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Gerontological Nursing Ninth Edition

Charlotte Eliopoulos, PhD, MPH, RN Specialist in Holistic Gerontological Care

Acquisitions Editor: Natasha McIntyre Director of Product Development: Jennifer K. Forestieri Development Editor: Meredith L. Brittain Editorial Assistant: Leo Gray Production Project Manager: Priscilla Crater Design Coordinator: Elaine Kasmer Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Production Services/Compositor: SPi Global

9th Edition

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Nursing diagnoses in this title are reprinted with permission from: Herdman, T.H. & Kamisuru, S. (Eds.) Nursing Diagnoses — Definitions and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.

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This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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9th Edition

9 8 7 6 5 4 3 2 1

Printed in China

Cataloging in Publication data available on request from publisher ISBN 9781496377258

LWW.com

mailto:[email protected]

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This book is dedicated to my husband, George Considine, for his unending patience, support, and encouragement.

Preface

Whether they are aware of it or not, most nurses today are doing some form of gerontological nursing. Hospitals are caring for increasing numbers of older adults whose age-related changes, multiple diagnoses, and psychosocial complexities present many challenges. Settings that provide long-term care are expanding beyond the nursing home. More older adults are remaining in the community and presenting new demands for nursing services to be provided in innovative ways. Growing numbers of older individuals are heading multigenerational households and caring for younger family members, which brings them into contact with nurses in specialties beyond geriatrics.

Not only do older individuals have a greater presence in various specialties but they also are presenting new challenges. They are better informed about their health conditions and expect to have explanations for treatment decisions. Many are using complementary and alternative therapies and desire approaches that integrate those therapies into conventional care. They not only want their diseases managed but they also want to enhance their function so they can enjoy an active, meaningful life. They may make choices that forfeit treatments that can extend the quantity of life for those that offer the freedom to enjoy a high quality of life for whatever time remains. Such challenges demand that nurses not only be knowledgeable about aging and geriatric care but also skillful at assessing that which is important to the older person and providing care that addresses the person holistically. It is indeed an exciting time to be a gerontological nurse!

Gerontological Nursing has evolved since its first publication. In the early editions of the text, the focus was on providing facts about the aging process and the unique modifications that were necessary to properly assess, plan, and provide care to older adults. We now understand that a “one size fits all” approach to nursing older adults is inappropriate as the diversity of this population grows. In addition to expecting from the gerontological nurse assistance with managing their medical conditions, today’s older adults may seek guidance on the selection of brain exercises to improve mental function, the value of an herbal supplement over their prescription drug, strategies to fill the void resulting from retiring from a job they enjoyed, suggestions for the best lubricant to facilitate sexual intercourse, opinions as to the value of marijuana in controlling their pain, and recommendations for the best type of approach to reduce their wrinkles. This edition of Gerontological Nursing provides the evidence-based knowledge that can help the gerontological nurse address, with competency and sensitivity, the complexities of meeting the comprehensive, holistic needs of the older population.

Text Organization Gerontological Nursing, Ninth Edition, is organized into five units. Unit 1, The Aging Experience, provides basic knowledge about the older population and the aging process. The growing cultural and sexual diversity of this population is discussed, along with the navigation of life transitions and the changes to the body and mind that typically are experienced.

Unit 2, Foundations of Gerontological Nursing, provides an understanding of the development and scope of the specialty, along with descriptions of the various settings that provide services to older persons. This unit reviews legal and ethical issues that are relevant to gerontological nursing and offers guidance in applying a holistic model to gerontological care.

Unit 3, Health Promotion, addresses the importance of measures to prevent illness and maximize function. Chapters dedicated to nutrition and hydration, sleep and rest, comfort and pain management, safety, and medications guide the nurse in promoting basic health and preventing avoidable complications. A chapter dedicated to spirituality supports the holistic approach that is meaningful in gerontological care. In addition, because people often feel sufficiently comfortable with nurses to discuss sensitive matters, a chapter on sexuality and intimacy is included.

Unit 4, Geriatric Care, encompasses chapters dedicated to respiration, circulation, digestion and bowel elimination, urinary elimination, reproductive system health, mobility, neurologic function, vision and hearing, endocrine function, skin health, and cancer. A review of the impact of aging, interventions to promote health, the unique presentation and treatment of illnesses, and integrative approaches to illness are discussed within each of these areas. In addition to a chapter on mental health disorders, a chapter reviewing delirium and dementia is included in recognition of the prevalence and care challenges of these conditions in the geriatric population. Because chronic conditions affect most of this population, the last chapter of this unit is dedicated to nursing actions that can assist older individuals in living a full life with chronic conditions.

The unique challenges gerontological nurses face in various care settings are discussed in Unit 5, Settings and Special Issues in Geriatric Care. Chapters in this unit cover rehabilitative care, acute care, long-term care, family caregiving, and end-of-life care.

Features A variety of features enrich the content:

Learning Objectives prepare the reader for outcomes anticipated in reading the chapter. Chapter Outlines present an overview of the chapter’s content. Terms to Know define new terms pertaining to the topic. Communication Tips offer suggestions to facilitate patient education and information exchange with older adults. Consider This Case features present clinical situations that offer opportunities for critical thinking. Concept Mastery Alerts clarify fundamental nursing concepts to improve the reader’s understanding of potentially confusing topics, as identified by Misconception Alerts in Lippincott’s Adaptive Learning Powered by prepU. Key Concepts emphasize significant facts. Points to Ponder pose questions to stimulate thinking related to the content. Assessment Guides outline the components of general observations, interview, and physical assessment of major body systems. Nursing Diagnosis Highlights provide an overview of selected nursing diagnoses common in older adults. Nursing Care Plans demonstrate the steps in developing nursing diagnoses, goals, and actions from identified needs. Bringing Research to Life presents current research and describes how to apply that knowledge in practice. Practice Realities pose real-life examples of challenges that could be faced by a nurse in practice. Critical Thinking Exercises guide application. Resources and References assist with additional exploration of the topic.

Teaching and Learning Package A comprehensive teaching/learning package has been developed to assist faculty and students.

Resources for Instructors Tools to assist you with teaching your course are available upon adoption of this text at http://thePoint.lww.com/Eliopoulos9e.

An E-book on gives you access to the book’s full text and images online. The Test Generator lets you put together exclusive new tests from a bank containing hundreds of questions to help you in assessing your students’ understanding of the material. Test questions link to chapter learning objectives. This test generator comes with a bank of more than 900 questions. PowerPoint Presentations provide an easy way for you to integrate the textbook with your students’ classroom experience, via either slide shows or handouts. Multiple choice and true/false questions are integrated into the presentations to promote class participation and allow you to use i-clicker technology. Clinical Scenarios posing What If questions (and suggested answers) give your students an opportunity to apply their knowledge to a client case similar to the one they might encounter in practice. Assignments (and suggested answers) include group, written, clinical, and web assignments. An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course. A QSEN Competency Map and a BSN Essentials Map show you how content connects with these important competencies. Suggested Answers to the Critical Thinking Exercises in the book allow you to gauge whether students’ answers are on the right track by giving you main points that students are expected to address in the answers. Plus a Sample Syllabus, Strategies for Effective Teaching, and Learning Management System Cartridges.

Resources for Students An exciting set of free resources is available to help students review material and become even more familiar with vital concepts. Students can access all these resources at http://thePoint.lww.com/Eliopoulos9e using the codes printed in the front of their textbooks.

Current Journal Articles offer access to current research available in Wolters Kluwer journals. Watch & Learn Video Clips explain How to Assist a Person Who Is Falling, Alternatives to Restraints, and the Five Stages of Grief. (Icons in the textbook direct readers to relevant videos.) Recommended Readings expand the network of available information. Plus Learning Objectives from the textbook, Nursing Professional Roles and Responsibilities, and Heart and Breath Sounds.

http://thePoint.lww.com/Eliopoulos9e.

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A Fully Integrated Course Experience We are pleased to offer an expanded suite of digital solutions and ancillaries to support instructors and students using Gerontological Nursing, Ninth Edition. To learn more about any solution, please contact your local Wolters Kluwer representative.

Lippincott CoursePoint+ Lippincott CoursePoint+ is an integrated digital learning solution designed for the way students learn. It is the only nursing education solution that integrates:

Leading content in context: Content provided in the context of the student learning path engages students and encourages interaction and learning on a deeper level. Powerful tools to maximize class performance: Course-specific tools, such as adaptive learning powered by prepU, provide a personalized learning experience for every student. Real-time data to measure students’ progress: Student performance data provided in an intuitive display lets you quickly spot which students are having difficulty or which concepts the class as a whole is struggling to grasp. Preparation for practice: Integrated virtual simulation and evidence-based resources improve student competence, confidence, and success in transitioning to practice.

vSim for Nursing: Co-developed by Laerdal Medical and Wolters Kluwer, vSim for Nursing simulates real nursing scenarios and allows students to interact with virtual patients in a safe, online environment. Lippincott Advisor for Education: With over 8,500 entries covering the latest evidence-based content and drug information, Lippincott Advisor for Education provides students with the most up-to-date information possible, while giving them valuable experience with the same point-of- care content they will encounter in practice.

Training services and personalized support: To ensure your success, our dedicated educational consultants and training coaches will provide expert guidance every step of the way.

Simulation and Other Resources

vSim for Nursing | Gerontology, a virtual simulation platform (available via ). Co-developed by Laerdal Medical and Wolters Kluwer, vSim for Nursing | Gerontology includes 12 gerontology patient scenarios that correspond to the National League for Nursing (NLN) Advancing Care Excellence for Seniors (ACES) Unfolding Cases. vSim for Nursing | Gerontology helps students develop clinical competence and decision-making skills as they interact with virtual patients in a safe, realistic environment. vSim for Nursing records and assesses student decisions throughout the simulation, then provides a personalized feedback log highlighting areas needing improvement.

Lippincott DocuCare (available via thePoint). Lippincott DocuCare combines web-based electronic health record simulation software with clinical case scenarios. Lippincott DocuCare’s nonlinear solution works well in the classroom, simulation lab, and clinical practice.

Reviewers

Carol Amann, PhD, RN-BC, CDP

Assistant Professor for the Villa Maria School of Nursing Gannon University Erie, Pennsylvania

Jan Atwell, MSN, RN

Clinical Assistant Professor Missouri State University Springfield, Missouri

Judy L. Barrera, RN, CNS

Clinical Learning Lab Coordinator Galen College of Nursing Louisville, Kentucky

Evelyn Biray, RN, MS, PMed, CCRN, CMSRN

Professor of Nursing Long Island University Brooklyn New York, New York

Dr.Melissa Brock , MSM, MSN, ANP-C, DHEd

Nursing Professor Indiana Wesleyan University Indianapolis, Indiana

Celeste Brown-Apoh, RN, MSN

Instructor Rowan College at Burlington County Pemberton, New Jersey

Jean Burt, MSN, RN

Instructor Wilbur Wright College Chicago, Illinois

Nicola Contreras, MSN, RN

VN/ADN Faculty

Galen College of Nursing San Antonio, Texas

Sherri Cozzens, RN, MS

Nursing Faculty De Anza College Cupertino, California

Jodie Fox, MSN, RN-BC

Assistant Professor Viterbo University Lacrosse, Wisconsin

Florida Freeman, PhD, MSN, RN

Professor of Nursing University of St. Francis Joliet, Illinois

Betsy D. Gulledge, PhD, RN, CNE, NEA-BC

Associate Dean/Assistant Professor of Nursing Jacksonville State University Jacksonville, Alabama

Kris Hale, MSN, RN

Professor/Department Chair San Diego City College San Diego, California

Cheryl Harrington, MSN, RN, MHA

Clinical Simulation Specialist Morningside College Sioux City, Iowa

Mary Jane Holman, RN

Instructor Louisiana State University Shreveport Shreveport, Louisiana

Laly Joseph, DVM, DNP, MSN, RN, C, ARNP, BC

Clinical Assistant Professor Fairleigh Dickinson University Teaneck, New Jersey

Ronnie Knabe, MSN, RN, CCRN

Associate Professor, Nursing Bakersfield College Bakersfield, California

Amy Langley

Health Science Division Director Snead State Community College Boaz, Alabama

Debora Lemon, MN, RN

Associate Professor Lewis-Clark State College Lewiston, Idaho

Susan McClendon, MSN, RN, CNS

Nursing Faculty Lakeland Community College Kirkland, Ohio

Mary Alice Momeyer, DNP, ANP-BC, GNP-BC

Assistant Clinical Professor The Ohio State University College of Nursing Columbus, Ohio

Jon F. Nutting, MA, RN-BC

Instructor Galen College of Nursing Tampa Bay Campus St. Petersburg, Florida

Teresa M. Page, DNP, EdS, MSN, RN, FNP-BC

Assistant Professor of Nursing Liberty University Lynchburg, Virginia

LoriAnn Pajalich, MS, RN, CNS, GCNS-BC

Assistant Professor of Nursing Wilkes University Wilkes-Barre, Pennsylvania

Debra Parker, DNP, RN

Assistant Professor Indiana Wesleyan University Marion, Indiana

Cordelia Schaffer, MSN, RN, CHPN

Associate Professor Westminster College Salt Lake City, Utah

Crystal Schauerte-O'Connell

Program Coordinator, Year 2 Algonquin College Ottawa, Ontario

Maura C. Schlairet, EdD, MA, MSN, RN, CNL (A/H)

Professor of Nursing Valdosta State University Valdosta, Georgia

Nichole Spencer, MSN, APRN, ANP-C

Assistant Professor of Nursing William Jewell College Liberty, Missouri

Carolyn Sue-Ling, MSN, MPA, RN

Instructor University of South Carolina Aiken Aiken, South Carolina

Michael T. Valenti, AAS, BS, MS

Assistant Professor of Nursing Long Island University Brookville, New York

Stephanie Vaughn, PhD, RN, CRRN, FAHA

Professor/Director School of Nursing California State University, Fullerton Fullerton, California

Erica Williams-Woodley, MSN, NP

Assistant Professor of Nursing

Bronx Community College New York, New York

Jane Zaccardi, MA, RN, GCNS-BC

Director of Practical Nursing and Health Occupations Programs Johnson County Community College Overland Park, Kansas

For a list of the contributors to the Instructor Resources and a list of the reviewers of the Test Generator questions accompanying this book, please visit http://thepoint.lww.com/Eliopoulos9e.

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Acknowledgments

There are many individuals who played important roles in the birth and development of this book. I will always be grateful to Bill Burgower, a Lippincott editor, who decades ago responded to my urging that the new specialty of gerontological nursing needed resources by encouraging me to write the first edition of Gerontological Nursing. Many fine members of the Wolters Kluwer team have guided and assisted me since, including Natasha McIntyre, Acquisitions Editor, who consistently offered encouragement and direction; Meredith Brittain, Senior Development Editor, who brought a new set of eyes to the book and ironed out the rough edges through her fine editorial skills; Dan Reilly and Leo Gray, Editorial Assistants at different points in this project, who attended to the details that contribute to a quality finished product; and Priscilla Crater, Production Project Manager, who shepherded the book from manuscript through printed pages.

Lastly, I am deeply indebted to those mentors and leaders in gerontological care who generously offered encouragement and the many older adults who have touched my life and showed me the wisdom and beauty of aging. The insight these individuals provided could have never been learned in a book!

Charlotte Eliopoulos

Brief Contents

UNIT 1 THE AGING EXPERIENCE 1 The Aging Population 2 Theories of Aging 3 Diversity 4 Life Transitions and Story 5 Common Aging Changes

UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6 The Specialty of Gerontological Nursing 7 Holistic Assessment and Care Planning 8 Legal Aspects of Gerontological Nursing 9 Ethical Aspects of Gerontological Nursing 10 Continuum of Care in Gerontological Nursing

UNIT 3 HEALTH PROMOTION 11 Nutrition and Hydration 12 Sleep and Rest 13 Comfort and Pain Management 14 Safety 15 Spirituality 16 Sexuality and Intimacy 17 Safe Medication Use

UNIT 4 GERIATRIC CARE 18 Respiration 19 Circulation 20 Digestion and Bowel Elimination 21 Urinary Elimination 22 Reproductive System Health 23 Mobility 24 Neurologic Function 25 Vision and Hearing

26 Endocrine Function 27 Skin Health 28 Cancer 29 Mental Health Disorders 30 Delirium and Dementia 31 Living in Harmony With Chronic Conditions

UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32 Rehabilitative and Restorative Care 33 Acute Care 34 Long-Term Care 35 Family Caregiving 36 End-of-Life Care Index

Contents

UNIT 1 THE AGING EXPERIENCE 1 The Aging Population Views Of Older Adults Through History

Characteristics Of The Older Adult Population

Population Growth and Increasing Life Expectancy Marital Status and Living Arrangements Income and Employment

Health Insurance

Health Status Implications Of An Aging Population

Impact of the Baby Boomers Provision of and Payment for Services

2 Theories of Aging Biological Theories Of Aging

Stochastic Theories Nonstochastic Theories

Sociologic Theories of Aging

Disengagement Theory Activity Theory Continuity Theory Subculture Theory Age Stratification Theory

Psychological Theories of Aging

Developmental Tasks Gerotranscendence

Nursing Theories of Aging

Functional Consequences Theory Theory of Thriving Theory of Successful Aging

Applying Theories of Aging to Nursing Practice

3 Diversity Increasing Diversity Of The Older Adult Population

Overview Of Diverse Groups Of Older Adults In The United States

Hispanic Americans Black Americans Asian Americans Jewish Americans

Native Americans Muslims Gay, Lesbian, Bisexual, and Transgender Older Adults

Nursing Considerations For Culturally Sensitive Care Of Older Adults

4 Life Transitions and Story Ageism

Changes In Family Roles And Relationships

Parenting Grandparenting

Loss Of Spouse

Retirement

Loss of the Work Role Reduced Income

Changes In Health And Functioning

Cumulative Effects Of Life Transitions

Shrinking Social World Awareness of Mortality

Responding To Life Transitions

Life Review and Life Story Self-Reflection Strengthening Inner Resources

5 Common Aging Changes Changes To The Body

Cells Physical Appearance Respiratory System Cardiovascular System Gastrointestinal System Urinary System Reproductive System Musculoskeletal System Nervous System Sensory Organs Endocrine System Integumentary System Immune System Thermoregulation

Changes To The Mind

Personality Memory Intelligence

Learning Attention Span

Nursing Implications Of Age-Related Changes

UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6 The Specialty of Gerontological Nursing Development Of Gerontological Nursing

Core Elements Of Gerontological Nursing Practice

Evidence-Based Practice Standards Competencies Principles

Gerontological Nursing Roles

Healer Caregiver Educator Advocate Innovator

Advanced Practice Nursing Roles

Self-Care And Nurturing

Following Positive Health Care Practices Strengthening and Building Connections Committing to a Dynamic Process

The Future Of Gerontological Nursing

Utilize Evidence-Based Practices Advance Research Promote Integrative Care Educate Caregivers Develop New Roles Balance Quality Care and Health Care Costs

7 Holistic Assessment and Care Planning Holistic Gerontological Care

Holistic Assessment Of Needs

Health Promotion–Related Needs Health Challenges–Related Needs Requisites to Meet Needs

Gerontological Nursing Processes

Examples Of Application

Applying the Holistic Model: The Case of Mrs. D The Nurse As Healer

Healing Characteristics

8 Legal Aspects of Gerontological Nursing Laws Governing Gerontological Nursing Practice

Legal Risks In Gerontological Nursing

Malpractice Confidentiality Patient Consent Patient Competency Staff Supervision Medications Restraints Telephone Orders Do Not Resuscitate Orders Advance Directives and Issues Related to Death and Dying Elder Abuse

Legal Safeguards For Nurses

9 Ethical Aspects of Gerontological Nursing Philosophies Guiding Ethical Thinking

Ethics In Nursing

External and Internal Ethical Standards Ethical Principles Cultural Considerations

Ethical Dilemmas Facing Gerontological Nurses

Changes Increasing Ethical Dilemmas for Nurses Measures to Help Nurses Make Ethical Decisions

10 Continuum of Care in Gerontological Nursing Services In The Continuum Of Care For Older Adults

Supportive and Preventive Services Partial and Intermittent Care Services Complete and Continuous Care Services Complementary and Alternative Services

Matching Services To Needs

Settings And Roles For Gerontological Nurses

UNIT 3 HEALTH PROMOTION 11 Nutrition and Hydration Nutritional Needs Of Older Adults

Quantity and Quality of Caloric Needs Nutritional Supplements Special Needs of Women

Hydration Needs Of Older Adults

Promotion Of Oral Health

Threats To Good Nutrition

Indigestion and Food Intolerance Anorexia Dysphagia Constipation Malnutrition

Addressing Nutritional Status And Hydration In Older Adults

12 Sleep and Rest Age-Related Changes in Sleep

Circadian Sleep–Wake Cycles Sleep Stages Sleep Efficiency and Quality

Sleep Disturbances

Insomnia Nocturnal Myoclonus and Restless Legs Syndrome Sleep Apnea Medical Conditions That Affect Sleep Drugs That Affect Sleep Other Factors Affecting Sleep

Promoting Rest and Sleep in Older Adults

Pharmacologic Measures to Promote Sleep Nonpharmacologic Measures to Promote Sleep Pain Control

13 Comfort and Pain Management Comfort

Pain: A Complex Phenomenon

Prevalence Of Pain In Older Adults

Types of Pain Pain Perception Effects of Unrelieved Pain

Pain Assessment

An Integrative Approach To Pain Management

Complementary Therapies Dietary Changes Medication Comforting

14 Safety Aging And Risks To Safety

Importance Of The Environment To Health And Wellness

Impact Of Aging On Environmental Safety And Function

Lighting

Temperature Colors Scents Floor Coverings Furniture Sensory Stimulation Noise Control Bathroom Hazards Fire Hazards Psychosocial Considerations

The Problem Of Falls

Risks and Prevention Risks Associated With Restraints

Interventions To Reduce Intrinsic Risks To Safety

Reducing Hydration and Nutrition Risks Addressing Risks Associated With Sensory Deficits Addressing Risks Associated With Mobility Limitations Monitoring Body Temperature Preventing Infection Suggesting Sensible Clothing Using Medications Cautiously Avoiding Crime Promoting Safe Driving Promoting Early Detection of Problems Addressing Risks Associated With Functional Impairment

15 Spirituality Spiritual Needs

Love Meaning and Purpose Hope Dignity Forgiveness Gratitude Transcendence Expression of Faith

Assessing Spiritual Needs

Addressing Spiritual Needs

Being Available Honoring Beliefs and Practices Providing Opportunities for Solitude

Promoting Hope Assisting in Discovering Meaning in Challenging Situations Facilitating Religious Practices Praying With and for

16 Sexuality and Intimacy Attitudes Toward Sex And Older Adults

Realities Of Sex In Older Adulthood

Sexual Behavior and Roles Intimacy Age-Related Changes and Sexual Response

Menopause As A Journey To Inner Connection

Symptom Management and Patient Education Self-Acceptance Andropause

Identifying Barriers To Sexual Activity

Unavailability of a Partner Psychological Barriers Medical Conditions Erectile Dysfunction Medication Adverse Effects Cognitive Impairment

Promoting Healthy Sexual Function

17 Safe Medication Use Effects Of Aging On Medication Use

Polypharmacy and Interactions Altered Pharmacokinetics Altered Pharmacodynamics Increased Risk of Adverse Reactions

Promoting The Safe Use Of Drugs

Avoiding Potentially Inappropriate Drugs: Beers Criteria Reviewing Necessity and Effectiveness of Prescribed Drugs Promoting Safe and Effective Administration Providing Patient Teaching Monitoring Laboratory Values

Alternatives To Drugs

Review Of Selected Drugs

Analgesics Antacids Antibiotics Anticoagulants Anticonvulsants

Antidiabetic (Hypoglycemic) Drugs Antihypertensive Drugs Nonsteroidal Anti-inflammatory Drugs Cholesterol-Lowering Drugs Cognitive Enhancing Drugs Digoxin Diuretics Laxatives Psychoactive Drugs

UNIT 4 GERIATRIC CARE 18 Respiration Effects Of Aging On Respiratory Health

Respiratory Health Promotion

Selected Respiratory Conditions

Chronic Obstructive Pulmonary Disease Pneumonia Influenza Lung Cancer Lung Abscess

General Nursing Considerations For Respiratory Conditions

Recognizing Symptoms Preventing Complications

Ensuring Safe Oxygen Administration

Performing Postural Drainage Promoting Productive Coughing Using Complementary Therapies Promoting Self-Care Providing Encouragement

19 Circulation Effects Of Aging On Cardiovascular Health

Cardiovascular Health Promotion

Proper Nutrition Adequate Exercise Cigarette Smoke Avoidance Stress Management Proactive Interventions

Cardiovascular Disease And Women

Selected Cardiovascular Conditions

Hypertension

Hypotension Congestive Heart Failure Pulmonary Emboli Coronary Artery Disease Hyperlipidemia Arrhythmias Peripheral Vascular Disease

General Nursing Considerations For Cardiovascular Conditions

Prevention Keeping the Patient Informed Preventing Complications Promoting Circulation Providing Foot Care Managing Problems Associated With Peripheral Vascular Disease Promoting Normality Integrating Complementary Therapies

20 Digestion and Bowel Elimination Effects Of Aging On Gastrointestinal Health

Gastrointestinal Health Promotion

Selected Gastrointestinal Conditions And Related Nursing Considerations

Dry Mouth (Xerostomia) Dental Problems Dysphagia Hiatal Hernia Esophageal Cancer Peptic Ulcer Cancer of the Stomach Diverticular Disease Colorectal Cancer Chronic Constipation Flatulence Intestinal Obstruction Fecal Impaction Fecal Incontinence Acute Appendicitis Cancer of the Pancreas Biliary Tract Disease

21 Urinary Elimination Effects Of Aging On Urinary Elimination

Urinary System Health Promotion

Selected Urinary Conditions

Urinary Tract Infection Urinary Incontinence Bladder Cancer Renal Calculi Glomerulonephritis

General Nursing Considerations For Urinary Conditions

22 Reproductive System Health Effects Of Aging On The Reproductive System

Reproductive System Health Promotion

Selected Reproductive System Conditions

Problems of the Female Reproductive System Problems of the Male Reproductive System

23 Mobility Effects Of Aging On Musculoskeletal Function

Musculoskeletal Health Promotion

Promotion of Physical Exercise in All Age Groups Exercise Programs Tailored for Older Adults The Mind–Body Connection Prevention of Inactivity Nutrition

Selected Musculoskeletal Conditions

Fractures Osteoarthritis Rheumatoid Arthritis Osteoporosis Gout Podiatric Conditions

General Nursing Considerations For Musculoskeletal Conditions

Managing Pain Preventing Injury Promoting Independence

24 Neurologic Function Effects Of Aging On The Nervous System

Neurologic Health Promotion

Selected Neurologic Conditions

Parkinson’s Disease Transient Ischemic Attacks Cerebrovascular Accidents

General Nursing Considerations For Neurologic Conditions

Promoting Independence

Preventing Injury

25 Vision and Hearing Terms to Know

Effects of Aging on Vision and Hearing

Sensory Health Promotion

Promoting Vision Promoting Hearing Assessing Problems

Selected Vision and Hearing Conditions and Related Nursing Interventions

Visual Deficits Hearing Deficits

General Nursing Considerations for Visual and Hearing Deficits

26 Endocrine Function Effects Of Aging On Endocrine Function

Selected Endocrine Conditions And Related Nursing Considerations

Diabetes Mellitus Hypothyroidism Hyperthyroidism

27 Skin Health Effects Of Aging On The Skin

Promotion Of Skin Health

Selected Skin Conditions

Pruritus Keratosis Seborrheic Keratosis Skin Cancer Vascular Lesions Pressure Injury

General Nursing Considerations For Skin Conditions

Promoting Normalcy Using Alternative Therapies

28 Cancer Aging And Cancer

Unique Challenges for Older Persons With Cancer Explanations for Increased Incidence in Old Age

Risk Factors, Prevention, And Screening

Treatment

Conventional Treatment Complementary and Alternative Medicine

Nursing Considerations For Older Adults With Cancer

Providing Patient Education

Promoting Optimum Care Providing Support to Patients and Families

29 Mental Health Disorders Aging And Mental Health

Promoting Mental Health In Older Adults

Selected Mental Health Conditions

Depression Anxiety Substance Abuse Paranoia

Nursing Considerations For Mental Health Conditions

Monitoring Medications Promoting a Positive Self-Concept Managing Behavioral Problems

30 Delirium and Dementia Delirium

Dementia

Alzheimer’s Disease Other Dementias Caring for Persons With Dementia

31 Living in Harmony With Chronic Conditions Chronic Conditions And Older Adults

Goals For Chronic Care

Assessment Of Chronic Care Needs

Maximizing The Benefits Of Chronic Care

Selecting an Appropriate Physician Using a Chronic Care Coach Increasing Knowledge Locating a Support Group Making Smart Lifestyle Choices Using Complementary and Alternative Therapies

Factors Affecting The Course Of Chronic Care

Defense Mechanisms and Implications Psychosocial Factors Impact of Ongoing Care on the Family The Need for Institutional Care

Chronic Care: A Nursing Challenge

UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32 Rehabilitative and Restorative Care Rehabilitative And Restorative Care

Living With Disability

Importance of Attitude and Coping Capacity Losses Accompanying Disability

Principles Of Rehabilitative Nursing

Functional Assessment

Interventions To Facilitate And Improve Functioning

Facilitating Proper Positioning Assisting with Range-of-Motion Exercises Assisting with Mobility Aids and Assistive Technology Teaching About Bowel and Bladder Training Maintaining and Promoting Mental Function Using Community Resources

33 Acute Care Risks Associated With Hospitalization Of Older Adults

Surgical Care

Special Risks for Older Adults Preoperative Care Considerations Operative and Postoperative Care Considerations

Emergency Care

Infections

Discharge Planning For Older Adults

34 Long-Term Care Development Of Long-Term Institutional Care

Before the 20th Century During the 20th Century Lessons to Be Learned From History

Nursing Homes Today

Nursing Home Standards Nursing Home Residents Nursing Roles and Responsibilities

Other Settings For Long-Term Care

Assisted Living Communities Community-Based and Home Health Care

Looking Forward: A New Model Of Long-Term Care

35 Family Caregiving The Older Adult’s Family

Identification of Family Members Family Member Roles Family Dynamics and Relationships

Scope Of Family Caregiving

Long-Distance Caregiving

Protecting The Health Of The Older Adult And Caregiver

Family Dysfunction And Abuse

Rewards Of Family Caregiving

36 End-of-Life Care Definitions Of Death

Family Experience With The Dying Process

Supporting The Dying Individual

Stages of the Dying Process and Related Nursing Interventions Rational Suicide and Assisted Suicide Physical Care Challenges Spiritual Care Needs Signs of Imminent Death Advance Directives

Supporting Family And Friends

Supporting Through the Stages of the Dying Process Helping Family and Friends After a Death

Supporting Nursing Staff

Index

Index of Selected Features

Consider This Case

For Chapter 1

For Chapter 2

For Chapter 3

For Chapter 4

For Chapter 5

For Chapter 6

For Chapter 7

For Chapter 8

For Chapter 9

For Chapter 10

For Chapter 11

For Chapter 12

For Chapter 13

For Chapter 14

For Chapter 15

For Chapter 16

For Chapter 17

For Chapter 18

For Chapter 19

For Chapter 20

For Chapter 21

For Chapter 22

For Chapter 23

For Chapter 24

For Chapter 25

For Chapter 26

For Chapter 27

For Chapter 28

For Chapter 29

For Chapter 30

For Chapter 31

For Chapter 32

For Chapter 33

For Chapter 34

For Chapter 35

For Chapter 36

Assessment Guides

Assessment Guide 11-1 Nutritional Status

Assessment Guide 13-1 Pain

Assessment Guide 15-1 Spiritual Needs

Assessment Guide 16-1 Sexual Health

Assessment Guide 18-1 Respiratory Function

Assessment Guide 19-1 Cardiovascular Function

Assessment Guide 20-1 Gastrointestinal Function

Assessment Guide 21-1 Urinary Function

Assessment Guide 22-1 Reproductive System Health

Assessment Guide 23-1 Musculoskeletal Function

Assessment Guide 24-1 Neurologic Function

Assessment Guide 25-1 Vision and Hearing

Assessment Guide 27-1 Skin Status

Assessment Guide 29-1 Mental Health

Assessment Guide 30-1 Mental Health

Nursing Care Plans

Nursing Care Plan 7-1 Holistic Care For Mrs. D

Nursing Care Plan 18-1 The Older Adult With Chronic Obstructive Pulmonary Disease

Nursing Care Plan 19-1 The Older Adult With Heart Failure

Nursing Care Plan 20-1 The Older Adult With Hiatal Hernia

Nursing Care Plan 20-2 The Older Adult With Fecal Incontinence

Nursing Care Plan 21-1 The Older Adult With Urinary Incontinence

Nursing Care Plan 22-1 The Older Adult Recovering From Prostate Surgery

Nursing Care Plan 23-1 The Older Adult With Osteoarthritis

Nursing Care Plan 24-1 The Older Adult With A Cerebrovascular Accident: Convalescence Period

Nursing Care Plan 25-1 The Older Adult With Open-Angle Glaucoma

Nursing Care Plan 30-1 The Older Adult With Alzheimer’s Disease

UNIT 1 The Aging Experience

1. The Aging Population 2. Theories of Aging

3. Diversity 4. Life Transitions and Story 5. Common Aging Changes

CHAPTER 1

The Aging Population

CHAPTER OUTLINE

Views Of Older Adults Through History

Characteristics Of The Older Adult Population

Population Growth and Increasing Life Expectancy

Marital Status and Living Arrangements

Income and Employment

Health Insurance

Health Status

Implications Of An Aging Population

Impact of the Baby Boomers

Provision of and Payment for Services

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Explain the different ways in which older adults have been viewed throughout history. 2. Describe characteristics of today’s older population in regard to:

life expectancy marital status living arrangements income and employment health status

3. Discuss projected changes in future generations of older people and the implications for health care.

TERMS TO KNOW Comorbidity: the simultaneous presence of multiple chronic conditions

Compression of morbidity: hypothesis that serious illness and decline can be delayed or postponed so that an extended life expectancy results in more functional, healthy years

Life expectancy: the length of time that a person can be predicted to live

Life span: the maximum years that a person has the potential to live

“Families forget their older relatives … most people become senile in old age … Social Security provides every older person with a decent retirement income … a majority of older people reside in nursing homes … Medicare covers all health care–related costs for older people.” These and other myths continue to be perpetuated about older people. Misinformation about the older population is an injustice not only to this age group but also to persons of all ages who need accurate information to prepare realistically for their own senior years. Gerontological nurses must know the facts about the older population to effectively deliver services and educate the general public.

VIEWS OF OLDER ADULTS THROUGH HISTORY The members of the current older population in the United States have offered the sacrifice, strength, and spirit that made this country great. They were the proud GIs who served in wars, the brave immigrants who ventured into a new country, the bold entrepreneurs who took risks that created wealth and opportunities for employment, the campus rebels who advocated for the rights of minorities, and the unselfish parents who struggled to give their children a better life. They have earned respect, admiration, and dignity. Today, older adults are viewed with positivism rather than prejudice, knowledge rather than myth, and concern rather than neglect. This positive view was not always the norm, however.

Historically, societies have viewed their elder members in a variety of ways. In the time of Confucius, there was a direct correlation between a person’s age and the degree of respect to which he or she was entitled. The early Egyptians dreaded growing old and experimented with a variety of potions and schemes to maintain their youth. Opinions were divided among the early Greeks. Plato promoted older adults as society’s best leaders, whereas Aristotle denied older people any role in governmental matters. In the nations conquered by the Roman Empire, the sick and aged were customarily the first to be killed. And, woven throughout the Bible is God’s concern for the well-being of the family and desire for people to respect elders (Honor your father and your mother … Exodus 20:12). Yet, the honor bestowed on older adults was not sustained.

Medieval times gave rise to strong feelings regarding the superiority of youth; these feelings were expressed in uprisings of sons against fathers. Although England developed Poor Laws in the early 17th century that provided care for the destitute and enabled older persons without family resources to have some modest safety net, many of the gains were lost during the Industrial Revolution. No labor laws protected persons of advanced age; those unable to meet the demands of industrial work settings were placed at the mercy of their offspring or forced to beg on the streets for sustenance.

The first significant step in improving the lives of older Americans was the passage of the Federal Old Age Insurance Law under the Social Security Act in 1935, which provided some financial security for older persons. The profound “graying” of the population started to be realized in the 1960s, and the United States responded with the formation of the Administration on Aging, enactment of the Older Americans Act, and the introduction of Medicaid and Medicare, all in 1965 (Box 1-1).

Box 1-1 Publicly Supported Programs of Benefit to Older Americans

1900 Pension laws passed in some states

1935 Social Security Act

1961 First White House Conference on Aging

1965 Older Americans Act: nutrition, senior employment, and transportation programs

Administration on Aging

Medicare (Title 18 of Social Security Act)

Medicaid (Title 19 of Social Security Act) for poor and disabled of any age

1972 Supplemental Security Income (SSI) enacted

1991 Omnibus Budget Reconciliation Act (nursing home reform law) implemented

Since that time, American society has demonstrated a profound awakening of interest in older persons as their numbers have grown. A more humanistic attitude toward all members of society has benefited older adults, and improvements in health care and general living conditions ensure that more people have the opportunity to attain old age and live longer, more fruitful years in later adulthood than previous generations (Fig. 1-1).

FIGURE 1-1 • It is important for gerontological nurses to be as concerned with adding quality to the lives of older adults as they are with increasing the quantity of years.

CHARACTERISTICS OF THE OLDER ADULT POPULATION Older adults are generally defined as individuals aged 65 years and older. At one time, all persons over 65 years of age were grouped together under the category of “old.” Now it is recognized that much diversity exists among different age groups in late life, and older individuals can be further categorized as follows:

young-old: 65 to 74 years old: 75 to 84 years oldest-old 85+

The profile, interests, and health care challenges of each of these subsets can be vastly different. For example, a 66-year-old may desire cosmetic surgery to stay competitive in the executive job market; a 74-year-old may have recently remarried and want to do something about her dry vaginal canal; an 82-year-old may be concerned that his arthritic knees are limiting his ability to play a round of golf; and a 101-year-old may be desperate to find a way to correct her impaired vision so that she can enjoy television.

In addition to chronological age, or the years a person has lived since birth, functional age is a term used by gerontologists to describe physical, psychological, and social function; this is relevant in that how older adults feel and function may be more indicative of their needs than their chronological age. Perceived age is another term that is used to describe how people estimate a person’s age based on appearance. Studies have shown a correlation between perceived age and health, in addition to how others treated older adults based on perceived age and the resultant health of those older adults (Sutin, Stephan, Carretta, & Terracciano, 2014).

How people feel or perceive their own age is described as age identity. Some older adults will view peers of similar age as being older than themselves and be reluctant to join senior groups and other activities because they see the group members as “old people” and different from themselves.

Any stereotypes held about older people must be discarded; if anything, greater diversity rather than homogeneity will be evident. Further, generalizations based on age need to be eliminated as behavior, function, and self-image can reveal more about priorities and needs than chronological age alone.

COMMUNICATION TIP Not all persons of the same age will be similar in terms of language style, familiarity with current terms, use of technology, education, and life experience. Communication style and method must be based on assessed language competency, style, and preference of the individual.

Population Growth and Increasing Life Expectancy There was a significant growth in the number of older people for most of the 20th century. Except for the 1990s, the older population grew at a rate faster than that of the total population under age 65. The U.S. Census Bureau projects that a substantial increase in the number of individuals over age 65 will occur between 2010 and 2030 due to the impact of the baby boomers, who began to enter this group in 2011. In 2030, it is projected that this group will represent nearly 20% of the total U.S. population.

Currently, persons older than 65 years represent more than 13% of the population in the United States. This growth of the older adult population is due in part to increasing life expectancy. Advancements in disease control and health technology, lower infant and child mortality rates, improved sanitation, and better living conditions have increased life expectancy for most Americans. More people are surviving to their senior years than ever before. In 1930, slightly more than 6 million persons were aged 65 years or older, and the average life expectancy was 59.7 years. The life expectancy in 1965 was 70.2 years, and the number of older adults exceeded 20 million. Life expectancy has now reached 78.2 years, with over 34 million persons exceeding age 65 years (Table 1-1). Not only are more people reaching old age, but they are living longer once they do; the number of people in their 70s and 80s has been steadily increasing and is expected to continue to increase. The population over age 85 years is projected to double by the year 2036 and triple by 2049. The life span currently is 122 years for humans.

TABLE 1-1 Differences in Life Expectancy at Birth by Race, Sex, and Hispanic Origin

Source: National Center for Health Statistics. (2013). Table 18. Life expectancy at birth, at age 65, and at age 75 by sex, race, and national origin: United States, selected years. Health, United States, 2013. Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/hus/hus13.pdf#018; U.S. Census Bureau. Table 10. Projected life expectancy at birth by sex, race, and Hispanic origin for the United States. Retrieved from http://www.census.gov/population/projections/data/national/2012/summarytables.html

KEY CONCEPT More people are achieving and spending longer periods of time in old age than ever before in history.

Although life expectancy has increased, it still differs by race and gender, as Table 1-1 shows. From the late 1980s to the present, the gap in life expectancy between white people and black people has widened because the life expectancy of the black population has declined. The U.S. Department of Health and Human Services attributes the declining life expectancy of black people to heart disease, cancer, homicide, diabetes, and perinatal conditions. This reality underscores the need for nurses to be concerned with health and social issues

http://www.cdc.gov/nchs/data/hus/hus13.pdf#018

http://www.census.gov/population/projections/data/national/2012/summarytables.html

of persons of all ages because these impact a population’s aging process.

Whereas the gap in life expectancy has widened among the races, the gap is narrowing between the sexes. Throughout the 20th century, the ratio of men to women had steadily declined to the point where there were fewer than 7 older men for every 10 older women. The ratio declined with each advanced decade. However, in the 21st century, this trend is changing, and the ratio of men to women is increasing.

Although living longer is desirable, of significant importance is the quality of those years. More years to life means little if those additional years consist of discomfort, disability, and a poor quality of life. This has led to a hypothesis advanced by James Fries, a professor of medicine at Stanford University, called the compression of morbidity (Fries, 1980; Swartz, 2008). This hypothesis suggests that if the onset of serious illness and decline would be delayed, or compressed, into a few years prior to death, people could live a long life and enjoy a healthy, functional state for most of their lives.

POINT TO PONDER A higher proportion of older adults in our society means that younger age groups will be carrying a greater tax burden to support the older population. Should young families sacrifice to support services for older adults? Why or why not?

Marital Status and Living Arrangements 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 are widowed, and most of their male contemporaries are married. Married people have a lower mortality rate than do unmarried people at all ages, with men having a larger advantage.

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. Realities of the aging family are discussed in greater detail in Chapter 35.

KEY CONCEPT Women are more likely to be widowed and living alone in late life than are their male counterparts.

Income and Employment The percentage of older people living below the poverty level has been declining, with about 10% now falling into this category. However, older adults still do face financial problems. Most older people depend on Social Security for more than half of their income (Box 1-2). Women and minority groups have considerably less income than do white men. Although the median net worth of older households is nearly twice the national average because of the high prevalence of home ownership by elders, many older adults are “asset rich and cash poor.” The recent decline in housing prices, however, has made that asset a less valuable one for many older adults.

Box 1-2 Social Security and Supplemental Security Income Social Security: a benefit check paid to retired workers of specific minimum age (e.g., 65 years), disabled workers of any age, and spouses and minor children of those workers. Benefits are not dependent on financial need. It is intended to serve as supplement to other sources of income in retirement.

Supplemental Security Income (SSI): a benefit check paid to persons over age 65 and/or persons with disabilities based on financial need.

Although the percentage of the total population that older adults represent is growing, they constitute a steadily declining percentage of workers in the labor force. The withdrawal of men from the workforce at earlier ages has been one of the most significant labor force trends since World War II. There has been, however, a significant rise in the percentage of middle-aged women who are employed, although there has been little change in the labor force participation of women 65 years of age and older. Most baby boomers are expressing a desire and need to continue working as they enter retirement age.

CONSIDER THIS CASE

Mr. and Mrs. Murdock are both 67 years of age and in good health. Mr. Murdock owns and manages several investment properties that require him to maintain records, respond to tenants’ service calls, and plan maintenance work. Mrs. Murdock is a nurse who works in a community health center for children. Both of them are working full-time and enjoy their work; however, they both admit that their energy level is not what it used to be and that it takes them

more time to complete activities than it did in the past.

Although she does see positives to her work activities, Mrs. Murdock feels that after many years of working, she deserves to relax and enjoy other activities. When she suggests to her husband that he either retire or, at the least, reduce his work activities so that they can enjoy this season of life together, he is adamant about continuing to work because he believes the income is beneficial to maintaining their lifestyle and he has no other activities that he is interested in doing. She thinks he is being unrealistic, claims that they can “get along just fine on Social Security,” and repeatedly reminds him that they are at the age when people retire.

THINK CRITICALLY

What issues would be helpful for each of these individuals to consider regarding their decision to retire or continue working? What challenges could each of these individuals potentially face if they continued to work for another 5 years? 10 years? What actions could the Murdocks have taken in the past to face their decisions about continued work or retirement differently? What are the implications to society of people like the Murdocks continuing to stay in the labor force?

KEY CONCEPT Although Social Security was intended to be a supplement to other sources of income for older adults, it is the main source of income for more than half of all these individuals.

HEALTH INSURANCE This decade has shaken the health care reimbursement systems in the United States, and changes will be unfolding as the need to assure that every American will have access to health care is balanced against unsustainable costs to support that care. Passed in 1965 as Title 18 of the Social Security Act, Medicare is the health insurance program for older adults who are eligible for Social Security benefits. This federally funded program primarily covers hospital and physician services with very limited skilled home health and nursing home services under Part A. Preventive services and nonskilled care (e.g., personal care assistance) are not covered. To supplement the basic coverage, a person can purchase Medicare Part B, which includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments, and other outpatient medical treatments administered in a doctor’s office. Part B also assists with the payment of durable medical equipment, including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use are also covered. Medicare Part C or Medicare Advantage Plans give people the option of purchasing coverage through private insurance plans to cover benefits not provided by Medicare Parts A and B plus additional services. Although regulated and funded by the federal government, these plans are managed by private insurance companies. Some of these plans also include prescription drug benefits, known as a Medicare Advantage Prescription Drug Plan or Medicare Part D.

Persons who meet the income criteria can qualify for Medicaid, the health insurance program for the poor of any age. This program was developed at the same time as Medicare and is Title 19 of the Social Security Act. Medicaid supplements Medicare for poor elderly individuals, and most nursing home care is paid for by this program. Medicaid is supported by federal and state funding. Provisions in the Affordable Care Act expand Medicaid benefits to many older persons who did not previously qualify for the program.

People of any age can purchase long-term care insurance to cover health care costs not paid by Medicare or other health insurance. These policies can provide benefits for home care, respite, adult day care, nursing home care, assisted living, and other services. Policies vary in waiting periods, amount of funds paid per day or month, and types of services that qualify. Although beneficial, long-term care insurance has not attracted a significant number of subscribers. Part of the reason for this is that policies are expensive for older adults, and although less costly for persons of younger age groups, younger and healthier individuals tend not to think about long-term care.

Health Status The older population experiences fewer acute illnesses 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.

Chronic illness is a major problem for the older population. Most older adults have at least one chronic disease, and typically, they have multiple chronic conditions, termed comorbidity, that requires them to manage the care of several conditions simultaneously (Box 1-3). Chronic conditions result in some limitations in activities of daily living and instrumental activities of daily living for many individuals. The older the person is, the greater the likelihood of difficulty with self-care activities and independent living.

Box 1-3 Ten Leading Chronic Conditions Affecting Population Aged 65 Years and Older

1. Arthritis 2. High blood pressure 3. Hearing impairments 4. Heart conditions 5. Visual impairments (including cataracts) 6. Deformities or orthopedic impairments 7. Diabetes mellitus 8. Chronic sinusitis 9. Hay fever and allergic rhinitis (without asthma)

10. Varicose veins

Source: Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion. Retrieved April 14, 2012 from http://www.cdc.gov/chronicdisease/index.html

KEY CONCEPT 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.

Chronic diseases are also the leading causes of death (Table 1-2). A shift in death rates from various causes of death has occurred over the past three decades; deaths from heart disease have declined, whereas those from cancer have increased.

TABLE 1-2 Leading Causes of Death for Persons 65 Years of Age and Older

http://www.cdc.gov/chronicdisease/index.html

From National Center for Health Statistics. (2016). Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of death in selected age groups, by race and sex: United States, 2013. National Vital Statistics Reports, Vol. 65, No. 2, February 16, 2016. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_02.pdf

Concept Mastery Alert When planning health education sessions for older adults that address the health risks they face, the nurse should provide teaching about cancer risks, screening, recognition, and treatment. Often, educational sessions prioritize heart disease, although deaths from this cause are declining while cancer deaths are rising.

Despite the advances in the health status of the older population, disparities exist. Studies have found that older minorities have lower levels of health and function. The number of older Hispanics, blacks, and Asians admitted to nursing homes has been increasing, whereas the number of older white nursing home residents has been declining (Feng, Fennell, Tyler, Clark, & Mor, 2011).

http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_02.pdf

IMPLICATIONS OF AN AGING POPULATION The growing number of persons older than 65 years impacts health and social service agencies and health care providers—including gerontological nurses—that serve this group. As the older adult population grows, these agencies and providers must anticipate future needs of services and payment for these services.

Impact of the Baby Boomers In anticipating needs and services for future generations of older adults, gerontological nurses must consider the realities of the baby boomers—those born between 1946 and 1964—who will be the next wave of senior citizens. Their impact on the growth of the older population is such that it has been referred to as a demographic tidal wave. Baby boomers began entering their senior years in 2011 and will continue to do so until 2030. Although they are a highly diverse group, representing people as different as Bill Clinton, Bill Gates, and Cher, they do have some clearly defined characteristics that set them apart from other groups:

Most have children, but this generation’s low birth rate means that they will have fewer biologic children available to assist them in old age. They are better educated than preceding generations with slightly more than half having attended or graduated from college. Their household incomes tend to be higher than other groups, partly due to two incomes (three out of four baby boomer women are in the labor force), and most own their own homes They favor a more casual dress code than do previous generations of older adults. They are enamored with “high-tech” products, are likely to own a computer, and spend several hours online daily. Their leisure time is scarcer than other adults, and they are more likely to report feeling stressed at the end of the day. As inventors of the fitness movement, they exercise more frequently than do other adults.

Some assumptions can be made concerning the baby boomer population as senior adults. They are informed consumers of health care and desire a highly active role in their care; their ability to access information often enables them to have as much knowledge as their health care providers on some health issues. They are most likely not going to be satisfied with the conditions of today’s nursing homes and will demand that their long- term care facilities be equipped with bedside Internet access, gymnasiums, juice bars, pools, and alternative therapies. Their blended families may need special assistance because of the potential caregiving demands of several sets of stepparents and stepgrandparents. Plans for services and architectural designs must take these factors into consideration.

COMMUNICATION TIP Many baby boomers want to be informed health care consumers and are comfortable communicating via e-mail and text messages. They may prefer electronic appointment reminders and reports from diagnostic tests rather than telephone calls, and they appreciate links to fact sheets about their conditions and treatments. However, some members of this generation are not tech savvy and prefer traditional communication means, so it is important to ask about preferred style of communication during the assessment.

Provision of and Payment for Services The growing number of persons older than 65 years also impacts the government that is the source of payment for many of the services older adults need. The older population has higher rates of hospitalization, surgery, and physician visits than other age groups (Table 1-3), and this care is more likely to be paid by federal dollars than private insurers or older adults themselves.

TABLE 1-3 Average Length of Hospital Stay

National Center for Health Statistics. (2013). Health, United States, 2013. Table 98. Average length of stay in nonfederal short-stay hospitals, by sex, age, and selected first-listed diagnosis: United States, selected years 1990–2010. Retrieved from http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2011-a.pdf

Less than 5% of the older population is in a nursing home, assisted living community, or other institutional setting at any given time. Approximately one in four older adults will spend some time in a nursing home during the last years of their lives. Most people who enter nursing homes as private pay residents spend their assets by the end of 1 year and require government support for their care; most of the Medicaid budget is spent on long-term care.

As the percentage of the advanced-age population grows, society will face an increasing demand for the provision of and payment for services to this group. In this era of budget deficits, shrinking revenue, and increased competition for funding of other special interests, questions may arise about the ongoing ability of the government to provide a wide range of services for older adults. There may be concern that the older population is using a disproportionate amount of tax dollars and that limits should be set.

Gerontological nurses must be actively involved in discussions and decisions pertaining to the rationing of services so that the rights of older adults are expressed and protected. Likewise, gerontological nurses must assume leadership in developing cost-effective methods of care delivery that do not compromise the quality of services to older adults.

KEY CONCEPT Gerontological nurses need to be advocates in ensuring that cost-containment efforts do not jeopardize the welfare of older adults.

http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2011-a.pdf

BRINGING RESEARCH TO LIFE Geographical Variation in Health-Related Quality of Life Among Older US Adults, 1997–2010

Source: Kachan, D., Tannebaum, S. L., LeBanc, W. G., McClure, L. A., & Lee, D. J. (2014). Preventing Chronic Disease, 11:140023. doi: 10.5888/pcd11.140023#_blank. Retrieved from http://dx.doi.org/10.5888/pcd11.140023

Although the health-related quality of life (HRQOL) has been considered a predictor of morbidity and mortality, there had not been an exploration of its geographic variation. This study sought to investigate this issue by comparing the HRQOL in all of the states and the District of Columbia using the Health and Activities Limitation Index (HALex), in which higher values indicated better health. Data from the National Health Interview Survey for people aged 65 and older were analyzed as part of the study.

According to the study, the lowest health scores were found among older residents of Alaska, Alabama, Arkansas, Mississippi, and West Virginia, and the highest health scores were found among residents of Arizona, Delaware, Nevada, New Hampshire, and Vermont. Residents in the Northeast had health scores higher than those in the Midwest and South after adjustment for sociodemographics, health behaviors, and survey design. It was noted that older adults who migrated from the South to other states had higher disability rates. Older Floridians had a higher life expectancy than did older persons in other states, attributed to a high degree of compliance with physical exercise recommendations and a lower prevalence of smoking. Older Alaskans had the highest prevalence of drinking of all states, which could contribute to their low health scores.

Understanding differences in health status among states and the factors affecting them could assist in identifying and tailoring health promotion and education needs for persons of all ages that could contribute to healthier future generations of older adults.

http://dx.doi.org/10.5888/pcd11.140023

PRACTICE REALITIES You are in the break room of a hospital unit where several of the nurses are eating the birthday cake of Nurse Clark who is celebrating her 66th birthday. “I’m so glad to have coworkers like you and work that gives me a sense of purpose,” Nurse Clark commented as she thanked everyone and left the room.

Nurse Blake, in a low voice commented to the person sitting next to her, “I just don’t get it. I’m half her age and this job drains me, so you know it’s got to be taking its toll on her. Plus, we often get stuck doing the heavy work that she can’t do.”

“I know she doesn’t have the physical capabilities that some others may,” says Nurse Edwards, “but she sure is a storehouse of information and the patients love her.”

“Yes, but that isn’t helping my back when I have to pick up the slack for her,” responds Nurse Blake.

What are the challenges of having different generations in the workplace? Should allowances be made for older workers, and if so, what can be done to support these?

CRITICAL THINKING EXERCISES

1. What factors influence a society’s willingness to provide assistance to and display a positive attitude toward older individuals (e.g., general economic conditions for all age groups)?

2. List the anticipated changes in the characteristics of the older population of the future, and describe the implications for nursing.

3. What problems may older women experience as a result of gender differences in life expectancy and income?

4. What are some of the differences between older white and black Americans?

Chapter Summary Increases in life expectancy have resulted in persons over the age of 65 years now constituting more than 13% of the U.S. population. Although life expectancy has increased in general, the black population has a lower life expectancy than does the white population, reinforcing the importance of addressing health and social problems throughout the life span to promote longer and healthier life expectancies. In addition to extending life, there also must be concern for the compression of morbidity to assure added years of life are high-quality ones.

The primary source of health insurance for older adults is Medicare. Medicaid provides supplemental insurance for individuals with low incomes.

Although acute conditions occur at a lower rate in older adults than younger age groups, when they do develop they usually result in more complications and longer periods for recovery. Chronic conditions are the major health problems among older persons, with a majority being affected by at least one chronic disease. Chronic conditions contribute to the leading causes of death.

Baby boomers, a group composed of persons born between 1946 and 1964, have begun entering their senior years and are changing the profile of the older population. They are highly diverse, are better educated, have fewer children, have had higher incomes, and are greater users of technology than previous generations. Gerontological nurses will be challenged to recognize diversity among older adults as they assist these individuals in health promotion and disease management activities.

Online Resources National Center for Health Statistics

http://www.cdc.gov/nchs

References Feng, Z., Fennell, M. L., Tyler, D. A., Clark, M., & Mor, V. (2011). Growth of racial and ethnic minorities in U.S. nursing homes driven by demographics and possible disparities in options. Health Affairs, 33(7), 1358–1365.

Fries, J. F. (1980). Aging, natural death, and the compression of morbidity. New England Journal of Medicine, 303(3), 130–135.

Sutin, A. R., Stephan, Y., Carretta, H., & Terracciano, A. (2014). Perceived discrimination and physical, cognitive, and emotional health in older adulthood. American Journal of Geriatric Psychiatry, 22(3), 164–167.

Swartz, A. (2008). James Fries: healthy aging pioneer. American Journal of Public Health, 98(7), 1163–1166.

Recommended Readings Recommended Readings associated with this chapter can be found on the Web site that accompanies the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and additional resources associated with this chapter.

http://thepoint.lww.com/Eliopoulos9e

CHAPTER 2

Theories of Aging

CHAPTER OUTLINE

Biological Theories Of Aging

Stochastic Theories

Nonstochastic Theories

Sociologic Theories of Aging

Disengagement Theory

Activity Theory

Continuity Theory

Subculture Theory

Age Stratification Theory

Psychological Theories of Aging

Developmental Tasks

Gerotranscendence

Nursing Theories of Aging

Functional Consequences Theory

Theory of Thriving

Theory of Successful Aging

Applying Theories of Aging to Nursing Practice

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Discuss the change in focus regarding learning about factors influencing aging. 2. List the major biological theories of aging. 3. Describe the major psychosocial theories of aging. 4. Identify factors that promote a healthy aging process. 5. Describe the way in which gerontological nurses can apply theories of aging to nursing practice.

TERMS TO KNOW Aging:the process of growing older that begins at birth

Nonstochastic theories:explain biological aging as resulting from a complex, predetermined process

Stochastic theories:view the effects of biological aging as resulting from random assaults from both the internal and external environment

For centuries, people have been intrigued by the mystery of aging and have sought to understand it, some in hopes of achieving everlasting youth and others seeking the key to immortality. Throughout history, there have been numerous searches for a fountain of youth, the most famous being that of Ponce de León. Ancient Egyptian and Chinese relics show evidence of concoctions designed to prolong life or achieve immortality, and various other cultures have proposed specific dietary regimens, herbal mixtures, and rituals for similar ends. Ancient life extenders, such as extracts prepared from tiger testicles, may seem ludicrous until they are compared with more modern measures such as injections of embryonic tissue and Botox. Even persons who

would not condone such peculiar practices may indulge in nutritional supplements, cosmetic creams, and exotic spas that promise to maintain youth and delay the onset or appearance of old age.No single known factor causes or prevents aging; therefore, it is unrealistic to think that one theory can explain the complexities of this process. Explorations into biological, psychological, and social aging continue, and although some of this interest focuses on achieving eternal youth, most sound research efforts aim toward a better understanding of the aging process so that people can age in a healthier fashion and postpone some of the negative consequences associated with growing old. In fact, recent research has concentrated on learning about keeping people healthy and active for a longer period of time, rather than on extending their lives in a state of long- term disability. Recognizing that theories of aging offer varying degrees of universality, validity, and reliability, nurses can use this information to better understand the factors that may positively and negatively influence the health and well-being of persons of all ages.

BIOLOGICAL THEORIES OF AGING The process of biological aging differs not only from species to species but also from one human being to another. Some general statements can be made concerning anticipated organ changes, as described in Chapter 5; however, no two individuals age identically (Fig. 2-1). Varying degrees of physiologic changes, capacities, and limitations will be found among peers of a given age group. Further, the rate of aging among different body systems within one individual may vary, with one system showing marked decline while another demonstrates no significant change.

FIGURE 2-1 • Aging is a highly individualized process, demonstrated by the differences between persons of similar ages.

KEY CONCEPT The aging process varies not only among individuals but also within different body systems of the same person.

To explain biological aging, theorists have explored many factors, both internal and external to the human body, and have divided them into two categories: stochastic and nonstochastic. Stochastic theories view the

effects of aging as resulting from random assaults from both the internal and external environment.

Nonstochastic theories see aging changes resulting from a complex, predetermined process.

Stochastic Theories

Cross-Linking Theory The cross-linking theory proposes that cellular division is threatened as a result of radiation or a chemical reaction in which a cross-linking agent attaches itself to a DNA strand and prevents normal parting of the strands during mitosis. Over time, as these cross-linking agents accumulate, they form dense aggregates that impede intracellular transport; ultimately, the body’s organs and systems fail. An effect of cross-linking on collagen (an important connective tissue in the lungs, heart, blood vessels, and muscle) is the reduction in tissue elasticity associated with many age-related changes.

Free Radicals and Lipofuscin Theories The free radical theory suggests that aging is due to oxidative metabolism and the effects of free radicals (Hayflick, 1985). Free radicals are highly unstable, reactive molecules containing an extra electrical charge that are generated from oxygen metabolism. They can result from normal metabolism, reactions with other free radicals, or oxidation of ozone, pesticides, and other pollutants. These molecules can damage proteins, enzymes, and DNA by replacing molecules that contain useful biological information with faulty molecules that create genetic disorder. It is believed that these free radicals are self-perpetuating; that is, they generate other free radicals. Physical decline of the body occurs as the damage from these molecules accumulates over time. However, the body has natural antioxidants that can counteract the effects of free radicals to an extent. Also, beta-carotene and vitamins C and E are antioxidants that can offer protection against free radicals.

There has been considerable interest in the role of lipofuscin “age pigments,” a lipoprotein by-product of oxidation that can be seen only under a fluorescent microscope, in the aging process. Because lipofuscin is associated with the oxidation of unsaturated lipids, it is believed to have a role similar to that of free radicals in the aging process. As lipofuscin accumulates, it interferes with the diffusion and transport of essential metabolites and information-bearing molecules in the cells. A positive relationship exists between an individual’s age and the amount of lipofuscin in the body. Investigators have discovered the presence of lipofuscin in other species in amounts proportionate to the life span of the species (e.g., an animal with one tenth the life span of a human being accumulates lipofuscin at a rate approximately 10 times greater than human beings).

Wear and Tear Theories The comparison of the body’s wearing down to machines that lost their ability to function over time arose during the Industrial Revolution. Wear and tear theories attribute aging to the repeated use and injury of the body over time as it performs its highly specialized functions. Like any complicated machine, the body will function less efficiently with prolonged use and numerous insults (e.g., smoking, poor diet, and substance abuse).

In recent years, the effects of stress on physical and psychological health have been widely discussed. Stresses to the body can have adverse effects and lead to conditions such as gastric ulcers, heart attacks, thyroiditis, and inflammatory dermatoses. However, because individuals react differently to life’s stresses—one

person may be overwhelmed by a moderately busy schedule, whereas another may become frustrated when faced with a slow, dull pace—the role of stress in aging is inconclusive.

Evolutionary Theories Evolutionary theories of aging are related to genetics and hypothesize that the differences in the aging process and longevity of various species occur due to interplay between the processes of mutation and natural selection (Ricklefs, 1998; Gavrilov & Gavrilova, 2002). Attributing aging to the process of natural selection links these theories to those that support evolution.

There are several general groups of theories that relate aging to evolution. The mutation accumulation theory suggests that aging occurs due to a declining force of natural selection with age. In other words, genetic mutations that affect children will eventually be eliminated because the victims will not have lived long enough to reproduce and pass this to future generations. Genetic mutations that appear late in life, however, will accumulate because the older individuals they affect will have already passed these mutations to their offspring.

The antagonistic pleiotropy theory suggests that accumulated mutant genes that have negative effects in late life may have had beneficial effects in early life. This is assumed to occur either because the effects of the mutant genes occur in opposite ways in late life as compared with their effects in early life or because a particular gene can have multiple effects—some positive and some negative.

The disposable soma theory differs from other evolutionary theories by proposing that aging is related to the use of the body’s energy rather than to genetics. It claims that the body must use energy for metabolism, reproduction, maintenance of functions, and repair, and with a finite supply of energy from food to perform these functions, some compromise occurs. Through evolution, organisms have learned to give priority of energy expenditure to reproductive functions over those functions that could maintain the body indefinitely; thus, decline and death ultimately occur.

KEY CONCEPT Evolutionary theories suggest that aging “is fundamentally a product of evolutionary forces, not biochemical or cellular quirks … a Darwinian phenomenon, not a biochemical one” (Rose, 1998).

Concept Mastery Alert The evolutionary theory of aging proposes that people are living longer due to the emphasis on natural selection through reproduction, whereas the biogerontology theory of aging attributes longer life to the prevention and control of pathogens.

Biogerontology The study of the connection between aging and disease processes has been termed biogerontology (Miller, 1997). Bacteria, fungi, viruses, and other organisms are thought to be responsible for certain physiologic changes during the aging process. In some cases, these pathogens may be present in the body for decades before they begin to affect body systems. Although no conclusive evidence exists to link these pathogens with the body’s decline, interest in this theory has been stimulated by the fact that human beings and animals have enjoyed longer life expectancies with the control or elimination of certain pathogens through immunization and the use of antimicrobial drugs.

Nonstochastic Theories

Apoptosis Apoptosis is the process of programmed cell death that continuously occurs throughout life due to biochemical events (Green, 2011). In this process, the cell shrinks and there is nuclear and DNA fragmentation, although the membrane maintains its integrity. It differs from cell death that occurs from injury in which there is swelling of the cell and loss of membrane integrity. According to this theory, this programmed cell death is part of the normal developmental process that continues throughout life.

Genetic Theories Among the earliest genetic theories, the programmed theory of aging proposes that animals and humans are born with a genetic program or biological clock that predetermines the life span (Hayflick, 1965). Various studies support this idea of a predetermined genetic program for life span. For example, studies have shown a positive relationship between parental age and filial life span. Additionally, studies of in vitro cell proliferation have demonstrated that various species have a finite number of cell divisions. Fibroblasts from embryonic tissue experience a greater number of cell divisions than those derived from adult tissue, and among various species, the longer the life span, the greater the number of cell divisions. These studies support the theory that senescence—the process of becoming old—is under genetic control and occurs at the cellular level (Harvard Gazette Archives, 2001; Martin, 2009; University of Illinois at Urbana-Champaign, 2002).

The error theory also proposes a genetic determination for aging. This theory holds that genetic mutations are responsible for aging by causing organ decline as a result of self-perpetuating cellular mutations, as illustrated in Figure 2-2.

FIGURE 2-2 • The error theory proposes a genetic determination for aging.

Other theorists think that aging results when a growth substance fails to be produced, leading to the cessation of cell growth and reproduction. Others hypothesize that an aging factor responsible for development and cellular maturity throughout life is excessively produced, thereby hastening aging. Some hypothesize that the cell’s ability to function and divide is impaired. Although minimal research has been done to support the theory, aging may be the result of a decreased ability of RNA to synthesize and translate messages.

POINT TO PONDER What patterns of aging are apparent in your biological family? What can you do to influence these?

Autoimmune Reactions The primary organs of the immune system, the thymus and bone marrow, are believed to be affected by the aging process. The immune response declines after young adulthood. The weight of the thymus decreases throughout adulthood, as does the ability to produce T-cell differentiation. The level of thymic hormone declines after age 30 and is undetectable in the blood of persons older than 60 years (Goya, Console, Herenu, Brown, & Rimoldi, 2002; Williams, 1995). Related to this is a decline in the humoral immune response, a delay in the skin allograft rejection time, a reduction in the intensity of delayed hypersensitivity, and a decrease in the resistance to tumor cell challenge. The bone marrow stem cells perform less efficiently. The reduction in immunologic functions is evidenced by an increase in the incidence of infections and many cancers with age.

Some theorists believe that the reduction in immunologic activities also leads to an increase in autoimmune response with age. One hypothesis regarding the role of autoimmune reactions in the aging process is that the cells undergo changes with age, and the body misidentifies these aged, irregular cells as foreign agents and develops antibodies to attack them. An alternate explanation for this reaction could be that cells are normal in old age, but a breakdown of the body’s immunochemical memory system causes it to misinterpret normal cells as foreign substances. Antibodies are formed to attack and rid the body of these “foreign” substances, and cells die.

CONSIDER THIS CASE

You volunteer with a service organization that is involved with several community projects. Mrs. Janus, one of the volunteers you work with, shares with you and the other volunteers that she and her husband have become distributors for “a fantastic product that makes you look and feel younger.” She claims they have been using the product for nearly a year and have seen significant improvements in the way they look and feel. The couple is in their 70s and are attractive and

active.

Mrs. Janus passes out invitations to you and the other volunteers to attend a meeting at their home to learn more about the products. Many of the volunteers show considerable interest and indicate they will attend. One of the volunteers then turns to you and says, “You’re a nurse. Do you think these things work?”

THINK CRITICALLY

How can consumers judge the validity of claims of antiaging products? What evidence-based advice can be given to aging persons to help them reduce the potential for some of the negative outcomes of aging?

Neuroendocrine and Neurochemical Theories Neuroendocrine and neurochemical theories suggest that aging is the result of changes in the brain and endocrine glands. Some theorists claim that specific anterior pituitary hormones promote aging. Others believe that an imbalance of chemicals in the brain impairs healthy cell division throughout the body.

Radiation Theories The relationship between radiation and age continues to be explored. Research using rats, mice, and dogs has shown that a decreased life span results from nonlethal doses of radiation. In human beings, repeated exposure to ultraviolet light is known to cause solar elastosis, the “old age” type of skin wrinkling that results from the replacement of collagen by elastin. Ultraviolet light is also a factor in the development of skin cancer. Radiation may induce cellular mutations that promote aging.

Nutrition Theories The importance of good nutrition throughout life is a theme hard to escape in our nutrition-conscious society. It is no mystery that diet impacts health and aging. Obesity is shown to increase the risk of many diseases and shorten life (NIDDK, 2001; Preston, 2005; Taylor & Ostbye, 2001).

The quality of diet is as important as the quantity. Deficiencies of vitamins and other nutrients and excesses of nutrients such as cholesterol may cause various disease processes. Recently, increased attention has been given to the influence of nutritional supplements on the aging process; vitamin E, bee pollen, ginseng, gotu kola, peppermint, and kelp are among the nutrients believed to promote a healthy, long life (Margolis, 2000; Smeeding, 2001). Although the complete relationship between diet and aging is not well understood, enough is known to suggest that a good diet may minimize or eliminate some of the ill effects of the aging process.

KEY CONCEPT

It is beneficial for nurses to advise aging persons to scrutinize products that claim to cause, stop, or reverse the aging process.

Environmental Theories Several environmental factors are known to threaten health and are thought to be associated with the aging process. The ingestion of mercury, lead, arsenic, radioactive isotopes, certain pesticides, and other substances can produce pathologic changes in human beings. Smoking and breathing tobacco smoke and other air pollutants also have adverse effects. Finally, crowded living conditions, high noise levels, and other factors are thought to influence how we age.

POINT TO PONDER Do you believe nurses have a responsibility to protect and improve the environment? Why or why not?

Sociologic Theories of Aging Disengagement Theory Sociologic theories address the impact of society on older adults and vice versa. These theories often reflect the view held about older adults at the time they were developed. The norms of society affected how the older adult’s roles and relationships were viewed.

Developed by Elaine Cumming and William Henry, the disengagement theory (Cumming, 1964; Cumming & Henry, 1961) has been one of the earliest, most controversial, and most widely discussed theories of aging. It views aging as a process in which society and the individual gradually withdraw, or disengage, from each other, to the mutual satisfaction and benefit of both. The benefit to individuals is that they can reflect and be centered on themselves, having been freed from societal roles. The value of disengagement to society is that some orderly means is established for the transfer of power from the old to the young, making it possible for society to continue functioning after its individual members die. The theory does not indicate whether society or the individual initiates the disengagement process.

Several difficulties with this concept are obvious and this theory has now been discredited (Johnson, 2009). Many older persons desire to remain engaged and do not want their primary satisfaction to be derived from reflection on younger years. Senators, Supreme Court justices, college professors, and many senior volunteers are among those who commonly derive satisfaction and provide a valuable service to society by not disengaging. Because the health of the individual, cultural practices, societal norms, and other factors influence the degree to which a person will participate in society during his or her later years, some critics of this theory claim that disengagement would not be necessary if society improved the health care and financial means of older adults and increased the acceptance, opportunities, and respect afforded to them.

A careful examination of the population studied in the development of the disengagement theory hints at its limitations. The disengagement pattern that Cumming and Henry described was based on a study of 172 middle-class persons between 48 and 68 years of age. This group was wealthier, better educated, and of higher occupational and residential prestige than the general aged population. No black people or chronically ill people were involved in the study. Caution is advisable in generalizing findings for the entire aged population based on fewer than 200 persons who are generally not representative of the average aged person. (This study exemplifies some of the limitations of gerontological research before the 1970s.) Although nurses should appreciate that some older individuals may wish to disengage from the mainstream of society, this is not necessarily a process to be expected from all aging persons.

Activity Theory At the opposite pole from the disengagement theory, the activity theory asserts that an older person should continue a middle-aged lifestyle, denying the existence of old age as long as possible, and that society should apply the same norms to old age as it does to middle age and not advocate diminishing activity, interest, and involvement as its members grow old (Havighurst, 1963). This theory suggests ways of maintaining activity in the presence of multiple losses associated with the aging process, including substituting intellectual activities for physical activities when physical capacity is reduced, replacing the work role with other roles when retirement occurs, and establishing new friendships when old ones are lost. Declining health, loss of roles, reduced income, a shrinking circle of friends, and other obstacles to maintaining an active life are to be resisted and overcome instead of being accepted.

This theory has some merit. Activity is generally assumed to be more desirable than inactivity because it facilitates physical, mental, and social well-being. Like a self-fulfilling prophecy, the expectation of a continued active state during old age may be realized to the benefit of older adults and society. Because of society’s negative view of inactivity, encouraging an active lifestyle among the aged is consistent with societal values. Also supportive of the activity theory is the reluctance of many older persons to accept themselves as old.

A problem with the activity theory is its assumption that most older people desire and are able to maintain a middle-aged lifestyle. Some aging persons want their world to shrink to accommodate their decreasing capacities or their preference for less active roles. Many older adults lack the physical, emotional, social, or economic resources to maintain active roles in society. Aged people who are expected to maintain an active middle-aged lifestyle on an income of less than half that of middle-aged people may wonder if society is giving them conflicting messages. More research and insights are needed regarding the effects on the older adults of not being able to fulfill expectations to remain active.

Continuity Theory The continuity theory of aging, also referred to as the developmental theory, relates personality and predisposition toward certain actions in old age to similar factors during other phases of the life cycle (Neugarten, 1964). Personality and basic patterns of behavior are said to remain unchanged as the individual ages. For instance, activists at 20 years of age will most likely be activists at 70 years of age, whereas young recluses will probably not be active in the mainstream of society when they age. Patterns developed over a lifetime will determine whether individuals remain engaged and active or become disengaged and inactive.

The recognition that the unique features of each individual allow for multiple adaptations to aging and that the potential exists for a variety of reactions gives this theory validity and support. Aging is a complex process, and the continuity theory considers these complexities to a greater extent than most other theories. Although the full implications and impact of this promising theory are at the stage of research, it offers a reasonable perspective. Also, it encourages the young to consider that their current activities will lay a foundation for their own future old age.

KEY CONCEPT Basic psychological patterns are consistent throughout the life span.

Subculture Theory This theory views older adults as a group with distinct norms, beliefs, expectations, habits, and issues that separate them from the rest of society (Rose, 1965). Their formation of a subculture is a response to the negative attitudes and treatment by society. Older persons are accepted by and more comfortable among their own age group. A component of this theory is the argument for social reform and greater empowerment of the older populations so that their rights and needs can be respected.

As the population of older adults becomes more diverse, their needs better addressed, and their power recognized, the question can be raised that this theory is less relevant today than it was in the 1960s when it was first offered.

Age Stratification Theory This theory, appearing in the 1970s, suggests that society is stratified by age groups (Riley, Johnson, & Foner, 1972). Persons within a similar age group generally have similar experiences, beliefs, attitudes, and life transitions that offer them a unique shared history. New age groups are continually being formed with the birth of new individuals; thus, the interaction between society and the aging population is dynamic. As each group ages, they have their own unique experience with and influence on society, and there is an interdependence between society and the group.

POINT TO PONDER How would you expect the aging experience of Generation X and Generation Y to differ from that of the baby boomers and their parents?

Psychological Theories of Aging Developmental Tasks Psychological theories of aging explore the mental processes, behavior, and feelings of persons throughout the life span, along with some of the mechanisms people use to meet the challenges they face in old age. Among these theories are those that describe the process of healthy psychological aging as the result of the successful fulfillment of developmental tasks. Developmental tasks are the challenges that must be met and adjustments that must be made in response to life experiences that are part of an adult’s continued growth through the life span.

Erik Erikson (1963) described eight stages through which human beings progress from infancy to old age and the challenges, or tasks, that confront individuals during each of these stages (Table 2-1). The challenge of old age is to accept and find meaning in the life the person has lived; this gives the individual ego integrity that aids in adjusting and coping with the reality of aging and mortality. Feelings of anger, bitterness, depression, and inadequacy can result in inadequate ego integrity (e.g., despair).

TABLE 2-1 Erikson’s Developmental Tasks

Refining Erikson’s description of old age tasks in the eighth stage of development, Robert Peck (1968) detailed three specific challenges facing the older adults that influence the outcome of ego integrity or despair:

Ego differentiation versus role preoccupation: to develop satisfactions from oneself as a person rather than

through parental or occupational roles

Body transcendence versus body preoccupation: to find psychological pleasures rather than become absorbed with health problems or physical limitations imposed by aging Ego transcendence versus ego preoccupation: to achieve satisfaction through reflection on one’s past life and accomplishments rather than be preoccupied with the finite number of years left to live

Robert Butler and Myrna Lewis (1982) outlined additional developmental tasks of later life:

Adjusting to one’s infirmities Developing a sense of satisfaction with the life that has been lived Preparing for death

Gerotranscendence Gerotranscendence is a recent theory that suggests aging entails a transition from a rational, materialistic metaperspective to a cosmic and transcendent vision (Tornstam, 2005). As people age, they are less concerned with their physical bodies, material possessions, meaningless relationships, and self-interests and instead desire a life of more significance and a greater connection with others. There is a desire to shed roles and invest time in discovering hidden facets of oneself.

POINT TO PONDER How do you see examples of gerotranscendence in the lives of others and yourself?

KEY CONCEPT Nurses can promote joy and a sense of purpose in the older adults by viewing old age as an opportunity for continued development and satisfaction rather than a depressing, useless period of life.

Nursing Theories of Aging Although there are many classic theories that describe biological, social, and psychological aging, none integrate all of these various dimensions of aging into a holistic theory. Because nurses address all aspects of the person, theories that offer the holistic perspective would be valuable in guiding nursing care. In an effort to address this need, several nurses have recently developed theories of aging.

Functional Consequences Theory The Functional Consequences Theory for Promoting Wellness in Older Adults (Miller, 2014) integrates theories from aging and holistic nursing. It holds that nurses can promote wellness by addressing individuals holistically, recognizing the interconnection of body, mind, and spirit. The consequences of age-related changes and risk factors can result in either positive or negative functional consequences (i.e., wellness outcomes) for older adults. Through interventions that promote wellness and alleviate or reduce the impact of negative factors, nurses can promote positive functional consequences.

Theory of Thriving Based on their view that aging theories have been remiss in linking theories together, the authors of this theory propose that everything that impacts people throughout their lives must be linked to create a holistic view of aging (Haight, Barba, Tesh, & Courts, 2002). They base their theory on the failure to thrive concept as it related to older adults in nursing homes (Newbern & Krowchuk, 1994); the clinical characteristics of older persons experiencing failure to thrive include disconnectedness, inability to find meaning in life, problems with social relationships, and physical and cognitive dysfunction. In contrast, thriving is possible when harmony exists between individuals and their physical and human environments. The process of thriving is continuous and enables aging individuals to find meaning in life and adapt to changes. This theory reinforces the importance of nurses considering the many factors that can impact health and quality of life for older adults.

Theory of Successful Aging By integrating Roy’s adaptation model with the theory of gerotranscendence and other aging literature, Flood (2005) attempt to develop a nursing theory to guide the care of older adults. The Adaptation Model of Nursing, developed by Sister Callista Roy, saw the individual as a biopsychosocial being that continuously interacts with and adapts to the changing internal and external environment (Roy & Andrews, 2008). Roy viewed health on a continuum and involves the person becoming an integrated, whole individual.

The Theory of Successful Aging not only considers successful aging in terms of the older adult’s physical, mental, and spiritual well-being but also includes the individual’s self-appraisal. Flood hypothesizes that people with high levels of personal control and a positive affect will experience higher levels of wellness in aging due to their ability to participate in health-promoting activities. Higher levels of physical health, in turn, contribute to deeper spirituality. These factors contribute to greater life satisfaction and the aging individual’s positive perception of his or her status. By aiding older adults in achieving high levels of health and personal control over their lives, nurses can help aging individuals to have a positive view of their lives, which in turn can promote their ability to cope and achieve greater life satisfaction with age.

COMMUNICATION TIP Nurses occasionally may hear people mentioning factors that influence aging and suggestions for addressing them. This can range from them stating that “there’s nothing that can be done about how we age” to “taking supplement x can keep you from showing any signs of aging.” These thoughts can result in people either not taking actions that can influence a healthy aging process or risking their health and finances on unproven antiaging products. Clarifying misconceptions is beneficial. (See Box 2-1.)

Box 2-1 Factors Contributing to a Long and Healthy Life Diet. A positive health state that can contribute to longevity is supported by reducing saturated fats in the diet, limiting daily fat consumption to less than 30% of caloric intake, avoiding obesity, decreasing the amount of animal foods eaten, substituting natural complex carbohydrates for refined sugars, and increasing the consumption of whole grains, vegetables, and fruits.

Activity. Exercise is an important ingredient to good health. It increases strength and endurance, promotes cardiopulmonary function, and has other beneficial effects that can affect a healthy aging process.

Play and laughter. Laughter causes a release of endorphins, stimulates the immune system, and reduces stress. Finding humor in daily routines and experiencing joy despite problems contribute to good health. It has been suggested since the time of Solomon that “a cheerful heart is good medicine, but a crushed spirit dries up the bones” (Proverbs 17:22).

Faith. A strong faith, church attendance, and prayer are directly related to lower rates of physical and mental illness. Religion and spirituality can have a positive effect on the length and quality of life.

Empowerment. Losing control over one’s life can threaten self-confidence and diminish self-care independence. Maximum control and decision making can have a positive effect on morbidity and mortality.

Stress management. It is the rare individual who is unaware of the negative consequences of stress. The unique stresses that may accompany aging, such as the onset of chronic conditions, retirement, deaths of significant others, and change in body appearance, can have significantly detrimental effects. Minimizing stress when possible and using effective stress management techniques are useful interventions.

Applying Theories of Aging to Nursing Practice The number, diversity, and complexity of factors that potentially influence the aging process show that no one theory can adequately explain the cause of this phenomenon. Even when studies have been done with populations known to have a long life expectancy, such as the people of the Caucasus region in southern Russia, longevity has not been attributable to any single factor.

The biological, psychological, and social processes of aging are interrelated and interdependent. Frequently, loss of a social role affects an individual’s sense of purpose and speeds physical decline. Poor health may force retirement from work, promoting social isolation and the development of a weakened self- concept. Although certain changes occur independently as separate events, most are closely associated with other age-related factors. Wise nurses will be open-minded in choosing the aging theories they use in the care of older adults; they will also be cognizant of the limitations of these theories.

Nurses can adapt these theories by identifying elements known to influence aging and using them as a foundation to promote positive practices. Box 2-1 highlights some factors to consider in promoting a healthy aging process.

In addition, gerontological nurses play a significant role in helping aging persons experience health, fulfillment, and a sense of well-being. In addition to specific measures that can assist the older adults in meeting their psychosocial challenges (Box 2-2), nurses must be sensitive to the tremendous impact their own attitudes toward aging can have on patients. Nurses who consider aging as a progressive decline ending in death may view old age as a depressing, useless period and foster hopelessness and helplessness in older patients. However, nurses who view aging as a process of continued development may appreciate late life as an opportunity to gain new satisfaction and understanding, thereby promoting joy and a sense of purpose in patients.

Box 2-2 Assisting Individuals in Meeting the Psychosocial Challenges of Aging OVERVIEW As individuals progress through their life span, they face challenges and adjustments in response to life experiences called developmental tasks. These developmental tasks can be described as:

Coping with losses and changes Establishing meaningful roles Exercising independence and control Finding purpose and meaning in life

Satisfaction with oneself and the life one has lived is gained by successfully meeting these tasks; unhappiness, bitterness, and fear of one’s future can result from not adjusting to and rejecting the realities of aging.

GOAL

Aging persons will express a sense of ego integrity and psychosocial well-being.

ACTIONS

Learn about patients’ life stories; ask about family backgrounds, faith, work histories, hobbies, achievements, and life experiences. Encourage patients to discuss these topics, and listen with sincere interest. Build on lifelong interests and offer opportunities for patients to experience new pleasures and interests. Accept patients’ discussions of their regrets and dissatisfactions. Help them to put these in perspective of their total lives and accomplishments. Encourage reminiscence activities between patients and their families. Help families and staff to understand the therapeutic value of reminiscence. Respect patients’ faith and assist them in the fulfillment of spiritual needs (e.g., help them locate a church of their religious affiliation, request visits from clergy, pray with or for them, and obtain a Bible or other religious book). Use humor therapeutically. If patients reside in an institutional setting, personalize the environment to the maximum degree possible. Recognize the unique assets and characteristics of each patient.

POINT TO PONDER How would you evaluate the quality of the factors that promote longevity in your own life?

BRINGING RESEARCH TO LIFE Construction, Deconstruction, and Reconstruction: The Roots of Successful Aging Theories

Source: Topaz, M., Troutman-Jordan, M., & MacKenzie, M. (2014). Nursing Science Quarterly, 27(3), 226–233.

This article reviews the evolution of theories explaining successful aging as they relate to nursing. Theories of aging arising in the early 20th century were dominated by the belief that absolute truth could be derived through scientific objectivity and observation. The aging process was considered to be similar for all individuals and characterized by decreasing functional capacity. Most nurse theorists at this time concurred with the thinking of the theorists and viewed aging as a biological and functional process common to all.

The postmodern era deconstructed boundaries. Rather than view aging as a universal experience, theorists of this era believed that each individual personally defines what aging means. They challenged the stereotyping of older adults. During this era, there was a growth in qualitative methodologies and diverse nursing theories that promoted a holistic approach to individuals and their care.

The 21st century brought the reconstruction of theories of aging. Subjective understanding was valued along with the objective of gaining knowledge about aging. Successful aging was conceptualized as the ability to preserve physical and mental function and adapt to change into old age to enable continued active engagement in life. Positive spirituality also was recognized as serving an important role in successful aging. Interventions to assist older adults to adapt and meet their own personal goals became part of nursing’s focus.

It is important for nurses to understand the evolution of theories of successful aging because they influence values and beliefs about the aging process and older adults. From viewing all aging individuals similarly and focusing care on anticipated functional declines to adopting a holistic view that respects individual differences in aging experiences and desires, approaches to care are significantly influenced by predominant theories.

PRACTICE REALITIES You are presenting a class on positive health practices to a group at a local senior center. At the end of the class, there is a lively discussion and one of the older participants comments, “No matter what you do, how you age is decided by your ancestors. My grandparents ate tons of fatty foods and never exercised and they lived to their 90s.”

“Oh, you’re wrong,” offers another member of the group. “I’ve been taking a supplement that my neighbor sells that will override the problems you inherited and I’m much healthier than my parents were at my age.”

How would you react to these comments and guide the discussion?

CRITICAL THINKING EXERCISES

1. What disease processes are caused by or related to factors believed to influence aging? 2. You are asked to speak to a community group regarding environmental issues. What recommendations

could you make for promoting a healthy environment? 3. Think about everyday life in your community. What examples do you see of opportunities to engage and

disengage older adults? 4. What specific methods could you use to assist an older adult in achieving ego integrity?

Chapter Summary The aging process varies not only among individuals but among systems within an individual. Biological aging has been described by stochastic theories that view aging as the result of random assaults from the internal and external environment and nonstochastic theories that view aging as being a complex, predetermined process. Stochastic theories include the cross-link, free radicals, lipofuscin, wear and tear, evolutionary, and biogerontology theories. Nonstochastic theories describe the role of apoptosis, genetic programming and mutations, autoimmune reactions, neuroendocrines, neurochemicals, radiation, nutrition, and the environment in the aging process.

Among the sociologic theories of aging, the disengagement theory is one of the earliest, viewing aging as a process in which society and the individual gradually withdraw, or disengage, from each other, to the mutual satisfaction and benefit of both; this theory has fallen out of favor. The activity theory proposes that to age in a healthy manner, individuals need to stay active and engaged in society. Recognizing that not all individuals disengage or are active in society as they age, the continuity theory suggests that individuals will maintain the patterns of engagement in old age that they practiced throughout their life span. Due to their distinct norms, beliefs, and issues, some theorize that older adults constitute a subculture; however, this theory may have less relevancy as the population of older adults becomes increasingly diverse. The age stratification theory suggests the similarities among various age groups cause them to have unique experiences and interactions with society. Psychological theories of aging explore the mental processes, behavior, and feelings of persons throughout the life span, along with some of the mechanisms people use to meet the challenges they face in old age. Erikson described developmental tasks that face people during each stage of life, with the task in old age to find ego integrity versus despair. Peck developed this further by offering specific challenges that older adults face as they strive for ego integrity; Butler and Lewis also offered specific developmental tasks of late life. Some theorists propose that with age, there is a transition from material to nonmaterial concerns, known as gerotranscendence.

The journey of aging can be unique for each individual and impacted by many factors. Therefore, nurses need to have a holistic focus in assessing, planning, and providing care.

References Butler, R. N., & Lewis, M. I. (1982). Aging and mental health (3rd ed., pp. 142, 376). St. Louis, MO: Mosby.

Cumming, E. (1964). New thoughts on the theory of disengagement. In R. Kastenbaum (Ed.), New thoughts on old age. New York, NY: Springer-Verlag.

Cumming, E., & Henry, E. (1961). Growing old: The process of disengagement. New York, NY: Basic Books.

Erikson, E. (1963). Childhood and society (2nd ed.). New York, NY: Norton.

Flood, M. (2005). A mid-range nursing theory of successful aging. Journal of Theory Construction & Testing, 9(2), 35–39.

Gavrilov, L. A., & Gavrilova, N. S. (2002). Evolutionary theories of aging and longevity. The Scientific World Journal, 2, 339–356.

Goya, R. G., Console, G. M., Herenu, C. B., Brown, O. A., & Rimoldi, O. J. (2002). Thymus and aging: Potential of gene therapy for restoration of endocrine thymic function in thymus-deficient animal models. Gerontology, 48(5), 325–328.

Green, D. (2011). Means to an end. New York, NY: Cold Spring Harbor Laboratory Press.

Haight, B. K., Barba, B. E., Tesh, A. S., & Courts, N. F. (2002). Thriving: A life span theory. Journal of Gerontological Nursing, 28(3), 14–22.

Harvard Gazette Archives. (2001). Scientists identify chromosome location of genes associated with long life. Harvard University Gazette. Retrieved August 28, 2001 from http://www.news.harvard.edu/gazette/2001/08.16/chromosomes.html

Havighurst, J. (1963). Successful aging. In R. H. Williams, C. Tibbitts, & W. Donahue (Eds.), Processes of aging (Vol. 1, p. 299). New York, NY: Atherton Press.

Hayflick, L. (1965). The limited in vitro lifetime of human diploid cell strains. Experimental Cell Research, 37, 614–636.

Hayflick, L. (1985). Theories of biologic aging. Experimental Gerontology, 10, 145–159.

Johnson, M. (2009). Spirituality, finitude, and theories of the life span. In V. I. Bengston, M. Silverstein, N. M. Putney, & D. Gans (Eds.), Handbook of theories of aging (2nd ed., pp. 659–674). New York, NY: Springer Publishing Co.

Margolis, S. (Ed.). (2000). Vitamin E recommendations. The Johns Hopkins Medical Letter: Health After 50, 12(1), 8.

Martin, G. M. (2009). Modalities of gene action predicted by the classical evolutional theories of aging. In V. I. Bengston, M. Silverstein, N. M. Putney, & D. Gans (Eds.), Handbook of theories of aging (2nd ed., pp. 179–191). New York, NY: Springer Publishing Co.

Miller, C. A. (2014). Nursing for wellness in older adults (7th ed., pp. 40–45). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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Miller, R. A. (1997). When will the biology of aging become useful? Future landmarks in biomedical gerontology. Journal of the American Geriatrics Society, 45, 1258–1267.

National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. (2001). Understanding adult obesity. Bethesda, MD: Author. NIH Publication No. 01-3680.

Neugarten, L. (1964). Personality in middle and late life. New York, NY: Atherton Press.

Newbern, V. B., & Krowchuk, H. V. (1994). Failure to thrive in elderly people: A conceptual analysis. Journal of Advanced Nursing, 19(5), 840–849.

Peck, R. (1968). Psychological developments in the second half of life. In B. Neugarten (Ed.), Middle age and aging (p. 88). Chicago, IL: University of Chicago.

Preston, S. H. (2005). Deadweight? The influence of obesity on longevity. New England Journal of Medicine, 352(11), 1135–1137.

Ricklefs, R. E. (1998). Evolutionary theories of aging: confirmation of a fundamental prediction, with implications for the genetic basis and evolution of life span. The American Naturalist, 152(1), 24–44.

Riley, M. M., Johnson, M., & Foner, A. (1972). Aging and society, vol. 3: A sociology of age stratification. New York, NY: Russell Sage Foundation.

Rose, A. M. (1965). The subculture of the aging: A framework for research in social gerontology. In A. M. Rose, & W. Peterson (Eds.), Older people and their social worlds. Philadelphia, PA: F.A. Davis.

Rose, M. R. (1998). Darwinian anti-aging medicine. Journal of Anti-Aging Medicine, 1, 106.

Roy, C., & Andrews, H. A. (2008). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Prentice- Hall.

Smeeding, S. J. W. (2001). Nutrition, supplements, and aging. Geriatric Nursing, 22(4), 219–224.

Taylor, D. H., & Ostbye, T. (2001). The effect of middle- and old-age body mass index on short-term mortality in older people. Journal of the American Geriatrics Society, 49(10), 1319–1326.

Tornstam, L. (2005). Gerotranscendence: A developmental theory of positive aging. New York, NY: Springer.

University of Illinois at Urbana-Champaign. (2002). Study backs theory that accumulating mutations of “quiet” genes foster aging. Science News Daily. Retrieved October 15, 2002 from http://www.sciencedaily.com/releases/2002/10/021015073143.htm

Williams, M. E. (1995). The American Geriatrics Society’s complete guide to aging and health (p. 13). New York, NY: Harmony Books.

Recommended Readings Recommended readings associated with this chapter can be found on the Web site that accompanies the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and additional resources associated with this chapter.

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http://thepoint.lww.com/Eliopoulos9e

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CHAPTER 3

Diversity

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CHAPTER OUTLINE

Increasing Diversity Of The Older Adult Population

Overview Of Diverse Groups Of Older Adults In The United States

Hispanic Americans

Black Americans

Asian Americans

Jewish Americans

Native Americans

Muslims

Gay, Lesbian, Bisexual, and Transgender Older Adults

Nursing Considerations For Culturally Sensitive Care Of Older Adults

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Describe projected changes in the diversity of the older population in the United States. 2. Describe unique views of health and healing among major ethnic groups. 3. Identify ways in which nursing care may need to be modified to accommodate persons of diverse ethnic backgrounds.

TERMS TO KNOW Bisexual someone sexually attracted to persons of both sexes

Culture shared beliefs and values of a group: the beliefs, customs, practices, and social behavior of a particular group of people

Ethnic a group of people sharing a common racial, national, religious, linguistic, or cultural heritage

Ethnogeriatrics the effects of ethnicity and culture on the health and well-being of older adults

Gay someone sexually attracted to a person of the same sex; homosexual

Lesbian a woman who is sexually attracted to other women

Race a group of people that share some biological characteristics

Transgender a person whose identity, appearance, and/or behavior varies from that which the culture views as conventional for his or her gender; sometimes referred to as transsexual or transvestite

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INCREASING DIVERSITY OF THE OLDER ADULT POPULATION Population projections support the view that the older population in the United States is becoming more ethnically and racially diverse. Nearly one in eight people in the United States speak a language other than English at home, with one third of these people speaking Spanish (Wan, Sengupta, Velkoff, & DeBarros, 2005). In 2000, approximately 84% of older Americans were non-Hispanic White, while it is projected that this population will decrease to 64% by 2050. During this same period, there will be a dramatic growth among Hispanic older adults, who will represent nearly 20% of the older population. Black individuals will grow from 8% to over 12% of the older population during this time. By 2020, one quarter of America’s older population will belong to a minority racial or ethnic group (Administration on Aging, 2014; U.S. Census Bureau, 2014). And, in addition to racial and ethnic diversity, there will be growing numbers of lesbian, gay, bisexual, and transgender persons entering their senior years who will present a unique set of challenges.

KEY CONCEPT Ethnogeriatrics is a term used to describe the effects of ethnicity and culture on the health and well- being of older adults. The American Geriatrics Society has identified this as an important component of geriatrics.

The growing diversity of the older population presents challenges for gerontological nursing in providing culturally competent care. Essential to the provision of culturally competent care is an understanding of:

The experiences of individuals of similar ethnic or racial backgrounds Beliefs, values, traditions, and practices of various ethnic and racial groups Unique health-related needs, experiences, and risks of various ethnic and racial groups and persons of similar sexual orientation One’s own attitudes and beliefs toward people of various ethnic and racial groups, and persons of similar sexual orientation, as well as those attitudes of coworkers Language barriers that can affect the ability of patients to communicate health-related information, understand instructions, provide informed consent, and fully participate in their care

An understanding of cultural, ethnic, and sexual orientation differences can help to erase the stereotypes and biases that can interfere with effective care and demonstrate an appreciation for the unique characteristics of each individual.

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OVERVIEW OF DIVERSE GROUPS OF OLDER ADULTS IN THE UNITED STATES People from a variety of countries have ventured to America to seek a better life in a new land. To an extent, they assimilated and adopted the American way of life; however, the values and customs instilled in them by their native cultures are often deeply ingrained, along with their language and biological differences. The unique backgrounds of these newcomers to America influence the way they react to the world around them and the manner in which that world reacts to them. To understand the uniqueness of each older adult encountered, consideration must be given to the influences of ethnic origin.

Members of an ethnic or cultural group share similar history, language, customs, and characteristics; they also hold distinct beliefs about aging and older adults. Ethnic norms can influence diet, response to pain, compliance with self-care activities and medical treatments, trust in health care providers, and other factors. The traditional responsibilities assigned to the aged of some ethnic groups can afford them opportunities for meaningful roles and high status.

Studies of cultural influences on aging and effects on older adults have been sparse but are growing. Experiences and observations can provide insight into the unique characteristics of specific ethnic groups. Although individual differences within a given ethnic group exist and stereotypes should not be made, an understanding of the general characteristics of various ethnic groups can assist nurses in providing more individualized and culturally sensitive care.

KEY CONCEPT Although ethnic origin is important, the nurse needs to remember that not all individuals conform to the beliefs, values, roles, and traditions of the group of which they are a part. Stereotyping individuals who belong to the same cultural or ethnic group runs contrary to individualized care.

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Hispanic Americans The term Hispanic encompasses a variety of Spanish-speaking persons in America, including those from Spain, Mexico, Cuba, and Puerto Rico. Hispanic people now represent approximately 6% of the older population in the United States, but this percentage is expected to increase. Today, there are approximately 250,000 Hispanic Americans living in the United States, and the fastest growing segment of the US population is Hispanic Americans older than 65 years.

KEY CONCEPT The terms Hispanic and Latino are often used interchangeably, and in the United States, Latino has become equated with Hispanics. However, technically, there are differences in that Latino refers to persons from countries once under Roman rule (e.g., Spain, Italy, and Portugal), whereas Hispanic describes persons from countries once under Spanish rule (e.g., Mexico, Central America, and most of South America).

Although Mexican people inhabited the Southwest United States for decades before the arrival of the Pilgrims, most Mexican immigration occurred during the 20th century as a result of the Mexican Revolution and the poor economic conditions in Mexico. Poor economic conditions continue to cause Mexicans to immigrate to the United States. The Mexican population in this country totals more than 8 million, plus an estimated 3 to 5 million illegal immigrants; most reside in California and Texas.

Most Puerto Rican immigration occurred after the United States granted citizenship to all Puerto Ricans. After World War II, nearly one third of all Puerto Rico’s inhabitants immigrated to America; in the 1970s, “reverse immigration” began as growing numbers of Puerto Rican people left the United States to return to their home island. An estimated 1 million Puerto Ricans live in New York City, where most of them have settled.

Most Cuban immigrants are recent newcomers to America; the majority of the greater than 1 million Cuban Americans fled Cuba after Castro seized power. More than 25% of the Cuban American population resides in Florida, with other large groups in New York and New Jersey. Among all Hispanics, Cuban people are the most highly educated and have the highest earnings.

KEY CONCEPT Although cancer deaths have declined for all persons, they remain disproportionately high among Hispanic Americans and African Americans (American Cancer Society, 2014a, 2014b).

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Many Hispanic people view states of health and illness as the actions of God; by treating one’s body with respect, living a good life, and praying, one will be rewarded by God with good health. Illness results when one has violated good practices of living or is being punished by God. Medals and crosses may be worn at all times to facilitate well-being, and prayer plays an important part in the healing process. Illness may be viewed as a family affair, with multiple family members involved with the care of the sick individual. Rather than using practitioners of Western medicine to treat their health problems, some Hispanic persons may prefer traditional practitioners, such as:

Curanderos: women who have special knowledge and charismatic qualities Sobadoras: persons who give massages and manipulate bones and muscles Espiritualistas: persons who analyze dreams, cards, and premonitions Brujos: women who practice witchcraft Senoras: older women who have learned special healing measures

The Hispanic population holds older relatives in high esteem. Old age is viewed as a positive time in which the older person can reap the harvest of his or her life. Hispanic people may expect that children will take care of their aging parents, and families may try to avoid institutionalization at all costs. Indeed, this group has a lower rate of nursing home use than the general population; less than 7% of nursing home residents are Hispanic.

COMMUNICATION TIP Nurses may find that English is a second language for some Hispanic people, which becomes particularly apparent during periods of illness when stress causes a retreat to the native tongue. An interpreter can be used to facilitate communication. In addition, some Hispanic individuals may be more competent speaking English than reading and writing in English; this needs to be considered when written instructions or questionnaires are used.

Although older Hispanic and non-Hispanic persons have similar types of chronic conditions, older Hispanic individuals are less likely to visit physicians or obtain preventive services (e.g., mammograms and vaccines) and more likely to have difficulty obtaining care (Georgetown University Center on an Aging Society, 2012).

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Black Americans Although nearly 14% of the entire US population is black, they represent only 8.4% of the older population. Most of this group is of African descent. Historically, black Americans have experienced a lower standard of living and less access to health care than their white counterparts. This is reflected in the lower life expectancy of black Americans (see demographics in Chapter 1). However, once a black individual reaches the seventh decade of life, survival begins to equal that of similarly aged white people.

To survive to old age is considered by this ethnic group as a major accomplishment that reflects strength, resourcefulness, and faith; thus, old age may be considered a personal triumph by black people, not a dreaded curse. Considering their history, it should not be surprising to find that many black older adults:

Possess many health problems that have accumulated over a lifetime due to a poor standard of living and limited access to health care services Hold health beliefs and practices that may be unconventional to stay healthy and treat illness Are twice as likely to live in poverty compared with other older adults, which can influence their utilization of health care services Look to family members for decision making and care rather than using formal service agencies May have a degree of caution in interacting with and using health services, as a defense against prejudice (Egede, 2006)

Diverse subgroups within the black population, such as Africans, Haitians, and Jamaicans, possess their own unique customs and beliefs. Differences can be apparent even among black Americans from various regions of the United States. Nurses should be sensitive to the fact that the lack of awareness and respect for these differences can be interpreted as a demeaning or prejudicial sign.

Black skin color is the result of high melanin content and can complicate the use of skin color for the assessment of health problems. To diagnose cyanosis effectively, for instance, examine the nail beds, palms, soles, and gums and under the tongue. The absence of a red tone or glow to the skin can indicate pallor. Petechiae are best detected on the conjunctiva, abdomen, and buccal mucosa.

Hypertension is a prevalent health problem among black Americans and occurs at a higher rate than in the white population. One of the factors responsible for this problem is blunted nocturnal response. Only a minor decline in blood pressure occurs during sleep, which increases the strain on the heart and vessels; this is found to occur in the black population more than in any other group. Blood pressure monitoring is an important preventive measure for black clients (Fig. 3-1).

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FIGURE 3-1 • Blood pressure monitoring is an important intervention for populations at higher risk for hypertension.

In addition to hypertension, other health conditions are more prevalent in the black population than in the while population. For instance, as compared with the White population, African Americans have a higher prevalence of heart disease, cancer, and diabetes and a higher death rate from these diseases (Centers for Disease Control and Prevention, 2014b).

In recent years, HIV and AIDS have become the third leading cause of death among African American males; the African American population has the highest rate of HIV infection among other racial and ethnic groups (Centers for Disease Control and Prevention, 2014b). The high prevalence of these diseases among African American males suggests the need for education and counseling of younger adults in order to promote a healthy lifestyle and longevity.

According to the Centers for Disease Control and Prevention (2014c), African American individuals when compared with the White population are more likely to smoke, be obese, and have a poor health status. Many causes of morbidity and mortality among black Americans can be prevented and effectively controlled by lifestyle changes (e.g., good nutrition, regular exercise, and effective stress management) and regular health screening. These are important considerations in planning health services to communities.

Despite the health problems of aged black Americans, their rate of institutionalization is lower than that of the white population: about 13% of older black people experience institutional health care in their lifetimes compared with 23% of older white people (Centers for Disease Control and Prevention, 2014a).

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Asian Americans More than 10 million Asian Americans reside in the United States, representing approximately 4% of the population. Asian Americans are a diverse group comprised of individuals from countries such as China, Japan, the Philippines, Korea, Vietnam, and Cambodia.

Chinese Americans Although Chinese laborers probably lived in America for centuries before the mid-1800s, it was not until then that large-scale Chinese immigration occurred. The largest American Chinese populations are in California, New York, Texas, New Jersey, Massachusetts, and Illinois.

Care of the body and health are of utmost importance in traditional Chinese culture, but their approach may be vastly different from that of conventional Western medicine (Box 3-1). Chinese medicine is based on the belief of the balance of yin and yang; yin is the female negative energy that protects the inner body, and yang is the male positive energy that protects the body from external forces. Traditionally, Chinese people have used the senses for assessing medical problems (touching, listening to sounds, and detecting odors) rather than machinery or invasive procedures. Herbs, acupuncture, acupressure, and other treatment modalities, which are just being recognized by the Western world, continue to be treatments of choice for many Chinese individuals. These traditional treatments may be selected as alternatives or adjuncts to the use of modern treatment modalities. Ivory figurines of reclining women, now collectors’ items, were used by female patients to point to the area of their problems because it was inappropriate for the male physician to touch a woman; although modern Chinese women may have forfeited this practice, they still may be embarrassed to receive a physical examination or care from a man. Typically, disagreement or discomfort is not aggressively or openly displayed by Chinese persons. Nurses may need to observe more closely and ask specific questions (e.g., Can you describe your pain? How do you feel about the procedure you are planning to have done? Do you have any questions?) to ensure that the quiet nature of the patient is not misinterpreted to imply that no problems exist.

Box 3-1 Chinese Medicine For thousands of years, the Chinese have practiced a form of medicine that appears very different from medicine in the Western world. It is based on a system of balance; illness is seen as an imbalance and disharmony of the body. One of the theories that explains this balance is that of yin and yang. Yin is the negative, female energy that is represented by that which is soft, dark, cold, and wet. Organs associated with yin qualities include the lungs, kidneys, liver, heart, and spleen. Yang is the positive, male energy that is represented by that which is hard, bright, hot, and dry. The gallbladder, small intestine, stomach, colon, and bladder are yang organs. Daytime activity is considered more of a yang state, whereas sleep is more of a yin state.

Chinese medicine also considers the body’s balance in relation to the five elements or phases: wood (spring), fire (summer), earth (long summer), metal (autumn), and water (winter).

Qi is the life force that circulates throughout the body in invisible pathways called meridians. A deficiency or blockage of qi can cause symptoms of illnesses. Acupuncture and acupressure can be

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applied to various points along the meridians to stimulate the flow of qi.

In addition to acupuncture and acupressure, traditional Chinese medicine uses herbs, massage, and therapeutic exercises (such as t’ai chi) to promote a free flow of chi and achieve balance and harmony. These modalities are gaining increasing acceptance in the United States, and research supporting their effectiveness is increasing rapidly.

CONSIDER THIS CASE

Mrs. C is a very traditional Chinese woman who began living with her son and daughter-in-law 3 years ago, after her husband’s death. Mrs. C and her husband had lived in a “Chinatown” part of the city where they could freely communicate in Chinese and interact with other Chinese individuals. She never developed fluency in English and has experienced considerable difficulty communicating with neighbors since moving into her son’s suburban community. Mrs. C’s son has assimilated American values and practices and has been critical of his mother for her traditional ways; he would not acknowledge her when she spoke in Chinese and refused to allow her to cook Chinese foods. His wife is not Chinese but has been sympathetic to the elder Mrs. C.

Last week, Mrs. C suffered a stroke that left her with weakness and some aphasia. She will require care and supervision. Mrs. C’s son states that he does not want his mother in a nursing home, but that he is not sure he can manage her; his wife says she is willing to take a leave of absence from work and help care for her mother-in-law, if that is what her husband wants.

THINK CRITICALLY

What problems do you anticipate for each of the C family members? What can be arranged to assist the family? How could you assist Mrs. C in preserving her ethnic practices?

KEY CONCEPT Traditional Chinese medicine is based on the belief that the female negative energy (yin) and the male

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positive energy (yang) must be in balance.

In Chinese culture, achieving old age is a blessing, and older adults are held in high esteem. They are respected and sought for advice. The family unit is expected to take care of its elder members; thus, there may be a reluctance to use service agencies for older adults.

Japanese Americans In the past, when they first immigrated to the United States, many Japanese Americans had held jobs as gardeners and farmers. Today, they, like Chinese Americans, have a lower unemployment rate and a higher percentage of professionals than the national average. Today, there are approximately 796,700 Japanese Americans, most of whom live in California and Hawaii.

Although Japanese Americans have not tended to live in separate subcommunities to the same extent as Chinese Americans, they have preserved many of their traditions. They are bonded by their common heritage, and their culture places a high value on the family. The following terms describe each generation of Japanese American: Issei, first generation (immigrant to America); Nisei, second generation (first American born); Sansei, third generation; and Yonsei, fourth generation. It is expected that families will take care of their elder members. As in the Chinese culture, the aged are viewed with respect.

Similar to the Chinese, Japanese Americans may subscribe to traditional health practices either to supplement or replace modern Western technology. They may not express their feelings openly or challenge the health professional; therefore, nursing sensitivity to covert needs is crucial.

Other Asian Groups In the early 1700s, Filipino people began immigrating to America, but most Filipino immigrants arrived in the early 1900s to work as farm laborers. In 1934, an annual immigration quota of 50 was enacted; this quota stayed in place until 1965.

In the early 1900s, Korean people immigrated to America to work on plantations. Many of these individuals settled in Hawaii. Another large influx of Koreans, many of whom were wives of American servicemen, immigrated after the Korean War.

The most recent Asian American immigrants have been from Vietnam and Cambodia. Most of these individuals came to the United States to seek political refuge after the Vietnam War.

Although differences among various Asian American groups exist, some similarities are strong family networks and the expectation that family members will care for their older relatives at home. Asian Americans represent about 2% of the total nursing home population.

POINT TO PONDER What attitudes toward people of different cultures were you exposed to as a child, and how has this

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molded your current attitudes?

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Jewish Americans In the sense that they come from a variety of nations, with different customs and cultures, Jewish people are not an ethnic group per se. However, the strength of the Jewish faith forms a bond that crosses national origin and gives this group a strong sense of identity and shared beliefs.

Jewish Americans have demonstrated profound leadership in business, arts, and sciences and have made positive contributions to American life. Scholarship is important in the Jewish culture; nearly 60% of all Jewish Americans have graduated from college (Pew Research Center, 2015). Approximately 6.5 million Jewish people reside in the United States, representing 2.2% of the total population, with most living in urban areas of the Middle Atlantic states. It is estimated that half of the world’s Jewish population resides in America.

Religious traditions are important in the Jewish faith (Fig. 3-2). Sundown Friday to sundown Saturday is the Sabbath, and medical procedures may be opposed during that time (exceptions may be made for seriously ill individuals). Because of a belief that the head and feet should always be covered, some Jewish people may desire to wear a skullcap and socks at all times. Orthodox Jews may oppose shaving. The Kosher diet (e.g., exclusion of pork and shellfish, prohibition of serving milk and meat products at the same meal or from the same dishes) is a significant aspect of Jewish religion and may be strictly adhered to by some. Fasting on holy days, such as Yom Kippur and Tisha B’Av, and the replacement of matzo for leavened bread during Passover may occur.

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FIGURE 3-2 • Celebrating religious holidays may be important for certain groups, such as Jewish older

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adults.

Modern medical care is encouraged. Rabbinical consultation may be desired for decisions involving organ transplantation or life-sustaining measures. Certain rituals may be practiced at death, such as members of the religious group washing the body and sitting with it until burial. Autopsy is usually opposed.

Family bonds are strong in Jewish American culture; they have strong and positive feelings for older adults. Illness often draws Jewish families together. Jewish communities throughout the country have shown leadership in developing a network of community and institutional services for their aged, geared toward providing service while preserving Jewish tradition.

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Native Americans Native Americans are comprised of American Indians and Alaskan Natives; together they represent 5.2 million individuals. Native Americans inhabited North America for centuries before Columbus explored the New World. An estimated 1 to 1.5 million Native Americans populated America at the time of the arrival of Columbus; however, many battles with the new settlers during the next four centuries reduced the Native American population to a quarter million. The Native American population has been steadily increasing, with the U.S. Census Bureau now showing approximately 2.9 million Native American people who belong to more than 500 recognized tribes, nations, and villages in the United States. The median age for the American Indian and Alaska Native population is lower than for the general US population. Only 8% of the Native American population is older than 65 years, representing less than 1% of all older adults; however, they are one of the fastest growing minorities of the older population.

Less than half of all American Indians live on reservations, with the highest populations found in Arizona, Oklahoma, California, New Mexico, and Alaska. The Indian Health Service, a division of the United States Public Health Service, provides free, universal access to health care to American Indians who reside on reservations. More than half live in urban areas where access to health care is inferior to that on reservations. An estimated 150 different Native American languages are spoken, although most Native American people speak English as their first language.

Native American culture emphasizes a strong reverence for the Great Creator. A person’s state of health may be linked to good or evil forces or to punishment for their acts. Native American medicine promotes the belief that a person must be in balance with nature for good health and that illness results from imbalance.

KEY CONCEPT Spiritual rituals, medicine men, herbs, homemade drugs, and mechanical interventions can be used by Native American people to treat illness.

Close family bonds are typical among the Native American population. Family members may address each other by their family relationship rather than by name (e.g., cousin, son, uncle, and grandfather). The term elder is used to denote social or physical status, not just age. Elders are respected and viewed as leaders, teachers, and advisors to the young, although younger and more “Americanized” members are starting to feel that the advice of their elders is not as relevant in today’s world and are breaking from this tradition. Native American people strongly believe that individuals have the right to make decisions affecting their lives. The typical nursing assessment process may be offensive to the Native American patient, who may view probing questions, validation of findings, and documentation of responses as inappropriate and disrespectful behaviors during the verbal exchange. A Native American patient may be ambivalent about accepting services from agencies and professionals. Such assistance has provided many social, health, and economic benefits to

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improve the life of Native Americans, but it also conflicts with Native American beliefs of being useful, doing

by oneself, and relying on spiritual powers to chart the course of life. Native American patients often remain calm and controlled, even in the most difficult circumstances; it is important that providers not mistake this behavior for the absence of feeling, caring, or discomfort.

Various tribes may have specific rituals that are performed at death, such as burying certain personal possessions with the individual. Consulting with members of the specific tribe to gain insight into special rituals during sickness and at death would be advantageous for nurses working with Native American populations.

The last part of the 20th century saw a rise in certain preventable diseases among Native Americans, attributable to their exposure to new risks, such as a poor diet, insufficient exercise, and unhealthy lifestyle choices. For example, diabetes, a disease uncommon among Native Americans at the start of the 20th century, now affects Native Americans 2.7 times as much as White Americans (Office of Minority Health, 2014). Native Americans are more likely than the White non-Hispanic population to be obese and hypertensive and to suffer a stroke. The relatively recent high prevalence of rheumatoid diseases among Native Americans as compared with White older adults may be related to a genetic predisposition to autoimmune rheumatic disease. The cancer survival rate among Native Americans is the lowest of any US population. Nurses must promote health education and early screening to aid this population in reducing risks and identifying health conditions early.

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Muslims There are over a billion Muslims in the world who share a common culture based on the belief that Allah is God and Muhammad is his messenger. Muslim customs and traditions are centered on religious beliefs and customs derived from Muslim’s holy book, the Quran.

Older adults represent less than 1% of the Muslim population. They are viewed with high esteem and treated with respect; mothers are especially honored. The tradition has been for older Muslims to be cared for by their families, although this is anticipated to change as more Muslim women enter the workforce.

Muslims eat only meat that has been slaughtered according to religious requirements (halal meat) and do not eat pork or pork products. Water typically is consumed with every meal. Muslim patients who adhere strictly to fasting may not take medications during fasting times; sensitivity to this practice may require an adjustment of medication administration times.

A Muslim patient may prefer to be cared for by a person of the same sex and to have exposure of the body kept to a minimum. Muslims do not like to have their head touched unless it is part of an examination or treatment.

Muslim patients who are unconscious or terminally ill should be positioned so that their face is turned to face Mecca, which typically is west to northwest. Family and friends may recite the Quran or prayers in front of the patient or in a nearby room. If a chapel is provided for praying, it is important that no crosses or icons be present. The family should be asked if they would like their religious leader to visit.

POINT TO PONDER In what ways do you honor and celebrate your unique heritage?

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Gay, Lesbian, Bisexual, and Transgender Older Adults Despite the growing awareness and acceptance of gay, lesbian, bisexual, and transgender (LGBT) persons in society as a whole, there has been minimal consideration of the challenges and needs of these individuals when they reach late life. In fact, they are referred to as a largely invisible population (Fredriksen-Goldsen et al., 2011). This invisible population is growing, however; as much as 10% of the population identifies themselves as being lesbian, gay, bisexual, or transgender; the LGBT population is projected to double by 2030.

This generation lived through a period when considerable prejudice and discrimination existed against persons who were LGBT; therefore, these individuals may not be open about sexual orientation when seeking health services. Studies have found that LGBT older adults in community and long-term care settings reported being fearful of rejection and neglect by caregivers, not being accepted by other residents, and being forced to hide their sexual orientation (Stein, Beckerman, & Sherman, 2010). In addition, among LGBT elderly (Fredriksen-Goldsen et al., 2011):

Nearly one half have a disability and nearly one third report depression. There are higher rates of mental distress and a greater likelihood of smoking and engaging in excessive drinking than heterosexual persons. Almost two thirds have been victimized three or more times. Thirteen percent have been denied health care or received inferior care. More than 20% do not disclose their sexual or gender identity to their physician.

Recent years have noted progress in addressing the needs of the LGBT population. The American Association of Retired Persons has created an online LGBT community, the American Society on Aging has an LGBT Aging Issues Network, and the Joint Commission has added respect for sexual orientation to the rights of residents of assisted living communities and skilled nursing homes. In addition, Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders (SAGE) and the Movement Advancement Project (MAP) have been aggressively addressing policy and regulatory changes that are needed to address the needs of this population.

Nurses need to appreciate that the LGBT elder population represents unique individuals with different experiences, profiles, and needs. As with any patient, individualized approaches are essential and stereotypes need to be avoided. Nurses should inquire about partners these patients may desire to have involved with care and should include these partners as desired by the patients. Further, nurses need to assure that LGBT individuals can receive services without prejudice, stigmatization, or threat.

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NURSING CONSIDERATIONS FOR CULTURALLY SENSITIVE CARE OF OLDER ADULTS Numerous minority, ethnic, or cultural groups that have not been mentioned also possess unique histories, beliefs, and practices. Rather than viewing differences as odd and forcing patients to conform to “American” traditions, nurses should respect the beauty of this diversity and make every effort to preserve it. The beliefs, values, relationships, roles, and traditions associated with cultural and ethnic identity add a special significance to life.

The effectiveness of care can be largely influenced by the initial impression made by the nurse. Nurses need to reflect on any personal feelings or attitudes that could influence the nurse–patient relationship or convey a prejudicial attitude. For example, if a nurse comes from a religious belief that homosexuality is abnormal and sinful, the nurse may display discomfort in the nurse–patient interactions when faced with a patient who is gay. As a result, the patient may sense the nurse is prejudiced and be reluctant to share all aspects of his history and problems. Likewise, if the nurse has had limited experiences with persons of a different racial group, he or she may appear uneasy or unnatural in communicating with those individuals. Reflection on their feelings and discussing these issues with other professionals can assist in preventing personal feelings from interfering with the professional relationship.

Nurses need to be careful not to stereotype patients based on race, ethnicity, sexual orientation, or other factors. All patients should be addressed by their last name unless they request otherwise. Recognizing that based on their cultural or ethnic backgrounds some persons may be guarded with the personal information, nurses should explain the reason various questions will be asked during the interview. Ample time should be allotted for patients to share their histories and cultural or religious practices. The use of touch (e.g., patting the person’s hand or touching an arm) often demonstrates caring and assists in putting a person at ease; however, be aware that in some cultural groups, being touched by a stranger is viewed as inappropriate. The same holds true for the spatial distance between the nurse and the patient during the interview. This reinforces the importance of nurses becoming familiar with the beliefs and practices of various groups.

Dietary preferences should be accommodated, adaptations made for special practices, and unique ways of managing illness understood. Consideration should be given to differences in the expression of pain, fear, and other feelings. Reactions to illness and care can vary. For example, one person may view illness as punishment for wrongdoing; however, another sees it as part of the normal human experience. Some individuals may desire the active participation of family members or traditional healers in their care, whereas others, even those whose ethnic or cultural group traditionally do desire these things, do not.

If nurses are unfamiliar with a particular group, they should invite the patient and the family members to educate them or contact churches or ethnic associations (e.g., Polish National Alliance, Celtic League, Jewish Family and Children’s Services, and Slovak League of America) for interpreters or persons who can serve as cultural resources. One powerful means to learn about cultural influences for individual patients is to ask them to describe their life stories (see Chapter 4). Nurses convey sensitivity and caring when they try to recognize and support patients’ ethnic and cultural backgrounds. Nurses also will become enriched by gaining an

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appreciation and understanding of the various interesting ethnic groups.

The U.S. Department of Health and Human Services has developed standards for culturally and linguistically appropriate services that can guide clinical settings in working with diverse populations; their Web site can be accessed at http://minorityhealth.hhs.gov.

The increasing diversity of future aged populations will affect services in a variety of ways. Among the needs that could present are:

Institutional meal planning that incorporates ethnic foods Multilingual health education literature Readily available translators Provisions for celebration of holidays (e.g., Chinese New Year, St. Patrick’s Day, Black History Month, Greek Orthodox Easter) Special interest groups for residents of long-term care facilities and assisted living communities

An uncomfortable reality that a nurse may face is the prejudicial comment by a patient. As patients will reflect the society in which they live and with prejudices, unfortunately, being alive and well in society, it stands to reason that the nurse will encounter prejudiced patients. For example, a patient may refuse to receive care from a nurse of a different race. At times, persons who are highly stressed or who have dementias may use offensive racial language. Understandably, this can be hurtful to the nurse. The individual patient and situation, as well as the nurse’s experience in handling these situations, will determine the action the nurse should take; options include requesting the patient not to make the comment, asking the patient if he or she would prefer to have someone else assigned as his or her nurse, asking to be reassigned, and discussing the situation with one’s manager.

Nurses need to ensure that cultural, religious, and sexual orientation differences of older adults are understood, appreciated, and respected. Demonstrating this sensitivity honors the older adult’s unique history and preserves the familiar and important. The challenges faced by older adults need not be compounded by insensitive or prejudicial behaviors by nurses.

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http://minorityhealth.hhs.gov

BRINGING RESEARCH TO LIFE Preparing Nurses to Address Health Care Disparities in the Lesbian, Gay, Bisexual, and Transgender Population: A Review of Best Practices

Source: Lim, F., Brown, D. V ., Kim, J., & Min, S. (2014). American Journal of Nursing, 114(6), 24–34.

A review of 17 studies of nurses’ attitudes toward persons who were LGBT revealed that although nearly half of the studies revealed evidence of some positive attitudinal changes, every study found that negative attitudes persisted. Another literature review of 16 studies related to nursing students’ attitudes toward people with HIV infection or AIDS found some degree of homophobia and a negative attitude about persons with these diseases.

The article included a review of research analyzing the major health issues of the LGBT population. Findings included a greater risk of obesity and its secondary outcomes among lesbians, disproportionately higher rates of HIV infection among gay men, a higher prevalence of smoking among gay and bisexual men and lesbians and bisexual women, and a lower likelihood of transgender people to have health insurance. Health promotion for these individuals is needed, and reducing health care disparities can assist in this effort.

The challenges faced by older individuals who may be subjected to ageism will be greater if they also must face prejudicial treatment when utilizing health care services. It is recommended that nursing programs assess the LGBT health issues included in their training curricula, identify gaps, and develop strategies for meeting those gaps. Nurses should assess their own attitudes toward persons who are LGBT to determine how these may influence their interactions and care of these individuals. As the largest group of health care providers, nurses can model positive behaviors toward the LGBT population, which can set an example for others.

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PRACTICE REALITIES You are a nurse manager in an assisted living community that serves an affluent population. The current resident population is all White, whereas most of the caregiving staff is African American.

Some of the staff shared with the nurse manager their frustration at the way several residents treat them. Although most of the residents are courteous and polite in their manner of speaking to staff, many have a tendency to use terms like “girls,” “you people,” and “help.” A few of the nursing assistants reported that they have heard residents make comments to each other and their visitors that “You need to watch what you keep here because these people have sticky fingers,” and “Those people basically are lazy, so you need to stay on their back.” In addition, staff complain that visitors often ask them to do things that really are not part of their jobs, such as having them go to visitor’s cars to retrieve something or serve food that the visitor brought in for herself, the resident, and other family members.

The African American staff believe they are being treated in a prejudicial manner. One nursing assistant comments, “You would think this was their plantation and we were their slaves.” Another reacts, “Yes, but if we daresay something to them they’ll be running to administration. I can’t afford to lose this job.” Yet another adds, “Maybe we should live with it. White people have always been this way to our people.”

As the nurse manager, how would you handle this situation?

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CRITICAL THINKING EXERCISES

1. What are some reasons for older adults of minority groups to be suspicious or distrustful of health care services in this country?

2. What would you do if faced with a situation in which an older client refused to allow you to provide nursing care for him because you are of a different ethnic or racial group?

3. You are working in a hospital that serves a large population of immigrants who have not entered the country legally. These individuals frequently have had poor health care and present with multiple chronic conditions. The hospital is concerned that the care offered to these immigrants is placing a significant strain on its budget and may threaten its survival. The local community does not want to lose its hospital and has voiced opposition to providing free care for this group of immigrants. What do you see as concerns for all parties involved? What are the implications of either continuing or discontinuing free care to this group of immigrants? What solutions could you recommend?

4. A nursing home has a variety of ethnic groups represented in the resident population. What can the facility do to show sensitivity to their backgrounds?

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Chapter Summary The aging population is becoming more racially, ethnically, and sexually diverse. Older Hispanics are the fastest growing segment of the US population. English may be a second language to them. They view God as having an important role in their health and healing and may utilize traditional practitioners to treat health problems. Families hold older relatives in high esteem and try to avoid placing them in nursing homes.

The black population consists of Africans, Haitians, Jamaicans, and other diverse subgroups who have unique customs and beliefs. Although the black population has a lower life expectancy, black individuals who reach their seventh decade of life have the same potential life expectancy as the white population. Hypertension, heart disease, cancer, and diabetes are leading causes of death among older black persons.

Individuals from China, Japan, the Philippines, Korea, Vietnam, and Cambodia are among the population of Asian Americans. Some of these individuals may prefer traditional medicine to conventional Western medicine. Families play an important role in the lives of older Asian Americans.

Jewish Americans are bound by a common faith. Sabbath is from sundown Friday to sundown Saturday; medical procedures may be opposed during this time. Adhering to a Kosher diet may be important to faithful Jews, as may fasting on holy days. Western medicine is accepted. Family bonds are important.

American Indians and Alaskan Natives constitute Native Americans and are one of the fastest growing minorities in the United States. Less than half of American Indians reside on reservations, and those who do have access to free services from the United States Public Health Service. Diabetes, obesity, hypertension, and rheumatoid arthritis occur more commonly among Native American elders than in other older populations. Native rituals and healers may be preferred to Western medicine. Families share close relationships and hold their elders in high esteem.

Muslims share a common culture based on the belief that Allah is God and Muhammad his messenger. Customs and rituals arise from their religious beliefs. Older Muslims represent less than 1% of the Muslim population and are held in high esteem. There are specific dietary practices adhered to by Muslims. They may prefer care by a person of the same sex. Muslim individuals who are unconscious or terminally ill should lie so their face is positioned to look toward Mecca.

The LGBT population is growing. Some older LGBT individuals lived during an era when their sexual preferences were not as accepted as they are today; thus, the sexual preferences of these persons may not be recognized. Health care facilities are gaining in their understanding of the needs and rights of these individuals.

Although there may be similar characteristics among members of a group, nurses must be careful to assess individual characteristics, preferences, and practices and avoid stereotyping. It is important for nurses to respect individual differences and assess for and incorporate personal preferences and practices into care.

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Online Resources Bureau of Indian Affairs

http://www.bia.gov

Center of Excellence for Transgender Health

http://transhealth.ucsf.edu#sthash.8g2c7ai7.dpuf

National Asian Pacific Center on Aging

http://www.napca.org

National Association for Hispanic Elderly

http://www.anppm.org

National Caucus & Center on Black Aged

http://www.ncba-aged.org

National Hispanic Council on Aging

http://www.nhcoa.org

National Indian Council on Aging

http://www.nicoa.org

National Resource Center on Native American Aging

http://www.med.und.nodak.edu/depts/rural/nrcnaa/

Office of Minority Health Resource Center

http://www.minorityhealth.hhs.gov

Organization of Chinese Americans

http://www.ocanational.org

SAGE (Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders)

http://sageusa.org/index.cfm

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http://www.bia.gov

http://transhealth.ucsf.edu#sthash.8g2c7ai7.dpuf

http://www.napca.org

http://www.anppm.org

http://www.ncba-aged.org

http://www.nhcoa.org

http://www.nicoa.org

http://www.med.und.nodak.edu/depts/rural/nrcnaa/

http://www.minorityhealth.hhs.gov

http://www.ocanational.org

http://sageusa.org/index.cfm

References Administration on Aging. (2014). Minority aging. Retrieved September 1, 2014 from http://www.aoa.gov/AoARoot/Aging_Statistics/Minority_Aging/index.aspx

American Cancer Society. (2014a). Cancer facts and figures for African Americans 2013-2014. Retrieved September 3, 2014 from http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc- 036921.pdf

American Cancer Society. (2014b). Cancer facts and figures for Hispanics/Latinos 2012–2014. Retrieved September 3, 2014 from http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc- 034778.pdf

Centers for Disease Control and Prevention. (2014a). U.S. census populations with bridged race categories. Retrieved September 1, 2014 from http://www.cdc.gov/nchs/nvss/bridged_race.htm

Centers for Disease Control and Prevention. (2014b). Minority health: Black or African American populations. Retrieved September 3, 2014 from http://www.cdc.gov/minorityhealth/populations/REMP/black.html

Centers for Disease Control and Prevention. (2014c). Health of black or African American non-Hispanic population. FastStats. Retrieved September 1, 2014 from http://www.cdc.gov/nchs/fastats/black-health.htm

Egede, L. (2006). Race, ethnicity, culture, and disparities in health care. Journal of General Internal Medicine, 21(6), 667–669.

Fredriksen-Goldsen, K. I., Kim, H. -J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., … Petry, H. (2011). The aging and health report: Disparities and resilience among Lesbian, Gay, Bisexual, and Transgender older adults. Seattle, WA: Institute for Multigenerational Health.

Georgetown University Center on an Aging Society. (2012). Older Hispanic Americans. Data Profile, No. 9. Retrieved March 15, 2012 from http://ihcrp.georgetown.edu/agingsociety/pubhtml/hispanics/hispanics.html

Office of Minority Health. (2014). Diabetes and American Indians/Alaska Natives. Retrieved September 22, 2014 from http://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=33

Pew Research Center. (2015). A portrait of Jewish Americans. Retrieved July 23, 2015 from http://www.pewforum.org/2013/10/01/jewish-american-beliefs-attitudes-culture-survey/

Stein, G. L., Beckerman, N. L., & Sherman, P. A. (2010). Lesbian and gay elders and long-term care: Identifying the unique psychosocial perspectives and challenges. Journal of Gerontological Social Work, 53(5), 421–435.

U.S. Census Bureau. (2014). Population Projections. Retrieved September 2, 2014 from http://www.census.gov/population/projections/data/national/2012.html

Wan, H., Sengupta, M., Velkoff, V. A., & DeBarros, K. A. (2005). U.S. Census Bureau, current population reports, 60+ in the United States: 2005 (p. 16). Washington, DC: U.S. Government Printing Office.

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http://www.aoa.gov/AoARoot/Aging_Statistics/Minority_Aging/index.aspx

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036921.pdf

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-034778.pdf

http://www.cdc.gov/nchs/nvss/bridged_race.htm

http://www.cdc.gov/minorityhealth/populations/REMP/black.html

http://www.cdc.gov/nchs/fastats/black-health.htm

http://ihcrp.georgetown.edu/agingsociety/pubhtml/hispanics/hispanics.html

http://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=33

http://www.pewforum.org/2013/10/01/jewish-american-beliefs-attitudes-culture-survey/

http://www.census.gov/population/projections/data/national/2012.html

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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 4

Life Transitions and Story

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CHAPTER OUTLINE

Ageism

Changes In Family Roles And Relationships

Parenting

Grandparenting

Loss Of Spouse

Retirement

Loss of the Work Role

Reduced Income

Changes In Health And Functioning

Cumulative Effects Of Life Transitions

Shrinking Social World

Awareness of Mortality

Responding To Life Transitions

Life Review and Life Story

Self-Reflection

Strengthening Inner Resources

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Discuss ageism and its consequences. 2. Discuss changes that occur in aging families. 3. Describe challenges faced by widows. 4. Outline the phases and challenges of retirement. 5. Discuss the impact of age-related changes in health and functioning on roles. 6. Describe cumulative effects of life transitions. 7. List nursing measures to assist individuals in adjusting to the challenges and changes of aging.

TERMS TO KNOW Ageism:applying prejudices to older adults due to their age

Inner resources:strength within the person that can be drawn upon when needed

Life review:a process of reminiscing or reflecting on one’s life

Retirement:the period in which one no longer works

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Growing old is not easy. Various changes during the aging process demand multiple adjustments that require stamina, ability, and flexibility. Frequently, more simultaneous changes are experienced in old age than during any other period of life. Many young adults find it exhausting to keep pace with technological advances, societal changes, cost-of-living fluctuations, and labor market trends. Imagine how complex and complicated life can be for older individuals, who must also face retirement, reduced income, possible housing changes, frequent losses through deaths of significant persons, and a declining ability to function. Further, each of these life events can be accompanied by role changes that can influence behavior, attitudes, status, and psychological integrity. To promote awareness and appreciation of the complex and arduous adjustments involved in aging, this chapter considers some of the factors that affect older adults’ ability to cope with multiple changes associated with aging and their achievement of satisfaction and well-being during the later years.

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AGEISM Ageism is a concept introduced decades ago and defined as “the prejudices and stereotypes that are applied to older people sheerly on the basis of their age …” (Butler, Lewis, & Sutherland, 1991). It is not difficult to detect overt ageism in our society. Rather than showing appreciation for the vast contributions of older adults and their wealth of resources, society is beset with prejudices and lacks adequate provisions for them, thus derogating their dignity. The same members of society who object to providing sufficient income and health care benefits for the older population enjoy an affluence and standard of living that was the result of the efforts of these older persons.

Although older adults constitute the most diverse and individualized age group in the population, they continue to be stereotyped by the following misconceptions:

Old people are sick and disabled. Most old people are in nursing homes. Dementia comes with old age. People are either very tranquil or very cranky as they age. Old people have lower intelligence and are resistant to change. Old people are not able to have sexual intercourse and are not interested in sex. There are few satisfactions in old age.

For most older persons, the above statements are not true. Increased efforts are necessary to heighten societal awareness of the realities of aging. Groups such as the Gray Panthers have done an outstanding job of informing the public about the facts regarding aging and the problems and rights of older adults. More advocates for older persons are needed.

COMMUNICATION TIP Upon first contact with an older adult, assume that interactions should be no different than with adults of other ages unless information gleaned from the history reveals problems that could alter communication (e.g., dementia, impaired hearing). Address the person with an honorific (Mr., Mrs., etc.) and then his or her last name. Refrain from speaking as though addressing a child or using terms such as “sweetie” and “dear.” Avoid medical jargon and periodically ask if the person understands what is being said.

Ageism carries several consequences. By separating people of advanced age from themselves, younger people are less likely to see the similarities between themselves and older adults. This not only leads to a lack of understanding of older people but also reduces the opportunities for the young to gain realistic insights into aging. Furthermore, separating older individuals from the rest of society makes it easier for younger

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individuals to minimize the socioeconomic challenges of the older population. However, systematically stereotyping and discriminating against older persons will not prevent individuals from growing old themselves and experiencing the challenges of old age.

Chapter 2 outlines Erikson’s (1963) stages of life in which he describes the last stage of the life cycle as concerned with achieving integrity versus despair. Integrity results when the older individual derives satisfaction from an evaluation of his or her life. Disappointment with life and the lack of opportunities to alter the past bring despair. Ageism, unfortunately, can predispose aging persons to disappointment because they may believe stereotypical views that old age is a time of purposelessness and decline. The experiences of our entire lifetime determine whether our old age will be an opportunity for freedom, growth, and contentment or a miserable imprisonment of our human potential.

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CHANGES IN FAMILY ROLES AND RELATIONSHIPS The emergence of today’s nuclear family units changed the roles and functions of the individuals in a family. Older parents are expected to have limited input into the lives of their adult children. Children are not required to meet the needs of their aging parents for financial support, health services, or housing. Parents increasingly do not depend on their children for their needs, and the belief that children are the best insurance for old age is fading. In addition, grandparenting, although satisfying, is not usually as active a role as in the past, especially because grandchildren may be scattered throughout the country. These changes in family structure and function are not necessarily negative. Older adults may enjoy the independence and freedom from responsibilities that nuclear family life offers. Adjusting to changes in responsibilities and roles over time, though, is an important challenge of aging.

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Parenting The dynamic parental role frequently changes to meet the growth and development needs of both parent and child. During middle and later life, parents must adjust to the independence of their children as they become responsible adult citizens and leave home. The first child usually leaves home and establishes an independent unit 22 to 25 years after the parents married. For persons who have invested most of their adult lives nurturing and providing for their offspring, a child’s independence may have significant impact. Although parents who are freed from the responsibilities and worries of rearing children have more time to pursue their own interests, they are also freed from the meaningful, purposeful, and satisfying activities associated with child rearing, and this frequently results in a profound sense of loss.

Today’s older woman has been influenced by a historical period that emphasized the role of wife and mother. For instance, to provide job opportunities for men returning from World War II, women were encouraged to focus their interests on raising a family and to forfeit the scarce jobs to men. Unlike many of today’s younger women, who pursue and may equally value both a career and motherhood, these older women centered their lives on their families, from which they derived their sense of fulfillment. Having developed few roles from which to achieve satisfaction other than those of wife and mother, many of these older women feel a void when their children are grown and gone. Compounding this problem, the highly mobile lifestyle of many young persons limits the degree of direct contact an older woman has with her adult children and grandchildren.

The older man shares many of the same feelings as his wife. Throughout the years, he may have felt that he has performed useful functions that made him a valuable member of the family. Most likely, he worked hard to support his wife and children, and his masculinity was reinforced with proof of his ability to beget and provide for offspring. Now, with his children grown, he is no longer required to provide—a mixed blessing in which he may find both relief and purposelessness. In addition, he learns that the rules have changed—his ability to support a family without the need for his wife to work is now viewed by some as oppressive, his efforts to replenish the earth are scorned by zero population proponents, and his attempt to fill the masculine role for which he was socialized is considered oppressive or inane by today’s standards.

However, this lessening of the parenting role and the changes in family function are not necessarily negative. Most children do not abandon or neglect their aging parents; they maintain regular contact. Separate family units may help the parent–child relationship develop on a more adult-to-adult basis, to the mutual satisfaction of both the young and the old. If older adults adjust to their new role as parents of independent, adult children, they may enjoy the freedom from previous responsibilities and the new developments in their family relationships.

POINT TO PONDER List at least three ways that your life is different from the lives of your parents and grandparents.

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Grandparenting In addition to experiencing changes in the parenting role that come with age, many older adults enter a new role as grandparents. Americans’ extended life expectancy enables more people to experience the role of grandparent and spend more years in that role than previous generations. More than 65 million Americans are grandparents, and:

Most are baby boomers, more likely to be college educated and employed than previous generations of grandparents. One in five grandparents is African American, Hispanic, or Asian. They are spending more on grandchildren than previous generations (MetLife, 2011).

Grandchildren can bring considerable joy and meaning to the lives of older adults (Fig. 4-1). In turn, grandparents who are not burdened with the same daily child-rearing responsibilities of parents can offer love, guidance, and enjoyment to the family’s young. They can share lessons learned from their life experiences and family history and traditions that help the young understand their roots. There can be as many grandparenting styles as there are personalities; there is no single model of grandparenthood.

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FIGURE 4-1 • Grandparenting offers new roles and joys for many older adults.

Changes in the family structure and activities present new challenges to today’s grandparents. Most mothers are employed outside of the home. This is compounded by the fact that approximately one third of children are being raised by one parent. As a result, grandparents may assume childcare responsibilities to a greater

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extent than previous generations did. Grandparents may even provide for or share a home with their children and grandchildren. Family structures may differ from older adults’ experience, with an increase in remarriage and blended families as well as homosexual households. More than one third of children under 18 years live in blended households, and it is estimated that as many as 9 million children have gay or lesbian parents (Linville & O’Neil, 2015). As a result of an adult child’s marriage or relationship, older adults may find themselves becoming step-grandparents, a role for which few are prepared. Conscious choices will be needed to love and accept these new family members.

In addition to older adults having to adapt to new family lifestyles and structures, children and grandchildren may need to adapt to grandparents who have different lifestyles from previous generations. Rather than the stay-at-home grandma who cooked elaborate family dinners and welcomed grandchildren whenever they needed a sitter, today’s grandmother may have an active career and social calendar and not want to be burdened with frequent babysitting responsibilities or hosting family functions. Grandparents may be divorced, causing their children and grandchildren to face issues such as grandmother’s weekend trips with her new male friend or grandpop’s new, much younger wife. The family may need to be referred for counseling to help them address these issues.

Grandparenthood is a learned role and some older individuals may need guidance to become effective grandparents. Older adults may need to be guided in thinking through issues such as:

Respecting their children as parents and not interfering in the parent–child relationship Calling before visiting Establishing rules for babysitting Allowing their children to establish their own traditions within their family and not expecting them to adhere to the grandparent’s traditions

Nurses can help families locate resources that can assist in meeting the challenges of grandparenting. Also, nurses can suggest activities that can help grandparents be connected with their grandchildren, particularly if they are not geographically close; these can include audio- and videotapes, e-mails, videoconferencing, texting, faxes, and handwritten letters. (In addition to offering a means of communication, these can provide lasting memories that can be passed from one generation to the next.) Older adults can be encouraged to keep diaries, scrapbooks, and notebooks of family recipes and customs that can help their grandchildren and future generations have special insights into their ancestors.

In addition to fulfilling the grandparenting role, many older adults may assume primary child-rearing responsibilities for their grandchildren. An increasing number of grandparents are raising grandchildren. Over 6 million grandparents have grandchildren under the age of 18 living with them, and many more live with their grandparents off and on; a grandparent is providing care for nearly one fourth of children younger than 5 years (U.S. Census Bureau, 2012). Full-time caregiving often arises out of crises with the child’s parents, such as substance abuse, teen pregnancy, or incarceration. Older persons may need help thinking through the implications of deciding to raise a grandchild; some questions that nurses can raise with grandparents contemplating this decision include:

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How will raising this child affect your own health, marriage, and lifestyle? Have you any health conditions that could interfere with this responsibility? What is your backup plan in the event that you become ill or disabled? Do you have the energy and physical health required to care for an active child? Can you afford to care for the child, pay medical and educational expenses, and the like? What rights and responsibilities will the child’s parent(s) have? Do you have the legal right to serve as a surrogate parent (e.g., to give consent for medical procedures)? Have you consulted with an attorney?

Organizations exist to assist grandparents who are raising grandchildren; some are listed at the end of this chapter.

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LOSS OF SPOUSE The death of a spouse is a common event that alters family life for many older persons. The loss of that individual with whom one has shared more love and life experiences and more joys and sorrows than anyone else may be intolerable. How, after many decades of living with another person, does one adjust to his or her sudden absence? How does one adjust to setting the table for one, to coming home to an empty house, or to not touching that warm, familiar body in bed? Adjustment to this significant loss is coupled with the demand to learn the new task of living alone (Fig. 4-2).

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FIGURE 4-2 • For an older adult, the loss of a spouse means the loss of one’s closest companion of many years.

The death of a spouse affects more women than men because women tend to have a longer life expectancy than men. In fact, most women will be widowed by the time they reach their eighth decade of life. Unlike

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many of today’s younger women, who have greater independence through careers and changed norms, most of today’s older women have led family-oriented lives and have been dependent on their husbands. Their age, limited education, lack of skills, and long period of unemployment while raising their families are limitations in a competitive job market. If these women can find employment, adjusting to the new demands of work may be difficult and stressful. The unemployed widow, however, may learn that pensions or other sources of income may be reduced or discontinued when the husband dies, necessitating an adjustment to an extremely limited budget. In addition to financial dependence, the woman may have depended on her husband’s achievements to provide her with gratification and identity. Frequently, the achievements of children serve this same purpose. Sexual desires may be unfulfilled because of lack of opportunity, religious beliefs regarding sex outside marriage, fear of repercussion from children and society, or residual attitudes from early teachings about sexual mores. If a woman’s marriage promoted friendships with other married couples and only inactive relationships with single friends, the new widow may find that her number of single female friends is small.

For the most part, when the initial grief of the husband’s death passes, most widows adjust quite well. The high proportion of older women who are widowed provides an availability of friends who share similar problems and lifestyles, especially in urban areas. Old friendships may be revived to provide sources of activity and enjoyment. Some widows may discover that the loss of certain responsibilities, such as cooking and laundering for their husbands, brings them a new, pleasant freedom. With alternative roles to develop, sufficient income, and choice over lifestyle, many women are able to make a successful adjustment to widowhood.

The likelihood of an older adult remarrying after the loss of a spouse diminishes with age. This is especially true for women who often live longer than men and find a shortage of eligible men, because men of the same age tend to marry women younger than themselves.

Nurses may facilitate the adjustment to widowhood by identifying sources of friendships and activities such as clubs, volunteer organizations, or groups of widows in the community and by helping the widow understand and obtain all the benefits to which she is entitled. This may require reassuring the widow that enjoying her new freedom and desiring relationships with other men is no reason to feel guilty and may help her to adjust to the loss of her husband and the new role of widow. (See Chapter 36 for more information on death and dying.)

KEY CONCEPT The high prevalence of widows provides opportunities for friendships between women who share similar challenges and lifestyles.

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RETIREMENT Retirement is another of the major adjustments of an aging individual. This transition brings the loss of a work role and is often an individual’s first experience of the impact of aging. In addition, retirement can require adjusting to a reduced income and consequent changes in lifestyle.

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Loss of the Work Role Retirement is especially difficult in Western society, in which worth is commonly measured by an individual’s productivity. Work is also often viewed as the dues required for active membership in a productive society. Many of today’s older persons, raised to value a strong work ethic, hold the attitude that unemployment, for whatever reason, is an undesirable state.

KEY CONCEPT Older adults often view work as the dues required for active membership in a productive society.

Occupational identity largely determines an individual’s social position and social role. Although individuals function differently in similar roles, some behaviors continue to be associated with certain roles, which promote stereotypes. Certain stereotypes continue to be heard frequently—the tough construction worker, the wild exotic dancer, the fair judge, the righteous clergyman, the learned lawyer, and the eccentric artist. The realization that these associations are not consistently valid does not prevent their propagation. Too frequently, individuals are described in terms of their work role rather than their personal characteristics, for example, “the nurse who lives down the road” or “my son the doctor.” Considering the extent to which social identity and behavioral expectations are derived from the work role, it is not surprising that retirement threatens an individual’s sense of identity (Fig. 4-3). During childhood and adolescence, we are guided toward an independent, responsible adult role, and in academic settings, we are prepared for our professional roles, but where and when are we prepared for the role of retiree?

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FIGURE 4-3 • People who define self by their work role may have difficulty adjusting to retirement.

POINT TO PONDER What do you derive, or think you will derive, from being a nurse in terms of purpose, identity, values, relationships, activities, and so on? What similar gains are you achieving from other roles in your life?

When one’s work is one’s primary interest, activity, and source of social contacts, separation from work leaves a significant void in one’s life. Aging individuals should be urged to develop interests unrelated to work. Retirement is facilitated by learning how to use, appreciate, and gain satisfaction from leisure time throughout an employed lifetime. In addition, enjoying leisure time is a therapeutic outlet for life stresses throughout the aging process.

KEY CONCEPT When work is one’s primary interest, activity, and source of social contacts, separation from work leaves

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a significant void in one’s life.

Gerontological nurses must understand the realities and reactions encountered when working with retired persons. Although the experience of retirement is unique for each individual, some reactions and experiences tend to be fairly common. The phases of retirement described by Robert Atchley decades ago continue to offer insight into this complicated process:

Preretirement phase. When the reality of retirement is evident, preparation for leaving one’s job begins, as does fantasy regarding the retirement role. Retirement phase. Following the retirement event, a somewhat euphoric period begins, a “honeymoon period,” in which fantasies from the preretirement phase are tested. Retirees attempt to do everything they never had time for simultaneously. A variety of factors (e.g., finances and health) limit this, leading to the development of a stable lifestyle. As contrasted with those retirees who want to engage in every fantasy, some individuals choose to rest and do very little; their activity level tends to increase after a few years. Disenchantment phase. As life begins to stabilize, a letdown, sometimes a depression, is experienced. The more unrealistic the preretirement fantasy, the greater the degree of disenchantment. Reorientation phase. As realistic choices and alternative sources of satisfaction are considered, the disenchantment with the new retirement routine can be replaced by developing a lifestyle that provides some satisfaction. Retirement routine phase. An understanding of the retirement role is achieved, and this provides a framework for concern, involvement, and action in the older person’s life. Some enter this phase directly after the honeymoon phase, and some never reach it at all. Termination of retirement. The retirement role is lost as a result of either the resumption of a work role or dependency due to illness or disability (Atchley, 1975, 2000).

Different nursing interventions may be required during each phase of retirement. Assisting aging individuals with their retirement preparations during the preretirement phase is a preventive intervention that enhances the potential for health and well-being in late life. As a part of such intervention, nurses can encourage aging individuals to establish and practice good health habits such as following a proper diet; avoiding alcohol, drug, and tobacco use; and having regular physical examinations. Counseling regarding the realities of retirement may be part of retirement preparation, whereas helping retirees place their newfound freedom into proper perspective may be warranted during the honeymoon period of the retirement phase. Being supportive of retirees during the disenchantment phase without fostering self-pity and helping them identify new sources of satisfaction may facilitate the reorientation process. Appreciating and promoting the strengths of the stability phase may reinforce an adjustment to retirement. When the retirement phase is terminated due to disease or disability, the tactful management of dependency and the respectful appreciation of losses are extremely important.

As they have done with other life events, baby boomers are changing the thinking about work and retirement. Increasingly, they are replacing the model of a person being defined by his or her work with one

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that defines a person’s work based on the totality of his or her life. Life coaches and retirement planners are helping individuals to see that the retirement stage is more meaningful when individuals create a balance of work, learning, leisure, family time, service to others, and interests and desires postponed during the active career years (Corbett, 2007). Rather than forfeit working altogether, it is suggested that people stay in the workforce, but in a different style—that is, one that leaves time for the enjoyment of other interests and a high quality of life. The baby boomers also are remaining in the workforce longer, with many finding new paths of employment that enable them to explore their passions and achieve a different sense of purpose, even if it is at lower levels of compensation.

Nurses’ evaluations of their own attitudes toward retirement are beneficial. Does the nurse see retirement as a period of freedom, opportunity, and growth or as one of loneliness, dependency, and meaninglessness? Is the nurse intelligently planning for her own retirement or denying it by avoiding encounters with retirement realities? Nurses’ views of retirement affect the retiree–nurse relationship. Gerontological nurses can provide especially good models of constructive retirement practices and attitudes.

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Reduced Income In addition to the adjustment in work role, retirement often requires older adults to live on a reduced income. Financial resources are important at any age because they affect our diet, health, housing, safety, and independence and influence many of our choices in life. Retirement income is less than half the income earned while fully employed. For most older Americans, Social Security income, originally intended as a supplement, is actually the primary source of retirement income—and it has not kept pace with inflation. As a result, the economic profile of many older persons is poor.

Only a minority of the older population has income from a private pension plan, and those who do often discover that the fixed benefits established when the plan was subscribed are meager by today’s standards because of inflation. Of the workers who are currently active in the labor force, more than half will not have pension plans when they retire. More than one in six of all older adults live in poverty, with older African Americans and Hispanics having nearly twice the rate of poverty as older white persons. Only a minority are fully employed or financially comfortable. Few older persons have accumulated enough assets during their lifetime to provide financial security in old age.

A reduction in income is a significant adjustment for many older persons because it triggers other adjustments. For instance, an active social life and leisure pursuits may have to be markedly reduced or eliminated. Relocation to less expensive housing may be necessary, possibly forcing the aged to break many family and community ties. Dietary practices may be severely altered, and health care may be viewed as a luxury over which other basic expenses, such as food and rent, take priority. If the older parent has to depend on children for supplemental income, an additional adjustment may be necessary.

Making financial preparations for old age many years before retirement is important. Nurses should encourage aging working people to determine whether their retirement income plans are keeping pace with inflation. Also, older individuals need assistance in obtaining all the benefits they are entitled to and in learning how to manage their income wisely. Nurses should be aware of the impact of economic welfare on health status and should actively involve themselves in political issues that promote adequate income for all individuals.

POINT TO PONDER What are you doing to prepare for your own retirement?

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CHANGES IN HEALTH AND FUNCTIONING The changes in appearance and bodily function that occur during the aging process make it necessary for the aging individual to adjust to a new body image. Colorful soft hair turns gray and dry, flexible straight fingers become bent and painful, body contours are altered, and height decreases. Stairs once climbed several times daily demand more time and energy to negotiate as the years accumulate. As subtle, gradual, and natural as these changes may be, they are noticeable and, consequently, affect body image and self-concept.

The manner in which individuals perceive themselves and their functional abilities can determine the roles they play. A construction worker who has reduced strength and energy may forfeit his work role; a club member who cannot hear conversations may cease attending meetings; fashion models may stop seeking jobs when they perceive themselves as old. Interestingly, some persons well into their seventh and eighth decades refuse to join a senior citizen club because they do not perceive themselves as being “like those old people.” The nurse will gain insight into the self-concept of older persons by evaluating what roles they are willing to accept and what roles they reject. Refer to Nursing Diagnosis Highlight 4-1 for a discussion of the possible nursing diagnosis of Ineffective Role Performance.

It is sometimes difficult for the aging person to accept the body’s declining efficiency. Poor memory, slow response, easy fatigue, and altered appearance are among the many frustrating results of declining function, and they are dealt with in various ways. Some older people deny them and often demonstrate poor judgment in an attempt to make the same demands on their bodies as they did when younger. Others try to resist these changes by investing in cosmetic surgery, beauty treatments, miracle drugs, and other expensive endeavors that diminish the budget but not the normal aging process. Still, others exaggerate these effects and impose an unnecessarily restricted lifestyle on themselves. Societal expectations frequently determine the adjustment individuals make to declining function.

Common results of declining function are illness and disability. As described in Chapter 1, most older people have one or more chronic diseases, and more than one third have a serious disability that limits major activities such as work and housekeeping. Older adults often fear that illness or disability may cause them to lose their independence. Becoming a burden to their family, being unable to meet the demands of daily living, and having to enter a nursing facility are some of the fears associated with dependency. Children and parents may have difficulty exchanging dependent–independent roles. The physical pain arising from an illness may not be as intolerable as the dependency it causes.

Nurses should help aging persons understand and face the common changes associated with advanced age. Factors that promote optimum function should be encouraged, including proper diet, paced activity, regular physical examination, early correction of health problems, effective stress management, and avoidance of alcohol, tobacco, and drug abuse. Nurses should offer assistance, with attention to preserving as much of the individual’s independence and dignity as possible.

NURSING DIAGNOSIS HIGHLIGHT 4-1

DISTURBANCE IN THE PERFORMANCE OF THE ROLE

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Overview Disturbance in the performance of the role exists when there is a change in the perception of how a person exercises his or her role. This can be associated with a physical, emotional, intellectual, motivational, educational, or socioeconomic limitation in the ability to fill the role or restrictions in role performance imposed by others. There can be considerable distress, depression, or anger at not fulfilling the accustomed role and its associated responsibilities.

Causative or Contributing Factors Illness, fatigue, pain, declining function, altered cognition, depression, anxiety, knowledge deficit, limited finances, retirement, lack of transportation, loss of significant other, ageism, and restrictions imposed by others.

Goal The client realistically appraises role performance, adjusts to changes in role performance, and learns to perform responsibilities associated with roles.

Interventions

Assess client’s roles and responsibilities; identify deficits in role performance and reasons for deficits; review client’s perception of role and feelings associated with altered role performance. Assist client in realistically evaluating cause of altered role performance and potential for improvement in role performance. Identify specific strategies to improve role performance (e.g., instructing, negotiating with family members to allow client to perform role, counseling client to accept real limitations, referring to community resources, improving health problem, encouraging client to seek help with responsibilities, and advising for stress management). Encourage client to discuss concerns with family members; assist client in arranging family conference. Refer client to assistive resources, as appropriate, such as support groups, occupational therapist, financial counselor, Over 60 Counseling & Employment Service, visiting nurse, or social services.

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CUMULATIVE EFFECTS OF LIFE TRANSITIONS Shrinking Social World Many of the changes associated with aging result in loss of social connections and increasing risk of loneliness. Children are grown and gone, friends and spouse may be deceased, and others who could allay the loneliness may avoid the older individual because they find it difficult to accept the changes they see or to face the fact that they too will be old someday. Living in a sparsely populated rural area can geographically isolate older persons, and fears of crime when living in an urban area may prevent older adults from venturing outside their homes.

Hearing and speech deficits and language differences can also foster loneliness. Even if in the company of others, these functional limitations can socially isolate an older person. In addition, insecurity resulting from multiple losses in communication abilities can lead to suspiciousness of others and a self-imposed isolation.

At a time of many losses and adjustments, personal contact, love, extra support, and attention—not isolation—are needed. These are essential human needs. It is likely that a failure to thrive will occur in adults who feel unwanted and unloved just as it does in infants, who display anxiety, depression, anorexia, and behavioral and other difficulties when they perceive love and attention to be inadequate.

Nurses should attempt to intervene when they detect isolation and loneliness in an older person. Various programs provide telephone reassurance or home visits as a source of daily human contact. The person’s faith community may also provide assistance. Nurses can help the older adult locate and join social groups and perhaps even accompany the individual to the first meeting. A change in housing may be necessary to provide a safe environment conducive to social interaction. If the older person speaks a language other than English, relocation to an area in which community members speak that language can often remedy loneliness. Frequently, pets serve as significant and effective companions for older adults.

Using common sense in nursing care will facilitate social activity. The nurse can review and perhaps readjust the person’s schedule to conserve energy and maximize opportunities for socialization. Medication administration should be planned so that during periods of social activity analgesics will provide relief, tranquilizers will not sedate, diuretics will not reach their peak, and laxatives will not begin working. Likewise, fluid intake and bathroom visits before activities begin should be planned to reduce the fear or actual occurrence of incontinence; activities for older adults should include frequent break periods for bathroom visits. The control of these minor obstacles can often facilitate social interaction.

Nurses should also understand that being alone is not synonymous with being lonely. Periods of solitude are essential at all ages and provide the opportunity to reflect, analyze, and better understand the dynamics of one’s life. Older individuals may want periods of solitude to reminisce and review their lives. Some individuals, young and old, prefer and choose to be alone and do not feel isolated or lonely in any way. Of course, nurses should always be alert to hearing, vision, and other health problems that may be the cause of social isolation.

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CONSIDER THIS CASE

Mrs. Ko is a 66-year-old Korean woman who has been widowed for 5 years. She and her late husband immigrated to the United States 25 years ago and until his death ran a small convenience store in an area close to where she currently lives. They worked hard and were able to put their two sons through college. Her health is good, and she manages her home without any problem. She has two sons, one of which has lived in another state for the past 15 years and the other who has just married and moved to another state. Mrs. Ko doesn’t drive nor does she live in an area that has public transportation. She attends a Korean church and is friends with a couple who drive her to church and take her shopping.

The couple with whom she is friends informs Mrs. Ko that they will be moving in with their daughter, who lives in another part of the state, so they will not be able to continue their visits with her. They suggest that she speak to her sons about moving in with one of them, stating that “our children are supposed to take care of us.” Mrs. Ko agrees that this is the tradition with which she was raised.

During her next telephone conversations with her sons, Mrs. Ko shares the news about her friends’ upcoming relocation and mentions that this has caused her to give some thought to her own future. Neither son volunteers to have her live with his family. A few days later, she receives a call from one of her sons, who says, “Mom, Ron (his brother) and I were talking and we think it may be best if you moved. We found a retirement village not far from where you live that will be good for you and that we are willing to pay for. We’re coming into town next week to take you there to fill out the paperwork.” Mrs. Ko is shocked by this because she has never thought of living in a retirement community, but she doesn’t feel she should object to her sons’ decision.

THINK CRITICALLY

1. What options are there for an older adult like Mrs. Ko to make someone aware of her situation so that they can assist her in having her preferences expressed and respected?

2. If Mrs. Ko’s sons are unable or unwilling to have her move in with them, what options could be recommended?

3. How would you counsel a family when a parent’s traditional views about children’s responsibility for their older parents conflict with the children’s views?

KEY CONCEPT

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Periods of solitude are essential to reflect, analyze, and better understand the dynamics of life.

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Awareness of Mortality Widowhood, the death of friends, and the recognition of declining functions heighten older persons’ awareness of the reality of their own deaths. During their early years, individuals intellectually understand they will not live forever, but their behaviors often deny this reality. The lack of a will and burial plans may be indications of this denial. As the reality of mortality becomes acute with advancing age, interest in fulfilling dreams, deepening religious convictions, strengthening family ties, providing for the ongoing welfare of family, and leaving a legacy are often apparent signs.

The thought of impending death may be more tolerable if people understand that their life has had depth and meaning. Unresolved guilt, unachieved aspirations, perceived failures, and other multitudinous aspects of “unfinished business” may be better understood and perhaps resolved. Although the state of old age may provide limited opportunities for excitement and achievement, satisfaction may be gained in knowing that there were achievements and excitements in other periods of life. The old woman may be frail and wrinkled, but she can still delight in remembering how she once drove young men wild. The retired old man may feel that he is useless to society now, but he realizes his worth through the memory of wars he fought to protect his country and the pride he feels in knowing he enabled his children to obtain an education and start in life that his parents were unable to provide him. Nurses can help older adults gain this perspective on their lives through some of the interventions discussed in the following sections.

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RESPONDING TO LIFE TRANSITIONS When faced with ageism and numerous changes affecting relationships, roles, and health, older adults may respond in a variety of ways. The older adult’s ability to cope and adjust to life changes determines whether they reach a stage of integrity or fall to despair. Nurses can help older adults respond to life transitions by facilitating life review and eliciting a life story, promoting self-reflection, and strengthening older adults’ inner resources.

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Life Review and Life Story Life review is the process of intentionally reflecting on past experiences in an effort to resolve troublesome or traumatic life events and assess one’s life in totality. The significance of a life review in interpreting and refining our past experiences as they relate to our self-concept and help us understand and accept our life history has been well discussed (Butler & Lewis, 1982; Webster & Haight, 2002). In gerontological care, life review has long been recognized as an important process to facilitate integrity in old age (i.e., to help older people appreciate that their lives have had meaning).

Rather than being a pathologic behavior, discussing the past is therapeutic and important for older individuals (Fig. 4-4). Life review can be a positive experience because older adults can reflect on the obstacles they have overcome and accomplishments they have made. It can provide the incentive to heal fractured relationships and complete unfinished business. Life review, however, can be a painful experience for older adults who realize the mistakes they’ve made and the lives they’ve hurt. Rather than conceal and avoid these negative feelings, older adults can benefit by discussing them openly and working through them; referrals to therapists and counselors may be indicated to assist with unresolved grief, depression, or anxiety.

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FIGURE 4-4 • Reminiscing is a culturally universal phenomenon of aging. It is a way for the older adult to

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reassess life experiences and further develop a sense of accomplishment, fulfillment, and reward in life.

The young can also benefit from the reminiscences of older adults by gaining a new perspective on life as they learn about their ancestry. Imagine the impact of hearing about slavery, immigration, epidemics, industrialization, or wars from an older relative who has been part of that history. What history book’s description of the Great Depression can compare with hearing a grandparent describe events one’s own family experienced, such as going to bed hungry at night? In addition to their place in the future, the young can fully realize their link with the past when the desire of older people to reminisce is appreciated and fostered.

The nurse can facilitate life review by eliciting the older adult’s life story. Rich threads of life experience that create the unique fabric of one’s life are accumulated with aging. When seen in isolation, some of these threads may seem to have little value or make little sense, much like a network of threads on the undersurface of a tapestry. However, when the threads are woven together and the tapestry can be viewed as a whole, a person can see the special purpose of individual life experiences—good and bad. Weaving the threads of life experiences into the tapestry of a life story can be highly beneficial to the older person and others. Successes can be appreciated and the value of trials and failures can be realized. Others are able to gain insight into the person’s life in totality rather than have their understanding limited by what may be an unrepresentative segment of life that now presents. Customs, knowledge, and wisdom can be recognized, preserved, and passed to younger generations.

Point to Ponder What are the major threads that have woven your life tapestry thus far?

Eliciting life stories from older persons is not a difficult process; in fact, many older adults welcome opportunities to share their life histories and life lessons to interested listeners. Nurses can encourage older adults to discuss and analyze the dynamics of their lives, and they can be receptive and accepting listeners. Box 4-1 outlines some of the variety of approaches nurses can use to elicit life stories.

Box 4-1 Eliciting Life Stories Older adults possess rich life histories that have accrued during the many years they have lived. These unique histories contribute to each person’s identity and individuality. Learning about life histories aids nurses in understanding older adults’ preferences and activities, facilitating self-actualization, and preserving identity and continuity of life experiences. Knowledge of life histories also enables caregivers to see their patients in a larger context, connected to a past full of varied roles and experiences.

A basic requisite to eliciting life stories is a willingness to listen. Often, a direct request will be sufficient to open the door to a life history. Activities to facilitate this process include the following:

Tree of Life. Ask the older adult to write significant events (graduation, first job, relocations,

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marriages, deaths, childbirths, etc.) from the past on each branch and then discuss each. Time Line. Ask the older person to write significant events on or near the year when they occurred and then discuss each. Life Map. Ask the older adult to write significant events on the map and discuss each. Oral History. Ask the older adult to start with his or her earliest memory and record the story of his or her life into a tape recorder. (Suggest that the older person make this recording as a gift for younger family members.) If the person needs guidance in telling their history, offer a written outline or questions, or have a volunteer function as an interviewer.

For older adults who may require some facilitation, creative activities, such as compiling a scrapbook or dictating a family history, can stimulate the process. These creative efforts, as unsophisticated as they may be, should be recognized as significant legacies from the old to the young. For example, one 75-year-old man started a family scrapbook for each of his children. Any photograph, newspaper article, or announcement pertaining to any family member was reproduced and included in every album. The family patiently tolerated this activity and sent him copies of graduation programs and photographs for every scrapbook. The family viewed the main value of this activity as providing something benign to keep him occupied. It was not until years after his death that the significance of this great task was appreciated as a priceless gift. Such tangible items may serve as an assurance to both young and old that the impact of an aged relative’s life will not cease at death. Guiding older adults through this experience of compiling a life story not only provides a therapeutic exercise for them and an invaluable legacy for loved ones but also offers the gerontological nurse the gift of sharing and honoring the unique life journeys of older adults.

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Self-Reflection One of the hallmarks of successful aging is knowledge of self—that is, an awareness of the realities of who one is and one’s place in the world. From infancy on, we engage in dynamic experiences that mold the unique individuals we are. By adulthood, we have formed the skeleton of our identities. Continued interactions and life experiences as we journey through life further add to the development of our identities.

The self, the personal identity an individual possesses, has several dimensions that basically can be described as body, mind, and spirit. The body includes physical characteristics and functioning; the mind encompasses cognition, perception, and emotions; and the spirit consists of meaning and purpose derived from a relationship with God or other higher power. A variety of factors affect the development of body, mind, and spirit, such as genetic makeup, family composition and dynamics, roles, ethnicity, environment, education, religious experiences, relationships, culture, lifestyle, and health practices (Fig. 4-5).

FIGURE 4-5 • The holistic self.

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POINT TO PONDER What are the significant factors of your background that influenced your unique body, mind, and spirit?

Although a realistic appraisal of one’s identity and place in the world fosters healthy aging, not all persons complete this task successfully. Some people may live with unrealistic expectations or views of themselves, going through life playing parts that are ill suited for them and wasting time in fruitless or unfulfilling activities. Harry is an example of this:

Harry, the eldest of five children, was raised in an inner-city community in which poverty was the norm. His father was an auto mechanic who had difficulty holding jobs. His mother didn’t miss an opportunity to voice her dissatisfaction with her husband’s meager income nor to emphasize to Harry that he needed to be sure to “make it big and not be like his father.”

The message instilled by his mother and his desire for a better life than he enjoyed as a child fueled Harry to be a high achiever. By age 30, Harry owned a small chain of convenience stores, a large home in the suburbs, several luxury cars, and most of the possessions that reflected an upper-middle-class lifestyle. Harry was proud that he could provide a comfortable life for his wife and expensive education for his children—quite the opposite of what his father achieved. Yet, something was missing. His business demanded most of his time and energy; therefore, he had little left of himself to offer his family. He also rarely had the time for his passion, restoring classic cars. His life seemed to consist of managing his businesses and sleeping, with an occasional social event with his family. Time for relaxation and reflection had no place in Harry’s busy life.

In his late 50s, with children grown and his business worth enough to provide a comfortable retirement income, Harry was in a position where he didn’t have to work the long days—or at all for that matter. His wife encouraged him to consider selling his business and spend his time “tinkering with cars and taking it easy.” Although he was tempted, Harry felt that he just couldn’t do this. Unfortunately, the script to “make it big,” programmed into Harry’s mind as a child, held him prisoner to a role that brought him little joy and fulfillment. Furthermore, he had no idea of what his purpose and identity was other than being an entrepreneur.

Like Harry, many individuals may reach their senior years without having evaluated who they really are, what drives them to behave as they do, or what their true purposes and pleasures are.

KEY CONCEPT Some adults may not have invested the time and effort in self-evaluation and, consequently, reach old age with a lack of clarity of their identity.

Exploring and learning about one’s true self are significant to holistic health in late life. Examining and

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coming to terms with thoughts, feelings, beliefs, and behaviors foster older adults’ reaching a state of integrity rather than feeling despair over the lives they’ve lived. However, as important a process as it is, self-reflection does not come easily or naturally for some individuals. They may require interventions to facilitate this process; therefore, guiding aging people through self-reflective activities is an important therapeutic measure that gerontological nurses may need to offer. Life review and telling one’s life story can function as self- reflective activities. In addition, other activities that facilitate self-reflection include journaling, writing letters and e-mails, and reflecting through art. These certainly do not exhaust the strategies that can be used to foster self-reflection. Nurses are bound only by their creativity in the approaches used for promoting self-reflection.

Journaling Whether it is done with pencil and paper or a word processing program, the process of writing often facilitates self-reflection. There is no one right way to keep a journal or diary; individuals should develop styles that are comfortable for them. Some people may make daily entries that include details about their communications, sleep patterns, mood, and activities, whereas others make periodic entries that address major emotional and spiritual issues. Nurses can assist individuals who have not kept journals and diaries by guiding them in the selection of a blank book and writing instrument. This is an important step, not only because these tools will be used often but also because the book will be a tangible compilation of significant thoughts and feelings that could have meaning to others in years to come. Novices to journaling can be encouraged to start by reflecting on their lives and beginning their journals/diaries with a summary of the past. Suggesting that feelings and thoughts be written, in addition to the events of the day, can contribute to the process being one that fosters self-reflection.

Writing Letters and E-Mails Letters or e-mails are another means to reflect and express feelings. Often, thoughts and feelings that individuals may not feel comfortable verbalizing can be expressed in writing. For some older adults, letters of explanation and apology to friends and family with whom there have been strained relationships can be a healing exercise. Older people can be encouraged to locate friends and family in other parts of the country (or world) with whom they have not had contact for a while and to initiate communication concerning what has transpired in their lives and current events. Letters to grandchildren and other younger members of the family can provide a means to share relevant family history and offer special attention (many children love to receive their own mail!). Older adults may enjoy communicating by e-mail because of the ease and relatively low cost. If older adults do not own their own computers, nurses can refer them to local senior centers or libraries that offer free or nominal cost access to the Internet.

Reflecting Through Art Many people find that painting, sculpting, weaving, and other forms of creative expression facilitate self- reflection and expression. It is important that the process, not the finished product, be emphasized. Arts and crafts classes and groups often are offered by local organizations dedicated to specific activities (e.g., weavers’ guild and arts’ council), schools, and senior centers. Nurses can assist older adults in locating such groups in their communities.

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KEY CONCEPT Producing a work of art, discussing literature, and sharing one’s life story are among the many interventions that can be used to foster self-reflection.

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Strengthening Inner Resources The declines and dependencies that increasingly are present in late life can cause us to view older adults as being fragile and incapable. However, most older individuals possess significant inner resources—physical, emotional, and spiritual—that have enabled them to survive to old age. Behaviors that exemplify their survivor capabilities are described in Box 4-2.

Box 4-2 Characteristics Reflective of Survivor Competencies of Aging Individuals

Assumption of responsibility for self-care Mobilization of internal and external resources to solve problems and manage crises Development of support system via a network of family, friends, and professional individuals and groups (e.g., social clubs, churches, physicians, and volunteers) Sense of control over life events Adaptation to change Perseverance in the face of obstacles and difficulties Recovery from trauma Realization and acceptance of reality that life includes positive and negative events Discovery of meaning in life events Determination to fulfill personal, family, community, and work expectations despite difficulties and distractions Recognition of limitations and competencies Ability to trust, love, and forgive and to accept trust, love, and forgiveness

KEY CONCEPT By considering the strengths displayed by older adults as they navigate the aging process, nurses and others can develop an enlightened perspective of the older population.

Against the backdrop of threats to independence and self-esteem, nurses best serve older adults by maintaining and bolstering their inner strengths. Basic to this effort is ensuring physical health and well- being. It is quite challenging for persons of any age to optimally meet intellectual, emotional, socioeconomic, and spiritual challenges when their basic physical needs are not fully satisfied or they are experiencing the symptoms associated with deviations from health. Comprehensive and regular assessment of health status and interventions to promote health provide a solid base from which inner strengths can be nurtured.

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POINT TO PONDER How would you judge your “survivor competencies?” What experiences have contributed to this?

By being empowerment facilitators, nurses can support older adults’ inner strengths. Nurses must begin this process by examining and strengthening their own level of empowerment. When nurses develop a mindset of seeing possibilities despite fiscal and other constraints, they are better able to help older adults see possibilities despite potential constraints imposed by age and illness. In addition to being role models, nurses can facilitate empowerment by:

Including and encouraging the active participation of older adults in care planning and caregiving activities to the maximum extent possible Avoiding ageist attitudes that can be communicated through the manner of speaking to older adults (e.g., raising voice due to assumption all older people are hearing impaired and using terms like “Sweetie” or “Pops”) and practices (e.g., having signs like “Fall Risk” or “Toilet q2h” in view of others and labeling clothing in a manner that is visible to others) Providing a variety of options to older people and freedom to choose among them Equipping older adults for maximum self-care and self-direction by educating, relating, coaching, sharing, and supporting them Advocating for older adults as they seek information, make decisions, and execute their own selected self-care strategies Offering feedback, positive reinforcement, encouragement, and support

Concept Mastery Alert Nurses can facilitate empowerment by avoiding ageist attitudes and practices, such as having signs like “Fall risk” taped to a client’s door, in view of others.

A sense of hope fosters empowerment and is a thread that reinforces the fabric of inner strengths. Hope is an expectation that a problem will be resolved, relief will be obtained, and something desired will be obtained. Hope enables people to see beyond the present and make sense of the senseless. It empowers them to take action. Nurses foster hope in older people by honoring the value of their lives despite infirmities and limitations, assisting in establishing goals, supporting the use of coping strategies, building on capabilities, and displaying an optimistic, caring attitude. Spiritual beliefs and practices also provide inner strength that enables older adults to cope with current challenges and maintain hope and optimism for the future (see Chapter 15); nurses need to support older individuals in their prayers, devotional readings, church attendance, and other expressions of spirituality.

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BRINGING RESEARCH TO LIFE The Role of Transcendence in a Holistic View of Successful Aging: a Concept Analysis and Model of Transcendence in a Maturation and Aging

Source: McCarthy, V. L., & Bockweg, A. (2013). Journal of Holistic Nursing, 31(2), 84–94.

The authors adapted a method of concept analysis (a technique of systematically describing phenomena to enhance understanding) to analyze literature from nursing and other disciplines to gain an understanding of transcendence. Transcendence refers to that which exists beyond the material universe or physical human experience. They examined empirical studies on transcendence to clarify the meaning of the term and identify indicators by which it could be measured. They found few studies of transcendence as it related to successful aging. They did find more studies related to self-transcendence, a process in which there is a gradual expansion of one’s personal limits and expectations for self, others, and the world; this is a process viewed as achievable for persons of any age.

Antecedents (conditions that promoted transcendence) and attributes (the products of transcendence) were identified. Antecedents included storytelling, communicating feelings, opportunities for positive solitude, time spent in activities, closeness to nature, engagement in art-related activities, intellectual creativity, lifelong learning, and belonging to a family, group, or community. Attributes of transcendence included unity with self and God/the sacred, awareness of dimensions greater than oneself, sense of purpose, altruism, increased self-acceptance, self-fulfillment, and integration of past and future to make sense of the present. Based on their findings, they identified five domains associated with transcendence: relationships, creativity, contemplation, introspection, and spirituality.

The conceptual model developed by the authors could offer gerontological nurses guidance in planning interventions to assist aging individuals in healthy, successful aging. These interventions could include providing guided imagery to stimulate artistic activities, assisting the older adult in finding periods of solitude in natural settings, and planning activities that offer the opportunity for the older adult to share his or her life story.

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PRACTICE REALITIES Widowed 78-year-old Mrs. Knight lives in the house she was raised in and in which she raised her own family. Her 56-year-old unemployed son lives with her, and a daughter lives in a neighboring state.

Despite her independence, Mrs. Knight is a cause of concern for her daughter who believes her brother is taking advantage of their mother. The daughter has suggested to Mrs. Knight that she move in with her. Mrs. Knight has refused, stating that her son “just couldn’t make it on his own.”

The daughter shares her concerns with the nurse practitioner who works in the practice that manages Mrs. Knight’s care.

What would be reasonable actions for the nurse practitioner to take?

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CRITICAL THINKING EXERCISES

1. What examples of ageism can be found in television programs, advertisements, and other vehicles of communication?

2. How will the life experiences of today’s 30-year-old woman affect her ability to adapt to old age? What factors will enable her to cope more or less as well than her grandmother’s generation of women?

3. Describe actions nurses can take to help aging individuals prepare for retirement. 4. How can you determine if an older individual’s time alone is reflective of needed solitude or social

isolation? 5. How can the gerontological nurse elicit life stories from older adults in the midst of caregiving demands

during a busy shift? 6. In what ways will today’s young generation be in a better or worse position than today’s older population

in developing survivor competencies?

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Chapter Summary One challenge and transition individuals face as they age is changes in family roles and relationships. Nuclear families have reduced the daily interaction and fulfillment of needs between older parents and their children. Many older adults are grandparents, and increased numbers are providing care for minor grandchildren.

The tendency for women to marry men older than themselves and to have a longer life expectancy than men causes a greater prevalence of older widows than widowers. Adjusting to widowhood can be a challenge for some older women.

Retirement can be a transition viewed both positively and negatively. The loss of one’s roles, routines, and relationships can be difficult, but the freedom to explore other interests and shed unwanted responsibilities can be welcomed. Different types of support can be beneficial during the various phases of retirement.

Changes in health, function, and appearance are significant reminders of the changes with age. Nurses can aid aging persons by guiding them in positive health practices and measures to promote optimal function.

There are several processes that can help aging persons respond to life transitions in a healthy manner. These include life review, self-reflections, and strengthening inner resources. Nurses should explore the manner in which older adults are responding to life transitions and offer support and guidance to assist them in navigating these new challenges.

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Online Resources AARP Grandparent Information Center

http://www.aarp.org

AARP Retirement Calculator

http://www.aarp.org

Grandparents Raising Grandchildren

http://www.uwex.edu

International Institute for Reminiscence and Life Review

http://www.uwsuper.edu

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http://www.aarp.org

http://www.uwex.edu

http://www.uwsuper.edu

References Atchley, R. C. (1975). The sociology of retirement. Cambridge, MA: Schenkman.

Atchley, R. C. (2000). Social forces and aging (9th ed.). Belmont, CA: Wadsworth.

Butler, R. H., & Lewis, M. I. (1982). Aging and mental health (3rd ed., p. 58). St. Louis, MO: Mosby.

Butler, R. H., Lewis, M. I., & Sutherland, T. (1991). Aging and mental health (4th ed.). New York, NY: Merrill/MacMillan.

Corbett, D. (2007). Portfolio life. The new path to work, purpose, and passion after 50. San Francisco, CA: John Wiley and Sons.

Erikson, E. (1963). Childhood and society (2nd ed.). New York, NY: Norton.

Linville, D., & O’Neil, M. (2015). Same sex parents and their children. American Association for Marriage and Family Therapy. Retrieved July 23, 2015 from http://www.aamft.org/imis15/aamft/Content/Consumer_Updates/Same- sex_Parents_and_Their_Children.aspx

MetLife. (2011). The MetLife report on American grandparents: new insights for a new generation of grandparents. Westport, CT: MetLife Mature Market Institute.

U.S. Census Bureau. (2012). 2007 American community survey. Retrieved April 9, 2012 from http://www.census.gov/acs/www/

Webster, J. D., & Haight, B. K. (2002). Critical advances in reminiscence work: from theory to application. New York, NY: Springer.

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http://www.aamft.org/imis15/aamft/Content/Consumer_Updates/Same-sex_Parents_and_Their_Children.aspx

http://www.census.gov/acs/www/

http://thepoint.lww.com/Eliopoulos9e

CHAPTER 5

Common Aging Changes

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CHAPTER OUTLINE

Changes To The Body

Cells

Physical Appearance

Respiratory System

Cardiovascular System

Gastrointestinal System

Urinary System

Reproductive System

Musculoskeletal System

Nervous System

Sensory Organs

Endocrine System

Integumentary System

Immune System

Thermoregulation

Changes To The Mind

Personality

Memory

Intelligence

Learning

Attention Span

Nursing Implications Of Age-Related Changes

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. List common age-related changes at the cellular level; in physical appearance; and to the respiratory, cardiovascular, gastrointestinal, urinary, reproductive, musculoskeletal, nervous, endocrine, integumentary, and immune systems, the sensory organs, and thermoregulation.

2. Describe psychological changes experienced with age. 3. Discuss nursing actions to promote health and reduce risks associated with age-related changes.

TERMS TO KNOW Crystallized intelligence knowledge accumulated over a lifetime; arises from the dominant hemisphere of the brain

Fluid intelligence involves new information emanating from the nondominant hemisphere; controls emotions, retention of nonintellectual information, creative capacities, spatial perceptions, and aesthetic appreciation

Immunosenescence the aging of the immune system

Presbycusis progressive hearing loss that occurs as a result of age-related changes to the inner ear

Presbyesophagus a condition characterized by a decreased intensity of propulsive waves and an increased frequency of nonpropulsive waves in the esophagus

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Presbyopia the inability to focus or accommodate properly due to reduced elasticity of the lens

Living is a process of continual change. Infants become toddlers, prepubescent children blossom into young men and women, and dependent adolescents develop into responsible adults. The continuation of change into later life is natural and expected.

The type, rate, and degree of physical, emotional, psychological, and social changes experienced during life are highly individualized; such changes are influenced by genetic factors, environment, diet, health, stress, lifestyle choices, and numerous other elements. The result is not only individual variations among older persons but also differences in the pattern of aging of various body systems within the same individual. Although some similarities exist in the patterns of aging among individuals, the pattern of aging is unique in each person.

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CHANGES TO THE BODY Cells Organ and system changes can be traced to changes at the basic cellular level. The number of cells is gradually reduced, leaving fewer functional cells in the body. Lean body mass is reduced, whereas fat tissue increases until the sixth decade of life. Total body fat as a proportion of the body’s composition increases (St-Onge & Gallagher, 2010; Woo, Leung, & Kwok, 2007). Cellular solids and bone mass are decreased. Extracellular fluid remains fairly constant, whereas intracellular fluid is decreased, resulting in less total body fluid. This decrease makes dehydration a significant risk to older adults.

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Physical Appearance Many physical changes of aging affect a person’s appearance (Fig. 5-1). Some of the more noticeable effects of the aging process begin to appear after the fourth decade of life. It is then that men experience hair loss, and both sexes develop gray hair and wrinkles. As body fat atrophies, the body’s contours gain a bony appearance along with a deepening of the hollows of the intercostal and supraclavicular spaces, orbits, and axillae. Elongated ears, a double chin, and baggy eyelids are among the more obvious manifestations of the loss of tissue elasticity throughout the body. Skinfold thickness is significantly reduced in the forearm and on the back of the hands. The loss of subcutaneous fat content, responsible for the decrease in skinfold thickness, is also responsible for a decline in the body’s natural insulation, making older adults more sensitive to cold temperatures.

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FIGURE 5-1 • Age-related changes noticeable on inspection.

Stature decreases, resulting in a loss of approximately 2 in. in height by 80 years of age. Body shrinkage is due to reduced hydration, loss of cartilage, and thinning of the vertebrae. The decrease in stature causes the long bones of the body, which do not shrink, to appear disproportionately long. Any curvature of the spine, hips, and knees that may be present can further reduce height.

These changes in physical appearance are gradual and subtle. Further differences in physiologic structure and function can arise from changes to specific body systems.

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Respiratory System The changes to the respiratory system are apparent at the entrance to the system with changes to the nose. Connective tissue changes cause a relaxation of the tissue at the lower edge of the septum; the reduced support causes the tip of the nose to slightly rotate downward. Septal deviations can occur, as well. Mouth breathing during sleep becomes more common as a result, contributing to snoring and obstructive apnea. The submucosal glands have decreased secretions, reducing the ability to dilute mucus secretion; the thicker secretions are more difficult to remove and give the older person a sensation of nasal stuffiness.

Various structural changes occur in the chest with age that reduce respiratory activity (Fig. 5-2). The calcification of costal cartilage makes the trachea and rib cage more rigid; the anterior–posterior chest diameter increases, often demonstrated by kyphosis; and thoracic inspiratory and expiratory muscles are weaker. There is a blunting of the cough and laryngeal reflexes. In the lungs, cilia reduce in number and there is hypertrophy of the bronchial mucous gland, further complicating the ability to expel mucus and debris. Alveoli reduce in number and stretch due to a progressive loss of elasticity—a process that begins by the sixth decade of life. The lungs become smaller, less firm, lighter, and more rigid and have less recoil.

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FIGURE 5-2 • Respiratory changes that occur with aging.

The sum of these changes causes less lung expansion, insufficient basilar inflation, and decreased ability to expel foreign or accumulated matter. The lungs exhale less effectively, thereby increasing the residual volume. As the residual volume increases, the vital capacity is reduced; maximum breathing capacity also decreases. Immobility can further reduce respiratory activity. The decline in ventilatory capacity is noticeable primarily when an extra breathing demand is present, as the lower pulmonary reserve results in dyspnea more easily occurring. With less effective gas exchange and lack of basilar inflation, older adults are at high risk for developing respiratory infections. Endurance training can produce a significant increase in lung capacity of older adults.

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Cardiovascular System Some cardiovascular changes commonly attributed to age actually result from pathological conditions. Heart size does not change significantly due to age; rather, enlarged hearts are associated with cardiac disease, and marked inactivity can cause cardiac atrophy. There is a slight left ventricular hypertrophy with age, and the aorta becomes dilated and elongated. Atrioventricular valves become thick and rigid as a result of sclerosis and fibrosis, compounding the dysfunction associated with any cardiac disease that may be present. There may be incomplete valve closure resulting in systolic and diastolic murmurs. Extra systolic sinus bradycardia and sinus arrhythmia can occur in relation to irritability of the myocardium.

Age-related physiologic changes in the cardiovascular system appear in a variety of ways (Fig. 5-3). Throughout the adult years, the heart muscle loses its efficiency and contractile strength, resulting in reduced cardiac output under conditions of physiologic stress. Pacemaker cells become increasingly irregular and decrease in number, and the shell surrounding the sinus node thickens. The isometric contraction phase and relaxation time of the left ventricle are prolonged; the cycle of diastolic filling and systolic emptying requires more time to be completed.

FIGURE 5-3 • Cardiovascular changes that occur with aging.

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Concept Mastery Alert Incomplete valve closures can result in systolic and diastolic murmurs in older adults. Diastolic filling and systolic emptying do not decrease with age but take more time to be completed.

Usually, adults adjust to changes in the cardiovascular system quite well; they learn that it is easier and more comfortable for them to take an elevator rather than the stairs, to drive instead of walking a long distance, and to pace their activities. When unusual demands are placed on the heart (e.g., shoveling snow for the first time of the season, receiving bad news, and running to catch a bus), the person feels the effects. The same holds true for older individuals who are not severely affected by less cardiac efficiency under nonstressful conditions. When older persons are faced with an added demand on their hearts, however, they note the difference. Although the peak rate of the stressed heart may not reach the levels experienced by younger persons, tachycardia in older people will last for a longer time. Stroke volume may increase to compensate for this situation, which results in elevated blood pressure, although the blood pressure can remain stable as tachycardia progresses to heart failure in older adults. The resting heart rate is unchanged.

KEY CONCEPT Age-related cardiovascular changes are most apparent when unusual demands are placed on the heart.

Maximum exercise capacity and maximum oxygen consumption vary among older people. Older adults in good physical condition have comparable cardiac function to younger persons who are in poor condition.

Blood vessels consist of three layers, each of which is affected differently by the aging process. The tunica intima, the innermost layer, experiences the most direct changes, including fibrosis, calcium and lipid accumulation, and cellular proliferation. These changes contribute to the development of atherosclerosis. The middle layer, the tunica media, undergoes a thinning and calcification of elastin fibers and an increase in collagen, which cause a stiffening of the vessels. Impaired baroreceptor function and increased peripheral resistance occur, which can lead to a rise in systolic blood pressure. Interestingly, although a gradual increase in blood pressure is common in the United States and other industrialized nations, it does not tend to occur in less industrialized societies; cross-cultural studies that currently are being conducted will help to clarify if the rise in blood pressure is a result of normal aging or other factors. The outermost layer, the tunica adventitia, is not affected by the aging process. Decreased elasticity of the arteries is responsible for vascular changes to the heart, kidney, and pituitary gland. Reduced sensitivity of the blood pressure–regulating baroreceptors increases problems with postural hypotension and postprandial hypotension (blood pressure reduction of at least 20 mm Hg within 1 hour of eating). The reduced elasticity of the vessels, coupled with thinner skin and less subcutaneous fat, causes the vessels in the head, neck, and extremities to become more prominent.

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Gastrointestinal System Although not as life threatening as respiratory or cardiovascular problems, gastrointestinal symptoms may be of more bother and concern to older persons. This system is altered by the aging process at all points. Changes in the teeth and mouth and accessory structures such as the liver also affect gastrointestinal function. Figure 5- 4 summarizes gastrointestinal system changes.

FIGURE 5-4 • Gastrointestinal changes that occur with aging.

Tooth enamel becomes harder and more brittle with age. Dentin, the layer beneath the enamel, becomes more fibrous and its production is decreased. The nerve chambers become narrower and shorter and teeth are less sensitive to stimuli. The root pulp experiences shrinkage and fibrosis, the gingiva retracts, and bone density in the alveolar ridge is lost. Increasing numbers of root cavities and cavities around existing dental work occur. Flattening of the chewing cusps is common. The bones that support the teeth decrease in density and height, contributing to tooth loss. Tooth loss is not a normal consequence of growing old, but poor dental care, diet, and environmental influences have contributed to many of today’s older population being edentulous. After 30 years of age, periodontal disease is the major reason for tooth loss. More than half of all older adults must rely on partial or full dentures, which may not be worn regularly because of discomfort or poor fit. If natural teeth are present, they often are in poor condition; fracture easier; and have flatter surfaces,

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stains, and varying degrees of erosion and abrasion of the crown and root structure. The tooth brittleness of some older people creates the possibility of aspiration of tooth fragments.

Taste sensations become less acute with age because the tongue atrophies, affecting the taste buds; chronic irritation (as from pipe smoking) can reduce taste efficiency to a greater degree than that experienced through aging alone. The sweet sensations on the tip of the tongue tend to suffer a greater loss than the sensations for sour, salt, and bitter flavors. Excessive seasoning of foods may be used to compensate for taste alterations and could lead to health problems for older individuals. Loss of papillae and sublingual varicosities on the tongue are common findings.

Older adults produce approximately one third of the amount of saliva they produced in younger years (Gupta, Epstein, & Sroussi, 2006; Smith et al., 2013). Saliva often is diminished in quantity and is of increased viscosity as a result of some of the medications commonly used to treat geriatric conditions. Salivary ptyalin is decreased, interfering with the breakdown of starches. Diminished muscle strength and tongue pressure can interfere with mastication and swallowing (Hiramatsu, Kataoka, Osaki, & Hagino, 2015; Ney, Weiss, Kind, & Robinson, 2009).

Esophageal motility is affected by age. Presbyesophagus is a condition characterized by a decreased intensity of propulsive waves and an increased frequency of nonpropulsive waves in the esophagus. The esophagus tends to become slightly dilated, and esophageal emptying is slower, which can cause discomfort because food remains in the esophagus for a longer time. Relaxation of the lower esophageal sphincter may occur; when combined with the older person’s weaker gag reflex and delayed esophageal emptying, aspiration becomes a risk.

The stomach is believed to have reduced motility in old age, along with decreases in hunger contractions. Studies regarding changes in gastric emptying time have been inconclusive, with some claiming delayed gastric emptying to occur with normal aging and others attributing it to other factors. The gastric mucosa atrophies. Hydrochloric acid and pepsin decline with age; the higher pH of the stomach contributes to an increased incidence of gastric irritation in the older population.

Some atrophy occurs throughout the small and large intestines, and fewer cells are present on the absorbing surface of intestinal walls. There is a gradual reduction in the weight of the small intestine and shortening and widening of the villi, leading to them developing the shape of parallel ridges rather than the finger-like projections of earlier years. Functionally, there is no significant change in mean small bowel transit time with age. Fat absorption is slower, and dextrose and xylose are more difficult to absorb. Absorption of vitamin B, vitamin B12, vitamin D, calcium, and iron is faulty. The large intestine has reductions in mucous

secretions and elasticity of the rectal wall. Normal aging does not interfere with the motility of feces through the bowel, although other factors that are highly prevalent in late life do contribute to constipation. An age- related loss of tone of the internal sphincter can affect bowel elimination. Slower transmission of neural impulses to the lower bowel reduces awareness of the need to evacuate the bowels.

With advancing age, the liver has reduced weight and volume but this seems to produce no ill effects. The older liver is less able to regenerate damaged cells. Liver function tests remain within a normal range. Less efficient cholesterol stabilization and absorption cause an increased incidence of gallstones. The pancreatic

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ducts become dilated and distended, and often, the entire gland prolapses.

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Urinary System The urinary system is affected by changes in the kidneys, ureters, and bladder (Fig. 5-5). The renal mass becomes smaller with age, which is attributable to a cortical loss rather than a loss of the renal medulla. Renal tissue growth declines and atherosclerosis may promote atrophy of the kidney. These changes can have a profound effect on renal function, reducing renal blood flow and the glomerular filtration rate by approximately one half between the ages of 20 and 90 years (Cohen et al., 2014; Lerma, 2009).

FIGURE 5-5 • Urinary tract changes that occur with aging.

Tubular function decreases. There is less efficient tubular exchange of substances, conservation of water and sodium, and suppression of antidiuretic hormone secretion in the presence of hypo-osmolality. Older kidneys have less ability to conserve sodium in response to sodium restriction. Although these changes can contribute to hyponatremia and nocturia, they do not affect specific gravity to any significant extent. The decrease in tubular function also causes decreased reabsorption of glucose from the filtrate, which can cause 1+ proteinurias and glycosurias not to be of major diagnostic significance.

Urinary frequency, urgency, and nocturia accompany bladder changes with age. Bladder muscles weaken and bladder capacity decreases. Emptying of the bladder is more difficult; retention of large volumes of urine

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may result. The micturition reflex is delayed. Although urinary incontinence is not a normal outcome of aging, some stress incontinence may occur because of a weakening of the pelvic diaphragm, particularly in multiparous women.

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Reproductive System As men age, the seminal vesicles are affected by a smoothing of the mucosa, thinning of the epithelium, replacement of muscle tissue with connective tissue, and reduction of fluid-retaining capacity. The seminiferous tubules experience increased fibrosis, thinning of the epithelium, thickening of the basement membrane, and narrowing of the lumen. The structural changes can cause a reduction in sperm count in some men. Increases in follicle-stimulating and luteinizing hormone levels occur, along with decreases in both serum and bioavailable testosterone levels. Venous and arterial sclerosis and fibroelastosis of the corpus spongiosum can affect the penis with age. The older man does not lose the physical capacity to achieve erections or ejaculations, although orgasm and ejaculation tend to be less intense (Sampson, Untergasser, Plas, & Berger, 2007). There is some atrophy of the testes.

Prostatic enlargement occurs in most older men (Marks, Roehrborn, & Andiole, 2006). The rate and type vary among individuals. Three fourths of men aged 65 years and older have some degree of prostatism, which causes problems with urinary frequency. Although most prostatic enlargement is benign, it does pose a greater risk of malignancy and requires regular evaluation.

The female genitalia demonstrate many changes with age, including atrophy of the vulva from hormonal changes, accompanied by the loss of subcutaneous fat and hair and a flattening of the labia. The vagina of the older woman appears pink and dry with a smooth, shiny canal because of the loss of elastic tissue and rugae. The vaginal epithelium becomes thin and avascular. The vaginal environment is more alkaline in older women and is accompanied by a change in the type of flora and a reduction in secretions. The cervix atrophies and becomes smaller; the endocervical epithelium also atrophies. The uterus shrinks and the endometrium atrophies; however, the endometrium continues to respond to hormonal stimulation, which can be responsible for incidents of postmenopausal bleeding in older women on estrogen therapy. The ligaments supporting the uterus weaken and can cause a backward tilting of the uterus; this backward displacement along with the reduced size of the uterus can make it difficult to palpate during an exam. The fallopian tubes atrophy and shorten with age, and the ovaries atrophy and become thicker and smaller. The ovaries can shrink to such a small size that they are not palpable during an exam. Despite these changes, the older woman does not lose the ability to engage in and enjoy intercourse or other forms of sexual pleasure. Estrogen depletion also causes a weakening of pelvic floor muscles, which can lead to an involuntary release of urine when there is an increase in intra-abdominal pressure.

Figure 5-6 summarizes age-related changes in male and female reproductive systems.

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FIGURE 5-6 • Changes in the male and female reproductive structures that occur with aging.

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Musculoskeletal System The kyphosis, enlarged joints, flabby muscles, and decreased height of many older persons result from the variety of musculoskeletal changes occurring with age (Fig. 5-7). Along with other body tissue, muscle fibers atrophy and decrease in number, with fibrous tissue gradually replacing muscle tissue. Overall muscle mass, muscle strength, and muscle movements are decreased; the arm and leg muscles, which become particularly flabby and weak, display these changes well. Sarcopenia, the age-related loss of muscle mass, strength, and function, is mostly seen in inactive persons; thus, the importance of exercise to minimize the loss of muscle tone and strength cannot be emphasized enough. Muscle tremors may be present and are believed to be associated with degeneration of the extrapyramidal system. The tendons shrink and harden, which causes a decrease in tendon jerks. Reflexes are lessened in the arms, are nearly totally lost in the abdomen, but are maintained in the knee. For various reasons, muscle cramping frequently occurs.

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FIGURE 5-7 • Skeletal changes that occur with aging.

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Bone mineral and bone mass are reduced, contributing to the brittleness of the bones of older people, especially older women who experience an accelerated rate of bone loss after menopause. Bone density decreases at a rate of 0.5% each year after the third decade of life. There is diminished calcium absorption, a gradual resorption of the interior surface of the long bones, and a slower production of new bone on the outside surface. These changes make fractures a serious risk to the older adults. Although long bones do not significantly shorten with age, thinning disks and shortening vertebrae reduce the length of the spinal column, causing a reduction in height with age. Height may be further shortened because of varying degrees of kyphosis, a backward tilting of the head, and some flexion at the hips and knees. A deterioration of the cartilage surface of joints and the formation of points and spurs may limit joint activity and motion.

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Nervous System It is difficult to identify with accuracy the exact impact of aging on the nervous system because of the dependence of this system’s function on other body systems. For instance, cardiovascular problems can reduce cerebral circulation and be responsible for cerebral dysfunction. There is a decline in brain weight and a reduction in blood flow to the brain; however, these structural changes do not appear to affect thinking and behavior (Rabbitt et al., 2007). Declining nervous system function may be unnoticed because changes are often nonspecific and slowly progressing.

A reduction in neurons, nerve fibers, cerebral blood flow, and metabolism is known to occur. Reduced cerebral blood flow is accompanied by a reduction in glucose utilization and metabolic rate of oxygen in the brain. Although β-amyloid and neurofibrillary tangles are associated with Alzheimer’s disease, they can be present in older adults with normal cognitive function.

The nerve conduction velocity is lower (Fig. 5-8). These changes are manifested by slower reflexes and delayed response to multiple stimuli. Kinesthetic sense lessens. There is a slower response to changes in balance, a factor contributing to falls. Slower recognition and response to stimuli is associated with a decrease in new axon growth and nerve reinnervation of injured peripheral nerves.

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FIGURE 5-8 • Neurologic changes that occur with aging.

The hypothalamus regulates temperature less effectively. Brain cells slowly decline over the years, the cerebral cortex undergoes some loss of neurons, and there is some decrease in brain size and weight, particularly after age 55 years. Because the brain affects the sleep–wake cycle, and circadian and homeostatic factors of sleep regulation are altered with aging, changes in the sleep pattern occur, with stages III and IV of sleep becoming less prominent (Munch, Knoblauch, Blatter, Wirz-Justice, & Cajochen, 2007). Frequent awakening during sleep is not unusual, although only a minimal amount of sleep is actually lost.

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Sensory Organs Each of the five senses becomes less efficient with advanced age, interfering in varying degrees with safety, normal activities of daily living, and general well-being (Fig. 5-9).

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FIGURE 5-9 • Effects of sensory changes that occur with aging.

Vision Perhaps the sensory changes having the greatest impact are changes in vision. Presbyopia, the inability to focus or accommodate properly due to reduced elasticity of the lens, is characteristic of older eyes and begins in the fourth decade of life. The stiffening of the muscle fibers of the lens that occurs with presbyopia decreases the eye’s ability to change the shape of the lens to focus on near objects and decreases the ability to adapt to light. This vision problem causes most middle-aged and older adults to need corrective lenses to accommodate close and detailed work. The visual field narrows, making peripheral vision more difficult. There is difficulty maintaining convergence and gazing upward. The pupil is less responsive to light because the pupillary sphincter hardens, the pupil size decreases, and rhodopsin content in the rods decreases. As a result, the light perception threshold increases and vision in dim areas or at night is difficult; older individuals require more light than younger persons to see adequately.

Alterations in the blood supply of the retina and retinal pigmented epithelium can cause macular degeneration, a condition in which there is a loss in central vision. Changes in the retina and retinal pathway interfere with critical flicker fusion (the point at which a flickering light is perceived as continuous rather than intermittent).

The density and size of the lens increase, causing the lens to become stiffer and more opaque.

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Opacification of the lens, which begins in the fifth decade, leads to the development of cataracts, which increases sensitivity to glare, blurs vision, and interferes with night vision. Exposure to the ultraviolet rays of the sun contributes to cataract development. Yellowing of the lens (possibly related to a chemical reaction involving sunlight with amino acids) and alterations in the retina that affect color perception make older people less able to differentiate the low-tone colors of the blues, greens, and violets.

Depth perception becomes distorted, causing problems in correctly judging the height of curbs and steps. This change results from a disparity between the retinal images caused by the separation of the two eyes and is known as stereopsis. Dark and light adaptation takes longer, as does the processing of visual information. Less efficient reabsorption of intraocular fluid increases the older person’s risk of developing glaucoma. The ciliary muscle gradually atrophies and is replaced with connective tissue.

The appearance of the eye may be altered; reduced lacrimal secretions can cause the eyes to look dry and dull, and fat deposits can cause a partial or complete glossy white circle to develop around the periphery of the cornea (arcus senilis). Corneal sensitivity is diminished, which can increase the risk of injury to the cornea. The accumulation of lipid deposits in the cornea can cause a scattering of light rays, which blurs vision. In the posterior cavity, bits of debris and condensation become visible and may float across the visual field; these are commonly called floaters. Vitreous decreases and the proportion of liquid increases, causing the vitreous body to pull away from the retina; blurred vision, distorted images, and floaters may result. Visual acuity progressively declines with age due to decreased pupil size, scatter in the cornea and lens, opacification of the lens and vitreous, and loss of photoreceptor cells in the retina.

Hearing Presbycusis is progressive hearing loss that occurs as a result of age-related changes to the inner ear, including loss of hair cells, decreased blood supply, reduced flexibility of basilar membrane, degeneration of spiral ganglion cells, and reduced production of endolymph. This degenerative hearing impairment is the most serious problem affecting the inner ear and retrocochlea. High-frequency sounds of 2,000 Hz and above are the first to be lost; middle and low frequencies also may be lost as the condition progresses. A variety of factors, including continued exposure to loud noise, may contribute to the occurrence of presbycusis. This problem causes speech to sound distorted as some of the high-pitched sounds (s, sh, f, ph, and ch) are filtered from normal speech and consonants are less able to be discerned. This change is so gradual and subtle that affected persons may not realize the extent of their hearing impairment. Hearing can be further jeopardized by an accumulation of cerumen in the middle ear; the higher keratin content of cerumen as one ages contributes to this problem. The acoustic reflex, which protects the inner ear and filters auditory distractions from sounds made by one’s own body and voice, is diminished due to a weakening and stiffening of the middle ear muscles and ligaments. In addition to hearing problems, equilibrium can be altered because of degeneration of the vestibular structures and atrophy of the cochlea, organ of Corti, and stria vascularis.

KEY CONCEPT

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Although hearing declines with age, impaired hearing can occur at younger ages due to exposure to loud music, traffic, and other environmental noise. This noise-induced hearing loss is preventable.

Taste and Smell Approximately half of all older persons experience some loss of their ability to smell. The sense of smell reduces with age because of a decrease in the number of sensory cells in the nasal lining and fewer cells in the olfactory bulb of the brain. By age 80 years, the detection of scent is almost half as sensitive as it was at its peak. Men tend to experience a greater loss in the ability to detect odors than women.

As most of the taste acuity is dependent on smell, the reduction in the sense of smell alters the sense of taste. Atrophy of the tongue with age can diminish taste sensations, although there is no conclusive evidence that the number or responsiveness of taste buds decreases (Fukunaga, Uematsu, & Sugimoto, 2005; Mondon, Naudin, Beaufilis, & Atanasova, 2014). The ability to detect salt is affected more than other taste sensations. Reduced saliva production, poor oral hygiene, medications, and conditions such as sinusitis can also affect taste.

Touch A reduction in the number of and changes in the structural integrity of touch receptors occurs with age. Tactile sensation is reduced, as observed in the reduced ability of older persons to sense pressure and pain and differentiate temperatures. These sensory changes can cause misperceptions of the environment and, as a result, profound safety risks.

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Endocrine System The endocrine system has groups of cells and glands that produce the chemical messengers known as hormones. With age, the thyroid gland undergoes fibrosis, cellular infiltration, and increased nodularity. The resulting decreased thyroid gland activity causes a lower basal metabolic rate, reduced radioactive iodine uptake, and less thyrotropin secretion and release. Protein-bound iodine levels in the blood do not change, although total serum iodide is reduced. The release of thyroidal iodide decreases with age, and excretion of the 17-ketosteroids declines. The thyroid gland progressively atrophies, and the loss of adrenal function can further decrease thyroid activity. Secretion of thyroid-stimulating hormone (TSH) and the serum concentration of thyroxine (T4) do not change, although there is a significant reduction in triiodothyronine (T3), believed to be a result of the reduced conversion of T4 to T3. Overall, the thyroid function remains adequate.

Much of the secretory activity of the adrenal cortex is regulated by adrenocorticotropic hormone (ACTH), a pituitary hormone. As ACTH secretion decreases with age, secretory activity of the adrenal gland also decreases. Although the secretion of ACTH does not affect aldosterone secretion, it has been shown that less aldosterone is produced and excreted in the urine of older persons. The secretion of glucocorticoids, 17- ketosteroids, progesterone, androgen, and estrogen, also influenced by the adrenal gland, is reduced as well.

The pituitary gland decreases in volume by approximately 20% in older persons. Somatotropic growth hormone remains present in similar amounts, although the blood level may be reduced with age. Decreases are seen in ACTH, TSH, follicle-stimulating hormone, luteinizing hormone, and luteotropic hormone to varying degrees. Gonadal secretion declines with age, including gradual decreases in testosterone, estrogen, and progesterone. With the exception of alterations associated with changes in plasma calcium level or dysfunction of other glands, the parathyroid glands maintain their function throughout life.

There is a delayed and insufficient release of insulin by the beta cells of the pancreas in older people, and there is believed to be decreased tissue sensitivity to circulating insulin. The older person’s ability to metabolize glucose is reduced, and sudden concentrations of glucose cause higher and more prolonged hyperglycemia levels; therefore, it is not unusual to detect higher blood glucose levels in nondiabetic older persons.

KEY CONCEPT Higher blood glucose levels than are normal in the general adult population are not unusual in nondiabetic older people.

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Integumentary System Diet, general health, activity, exposure, and hereditary factors influence the normal course of aging of the skin. This system’s changes are often the most bothersome because they are obvious and clearly reflect advancing years. Flattening of the dermal–epidermal junction, reduced thickness and vascularity of the dermis, slowing of epidermal proliferation, and an increased quantity and degeneration of elastin fibers occur. Collagen fibers become coarser and more random, reducing skin elasticity. The dermis becomes more avascular and thinner. As the skin becomes less elastic and more dry and fragile, and as subcutaneous fat is lost, lines, wrinkles, and sagging become evident. Skin becomes irritated and breaks down more easily. There is a reduction in the number of melanocytes by 10% to 20% each decade beginning by the third decade of life, and the melanocytes cluster, causing skin pigmentation, commonly referred to as age spots; these are more prevalent in areas of the body exposed to the sun. The reduction in melanocytes causes older adults to tan more slowly and less deeply. Skin immune response declines, causing older people to be more prone to skin infections. Benign and malignant skin neoplasms occur more with age.

Scalp, pubic, and axillary hair thins and grays due to a progressive loss of pigment cells and atrophy and fibrosis of hair bulbs; hair in the nose and ears becomes thicker. By age 50 years, most white men have some degree of baldness and about half of all people have evidence of gray hair. Growth rate of scalp, pubic, and axillary hair declines; the growth of facial hair may occur in older women. An increased growth of eyebrow, ear, and nostril hair occurs in older men. Fingernails grow more slowly, are fragile and brittle, develop longitudinal striations, and experience a decrease in lunula size. Perspiration is slightly reduced because the number and function of the sweat glands are lessened.

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Immune System The aging of the immune system, known as immunosenescence, includes a depressed immune response, which can cause infections to be a significant risk of older adults. After midlife, thymic mass decreases steadily, to the point that serum activity of thymic hormones is almost undetectable in the aged. T-cell activity declines and more immature T cells are present in the thymus. A significant decline in cell-mediated immunity occurs, and T lymphocytes are less able to proliferate in response to mitogens. Changes in the T cells contribute to the reactivation of varicella zoster and Mycobacterium tuberculosis, infections that are witnessed in many older individuals. Serum immunoglobulin (Ig) concentration is not significantly altered; the concentration of IgM is lower, whereas the concentrations of IgA and IgG are higher. Responses to influenza, parainfluenza, pneumococcus, and tetanus vaccines are less effective (although vaccination is recommended because of the serious potential consequences of infections for older adults). Inflammatory defenses decline, and, often, inflammation presents atypically in older individuals (e.g., low-grade fever and minimal pain). In addition, an increase in proinflammatory cytokines occurs with age, which is believed to be linked to atherosclerosis, diabetes, osteoporosis, and other diseases that increase in prevalence with age.

In addition to maintaining a good nutritional state, older people can include foods in their diet that positively affect immunity, such as milk, yogurt, nonfat cottage cheese, eggs, fresh fruits and vegetables, nuts, garlic, onion, sprouts, pure honey, and unsulfured molasses. A daily multivitamin and mineral supplement is also helpful. Regular physical activity can enhance immune function, including exercises such as yoga and t’ai chi, which are low impact and have a positive effect on immunity. Stress can affect the function of the immune system because elevated cortisol levels can lead to a breakdown in lymphoid tissue, inhibition of the production of natural killer cells, increases in T-suppressor cells, and reductions in the levels of T-helper cells and virus-fighting interferon.

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Thermoregulation Normal body temperatures are lower in later life than in younger years. Mean body temperature ranges from 96.9°F to 98.3°F orally and 98°F to 99°F rectally. Rectal and auditory canal temperatures are the most accurate and reliable indicators of body temperature in older adults.

There is a reduced ability to respond to cold temperatures due to inefficient vasoconstriction, reduced peripheral circulation, decreased cardiac output, diminished shivering, and reduced muscle mass and subcutaneous tissue. At the other extreme, differences in response to heat are related to impaired sweating mechanisms and decreased cardiac output. These age-related changes cause older adults to be more susceptible to heat stress. Alterations in response to cold and hot environments increase the risks for accidental hypothermia, heat exhaustion, and heat stroke.

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CHANGES TO THE MIND Psychological changes can be influenced by general health status, genetic factors, educational achievement, activity, and physical and social changes. Sensory organ impairment can impede interaction with the environment and other people, thus influencing psychological status. Feeling depressed and socially isolated may obstruct optimum psychological function. Recognizing the variety of factors potentially affecting psychological status and the range of individual responses to those factors, some generalizations can be discussed.

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Personality Drastic changes in basic personality normally do not occur as one ages. The kind and gentle old person was most likely that way when young; likewise, the cantankerous old person probably was not mild and meek in earlier years. Excluding pathologic processes, the personality will be consistent with that of earlier years; possibly, it will be more openly and honestly expressed. The alleged rigidity of older persons is more a result of physical and mental limitations than a personality change. For example, an older person’s insistence that her furniture not be rearranged may be interpreted as rigidity, but it may be a sound safety practice for someone coping with poor memory and visual deficits. Changes in personality traits may occur in response to events that alter self-attitude, such as retirement, death of a spouse, loss of independence, income reduction, and disability. No personality type describes all older adults; personality in late life is a reflection of lifelong personality. Morale, attitude, and self-esteem tend to be stable throughout the life span.

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Memory The three types of memory are short term, lasting from 30 seconds to 30 minutes; long term, involving that learned long ago; and sensory, which is obtained through the sensory organs and lasts only a few seconds. Retrieval of information from long-term memory can be slowed, particularly if the information is not used or needed on a daily basis. The ability to retain information in the consciousness while manipulating other information—working memory function—is reduced. Older adults can improve some age-related forgetfulness by using memory aids (mnemonic devices) such as associating a name with an image, making notes or lists, and placing objects in consistent locations. Memory deficits can result from a variety of factors other than normal aging.

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Intelligence In general, it is wise to interpret the findings related to intelligence and the older population with much caution because results may be biased from the measurement tool or method of evaluation used. Early gerontological research on intelligence and aging was guilty of such biases. Sick old people cannot be compared with healthy persons; people with different educational or cultural backgrounds cannot be compared; and one group of individuals who are skilled and capable of taking an IQ test cannot be compared with those who have sensory deficits and may not have ever taken this type of test. Longitudinal studies that measure changes in a specific generation as it ages and that compensate for sensory, health, and educational deficits are relatively recent, and they serve as the most accurate way of determining intellectual changes with age.

Basic intelligence is maintained; one does not become more or less intelligent with age. The abilities for verbal comprehension and arithmetic operations are unchanged. Crystallized intelligence, which is the knowledge accumulated over a lifetime and arises from the dominant hemisphere of the brain, is maintained through the adult years; this form of intelligence enables the individual to use past learning and experiences for problem solving. Fluid intelligence, involving new information and emanating from the nondominant hemisphere, controls emotions, retention of nonintellectual information, creative capacities, spatial perceptions, and aesthetic appreciation; this type of intelligence is believed to decline in later life. Some decline in intellectual function occurs in the moments preceding death. High levels of chronic psychological stress have been found to be associated with an increased incidence of mild cognitive impairment (Wilson et al., 2007).

COMMUNICATION TIP Altered vision and hearing, the need for more time to process new information, and the stress of an interaction with a health care professional can prevent older adults from contributing valuable information during the assessment process and block them from hearing instructions. While respecting the individual’s level of function, employ these strategies: Allow time for questions to be answered, provide examples to trigger memory, and reinforce instructions through repetition and supplementing oral instructions with written ones.

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Learning Although learning ability is not seriously altered with age, other factors can interfere with the older person’s ability to learn, including motivation, attention span, delayed transmission of information to the brain, perceptual deficits, and illness. Older persons may display less readiness to learn and depend on previous experience for solutions to problems rather than experiment with new problem-solving techniques. Differences in the intensity and duration of the older person’s physiologic arousal may make it more difficult to extinguish previous responses and acquire new material. The early phases of the learning process tend to be more difficult for older persons than younger individuals; however, after a longer early phase, they are then able to keep equal pace. Learning occurs best when the new information is related to previously learned information. Although little difference is apparent between the old and young in verbal or abstract ability, older persons do show some difficulty with perceptual motor tasks. Some evidence indicates a tendency toward simple association rather than analysis. Because it is generally a greater problem to learn new habits when old habits exist and must be unlearned, relearned, or modified, older persons with many years of history may have difficulty in this area.

KEY CONCEPT Older adults maintain the capacity to learn, although a variety of factors can easily interfere with the learning process.

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Attention Span Older adults demonstrate a decrease in vigilance performance (i.e., the ability to retain attention longer than 45 minutes). They are more easily distracted by irrelevant information and stimuli and are less able to perform tasks that are complicated or require simultaneous performance.

POINT TO PONDER In the past 10 years, what changes have you experienced in regard to appearance, behaviors, and attitudes? How do you feel about these changes?

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NURSING IMPLICATIONS OF AGE-RELATED CHANGES An understanding of common aging changes is essential to ensure competent gerontological nursing practice. Such knowledge can aid in promoting practices that enhance wellness, thereby reducing risks to health and well-being. Differentiating normal from unusual findings in older adults and the atypical presentation of illness can be invaluable in identifying pathology and obtaining treatment in a timely manner. Table 5-1 lists some nursing actions related to age-related changes.

TABLE 5-1 Nursing Actions Related to Age-Related Changes

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CONSIDER THIS CASE

Mr. G is a 72-year-old retired truck driver admitted to the hospital for the treatment of acute glomerulonephritis. His height is 5 ft 11 in., and his weight is 180 lb. You note from the record that he weighed 220 lb last year and has experienced a reduction in weight at each of his monthly physician’s visits. Although he has a moderate degree of chronic obstructive pulmonary disease, he continues to smoke one pack of cigarettes daily. He has varicosities on both lower extremities and hemorrhoids. Mr. G is coherent and responds appropriately. His wife comments that he has always had a sharp mind, although in the past few years he has become considerably quieter and less gregarious. As you observe Mr. G throughout the day, you note that he:

Becomes short of breath with minimal exertion Develops edema Has urinary hesitancy and scanty urine output Adds considerable salt to his food before tasting it Has difficulty hearing normal conversation Moves very little when in bed

THINK CRITICALLY

Which signs and observations are related to normal aging and which can you attribute to pathology? What factors contributed to the health conditions possessed by Mr. G? Describe the risks that are high for Mr. G and list nursing measures that could minimize them.

KEY CONCEPT By promoting positive practices in persons of all ages, nurses can help greater numbers of individuals enter late life with high levels of health and function.

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Nurses caring for older adults must realize that, despite the numerous changes commonly experienced with age, most older adults function admirably well and live normal, satisfying lives. Although nurses need to acknowledge factors that can alter function with aging, they should also emphasize the capabilities and assets possessed by older adults and assist persons of all ages in achieving a healthy aging process.

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BRINGING RESEARCH TO LIFE The Effects of an 8-Week Hatha Yoga Intervention on Executive Function in Older Adults

Source: Gothe, N. P., Kramer, A. F., & McAuley, E. (2014). The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 69(9), 1109–1116.

In this study, community-dwelling older adults were randomly placed into two groups. One group participated in a Hatha yoga intervention and the other a stretching–strengthening control intervention. Both groups engaged in hour-long exercise classes over an 8-week period and completed tests of executive function at the beginning of the intervention and at its end.

Results showed significant improvement in executive function measures of working memory capacity and efficiency of mental set shifting and flexibility in the group who participated in yoga. There is a need for further research to gain an understanding of the underlying mechanisms affecting the results.

This research demonstrates that there are a variety of exercises that can impact cognitive function. It also alerts nurses to the importance of being open to complementary and alternative modalities that can have a positive impact on health and aging, and the need to learn how to use these modalities in practice.

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PRACTICE REALITIES You are working in an office with a group of medical doctors who have had some of the same patients in their practice for nearly two decades. Although many of their patients have aged, the physicians use basically the same approach, reorder the same medications, and include no review of psychosocial issues.

What could you suggest to update the practice to assure the needs of the aging patients are adequately being addressed?

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CRITICAL THINKING EXERCISES

1. What efforts do you see to educate persons of all ages in practices that will foster a healthy aging experience?

2. What age-related changes can you identify in yourself and in your parents? 3. Consider recommendations that you would give young adults for promotion of a healthy aging process.

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Chapter Summary Changes at the basic cellular level impact all body systems. The atrophy of body fat, loss of tissue elasticity, and reduction in subcutaneous fat contribute to changes in the appearance of the body with age. Changes to body systems contribute to a higher prevalence in the older population of conditions such as infections, hypertension, poor dental status, indigestion, constipation, urinary frequency, prostatic enlargement, fractures, reduced vision, presbycusis, hypothermia, and hyperthermia. Basic intelligence is maintained, and there is some reduction in fluid intelligence. The ability to retain new information is reduced, and the retrieval of information from long-term memory can be slower. Learning ability is maintained, although several factors that can interfere with learning. A variety of nursing actions can be utilized to prevent and reduce the negative impact of aging changes and promote optimal health and function in older adults.

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References Cohen, E., Nardi, Y., Krause, I., Goldberg, E., Milo, G., Garty, M., & Krause, I. (2014). A longitudinal assessment of the natural rate of decline in renal function with age. Journal of Nephrology, 27(6), 635–641.

Fukunaga, A., Uematsu, H., & Sugimoto, K. (2005). Influences of aging on taste perception and oral somatic sensation. Journal of Gerontology, Series A, Biological Sciences, 60(1), 109–113.

Gupta, A., Epstein, J. B., & Sroussi, H. (2006). Hyposalivation in elderly patients. Journal of the Canadian Dental Association, 72(9), 841–846.

Hiramatsu, T., Kataoka, H., Osaki, M., & Hagino, H. (2015). Effect of aging on oral and swallowing function after meal consumption. Clinical Interventions in Aging, 10(1), 229–235.

Lerma, E. V. (2009). Anatomic and physiologic changes of the aging kidney. Clinics in Geriatric Medicine, 25, 325–329.

Marks, L. S., Roehrborn, C. G., & Andiole, G. L. (2006). Prevention of benign prostatic hyperplasia disease. Journal of Urology, 176(4), 1299–1406.

Mondon, K., Naudin, M., Beaufilis, E. & Atanasova, B. (2014). Perception of taste and smell in normal and pathological aging: An update. Geriatric Psychology and Neuropsychiatry, 12(3), 313–320.

Munch, M., Knoblauch, V., Blatter, K., Wirz-Justice, A., & Cajochen, C. (2007). Is homeostatic sleep regulation under low sleep pressure modified by age? Sleep, 30(6), 781–792.

Ney, D., Weiss, J, Kind, A., & Robinson, J. A. (2009). Senescent swallowing: Impact, strategies and interventions. Nutrition in Clinical Practice, 24(3), 395–413.

Rabbitt, P., Scott, M., Lunn, M., Thacker, N., Lowe, C., Pendleton, N., … Jackson, A. (2007). White matter lesions account for all age-related declines in speed but not in intelligence. Neuropsychology, 21(3), 363–370.

Sampson, N., Untergasser, G., Plas, E., & Berger, P. (2007). The aging male reproductive tract. Journal of Pathology, 211(2), 206–218.

Smith, C. H., Boland, B., Daureeawoo, Y., Donaldson, E., Small, K., & Tuomainen, J. (2013). Effect of aging on stimulated salivary flow in adults. Journal of the American Geriatrics Society, 61(5), 805–808.

St-Onge, M. P., & Gallagher, D. (2010). Body composition changes with aging: The cause or the result of alternations in metabolic rate and macronutrient oxidation? Nutrition, 26(2), 152–155.

Wilson, R. S., Schneider, J. A., Boyle, P. A., Arnold, S. E., Tang, Y., & Bennett, D. A. (2007). Chronic distress and incidence of mild cognitive impairment. Neurology, 68(24), 2085–2092.

Woo, J., Leung, J., & Kwok, T. (2007). BMI, body composition, and physical functioning in older adults. Obesity, 15(7), 1886–1894.

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http://thepoint.lww.com/Eliopoulos9e

additional resources associated with this chapter.

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UNIT 2 Foundations of Gerontological Nursing

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6. The Specialty of Gerontological Nursing 7. Holistic Assessment and Care Planning 8. Legal Aspects of Gerontological Nursing 9. Ethical Aspects of Gerontological Nursing 10. Continuum of Care in Gerontological Nursing

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CHAPTER 6

The Specialty of Gerontological Nursing

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CHAPTER OUTLINE

Development Of Gerontological Nursing

Core Elements Of Gerontological Nursing Practice

Evidence-Based Practice

Standards

Competencies

Principles

Gerontological Nursing Roles

Healer

Caregiver

Educator

Advocate

Innovator

Advanced Practice Nursing Roles

Self-Care And Nurturing

Following Positive Health Care Practices

Strengthening and Building Connections

Committing to a Dynamic Process

The Future Of Gerontological Nursing

Utilize Evidence-Based Practices

Advance Research

Promote Integrative Care

Educate Caregivers

Develop New Roles

Balance Quality Care and Health Care Costs

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Describe the importance of evidence-based practice in gerontological nursing. 2. Identify standards used in gerontological nursing practice. 3. List principles guiding gerontological nursing practice. 4. Discuss major roles for gerontological nurses. 5. Discuss future challenges for gerontological nursing. 6. Describe activities that contribute to self-care for gerontological nurses.

TERMS TO KNOW Competency having skill, knowledge, and ability to do something according to a standard

Evidence-based practice using research and scientific information to guide actions

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Geriatric nursing nursing care of sick older adults

Gerontological nursing nursing practice that promotes wellness and highest quality of life for aging individuals

Standard desired, evidence-based expectations of care that serve as a model against which practice can be judged

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The specialty of gerontological nursing was not always a popular or well-respected area of practice. However, over the past few decades, the specialty has experienced profound growth and has benefited from societal recognition of the importance of the older segment of the population. Nurses have many opportunities to play significant roles in the care of the aging population today and to shape the future of gerontological nursing.

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DEVELOPMENT OF GERONTOLOGICAL NURSING Nurses, long interested in the care of older adults, seem to have assumed more responsibility than other professional disciplines for this segment of the population. In 1904, the American Journal of Nursing printed the first nursing article on the care of the aged, presenting many principles that continue to guide gerontological nursing practice today (Bishop, 1904): “You must not treat a young child as you would a grown person, nor must you treat an old person as you would one in the prime of life.” Interestingly, this same journal featured an article entitled “The Old Nurse,” which emphasized the value of the aging nurse’s years of experience (DeWitt, 1904).

After the Federal Old Age Insurance Law (better known as Social Security) was passed in 1935, many older persons had an alternative to almshouses and could independently purchase room and board. Because many of the homes that offered these services for older persons were operated by women who called themselves nurses, such residences later became known as nursing homes.

For many years, care of older adults was an unpopular branch of nursing practice. Geriatric nurses—those nurses who care for ill older adults—were thought to be somewhat inferior in capabilities, neither good enough for acute care settings nor ready to retire. Geriatric facilities may have further discouraged many competent nurses from working in these settings by paying low salaries. Little existed to counter the negativism in educational programs, where experiences with older persons were inadequate in both quantity and quality and attention focused on the sick rather than the well, who were more representative of the older population. Although nurses were among the few professionals involved with older adults, gerontology was missing from most nursing curriculums until recently.

Frustration over the lack of value placed on geriatric nursing led to an appeal to the American Nurses Association (ANA) for assistance in promoting the status of this area of practice. After years of study, in 1961, the ANA recommended that a specialty group for geriatric nurses be formed. In 1962, the ANA’s Conference Group on Geriatric Nursing Practice held its first national meeting. This group became the Division of Geriatric Nursing in 1966, gaining full recognition as a nursing specialty. An important contribution by this group was the development in 1969 of Standards for Geriatric Nursing Practice, first published in 1970. Certification of nurses for excellence in geriatric nursing practice followed, with the first 74 nurses achieving this recognition in 1975. The birth of the Journal of Gerontological Nursing, the first professional journal to meet the specific needs and interests of gerontological nurses, also occurred in 1975.

Through the 1970s, nurses became increasingly aware of their role in promoting a healthy aging experience for all individuals and ensuring the wellness of older adults. As a result, they expressed interest in changing the name of the specialty from geriatric to gerontological nursing to reflect a broader scope than the care of the ill aged. In 1976, the Geriatric Nursing Division became the Gerontological Nursing Division. Box 6-1 lists landmarks in the development and growth of gerontological nursing.

Box 6-1 Landmarks in the Growth of Gerontological Nursing 1902 First article on care of aged in American Journal of Nursing written by a physician

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1904 First article on care of aged in American Journal of Nursing written by a nurse

1950 First geriatric nursing text published (Geriatric Nursing, K. Newton)

First master’s thesis on care of aged (Eleanor Pingrey)

Geriatrics recognized as an area of specialization in nursing

1952 First nursing study on care of aged published in Nursing Research

1961 American Nurses Association (ANA) recommends specialty group for geriatric nurses

1962 First national meeting of ANA Conference on Geriatric Nursing Practice

1966 Formation of Geriatric Nursing Division of ANA

First gerontological nursing clinical specialist nursing program (Duke University)

1968 First nurse makes presentation at International Congress of Gerontology (Laurie Gunter)

1969 Development of standards for geriatric nursing practice

1970 First publication of ANA Standards of Gerontological Nursing Practice

1973 First offering of ANA Certification in Gerontological Nursing (74 nurses certified)

1975 First specialty publication for gerontological nurses, Journal of Gerontological Nursing

First nursing conference at International Congress of Gerontology

1976 ANA changes name from Geriatric Nursing Division to Gerontological Nursing Division.

Publication of ANA Standards of Gerontological Nursing

ANA Certification of Geriatric Nurse Practitioners initiated

1980 Geriatric Nursing journal launched by American Journal of Nursing company

1981 First International Conference on Gerontological Nursing

ANA Division of Gerontological Nursing develops statement on scope of practice

1982 Development of Robert Wood Johnson Teaching Home Nursing Program

1983 First university chair in gerontological nursing in the United States (Case Western Reserve)

1984 National Gerontological Nursing Association (NGNA) formed

ANA Division of Gerontological Nursing Practice becomes Council on Gerontological Nursing

1986 National Association for Directors of Nursing Administration in Long-Term Care (NADONA/LTC) formed

1987 ANA published combined Scope and Standards of Gerontological Nursing Practice

1989 ANA Certification of Gerontological Clinical Specialists first offered

1990 Division of Long-Term Care established within ANA Council of Gerontological Nursing

1996 Hartford Gerontological Nursing Initiatives funding launched by John A. Hartford Foundation

2001 ANA publishes revised Standards and Scope of Gerontological Nursing Practice

2002 Nurse Competence in Aging initiative to provide gerontological education and activities within specialty nursing associations

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2004 American Association of Colleges of Nursing publishes competencies for advanced practice programs in gerontological nursing

2007 American Association for Long-Term Care Nursing formed

2008 Retooling for an Aging America published by the Institute of Medicine recommending improved geriatric competencies for health care workers

KEY CONCEPT Gerontological nursing involves the care of aging people and emphasizes the promotion of the highest possible quality of life and wellness throughout the life span. Geriatric nursing focuses on the care of sick older persons.

In the past few decades, the specialty of gerontological nursing has experienced profound growth. Whereas only 32 articles on the topic of the nursing care of older adults were listed in the Cumulative Index to Nursing Literature in 1956, and only twice that number appeared a decade later, the number of articles published has grown considerably since. Gerontological nursing texts grew from a few in the 1960s to dozens currently, and the quantity and quality of this literature have been rising as well. Growing numbers of nursing schools are including gerontological nursing courses in their undergraduate programs and offering advanced degrees with a major in this area. Certification offers a means by which the nurse’s knowledge and competencies are validated through a professional nursing organization. Registered nurses can receive certification as a generalist in gerontological nursing with a basic nursing degree and 2 years of experience in the specialty or advanced certification as a clinical nurse specialist in gerontological nursing or gerontological nurse practitioner with graduate education and additional experience. (For information on certification, see the Resource listing for the American Nurses’ Credentialing Center at the end of this chapter.) Nursing administration in long-term care, geropsychiatric nursing, geriatric rehabilitation, and other areas of subspecialization has evolved; many nursing specialty associations have developed position papers related to the integration of geriatric nursing into their unique specialty practice (these often are posted on the association Web sites). The Hartford Institute for Geriatric Nursing, established in the 1990s, has significantly contributed to the advancement of the specialty by identifying and developing best practices and facilitating the implementation of these practices (for more information, visit http://www.hartfordign.org). In 2003, the Hartford Institute for Geriatric Nursing collaborated with the American Academy of Nursing and the American Association of Colleges of Nursing to develop the Hartford Geriatric Nursing Initiative that has significantly contributed to the growth of evidence-based practice in the specialty. Gerontological nursing has indeed advanced rapidly, and all indications are that this growth will continue.

Along with the growth of the specialty, there has been a heightened awareness of the complexity of gerontological nursing. Older people exhibit great diversity in terms of health status, cultural background, lifestyle, living arrangement, socioeconomic status, and other variables. Most have chronic conditions that

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uniquely affect acute illnesses, reactions to treatments, and quality of life. Symptoms of illness can be atypical. Multiple health conditions can coexist and muddle the ability to chart the course of a single disease or identify the underlying cause of symptoms. The conditions that older adults experience can cut across many clinical specialties, thereby challenging gerontological nurses to have a broad knowledge base. The risk of complications is high. Other factors, such as limited finances or social isolation, affect the state of health and well-being. Also, the elective status of geriatrics in many medical and nursing schools can limit the pool of colleagues who are knowledgeable about the unique aspects of caring for older adults.

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CORE ELEMENTS OF GERONTOLOGICAL NURSING PRACTICE With the formalization and growth of the gerontological nursing specialty, nurses and nursing organizations have developed informal and formal guidelines for clinical practice. Some of these core elements include evidence-based practice and standards and principles of gerontological nursing.

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Evidence-Based Practice There was a time when nursing care was guided more by trial and error than sound research and knowledge. Fortunately, that has changed, and nursing now follows a systematic approach that uses existing research for clinical decision making—a process known as evidence-based practice. Testing, evaluating, and using research findings in the nursing care of older adults are of such importance that it is among the ANA Standards of Professional Gerontological Nursing Performance.

Evidence-based practice relies on the synthesis and analysis of available information from research. Among the more popular ways to report this information are the meta-analysis and cost-analysis. Meta- analysis is a process of analyzing and compiling the results of published research studies on a specific topic. This process combines the results of many small studies to allow more significant conclusions to be made. With cost-analysis reporting, cost-related data are gathered on outcomes to make comparisons. Performance also can be compared with best practices or industry averages through a process of benchmarking. For instance, the rate of pressure ulcers in one facility may be compared with another facility that has similar characteristics. The data can be used to stimulate improvements.

KEY CONCEPT Best practices are evidence based and are built on the expertise of the nurse.

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Standards Professional nursing practice is guided by standards. Standards reflect the level and expectations of care that are desired and serve as a model against which practice can be judged. Thus, standards serve to both guide and evaluate nursing practice.

Standards arise from a variety of sources. State and federal regulations outline minimum standards of practice for various health care workers (e.g., nurse practice acts) and agencies (e.g., nursing homes). The Joint Commission has developed standards for various clinical settings that strive to describe the maximum attainable performance levels. The ANA Scope and Standards of Practice for Gerontological Nursing, as listed in Box 6-2, are the only standards developed by and for gerontological nurses. Nurses must regularly evaluate their actual practices against all standards governing their practice areas to ensure their actions reflect the highest quality care possible.

Box 6-2 ANA Standards of Practice for Gerontological Nursing STANDARD 1. ASSESSMENT The gerontological nurse collects comprehensive data pertinent to the older adult’s physical and mental health or situation.

STANDARD 2. DIAGNOSIS The gerontological nurse analyzes the assessment data to determine the diagnoses or issues.

STANDARD 3. OUTCOME IDENTIFICATION The gerontological nurse identifies expected outcomes for a plan individualized to the older adult or situation.

STANDARD 4. PLANNING The gerontological nurse develops a plan to attain expected outcomes.

STANDARD 5. IMPLEMENTATION The gerontological nurse implements the identified plan.

STANDARD 5A: COORDINATION OF CARE The gerontological nurse coordinates care delivery.

STANDARD 5B: HEALTH TEACHING AND HEALTH PROMOTION The gerontological registered nurse employs strategies to promote health and a safe environment.

STANDARD 5C: CONSULTATION The gerontological advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change.

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STANDARD 5D: PRESCRIPTIVE AUTHORITY AND TREATMENT The gerontological advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.

STANDARD 6. EVALUATION The gerontological nurse evaluates the older adult’s progress toward attainment of expected outcomes.

Source: American Nurses Association. (2010). Gerontological nursing scope and standards of practice. Silver Spring, MD: Nursebooks.org. (A full copy of the standards that includes the measurement criteria and Standards of Professional Performance for Gerontological Nursing can be ordered from the American Nurses Association, http://www.nursesbooks.org.)

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Competencies Nurses who work with older adults need to have competencies specific to gerontological nursing to promote the highest possible quality of care to older adults. Although they can vary based on educational preparation, level of practice, and practice setting, some basic competencies of the gerontological nurse include the ability to:

differentiate normal from abnormal findings in the older adult assess the older adult’s physical, emotional, mental, social, and spiritual status and function engage the older adult in all aspects of care to the maximum extent possible provide information and education on a level and in a language appropriate for the individual individualize care planning and implementation of the plan identify and reduce risks empower the older adult to exercise maximum decision making identify and respect preferences arising from the older adult’s culture, language, race, gender, sexual preference, lifestyle, experiences, and roles assist the older adult in evaluating, deciding, locating, and transitioning to environments that fulfill living and care needs advocate for and protect the rights of the older person facilitate discussion of and honor advance directives

To maintain and improve competencies, nurses need to stay abreast of new research, resources, and best practices. This is a personal responsibility of the professional nurse.

CONSIDER THIS CASE

Nurse Haley is a new graduate who is employed on a coronary care unit of an acute hospital. In her short time on the unit, she has noticed that the nurses who have worked on the unit for many years show certain tendencies when caring for patients over age 65. For example, they address comments and questions to these patients’ children rather than directly to the patients, address them in a child-like manner, tend not to inquire about their lifestyles and preferences, assume they have sedate lives, and omit the discussion of topics that they do discuss with younger patients, such as sexual activity, exercise, resuming work activities, and using alternative and complementary therapies.

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Nurse Haley feels her coworkers’ behaviors fail to respect the individuality and rights of older patients

and could jeopardize the quality of care they are afforded.

THINK CRITICALLY

What gerontological nursing competencies seem to be absent from the practice of the nurses Nurse Haley describes? What are some of the factors that could have contributed to the nurses’ behaviors? How should Nurse Haley address the problems she observes to promote good gerontological nursing practice?

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Principles Scientific data regarding theories, life adjustments, normal aging, and pathophysiology of aging are combined with selected information from psychology, sociology, biology, and other physical and social sciences (Fig. 6- 1) to develop nursing principles. Nursing principles are those proven facts or widely accepted theories that guide nursing actions. Professional nurses are responsible for using these principles as the foundation for nursing practice and ensuring through educational and managerial means that other caregivers use a sound knowledge base.

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FIGURE 6-1 • Information system of the gerontological nurse.

In addition to the basic principles that direct the delivery of care to persons in general, specific and unique principles guide care for individuals of certain age groups or those who possess particular health problems. Some of the principles guiding gerontological nursing practice are listed in Box 6-3 and are discussed below.

Box 6-3 Principles of Gerontological Nursing Practice Aging is a natural process common to all living organisms. Various factors influence the aging process.

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Unique data and knowledge are used in applying the nursing process to the older population. Older adults share similar self-care and human needs with all other human beings. Gerontological nursing strives to help older adults achieve wholeness by reaching optimum levels of physical, psychological, social, and spiritual health.

Aging: A Natural Process Every living organism begins aging from the time of conception. The process of maturing or aging helps the individual achieve the level of cellular, organ, and system function necessary for the accomplishment of life tasks. Constantly and continuously, every cell of every organism ages. Despite the normality and naturalness of this experience, many people approach aging as though it were a pathologic experience. For example, commonly heard comments associate aging with:

“looking gray and wrinkled” “losing one’s intellectual function” “becoming sick and frail” “obtaining little satisfaction from life” “returning to child-like behavior” “being useless”

These are hardly valid descriptions of the outcomes of aging for most people. Aging is not a crippling disease; even with limitations that could be imposed by pathologies of late life, opportunities for usefulness, fulfillment, and joy are readily present. A realistic understanding of the aging process can promote a positive attitude toward old age.

Factors Influencing the Aging Process Heredity, nutrition, health status, life experiences, environment, activity, and stress produce unique effects in each individual. Among the variety of factors either known or hypothesized to affect the usual pattern of aging, inherited factors are believed by some researchers to determine the rate of aging. Malnourishment can hasten the ill effects of the aging process, as can exposure to environmental toxins, diseases, and stress. In contrast, mental, physical, and social activity can reduce the rate and degree of declining function with age. These factors are examined in more detail in Chapter 2.

Every person ages in an individualized manner, although some general characteristics are evident among most people in a given age category. Just as one would not assume that all 30-year-old people are identical but would evaluate, approach, and communicate with each person in an individualized manner, nurses must recognize that no two persons 60, 70, or 80 years of age are alike. Nurses must understand the multitude of factors that influence the aging process and recognize the unique outcomes for each individual.

The Nursing Process Framework Scientific data related to normal aging and the unique psychological, biological, social, and spiritual characteristics of the older person must be integrated with a general knowledge of nursing. The nursing

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process provides a systematic approach to the delivery of nursing care and integrates a wide range of knowledge and skills. The scope of nursing includes more than following a medical order or performing an isolated task; the nursing process involves a holistic approach to individuals and the care they require. The unique physiologic, psychological, social, and spiritual challenges of older adults are considered in every phase of the nursing process.

Common Needs Core needs that promote health and optimum quality of life for all patients are:

Physiological balance: respiration, circulation, nutrition, hydration, elimination, movement, rest, comfort, immunity, and risk reduction Connection: familial, relational, societal, cultural, environmental, spiritual, and self Gratification: purpose, pleasure, and dignity

Through self-care practices, people usually perform activities independently and voluntarily to meet these life requirements. When an unusual circumstance interferes with an individual’s ability to meet these demands, nursing intervention could be warranted. The requirements for these needs and specific problems that older persons may experience in fulfilling them are discussed in Units III through V.

Optimal Health and Wholeness One can view aging as the process of realizing one’s humanness, wholeness, and unique identity in an ever- changing world. In late life, people achieve a sense of personhood that allows them to demonstrate individuality and move toward self-actualization. By doing so, they are able to experience harmony with their inner and external environment, realize their self-worth, enjoy full and deep social relationships, achieve a sense of purpose, and develop the many facets of their being. Gerontological nurses play an important role in promoting health and helping people achieve wholeness. Within the framework of the self-care theory, nursing actions toward this goal are:

Strengthening the individual’s self-care capacity Eliminating or minimizing self-care limitations Providing direct services by acting for, doing for, or assisting the individual when demands cannot be met independently

The thread woven throughout the above nursing actions is the promotion of maximum independence. Although it may be more time consuming and difficult, allowing older persons to do as much for themselves as possible produces many positive outcomes for their biopsychosocial health.

POINT TO PONDER What self-care practices are routine parts of your life? What is lacking?

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GERONTOLOGICAL NURSING ROLES In their activities with older adults, nurses function in a variety of roles, most of which fall under the categories of healer, caregiver, educator, advocate, and innovator (Fig. 6-2).

FIGURE 6-2 • Gerontological nursing roles.

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Healer Early nursing practice was based on the Christian concept of the intertwining of the flesh and spirit. In the mid-1800s, nursing’s role as a healing art was recognized; this is apparent through Florence Nightingale’s writings that nursing “puts the patient in the best condition for nature to act upon him” (Nightingale, 1860). As medical knowledge and technology grew more sophisticated and the nursing profession became grounded more in science than in healing arts, the early emphasis on nurturance, comfort, empathy, and intuition was replaced by detachment, objectivity, and scientific approaches. However, the revival of the holistic approach to health care has enabled nurses to again recognize the interdependency of body, mind, and spirit in health and healing.

Nursing plays a significant role in helping individuals stay well, overcome or cope with disease, restore function, find meaning and purpose in life, and mobilize internal and external resources. In the healer role, the gerontological nurse recognizes that most human beings value health, are responsible and active participants in their health maintenance and illness management, and desire harmony and wholeness with their environment. A holistic approach is essential, recognizing that older individuals must be viewed in the context of their biological, emotional, social, cultural, and spiritual elements. (Information on holistic nursing can be obtained from the American Holistic Nurses’ Association, listed under Resources at the end of this chapter.)

POINT TO PONDER Henri Nouwen (1990) spoke of the “wounded healer” who uses his or her own problems or wounds as a means to assist in the healing of others. What life experiences or “wounds” do you possess that enable you to assist others in their healing journeys?

For healing to be a dynamic process, nurses need to identify their own weaknesses, vulnerabilities, and need for continued self-healing. This belief is consistent with the concept of the wounded healer and suggests that by recognizing the wounds of all human beings, including themselves, nurses can provide services within a loving, compassionate framework.

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Caregiver The major role played by nurses is that of a caregiver. In this role, gerontological nurses use gerontological theory in the conscientious application of the nursing process to the care of older adults. Inherent in this role is the active participation of older adults and their significant others and promotion of the highest degree of self-care. This is especially significant in that older adults who are ill and disabled are at risk for having decisions made and actions taken for them—in the interest of “providing care,” “efficiency,” and “best interest”—that rob them of their existing independence.

Although the body of knowledge of geriatrics and gerontological care has grown considerably, many practitioners lack this information. Gerontological nurses are challenged to ensure that the care of older adults is based on sound knowledge that reflects the unique characteristics, needs, and responses of older persons by disseminating gerontological principles and practices. Nurses working in this specialty area are challenged to gain the knowledge and skills that will enable them to meet the unique needs of older adults and to assure evidence-based practices are utilized.

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Educator Gerontological nurses must be prepared to take advantage of formal and informal opportunities to share knowledge and skills related to the care of older adults. This education extends beyond professionals to the general public. Areas in which gerontological nurses can educate others include normal aging, pathophysiology, geriatric pharmacology, health promotion, and available resources. With the diversity and complexities of health insurance plans, an important area for consumer education is teaching older adults how to interpret and compare various plans to enable them to make informed decisions. Essential to the educator role is effective communication involving listening, interacting, clarifying, coaching, validating, and evaluating.

The nurse’s educator role also surfaces during routine nurse–patient interactions. The nurse educates the patient to address knowledge deficits identified during the assessment process. New medications, treatments, and choices create the need for teaching to assure the patient has the knowledge and skill to competently make decisions and engage in care. Box 6-4 outlines some of the principles of adult learning and some of the barriers to learning.

Box 6-4 Teaching Older Adults When teaching older adults:

Assess knowledge deficits, readiness to learn, and obstacles that could interfere with the learning process Organize the material prior to the teaching experience Plan strategies to actively engage them in the learning process Assure the environment is conducive to learning (e.g., comfortable room temperature, noise control, avoidance of glare, and lack of distractions and interruptions) Be sensitive to vision and hearing deficits that are present Speak on a level and in a language that is understandable Avoid medical jargon Use several different teaching methods to supplement verbal presentation (e.g., videos, demonstration, PowerPoint slides, pamphlets, and fact sheets) Provide written material to complement verbal instruction; as blues and greens are difficult colors for older eyes, avoid using blue print on green paper Summarize what has been taught and recognize knowledge gains

Be aware of potential barriers to learning:

Stress Sensory deficits Limited educational or intellectual abilities Emotional state Pain, fatigue, and other symptoms

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Unmet physiological needs Attitudes or beliefs held about topic Prior experience with issue Feelings of helplessness and hopelessness

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Advocate The gerontological nurse can function as an advocate in several ways. First and foremost, advocacy for individual clients is essential and can include aiding older adults in asserting their rights and obtaining required services. In addition, nurses can advocate to facilitate a community’s or other group’s efforts to effect change and achieve benefits for older adults and to promote gerontological nursing, including new and expanded roles of nurses in this specialty.

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Innovator Gerontological nursing continues to be an evolving specialty; therefore, nurses have opportunities to develop new technologies and different modalities of care delivery. As an innovator, the gerontological nurse assumes an inquisitive style, making conscious decisions and efforts to experiment for an end result of improved gerontological practice. This requires the nurse to be willing to think “out of the box” and take risks associated with traveling down new roads, transforming visions into reality.

These roles can be actualized in a variety of practice settings, discussed in Chapter 10, and offer opportunities for gerontological nurses to demonstrate significant creativity and leadership.

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ADVANCED PRACTICE NURSING ROLES To competently and effectively care for the clinical complexities of older adults, nurses need preparation in the unique principles and best practices of geriatric care. This requires a broad knowledge base, capacity for independent practice and leadership, and complex clinical problem-solving ability that is possible by nurses prepared for advanced practice roles. Advance practice roles include geriatric nurse practitioners, geriatric nurse clinical specialists, and geropsychiatric nurse clinicians. Most of these roles require the completion of a master’s degree at a minimum.

There is strong evidence that nurses in advanced practice roles make a significant difference to the care of older adults. Gerontological nurse practitioners and clinical nurse specialists have been shown to improve the quality and reduce the cost of care for older persons in a variety of settings, including hospitals, nursing homes, and ambulatory care. The clear positive impact on the health and well-being of older adults should encourage gerontological nurses to pursue these types of advanced practice roles and to encourage the employment of these advanced practitioners in their clinical settings.

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SELF-CARE AND NURTURING The depth and intensity of the nurse–patient relationship that results when nurses function as healers creates a highly therapeutic and meaningful experience that reflects the essence of professional nursing. Although the formal educational preparation of nurses offers the foundation for this level of healing relationship, the nurse’s self-care influences the potential height and depth that can be realized. Some strategies for self-care include following positive health care practices and strengthening and building connections.

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Following Positive Health Care Practices Like all human beings, nurses have basic physiological needs. Although most nurses are familiar with the requirements necessary to meet each of these needs (e.g., proper diet, adequate rest, exercise, etc.), they may not be applying this knowledge to their personal lives. Self-care can suffer as a result.

A periodic “checkup” of physical status can prove useful in disclosing problems that could not only minimize the ability to provide optimal services to patients but also threaten personal health and well-being. It could prove useful for nurses to allocate a few hours, find a quiet place, and critically review their health status.

After identifying problems, nurses can plan realistic actions to improve health. Writing the actions on an index card and placing that card in an area that is regularly seen (e.g., dresser, desk, or dashboard) can provide regular reminders of intended corrective actions.

KEY CONCEPT Efforts to improve self-care practices can be facilitated by partnering with a “buddy” who can offer support, encouragement, and a means for accountability.

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Strengthening and Building Connections Humans are relational beings who are intended to live in a community with others. The richness of nurses’ connections in their personal lives provides fertile soil to grow meaningful connections with patients. Yet, as basic and common as relationships can be, they can be quite challenging. Among the major challenges nurses may face are finding and protecting the time and energy to connect with others in meaningful ways. Like many other professionals in helping professions, nurses may find that the physical, emotional, and mental energies exerted in a typical workday leave little in reserve to invest in nurturing relationships with friends and family. The reactions to work-related stress can be displaced to significant others, thereby interfering with positive personal relationships. To compound the problem, concern for patients’ welfare or employer pressure can lead to excessive overtime work, leaving precious little time and energy for nurses to do anything more in their off hours than attend to basics. Strained personal connections are the weeds of untended relationship gardens.

POINT TO PONDER List five significant individuals in your life. Reflect on the amount of quality time you have with each of them and determine if this time is conducive to a strong relationship.

Relationships The allocation of time and energy requires the same planning as the allocation of any finite resource. Ignoring this reality risks suffering the consequences of poor relationships. Recognizing that there always will be activities to vie for time and energy, nurses need to take control and develop practices that reflect the value of personal relationships. This can involve limiting the amount of overtime worked to no more than “x” hours each week, dedicating every Thursday evening to dining out with the family or blocking out Sunday afternoons to visit or telephone friends. Expressing intentions through understood “personal policies” (e.g., informing a supervisor that you will work no more than one double shift per month) and committing time on your calendar (e.g., blocking off every Sunday afternoon for time with friends) increase the likelihood that significant relationships will receive the attention they require.

Spirituality Time and energy also must be protected to afford ample time for connecting with the nonphysical power that offers inspiration, gives life meaning, and implies something greater than one’s self. For some, this can be God, for others, a nondescript higher power, yet for others, a connection with nature and all living things. The spiritual grounding resulting from this connection enables nurses to better understand and serve the spiritual needs of patients. Nurses can enhance spiritual connection through prayer, fasting, attending church or temple, engaging in Bible or other holy book studies, taking periodic retreats, and practicing days of solitude and silence.

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Connection with Self Connection with self is essential to nurses’ self-care, and this begins with a realistic self-appraisal. Examples of strategies to facilitate this process include sharing life stories, journaling, meditating, and taking retreats.

POINT TO PONDER What does it mean to you to be connected to self?

Sharing Life Stories Every adult has a unique and rich storehouse of experiences that have been cemented into the life in which he or she dwells. Oral sharing of life stories with others helps people gain self-insight and puts experiences into a perspective that affords meaning. As people share stories, they begin to see that their lives are not the only ones that have been less than ideal and sprinkled with pain or have unfolded in unintended ways. They also are able to reflect on positive experiences that influenced their lives. Writing one’s life story is a powerful means of reflection that affords a permanent record that can be revisited and reconsidered as one gains deeper wisdom about self and others. The process of sharing life stories can be particularly meaningful for gerontological nurses in their work with older adults who often have interesting life histories that they are eager to share—and that frequently can offer rich life lessons.

COMMUNICATION TIP To encourage older adults to write their life stories, discuss the value that this record could have for younger family members and offer specific suggestions for how their stories could be structured, such as by:

Significant events during each decade of life descriptions of major events, people, or issues such as their parents, immigration to this country, childhood friends, neighborhood in which they grew up, school experiences, firsts (e.g., date, car, job, home), work experiences, adult friends, hobbies, accomplishments, disappointments, things they felt positive about, and major societal changes they witnessed

Emphasize that it isn’t the writing skill that matters but the gift of documented memories that will be shared with future generations.

Journaling Writing personal notes in a journal or diary can facilitate reflection on one’s life. These writings differ from

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written life stories in that they record current activities and thoughts rather than past ones. An honest written account of feelings, thoughts, conflicts, and behaviors can help people learn about themselves and work through issues.

Meditating The ancient practice of meditation has helped people sort out thoughts and gain clarity of direction for ages. Many nurses find meditation challenging because the nature of their work consists of doing—and multitask doing, at that! However, periods of being still enable nurses to offer an optimum healing presence to their patients.

There are several techniques that can be used for meditating; individuals vary in their preference for the different forms of meditation. Some people may focus on a word or prayer, whereas others may choose to have no intentional thought and to be open to whatever thoughts drift into their minds. Essential elements to any form of meditation are a quiet environment, comfortable position, and calm and passive attitude. The physiological responses associated with the deep relaxation achieved during meditation have many health benefits (e.g., improved immunity, reduced blood pressure, and increased peripheral blood flow). Often, issues a person has been struggling with can be clarified through meditation.

Taking Retreats To many nurses, taking a few days off “to do nothing” seems like a luxury that cannot be afforded. After all, there is the house to get in order, shopping that must be done, and overtime that can be worked to gather a few extra dollars for vacation. In addition to the tasks that compete for attention and time, there may be the mental script that insidiously gives the message that it is selfish to forfeit tangibly productive activities to spend time thinking, reflecting, and experiencing. Yet, unless nurses want their interactions with patients to be solely mechanical (i.e., task oriented), they must treat themselves as more than machines. Their bodies, minds, and spirits must be restored and refreshed periodically to offer holistic care—and retreats offer an ideal means to achieve that.

A retreat is a withdrawal from normal activities. It can be structured or unstructured, guided by a leader or self-directed, and taken with a group or alone. Although retreats are offered in exotic locations that offer lavish provisions, they need not be luxurious or expensive. Whatever the location or structure, key elements of the retreat experience include a respite from routine responsibilities; freedom from distractions (telephones, e- mails, children, and doorbells); no one to care for and worry about other than self; and a quiet place. The charge that a retreat provides to one’s physical, emotional, and spiritual batteries will more than compensate for the tasks that were postponed.

KEY CONCEPT When nurses have strong, grounded connections to themselves, they are in a better position to have meaningful connections with patients.

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Committing to a Dynamic Process Self-care is an ongoing process that demands active attention. However, knowing the actions that support self-care is only the beginning. Committing to engaging in one’s self-care completes the picture. This may mean that limits are set on the amount of overtime worked to adhere to an exercise schedule or that one is willing to face the uncomfortable feelings experienced during the process of reflecting on less than pleasant life experiences. Sacrifices, unpopular decisions, and discomfort can result when one chooses to “work on oneself.” Yet, it is this inner work that contributes to nurses being effective healers and models of healthy aging practices.

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THE FUTURE OF GERONTOLOGICAL NURSING Historically, nurses were the major caregivers to older adults. Going forward, gerontological nurses must strive to protect both the care of older adults and the specialty of gerontological nursing. Tremendous strides have been made already. Dynamic professionals are selecting gerontological nursing as a specialty that offers a multitude of opportunities to use a wide range of knowledge and skills and one that presents many challenges that can be independently addressed within the realm of nursing practice. Excellent research for and by nurses is growing to provide a strong scientific foundation for practice. Increasing numbers of nursing schools are adding specialization in gerontological nursing. New opportunities for gerontological nurses to develop practice models are emerging in acute hospitals, assisted-living settings, health maintenance organizations, life-care communities, adult day treatment centers, and other settings (Fig. 6-3). The future of gerontological nursing appears dynamic and exciting. Nevertheless, more challenges exist.

FIGURE 6-3 • The specialty of gerontological nursing offers multiple opportunities to use a wide range of knowledge and skills in a variety of settings.

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Utilize Evidence-Based Practices Considerable knowledge has been gained through research that can guide practice that is based on evidence rather than assumption; the body of knowledge continuously grows and changes. Practices that were routine in years past may have since been discovered to be ineffective or even harmful. This challenges nurses in keeping abreast of and utilizing evidence-based practices.

Gerontological nurses can access literature upon which evidence-based practice can be obtained from several sources. The Cochrane Collaboration (www.cochrane.org) publishes Cochrane Reviews, systematic assessments of research that meet the highest standard in evidence-based practice. Among the collaboration’s valuable resources are links to databases offering online access to medical evidence from other sites. The National Guideline Clearinghouse (www.guideline.gov), as the name implies, offers evidence-based guidelines. The Hartford Institute for Geriatric Nursing (www.hartfordign.org) offers many evidence-based resources to guide geriatric nursing practice. In addition, geriatric and gerontological journals and publications of professional associations provide reports of recent research.

The gerontological nurse should assure that when new policies and procedures are being developed in the workplace, they are based on evidence. This may require the nurse to conduct a literature search and summarize and present findings to other members of the team. Bridging research to the practice setting is an important function of the gerontological nurse.

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http://www.cochrane.org

http://www.guideline.gov

http://www.hartfordign.org

Advance Research The growing complexity of and demand for gerontological nursing services is exciting and challenging but is accompanied by the need for a strong knowledge base on which these services can be built. There is no room for the trial and error that flavored nursing actions in the past; older adults’ delicately balanced health status, increased consumer expectations, ever-present risk of litigation, and the requisites of professionalism demand scientific foundations for nursing practice. Fine nursing research is being conducted on a variety of issues, and gerontological nurses must encourage and support these efforts through various actions.

One way for nurses to advance research is to network with nurse researchers. Researchers can be important resources. Combining their research skills with the abilities of those in practice settings can help to solve clinical problems. Local academic institutions, teaching hospitals, and nursing homes may be conducting research that can be relevant to various gerontological settings or in which a service agency can participate.

Nurses can also help to support research efforts in a variety of ways. As funding is sought for research projects, nurses can write letters of support and testimony to help funding agencies understand the full benefit of the research effort. Regular contact with leaders who influence the allocation of funds can provide opportunities to educate these persons on the value of supporting research. No less significant to the support of research efforts is the assurance that protocols be followed, because the efforts of researchers can be facilitated or thwarted by colleagues in clinical settings.

Finally, nurses must keep abreast of new findings. Gerontological nursing knowledge is continuously expanding, disproving past beliefs and offering new insights. Nurses can engage in independent study, formal courses, and continuing education programs to keep current. Equally important to acquiring knowledge is implementing evidence-based practice to improve the care of older adults. Older adults’ delicately balanced health status and high risk of complications, along with rising consumer expectations and a highly litigious society, reinforce the importance of evidence-based practice.

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Promote Integrative Care In the United States, conventional medicine, with an emphasis on the diagnosis and treatment of diseases, has set the tone for health care practice. Current managed care and reimbursement priorities reinforce the medical model and disease-focused care. Unfortunately, the care of medical conditions is just one aspect of the services older adults need to be healthy and experience a high quality of life. In fact, older persons’ wellness practices; adjustments to life changes; sense of purpose, hopefulness, joy, connections to others; and ability to manage stress can be equally if not more significant to their health and quality of life than medical care.

Nurses must ensure that gerontological care is holistic, meaning that the physical, emotional, social, and spiritual facets of individuals are considered (see Chapter 7). This implies that nurses not only practice in a holistic manner themselves but also advocate for other disciplines to do so.

Alternative and complementary therapies play a role in holistic care. These therapies tend to be more comforting, safe, and less invasive than conventional treatments and empower older adults and their caregivers in self-care. Many people who use these therapies report positive experiences with their alternative therapists, who frequently spend more time getting to understand and address the needs of the total person than do staff in the typical medical office or hospital. However, the use of alternative therapies does not equate with holistic care. An alternative therapist with tunnel vision, believing that every malady can be corrected with the one modality he or she practices and excluding effective conventional treatments, is no different from the physician who prescribes an analgesic but does not consider imagery, massage, relaxation exercises, and other nonconventional forms of pain relief. Integrating the best of conventional and alternative/complementary therapy supports holistic care.

Part of a holistic approach to care includes care of the caregivers as well. Professional and family caregivers who are in poor health, struggling with psychosocial issues, feeling spiritually empty and disconnected, or managing stress poorly need to heal themselves before they can be effective caregivers. Nurses can assist these caregivers in identifying their needs and finding the help needed for their healing.

POINT TO PONDER Many nurses are in poor physical condition, smoke, regularly eat junk foods, take little time for themselves, and demonstrate other unhealthy habits. What do you think are some of the reasons for this? What can be done to improve nurses’ health habits?

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Educate Caregivers Be it the nursing director, a family member who cares for an older relative, a health aide who has more frequent contact with the patient than the professional nurse, or the physician who only occasionally has an older person in the caseload, caregivers at every level require competency in providing services to the older population. Gerontological nurses can influence the education of caregivers by:

Helping nursing schools identify relevant issues for inclusion in the curricula Participating in the classroom and field experiences of students Evaluating educational deficits of personnel and planning educational experiences to eliminate deficits Promoting interdisciplinary team conferences Attending and participating in continuing education programs Reading current nursing literature and sharing information with colleagues Serving as a role model by demonstrating current practices

With increasing numbers of family members providing more complex care in the home setting than ever before, it is essential that the education of this group not be overlooked. It should not be assumed that because the family has had contact with other providers or has been providing care they are knowledgeable in correct care techniques. The nurse must periodically evaluate and reinforce the family’s knowledge and skills.

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Develop New Roles As gerontological subspecialties and settings for care grow, so will the opportunities for nurses to carve new roles for themselves. Nurses can demonstrate creativity and leadership as they break from traditional roles and settings and develop new models of practice, which may include the following:

Geropsychiatric nurse specialist in the assisted-living setting Independent case manager for community-based chronically ill patients Columnist for local newspaper on issues pertaining to health and aging Owner or director of mature women’s health care center, geriatric day care program, respite agency, or caregiver training center Preretirement counselor and educator for private industry Faith community nurse Consultant, educator, and case manager for geriatric surgical patients

This list only begins to describe opportunities awaiting gerontological nurses. Many opportunities exist for nurses to develop new practice models in gerontological care. It will be important for gerontological nurses to identify nontraditional roles, approach them creatively, test innovative practice models, and share their successes and failures with colleagues to aid them in their development of new roles. Nurses must recognize that their biopsychosocial sciences knowledge, clinical competencies, and human relations skills give them a strong competitive edge over other disciplines in affecting a wide range of services.

POINT TO PONDER Based on changes in the health care system and society at large, what unique services could gerontological nurses offer in the future within your community?

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Balance Quality Care and Health Care Costs The increasing number of older adults is placing increasing demands for diverse health care services than ever before. At the same time, third-party insurers are trying to control the constantly escalating cost of services. Earlier hospital discharges, limited home health visits, increased complexity of nursing home residents, and greater out-of-pocket payment for services by patients demonstrate some of the effects of changes in reimbursement policy. There is concern that, as a result of these changes, patients are discharged from hospitals prematurely and suffer greater adverse consequences, nursing homes are confronting residents with complex problems for whom they are not adequately prepared or staffed, families are being strained by considerable caregiving burdens, and patients are being deprived of needed but unaffordable services.

Concept Mastery Alert Changes in reimbursement practices result in the earlier hospital discharge of patients with high acuity level care needs. The limited reimbursement for nursing home and home health care services may not provide the resources to adequately provide the type of care required by these individuals.

Such changes are disconcerting and may cause nurses to feel overwhelmed, frustrated, or dissatisfied. Unfortunately, more cost cutting is likely to occur. Rather than experience burnout or consider a change of occupation, nurses should become involved in cost-containment efforts so that a balance between quality services and budgetary concerns can be achieved. Efforts toward this goal can include the following:

Test creative staffing patterns. Perhaps six nurses can be more productive than three nurses and three unlicensed caregivers. Or, perhaps some of the high nonproductive time costs associated with unlicensed personnel are related to poor hiring and supervision practices; improved management techniques may increase the cost-effectiveness of these workers. Use lay caregivers. Neighbors assisting each other, a family member rooming-in during hospitalizations, and other methods to increase the resources available for service provision can be explored. Abolish unnecessary practices. Why must nurses spend time administering medications to patients who have successfully administered them before admission and who will continue to administer them after discharge, take vital signs every 4 hours on patients who have shown no abnormalities, bathe all patients on the same schedule regardless of skin condition or state of cleanliness, or rewrite assessments and care plans at specified intervals regardless of a patient’s changes or stability? Often regulations and policies are developed under the assumption that, without them, vital signs would never be taken, baths would not be given, and other facets of care would not be completed. Perhaps the time has come for nurses to aggressively convince others that they have the professional judgment to determine the need for and frequency of assessment, care planning, and care delivery. Ensure safe care. The implementation of cost-containment efforts should be accompanied by concurrent studies of its impact on rates of complications, readmissions, incidents, consumer satisfaction, and staff

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turnover, absenteeism, and morale. Specific numbers and documented cases carry more weight than broad criticisms or complaints that care is suffering. Advocate for older adults. The priorities of society and professions change. History shows us that at different times the spotlight has focused on various underserved groups, such as children, pregnant women, the mentally ill, the disabled, substance abusers, and, most recently, older adults. As interests and priorities shift to new groups, gerontological nurses must make certain that the needs of older individuals are not forgotten or shortchanged.

As gerontological nursing continues to shed its image of a less-than-challenging specialty for less-than- competent nurses and fully emerges as the dynamic, multifaceted, and opportunity-filled area of nursing that it is, it will be recognized as a specialty for the finest talent the profession has to offer. Gerontological nursing has just begun to show its true potential.

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BRINGING RESEARCH TO LIFE Quality Geriatric Care as Perceived by Nurses in Long-Term and Acute Care Settings

Source: Barba, B. E., Hu, J., & Efird, J. (2012). Journal of Clinical Nursing, 21(5), 833–840.

This descriptive study explored the differences between acute and long-term care nurses in regard to their satisfaction with the quality of care of older adults. The self-selected sample included 298 registered nurses and licensed practical nurses who provide care to minority, underserved, and disadvantaged older populations in 89 long-term care facilities and hospitals of less than 100 beds in a southern state. All completed the Agency Geriatric Nursing Care survey, which consisted of a 13-item scale measuring nurses’ satisfaction with the quality of geriatric care in their practice settings and an 11-item scale examining obstacles to providing quality geriatric care.

Significant differences were found between the two groups of nurses in regard to level of satisfaction and perceived obstacles to providing quality care. Long-term care nurses were more satisfied and perceived fewer obstacles to providing quality care than nurses in acute hospitals. The long-term care nurses believed their care was more evidence based and specialized to the geriatric population.

Although acute care nurses commonly do not identify themselves as geriatric nurses, they are engaged in geriatric nursing practice due to the large number of hospitalized older adults. These nurses need to know best practices for geriatric care. This study demonstrates that without evidence-based guidelines to assist nurses in providing care that promotes autonomy, independence, and high-quality services, they feel less satisfied with the care offered to older patients. It can be beneficial for acute care nurses to discuss this need with managerial and education staff at their hospitals and support efforts to bridge evidence-based geriatric nursing practices to their clinical setting.

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PRACTICE REALITIES Nurse Yen is a new graduate of a BSN program who has joined the staff of a subacute care unit of the local hospital. Most of the nurses on staff are diplomas and ADN graduates who have been out of school for more than a decade.

Ms. Yen notices that some of the nurses are unaware of current best practices and trends. In informal conversations, she has learned that none of the nurses subscribes to professional journals or belongs to a professional association, and the rare times they have attended continuing education programs was when the hospital sent them.

What can Nurse Yen do to help these nurses understand the importance and engage in continuing education?

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CRITICAL THINKING EXERCISES

1. What were some of the reasons for the poor status of gerontological nursing in the past? 2. Why is the nursing role of healer particularly meaningful to gerontological practice? 3. What theme regarding the involvement of the older adult is apparent in the ANA Standards of the

Gerontological Nurse? 4. Describe several issues that could warrant gerontological nursing research activities. 5. Describe how the increased use of holistic practices could have a positive effect on cost and consumer

satisfaction. 6. Outline functions that could be performed by a gerontological nurse in the roles of (a) assisted-living

community preadmission health screener, (b) health counselor in a retirement community, (c) caregiver trainer, (d) industrial preretirement health educator, and (e) faith community nurse.

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Chapter Summary Although nurses have a long history of caring for older adults, the formal creation of a specialty of gerontological nursing did not occur until the 1970s. Since that time the specialty has grown considerably with the creation of standards, clarification of competencies, and development of several organizations that address the unique needs of nurses in this specialty. As the specialty has developed there has been differentiation between geriatric nursing, which involves the nursing care of sick older adults, and gerontological nursing, which promotes wellness and healthy aging for all individuals.

The major roles for gerontological nurses include that of healer, caregiver, educator, advocate, and innovator. There also are advanced practice roles for nurses in this specialty.

To effectively care for others, gerontological nurses must care for themselves. This includes positive health care practices, having positive connections with others, attending to spiritual needs, and taking time for self. These practices not only promote health in nurses themselves but enable nurses to serve as models of healthy aging practices to others.

Gerontological nurses face challenges as the specialty continues to grow, such as assuring practice is based on evidence, advancing research, promoting integrative care, educating caregivers, developing new roles within the specialty, and balancing quality care with pressures to control health care costs.

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Resources American Holistic Nurses Association

http://www.ahna.org

American Nurses Credentialing Center

http://www.nursecredentialing.org

Hartford Institute for Geriatric Nursing

http://www.hartfordign.org

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http://www.ahna.org

http://www.nursecredentialing.org

http://www.hartfordign.org

References Bishop, L. F. (1904). Relation of old age to disease with illustrative cases. American Journal of Nursing, 4(4), 674.

DeWitt, K. (1904). The old nurse. American Journal of Nursing, 4(4), 177.

Nightingale, F. (1860). Notes on nursing: What it is, and what it is not. New York, NY: D. Appleton and Company.

Nouwen, H. J. M. (1990). The wounded healer. New York, NY: Doubleday.

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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 7

Holistic Assessment and Care Planning

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CHAPTER OUTLINE

Holistic Gerontological Care

Holistic Assessment Of Needs

Health Promotion–Related Needs

Health Challenges–Related Needs

Requisites to Meet Needs

Gerontological Nursing Processes

Examples Of Application

Applying the Holistic Model: The Case of Mrs. D

The Nurse As Healer

Healing Characteristics

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Explain holistic gerontological nursing care. 2. Describe the needs of older adults pertaining to the promotion of health and the management of health challenges. 3. List the requisites that influence older persons’ abilities to meet self-care needs. 4. Describe the general types of nursing interventions that are employed when older adults present self-care deficits. 5. Describe four characteristics of nurses who function as healers.

TERMS TO KNOW Holistic pertains to whole person; body, mind, and spirit

Presence being totally “with” or engaged with another individual

Surviving to old age is a tremendous accomplishment. Basic life requirements such as obtaining adequate nutrition, keeping oneself relatively safe, and maintaining the body’s normal functions have been met with some success to survive to this time. Older adults have confronted and overcome to varying degrees the hurdles of coping with crises, adjusting to change, and learning new skills. Throughout their lives, older individuals have faced many important decisions, such as should they:

Leave their country of birth to make a fresh start in America? Stay in the family business or seek a job in a local industry? Risk their lives to defend a cause in which they believe? Encourage their children to fight in an unpopular war? Invest their entire savings in launching a business of their own? Allow their children to continue their education when the children’s employment would ease a serious financial hardship?

Too often, nurses seek external resources to meet the needs of older persons rather than recognizing that older adults have considerable inner resources for self-care and empowering them to use these strengths. Older adults then become passive recipients of care rather than active participants. This seems unreasonable because

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most older adults have had a lifetime of taking care of themselves and others, making their own decisions, and meeting life’s most trying challenges. They may become angry or depressed at being forced to forfeit their decision-making functions to others. They may unnecessarily develop feelings of dependency, uselessness, and powerlessness. Gerontological nurses must recognize and mobilize the strengths and capabilities of older people so that they can be responsible and active participants in, rather than objects of, care. Tapping the resources of older individuals in their own care promotes normalcy, independence, and individuality; it aids in reducing risks of secondary problems related to the reactions of older adults to an unnecessarily imposed dependent role; and it honors their wisdom, experience, and capabilities.

KEY CONCEPT Older individuals have had to be strong and resourceful to navigate the stormy waters of life. Nurses should not overlook these strengths when planning care for older adults.

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HOLISTIC GERONTOLOGICAL CARE Holism refers to the integration of the biologic, psychological, social, and spiritual dimensions of an individual in which the synergy creates a sum that is greater than its parts; within this framework, healing the whole person is the goal of nursing (Dossey & Keegan, 2012). Holistic gerontological care incorporates knowledge and skills from a variety of disciplines to address the physical, mental, social, and spiritual health of individuals. Holistic gerontological care is concerned with:

Facilitating growth toward wholeness Promoting recovery and learning from an illness Maximizing quality of life when one possesses an incurable illness or disability Providing peace, comfort, and dignity as death is approached

In holistic care, the goal is not to treat diseases but to serve the needs of the total person through the healing of the body, mind, and spirit.

KEY CONCEPT Gerontological nurses help older individuals achieve a sense of wholeness by guiding them in understanding and finding meaning and purpose in life; facilitating harmony of the mind, body, and spirit; mobilizing their internal and external resources; and promoting self-care behaviors.

Health promotion and healing through a balance of the body, mind, and spirit of individuals are at the core of holistic care and have particular relevance for gerontological care. The impact of age-related changes and the effects of highly prevalent chronic conditions can easily threaten the well-being of the body, mind, and spirit; therefore, nursing interventions to reduce such threats are essential. Because chronic diseases and the effects of advanced age cannot be eliminated, healing rather than curative efforts will be most beneficial in gerontological nursing practice. Equally significant is assisting older adults toward self-discovery in their final phase of life so that they find meaning, connectedness with others, and an understanding of their place in the universe.

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HOLISTIC ASSESSMENT OF NEEDS There are many evidence-based assessment tools that can be useful to gerontological nurses. One of the most comprehensive listings of these tools can be found at the Hartford Institute for Geriatric Nursing (see Resource listing), which includes resources for assessment of activities of daily living (ADL), hearing, sleep, sexuality, elder mistreatment, dementia, hospital admission risk, and other topics. These tools can be used to supplement the holistic assessment, which has a slightly different emphasis. Holistic assessment identifies patient needs related to health promotion and health challenges and also identifies the older adult’s requisites to meet these needs.

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Health Promotion–Related Needs The concept of health seems simple, yet it is quite complex. Viewing health as the absence of disease offers little more clarity than defining cold as the absence of hot and creates an image that begs for a more positive, broad understanding. In regard to older adults, most of whom are living with chronic conditions, this definition would relegate most of them to the ranks of the unhealthy.

When asked to describe the factors that contribute to health, most people would be likely to list the basic life-sustaining needs such as breathing, eating, eliminating, resting, being active, and protecting oneself from risks. These are essential to maintaining the physiological balance that sustains life. However, the reality that we can have all of our physiological needs satisfied, yet still not feel well, demonstrates that physiological balance is but one component of overall health. Connection with ourselves, others, a higher power, and nature are important factors influencing health. The fulfillment of physiological needs and a sense of being connected promote well-being of the body, mind, and spirit that enables us to experience gratification through achieving purpose, pleasure, and dignity. This holistic model demonstrates that optimal health includes those activities that not only enable us to exist but also help us to realize effective, enriched lives (Fig. 7-1).

FIGURE 7-1 • Health promotion–related needs.

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POINT TO PONDER What does it mean to you to be healthy and whole?

An improved definition of health includes consideration of the root meaning of the word health: whole. Using this foundation, health is understood as a state of wholeness … an integration of body, mind, and spirit to achieve the highest possible quality of life each day (Fig. 7-2). For some individuals, this can mean exercising at the gym, engaging in challenging work, and having a personal relationship with God; for others, it can represent propelling oneself in a wheelchair to a porch, enjoying the beauty of nature, and connecting with a universal energy.

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FIGURE 7-2 • Rather than being limited to meaning the absence of disease, health implies a wholeness and

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harmony of body, mind, and spirit.

Views of health differ not only from individual to individual but also within the same individual from one time to another. Health priorities and expectations in a 70-year-old person may not resemble what they were when that individual was half that age. Cultural and religious influences can also affect one’s view of health.

Optimal health of older adults rests on the degree to which the needs for physiological balance, connection, and gratification are satisfied. There is the risk that in busy clinical settings, the less tangible needs of gratification and connection can be overlooked; as advocates for older adults, gerontological nurses must assure that comprehensive care is provided by not omitting these important needs.

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Health Challenges–Related Needs An unfortunate reality is that most older adults live with at least one chronic condition that challenges their health status. In fact, most involvement that nurses have with older adults typically involves assisting them with the demands imposed by health challenges. Older adults with acute or chronic conditions have the same basic health promotion needs as healthy individuals (i.e., physiological balance, connection, and gratification); however, their conditions may create new needs such as:

Education: As individuals face a new diagnosis, they need to understand the condition and its care. Counseling: A health condition can trigger a variety of feelings and impose lifestyle adjustments. Coaching: Just as athletes and musicians require the skills of a professional who can bring out the best in them, patients, too, can benefit from efforts to improve compliance and motivation. Monitoring: The complexities of health care and the changing status of aging people warrant oversight from the nurse who can track progress and needs. Coordination: Older adults with a health condition often visit several health care providers; assistance with scheduling appointments, following multiple instructions, keeping all members of the team informed, and preventing conflicting treatments are often needed. Therapies: Often, health conditions are accompanied by the need for medications, exercises, special diets, and procedures. These therapies can include conventional ones that are commonly used in mainstream practice or complementary ones, such as biofeedback, herbal remedies, acupressure, and yoga. Patients may need partial or total assistance as they implement these treatments. Advocacy: There are times when older adults may need support or interception with an issue. This could involve a nurse encouraging an older adult to express her objection to a treatment that the physician and her family are pressuring her to accept or assisting a nursing home resident in contacting the state ombudsman if the resident believes there is mismanagement of his funds.

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Requisites to Meet Needs As straightforward and clear as the health promotion and health challenges–related needs may seem, these needs are met with varying degrees of success because they are dependent on several factors unique to the patient. Nurses assess older adults’ requisites to meet needs to determine areas for intervention.

Physical, Mental, and Socioeconomic Abilities An individual relies on several factors to meet even the most basic life demands. For example, to normally fulfill nutritional needs, a person must have the ability to experience hunger sensations; proper cognition to adequately select, prepare, and consume food; good dental status to chew food; a functional digestive tract to utilize ingested food; energy to shop and prepare food; and the funds to purchase food. Deficits in any of these areas can create risks to nutritional status. A variety of nursing interventions can be used to reduce or eliminate physical, mental, and socioeconomic deficits.

Knowledge, Experience, and Skills Limitations exist when the knowledge, experience, or skills required for a given self-care action are inadequate or nonexistent. An individual with a wealth of social skills is capable of a normal, active life that includes friendship and other social interaction. People who have knowledge of the hazards of cigarette smoking will be more capable of protecting themselves from health risks associated with this habit. An older man who is widowed, however, may not be able to cook and provide an adequate diet for himself, having always depended on his wife for meal preparation. Similarly, the person who has diabetes and cannot self-inject the necessary insulin may not be able to meet the therapeutic demand for insulin administration. Specific nursing considerations for enhancing self-care capacities are offered in other chapters.

Desire and Decision to Take Action The value a person sees in performing the action, as well as the person’s knowledge, attitudes, beliefs, and degree of motivation, influences the desire and decision for action. Limitations result if a person lacks desire or decides against action. If an individual is not interested in preparing and eating meals because of social isolation and loneliness, a dietary deficiency may develop. A hypertensive individual’s lack of desire and decision not to forfeit potato chips and pork products in the diet because of an attitude that it is not worth the trade-off may create a real health threat. The person who is not informed of the importance of physical activity may not realize the need to arise from bed during an illness and consequently may develop complications. The dying individual who views death as a natural process may decide against medical intervention to sustain life and may not comply with the prescribed therapies.

Values, attitudes, and beliefs are deeply established and not easily altered. Although the nurse should respect the right of individuals to make decisions affecting their lives, if limitations restrict their ability to meet self-care demands, the nurse can help by explaining the benefit of a particular action, providing information, and motivating. In some circumstances, as with an emotionally ill or mentally incompetent person, desires and decisions may have to be superseded by professional judgments.

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KEY CONCEPT There can be vastly different reasons for older adults to have a deficit in meeting a similar need. This challenges the gerontological nurse to explore the unique and sometimes subtle dynamics of each older person’s life.

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GERONTOLOGICAL NURSING PROCESSES The assessment process considers patients’ effectiveness in meeting needs related to health promotion and health challenges. If the individual is successful in fulfilling needs, there is no need for nursing intervention except to reinforce the capability for self-care. When the older adult does not have the requisites to meet needs independently, however, nursing interventions are needed. Nursing interventions are directed toward empowering the older individual by strengthening self-care capacities, eliminating or minimizing self-care limitations, and providing direct services by acting for, doing for, or assisting the individual when requirements cannot be independently fulfilled (Fig. 7-3). Assessment factors pertaining to specific systems and areas of function are found in the related chapters throughout this book.

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FIGURE 7-3 • If the nurse identifies self-care deficits in the older adult for meeting health promotion– and health challenges–related needs, nursing interventions are needed.

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EXAMPLES OF APPLICATION Nursing care for older persons is often associated with implementing actions when health conditions exist. When individuals face health challenges, new needs frequently arise, such as administering medications, observing for specific symptoms, and performing special treatments; these needs exceed and may affect the needs related to health promotion. In geriatric nursing, consideration must be given to assessing the impact of the health challenge on the individual’s self-care capacity and identifying appropriate nursing interventions to ensure that the needs related to both health promotion and the management of health challenges are adequately met. During the assessment, the nurse identifies the specific health challenges–related needs that are present and the requisites (e.g., physical capability, knowledge, and desire) that need to be addressed to strengthen self-care capacity.

It is significant that interventions include those actions that can empower the older individual to achieve maximum self-care in regard to health challenges–related needs. Figure 7-3 demonstrates how the holistic self-care model becomes operational in geriatric nursing practice. The cases that follow demonstrate the application of this model.

KEY CONCEPT More effort may be needed to instruct and coach an older person to perform a self-care task independently, and more time may be taken for the person to perform the task independently than would be necessary if a caregiver did the task; however, the benefits of independence to the older person’s body, mind, and spirit are worth the investment.

CONSIDER THIS CASE

Mr. R, who has lived with diabetes for a long time, administers insulin daily and follows a diabetic diet. Because of a recent urologic problem, he may now need to take antibiotics daily and perform intermittent self-catheterization. During the assessment, the nurse identifies the presence of illness-imposed needs. For instance, Mr. R performs self-catheterization

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according to procedure and is administering his antibiotics as prescribed, but he is not adhering to his

diabetic diet and alters his insulin dosage based on “how he feels that day.” Mr. R has knowledge of the diabetic diet and wants to comply; however, he had depended on his wife to prepare meals, and now that she is deceased, he has difficulty cooking nutritious meals independently. He denies ever being informed of the need for regular doses of his insulin and states that he has relied on the advice of his brother-in-law, also a diabetic, who told him to “take an extra shot of insulin when he eats a lot of sweets.”

THINK CRITICALLY

What is the nurse’s next step once Mr. R’s needs have been identified? What factors must be considered in exploring Mr. R’s deficits in meeting his health challenges– related needs? What specific actions could be planned to address Mr. R’s needs?

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Applying the Holistic Model: The Case of Mrs. D The following case demonstrates how this model can work.

Mrs. D, 78 years old, was admitted to a hospital service for acute conditions with the identified problems of a fractured neck of the femur, malnutrition, and a need for a different living arrangement. Initial observation revealed a small-framed, frail-looking lady, with obvious signs of malnutrition and dehydration. She was well oriented to person, place, and time and was able to converse and answer questions coherently. Although her memory for recent events was poor, she seldom forgot to inform anyone who was interested that she neither liked nor wanted to be in the hospital. Her previous and only other hospitalization was 55 years earlier.

Mrs. D had been living with her husband and an unmarried sister for more than 50 years when her husband died. For the 5 years following his death, she depended heavily on her sister for emotional support and guidance. Then her sister died, which promoted feelings of anxiety, insecurity, loneliness, and depression.

For the year since her sister’s death, she has lived alone, caring for her six-room home in the country with no assistance other than that from a neighbor who did the shopping for Mrs. D and occasionally provided her with transportation.

On the day of her admission to the hospital, Mrs. D had fallen on her kitchen floor, weak from her malnourished state. Discovering her hours later, her neighbor called an ambulance, which transported Mrs. D to the hospital. Once the diagnosis of fractured femur was established, plans were made to perform a nailing procedure, to correct her malnourished state, and to find a new living arrangement because her home demanded more energy and attention than she was capable of providing.

Nursing Care Plan 7-1 illustrates how Mrs. D’s holistic needs directed nursing diagnoses and related nursing actions.

NURSING CARE PLAN 7-1 HOLISTIC CARE FOR MRS. D

NEEDS: Respiration and Circulation

Nursing Diagnoses: (1) Impaired Physical Mobility related to fracture and (2) Disruption of Gas Exchange related to immobility

Goals: The patient demonstrates signs of adequate respiration, is free from respiratory distress and infection, and is free from signs of impaired circulation.

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NEEDS: Nutrition and Hydration

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements, related to depression and loneliness

Goals: The patient consumes at least 1,500 mL of fluids and 1,800 calories of nutrients daily; increases weight to 125 lb.

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NEED: Elimination

Nursing Diagnoses: (1) Constipation related to immobility and (2) Risk of Infection related to malnutrition and interferences with normal bathing

Goals: The patient is free from infection, establishes a regular bowel elimination schedule, is free from constipation, and is clean and odor free.

NEED: Movement

Nursing Diagnoses: (1) Activity Intolerance related to malnutrition and fracture and (2) Impaired Physical Mobility related to fracture

Goals: The patient maintains/achieves sufficient range of joint motion to engage in ADL and is free from complications secondary to immobility.

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NEED: Rest

Nursing Diagnosis: Disturbed Sleep Pattern related to hospital environment and movement limitations associated with fracture

Goals: The patient obtains sufficient sleep to be free from fatigue and learns measures to facilitate sleep and rest.

NEED: Comfort

Nursing Diagnosis: Acute Pain related to fracture

Goals: The patient is free from pain and is able to participate in ADLs without pain-related restrictions.

NEED: Immunity

Nursing Diagnoses: (1) Ineffective Health Maintenance and (2) Risk of Infection

Goals: The patient is free from infection.

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NEED: Risk Reduction

Nursing Diagnoses: (1) Risk of Injury related to sensory deficits; (2) Risk of Impaired Skin Integrity related to immobility, malnutrition, and decreased sensations; and (3) Impaired Home Maintenance related to altered health state, convalescence

Goals: The patient is free from injury; possesses intact skin; effectively and correctly uses assistive devices, eyeglasses, and hearing aids (as prescribed) to compensate for sensory deficits; and has safe, acceptable living arrangements after discharge.

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NEED: Connection

Nursing Diagnoses: (1) Spiritual Distress, Hopelessness, and Powerlessness related to hospitalization, health state, and lifestyle changes and (2) Impaired Social Interaction related to hospitalization and health state

Goals: The patient expresses satisfaction with the amount of social interaction, identifies means for fulfilling spiritual needs, and is free from signs of emotional distress.

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NEED: Gratification

Nursing Diagnoses: (1) Anxiety, Fear, Hopelessness, and Powerlessness related to hospitalization and health state, (2) Impaired Social Interaction related to hospitalization, and (3) Chronic Low Self-Esteem related to health problems and life situation

Goals: The patient demonstrates preinjury level of physical activity, performs self-care activities to maximum level of independence, expresses satisfaction with the amount of solitude, and is free from signs of emotional distress.

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COMMUNICATION TIP A skillful assessment and comprehensive care plan mean little if the information remains in the record without being communicated to caregivers. A mechanism should be developed to share the care plan in a format that can be easily used by caregivers and on a level appropriate for them.

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THE NURSE AS HEALER Nurses are not merely task-doers but important instruments of their patients’ healing process. If completion of tasks was all that constituted nursing care, robots could easily replace nurses. After all, technology exists that could enable a machine to administer a medication, reposition a patient, monitor vital signs, record significant events, and perform other common tasks. Yet the nursing profession emerged as a healing art characterized by its practitioners offering comfort, compassion, support, and caring—factors that were equally (and perhaps sometimes more) important to patients’ healing than the procedural tasks of caregiving. The nurse serves as a healer whose interactions assist the patient in returning to wholeness (i.e., optimal function and harmony among body, mind, and spirit).

Nurses who support holism and healing do not sit on the sidelines as observers; they actively engage in patients’ healing processes. This level of engagement is similar to that of the dance instructor who takes the student by the hand and demonstrates the correct steps instead of merely offering directions from the sidelines.

KEY CONCEPT Nurses actively engage in the patient’s dance of healing—teaching, guiding, modeling, coaching, encouraging, and helping the patient through the various steps.

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Healing Characteristics Characteristics that enable nurses to engage as healers for older adults include presence, availability, willingness to form connections, and being models of holism.

Presence The ability to be present in the moment also characterizes nurse healers. Despite the many real activities that nurses typically must complete, the “busyness” of the average clinical setting, and the unending “to do” list lingering over them, nurse healers are able to protect their interactions with patients from distractions. When with patients, they are with them, giving their full, undivided attention. They actively listen; hear what patients are saying—and not saying—and use their senses to detect subtle clues about needs. Even if the time spent with individual patients is brief, the time fully belongs to their patients.

POINT TO PONDER Reflect on an interaction in which the person with whom you were speaking seemed distracted and hurried. How did that influence your communication?

Availability Nurse healers display availability of body, mind, and spirit. They provide the time and space for patients to express, explore, and experience. “That’s not my job” are words seldom heard from nurse healers. For example, a nurse may be monitoring a patient who is recovering from cataract surgery in an outpatient surgical unit when the patient confides to the nurse that he is distressed at learning that his grandchild was arrested for possession of illegal drugs. A response from the nurse along the lines of “You shouldn’t worry about that now” gives the message that the nurse is not available to discuss the patient’s concern and most likely will close the door to further discussion. By contrast, responding, “This must be very difficult for you” could be more helpful in conveying openness and interest. Although the nurse in the latter example may not be able to provide all the possible assistance that the patient may require, he or she can allow the patient the safe space to unload this burden on his mind and offer suggestions for follow-up help.

Willingness to Form Connections Nurse healers make connections with their patients. They engage with patients in meaningful ways that require openness, respect, acceptance, and a nonjudgmental attitude. They commit to learning about what makes each patient a unique individual—the life journey that has been traveled, the story that has formed. At times, this may require that nurses offer insights from their own journeys and share some of the chapters from their lives. Exploring the unique threads that have been woven into the tapestry of a patient’s life facilitates connection.

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Models of Holism Effective nurse healers are models of holism, which begins with good self-care practices. They not only eat a proper diet, exercise, obtain adequate rest, and follow other positive health practices, but they also are attentive to their emotional and spiritual well-being. Integrity demands that nurses know what they want others to know and behave as they want others to behave. Self-care also is essential to performing any other role as a nurse healer.

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BRINGING RESEARCH TO LIFE The Specialized Role of the RN in the Program of All-Inclusive Care for the Elderly (PACE) Interdisciplinary Care Team

Source: Madden, K.A., Waldo, M., & Cleeter, D. (2014). Geriatric Nursing, 35(3), 199–204.

PACE is the Program of All-inclusive Care for the Elderly, which is considered an innovative interdisciplinary model of health care delivery for community-based frail older adults, certified by their state to need skilled nursing care. Although PACE has been shown to provide positive outcomes in providing care for frail elderly individuals, there has been limited research on the role of the nurse within the PACE interdisciplinary team. This study was conducted to gain insight into the role of nurses within PACE and the nursing care delivery models that were used within the program.

The study consisted of an online structured survey of nurse leaders in PACE organizations throughout the country. A group of these nurses were then interviewed by telephone using a focused survey.

The study found that there was a high percentage of baccalaureate prepared nurses working in PACE organizations who were directly involved in care planning and nursing care management. A variety of nursing care models (functional, primary, or care management) were used, and there was no certainty as to which nursing care delivery model was the most appropriate for the program. The PACE nurses who participated in the study as well as the researchers saw value in conducting future research using specific quality indicators (e.g., hospital readmissions, pressure ulcer prevalence, patient satisfaction, etc.) to determine the best model that should be utilized.

When performing patient assessments, developing care plans, and implementing nursing services, nurses can use a variety of nursing care delivery models. Although each model has value, some may be more effective than others for a specific program or patient population. When new programs or services are launched, it could be beneficial for nurses to test different nursing care delivery models so they can identify relevant quality indicators that can be tracked and evaluated in an effort to determine the model, which yields the best results.

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PRACTICE REALITIES As a new staff member of a nursing home, you notice that other staff make decisions and perform activities for many residents who seem capable of doing these things for themselves. When caring for some of these residents, you give them the opportunity to make choices about their preferences, which they have been pleased and able to make. In addition, when encouraging them to feed themselves, residents have performed the task, although more time was required to complete care.

What could be the possible reasons for staff creating unnecessary dependence in the residents? How could you encourage a change in their approaches?

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CRITICAL THINKING EXERCISES

1. Identify life experiences that have been unique to today’s older population and that have prepared them to cope with some of the challenges of old age.

2. List age-related changes that could affect each of the health promotion–related needs. 3. What are some reasons for older adults not wanting to function independently in self-care activities? 4. Describe some situations in which older adults are at risk for losing independence as a result of nurses

doing for them rather than promoting independence.

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Chapter Summary Holistic gerontological care integrates the biologic, psychological, social, and spiritual dimensions of an individual in which the synergy creates a sum that is greater than its parts. It not only is concerned with the treatment of illnesses but also the facilitation of growth toward wholeness, maximization of quality of life, and the provision of peace, comfort, and dignity during the dying process.

Holistic gerontological nursing assessment considers physiological balance, the connection of the individual with self, others, the culture and the environment, and the degree to which the person is achieving gratification. When health challenges are present, the individual may present new needs, such as for education, counseling, coaching, monitoring, coordination, therapies, and advocacy. The requisites that must be present for the individual to meet these needs are physical, mental, and socioeconomic abilities; knowledge, experience, and skills; and the desire and decision to take action.

Nurses need to recognize the considerable inner resources that older adults possess and mobilize these resources to actively engage these individuals in their own care. Doing so will empower older adults and facilitate commitment to the plan of care.

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Online Resources American Holistic Health Association

http://www.ahha.org

American Holistic Medical Association

http://www.holisticmedicine.org

American Holistic Nurses Association

http://www.ahna.org

Hartford Institute for Geriatric Nursing Try This Assessment Tool Series

http://hartfordign.org/practice/try_this/

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http://www.ahha.org

http://www.holisticmedicine.org

http://www.ahna.org

http://hartfordign.org/practice/try_this/

Reference Dossey, B. M., & Keegan, L. (2012). Holistic nursing: a handbook for practice (6th ed.). Sudbury, MA: Jones & Bartlett Publishers.

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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 8

Legal Aspects of Gerontological Nursing

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CHAPTER OUTLINE

Laws Governing Gerontological Nursing Practice

Legal Risks In Gerontological Nursing

Malpractice

Confidentiality

Patient Consent

Patient Competency

Staff Supervision

Medications

Restraints

Telephone Orders

Do Not Resuscitate Orders

Advance Directives and Issues Related to Death and Dying

Elder Abuse

Legal Safeguards For Nurses

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Discuss laws governing gerontological nursing practice. 2. Describe legal issues in gerontological nursing practice and ways to minimize risks. 3. List legal safeguards for nurses.

TERMS TO KNOW Consent granting of permission to have an action taken or procedure performed

Durable power of attorney allows competent individuals to appoint someone to make decisions on their behalf in the event that they become incompetent

Duty a relationship between individuals in which one is responsible or has been contracted to provide service for another

HIPAA Health Insurance Portability and Accountability Act of 1996, assures confidentiality of health information and consumers’ access to their health records

Injury physical or mental harm to another or violation of a person’s rights resulting from a negligent act

Malpractice deviation from standard of care

Negligence failure to conform to the standard of care

Private law governs relationships between individuals and/or organizations

Public law governs relationships between private parties and the government

Standard of care the norm for what a reasonable individual in a similar circumstance would do

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Nurses in every specialty must be cognizant of the legal aspects of their practice, and gerontological nurses are no exception. In fact, legal risks can intensify and legal questions can arise when working in geriatric care settings. Frequently, gerontological nurses are in highly independent and responsible positions in which they must make decisions without an abundance of professionals with whom to confer. They are also often responsible for supervising unlicensed staff and ultimately are accountable for the actions of those they supervise. In addition, gerontological nurses are likely to face difficult situations in which their advice or guidance may be requested by patients and families; they may be asked questions regarding how to protect the assets of the wife of a patient with Alzheimer’s disease, how to write a will, what can be done to cease life- sustaining measures, and who can give consent for a patient. Also, the multiple problems faced by older adults, their high prevalence of frailty, and their lack of familiarity with laws and regulations may make them easy victims of unscrupulous practices. Advocacy is an integral part of gerontological nursing, reinforcing the need for nurses to be concerned about protecting the rights of their older patients. To fully protect themselves, their patients, and their employers, nurses must have knowledge of basic laws and ensure that their practice falls within legally sound boundaries.

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LAWS GOVERNING GERONTOLOGICAL NURSING PRACTICE Laws are generated from several sources. Because many laws are developed at the state and local levels, variation exists among the states. This variation necessitates nurses’ familiarity with the unique laws within their specific states, particularly those governing professional practice, labor relations, and regulation of health care agencies.

There are both public and private laws. Public law governs relationships between private parties and the government and includes criminal law and regulation of organizations and individuals engaged in certain practices. The scope of nursing practice and the requirements for being licensed as a home health agency fall under the enforcement of public law. Private law governs relationships among individuals or between individuals and organizations and involves contracts and torts (i.e., wrongful acts against another party, including assault, battery, false imprisonment, and invasion of privacy). These laws protect individual rights and also set standards of conduct, which, if violated, can result in liability of the wrongdoer.

In addition to laws, there are voluntary standards by which a nurse can be judged. The American Nurses Association publication Scope and Standards of Gerontological Nursing provides guidelines for gerontological nurses that offer descriptions of what is considered safe and effective care. (See Chapter 6 for a discussion of these standards.)

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LEGAL RISKS IN GERONTOLOGICAL NURSING Most nurses do not commit wrongful acts intentionally; however, certain situations can increase the nurse’s risk of liability. Such situations include working without sufficient resources, not checking agency policy or procedure, bending a rule, giving someone a break, taking shortcuts, or trying to work when physically or emotionally exhausted. Not only repeated episodes of carelessness but also the one-time deviation from standards can result in serious legal problems. Box 8-1 reviews some of the general acts that could make nurses liable for violating the law. Nurses must be alert to all the potential legal risks in their practice and make a conscious effort to minimize them. Some of the issues that could present legal risks for nurses are presented below.

Box 8-1 Acts That Could Result in Legal Liability for Nurses ASSAULT A deliberate threat or attempt to harm another person that the person believes could be carried through (e.g., telling a patient that he will be locked in a room without food for the entire day if he does not stop being disruptive).

BATTERY Unconsented touching of another person in a socially impermissible manner or carrying through an assault. Even a touching act done to help a person can be interpreted as battery (e.g., performing a procedure without consent).

DEFAMATION OF CHARACTER An oral or written communication to a third party that damages a person’s reputation. Libel is the written form of defamation; slander is the spoken form. With slander, actual damage must be proven, except when:

Accusing someone of a crime Accusing someone of having a loathsome disease Making a statement that affects a person’s professional or business activity Calling a woman unchaste

Defamation does not exist if the statement is true and made in good faith to persons with a legitimate reason to receive the information. Stating on a reference that an employee was fired from your agency for physically abusing patients is not defamation if, in fact, the employee was found guilty of those charges. However, stating on a reference that an employee was a thief because narcotics were missing every time he or she was on duty can be considered defamation if the employee was never proved guilty of those charges.

FALSE IMPRISONMENT Unlawful restraint or detention of a person. Preventing a patient from leaving a facility is an example of

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false imprisonment, unless it is shown that the patient has a contagious disease or could harm himself or herself or others. Actual physical restraint need not be used for false imprisonment to occur: telling a patient that he or she will be tied to the bed if he or she tries to leave can be considered false imprisonment.

FRAUD Willful and intentional misrepresentation that could cause harm or cause a loss to a person or property (e.g., selling a patient a ring with the claim that memory will be improved when it is worn).

INVASION OF PRIVACY Invading the right of an individual to personal privacy. Can include unwanted publicity, releasing a medical record to unauthorized persons, giving patient information to an improper source, or having one’s private affairs made public. (The only exceptions are reporting communicable diseases, gunshot wounds, and abuse.) Allowing a visiting student to look at a patient’s pressure ulcers without permission can be an invasion of privacy.

LARCENY Unlawful taking of another person’s possession (e.g., assuming that a patient will not be using his or her personally owned wheelchair anymore and giving it away to another patient without permission).

NEGLIGENCE Omission or commission of an act that departs from acceptable and reasonable standards, which can take several forms:

Malfeasance: committing an unlawful or improper act (e.g., a nurse performing a surgical procedure) Misfeasance: performing an act improperly (e.g., including the patient in a research project without obtaining consent) Nonfeasance: failure to take proper action (e.g., not notifying the physician of a serious change in the patient’s status) Malpractice: failure to abide by the standards of one’s profession (e.g., not checking that a nasogastric tube is in the stomach before administering a tube feeding) Criminal negligence: disregard to protecting the safety of another person (e.g., allowing a confused patient, known to have a history of starting fires, to have matches in an unsupervised situation)

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Malpractice Nurses are expected to provide services to patients in a careful, competent manner according to a standard of care. The standard of care is considered the norm for what a reasonable individual in a similar circumstance would do. When performance deviates from the standard of care, nurses can be liable for malpractice. Examples of situations that could lead to malpractice include the following:

Administering the incorrect dosage of a medication to a patient, thereby causing the patient to experience an adverse reaction Identifying respiratory distress in a patient but not informing the physician in a timely manner Leaving an irrigating solution at the bedside of a confused patient, who then drinks that solution Forgetting to turn an immobile patient during the entire shift, resulting in the patient developing a pressure ulcer Having a patient fall because one staff member attempted to lift the patient manually when the use of a lift device was the standard

The fact that a negligent act occurred in itself does not warrant that damages be recovered; instead, it must be demonstrated that the following conditions were present:

Duty: a relationship between the nurse and the patient in which the nurse has assumed responsibility for the care of the patient Negligence: failure to conform to the standard of care (i.e., malpractice) Injury: physical or mental harm to the patient or violation of the patient’s rights resulting from the negligent act

KEY CONCEPT Duty, negligence, and injury must be present for malpractice to exist.

The complexities involved in caring for older adults, the need to delegate responsibilities to others, and the many competing demands on the nurse contribute to the risk of malpractice. As the responsibilities assumed by nurses increase, so will the risk of malpractice. Nurses should be aware of the risks in their practice and be proactive in preventing malpractice (Box 8-2). Also, it is advisable for nurses to carry their own malpractice insurance and not rely only on the insurance provided by their employers. Employers may refuse to cover nurses under their policy if it is believed they acted outside of their job descriptions; further, jury awards can exceed the limits of employers’ policies.

Box 8-2 Recommendations for Reducing the Risk of Malpractice

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Be familiar with and follow the nurse practice act that governs nursing practice in the specific state. Keep current of and adhere to policies and procedures of the employing agency. Ensure that policies and procedures are revised as necessary. Do not discuss a patient’s condition, share patient information, or allow access to a patient’s medical record to anyone unless the patient has provided written consent. Consult with the physician when an order is unclear or inappropriate. Know patients’ normal status and promptly report changes in status. Assess patients carefully and develop realistic care plans. Read patients’ care plans and relevant nursing documentation before giving care. Identify patients before administering medications or treatments. Document observations about patients’ status, care given, and significant occurrences. Assure that documentation by self and subordinates is accurate and that documentation reflects care that actually was provided. Know the credentials and assure competency of all subordinate staff. Discuss with supervisory staff assignments that cannot be completed due to insufficient staff or supplies. Do not accept responsibilities that are beyond your capabilities to perform and do not delegate assignments to others unless you are certain that they are competent to perform the delegated tasks. Report broken equipment and other safety hazards. Report or file an incident report when unusual situations occur. Promptly report all actual or suspected abuse to the appropriate state and local agencies. Attend continuing education programs and keep current of knowledge and skills pertaining to your practice.

Adapted from Eliopoulos, C. (2002). Legal risks management guidelines and principles for long-term care facilities (p. 28). Glen Arm, MD: Health Education Network.

POINT TO PONDER In addition to the time and money involved in defending a lawsuit, what are some consequences of being accused of malpractice?

Other situations can cause nurses to be liable for negligence, if not malpractice, including the following:

Failing to take action (e.g., not reporting a change in the patient’s condition or not notifying the administration of a physician’s incompetent acts) Contributing to patient injury (e.g., not providing appropriate supervision of confused patients or failing

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to lock the wheelchair during a transfer) Failing to report a hazardous situation (e.g., not letting anyone know that the fire alarm system is inoperable or not informing anyone that a physician is performing procedures under the influence of alcohol) Handling patient’s possessions irresponsibly Failing to follow established policies and procedures

POINT TO PONDER Are you familiar with your state’s nurse practice act and the regulations governing the area in which you practice or will practice?

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Confidentiality It is the rare patient who is seen by only one health care provider. More often, the patient visits a variety of medical specialists, therapists, diagnostic facilities, pharmacies, and institutions. These providers often need to communicate information about the patient to ensure coordinated, quality care. However, with the potentially high number of individuals who have access to patients’ personal medical information and the ease with which information is able to be transferred, there are increased opportunities for confidential information to fall into unintended hands.

In an effort to protect the security and confidentiality of patients’ health information, the federal government developed the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides patients with access to their medical records and control over how their personal health information is used and disclosed. Patients can ask their providers to change incorrect information that they have discovered in their record or to add missing information. They also can request that their health information not be shared. Congress authorized civil and criminal penalties for covered entities that misuse personal health information. The Administrative Simplification Compliance Act amended HIPAA and required all claims submitted to Medicare be done so electronically, following guidelines to protect patient privacy.

There can be variations in the procedures providers and facilities use to review HIPAA-related facts with patients, protect patients’ information, and communicate information related to patients. It is important that nurses be familiar with and adhere to policies and procedures related to the protection of patients’ privacy.

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Patient Consent Patients are entitled to know the full implications of procedures and make an independent decision as to whether they choose to have them performed. This may sound simple enough, but it is easy for consent to be overlooked or improperly obtained by health care providers. For instance, certain procedures may become so routine to staff that they fail to realize patient permission must be granted, or a staff member may obtain a signature from a patient who has a fluctuating level of mental competency and who does not fully understand what he or she is signing. In the interest of helping patients and delivering care efficiently, or from a lack of knowledge concerning consent, staff members can subject themselves to considerable legal liability.

Consent must be obtained before performing any medical or surgical procedure; performing procedures without consent can be considered battery. Usually, when patients enter a health care facility, they sign consent forms that authorize the staff to perform certain routine measures (e.g., bathing, examination, care- related treatments, and emergency interventions). These forms, however, do not qualify as carte blanche consent for all procedures. Even blanket consent forms that patients may sign, authorizing staff to do anything required for treatment and care, are not valid safeguards and may not be upheld in a court of law. Consent should be obtained for anything that exceeds basic, routine care measures. Particular procedures for which consent definitely should be sought include any entry into the body, either by incision or through natural body openings; any use of anesthesia, cobalt or radiation therapy, electroshock therapy, or experimental procedures; any type of research participation, invasive or not; and any procedure, diagnostic or treatment, that carries more than a slight risk. Whenever there is doubt regarding whether consent is necessary, it is best to err on the safe side.

Consent must be informed. It is unfair to the patient and legally unsound to obtain the patient’s signature for a procedure without telling the patient what that procedure entails. Ideally, a written consent that describes the procedure, its purpose, alternatives to the procedure, expected consequences, and risks should be signed by the patient, witnessed, and dated (Fig. 8-1). It is best that the person performing the procedure (e.g., the physician or researcher) be the one to explain the procedure and obtain the consent. Nurses or other staff members should not be in the position of obtaining consent for the physician because it is illegal and because they may not be able to answer some of the medical questions posed by the patient. Patients who do not fully comprehend or who have fluctuating levels of mental function are incapable of granting legally sound consent. Nurses can play an important role in the consent process by ensuring that it is properly obtained, answering questions, reinforcing information, and making the physician aware of any misunderstanding or change in the desire of the patient. Finally, nurses should not influence the patient’s decision in any way.

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FIGURE 8-1 • It is important for the patient to give informed consent before any medical or surgical procedure. Written consent forms should describe the procedure, its purpose, alternatives to the procedure, expected consequences, and risks.

COMMUNICATION TIP When consent is being obtained, nurses should assess if the patient or his/her representative fully understand the procedure, its purpose, alternatives, expected consequences, and risks. If through questions, comments, or body language there is any indication that the matter is not understood, the nurse should ask if there are any questions or if more information is needed and to assure the need is addressed.

Every conscious and mentally competent adult has the right to refuse consent for a procedure. To protect the agency and staff, it is useful to have the patient sign a release stating that consent is denied and that the patient understands the risks associated with refusing consent. If the patient refuses to sign the release, this should be witnessed, and both the professional seeking consent and the witness should sign a statement that documents the patient’s refusal for the medical record.

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Patient Competency Increasingly, particularly in long-term care facilities, nurses are caring for patients who are confused, demented, or otherwise mentally impaired. Persons who are mentally incompetent are unable to give legal consent. Often in these circumstances, staff will turn to the next of kin to obtain consent for procedures; however, the appointment of a guardian to grant consent for the incompetent individual is the responsibility of the court. When the patient’s competency is questionable, staff should encourage family members to seek legal guardianship of the patient or request the assistance of the state agency on aging in petitioning the court for appointment of a guardian. Unless they have been judged incompetent by a judge, people are entitled to make their own decisions.

Various forms of guardianship (also called conservatorship) can be granted when a person has been judged incompetent (Box 8-3), each with its own restrictions. The guardian is monitored by the court to ensure that he or she is acting in the best interests of the incompetent individual. In the case of a guardian of property, the guardian must file financial reports with the court.

Box 8-3 Kinds of Decision-Making Authority That Individuals Can Legally Possess Over Patients GUARDIANSHIP Court appointment of an individual or organization to have the authority to make decisions for an incompetent person. Guardians can be granted decision-making authority for specific types of issues:

Guardian of property (conservatorship): this limited guardianship allows the guardian to take care of financial matters but not make decisions concerning medical treatment. Guardian of person: decisions pertaining to the consent or refusal for care and treatments can be made by persons granted this type of guardianship. Plenary guardianship (committeeship): all types of decisions pertaining to person and property can be made by guardians under this form.

POWER OF ATTORNEY Legal mechanism by which competent individuals appoint parties to make decisions for them; this can take the form of:

Limited power of attorney: decisions are limited to certain matters (e.g., financial affairs) and power of attorney becomes invalid if the individual becomes incompetent. Durable power of attorney: provides a mechanism for continuing or initiating power of attorney in the event the individual becomes incompetent.

Guardianship differs from power of attorney in that the latter is a mechanism used by competent individuals to appoint someone to make decisions for them. Usually, a power of attorney becomes invalid if the individual granting it becomes incompetent, except in the case of a durable power of attorney. A durable power of

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attorney allows competent individuals to appoint someone to make decisions on their behalf in the event that

they become incompetent; this is a recommended procedure for individuals with dementias and other disorders in which competency can be anticipated to decline.

To ensure protection of patients’ rights, nurses should recommend that patients and their families seek legal counsel for guardianship and power of attorney issues and, when such appointment has been made, clarify the type of decision-making authority that the appointed parties possess.

KEY CONCEPT A durable power of attorney can be useful for patients with Alzheimer’s disease because they can appoint someone to make decisions on their behalf at a time when they may be incompetent to do so.

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Staff Supervision In many settings, gerontological nurses are responsible for supervising other staff, many of whom may be unlicensed personnel. In these situations, nurses are responsible not only for their own actions but also for the actions of the staff they are supervising. This falls under the doctrine of respondeat superior (“let the master answer”). Nurses must understand that if a patient is injured by an employee they supervise while the employee is working within the scope of the applicable job description, nurses can be liable. Various types of situations can create risks for nurses:

Permitting unqualified or incompetent persons to deliver care Failing to follow up on delegated tasks Assigning tasks to staff members for which they are not qualified or competent Allowing staff to work under conditions with known risks (e.g., being short staffed and improperly functioning equipment)

These are considerations that nurses need to keep in mind when they accept responsibility for covering the house, sending an aide into a home to deliver care without knowing the aide’s competency, or allowing registry or other employees to work without fully orienting them to agency policies and procedures.

KEY CONCEPT A nurse needs to ensure that those caregivers to whom tasks are delegated are competent to perform the tasks and carry out their assignments properly.

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Medications Nurses are responsible for the safe administration of prescribed medications. Preparing, compounding, dispensing, and retailing medications fall within the practice of pharmacy, not nursing, and, when performed by nurses, can be interpreted as functioning outside their licensed scope of practice.

Concept Mastery Alert An act as seemingly benign as going into the agency’s pharmacy after hours, pouring some tablets into a container, labeling that container, and taking it to the unit so that a patient can receive the drug that is urgently needed is illegal.

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Restraints The Omnibus Budget Reconciliation Act (OBRA) heightened awareness of the serious impact of restraints by imposing strict standards on their use in long-term care facilities. This increased concern regarding and sensitivity to the use of chemical and physical restraints has had a ripple effect on other practice settings.

Anything that physically or mentally restricts a patient’s movement (e.g., protective vests, trays on wheelchairs, safety belts, geriatric chairs, side rails, and medications) can be considered a restraint. Improperly used restraining devices can not only violate regulations concerning their use but also result in litigation for false imprisonment and negligence. At no time should restraints be used for the convenience of staff.

Older adults with deliriums and dementias can pose challenges to staff in terms of behavioral management. There are several medications (e.g., haloperidol, benzodiazepines, and lorazepam) that can be useful in reducing agitation and the need for physical restraints; however, these can result in complications such as aspiration due to depression of the gag reflex and pneumonia due to reduced respiratory activity. It must be recognized that these drugs are forms of chemical restraints and should only be employed after other measures have proven ineffective. Further, nonpharmacological strategies to manage behaviors can reduce the amount of drug needed. Consultation with geropsychiatric specialists or psychologists can prove beneficial in identifying other strategies.

Alternatives to restraints should be used whenever possible. Measures to help manage behavioral problems and protect the patient include alarmed doors, wristband alarms, bed alarm pads, beds and chairs close to the floor level, and increased staff supervision and contact. Specific patient behavior that creates risks to the patient and others should be documented. Assessment of the risk posed by the patient not being restrained and the effectiveness of alternatives should be included.

When restraints are deemed absolutely necessary, a physician’s order for the restraints must be obtained, stating the specific conditions for which the restraints are to be used, the type of restraints, and the duration of use. Agency policies should exist for the use of restraints and should be followed strictly. Detailed documentation should include the times for initiation and release of the restraints, their effectiveness, and the patient’s response. The patient requires close observation while restrained.

At times, staff may assess that restraint use is required, but the patient or family objects and refuses to have a restraint used. If counseling does not help the patient and family understand the risks involved in not using the restraint, the agency may wish to have the patient and family sign a release of liability that states the risks of not using a restraint and the patient’s or family’s opposition. Although this may not free the nurse or agency from all responsibility, some limited protection may be afforded and, by signing the release, the patient and family may realize the severity of the situation.

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Telephone Orders In home health and long-term care settings, nurses often do not have the benefit of an on-site physician. Changes in the patient’s condition and requests for new or altered treatments may be communicated over the telephone and, in response, physicians may prescribe orders accordingly. Accepting telephone orders predisposes nurses to considerable risks because the order can be heard or written incorrectly or the physician can deny that the order was given. It may not be realistic or advantageous to patient care to totally eliminate telephone orders, but nurses should minimize their risks in every way possible.

Try to have the physician immediately fax the written order, if possible. Do not involve third parties in the order (e.g., do not have the order communicated by a secretary or other staff member for the nurse or the physician). Communicate all relevant information to the physician, such as vital signs, general status, and medications administered. Do not offer diagnostic interpretations or a medical diagnosis of the patient’s problem. Write down the order as it is given and immediately read it back to the physician in its entirety. Place the order on the physician’s order sheet, indicating it was a telephone order, the physician who gave it, time, date, and the nurse’s signature. Obtain the physician’s signature within 24 hours.

Recorded telephone orders may be a helpful way for nurses to validate what they have heard, but they may not offer much protection in the event of a lawsuit unless the physician is informed that the conversation is being recorded or unless special equipment with a 15-second tone sound is used.

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Do Not Resuscitate Orders The caseloads of many gerontological nurses contain a high prevalence of terminally ill patients. It may be understood by all parties involved that these patients are going to die and that resuscitation attempts would be inappropriate; however, unless an order specifically states that the patient should not be resuscitated, failure to attempt to save that person’s life could be viewed as negligence. Nurses must ensure that DNR (do not resuscitate) orders are legally sound, remembering several points. First, DNR orders are medical orders and must be written and signed on the physician’s order sheet to be valid. DNR placed on the care plan or a special symbol at the patient’s bedside is not legal without the medical order. Next, unless it is detrimental to the patient’s well-being or the patient is incompetent, consent for the decision not to resuscitate should be obtained; if the patient is unable to consent, family consent should be sought. Finally, every agency should develop a DNR policy to guide staff in these situations; this could be an excellent item for an ethics committee to review.

CONSIDER THIS CASE

You are working in a nursing home that supports a restraint-free environment. In the past month, one of the residents has slipped once from her wheelchair and once off the edge of her bed; she fell onto the floor both times. Although the resident was not injured in either of these incidents, the resident’s daughter is concerned that her mother has the potential to seriously hurt herself during a fall and requests that her mother be restrained while in bed and in her wheelchair. The resident has not expressed any preference but says she’ll do whatever her daughter wants. You explain the rationale for not using restraints, but the daughter is insistent that her mother be restrained. “You know my mother has the tendency to slip to the floor,” the daughter says, “so if you don’t tie her in the chair and keep her rails up when she is in bed and she falls, I’ll have my lawyers here before you can say boo!”

THINK CRITICALLY

How do you decide if the resident’s freedom to be unrestrained is worth the risk of her injuring herself during a fall? What dilemmas could you present for the resident if you ask her for her preference without consideration of the daughter’s desires?

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How much should a facility be influenced by the threat of litigation? What can you do to safeguard the resident and the facility?

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Advance Directives and Issues Related to Death and Dying A variety of issues surrounding patients’ deaths pose legal concern for nurses. Some of these issues arise long before death occurs, when patients choose to execute an advance directive or a living will. Advance directives express the desires of competent adults regarding terminal care, life-sustaining measures, and other issues pertaining to their dying and death.

KEY CONCEPT There are two types of advance directives. A durable power of attorney for health care is a document that appoints a person selected by the patient (called a health care proxy, attorney-in-fact, surrogate, or agent) to make decisions on the patient’s behalf should the patient be unable to make or communicate his or her decisions. A living will describes a patient’s preferences and gives instructions to health care providers if at a future time he or she is unable to make or communicate decisions and has no one appointed as proxy.

In 1990, Congress passed the Patient Self-Determination Act (which went into effect from December 1, 1991), which requires all health care institutions receiving Medicare or Medicaid funds to ask patients on admission if they possess a living will or durable power of attorney for health care. The patient’s response must be recorded in the medical record. Nurses can aid by making physicians and other staff aware of the presence of a patient’s advance directive, informing patients of any special measures they must take to have the document accepted into the medical record, and, unless contraindicated, following the patient’s wishes (Fig. 8-2). Following an advance directive protects health care professionals from civil and criminal liability when they are followed in good faith. Nurses are advised to check the status of advance directive legislation in their individual states.

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FIGURE 8-2 • Gerontological nurses guide older adults as they consider advance directives.

Other issues arise when patients are terminally ill and dying; one such issue involves wills. Wills are statements of individuals’ desires for the management of their affairs after their death. For a will to be valid, the person making it must be of sound mind and legal age and must not be coerced or influenced into making it. The will should be written—although under certain conditions, some states recognize oral, or nuncupative, wills—signed, dated, and witnessed by persons not named in the will. The required number of witnesses may vary among the states.

To avoid problems, such as family accusations that the patient was influenced by the nurse because of his dependency on her, nurses should avoid witnessing a will. Nurses should, however, help patients obtain legal counsel when they wish to execute or change a will. Legal aid agencies and local schools of law are also sources of assistance for older adults wishing to write their wills. If a patient is dying and wishes to dictate a will to the nurse, the nurse may write it exactly as stated, sign, and date it; have the patient sign it if possible; and forward it to the agency’s administrative offices for handling. It is useful for gerontological nurses to encourage persons of all ages to develop a will to avoid having the state determine how their property will be distributed in the event of their deaths.

The pronouncement of death is another area of concern. Nurses often are placed in the position and are capable of determining when a patient has died and notifying the family and funeral home. The physician is then notified of the death by telephone and signs the death certificate at a later time. This rather common and benign procedure actually may be illegal for nurses because in some states, the act of pronouncing a patient dead falls within the scope of medical practice, not nursing. Nurses should safeguard their licenses by either holding physicians responsible for the pronouncement of death if they are required to do so or lobbying to

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have the law changed so that they are protected in these situations.

Postmortem examinations of deceased persons are useful in learning more about the cause of death. They also contribute to medical education. In some circumstances, such as when the cause of death is suspected to be associated with a criminal act, malpractice, or an occupational disease, the death may be considered a medical examiner’s case and an autopsy may be mandatory. Unless it is a medical examiner’s case, consent for autopsy must be obtained from the next of kin, usually in the order of spouse, children, parents, siblings, grandparents, aunts, uncles, and cousins.

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Elder Abuse Elder abuse can occur in patients’ homes or in health care facilities by loved ones, caregivers, or strangers. Particularly in long-term caregiving relationships, in which family members or staff “burn out,” abuse may be an unfortunate consequence. Factors contributing to abuse by family caregivers are discussed in Chapter 35.

KEY CONCEPT Caregiver stress can lead to abuse of older adults.

There are several recognized types of elder abuse (National Center for Elder Abuse, 2012), which include the following:

Physical abuse Emotional abuse Sexual abuse Exploitation Neglect Abandonment

Abuse can assume many forms, including inflicting pain or injury, stealing, mismanaging funds, misusing medications, causing psychological distress, withholding food or care, or confining a person. Even threatening to commit any of these acts is considered abuse. Abuse may be undetected due to an older person’s lack of contact with others (e.g., being homebound and not having communication with anyone but the relative who is the abuser) or due to the reluctance to report the problem due to fear or shame. Nurses can assess for abuse using a tool such as the Elder Mistreatment Assessment (Fulmer, 2012). Gerontological nurses must also be alert to indications of possible abuse or neglect during routine interactions with older adults; signs could include the following:

Delay in seeking necessary medical care Malnutrition Dehydration Unexplained bruises Poor hygiene and grooming Urine odor, urine-stained clothing/linens Excoriation or abrasions of genitalia Inappropriate administration of medications Repeated infections, injuries, or preventable complications from existing diseases Evasiveness in describing condition, symptoms, problems, and home life

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Unsafe living environment Social isolation Anxiety, suspiciousness, and depression

Nurses have a legal responsibility to report all cases of known or suspected abuse. States vary regarding reporting mechanisms; nurses should thus consult specific state laws. The Resources listing includes organizations that can provide information on elder abuse and guidance on finding attorneys to assist a person who is the victim of abuse.

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LEGAL SAFEGUARDS FOR NURSES Common sense can be the best ally of sound nursing practice. Never forget that patients, visitors, and employees do not forfeit their legal rights or responsibilities when they are within the health care environment. Laws and regulations impose additional rights and responsibilities in patient–provider and employee–employer relationships. Nurses can and should protect themselves in the following ways:

Familiarize themselves with the laws and rules governing their specific care agency/facility, their state’s nurse practice act, and labor relations. Become knowledgeable about their agency’s policies and procedures and adhere to them strictly. Function within the scope of nursing practice. Determine for themselves the competency of employees for whom they are responsible. Check the work of employees under their supervision. Obtain administrative or legal guidance when in doubt about the legal ramifications of a situation. Report and document any unusual occurrence. Refuse to work under circumstances that create a risk to safe patient care. Carry liability insurance

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BRINGING RESEARCH TO LIFE A Staff Intervention Targeting Resident-to-Resident Elder Mistreatment (R-REM) in Long- Term Care Increased Staff Knowledge, Recognition, and Reporting: Results from a Cluster Randomized Trial

Source: Teresi, J. A., Ramirez, M., Ellis, J. M., Silver, S., Boratgis, G. et al. (2013). International Journal of Nursing Studies, 50(5), 644–656.

Aggression between nursing home residents has not received much attention and can be missed by nursing staff. Although these incidents can have negative effects for residents and staff, and can result in lawsuits, before this study, there had been no evidence-based training, interventions, and implementation strategies to address this issue. This study evaluated the impact of a training intervention to increase nursing staff knowledge of R-REM.

There were 685 residents selected in the control group and 720 in the intervention group from five different nursing homes. Staff in the intervention group received training, implementation protocols related to recognizing and managing R-REM, and guidance in implementing protocols. Data were collected at the start of the project and at 6 and 12 months.

The study demonstrated that the employees who received the training intervention were superior at recognizing and reporting R-REM. The intervention group also had significantly fewer incidents of R-REM despite having similar R-REM at the start of the intervention.

Reducing legal risks requires effective, evidence- based interventions that nursing staff can use. In addition to developing such resources, nurses need to advocate for staff education and training to enable staff to be aware and utilize these resources. In nursing homes and other settings where staffing often is limited, there could be resistance to the allocation of staff time for education and implementation of interventions. By helping decision makers to understand that such actions can aid not only in reducing the risk of litigation but also in preventing injuries and dissatisfaction of older adults and their caregivers, the cost–benefit of such approaches may be appreciated and the interventions supported.

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PRACTICE REALITIES You are working the night shift, where there have been several call outs on the unit for postoperative patients. All staff are carrying a heavier than usual load. During tonight’s shift, one of the nurses forgot to raise the side rail on a heavily sedated patient. In his confused, sedated state, the patient tries to get out of bed and falls. You and the assigned nurse hurry to his aid. The other nurse tells you to help her lift the patient back to bed. You resist, stating “He should be examined and the supervisor called.” The other nurse objects, stating “You know the policy. They’ll either suspend or fire me and I have kids to support. I checked him out and he is fine … and, he is too doped up to remember anything. There won’t be any harm; come on.”

The patient doesn’t appear injured and you don’t want the nurse to be in jeopardy of losing her job. What should you do?

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CRITICAL THINKING EXERCISES

1. Discuss the reasons why gerontological nursing is a high-risk specialty for legal liability. 2. Identify the process you would follow in your community to obtain guardianship for an incompetent

older adult who has no family. 3. Describe the approach you would use to discuss the development of an advanced directive with an older

adult. 4. Discuss the actions you would take if faced with the following situations:

A nurse whom you supervise makes repeated errors and does not seem competent to do his job. You begin documenting your observations but are told by your immediate supervisor to “just bite your tongue and live with it because he is the administrator’s son.” A patient confides in you that her son is forging her name on checks and gradually emptying out her bank accounts.

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Chapter Summary There are legal risks associated with nursing practice in any specialty. In gerontological nursing, the risks may be compounded by the unique problems faced by older adults and the care settings, which may be staffed with a high number of unlicensed caregivers. Gerontological nurses need to understand their legal responsibilities and risks.

There are both public and private laws that must be respected in practice. Public law governs the relationship between government and private parties; it includes issues such as the scope of practice, regulations that care settings must abide by, and criminal law. Private law involves the relationships among individuals or between individuals and organizations and includes issues such as assault, battery, false imprisonment, and invasion of privacy. In addition, there are voluntary standards upon which nurses can be judged, such as those developed by professional nursing associations.

Nurses need to be proactive in protecting themselves, their organizations, and their patients. This responsibility includes abiding by the laws and rules governing their practice, assuring the competency of individuals to whom care is delegated, reporting unusual circumstances and incidents, and obtaining legal consultation as needed.

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Resources American Association of Retired Persons (AARP) Elder Law Forum

http://www.aarp.org/research/legal-advocacy/

American Bar Association Senior Lawyers Division

http://www.abanet.org/srlawyers/home.html

Elder Justice Coalition

http://www.elderjusticecoalition.com

Hartford Institute for Geriatric Nursing

Try This: Best Practices in Nursing Care to Older Adults. Issue Number 15 (Revised 2007), Elder Mistreatment and Abuse Assessment. http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf

National Academy of Elder Law Attorneys

http://www.naela.com

National Center on Elder Abuse

http://www.ncea.aoa.gov

National Senior Citizens Law Center

http://www.nsclc.org

Nursing Home Abuse/Elder Abuse Attorneys Referral Network

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http://www.aarp.org/research/legal-advocacy/

http://www.abanet.org/srlawyers/home.html

http://www.elderjusticecoalition.com

http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf

http://www.naela.com

http://www.ncea.aoa.gov

http://www.nsclc.org

References Fulmer, T. (2012). Elder mistreatment assessment. Try This. Hartford Institute for Geriatric Nursing, Issue No. 15. Retrieved September 12, 2014 from http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf

National Center for Elder Abuse. (2014). Fact sheet about elder abuse. Retrieved September 12, 2014 from http://www.ncea.aoa.gov/Resources/Publication/docs/FinalStatistics050331.pdf

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http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf

http://www.ncea.aoa.gov/Resources/Publication/docs/FinalStatistics050331.pdf

http://thepoint.lww.com/Eliopoulos9e

CHAPTER 9

Ethical Aspects of Gerontological Nursing

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CHAPTER OUTLINE

Philosophies Guiding Ethical Thinking

Ethics In Nursing

External and Internal Ethical Standards

Ethical Principles

Cultural Considerations

Ethical Dilemmas Facing Gerontological Nurses

Changes Increasing Ethical Dilemmas for Nurses

Measures to Help Nurses Make Ethical Decisions

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Discuss various philosophies regarding right and wrong. 2. Describe ethical standards, principles, and cultural considerations guiding nursing practice. 3. List factors that have increased ethical dilemmas for nurses. 4. Identify measures to help nurses make ethical decisions.

TERMS TO KNOW Autonomy to respect individual freedoms, preferences, and rights

Beneficence to do good for patients

Confidentiality to respect the privacy

Ethics a system of moral principles that guides behaviors

Fidelity to respect our words and duty to patients

Justice to be fair, treat people equally

Nonmaleficence to prevent harm to patients

Veracity truthfulness

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Although the concept of principles guiding right and wrong conduct is not new to nursing, professional ethics has received increasing attention in nursing circles. Gerontological nurses commonly face ethical questions regarding the provision, scope, or cost of care for older adults. Many of these questions arise in nurses’ daily practice. It is important for nurses to understand both the ethics of the nursing profession and their own personal ethics and to be aware of the ethical dilemmas facing gerontological nurses today.

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PHILOSOPHIES GUIDING ETHICAL THINKING The word ethics originated in ancient Greece—ethos means those beliefs that guide life. Most current definitions of ethics revolve around the concept of accepted standards of conduct and moral judgment. Basically, ethics help determine right and wrong courses of action. As simple as this sounds, different philosophies disagree about what constitutes right and wrong; the following are some examples:

Utilitarianism. This philosophy holds that good acts are those from which the greatest number of people will benefit and gain happiness. Egoism. At the opposite pole from utilitarianism, egoism proposes that an act is morally acceptable if it is of the greatest benefit to oneself and that there is no reason to perform an act that benefits others unless one will personally benefit from it as well. Relativism. This philosophy can be referred to as situational ethics, in that right and wrong are relative to the situation. Within relativism are several subgroups of thinking. Some relativists believe that there can be individual variation in what is ethically correct, whereas others feel that the individual’s beliefs should conform to the overall beliefs of the society for the given time and situation. Absolutism. Under the theory of absolutism, there are specific truths to guide actions. The truths can vary depending on a person’s beliefs; for example, a Christian’s view may differ from an atheist’s view on certain moral behaviors, and a person who supports a political view of democracy may believe in truths different from those of a communist.

To illustrate the application of these four different philosophies, consider the hypothetical situation of four poor old men who share a household. One day, one of these men finds a lottery ticket in the mailBox while checking the household’s mail. The ticket holds the winning number for a million dollars. Ethically, does he owe his housemates any of the winnings? A utilitarian would propose that he split the winnings with his housemates because that would bring good to the greatest number of people. An egoist would encourage him to keep the winnings because that would do him the most good personally. A relativist might say that normally he should keep the winnings, but because in this situation he will have more money than he will need, he should share the winnings. An absolutist who happens to be Christian may say that keeping the ticket is morally wrong and an effort should be made to find the rightful owner.

Now consider the application of the philosophical approaches to the issue of federal subsidies to older adults. A utilitarian could say that 12% of the population should not use one third of the gross national product and that the money instead should be equally allocated on a per capita basis. An egoist would say that the individual old person should take whatever he feels he needs, regardless of the impact on others. A relativist could say that older people can use this proportion of the budget unless more is needed for dependent children or defense, at which point it would no longer be right to do so. Absolutists could hold various views depending on their belief systems, ranging from giving the older population whatever they need because of a moral responsibility to care for the sick and aged, to withholding funds from the older population so that finances are available to build the military and meet specific political goals.

Other philosophies guiding ethics exist, but the few that have been briefly described demonstrate the

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diversity of approaches to ethical thinking and reinforce the fact that determining right and wrong actions can be a complicated endeavor.

KEY CONCEPT Individuals can be guided by a wide range of ethical philosophies that cause them to view the same situations in vastly different ways.

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ETHICS IN NURSING External and Internal Ethical Standards Professions such as nursing require a code of ethics on which practice can be based and evaluated. A professional code of ethics is accepted by those who practice the profession as the formal guidelines for their actions. For example, the American Nurses Association (ANA) Code of Ethics for Nurses offers ethics that outline the broad values of the profession. (Information about the Code is available at http://www.nursingworld.org/codeofethics.) The American Holistic Nurses’ Association has developed the Code of Ethics for Holistic Nursing that provides guidance for nurses’ actions and responsibilities for self, others, and the environment (the full document is available at http://www.ahna.org).

Nurses are also subject to ethical standards created outside of the nursing profession. Federal, state, and local standards, in the form of regulations, guide the nursing practice. In addition, various organizations such as the Joint Commission and the American Healthcare Association develop standards for specific practitioners and care settings. Individual agencies, too, have philosophies, goals, and objectives that support a specific level of nursing practice.

Most importantly, individual nurses possess values that they have developed throughout their lives that will largely influence ethical thinking. Ideally, a nurse’s individual value system meshes with that of the profession, society, and employer; conflict can arise when value systems are incompatible.

KEY CONCEPT It is important for a nurse to understand his or her own values as conflict and distress can result when the nurse’s values differ from those of the employer or population served.

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http://www.nursingworld.org/codeofethics

http://www.ahna.org

Ethical Principles Several ethical principles are used to guide health care, including the following:

Beneficence: to do good for patients. This principle is based on the belief that the education and experience of nurses enable them to make sound decisions that serve patients’ best interests. Nurses are challenged to take actions that are good for patients while not ignoring patients’ desires. To override patients’ decisions and invoke professional authority to take actions that nurses view as in patients’ best interests is viewed as paternalism and interferes with the freedom and rights of patients. Nonmaleficence: to prevent harm to patients. This principle could be viewed as a subset of beneficence because the intent is ultimately to take action that is good for patients. In addition to not directly performing an act that causes harm, actions such as informing management that staffing is inadequate to provide safe care support nonmaleficence. Justice: to be fair, treat people equally, and give patients the service they need. At the foundation of this principle is the belief that patients are entitled to services based on need, regardless of the ability to pay. Scarce resources have challenged this concept of unrestricted access and use of health care services. Fidelity and veracity: fidelity means to respect our words and duty to patients; veracity means truthfulness. This principle is central to all nurse–patient interactions because the quality of this relationship depends on trust and integrity. Older patients may have higher degrees of vulnerability than do the younger adults and may be particularly dependent on the truthfulness of their caregivers. Autonomy: to respect patients’ freedoms, preferences, and rights. Ensuring and protecting older patients’ right to provide informed consent are consistent with this principle. Confidentiality: to respect the privacy of patients. Patients often share highly personal information with nurses and need to feel assured that their trust will not be violated. In addition to respecting confidentiality as being a morally sound principle, the Health Insurance Portability and Accountability Act and other laws have afforded people the legal right to privacy and consequences if this is violated.

Few nurses would argue with the value of these principles (Fig. 9-1). In fact, practices that reinforce these principles are widely promoted, such as ensuring that patients receive the care they need, respecting the rights of patients to consent to or deny consent for treatment, preventing incompetent staff from caring for patients, and following acceptable standards of practice. Actual nursing practice is seldom simple, however, and situations emerge that add new considerations to the application of moral principles to patient care. Ethical dilemmas can emerge when other circumstances interfere with the clear, basic application of ethical principles.

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FIGURE 9-1 • Nurses follow the principles of doing good, treating people equally, honoring their word, and

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respecting older adults’ rights.

POINT TO PONDER How do you respond to and try to solve ethical dilemmas? If you are in practice, do you accept different standards in practice from what you would accept in your personal life? If so, why?

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Cultural Considerations An issue that must be considered in nursing practice is that what may be considered an ethical practice for some individuals may not be viewed as such by others due to their cultural backgrounds. For instance, a nurse may be a white, Protestant woman born in the United States who holds the beliefs shown in the bulleted list below. The nurse may view these as sound ethical beliefs and allow them to guide her practice. Although these beliefs could be acceptable and appreciated by many individuals, they could conflict with the beliefs of others; for example:

The belief that individuals have the right to make their own decisions regardless of their sex and should be empowered to do so. In many Amish, German, Greek, Haitian, Irish, and Puerto Rican families, individuals discuss important decisions with family members and may prefer to have the family involved in the decisions. Jewish individuals may seek the advice of a rabbi. Some people may not want to discuss issues and confront decision making; for instance, Filipinos and Japanese view discussions of death as taboo. Women are equal to men. In Arab, Iranian, Hindu, and some Italian families, it is common for males to assume decision-making roles, and women may yield their decision-making authority to them. Prayer is a beneficial supplement to medical treatment: Prayer may not be welcomed by patients who are agnostic or atheistic. Even among persons who do believe in prayer, there may be differences in the deity worshipped and method of prayer. People have the right to have the confidentiality of their health information protected, even from relatives. To individuals who view family involvement in decision making as natural and preferable, there may be a desire to have health information shared with the family.

Nurses need to appreciate that ethical issues are influenced by culture. Learning about a patient’s culture and preferences based on it are essential to assuring actions do not inadvertently produce ethical conflicts. Also, it is important for nurses to remember that not all individuals from the same cultural group may share the same beliefs and practices, which further reinforces the important of learning about individual preferences.

COMMUNICATION TIP Older adults, especially when their function is compromised by illness, may look to family members to make decisions for them. They may accept the decisions others make on their behalf, even if they conflict with their own beliefs and desires.If the nurse sees that others are making decisions for the older adult that the person is competent of making independently, it is beneficial to review the decision with the person to ensure he or she fully understands, present all options available, ask the person to describe what is important to him or her in relation to the decision, reinforce to the person that he or she has the right to make a decision that is different from that of family members, and ensure that the person is in agreement and comfortable with the decision. It is beneficial to discuss with family members the

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importance and right of the older relative to make his or her own decision, even if it conflicts with what they think is best.

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ETHICAL DILEMMAS FACING GERONTOLOGICAL NURSES Nursing practice involves many situations that could produce conflicts—conflicts between nurses’ values and external systems affecting their decisions and conflicts between the rights of patients and nurses’ responsibilities to those patients. Box 9-1 presents examples of such dilemmas. These examples are typical of the decisions facing nurses every day and for which there are no simple answers.

Box 9-1 Examples of Ethical Dilemmas in Gerontological Nursing Practice While working in an outreach program to bring services to community-based older adults, you meet Mr. Brooks, a 68-year-old homeless man. Mr. Brooks asks your opinion about respiratory symptoms that he has been experiencing over the past several months. He reports a chronic cough, hemoptysis, and dyspnea. He appears thin and admits to having lost weight. He states he has smoked at least one pack of cigarettes daily for over 50 years and has no intention of changing his smoking habit. Although he is not cognitively impaired, he strongly resists efforts to find him housing and arrange for medical evaluation and treatment. You are convinced that without intervention, Mr. Brooks will not survive much longer.

Do you respect Mr. Brooks’ right to make his own decisions about his life, even if those decisions run contrary to what is best for his health and well-being?

You are the new director of nursing for a nursing home and were pleased to get the job because yours has become the sole source of income for your family. Ten cases of diarrhea develop among the residents, and you know that the regulations require that you report five cases or more. You bring this to the attention of the medical director and administrator, who direct you not to “cause trouble by putting the health department on their backs.” The medical director assures you that the problem is not serious and will pass in a few days. You know you should notify the health department, but you also know that the administrator fired the last nursing director for opposing him on a similar issue.

Do you allow a regulation to be violated or risk losing a job that you may badly need?

Insurance coverage expires tomorrow for 76-year-old Mrs. Brady, and the physician has written an order for her discharge. Because Mrs. Brady continued to be weak and slightly confused, she was not able to be instructed in the safe use of home oxygen and medication administration during her hospitalization. Her 80-year-old husband, who is expected to be her primary caregiver, is weak and in poor health himself. The social worker tells you that arrangements have been made for a nurse to visit the home daily but that the couple does not qualify for 24-hour home care assistance. You and other nursing staff members firmly believe that Mrs. Brady’s health will be in jeopardy if she is discharged tomorrow. The physician tells you that you are probably right, but “the hospital cannot be expected to eat the bills that Medicare does not want to pay.”

Do you increase the hospital’s financial risks by insisting that nonreimbursed care be provided?

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Seventy-nine-year-old Mr. Adams lies in his bed in a fetal position, unresponsive except to deep painful stimuli. He has multiple pressure ulcers, has recurrent infections, and must be fed with a nasogastric tube. His wife and children express concern over the quality of his life and state that Mr. Adams would never have wanted to survive in this state. The children privately tell the multidisciplinary team that if their father’s care expenses continue, their mother will be destitute, and they beg the staff to remove the tube. The family expresses that they do not have the emotional or financial resources to take the issue to court. The physician is sympathetic, but states he feels compelled to continue the feedings and antibiotics because he does not condone euthanasia; however, privately, the physician tells you that he will close his eyes and keep quiet if you want to pull the tube without anyone knowing.

Do you exceed your authority and discontinue a life-sustaining measure to grant the family’s request?

Mrs. Smith is dying of cancer and being cared for at home by her husband. The couple has been married for 63 years and has never been apart during that time. They are highly interdependent and each one’s world revolves around the other’s. During your home nursing visit, the couple openly discusses their plans with you. They tell you that they have agreed that when Mrs. Smith’s pain becomes too severe to tolerate, they will both ingest sufficient medication, which they have accumulated, to kill themselves, and die peacefully in each other’s arms.

Do you ignore your responsibility to report suicidal intent to respect a couple’s wish to end their lives together?

It is easy to say that nurses should always follow the regulations, adhere to principles, and do what is best for the patient. But can nurses realistically be expected to follow these guidelines 100% of the time? What if following the rules means they may lose the income on which their families depend, violate the rights of individuals to decide their own destinies, create problems for coworkers or their employers, or cause them to be labeled troublemakers? Is it alright to knowingly violate a regulation or law if no real harm will result? Do nurses need to limit how much of an advocacy role they can assume? Should nurses base their decisions on what is right for themselves, their patients, or their employers? To whom are nurses really most responsible and accountable?

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Changes Increasing Ethical Dilemmas for Nurses Questions of ethics are not new to nursing. However, changes within the profession and the entire health care delivery system have introduced new areas of ethical dilemmas to nursing practice.

Expanded Role of Nurses Nurses have gone beyond the confines of simply following doctors’ orders and providing basic comfort and care. They now perform sophisticated assessments, diagnose nursing problems, monitor and give complicated treatments, use alternative modalities of care, and, particularly in geriatric care settings, increasingly make independent judgments about patients’ clinical conditions. This wider scope of functions, combined with higher salaries and greater status, has increased the accountability and responsibility of nurses for the care of patients.

Medical Technology Artificial organs, genetic screening, new drugs, computers, lasers, ultrasound, and other innovations have increased the medical community’s ability to diagnose and treat problems and to save lives that once would have been given no hope. However, new problems have accompanied these advances, such as determining on whom, when, and how this technology should be used.

New Fiscal Constraints In the past, the major concern of health care providers and agencies was to provide quality services to help people maintain and restore health. Now, there are competing and sometimes overriding concerns, including the following: being cost-effective, minimizing bad debts, and developing alternate sources of revenue. Patients’ needs are weighed against economic survival, resulting in some difficult decisions. Further, in this era of rationed care and scarce resources, questions are raised regarding the right of older adults to expect a high quality and quantity of health and social services while other groups lack basic assistance.

KEY CONCEPT Increasingly, questions are raised regarding the right of older adults to expect greater benefits than other members of the society.

Conflict of Interest Nurses can face a variety of situations that present a conflict of interest. Examples of this could include the following: a nurse, believing a resident’s life could be extended with nasogastric feedings and antibiotic therapy, feeling that a resident’s and family’s rejection of this care is inappropriate; a patient’s physical therapy discontinued due to insurance restrictions and the nurse knowing that the patient has the potential to make continued progress with the therapy; and, the nurse knowing the employer is intentionally keeping staffing

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levels below what is needed but not objecting or advocating for proper staffing because the nurse does not want to jeopardize his or her position.

Greater Numbers of Older Adults Entitlement programs and services for older persons had less impact when only a small portion of the population was old, but with growing numbers of people spending more years in old age and the increasing ratio of dependent individuals to productive workers, society is beginning to feel burdened. Although older adults’ problems and needs are more evident, the ability and responsibility of society to support these needs are in question.

Assisted Suicide The ANA has been clear in its objection to assisted suicide, believing instead that nurses should provide competent, compassionate end-of-life care. However, although participating in a patient’s assisted suicide is unethical and inappropriate, nurses may care for terminally ill individuals who accept and desire assisted suicide. The situation becomes even more complicated by the fact that laws have been enacted in some states (e.g., Oregon, California, Vermont, and Washington) to allow terminally ill persons to end their lives with lethal medications, and individuals have the right to refuse care under self-determination directives. Nurses may face the dilemma of knowing that a competent patient is arranging an assisted suicide and believing that they must intervene. Or, they may know that a competent patient is arranging an assisted suicide, and while understanding and respecting the patient’s decision, they feel they are violating professional standards by not reporting it so that it may be halted.

POINT TO PONDER Do you believe that gerontological nurses have an ethical responsibility to advocate for older individuals by objecting to and bringing public attention to policy and reimbursement decisions that are not in older persons’ best interests?

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Measures to Help Nurses Make Ethical Decisions Although guidelines exist, no solid answers can solve all of the ethical dilemmas that nurses face. Nurses should, however, minimize their struggles in making ethical decisions by using critical thinking and employing the following measures:

Encourage patients to express their desires. Advise patients to express their desires in advance directives, wills, and other legally binding documents and advocate compliance with patients’ wishes. Box 9-2 offers suggestions on assisting patients in making decisions. Identify significant others who impact and are impacted. Consider family members, friends, and caregivers who are involved with the patient and the situation, and their concerns and preferences. Know yourself. The nurse should review his or her personal value system. The influences of religion, cultural beliefs, and personal experiences should be explored to understand one’s unique comfort zone with specific ethical issues. Read. Review the medical literature for discussions and case experiences of other nurses to gain a wider perspective into the types of ethical problems confronted within nursing and strategies for managing them. Literature outside the field of nursing can help add new facets to one’s thinking.

Box 9-2 Assisting Older Adults in Decision Making Assure the person is competent to make decisions. Even if the person has no diagnosis (e.g., dementia) that would interfere with decision making, the stress of a hospitalization and the effects of medications or other treatments could alter the mental ability to make competent decisions. Assess for alterations in mental status that could influence competent decision making. If competency is in question, consult with the organization’s social worker or other designated professional to have a surrogate properly appointed. Document the assessment of factors influencing the ability to make decisions, such as mental status, ability to express preferences, mood, effects of medications, and family influence.

If the individual is competent to make decisions:

Offer explanations and information regarding treatment options to increase the person’s understanding. Offer to include family members or significant others in the discussion if the person desires. Ensure that the person understands the diagnosis, prognosis, treatment options, and risks and benefits of various treatments. Encourage the person to ask questions and express any concerns. If there is question or confusion about procedures for which consent is needed or has been granted, request that the provider who will perform the procedure meet with the person to discuss the issue. Ensure that the person is not being coerced into any decision or feeling intimidated to state a refusal to give consent.

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Recognize that ability to make competent decisions can fluctuate (e.g., due to medications, pain) and ensure that explanations are provided and decisions made during times of lucidity. Document all assessment findings, explanations given, the person’s expressed preferences and concerns, and other relevant information.

CONSIDER THIS CASE

Seventy-nine-year-old Mr. J has been diagnosed with a rare liver cancer. The oncologist informs Mr. J that although he is willing to attempt a round of chemotherapy, no treatment has been effective in extending life for more than a few months for this aggressive type of cancer. Mr. J and his 66-year-old wife are devastated by this information and look to the Internet for help. They read testimonials of patients who have had similar liver cancers whose lives allegedly were extended for several years with an alternative treatment offered by a hospital in Germany. They make contact with the hospital and learn that Mr. J qualifies for their treatment, which consists of a 2-week- long stay at the hospital in Germany, every 2 months. Each of the hospitalizations costs $25,000 plus the couple’s travel expenses. The couple has no savings but owns a very modest house; they have no children. The couple discusses this option with the oncologist, who discourages the alternative treatment, stating, “Your time and money would be better spent in enjoying the remaining time you have together and making preparations for Mr. J’s declining health and ultimate death.” Despite the physician’s discouraging remarks, Mr. J wants to mortgage the house to pay for the alternative treatment. Mrs. J wants to help her husband extend his life but is concerned that she will face the prospect of losing the house or being required to pay off the mortgage on her limited Social Security check long after Mr. J dies. She is not comfortable with the idea, but feels that if she voices her concerns, her husband, friends, and family will consider her uncaring.

THINK CRITICALLY

Does Mr. J have the right to deplete the couple’s resources for a questionable treatment that may only extend his life for a few months? Does Mrs. J have the right to oppose this plan? Does Mr. J’s physician have the right to dash Mr. J’s hopes? How could you assist the couple?

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Discuss. In formal education programs or informal coffee breaks, talk about issues with other health team members. Members of the clergy, attorneys, ethicists, and others also can provide interesting perspectives. Form an ethics committee. Bring together various members of the health team, clergy, attorneys, and lay persons to study ethical problems within the specific care setting, clarify legal and regulatory boundaries, develop policies, discuss ethical problems that surface, and investigate charges of ethical misconduct. Consult. Clinical ethics consultation takes the form of an ethics committee or consultation provided by expert individuals or groups (e.g., lawyers, philosophers, and clinicians who specialize in bioethics). Clinical ethics consultants provide education, mediate moral conflict, facilitate moral reflection, and advocate for patients (American Society for Bioethics and the Humanities, 2010). (For information on the competencies and practice of Health Care Ethics Consultants, visit http://www.asbh.org/papers.) Share. When faced with a difficult ethical decision, talk with others and seek guidance and support. Evaluate decisions. Assess the outcomes of the actions and whether the same courses of action would be chosen in a similar situation in the future. Even the worst decision holds some lessons.

Gerontological nursing holds its share of ethical questions. Should resources be spent for a heart transplant for an octogenarian? Should an affluent child rather than public funds pay for a parent’s care? How much sacrifice must a family endure to care for a relative at home? How much compromise in care can nurses accept to keep an agency’s budget healthy? Nurses must be active participants in the process of developing ethically sound policies and practices affecting the care of older adults. The choice between being a leader or an ostrich in this arena can significantly determine the future status of gerontological nursing practice.

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http://www.asbh.org/papers

BRINGING RESEARCH TO LIFE Examination of Ethical Dilemmas Experienced by Adult Intensive Care Unit Nurses in Physical Restraint Practices

Source: Yont, G. H., Korhan, E. A., Dizer, B., Gumus, F., and Koyuncu, R. (2014). Holistic Nursing Practice, 28(2), 85–90.

Using physical restraints with patients can create a dilemma for nurses. On one hand, restraints may be beneficial in protecting a patient and others from injury and facilitating the delivery of care and treatments; this could be considered nonmaleficence because the restraints prevent harm or beneficence because they keep the patient safe. On the other hand, if a patient resists or does not want to be restrained but is restrained anyway, this could be a violation of beneficence and nonmaleficence because the action ignores the patient’s wishes and can cause emotional harm to the patient.

In this study, 55 nurses responded to questions pertaining to their perceptions of the ethical dilemmas that arose when they used physical restraints with patients. A descriptive analysis found that the nurses experienced ethical dilemmas concerning the harm versus benefit of restraint use. The main ethical principles creating dilemmas involved nonmaleficence and beneficence.

This is an example of how routine procedures that are intended to be beneficial in caring for patients can create ethical dilemmas. Nurses may be unaware that some of the stress associated with their work can be related to these ethical dilemmas. It is important that nurses not merely experience and talk about these types of ethical dilemmas among themselves but also address these issues with the organization’s decision makers. Nurses who carry out policies that cause them ethical dilemmas risk becoming so distressed about their choices that they may leave the organization or develop an emotional wall between themselves and their patients to avoid thinking about the implications of such actions.

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PRACTICE REALITIES A citizen action group is concerned about taxes and is developing a list of recommendations to offer its congressional representatives. Among the recommendations is one to limit Medicaid- and Medicare- reimbursed expensive surgeries (e.g., hip replacements and organ transplant) to only persons under the age of 80. The rationale is that the limited funds are best used in younger persons who have more years left of life.

Although you understand that health care dollars are limited and appreciate the impact of growing tax burdens, as a gerontological nurse you feel a responsibility to advocate for the rights of older adults to have the same services available as other age groups.

How would you react to the citizens’ group?

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CRITICAL THINKING EXERCISES

1. What factors have influenced your personal ethics? 2. Discuss the dilemmas arising from the following situations:

Having a terminally ill patient confide plans to commit suicide Being instructed to discharge a patient whose care is no longer being reimbursed while knowing that the patient is not ready for discharge Having to terminate a nursing assistant for attendance problems, knowing that she is the sole wage earner in her family Being asked by a senior citizen group to support its position of converting a local playground into a senior citizen center Learning of an insurer’s proposed policy of not reimbursing for dialysis and organ transplants for persons over 75 years of age

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Chapter Summary Ethics are beliefs that guide life and assist in determining the right course of action to take. Philosophical differences can cause variation in the way individuals view right and wrong. Some philosophies influencing ethical decision making include utilitarianism, egoism, relativism, and absolutism. In addition to personal ethics, nurses’ ethical decision making is influenced by codes of ethics developed by professional associations and regulatory standards.

Ethical principles that are used in nursing practice include beneficence, nonmaleficence, justice, fidelity and veracity, autonomy, and confidentiality. Nurses need to appreciate that patients’ cultural backgrounds can influence ethics for patients. Nurses need to be sensitive to the reality that the “right” action according to their belief may be in conflict with that which is considered “right” within some patients’ cultures.

Nurses may face ethical dilemmas in their daily work. These dilemmas can be compounded by changes within the profession and the entire health care system such as the expanded role of nurses, the use of medical technology, new fiscal constraints, conflicts of interest, growing numbers of older individuals, and growing interest in assisted suicide.

To foster ethical decision making, it is important for nurses to encourage patients to express their desires and involve significant others who are in the patients’ lives as appropriate, get in touch with personal values, continue to read and learn about ethical decision making, discuss and consult with others, form an ethics committee, and evaluate decisions.

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Resources American Nurses Association, Center for Ethics and Human Rights

http://www.nursingworld.org/ethics

American Society of Bioethics and Humanities

http://www.asbh.org

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http://www.nursingworld.org/ethics

http://www.asbh.org

Reference American Society for Bioethics and the Humanities. (2010). Core competencies for health care ethics consultation (2nd ed.). Glenview, IL: American Society for Bioethics and the Humanities.

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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 10

Continuum of Care in Gerontological Nursing

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CHAPTER OUTLINE

Services In The Continuum Of Care For Older Adults

Supportive and Preventive Services

Partial and Intermittent Care Services

Complete and Continuous Care Services

Complementary and Alternative Services

Matching Services To Needs

Settings And Roles For Gerontological Nurses

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Describe the continuum of services available to older adults. 2. Discuss factors that influence service selection for older adults. 3. Describe various practice settings for gerontological nurses. 4. List major functions of gerontological nurses.

TERMS TO KNOW Adult day services centers that provide health and social services for a portion of the day to persons with moderate physical or mental

disabilities and give respite to their caregivers

Assisted living residential care for persons who do not require nursing home level services but who cannot fulfill all personal care and/or health care needs independently are referred to as assisted living communities, residential care facilities, personal care, and boarding homes

Case management services provided by registered nurses or social workers who assess an individual’s needs, identify appropriate services, and help the person obtain and coordinate these services in the community

Hospice services that provide support and palliative care to dying individuals and their families in the home or an institutional setting

Nursing home facility that provides 24-hour supervision and nursing care to persons with physical or mental conditions who are unable to be cared for in the community

Respite services to provide short-term care to individuals, thereby offering their caregiver’s short-term relief from their caregiving responsibilities

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The effects of a graying population are all around us. The media report the spiraling costs of Medicare and Social Security. Banks advertise reverse annuity mortgage programs aimed at helping older adults remain in their homes. A new continuing care retirement community (CCRC) is constructed. A major corporation initiates an adult day care program. A family leave law is passed. The local hospital issues a circular informing the community of new services for senior citizens. A nearby church sponsors a caregiver support group.

One does not need to be a nurse or nursing student to be aware of the impact of older adults on all segments of society. We are increasingly aware that older adults are major consumers of virtually all health care services. Consider the following:

Growing numbers of Americans are interested in wellness programs that help them stay youthful, active, and healthy. More than one third of all surgical patients are older than 65 years of age (Centers for Disease Control and Prevention, 2010). The prevalence of mental health problems increases with age. Chronic diseases occur at a rate four times greater in old age than at other ages, with 80% of older adults having at least one chronic condition (Centers for Disease Control and Prevention, 2012). Approximately 40% of all older persons will spend some time in a nursing home during their lives (Centers for Medicare and Medicaid Services, 2011). Most beds in acute medical hospitals are filled by older patients. Older adults are the most significant users of home health services.

Whether working in nursing homes, health maintenance organizations (HMOs), outpatient surgical centers, hospice programs, rehabilitation units, or private practice, nurses are likely to be involved in gerontological nursing.

The diversity of the aging population and the complexity of needs it presents demands a wide range of nursing services. A continuum of care, including services for older adults who are the most independent and well at one end and the most dependent and ill at the other, is essential to meet the complex and changing needs presented by the older population.

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SERVICES IN THE CONTINUUM OF CARE FOR OLDER ADULTS The continuum of care consists of supportive and preventive services, partial and intermittent care services, and complete and continuous care services (Fig. 10-1). This continuum includes opportunities for community-based services, institution-based services, or a combination of both. Complementary and alternative services may also be included in the continuum.

FIGURE 10-1 • Continuum of care services for older adults.

To plan care for older adults effectively, nurses must be familiar with the various forms of care available. In fact, visiting various agencies to learn about their services firsthand can prove beneficial for the gerontological nurse. Although services can vary from one area to another, some general examples are described in the sections that follow.

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Supportive and Preventive Services Most older adults reside in the community and function with minimal or no formal assistance. Many of them adjust their lives to accommodate changes commonly experienced with aging; some manage complex care demands. Nurses are challenged to help older adults maintain independence, prevent risks to health and well- being, establish meaningful lifestyles, and develop self-care strategies for health and medical needs.

Supportive and preventive services support independent individuals in maintaining their self-care capacity so that they can avoid physical, emotional, social, and spiritual problems. In this category of services, nurses most likely will be involved with the following:

Identifying service needs Referring older adults to appropriate services Supporting and coordinating services

Local offices on aging, commissions on retirement education, libraries, and health departments usually provide assistance to older persons in learning about available services. Nurses should encourage older persons to use these resources for any questions and assistance needed. The Silver Pages telephone directory for older adults is also a useful resource. In addition, the Administration on Aging hosts a Web site that is a gateway to a wide range of information and services for older adults and their families; this can be accessed through http://www.aoa.gov/AoARoot/Elders_Families/index.aspx. Examples of supportive and preventive services for community-based older adults are described below.

KEY CONCEPT When working with community-based older adults, nurses focus on maintaining independence, preventing risks to health and well-being, establishing meaningful lifestyles, and developing self-care strategies for health and medical needs.

Financial Services The Social Security Administration may be able to help older persons obtain retirement income, disability benefits, supplemental security income, and Medicare or other health insurances. The district office of the Social Security Administration can provide direct assistance and information. The Department of Veterans Affairs (VA) can provide financial aid to older veterans and their families; interested persons should be directed to the local VA office. Various communities offer discounts to senior citizens at department stores, pharmacies, theaters, concerts, restaurants, and transportation services. Lists of discounts may be obtained from the local offices on aging.

Many banks offer free checking accounts and other special services to senior citizens. By completing a direct deposit form at their bank, older adults can have the Social Security Administration deposit Social

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http://www.aoa.gov/AoARoot/Elders_Families/index.aspx

Security and Supplemental Security Income checks directly to the bank; likewise, pension checks can be

deposited directly into checking accounts. This service saves older adults from having to travel to the bank and serves as a protection from crime. Reverse annuity mortgages can be arranged through banking institutions to allow older homeowners to use the equity in their homes to remain in the community. It is advisable for older persons to explore details of such services with their individual financial institution.

Financial assistance is also available for burial and funeral expenses. For instance, wartime veterans are eligible for some assistance from the VA. Also, the Social Security Administration provides a small payment for burial expenses to those who have been insured by that program. Local offices of these administrations can be contacted for information; funeral directors are also a good source of information about these benefits. Finally, social service agencies and religious organizations often provide assistance for persons with insufficient funds to pay for burial expenses.

COMMUNICATION TIP Discussing finances can be difficult for some older adults. This can be due to their embarrassment at experiencing financial problems, concern related to protecting their assets, or desire to avoid having family members and others learn about their financial status. Nurses who have established a trusting relationship with older adults may be in a good position to introduce discussions of finances. This can include assisting in identifying sources of aid to ease their financial burden, suggesting how to introduce topics for discussion (e.g., funeral arrangements, durable power of attorney, desires for distribution of assets) with family members, and providing referrals to professionals who can assist with financial planning and the development of wills.

Employment If older adults desire to work, nurses can refer them to employment services. State employment services and the Over 60 Counseling & Employment Service conduct programs that provide employment counseling and job placement. Various states also have foster grandparent programs, older businessperson associations, and senior aide projects. Local offices on aging can direct older persons to employment programs and opportunities in their community.

Nutrition The departments of social services can supply information about and applications for food stamps to help older persons purchase food within the constraints of their budget. These departments may also provide grocery shopping services and nutrition classes. Many senior citizen clubs and religious organizations offer lunch programs that combine socialization with nutritious meals. The local office or department on aging or the health department can direct persons to the sites of such programs.

Housing

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Local social service agencies and departments of housing and community development can assist older persons in locating adequate housing at an affordable cost. These agencies also may be able to direct the older homeowner to resources to assist in home repairs and provide information regarding property tax discounts. A variety of CCRCs (Box 10-1), villages, mobile home parks, and apartment complexes, specifically designed for older persons, are available throughout the United States. Some of these housing complexes include special security patrols, transportation services, health programs, recreational activities, and architectural adjustments (e.g., low cabinets, grab bars in bathrooms, tinted windows, slopes instead of stairs, and emergency call bells). Some of these housing options require a “buy-in fee” or purchase price, a monthly fee, or both. The older person exploring retirement housing should be advised that sound facts are more important to decision making than exciting promises. Visits to the housing complex and a full investigation of benefits and costs before making a contractual commitment are essential.

Box 10-1 Continuing Care Retirement Communities CCRCs offer a continuum of services in one location to provide various levels of housing and services to meet an older adult’s changing needs. Typically, people pay an entrance fee and a monthly fee, with an understanding that they will be able to have their needs provided by the community for the remainder of their lives. Contracts can vary and consist of a set fee for unlimited services, a set fee for time-limited services, or additional charges if assisted living, home health, or skilled nursing services are required.

Healthy individuals can enter and live in independent housing units, which could consist of single- family homes, apartments, or condominiums. Housekeeping, laundry, meals, transportation, social activities, and health services can be provided for additional fees.

As individuals require more assistance, they can receive assistance with personal care in their own housing unit or move to the assisted living community or nursing home section of the CCRC.

Entrance fees, conditions for refund of entrance fees, monthly costs, services available, and terms of contracts vary among CCRCs, so it is useful for older adults interested in CCRCs to visit and compare several and carefully review the contracts.

Health Care Nurses can encourage older adults to engage in preventive health practices to avoid illness and detect health problems at an early stage. Health services for older adults are provided by health departments, HMOs, private practitioners, and hospital outpatient services. In addition to health services, these providers may help older adults obtain transportation and financial assistance for their health care. Older individuals should inquire about such services at their nearest health care office.

Social Support and Activities Churches, synagogues, and mosques offer not only a place of worship but also a community that can provide tremendous fellowship, support, and assistance to persons of all ages. Many religious groups offer health and social services such as congregate eating programs, nursing homes, home visitation, and chore assistance. In many circumstances, recipients of services need not be members of the religious group. Increasing numbers of

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faith communities employ nurses to assist with members’ health and social needs, and Faith Community Nursing is a blossoming specialty. Individual churches and synagogues or the mother organization (e.g., Associated Jewish Charities and Catholic Charities) should be contacted for information.

Bureaus of recreation and other groups may also sponsor clubs and activities expressly for senior citizens. Local commissions or offices on aging can provide information related to the availability of such programs, their activities, schedules, and persons to contact for details. Local chapters of the American Association of Retired Persons (AARP) can provide valuable information on services that keep older persons active and independent, ranging from creative leisure endeavors at home to discount travel opportunities. Information about leisure pursuits is just one of the many services the AARP provides. Finally, art museums, libraries, theaters, concert halls, restaurants, and travel agencies should be contacted for special programs offered to senior citizens.

Volunteer Work Nurses can also encourage older adults to participate in volunteer activities. The wealth of knowledge and experience possessed by older persons makes them especially suited for volunteer work. Not only do older volunteers provide valuable services to others, but they may also achieve a sense of self-worth from their contributions to society. Communities offer numerous opportunities for senior volunteers in hospitals, nursing homes, organizations, schools, and other sites. Older persons should be encouraged to inquire about volunteer opportunities at the agency in which they are interested in serving. Frequently, agencies without a formal volunteer program are able to use a volunteer’s service if contacted. National programs also provide meaningful volunteer services in which older persons can participate. The American Red Cross, Service Corps of Retired Executives, and Retired and Senior Volunteer Program are a few such programs. Local offices of these programs should be consulted for details.

Education Some public schools offer literacy, high school equivalency, vocational, and personal interest courses for older adults. Many colleges have free tuition for older persons. Individual schools should be contacted for more details.

Counseling Financial problems, the need to locate new housing, strained family relationships, widowhood, adjustment to a chronic illness, and retirement are among the situations that may necessitate professional counseling. Local social service agencies, religious organizations, and private therapists are among the resources that offer assistance.

Consumer Affairs Senior adults are frequent victims of unscrupulous people who profit by making convincing but invalid promises. It is important for older adults to investigate cure-alls, vacation programs, and get-rich-quick schemes before investing their funds. Local offices of the Better Business Bureau and consumer protection agencies provide useful information to prevent fraud and deception and offer counseling if problems do arise.

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Legal and Tax Services Local legal aid bureaus and lawyer referral services of the Bar Association may help older adults obtain competent legal assistance at a nominal cost. The Internal Revenue Service can help older people prepare federal tax returns, and the state comptroller’s office can assist with state tax returns; local offices should be contacted for additional information. Various colleges and law schools should be investigated for free legal and tax services offered to senior citizens.

Transportation Older persons often receive discounts for bus, taxicab, subway, and train services; individual agencies should be contacted for more information. Commissions or offices on aging, health and social services departments, and local chapters of the American Red Cross may be able to direct persons to services accommodating wheelchairs and other special needs. Various health and medical facilities provide transportation for persons using their services; individual facilities should be explored for specific details.

Personal Emergency Response Systems A Personal Emergency Response System (PERS), also called a Medical Emergency Response System, is a small battery-operated transmitter device a person wears (around the next, on a belt or wristband, or in a pocket) that can be used to signal for help by pressing a button. The transmitter then sends a signal that dials an emergency response center. When signaled, the response center contacts the person or predesignated contacts. A variety of companies offer this service, and in most cases, it is not covered by health insurance programs. The local Area Agency on Aging can assist in advising what systems are available in a specific area.

Shopping at Home Persons who are homebound, who are geographically isolated from services, or who have busy schedules may find it useful to shop at home through mail-order catalogs, home-shopping services on television, and the Internet. Shopping by mail has a long tradition, and along with its newest sibling, Internet shopping reduces the inconveniences and risks associated with traveling to a shopping district, maneuvering in stores, handling large sums of money in public, and carrying packages. The shipping and handling charges may be no greater than transportation costs, not to mention the energy expended in direct shopping.

Additionally, many libraries have a service in which books and tapes can be borrowed by mail; older persons should be encouraged to inquire about such services at their local branch. The Internet offers many online books and publications, many of which are free. The U.S. Postal Service provides a service for a nominal fee in which stamps can be ordered by mail or Internet; order blanks for stamps by mail can be obtained by contacting the local postal station or postal carrier or visiting www.USPS.com.

CONSIDER THIS CASE

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http://www.USPS.com

A 78-year-old Mrs. Como lives alone and has managed independently until last month, when she began demonstrating periods of dizziness, weakness, and confusion. Last week, she had an accident in which she ran her car into a parked car; she reported to her daughter that this happened because she “couldn’t figure out which pedal was the brake.” Her daughter and son, concerned with the changes they are witnessing in their mother, take Mrs. Como to her physician for an examination. It is determined that Mrs. Como has congestive heart failure, and she is admitted to the hospital for treatment.

Mrs. Como is successfully treated and prepared for discharge. Mrs. Como feels insecure returning to her own home and indicates she thinks it may be best if she can live with one of her children, who live in the same city she does. Mrs. Como’s son is adamant that due to his work schedule, he cannot have his mother live with him. Although her daughter has several children at home, works part-time, and has a busy life, she feels that she can’t turn her mother away.

THINK CRITICALLY

What factors need to be considered in developing Mrs. Como’s discharge plan? What are the benefits and risks of the plan for Mrs. Como to live with her daughter? What services could be of benefit to Mrs. Como after discharge? Describe the approach that would be effective in discussing discharge plans with Mrs. Como and her children.

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Partial and Intermittent Care Services Partial and intermittent care services provide assistance to individuals with a partial limitation in self-care capacity or a therapeutic demand that requires occasional assistance. Because of either the degree of the self- care limitation or the complexity of the therapeutic action required, the individual could be at risk for new or a worsening of existing physical, emotional, and social problems if some assistance were not provided at periodic intervals. These services can be provided in community or institutional settings.

Assistance with Chores Social service agencies, health departments, private homemaker agencies, and faith communities have services for older persons that help them remain in their homes and maintain independence. These services include light housekeeping, minor repairs, errands, and shopping. Local agencies and programs should be contacted for specific information.

Home-Delivered Meals Persons unable to shop and prepare meals independently may benefit from having meals delivered to their homes. Such a service not only facilitates good nutrition but also provides an opportunity for social contact. Meals on Wheels is the most popularly known program for home delivery of meals, although various community groups provide a similar service. If a local Meals on Wheels is unavailable, departments of social services, health departments, and commissions or offices on aging should be consulted for alternative programs.

Home Monitoring Some hospitals, nursing homes, and commercial agencies provide home monitoring systems, whereby the older adult wears a small remote alarm that can be pressed in the event of a fall or other emergency. The alarm triggers a central monitoring station to call designated contact persons or the police to assist the individual. This type of service can be located by calling the local agency on aging or looking in the telephone directory under listings such as Medical Alarms.

A growing array of telemanagement technologies is affording the opportunity for patients to have vital signs, blood glucose levels, and other physiological measurements communicated from the home to providers. Tracking systems and sensors can enable family members or caregivers to monitor patients’ activity in their homes from a distance. Two-way audio and video devices allow patients to interact with their providers from their homes. Devices can be used to signal patients when to take medications and perform other tasks. Medication administration systems exist whereby family members and caregivers in another location can be informed if a patient has not taken drugs as scheduled. An Internet search of home care and patient care technology vendors will yield many suppliers of technological aids for home care.

Telephone Reassurance Older adults who are homebound, disabled, or lonely may benefit from a telephone reassurance program. Those who participate in the program receive a daily telephone call—usually at a mutually agreed on time—to

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provide them with social contact and ensure that they are safe and well. Local chapters of the American Red Cross and other health or social service agencies should be consulted for telephone reassurance programs that they may conduct.

Home Health Care Home health care provides nursing and other therapies in individuals’ homes. Visiting nurse associations have a long reputation of providing care in the home and are able to help many older persons remain in their homes rather than enter an institution. Programs vary, and services can include bedside nursing, home health aides, physical therapy, health education, family counseling, and medical services. Medicare is limited to skilled home care, which means that the person must:

Be homebound Have services ordered by a primary care provider Require skilled nursing or rehabilitative services Need intermittent but not full-time care

During the 1970s and the decades that followed, home health services significantly grew due to the enactment of the Older American’s Act and Title XX Social Services Act in 1975 that provided federal funds for home- based services and the Federal Health Services Program that gave grants for the establishment and expansion of these services. By the 1990s, home care became the fastest growing component of Medicare and the rising costs influenced Congress to place limitations on home care benefits for Medicare recipients as part of the Balanced Budget Act of 1997. At this same time, in an effort to control the rising costs of nursing home care on their Medicaid budgets, states began to develop more home care services as an alternative to nursing home care.

KEY CONCEPT The changes in home health care demonstrate the impact that government funds can have on the availability of services to older adults. At present, Medicare covers skilled nursing care but not long- term nonskilled care. States have various Medicaid programs to assist in nonskilled home care; private agencies also provide these services.

In addition to Medicare, the VA, Medicaid, and private insurers provide reimbursement for home health services, although the conditions and length of coverage vary; specific coverage should be reviewed with the insurer. These programs can be found through health departments, in telephone directories, or through social workers who assist with discharge planning.

Foster Care and Group Homes Adult foster care and group home programs offer services to individuals who are capable of self-care but who

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require supervision to protect them from harm. Older persons placed in these homes may need someone to direct their self-care activities (e.g., remind them to bathe and dress and encourage and provide good nutrition); they may also need someone to oversee their judgments (e.g., financial management). Foster care and group living can serve as short- or long-term alternatives to institutionalization for older persons unable to manage independently in the community. The local department of social services can supply details about these programs.

Adult Day Services Adult day services programs have been a growing component of community-based, long-term care, currently numbering over 4,600 centers in the United States (National Adult Day Services Association, 2014). These centers provide health and social services to persons with moderate physical or mental disabilities and give respite to their caregivers. Participants attend the program for a portion of the day and enjoy a safe, pleasant, therapeutic environment under the supervision of qualified personnel (Fig. 10-2). The programs attempt to maximize the existing self-care capacity of participants while preventing further limitations. Although the primary focus is social and recreational, there usually is some health component to these programs, such as health screening, supervision of medication administration, and monitoring of health conditions. Rest periods and meals accompany the planned therapeutic activities. Transportation to the site is provided, usually by vehicles equipped to accommodate wheelchairs and persons with other special needs.

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FIGURE 10-2 • Adult day care centers provide opportunities for a variety of recreational activities.

In addition to helping older persons avoid further limitations and institutionalization, day services programs are extremely beneficial to the families of participants. Families interested in caring for their older relatives may be able to continue their routine lifestyle (e.g., maintaining a job and raising small children), knowing that they can have respite from their caregiving responsibilities for a portion of the day while the older person is cared for and safe.

Adult day services programs are sponsored by public agencies, religious organizations, and private groups, with one third being freestanding and the remaining ones affiliated with a larger parent organization; each varies in schedule, activities, costs, and program focus. The local telephone directory or information and referral service, as well as the National Adult Day Services Association, can provide information on programs in specific communities.

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Concept Mastery Alert Adult day services provide health and social services to persons with moderate physical or mental disabilities who need some supervision and assistance with activities of daily living. A primary focus of these programs is to give respite to caregivers.

Day Treatment and Day Hospital Programs Day treatment and day hospital programs offer social and health services with a primary focus on the latter. Assistance is provided with self-care activities (e.g., bathing and feeding) and therapeutic needs (e.g., medication administration, wound dressing, physical therapy, and psychotherapy). Physicians, nurses, occupational therapists, physical therapists, psychologists, and psychiatrists are among the care providers affiliated with programs for day treatment. Like adult day services programs, geriatric day treatment or day hospital programs usually provide transportation to and from the program. Sponsored by hospitals, nursing homes, or other agencies, these programs can be used as alternatives to hospitalization and nursing home admission and can facilitate earlier discharge from these care settings. Many of these programs focus on the care of persons with psychiatric conditions. The local commission or office on aging can guide persons to programs for day treatment or day hospitals in their community.

Assisted Living Assisted living supplements independent living with special services that maximize an individual’s capacity for self-care. Terminology used to describe assisted living can fall under the categories of residential care facilities, personal care, and boarding homes; different states use different regulatory designations. The housing unit is adjusted to meet the needs of older or disabled persons (e.g., wide doorways, low cabinets, grab bars in bathroom, and call-for-help light). A guard, hostess, or resident screens and greets visitors in the lobby. Various degrees of personal care assistance may be provided. Residents are encouraged to develop mutual support systems; one example is a system in which residents check on one another every morning to see if anyone needs help. Tenant councils may determine policies for the facility. Some facilities have a health professional on call or on duty during certain hours; recognizing the unique health care needs in this setting that can be appropriately addressed by nurses, nursing in assisted living communities is a developing specialty. Social programs and communal meals may also be available. State health department regulatory agencies and the local office of the Department of Housing and Urban Development may be able to direct interested persons to such facilities.

Respite Care A variety of services can be utilized to provide short-term relief to caregivers from their caregiving responsibilities. The services depend on the need, status of the patient, and funds. For example, private home health aides/companions or nurses can be hired to live in or occasionally visit the older person while the caregiver is away; short-term admissions to assistive living communities or nursing homes can provide respite

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when the person’s caregiving demands and/or need for supervision is 24/7.

Health Ministry and Parish Nurse Programs Many churches and synagogues have programs to assist older adults and their caregivers such as support groups, health education classes, counseling, housekeeping and home maintenance assistance, meals, and home nursing visits. Many nurses are volunteers in these programs and some are paid to serve in these roles. These services are ideal ways to integrate health services with one’s faith. As services offered vary, nurses should contact the church or synagogue of the patient, or if the patient is not a member of one a local religious organization representing the patient’s faith, to learn of the availability of services.

KEY CONCEPT The American Nurses Association has recognized parish nursing as a specialty and in collaboration with the Health Ministries Association published the Faith Community Nursing: Scope and Standards of Practice.

Care and Case Management The identification of needs, location and coordination of services, and maintenance of an independent lifestyle can be tremendous challenges for older persons with chronic health problems. In response to these challenges, the field of geriatric care and case management has developed.

Care and case managers most often are registered nurses or social workers who assess an individual’s needs, identify appropriate services, and help the person obtain and coordinate these services. Such services include medical care, home health services, socialization programs, financial planning and management, and housing. By coordinating care and services, geriatric care and case managers assist older persons in remaining independent in the community for as long as possible. The services of care and case managers often provide peace of mind to family members who are unable to be involved with their older family members on a daily basis.

As a system of credentials within this field has surfaced, there is greater distinction between care management and case management. Both of these disciplines perform some type of assessment, develop plans, help people implement and coordinate services, and evaluate care. A distinguishing difference between the two, however, is that care management is a long-term relationship that could endure through multiple episodes of care (e.g., when a family contracts with a care manager to oversee the care of a relative on a long- term basis), whereas case management usually focuses on needs during a specific episode of care (e.g., from hospitalization through rehabilitation for a hip fracture). Case management is viewed as a means to control health care costs and may emphasize services for cost containment; care management may include case management in addition to services unrelated to health care.

Social workers, local information and referral services, and the National Association of Professional

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Geriatric Care Managers (http://www.caremanager.org) can provide assistance in locating care and case managers.

KEY CONCEPT The American Nurses Association has found professional nurses to be excellent case managers because of their knowledge and skills training, their ability to deliver care that includes both physical and sociocultural components, their familiarity with the process of services referral, and the parallels between the nursing process and the process of case management.

Programs of All-Inclusive Care for the Elderly Programs of all-inclusive care for the elderly (PACE) is a program that enables persons age 55 or older who are eligible for nursing home care to have all of their medical, social, and long-term care services provided in their homes in the community. It is a joint Medicare and Medicaid program available in states that have chosen to include it in their Medicaid programs. Individuals can find out if there is a PACE program in their area by calling their state Medicaid office or visiting www.cms.hhs.gov/PACE.

Hospice Although hospice care is listed here under partial and intermittent care services, it can also be included under complete and continuous care services. This is because the nature of the patient’s needs determines the level at which this service is provided.

Rather than a site of care, hospice is a philosophy of caring for dying individuals. Hospice provides support and palliative care to patients and their families. Typically, an interdisciplinary team helps patients and families meet physical, emotional, social, and spiritual needs. The focus is on the quality of remaining life rather than life extension. Survivor support is also an important component of hospice care. Although hospice programs can exist within an institutional setting, most hospice care is provided in the home. Insurers vary in the conditions that must be met for reimbursement of hospice services; individual insurers should be consulted for specific information. Health care and social service agencies can be consulted for information about hospice programs in specific communities.

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http://www.caremanager.org

http://www.cms.hhs.gov/PACE

Complete and Continuous Care Services At the far end of the continuum of care are services that provide regular or continuous assistance to individuals with some limitation in self-care capacity whose therapeutic needs require 24-hour supervision by a health care professional.

Hospital Care Hospital care for older persons may be required when diagnostic procedures and therapeutic actions indicate a need for specialized technologies or frequent monitoring. Older adults can be patients of virtually all acute hospital services, except, of course, pediatrics and obstetrics (and here they may be encountered as relatives of the primary patients). Although the procedure or diagnostic problem for which they are hospitalized will dictate many of their service needs, there are some basic measures that can enhance the quality of the hospital experience, as described in Box 10-2.

Box 10-2 Measures That Enhance the Quality of Hospital Care for Older Adults

Perform a comprehensive assessment. It is not uncommon for the patient’s diagnostic problem to be the primary and sometimes only concern during the hospitalization. However, the patient being treated for a myocardial infarction or hernia may also suffer from depression, caregiver stress, hearing deficit, or other problems that significantly affect the health status. By capitalizing on the contact with the patient during the hospitalization and conducting a comprehensive evaluation, nurses can reveal risks and problems that affect the health status and that have not been detected before. Broader problems, other than those for which the patient was admitted to the hospital, should be explored.

Recognize differences. Older patients should not be considered in the same way as younger patients: different norms may be used to interpret laboratory tests and clinical findings, the signs and symptoms of disease can appear atypically, more time is needed for care activities, and drug dosages must be age adjusted. The priorities of older patients can differ from those of younger patients. Nurses must be able to differentiate normal pathology from pathology in older adults and understand the modifications that must be made in caring for this population.

Reduce risks. The hospital experience can be traumatic for older patients if special protection is not afforded. The elderly require more time to recover from stress; therefore, procedures and activities must be planned to provide rest. Altered function of major systems and decreased immunity make it easy for infections to develop. Reduced ability of the heart to manage major shifts in fluid load demands close monitoring of intravenous infusion rates. Lower normal body temperature, the lack of shivering, and reduced capacity to adapt to severe changes in environmental temperature require that older patients receive special protection against hypothermia. Differences in pharmacodynamics and pharmacokinetics in older adults alter their response to medications and heighten the need for close monitoring of drug therapy. The strange environment, sensory deficits, and effects of illness and medications cause falls to occur more easily and make injury prevention a priority. Confusion often emerges as a primary sign of a complication, challenging staff to detect this disorder promptly and

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identify its cause. Nurses should ensure that measures are taken to reduce patients’ risks and recognize complications promptly when they do occur.

Maintain and promote function. Priorities addressing the primary reason for admission usually take the forefront during a patient’s hospitalization. For example, the arrhythmia must be corrected, the infection controlled, and the fracture realigned. In the midst of diagnostic procedures and treatment activities, there must be consideration of factors that will ensure the older patient’s optimal function and independence.

Increasingly, hospitals are establishing special services for older adults, such as geriatric assessment centers, telephone hot lines, long-term care units, and home visits. Local medical societies and state hospital associations can answer inquiries about specific hospitals.

Two issues that gerontological nurses need to consider regarding the hospital care of older adults are abbreviated stays and the move toward same-day outpatient services for procedures that once would have required hospitalization. Although shortening hospital stays can be effective in lowering costs and perhaps reducing or eliminating a patient’s hospital-induced complications, many older patients require a longer recovery time than younger adults and may not have adequate assistance in the home. Nurses must assess older patients’ capacity to care for themselves—the ability to obtain and prepare food and manage their households—before discharge and arrange assistance as necessary. A telephone call after discharge to check on the patient’s status is also useful. (Additional information on hospital care of older adults is provided in Chapter 33.)

Nursing Homes Nursing homes provide 24-hour supervision and nursing care to persons who are unable to be cared for in the community. Chapter 34 discusses these facilities and related nursing responsibilities.

KEY CONCEPT The Centers for Medicare and Medicaid Services offer a free online booklet, Your Guide to Choosing a Nursing Home, which can aid individuals in finding and comparing facilities, understanding nursing payment for this care, and learning about alternatives to nursing home care. It is available at http://publications.usa.gov/USAPubs.php?PubID=5337.

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http://publications.usa.gov/USAPubs.php?PubID=5337

Complementary and Alternative Services As the emphasis on holistic health and public awareness of and desire for complementary and alternative therapies grow, older adults may seek new or nonconventional types of services (Fig. 10-3). Examples of complementary and alternative services include the following:

FIGURE 10-3 • Increasingly, older adults are turning to yoga, meditation, and other complementary health

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practices.

Wellness and renewal centers Education, counseling, and case management from alternative practitioners Acupuncture and acupressure Tai chi, yoga, and meditation classes Therapeutic touch and healing touch Medicinal herbal prescriptions Herbal and homeopathic remedies Guided imagery sessions Sound, light, and aromatherapy

Nurses possess a wide range of knowledge and skills that, when combined with additional preparation in complementary and alternative therapies, makes them ideal providers of some of these nonconventional services. Even if they are not direct providers of alternative therapies, nurses can advocate for older adults’ rights to make informed choices about using such therapies; educate them about the benefits, risks, and limitations of therapies; and help them find reputable providers. Ideally, these therapies are used in concert with conventional ones in an integrative care model to enable patients to use the best of both worlds. Nurses should ensure the complementary and alternative therapies used have evidence supporting their claims and do not interfere or interact with other therapies.

POINT TO PONDER Increasing numbers of nurses are offering complementary therapies in independent practices. What types of factors must be considered when establishing a private practice? What do you think prevents more nurses from becoming self-employed nurse entrepreneurs?

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MATCHING SERVICES TO NEEDS The needs of the aging population are diverse and multitudinous. In addition, the needs of an individual older adult are dynamic; in other words, needs fluctuate as capacities and life demands change. These conditions require gerontological nursing services to be planned with consideration of several factors:

Services must address physical, emotional, social, and spiritual factors. Services must be available to meet the unique needs of the older population in a holistic manner. These services should be planned to address whatever problems or needs older adults are likely to develop and should be implemented in a manner relevant to the unique characteristics of this group. For instance, a local health department interested in meeting the special needs of older adults could add screening programs for hearing, vision, hypertension, and cancer to their existing services. Likewise, a social service agency with an abundance of programs for younger families may decide that a widow’s support group and retirement counseling services are relevant additions. The consideration of physical, emotional, social, and spiritual factors is essential to providing holistic nursing care. Services must consider unique and changing needs. Physical, emotional, social, and spiritual services are based on the individual’s needs at a given time, recognizing that priorities are not fixed. An older adult could be seen in an outpatient medical service for hypertension control and during that visit express concern regarding a recent rent increase. Unless assistance is obtained to provide additional income or lower cost housing, the potential effects of this social problem, such as stress and dietary sacrifices, may exacerbate the individual’s hypertension. Ignoring this individual’s need for particular social services, then, can minimize the effectiveness of the health services provided. Care and services must be flexible. Opportunities must exist for the older individual to move along the continuum of care, depending on his or her capacities and limitations at different times. Perhaps an older woman lives with her children and attends a senior citizen recreational program during the day. If this woman fractures her hip, she may move along the continuum to hospitalization for acute care and then to a nursing home for convalescence. As her condition improves and she becomes more independent, she moves along the continuum to home care and then possibly adult day care until she regains full independence. Services must be tailored to needs. Individualization must be practiced to match the unique needs of the individual with specific services. Just as it is inappropriate to assume that all persons over 65 years require nursing home placement, it is equally inappropriate to assume that all older persons would benefit from counseling, sheltered housing, home-delivered meals, adult day care, or any other service. Older individuals’ unique capacities and limitations and, most importantly, their preferences should be assessed to identify the most appropriate services for them.

The listing of resources at the end of the chapter can help gerontological nurses and nursing students locate and perhaps stimulate services for older adults. Nurses are encouraged to contact their local agencies on aging and information and referral services for the location of services within specific communities.

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SETTINGS AND ROLES FOR GERONTOLOGICAL NURSES Because the continuum of care includes community-based services, institution-based services, or a combination of both, gerontological nurses have an exciting opportunity to practice in a variety of settings. Some of these settings, such as long-term care facilities and home health agencies, have a long history of nursing participation. Others, such as senior housing complexes and adult day care centers, offer new opportunities for nurses to demonstrate creativity and leadership.

Although nurses’ specific roles and responsibilities can differ vastly in different settings, gerontological nurses in any setting may serve similar functions (Box 10-3). These functions are varied and multifaceted and address the following goals:

Educate persons of all ages in practices that promote a positive aging experience. Assess and provide interventions related to nursing diagnoses. Identify and reduce risks. Promote self-care capacity and independence. Collaborate with other health care providers in the delivery of services. Maintain health and integrity of the aging family. Advocate for and protect the rights of older adults. Promote the use of ethics and standards in the care of older adults. Help older persons face the transition to death with peace, comfort, and dignity.

Box 10-3 Functions of the Gerontological Nurse Guide persons of all ages toward a healthy aging process.

Eliminate ageism.

Respect the rights of older adults and ensure others do the same.

Oversee and promote the quality of service delivery.

Notice and reduce risks to health and well-being.

Teach and support caregivers.

Open channels for continued growth.

Listen and support.

Offer optimism, encouragement, and hope.

Generate, support, use, disseminate, and participate in research.

Implement restorative and rehabilitative measures.

Coordinate and manage care.

Assess, plan, implement, and evaluate care in an individualized, holistic manner.

Link services with needs.

Nurture futu