonia. Approximately 50,000 adults die each year from vaccine-preventable diseases in the U.S.  Pneumonia and influenza are the fifth leading cause of death in older adults in the U.S.  There are over 200,000 hospitalizations from influenza on average every year. An average of 36,000 Americans die annually due to influenza and its complications – most are people 65 years of age and over. The best way to prevent the flu is to get vaccinated each year during the fall season. Because flu viruses change from year to year, it is important to get a flu shot each year. There are over 40,000 cases of invasive pneumococcal disease in the U.S. and approximately one-third of these cases occur in people 65 and older. Over half of the more than 5,000 annual deaths from invasive pneumococcal disease occur in persons 65 years of age and older. Medicare covers one pneumococcal vaccination for all Medicare beneficiaries. One vaccine at age 65 generally provides coverage for a lifetime, but for some high risk persons, a booster vaccine is needed. Medicare pays for the influenza immunization or "flu vaccine" and one pneumococcal vaccination for all Medicare beneficiaries. Medicare will also cover a booster vaccine for high risk persons if 5 years have passed since their last vaccination. Literature is available about financial assistance for health care, crisis hot lines, community services and resources, transportation, and nutrition. In particular, older adults should optimize their intake of fiber, calcium, and vitamin D. Ideally, these individuals should try to eat 24 grams of fiber and take 1500 mg of calcium and 800 IU of vitamin D daily.
  • Common examples of carcinogens are inhaled asbestos, cigarette smoke, benzene, formaldehyde, nitrosamines, acrylamide.
  • Secondary prevention (health maintenance) – detection of diseases at early stage (where there are not yet any signs or symptoms or functional impairment). Prevents full-blown disease emergence. The goal of secondary prevention is to limit disability and stop disease progression at a much more treatable stage. These preclinical conditions are most often detected by disease screening (and follow-up of the findings). Examples of screening procedures that lead to the prevention of disease emergence include the Pap smear for detecting early cervical cancer, routine mammography for early breast cancer, sigmoidoscopy for detecting colon cancer, periodic determination of blood pressure and blood cholesterol levels, and screening for high blood-lead levels in persons with high occupational or other environmental exposures. Important components of health maintenance practices include being knowledgeable about self-care, and participating in screening. Health screenings and information from health fairs can specifically aid the older adult.
  • Tertiary prevention involves reducing the degree and quality of injury, disability, and damage following an illness, disease, disaster or crisis. This includes disaster relief following a catastrophic natural event such as Hurricane Katrina. Tertiary prevention for a person who has had a stroke may involve taking aspirin to prevent a second stroke from occurring. Tertiary prevention can involve providing supportive and rehabilitative services to prevent deterioration and maximize quality of life, such as rehabilitation from injuries, heart attack, or stroke. It also includes preventing complications among people with disabilities, such as preventing bed sores in those confined to bed. The best strategy for the control of diagnosed chronic disease in the older adult is to employ tertiary prevention and attempt to slow the progression of the illness and prevent or reverse disabling loss of function.
  • “ D”
  • “ B”
  • B
  • “ C”
  • “ A”
  • People are living longer today, but is the prolongation of life into old age always a benefit? Or have recent gains in longevity instead been a prolongation of decrepitude and frailty? Will further medical advances only make matters worse? This question was raised nearly three centuries ago by Jonathan Swift in his novel Gulliver’s Travels (1726). Swift described a voyage to the fictional country of Luggnagg, where his here, Lemuel Gulliver, meets a strange group of beings, the “Struldbruggs,” who are a race condemned to immortality. It turns out for the Struldbruggs, unlimited lifespan has not proved the blessing it promised to be. Longevity has come, but without good health. Their existence is a dismal prolongation of decline and decay, a nightmare like unlimited existence in a nursing home, as Swift describes them: “ They were the most mortifying sight I ever beheld… Besides the usual deformities in extreme old age, they acquired an additional ghastliness in proportion to their number of years, which is not to be described… The diseases they were subject o still continue without increasing or diminishing. In talking they forget the common appellation of things, and the names of persons, even of those who are their nearest friends and relations… The least miserable among them appear to be those who turn to dotage, and entirely lose their memories. The question therefore is not whether a man would choose to be always in the prime of youth, amended with prosperity and health, but how he would pass a perpetual life under all the usual disadvantages which old age brings along with it. Could medical breakthroughs have unforeseen consequences for society, either for good or for ill? If more and more members of the population live into advanced old age, we will see growing numbers of frail, chronically ill elderly in need of long-term care, at home or in institutions. Compression of mortality: delaying or compressing the years in which serious illness and decline occur so that an extended life expectancy results in more functional, healthy years Compression of morbidity hypothesis – looks forward to greater numbers of people who postpone the age of onset of chronic infirmity. In other words, we would aim for a healthy old age, followed by rapid decline and death. Sickness or morbidity would be compressed into the last few years or months of life.
  • The goals of geriatric assessment are to maintain health and health maintenance practices; minimize hospitalizations; examine areas that are frequently overlooked, including hearing impairment, vision deficits, early dementia, depression, poor nutrition, and falls. Geriatric evaluation can be conducted in Acute care hospital settings Outpatient ambulatory clinics Home settings Various settings of the long-term care system Underlying principles of comprehensive geriatric assessment include Physical, psychological, and socioeconomic factors The coordinated efforts of various healthcare professionals
  • Functional ability refers to one’s ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting. Functional ability also incorporates an older adult’s physiological and psychologic status and the physical and social environment. A functional assessment includes three overarching domains: activities of daily living, instrumental activities of daily living, and mobility. A functional evaluation should be systematic, with attention paid to the particular needs of the person, such as the presence of pain, fatigue, shortness of breath, or memory problems. There are tow approaches to use for performing a functional assessment, asking individuals about their abilities to perform the tasks (using self-reports) or actually observing their ability to perform the tasks. For persons with memory problems, the use of surrogate reporters (proxy reports) such as family members of caregivers may be necessary, keeping in mind that they may either overestimate or underestimate the actual abilities. The assessment of function is an important geriatric tenet to provide a baseline for continuing comparison, to predict prognosis, and to assist the practitioner with objective measures to determine efficacy of treatments. Just knowing the person’s medical diagnosis is not sufficient to predict functional abilities. Older adults may not experience the usual symptoms of an acute illness. Often a decline in functional status may herald the presence of another process such as an infection. A functional assessment of an older adult is the basis for care planning, goal setting, and discharge planning. A functional assessment also is needed for eligibility to obtain many services such as durable medical equipment, home modifications, and inpatient or outpatient rehabilitation services. For an older adult and family, a functional assessment can identify areas for current and future planning, such as the most appropriate living situation.
  • Nursing diagnoses of older client will be as varied as clients themselves Client status may change frequently, so reevaluation of nursing diagnoses on regular basis is warranted
  • 1. Gerontological nurses need to communicate effectively with older patients who possess a variety of physical and cognitive impairments in order to develop the therapeutic relationship with the patient. 2. Communication is an ongoing, continuous, dynamic process including verbal and nonverbal signals.
  • 3. Nonverbal communication is thought to compose 80% of the communication process and includes body language, such as position, eye contact, touch, and facial expression.  

Intro gerontological nursing_fall 2013 abridged Intro gerontological nursing_fall 2013 abridged Presentation Transcript

  • 1Introduction toGerontological NursingNURS 4100 Care of the Older AdultFall 2013Joy Shepard, PhD(c), MSN, RN, CNE, BC
  • 2Objectives Explain different ways older adults are viewed incontemporary society Describe major characteristics of today’s olderpopulation Discuss projected demographic changes in futuregenerations of older people and the implications forhealth care Describe the nursing process in care of older adults Discuss standards, major roles, principles, and futurechallenges for gerontological nurses
  • 3"Old age is like everything else.To make a success of it youvegot to start young." TheodoreRoosevelt"Anyone who stops learning isold, whether at twenty oreighty."Henry Ford
  • 4Aging: A Natural Process…NOT a disease!
  • 5Defining Old AgeChronological age – Exact agefrom birthBiological age - Age determined byphysiology rather than chronologyFunctional age – Age in terms offunctional performance
  • 6Activities of Daily Living (ADLs) Basic: Bathing (hygiene,grooming) Dressing Eating Toileting Transferring(mobility) Instrumental: Light housework Preparing meals Taking medications Shopping forgroceries or clothes Using the telephone Managing money
  • 7
  • 8Characteristics of AgingPopulation “Typical” older person? Age 65 start of “oldage?” Energetic, vibrant,influential, diverse Gerontology - identifiescommoncharacteristics,problems, diseaseprocesses, & concerns Nurse must considerindividual differences &characteristics whenplanning & implementingcare
  • 9Gerontological Nursing “The purpose of gerontological nursing isnot to save lives, but to prevent untimelydeath and needless suffering. Both thesegoals include respect for human dignity –the preservation of personhood as long aslife continues.” -Doris Schwartz, 1989
  • 10Definition of Terms Ageism - Prejudice, negative stereotyping basedsolely on age Geriatrics - Branch of medicine that deals withproblems & diseases of old age, aging people Gerontology – Comprehensive, multidisciplinarystudy of aging process & problems of older peoplewith holistic focus, including biologic, sociologic,psychological, spiritual, & economic issues Graying of America – Increased number olderadults in US Senescence - Process of aging within cells andorgans accompanied by loss of organ function
  • 11Definition of Terms Primary prevention – Activities directedtoward the protection from or avoidance ofpotential health risks Secondary prevention – Activities designedfor early diagnosis & treatment of diseaseor illness Tertiary prevention – Activities designed torestore disabled individuals to their optimallevel of functioning
  • 12Gerontological Nursing:Specialty Area Nursing – caring for the vulnerable Gerontological nursing – newest &youngest, most rapidly growing nursingspecialty ‘Nursing’s forgotten… little understoodspecialty’ Challenging practice areas: complex In just 50 yrs…. foremost concern of health care
  • GerontologyGerontology: ComplexComplex FieldEncompassing ThreeThree Levels of Complexity 1. Normal agingchanges 2. Chronic conditionsassociated with aging 3. Acuteexacerbations ofchronic conditions13
  • 14Development ofGerontological Nursing 1904: First article on care of the aged publishedin the American Journal of Nursing 1914: Dr. I. L. Nascher—“Father of Geriatrics”—first geriatric textbook 1935: Federal Old Age Insurance Law, or SocialSecurity 1950 – First geriatric nursing textbook 1962: First meeting of the ANA’s ConferenceGroup on Geriatric Nursing Practice
  • 15Development ofGerontological Nursing 1965: formation of the Administration on Aging,Older Americans Act, Medicare, & Medicaid 1966: Division of Geriatric Nursing—gerontological nursing as a nursing specialty 1976 – Professional Standards forGerontological Nursing Practice (ANA)– Certification – geriatric nurses– 1stcertification program by ANA
  • 16Development ofGerontological Nursing Growth in the last few decades– Increase in gerontological nursing texts– Increase in journal articles– Gerontological nursing education– Certification in gerontological nursing– Subspecialization– Hartford Institute for Geriatric Nursing
  • 17Advanced Practice NursingRoles Gerontological Clinical Nurse Specialist Gerontological Nurse Practitioner Preparation: unique principles, best practicesfor older adult– Broad knowledge base– Capacity for independent practice– Leadership– Complex clinical problem-solving abilities
  • Programs Adult-Gerontology Nurse Practitioner– ECU College of Nursing (Online) Adult-Gerontology Nurse Practitioner– UNC-Chapel Hill School of Nursing Adult Gerontological Nurse Practitioner Concentration– UNC-Greensboro School of Nursing Gerontological Nurse Practitioner– Duke University School of Nursing Adult-Gerontology CNS &Adult-Gerontology Critical Care CNS– Rush University (Online)
  • 19In Great Demand… Challenges for thefuture– Gerontologicalnursing as adynamic specialty– Multitude ofopportunities– Development of newpractice models
  • 20Geriatric Patients… TheCore Business of HealthCare
  • 21An Aging Population Increased #’s older people, particularly “old-old” 41.4 million older adults in 2011 – 13.3% ofthe population By 2030, adults ≥ 65 years, 20% ofpopulation 5.7 million 85+ population– 2040: 14.1 million– 2050: 19 millionSource: A Profile of Older Americans
  • 22
  • 23An Aging Population As the aging population expands, it will affectall aspects of society (esp healthcare) Currently 13.3% of U.S. population; consumedisproportionate amount of healthcareresources Aging-associated diseases – complicationsarising from senescense 2025: need an extra 260,000 full-time nurses totake care of aging populationSource: A Profile of Older Americans
  • 24Myths & Stereotypes of Aging
  • 25Ageism Prejudice towards anyage group Defined as “theprejudices andstereotypes that areapplied to older peoplesheerly on the basis oftheir age….”
  • True or False???To be old is to be sick?
  • 27Myths & Stereotypes of Aging Many cultures: older people accorded respect American society is youth-driven– Aging synonymous with death– Younger individuals – negative view of agingprocess– Fear & lack of exposure to older individualscontribute to ageism Older adults stereotyped: ill, bald, hard ofhearing, forgetful, rigid, grumpy, or boring
  • 28Myths of Aging “You can’t teach an old dog newtricks” “Dirty old man” Disease & disability are inevitablepart of aging Health promotion is wasted onolder people Elderly do not pull their ownweight Most people spend their lastyears in nursing homes
  • 29Myths of Aging Senility is a result of aging Incontinence is a result ofaging Older adults are no longerinterested in sexuality All elderly persons arefinancially impoverished
  • 30*Realities of Aging*
  • 31Myths of Aging Lead to: Ageism Reduced healthcare services Segregation of elders from mainstream society Nurse recruitment difficulties Health professionals must be diligent inavoiding age prejudice, as believingstereotypes can influence interactions betweenolder adults & caregivers
  • 32The Older Adult Population
  • 33Subsets of the Older AdultPopulation Young-old: 65-74 yrs Middle-old: 75-84 yrs Old-old: 85-100 yrs Centenarians: 100+ yrs Diversity rather thanhomogeneity
  • The Graying of the Population34
  • 35Number of Old and Old-Old
  • Distribution of the Projected OlderPopulation by Age for the US: 2010 to 2050
  • 37An Aging Population -Increased Life Expectancy Older adults currently 13% of U.S. population By 2030 – 20% of population Increasing life expectancy:– 1900: 47.3 years– 1930: 59.7 years– 1965: 70.2 years– Present: 78.7 years (2010)– 2050: projected to be 82.6 yrshttp://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf
  • 38First Wave of 76 Million BabyBoomers Started Turning 65in 2011!
  • 39Age Distribution of U.S.Population
  • 40Factors Influencing IncreasedLife Expectancy Advancements in disease control & healthtechnology (esp. vaccines & antibiotics) Lower infant & child mortality rates Improved sanitation (clean water & sewagedisposal) Better living conditions
  • 41Life Expectancy: Race andGender Gap between women& men (narrowing) Gap between Whites& Blacks (narrowing)– Societal issues– Concern for nursesGender /RaceWhites Blacks TotalFemales 81.3 78.0 81.1Males 76.5 71.8 76.2Total 79 75.1 78.7http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf
  • 43Marital Status & LivingArrangementsWomen more likely to be widowed,living alone in old ageMore than half of women ≥ 65 arewidowedOlder men more likely to be married Potential for living alone increases with age
  • 44Aging Women Women outlive men, outnumbermen 4 to 3– Feminization of later lifeWomen predominate at older ages,proportions increase with advancingage– Health & socioeconomic problemsof elderly = problems of elderlywomen Study of gerontology – closely linked tostudy of women’s health Potential problems:– Widowhood– Living alone– Poor– Coping with loss of mate– Difficulty finding anotherlife companion– Lack of a caregiver– Financial problems
  • Gender Distribution of ElderlyAmericans, by Age Group, 2010
  • 46Aging Men Shorter life expectancy,die at younger age More likely to remarry ifwidowed– Widows outnumberwidowers 5 to 1 Fewer financialproblems than women– More likely to have worked 30years or longer, qualify for fullSocial Security benefits
  • 47
  • Marital Status of Older Adults48
  • 49Income of Older Adults 8.7% live below poverty level “Fixed” income “Asset rich and cash poor” – What does thismean? Median net worth twice national average relatedto home ownership Dependent on Social Security for more than halfof their income Women & minority groups poorer than whitemen
  • Geographic Distribution: OlderAdults Greatest number(percentage wise):Florida, Maine, WestVirginia, Pennsylvania,Montana Dramatic increases inpast decade: Alaska,Nevada, Arizona,Idaho, Georgia Lowest percentage:Alaska, Utah, Texas,Georgia, Colorado North Carolina? 50
  • 51
  • 52Illness in the Older Population
  • 53Health Status of Older Adults:Acute Conditions (p. 8)Relatively fewer acute illnesses (i.e.,infections & parasites, colds, orinfluenza)Lower death rates from acute illnessesAfter an acute illness…– Longer period of recovery– More complications
  • 54Illness in the Older Population Chronic illness – major concern for older adult Chronic illnesses – cause disabilities, complicatecare, need skilled nursing care 80% – at least one chronic illness (i.e., heartdisease, diabetes, arthritis, or hypertension) Many elderly people with two or more chronicillnesses (comorbid) Comorbidity: the presence of multiple chronicconditions simultaneously Challenge: reach highest functional capacity
  • 55Health Status of Older Adults:Chronic ConditionsChronic Conditions Major problem: increaseswith age Most have at least onechronic disease; manyhave several (comorbidity) Comorbidity: the presenceof multiples chronicconditions simultaneously Result: limitations in ADLs& IADLs Leading cause: disability &death
  • 56Leading Chronic Conditions(Box 1-3, p. 8) 1. Arthritis 2. Hypertension 3. Hearingimpairments 4. Heart conditions 5. Visual impairments 6. Orthopedicimpairments
  • QuestionThe leading chronic conditionassociated with older adults is: (A) Arthritis (B) Diabetes (C) Hearing impairments (D) Hypertension (E) Orthopedic impairments
  • 58Question Is the following statement true or false? Chronic disorders most prevalent in theolder adult population are ones that canhave a significant impact on independenceand the quality of life
  • CDC: Chronic Diseases are LeadingCauses of Death & Disability in U.S.*7 of 10 deaths each year are from chronic diseases*1 of 2 adults (of all ages) at least 1 chronic illness*Obesity: major health concern: 1 in 3 adults*One-fourth of people with chronic conditions: At leastone ADL limitation*Arthritis: most common cause of disability: 19 millionAmericans report ADL limitationhttp://www.cdc.gov/chronicdisease/overview/index.htm#159
  •  Heart diseaseHeart disease Malignant neoplasms (cancer)Malignant neoplasms (cancer) Chronic lower respiratory dz (COPD)Chronic lower respiratory dz (COPD) Cerebrovascular dz (stroke)Cerebrovascular dz (stroke) Alzheimer’s diseaseAlzheimer’s disease Diabetes mellitusDiabetes mellitus Influenza/ pneumoniaInfluenza/ pneumonia Nephritis, nephrotic syndrome, nephrosis Accidents Septicemia 60Leading Causes of Death forPersons 65 Yrs of Age & Older(Table 1-3, p. 9)
  • http://www.cdc.gov/nchs/data/databriefs/db64.pdf
  • 63Question When planning a course about mortality rates fora group of elderly clients, emphasis should begiven to which of these topics because it is theleading cause of death for ages over 65?– A. Heart disease– B. Cancer– C. Infectious diseases– D. Accidents
  • 64Health Promotion & DiseasePrevention
  • 65Health Promotion Health promotion: “the science and art of helping peoplechange their lifestyle to move toward a state of optimalhealth" (American Journal of Health Promotion, 1986) Multidimensional, enhances wellness, self-actualization &individual fulfillment (Pender, 2002) Purpose:– Help older adults achieve a sense of well-being– Reduce premature mortality, enhance quality of lifeThe Health ContinuumBalance of physical, emotional, social, spiritual, and intellectual health
  • Healthy People 2020 Vision: A society in which all people live long, healthy livesA society in which all people live long, healthy lives Overarching Goals: Attain high quality, longer lives free of preventabledisease, disability, injury, and premature death Achieve health equity, eliminate disparities, and improvethe health of all groups Create social and physical environments that promotegood health for all Promote quality of life, healthy development and healthybehaviors across all life stages
  • 67Proposed Healthy People 2020 Goalsfor Older Adults Reduce the proportion of older adults who have moderate tosevere functional limitations. (Developmental) Reduce the proportion of unpaid caregivers ofolder adults who report an unmet need for caregiver supportservices. (Developmental) Increase the proportion of older adults with oneor more chronic health conditions who report confidence inmanaging their conditions. (Developmental) Reduce the proportion of noninstitutionalizedolder adults with disabilities who have an unmet need for long-term services and supports.
  • 68Proposed Healthy People 2020 Goalsfor Older Adults Cont’d… Reduce the rate of pressure ulcer-related hospitalizations amongolder adults. Increase the proportion of the health care workforce with geriatriccertification. Increase the number of States and Tribes that publicly reportelder maltreatment and neglect. Increase the proportion of older adults with reduced physical orcognitive function who engage in light, moderate, or vigorousleisure-time physical activities. Reduce the rate of emergency department visits due to fallsamong older adults.Healthy People 2020: The Road Ahead
  • 6970% Physical Decline due toModifiable Risk FactorsInactivityPoor nutritionTobaccoAlcohol Lack of preventivecare
  • 7070% Physical DeclineModifiable Through Physical activity Improved nutrition Smoking cessation Alcohol in moderation Prevention of injuries fromfalls Improved use Medicare-covered preventive services
  • 71QuestionName modifiable risk factors forphysical decline and illness in olderadults…Name non-modifiable risk factors forolder adults…
  • 72Health Promotion & DiseasePrevention Chronic conditions developover time Older adults must bealerted to means ofpreventing disease andreducing risks Important components ofhealth maintenance:– Knowledge of self-care– Participating in screeningtests Nurses intervene usingthree levels of prevention– Primary– Secondary– Tertiary
  • 73Health Promotion and DiseasePrevention Nurses should be aggressive in health promotion efforts Older adults must be alerted to means of preventingdisease & reducing risks– Take advantage preventive health services– Make healthy lifestyle changes Preventive care: most effective strategy to reducerisk of disability & chronic illness– HP 2020 goal: “Attain high quality, longer lives free ofpreventable disease, disability, injury, and prematuredeath”
  • Primary PreventionIn primary prevention, a disorderis actually prevented fromdeveloping…74
  • 75Primary Prevention – HealthPromotion Behaviors Education: Patient, family, caregiver; health care provider– Falls prevention– Pressure ulcer prevention Immunizations– Influenza, pneumococcal, tetanus/diphtheria, hepatitis B Maintain body weight (± 10% age-adjusted normal weight) Regular physical activity (as appropriate) Nutritional assessment & guidance– Well-balanced diet↑ Fiber, calcium, vitamin D Avoidance of tobacco Alcohol in moderation
  • 76Primary Prevention – HealthPromotion Behaviors Eight hours of sleep a night Positive mental attitude– Encourage family members to participate in positive lifereview with elderly client At least one friend to trust & confide in Self-discipline to enjoy pleasant things in moderation Relaxing & pleasant activities to look forward to Limiting exposure or avoiding known carcinogens
  • Secondary PreventionIn secondary prevention, diseasethat has not yet become symptomaticis detected and treated early, therebyminimizing serious consequences…77
  • 78Secondary Prevention – EarlyDiagnosis, Prompt Treatment Important components ofhealth maintenance practices– Self-care, screening– Regular visits PCP– Reduce cholesterol– Monitor blood pressure Appropriate diagnostic,screening tests:– Fecal occult blood test– Glaucoma screen (tonometry &visual field testing)– Fasting glucose– Colonoscopy– Prostate exam: PSA & DRE– Mammogram– Pap test, pelvic– Bone mass screening
  • Tertiary Prevention In tertiary prevention, an existing, usuallychronic disease is managed to preventcomplications or further damage. For example,tertiary prevention for people with diabetesfocuses on tight control of blood sugar, excellentskin care, frequent examination of the feet, andfrequent exercise to prevent heart and bloodvessel disease…79
  • 80Tertiary Prevention –Restoration, Rehabilitation Manage clinical diseases (esp chronic diseases) to preventthem from progressing– Aim: optimal functioning; avoid disability & complications Rehabilitation (physical, occupational, speech, recreationaltherapy)– Short-term placement or– Aggressive in-home rehabilitation Appropriate services/ aids to increase independence– Walkers, canes, homemaker/ home health aid, visiting nurse Disaster relief– Safe housing, counseling, physical care
  • Question Which of the following is an example ofprimary prevention? A. Administering digoxin to treat heart failure B. Obtaining a smear for a screening test C. Using occupational therapy to help a patientcope with arthritis D. Vaccinating an older adult during the fluseason
  • 82Question The gerontological nurse is teaching 86-year-oldPatricia Smith and her family about exercise programsfor the elderly. Which of the following statements aboutarthritis is an example of tertiary preventive care?– A. Exercise cures arthritis– B. Exercise can help control and manage the symptoms ofarthritis and prevent complications– C. Exercise is important for healthy joints and it alsostrengthens the surrounding muscles– D. Exercise helps prevent arthritis from developing
  • Question Which of the following describes secondaryprevention? A. aims to prevent disease from developing in the first place B. aims to detect and treat disease that has not yet becomesymptomatic C. directed at those who already have symptomatic disease,in an attempt to prevent further deterioration, recurrentsymptoms and subsequent events D. set of health activities that mitigate or avoid theconsequences of unnecessary or excessive interventions inthe health system
  • Question As they get older, men are more likely to bescreened for prostate cancer: 48% of men 50 to 59years as compared to 56% of men 80 years andolder. The nurse concludes that this is: A. An example of ageism and negative stereotyping B. An illustration of the belief that primary preventionstrategies should be promoted in the older adult population C. A proper allocation of scarce health care resources D. A societal trend based on higher numbers of aging men
  • Question While Medicare pays for some medical screenings for olderAmericans, nine of every ten adults over the age of 65 gowithout screenings, such as bone mass screenings, colorectalcancer screening, glaucoma screenings, mammograms, andpap tests and pelvic examinations. Findings show that primarycare providers are less aggressive when recommendingpreventive measures to the elderly. The nurse concludes that this is: A. An example of ageism B. An illustration of the belief that tertiary prevention strategies arewasted on elders C. A proper allocation of scarce health care resources D. Correct, since there is no need for aggressive screening measureswithin this age group
  • 86Prolongation of Frailty vsCompression of Morbidity?
  • 87Functional Assessment of theOlder Adult
  • 88Nursing Process and the OlderAdult Assessment– Health History– Physical Examination Goal: Individualize & tailor assessmentsand interventions to each patient Functional abilities should be a centralfocus of comprehensive assessment
  • 89Assessment of Function Three domainsThree domains: ADLs, IADLs, & mobility Systematic, focus on individual needs Two approaches: asking & observing Basis for care planning, goal setting, &discharge planning Eligibility to obtain many services
  • 90AssessmentHealth History– Nurse draws facts and interpretations fromolder client that will shed light on currenthealth status and health concerns– Eliciting data requires time & patience on thepart of both the nurse and client– Nurse may interview client & client’s supportmembers
  • 91AssessmentPhysical Examination• Nurse must beknowledgeable about normalphysical changes of aging inorder to conduct physicalexamination• Client may need assistancewith disrobing or positionchanges• Be alert to potential for injury
  • 92Challenges in Health andFunctioning Adjustment to a new body image Effect on body image and self-concept Self-concept and roles Acceptance of bodily changes Declining function resulting in illness anddisability Loss of independence
  • 93Diagnoses Frequently Seen inthe Older Adult Impaired Physical Mobility Activity Intolerance Risk for Injury, Falls Risk for Infection Self-Care Deficits Social Isolation Risk for Loneliness Acute, Chronic Confusion Imbalanced Nutrition Impaired HomeMaintenance Ineffective RolePerformance Ineffective HealthMaintenance Ineffective TherapeuticRegimen Management
  • 94Important Qualities of theGerontological Nurse
  • 95 “The care of old people requires just as much skill, tact,ingenuity, and patience as the care of children, andperhaps more, because one must keep in mind that oldpeople cannot be treated like children and thatfeebleness of physical and mental powers is notaccompanied by forgetfulness of early experiences. Agenuine affection, gentleness, sympathy, andimagination sufficient to grasp the patient’s point of vieware necessary.” Jessie Breeze, private duty nurse, 1909
  • 96Important Qualities of theGerontological Nurse Ability to form atherapeutic relationshipwith elderly adults Appreciation of theuniqueness of elders Clinical competencein basic nursing skills Good communicationskills Knowledge of physical &psychosocial changesthat occur with age Ability to work with &supervise others
  • 97Therapeutic CommunicationOngoing,continuous,dynamic processIncludes verbaland nonverbalsignals
  • 98Nonverbal Communication Nonverbal communicationcomposes up to 80% ofinformation exchange– Body language– Position– Eye contact– Touch– Tone of voice– Facial expression
  • 99Verbal CommunicationGuidelines Do not yell or speak tooloudly to patients– Yelling into a hearing aid canbe disturbing and painful Try to be at eye level Minimize backgroundnoise
  • 100Verbal CommunicationGuidelines Touch if appropriateand acceptable Supplement withwritten instructions asneeded Avoid complicatedexplanations
  • 101Verbal CommunicationGuidelines Ask how the patientwould like to beaddressed Avoid demeaningterms such as sweetie,honey, or dearie Use caring responsesand careful listening
  • 102Verbal CommunicationGuidelines Use open-ended statements– “Tell me more…” or “How doesthis affect you?” Avoid misunderstandings byclarifying– “I’m not sure what you mean…” Encourage reminiscing