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Gerontologic Nursing
FIFTH EDITION
Sue E. Meiner, EdD, APRN, BC- GNP President, Consultant on Health Issues, Inc., McKinney, Texas
Formerly: Nurse Practitioner in Private Practice Las Vegas, Nevada; and Assistant Professor University of Nevada, Las Vegas Las Vegas, Nevada
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Table of Contents
Cover image
Title page
Copyright
Dedication
About the Author
Contributors and Reviewers
Preface Organization Format
Features
Acknowledgments
Part 1: Introduction to Gerontologic Nursing Chapter 1: Overview of Gerontologic Nursing
Foundations of the specialty of gerontologic nursing
Demographic profile of the older population Health status of older adults
Impact of an aging population on gerontologic nursing Summary
Key points Critical thinking exercises
Chapter 2: Theories of aging Biologic theories of aging
Sociologic theories of aging Psychologic Theories of Aging
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Moral and spiritual development Summary
Key points Critical thinking exercises
Chapter 3: Legal and ethical issues Professional standards: their origin and legal significance
Overview of relevant laws Elder abuse and protective services
Nursing facility reform Autonomy and self-determination
The patient self-determination act Values history
Nurses’ ethical code and end-of-life care Summary
Key points Critical thinking exercises
Appendix 3A Values History Form Section 1
Section 2 Optional Questions
Suggestions for Use
Chapter 4: Gerontologic Assessment Special considerations affecting assessment Interrelationship between physical and psychosocial aspects of aging
Nature of disease and disability and their effects on functional status Tailoring the nursing assessment to the older person
The health history Additional assessment measures
Laboratory data Summary
Key points Critical thinking exercises
Part 2: Influences on Health and Illness Chapter 5: Cultural Influences
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Diversity of the older adult population in the united states Culturally sensitive gerontologic nursing care
Skills Putting it together
Summary Key points
Critical thinking exercises
Chapter 6: Family Influences Role and function of families Common late-life family issues and decisions
Interventions to support family caregivers Working with families of older adults: considerations and strategies
Summary Key points
Critical thinking exercises
Chapter 7: Socioeconomic and Environmental Influences Socioeconomic factors Environmental influences
Advocacy Summary
Key points Critical thinking exercises
Appendix 7A Resources Organizations of Professionals Working in the Field of Aging
Organizations of Both Professionals and Older Adults
Chapter 8: Health Promotion and Illness/Disability Prevention Essentials of health promotion for aging adults Models of health promotion
Barriers to health promotion and disease prevention Health protection
Disease prevention The nurse’s role in health promotion and disease prevention
Supporting empowerment of older adults Summary Key points
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Critical thinking exercises
Chapter 9: Health care delivery settings and older adults Characteristics of older adults in acute care Characteristics of the acute care environment
Nursing in the acute care setting Home care and hospice
Factors affecting the health care needs of noninstitutionalized older adults Community-based services
Home health care Continuity of care
Implementing the plan of treatment Oasis
Hospice Overview of long-term care
Clinical aspects of the nursing facility Management aspects of the nursing facility
Specialty care settings Innovations in the nursing facility
The future of the nursing facility Summary
Key points Critical thinking exercises
Part 3: Wellness Issues Chapter 10: Nutrition
Social and cultural aspects of food
Demographics of the aging population Physiologic changes in aging that affect nutritional status
Psychosocial and socioeconomic factors related to malnutrition Nutritional screening and assessment
Nutritional guidelines for all ages Drug–nutrient interactions
Nursing diagnoses associated with nutritional problems Specialized nutritional support
Failure to thrive
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Summary Key points
Critical thinking exercises
Chapter 11: Sleep and Activity Sleep and older adults Activity and older adults
Summary Key points
Critical thinking exercises
Chapter 12: Safety Falls Nursing management of falls
Safety and the home environment Seasonal safety issues
Disasters Storage of medications and health care supplies in the home
Living alone Automobile Safety
Abuse and neglect Firearms
Summary Key points
Critical thinking exercises
Chapter 13: Sexuality and Aging Older adult needs for sexualality and intimacy The importance of intimacy among older adults
Nursing’s reluctance to manage the sexuality of older adults Normal changes of the aging sexual response
Physiologic changes Pathologic conditions affecting older adults’ sexual responses
Environmental and psychosocial barriers to sexual practice Alternative sexual practice among older adults
Nursing management Summary Key points
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Critical thinking exercises
Part 4: Common Psychophysiologic Stressors Chapter 14: Pain
Understanding pain
Pathophysiology of pain in older adults Barriers to effective pain management in older adults
Pain assessment Nursing care of older adults with pain
Summary key Points
Critical thinking exercises
Chapter 15: Infection Learning objectives The chain of infection
Age-related changes in the immune system Factors affecting immunocompetence
Common problems and conditions Human immunodefiency virus infection in older adults
Significant nosocomial pathogens Nursing management
Summary Key points
Critical thinking exercises
Chapter 16: Chronic Illness and Rehabilitation Chronicity
Rehabilitation Summary
Key points Critical thinking exercise
Appendix 16A Resources
Chapter 17: Cancer Incidence Aging and its relationship to cancer
Common malignancies in older adults
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Screening and early detection: issues for older adults Major treatment modalities
Common physiologic complications Older adults’ experience of cancer
Summary Key points
Critical thinking exercises
Chapter 18: Loss and End-of-Life Issues Definitions Losses
Mourning Approaching death: older persons’ perspectives
Summary Key points
Critical thinking exercises
Part 5: Diagnostic Studies and Pharmacologic Management Chapter 19: Laboratory and Diagnostic Tests
Components of hematologic testing
Components of blood chemistry testing Components of urine chemistry testing
Components of arterial blood gas testing Blood level monitoring
Summary Key points Critical thinking exercises
Chapter 20: Pharmacologic Management Overview of medication use and problems
Commonly used medications Medication adherence
Substance abuse Definitions and common usage
Assessment Nursing diagnoses
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Nursing management Commonly abused substances in older adults
Future trends Summary
Key points Critical thinking exercises
Part 6: Nursing Care of Physiologic and Psychologic Disorders Chapter 21: Cardiovascular Function
Age-related changes in structure and function Common cardiovascular problems
Nursing management Nursing management
Nursing management Nursing management
Nursing management Nursing management
Nursing management Nursing management
Nursing management Nursing management
Summary Key points
Critical thinking exercises
Chapter 22: Respiratory Function Age-related changes in structure and function
Factors affecting lung function Respiratory symptoms common in older patients
Respiratory alterations in older patients Obstructive pulmonary disease
Nursing management Nursing management
Restrictive pulmonary disease Nursing management
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Nursing management Bronchopulmonary infection
Nursing management Nursing management
Other respiratory alterations Nursing management
Nursing management Nursing management
Summary Key points
Critical thinking exercises
Chapter 23: Endocrine Function Endocrine physiology in older adults Common endocrine pathophysiology in older adults
Nursing management Nursing management
Nursing management Nursing management
Nursing management Summary
Key points Critical thinking exercises
Chapter 24: Gastrointestinal Function Age-related changes in structure and function
Prevention Common gastrointestinal symptoms
Common diseases of the gastrointestinal tract Nursing management
Nursing management Nursing management
Nursing management Nursing management
Nursing management Nursing management Nursing management
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Nursing management Nursing management
Disorders of the accessory organs Nursing management
Nursing management Nursing management
Nursing management Nursing management
Gastrointestinal cancers Nursing management
Nursing management Nursing management
Nursing management Summary
Key points Critical thinking exercises
Chapter 25: Musculoskeletal Function Age-related changes in structure and function
Common problems and conditions of the musculoskeletal system Nursing management
Nursing management Nursing management
Nursing management Nursing management
Nursing management Nursing management
Nursing management Nursing management
Nursing management Foot problems
Muscle cramps Summary
Key points Critical thinking exercises
Chapter 26: Urinary Function
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Age-related changes in structure and function Prevalence of urinary incontinence
Common problems and conditions Nursing management
Age-related renal changes Common problems and conditions
Nursing management Nursing management
Nursing management Nursing management
Nursing management Summary
Key points Critical thinking exercises
Chapter 27: Cognitive and Neurologic Function Structural age-related changes of the neurologic system
Assessment of cognitive function Cognitive disorders associated with altered thought processes
Diagnostic assessment of altered thought processes Treatment of altered thought processes
Nursing management Challenges in the care of older adults with cognitive disorders
Other common problems and conditions Nursing management
Nursing management Nursing management
Nursing management Nursing management
Nursing management Nursing management
Medication management Mental health care resources
Trends and needs Summary Key points
Critical thinking questions
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Appendix 27A Resources
Chapter 28: Integumentary Function Age-related changes in skin structure and function Common problems and conditions
Nursing management Nursing management
Nursing management Nursing management
Premalignant skin growths: actinic keratosis Nursing management
Malignant skin growths Nursing management
Nursing management Nursing management
Lower extremity ulcers Nursing management
Pressure ulcers Summary
Key points Critical thinking exercises
Chapter 29: Sensory Function Vision
Nursing management Nursing management
Nursing management Nursing management
Hearing and balance Nursing management
Nursing management Nursing management
Nursing management Taste and smell
Nursing management Touch Summary
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Key points Critical thinking exercises
Index
Disorders Index
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Copyright
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Gerontologic Nursing, Fifth Edition
ISBN: 978-0-323-26602-4
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2011, 2006, 2000, 1996 by Mosby, an imprint of Elsevier Inc.
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Nursing Diagnoses: Definitions and Classifications 2012–2014, Herdman T.H. (ED). Copyright 2012, 1994–2012, National International; used by arrangement with John Wiley & Sons, Limited. In order to make safe and effective judgments using NANDA-I diagnoses it is essential that nurses refer to the
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definitions and defining characteristics of the diagnoses listed in this work.
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
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The Publisher
Library of Congress Cataloging-in-Publication Data
Gerontologic nursing (Lueckenotte)
Gerontologic nursing / [edited by] Sue E. Meiner. – Fifth edition.
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p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-26602-4 (pbk. : alk. paper)
I. Meiner, Sue, editor. II. Title.
[DNLM: 1. Geriatric Nursing. 2. Aged–psychology. 3. Chronic Disease–nursing. 4. Long-Term Care. 5. Terminal Care. WY 152]
RC954
618.97'0231–dc23
2014034663
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Dedication
Sue E. Meiner
I want to thank the many people that have contributed to the continued success of this book, especially the original editor (Annette G. Lueckenotte), and the contributors to this and
previous editions. The knowledge and time that was given was greatly appreciated. A special thanks to Jennifer J. Yeager, PhD,
RN, and Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C, who were exceptionally helpful in this 5th edition.
Thanks to the entire team at Elsevier for the production of this book. Each phase of work was done with care and patience.
Thank you for a job well done. Love and thanks go to Bob Meiner, my husband of 43 years
whose patience was unending during the revisions of this book. To the joys of my life - my daughters, Diane and Suzanne, and grandsons, Tristyn and Braedyn, your love keeps me motivated.
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About the Author
Sue E. Meiner, EdD, APRN, GNP-BC, began her nursing career in 1962 in St. Louis, Missouri. She began as a Licensed Practical Nurse (L.P.N.) prior to the availability of Associate Degree Nursing programs in the Midwest. She graduated from the second class of
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the Associate in Applied Science degree (A.D.N.) program from St. Louis Community College (Meramec campus). Continuing her education in nursing, she completed a Bachelor of Science in Nursing (B.S.N.) and a Master’s of Science in Nursing (M.S.N.) from St. Louis University. Later she received her Doctor of Education (EdD) from Southern Illinois University at Edwardsville, and a Certificate as a Gerontological Nurse Practitioner from the Barnes- Jewish Hospital College of Nursing in St. Louis. Dr. Meiner held certifications as both a Gerontological Clinical Nurse Specialist and a Gerontological Nurse Practitioner from the American Nurses Credentialing Center (A.N.C.C.) of the American Nurses Association (ANA). Additional courses toward counseling were taken at Lindenwood College, St. Charles, Missouri. She has received numerous awards and has been asked to speak at local, regional and national conferences and workshops. Dr. Meiner worked as a staff nurse in hospitals in the St. Louis area as well as home health nursing. Over time she worked as a hospital nursing supervisor and interim Director of Nursing. While her main clinical interest was in medical-surgical nursing, she began to focus on the special care needs of the older adult. She has practiced nursing for over 50 years; however, the last 30 years have been heavily focused in geriatric nursing. She has taught nursing at the L.P.N., A.D.N., B.S.N., and M.S.N. levels of education. She has been the Director of Nursing Programs at the L.P.N. and A.D.N. levels. Before returning to full-time clinical practice in Las Vegas as a Nurse Practitioner, she taught the final course of clinical nursing at the master’s level at the University of Nevada, Las Vegas, School of Nursing. Her clinical practice was directed at chronic and tertiary pain management, with a focus on the needs of the older adult. Dr. Meiner has engaged in the support of nursing through advocacy of both nurses and patients and their families by serving part-time as a Forensic Nurse. She has been active in legal nurse consulting since 1988 and incorporated her company in the early 2000s. Throughout those 25 years, she provided case reviews and expert witness testimony at depositions and trials across the United States. She authored and edited, Nursing Documentation: Legal Focus across Practice Setting, in 2000, as well as authored, co-authored, or edited multiple textbooks, and has written multiple professional articles
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on nursing care and issues. During 5 years in the 1980s, she was elected to serve her community of Creve Coeur, MO as a Director of the Fire Protection District. In her free time, Dr. Meiner enjoys national and international travel and spending time with her family.
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Contributors and Reviewers
Contributors
Dr.Jean Benzel-Lindley, PhD, RN Assistant Director of Nursing, Nevada Career Institute, Las Vegas, Nevada
Jacqueline Kayler DeBrew, PhD, MSN, RN Clinical Professor, University of North Carolina at Greensboro, Greensboro, North Carolina
Sabrina Friedman, EdD, DNP, FNP-C, PMHCNS-BC Associate Professor, Azusa Pacific University, Azusa, California
Laurie Kennedy-Malone, PhD, GNP-BC, FGSA Professor of Nursing, University of North Carolina at Greensboro, Greensboro, North Carolina
Cindy R. Morgan, RN, MSN, CHC, CHPN Associate VP of Hospice, Palliative Care & Clinical Innovations, Association of Home Health and Hospice Raleigh, North Carolina
Elizabeth C. Mueth, MLS, AHIP Resource Center and Archives Coordinator, Missouri Baptist Medical Center, Saint Louis, Missouri
Kathleen M. Rourke, PhD, MSN, RD, RN Associate Professor of Nursing, Director of Graduate Program in Nursing Administration, State University of New York Polytechnic Institute of Technology Utica, New York
Deb Bagnasco Stanford, MSN, RN, CCRN Clinical Assistant Professor, University of North Carolina at Greensboro, Greensboro, North Carolina
Marie H. Thomas, RN, PhD, FNP-C, CNE Clinical Assistant Professor, NP Coordinator, School of Nursing, University of North Carolina Charlotte, Charlotte, North Carolina
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Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD- C Consultant, Acute and Home Care Licensure Section, Division of Health Service Regulation, Department of Health and Human Services, Raleigh, North Carolina
Lois VonCannon, RN, MSN Clinical Associate Professor, University of North Carolina at Greensboro, Greensboro, North Carolina
Jennifer J. Yeager, PhD, RN Assistant Professor, Tarleton State University, Stephenville, Texas
Reviewers
Shelba Durston, MSN, RN, CCRN, SAFE
Professor of Nursing, San Joaquin Delta College, Stockton, California
San Joaquin General Hospital, French Camp, California
Barbara Hulsman, RN, PhD Associate Professor, Coordinator of Education Track, Division of Graduate Studies in Nursing, Indiana Wesleyan University, Marion, Indiana
Roberta Imhoff, RN, BSN, MSN, CNE, CCRN
Home Care Registered Nurse, Sparrow Health System Lansing, Michigan
Clinical Nursing Instructor, Baker College of Owosso, School of Nursing, Owosso, Michigan
Laura Ann Jaroneski, MSN, RN, OCN, CNE Nursing Instructor, Baker College of Clinton Township, Clinton Township, Michigan
Shari Kist, PhD, RN, CNE Assistant Professor, Goldfarb School of Nursing at Barnes-Jewish College, Saint Louis, Missouri
Amy J. Ponder, RN, MSN Instructor, University of Alabama at Birmingham, Birmingham, Alabama
Gail Potter, RN, BScN, MDiv, MN, CGN(C) Nursing Faculty, Selkirk College, Castlegar, BC, Canada
Barbara D. Powe, PhD, RN, FAAN Director, Cancer Communication Science, American Cancer Society, Atlanta,
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Georgia
Elizabeth Sibson-Tuan, RN, MS, AACN, ANA Bay Area Clinical Coordinator, Instructor, Samuel Merritt University, Oakland, California
Anne Van Landingham, RN, BSN, MSN Nursing Instructor, Orlando Tech, Orlando, Florida
Jeana Wilcox, PhD, RN, CNS, CNE Associate Dean for Undergraduate Programs, Associate Professor of Nursing, Graceland University School of Nursing, Independence, Missouri
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Preface
Sue E. Meiner
The field of gerontologic nursing has blossomed over the past decades as the population of baby boomers enters retirement age. The demand of health care for older adults is an ever-growing challenge. Age-appropriate and age-specific care is an expectation of current and future nurses across the globe. The varied issues related to health and wellness must be provided within a cost- effective and resource-sparse environment. The largest group of patients in hospitals (outside of obstetric and pediatric units) is older adults. Long-term and rehabilitation specialty facilities have predominantly older adults as residents. The specialty of gerontologic nursing is in greater demand now more than ever before.
Gerontologic Nursing, fifth edition, has been developed to provide today’s students with a solid foundation to meet the future challenges of gerontologic nursing practice. This textbook provides comprehensive, theoretic, and practical information about basic and complex concepts and issues relevant to the care of older people across the care continuum. The extensive coverage of material provides the student with the information necessary to make sound clinical judgments while emphasizing the concepts, skills, and techniques of gerontologic nursing practice. Psychologic and sociocultural issues and aspects of older adult care are given special emphasis, but they are also integrated throughout the textbook, reflecting the reality of practice with this unique population. Care of both well and sick older people and their families and caregivers is included.
Intended for use by undergraduate nursing students in all levels of professional nursing programs, Gerontologic Nursing was developed for use in either gerontologic nursing or medical- surgical courses, or within programs that integrate gerontologic
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content throughout the educational program.
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Organization The 29 chapters in Gerontologic Nursing are divided into six parts. Part 1, Introduction to Gerontologic Nursing, includes four chapters that serve as the foundation for the remainder of the textbook. Chapter 1 introduces the student to the specialty by addressing historical developments, educational preparation and practice roles, future trends, and demographic factors relevant to the health and well-being of older people. Basic tenets of selected biologic, sociologic, and psychologic theories of aging and their relevance to nursing practice are presented in Chapter 2. Chapter 3 presents an overview of practice standards, legal issues, and relevant laws applicable to the care of older adults across the care continuum and describes the principles of values and ethics associated with the care of older people. Chapter 4 discusses the importance of a nursing-focused assessment, special considerations affecting assessment of older people, and strategies and techniques for collecting a comprehensive health assessment. Functional, mental status, affective and social assessment tools and techniques are included.
Part 2, Influences on Health and Illness, includes chapters on cultural, family, and socioeconomic and environmental influences. Health promotion and illness/disability prevention are also included. The final chapter in this part presents an in-depth look at various health care delivery settings. Chapter 5 presents cultural concepts within the contexts of aging and the health and illness experiences of older people. Roles and functions of families, common family issues and decisions in later life, and family caregiving are described in Chapter 6. Specific tools and techniques for working with aging families, including crisis intervention, are also explained. Chapter 7 presents an overview of socioeconomic and environmental factors that affect health and illness, including issues associated with resource availability. Advocacy by and for older adults is included. Chapter 8 introduces the concepts of health promotion, protection, and disease prevention as they apply to older adults and includes strategies for health promotion activities
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with this population. Chapter 9 presents issues and trends associated with the care of older people in acute, home, hospice, and long-term care settings.
Part 3, Wellness Issues, details the needs and nursing care of older adults in the areas of nutrition, sleep and activity, safety, and sexuality issues. Chapter 10 explores the role of nutrition in health and illness, including nutritional requirements, screenings and assessments, therapeutic diets, and other nutritional support and therapies. Age-related factors in maintaining a balance between sleep and activity and their effect on the older person’s lifestyle are discussed in Chapter 11. Chapter 12 stresses the importance of a safe environment within the context of maintaining the older person’s autonomy. Chapter 13 sensitively addresses the intimacy and sexuality needs of older adults, offering practical management strategies. Each chapter in this section presents the age-related changes in structure and function and nursing interventions to promote healthy adaptation to the identified changes.
Part 4, Common Psychophysiologic Stressors, focuses on the special needs of older adults with pain, infection, cancer, chronic illness, and nursing care related to loss and end-of-life issues. Chapter 14 provides an overview of pain and the special issues surrounding pain management in older people. The importance and significance of immunity and factors affecting immunocompetence in aging, as well as associated common problems and conditions, are explored in Chapter 15. Chapter 16 examines the concepts of chronic illness and rehabilitation in aging, as well as the related concepts of compliance, self-care, functional ability, psychosocial and physiologic needs, and the impact on family and caregiver. The nursing management of older adults with the most commonly occurring cancers is addressed in Chapter 17. Chapter 18 discusses the topics of loss and end-of-life issues. Differences between the loss and death experiences of older people and younger adults are reviewed. All of these chapters emphasize the nurse’s role in effectively managing the nursing care of older patients with these problems.
Part 5, Diagnostic Studies and Pharmacologic Management, includes chapters on laboratory and diagnostic tests and
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pharmacologic management. Principles of laboratory testing in older adults, including age-related factors that influence laboratory values and age-specific values for hematologic, blood, and urine chemistry, are presented in Chapter 19. Chapter 20 contains current and comprehensive information on the critical issue of medications and the myriad of issues pertinent to drug use in this population. Substance abuse issues are included in this chapter.
Part 6, Nursing Care of Physiologic and Psychologic Disorders, contains nine chapters that detail nursing management of older adults with diseases or conditions of cardiovascular, respiratory, endocrine, gastrointestinal, musculoskeletal, urinary, cognitive and neurologic, integumentary, and sensory function.
In organizing the textbook every attempt was made to ensure a logical sequence by grouping related topics. However, it is not necessary to read the text in sequence. Material is cross-referenced throughout the text, and an extensive index is included. It is hoped that this approach provides the student with easy access to information of particular interest.
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Format The fifth edition has been revised and reflects the growth and change of gerontologic nursing practice and the learning needs of today’s student. The presentation of content has been designed for ease of use and reference. Consistent chapter pedagogy has been retained in this edition, and the textbook’s visual appeal has been carefully planned to make it easy to read and follow. Content that is traditionally covered in fundamental or medical-surgical nursing courses has been deleted. The clinical examples still depict nurses practicing in many different roles in a wide variety of practice settings, reflecting current practice patterns.
All body system chapters include an overview of age-related changes in structure and function. Common problems and conditions within each of the chapters are presented in a format that includes the definition, etiology, pathophysiology, and typical clinical presentation for each. The Nursing Management of the problems and conditions is central to each of these chapters and follows the five-step nursing process format of assessment, diagnosis, planning and expected outcomes, intervention, and evaluation. Nursing Care Plans for selected problems and conditions begin with a realistic clinical situation and emphasize nursing diagnoses pertinent to the situation, expected outcomes, and nursing interventions, all within an easy-to-reference, two-column format.
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Features Each chapter begins with Learning Objectives to help the student focus on the important subject matter. Patient/Family Teaching boxes are included where appropriate, providing key information on what to teach patients and families to enhance their knowledge and promote active participation in their care. Throughout the text, coupled with more content emphasizing health promotion and the needs of well older adults are Health Promotion/Illness Prevention boxes, which identify activities and interventions that promote a healthy lifestyle and prevent disease and illness. Nutritional Considerations boxes are found throughout the text to stress the importance of nutrition in the care of older adults. Evidence-Based Practice boxes are presented to emphasize the application of relevant study findings to current nursing practice and allow students to reflect on how to integrate evidence-based practice into everyday nursing practice. Cultural Awareness boxes are included where applicable to develop the student’s cultural sensitivity and promote the delivery of culture-specific care. At the conclusion of the body system and clinical chapters, Home Care boxes provide pragmatic suggestions for care of the homebound patient and family. Finally, each chapter concludes with a brief Summary, followed by Key Points that highlight important principles discussed in the chapter. Critical Thinking Exercises at the end of every chapter stimulate students to carefully consider the material learned and apply their knowledge to the situation presented.
As the scope of gerontologic nursing practice continues to expand, so must the knowledge guiding that practice reflect the most current standards and guidelines. Every effort has been made to incorporate the most current standards and guidelines from the AHCRQ, ANA, CDC, TJC, NANDA-I, OBRA, and CMS.
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Acknowledgments
Sue E. Meiner
The development of this fifth edition would not have been possible without the combined efforts of many talented professionals who supported me throughout the entire process. The contributors were especially dedicated to reviewing the fourth edition, researching all of the information for current status of information as well as investigating any new and updated information on each of the topics selected.
A special recognition goes to the editorial and production team at Elsevier. This team of professionals worked extremely hard to assist me in meeting the deadlines. I want to say a very special “Thank you so much” for all of the encouragement and dedicated work on this book.
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PA R T 1 Introduction to Gerontologic Nursing
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C H A P T E R 1
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Overview of Gerontologic Nursing Sue E. Meiner, EdD, APRN, BC, GNP
Learning objectives
On completion of this chapter, the reader will be able to: 1. Trace the historic development of gerontologic nursing as a specialty.
2. Distinguish the educational preparation, practice roles, and certification requirements of the gerontologic nurse generalist, acute or primary care nurse practitioner, and adult-gerontologic clinical nurse specialist.
3. Discuss the major demographic trends in the United States in relation to the older adult population.
4. Describe the effects of each of the following demographic factors on the health, well-being, and life expectancy of older adults:
• Gender and marital status • Race or ethnicity • Housing or living situation • Educational status • Economic status
5. Explain why old age is considered a woman’s problem.
6. Describe the effect of functional ability on the overall health status of older adults.
7. Discuss how the “aging of the aged” will affect health care delivery.
8. Explore future trends in gerontologic nursing care along the
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continuum of care.
9. Explore the concept of ageism as related to the care of older adults in various settings.
10. Identify the issues influencing gerontologic nursing education.
11. Analyze the issues affecting the development and future of gerontologic nursing research.
http://evolve.elsevier.com/Meiner/gerontologic
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Foundations of the specialty of gerontologic nursing The rich, diverse history of nursing has always been shaped by the population it serves. From the early beginnings of Florence Nightingale’s experiences during the 1800’s Crimean War to the present day, as nurses care for the growing immigrant and prison populations, those with mental illnesses, those with substance abuse problems, teenage mothers, homeless individuals, and those infected with the human immunodeficiency virus (HIV), nurses are reminded that these patients and their problems define the knowledge and skills required for practice.
As of 2011, the population of Americans aged 65 years or older comprised 41.4 million persons. The number of older adults has grown steadily since 1900, and they continue to be the fastest growing segment of the population (Administration on Aging [AOA], 2012). With a “gerontology boom” beginning, the specialty of gerontologic nursing is growing in recognition. It was not always the case, and the struggle for recognition can be traced back to the beginning of the twentieth century.
History and Evolution Burnside (1988) conducted an extensive review of the American Journal of Nursing (AJN) for historical materials related to gerontologic nursing. Between 1900 and 1940, she found 23 writings, including works by Lavinia Dock, with a focus on older adults that covered such topics as rural nursing, almshouses, and private duty nursing, as well as early case studies and clinical issues addressing home care for fractured femur, dementia, and delirium. Burnside discovered an anonymous column in AJN entitled “Care of the Aged” that was written in 1925, and it is now thought to be one of the earliest references to the need for a specialty in older adult care.
The modern health movement is constantly increasing life
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expectancy by its steady research and implementation of medical actions fighting preventable diseases. Therefore, nursing professionals must expect to care for steadily increasing numbers of patients with chronic and degenerative conditions.
During World War II and the postwar years (1940–1960), the population of older persons steadily increased, but articles about the care of older adults were general and not particularly comprehensive (Burnside, 1988). It was not until 1962, when the geriatric nursing conference group was established during the American Nurses Association (ANA) convention, that the question posed by the anonymous AJN columnist was finally addressed.
Professional Origins In 1966, the ANA established the Division of Geriatric Nursing Practice and defined geriatric nursing as “concerned with the assessment of nursing needs of older people; planning and implementing nursing care to meet those needs; and evaluating the effectiveness of such care.” In 1976, the name The Division of Geriatric Nursing Practice was changed to The Division of Gerontologic Nursing Practice to reflect the nursing roles of providing care to healthy, ill, and frail older persons. The division came to be called The Council of Gerontologic Nursing in 1984 to encompass issues beyond clinical practice. Certification for the Gerontologic Clinical Nurse Specialist was established through the ANA in 1989. In 2013, the differences in acute care and primary care for gerontologic nurse practitioners were identified and separate certification examinations were established by the American Nurses Credentialing Center (ANCC, 2013).
Standards of Practice The years 1960 to 1970 were characterized by many “firsts,” as the specialty devoted to the care of older adults began its exciting development (Table 1-1). Journals, textbooks, workshops and seminars, formal education programs, professional certification, and research with a focus on gerontologic nursing have since evolved. However, the singular event that truly legitimized the
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specialty occurred in 1969, when a committee appointed by the ANA Division of Geriatric Nursing Practice completed the first Standards of Practice for Geriatric Nursing (ANA, 1991). These standards were widely circulated during the next several years; in 1976, they were revised, and the title was changed to Standards of Gerontological Nursing Practice. In 1981, A Statement on the Scope of Gerontological Nursing Practice was published. The revised Scope and Standards of Gerontological Nursing Practice were published in 1987, 1995, and 2010 (ANA, 2010). The changes to this document reflect the comprehensive concepts and dimensions of practice for the nurse working with older adults. In 2010, the revised Scope and Standards of Gerontological Nursing Practice not only reflected the nature and scope of current gerontologic nursing practice but also incorporated the concepts of health promotion, health maintenance, disease prevention, and self-care. The scope and standards of practice were combined into a set of three books titled Nursing: Scope & Standards of Practice (ANA, 2010a), Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010b), and Guide to the Code of Ethics for Nurses: Interpretation and Application (ANA, 2010c). This merging of the standards of practice of all the specialties was an effort to outline the expectations of the professional role within which all registered nurses (RNs) must practice nursing. These documents can be obtained from the ANA website: www.nursingworld.org/.
Table 1-1 Development of Gerontologic Nursing: 1960–1970
Year Event 1961 Formation of a specialty group for geriatric nurses is recommended by the American Nurses Association (ANA). 1962 First national meeting of the ANA Conference on Geriatric
Nursing Practice is held in Detroit, Mich. American Nurses’ Foundation receives a grant for a workshop on the aged. First research in geriatric nursing is published in England (Norton D., et al. [1962]. An investigation of geriatric nursing problems in hospital, London, U.K.: National Corporation for the Care of Old People).
1966 First gerontologic clinical specialist nursing program is developed at Duke University by Virginia Stone. Geriatric Nursing Division of the ANA is formed; a monograph is published, entitled Exploring Progress in Geriatric Nursing Practice.
1968 Laurie Gunter is the first nurse to present a paper at the International Congress of Gerontology in Washington, DC. First gerontologic nursing interest group, Geriatric Nursing, is formed. Barbara Davis is the first nurse to speak before the American Geriatric Society. First article on nursing curriculum regarding gerontologic nursing is published (Delora JR, Moses DV [1969]. Specialty preferences and characteristics of nursing students in baccalaureate programs, Nurs Res March/April.). The nine standards for geriatric nursing practice are developed.
1970 Standards of Geriatric Nursing Practice is first published. First gerontologic clinical nurse specialists graduate from Duke University.
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Modified from Burnside, I.M. (1988). Nursing and the aged: a self-care approach (3rd ed). New York: McGraw-Hill.
Another hallmark in the continued growth of the gerontologic nursing specialty occurred in 1973, when the first gerontologic nurses were certified through the ANA. Certification is an additional credential granted by the ANA, providing a means for recognizing excellence in a clinical or functional area (ANA, 1995). Certification is usually voluntary, enabling the nurse to demonstrate to peers and others that a distinct degree of knowledge and expertise has been achieved. In some cases, certification may mean eligibility for third-party reimbursement for nursing services rendered. From the initial certification offering as a generalist in gerontologic nursing, to the first Gerontologic Nurse Practitioner (GNP) examination offering in 1979, to the most recent Gerontologic Clinical Nurse Specialist (GCNS) examination (first administered in 1989), this specialty has continued to grow and attract a high level of interest. Changes were being made as this edition was being written. The first combined certification for either acute care Adult-Gerontologic Nurse Specialist (AGCNS) or primary care AGCNS examination will take place beginning in 2014. Additionally, an AGCNS examination will take the place of the earlier GCNS. Eligibility criteria for the application process to take any one of the four certification examinations can be found in Box 1-1. Since changes are fluid, contact the ANA’s credentialing center for up-to-date requirements. Additional information can be retrieved from www.nursingworld.org/ancc.
Box 1-1
American Nurses Credentialing Center Eligibility Requirements for Certification in Gerontologic Nursing Gerontologic nurse (registered nurse—board certified [RN-BC])
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The nurse must meet all of the following requirements before application for examination:
1. Currently hold an active registered nurse (RN) license in the United States or its territories or the professional, legally recognized equivalent in another country.
2. Have practiced the equivalent of 2 years, full time, as an RN.
3. Have completed clinical practice of at least 2000 hours in gerontologic nursing within the past 3 years.
4. Have had 30 contact hours of continuing education applicable to gerontology/gerontologic nursing within the past 3 years.
More details on this option can be found by contacting the ANCC directly or online at www.nursingworld.org/ancc/certification.
Adult – gerontologic acute care nurse practitioner (ACAGNP–BC) The nurse must meet all of the following requirements:
1. Currently hold an active RN license in the United States or its territories or the professional, legally recognized equivalent in another country.
2. Hold a master’s, postgraduate, or doctorate degree from an adult-gerontologic acute care nurse practitioner program accredited by the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN).
3. A minimum of 500 faculty-supervised clinical hours must be included in the adult-gerontologic acute care nurse practitioner role and population.
4. Three separate, comprehensive graduate-level courses in the following:
a. Advanced physiology/pathophysiology, including general principles that apply across the life span
b. Advanced health assessment, which includes assessment of
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all human systems, advanced assessment techniques, concepts, and approaches
c. Advanced pharmacology, which includes pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents
Adult-gerontologic primary care nurse practitioner (PCAGNP–BC) The nurse must meet all of the following requirements:
1. Currently hold an active RN license in the United States or its territories or the professional, legally recognized equivalent in another country.
2. Hold a master’s, postgraduate, or doctorate degree from an adult-gerontologic primary care nurse practitioner program accredited by the CCNE or the ACEN. A minimum of 500 hours of faculty-supervised clinical hours must be included in the adult-gerontologic primary care nurse practitioner role and population.
3. Three separate, comprehensive graduate-level courses in the following:
a. Advanced physiology/pathophysiology, including general principles that apply across the life span
b. Advanced health assessment, which includes assessment of all human systems, advanced assessment techniques, concepts, and approaches
c. Advanced pharmacology, which includes pharmacodynamics, pharmacokinetics, and pharmacotherapeutics
4. Content in:
a. Health promotion and/or maintenance
b. Differential diagnosis and disease management, including the use and prescription of pharmacologic and nonpharmacologic interventions
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More details on these options can be found by contacting the ANCC directly or online at www.nursingworld.org/ancc/certification.
To keep current with the changing scope, standards, and education requirements, the eligibility criteria are reviewed yearly and are subject to change. Therefore if applying to take a certification examination, one must request a current catalog from the center; compliance with the current eligibility criteria is required. Applications can be downloaded from the Internet. Modified from American Nurses Credentialing Center Certification, 2013. Washington DC. www.nursingworld.org/ancc/certify.htm. Accessed September 17, 2013.
Roles The growth of the nursing profession as a whole, increasing educational opportunities, demographic changes, and changes in health care delivery systems have all influenced the development of the generalist’s role in adult and gerontologic nursing as well as the advanced practice roles. The generalist in gerontologic nursing has completed a basic entry-level educational program and is licensed in a state as an RN. A generalist nurse may practice in a wide variety of environments, including the home and the community. The challenge of the gerontologic nurse generalist is to identify older patients’ strengths and assist them with maximizing their independence. Patients participate as much as possible in making decisions about their care. The generalist consults with the advanced practice nurse and other interdisciplinary health care professionals for assistance in meeting the complex care needs of older adults.
The AGCNS has the requirement of at least a master’s degree in nursing and has to be licensed as an RN. The first program was launched in 1966 at Duke University. The gerontologic master’s program typically focuses on the advanced knowledge and skills required to care for younger through older adults in a wide variety of settings, and the graduate is prepared to assume a leadership role in the delivery of that care. AGCNSs have an expert understanding of the dynamics, pathophysiology, and psychosocial
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aspects of aging. They use advanced diagnostic and assessment skills and nursing interventions to manage and improve patient care (ANCC, 2013). The AGCNS functions as a clinician, educator, consultant, administrator, or researcher to plan care or improve the quality of nursing care for adults and their families. Specialists provide comprehensive care based on theory and research. Today, AGCNSs may be found practicing in acute care hospitals, long-term care or home care settings, or independent practices.
The Acute Care or Primary Care Adult Gerontologic Nurse Practitioner (ACAGNP/PCAGNP) may be educationally prepared in various ways but must hold a license as an RN. In the early 1970s, the first GNPs were prepared primarily through continuing education programs. Another early group of GNPs received their training and clinical supervision from physicians. Only since the late 1980s has master’s-level education with a focus on primary care been available. As a provider of primary care and a case manager, the AGNP conducts health assessments; identifies nursing diagnoses; and plans, implements, and evaluates nursing care for adult and older patients. The AGNP has knowledge and skills to detect and manage limited acute and chronic stable conditions; coordination and collaboration with other health care providers is a related essential function. The acute care or primary care AGNP’s activities include interventions for health promotion, maintenance, and restoration. AGNPs provide acute or primary ambulatory care in an independent practice or in a collaborative practice with a physician; they also practice in settings across the continuum of care, including the acute care hospital, subacute care center, ambulatory care setting, and long-term care setting. Health maintenance organizations (HMOs) are now including acute care or primary care AGNPs on their provider panels. Certification can elevate the status of the nurse practicing with older adults in any setting. More importantly, it enables the nurse to ensure the delivery of quality care to older adult patients. In most states within the United States, AGNPs hold prescriptive authority for nearly all classes of medications. Each state has determined the type and extent of prescriptive authority permitted.
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Terminology Any discussion of older adult nursing is complicated by the wide variety of terms used interchangeably to describe the specialty. Some terms are used because of personal preference or because they suggest a certain perspective. Still others are avoided because of the negative inferences they evoke. As described in the preceding overview of the evolution of the specialty, the terminology has changed over the years. The following are the most commonly used terms and definitions:
• Geriatrics—from the Greek geras, meaning “old age,” geriatrics is the branch of medicine that deals with the diseases and problems of old age. Viewed by many nurses as having limited application to nursing because of its medical and disease orientation, the term geriatrics is generally not used when describing the nursing of older adults.
• Gerontology—from the Greek geron, meaning “old man,” gerontology is the scientific study of the process of aging and the problems of aged persons; it includes biologic, sociologic, psychological, and economic aspects.
• Gerontologic nursing—this specialty of nursing involves assessing the health and functional status of older adults, planning and implementing health care and services to meet the identified needs, and evaluating the effectiveness of such care. Gerontologic nursing is the term most often used by nurses specializing in this field.
• Gerontic nursing—this term was developed by Gunter and Estes in 1979 and is meant to be more inclusive than geriatric or gerontologic nursing because it is not limited to diseases or scientific principles. Gerontic nursing connotes the nursing of older persons—the art and practice of nurturing, caring, and comforting. This term has not gained wide acceptance, but it is viewed by some as a more appropriate description of the specialty.
These terms and their usage spark a great deal of interest and controversy among nurses practicing with older adults. As the
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specialty continues to grow and develop, it is likely that the terminology will, too.
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Demographic profile of the older population Far from the beginnings of gerontologic nursing practice in almshouses and nursing homes, nurses today find themselves caring for older adults in a wider variety of settings. Emergency rooms, medical-surgical and critical care units in hospitals, outpatient surgical centers, home care agencies, clinics, and rehabilitation centers are just some of the sites where nurses are caring for the older population that is rapidly growing. Nurses in any of these settings need only count the number of adults 65 or older to understand firsthand what demographers have termed the graying of America. Although this trend has already attracted the attention of the health care marketplace, it promises to become an even greater influence on health care organizations. It is clearly a trend that promises to shape the future practice of nursing in profound and dramatic ways.
Demography is the science dealing with the distribution, density, and vital statistics of human populations. In the following review of basic demographic facts about older persons, the reader is cautioned against believing that the age 65 automatically defines a person as being old. The rate and intensity of aging is highly variable and individual. It occurs gradually and in no predictable sequence.
Butler (1975), in his classic book, Why Survive? Being Old in America, cautions against using chronologic age as a measure of being old. He offers the following on why age 65 is the discretionary cutoff for defining old age:
Society has arbitrarily chosen ages 60 to 65 as the beginning of late life (borrowing the idea from Bismarck’s social legislation in Germany in the 1880s) primarily for the purpose of determining a point for retirement and eligibility for services and financial entitlements for the elderly.
When the Social Security program was established in 1935, it was
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believed that age 65 would be a reasonable age for the purpose of allocating benefits and services. Today, with so many older persons living productive, highly functional lives well beyond age 65, this age is obviously an inappropriate one for determining whether a person is old. However, demographic information and other forms of data are still reported using age 65 as the defining standard for old. For example, older adults are categorized by cohort for some research and public policy purposes. Consequently, it is not uncommon to see older persons classified as young-old, middle-old, or old-old.
Although grouping older persons is useful in some circumstances, the nurse is cautioned against thinking of all persons older than age 65 as similar. In fact, older persons are far from being a homogeneous group. Landmarks for human growth and development are well established for infancy through middle age, but few norms have been as discretely defined for older adulthood. In fact, most developmental norms that have been described for later life categorize all older persons in the older-than-65 group. One could argue from a developmental perspective that great differences exist among 65-, 75-, 85-, and 95-year-olds as they do among 2-, 3-, 4-, and 5-year-olds, yet no definitive standards for older adult development have been established. Consequently, the nurse is urged to view each older patient as one would any patient —a being with a richly diverse and unique array of internal and external variables that ultimately influence how the person thinks and acts. Understanding how the variables interact and affect older adults enables the nurse to provide individualized care. Additionally, the nurse is encouraged to use the individual patient as the standard, comparing a patient’s previous level and pattern of health and function with the current status.
The Older Population For several decades, the American Association of Retired Persons (AARP) maintained a yearly update of the profile of older adults in America. This organization is a nonprofit, nonpartisan membership organization for people age 50 or older. The AARP is dedicated to enhancing the quality of life for all Americans as they age. The
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association acknowledges that its members receive a wide range of unique benefits, special products, and services (AARP, 2004). Additional information can be found at their website: www.aarp.org. In 1997, the organization stopped compiling profile demographics and began to collect more specific data on a narrower scope.
The federal government maintains aging statistics that are available to the public. These publications include an annual chart book with the name of the year. Information can be found at www.aoa.gov/Aging_Statistics/Profile/Index.aspx. This is now a part of public census and reporting data.
Before review of current statistics of older adults in America, a look at past issues that have led to these numbers is appropriate. The relatively high birth rate during the late nineteenth and early twentieth centuries accounts, in part, for the large number of older persons today (Burnside, 1988). Reduction in infant and child mortality as a result of improved sanitation, advances in vaccination, and the development of antibiotics has also contributed. The large influx of immigrants before World War I is an additional important factor. The net effect, associated with a reduction in mortality for all ages and fertility rates at a replacement level, has been an increase in the older adult population.
Highlights of the Profile of Older Americans A large number of persons are living to age 65 and to older ages. When the current figures are validated, the population aged 85 or older has increased to 5.7 million by 2010 and will increase to 8.5 million by 2020. Data obtained in 2010 found those adults 65 or older numbered 41.4 million, which is an increase of 18% since 2000. One in every eight Americans is an older adult. That accounts for 13.3% of the population of the United States (AOA, 2012). See Figure 1-1 for population trends of persons 65 years or older through 2060.
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FIGURE 1-1 Population estimates and projections of persons 65 or older: 1900–2060. (From Administration on Aging (2013). A profile of older
Americans: 2012. Washington, DC: U. S. Department of Health and Human Services.)
Gender and Marital Status Since 1930, women have been living longer than men as a result of reduced maternal mortality, decreased death rates from infectious diseases, and increased death rates in men from chronic diseases. Before that time, the numbers of older men and women were nearly equal. Older adults reaching age 65 have an average life expectancy of an additional 19.2 years (20.4 years for women and 17.8 years for men). As of 2012, older women outnumbered older men—at 23.4 million older women to 17.9 million older men. Older men were much more likely to be married than older women—72% of men versus 45% of women. In 2010, 37% of women older than age 65 were widows (AOA, 2012). Nearly half (46%) of older women over the age of 75 live alone. Marital status is an important determinant of health and well-being because it influences income, mobility, housing, intimacy, and social interaction.
The discrepancy between proportions of older women and older men is expected to continue to increase as the size of the age group older than 85 increases, and it is a group in which women represent the clear majority. This demographic fact has important health care and policy implications because the majority of older women are likely to be poor, live alone, and have a greater degree of functional
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impairment and chronic disease. The resulting increased reliance on social, financial, and health-related resources, coupled with emerging health care reforms, points to an uncertain future for older women. Because of these considerations, many gerontologists view aging as significantly a woman’s problem. The nursing profession, and gerontologic nurses in particular, must assume a prominent role in the political arena by advocating an agenda that addresses this important issue.
Race and Ethnicity Minority populations in America are projected to increase from 5.7 million in the year 2000 (16% of the older adult population) to 8.5 million in 2020. Statistics from 2012 indicate that 21% of persons 65 or older were minorities, with 9% being African Americans (not Hispanic), 4% were Asian or Pacific Islander (non-Hispanic), and less than 1% were American Indian or Native Alaskan. In addition, 0.6% of persons older than 65 identified themselves as being of two or more races. Persons of Hispanic origin (of any race) were 7% of the older population (AOA, 2012).
People of Hispanic origin may be of any race, but their origins are in the Spanish-speaking countries of Central or South America. They are counted in the census by racial groups, usually as white, black, or other. The higher proportion of older whites is expected to remain stable and continue into the mid-twenty-first century, at which time the nonwhite segment of the population is expected to increase at a higher rate. Hispanics will continue to be one of the fastest growing segments, and the numbers of African Americans, Native Americans, Native Alaskans, Asians, and Pacific Islanders will also increase. The nursing profession must consider the impact of such changing demographic characteristics. The health status of diverse populations will present unique nursing care challenges.
Living Arrangements Types of housing and arrangements differ according to the needs of individuals. Most of the older adults continue to live independently in their own residences. The residence could be a single-family
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home, an apartment or condominium, or a motor or prefabricated or manufactured home. The arrangements might include living alone, with family members, or with an unrelated individual. For those living independently, additional in-home care may be required; assisted-living communities, continuing care communities, and the controlled environments of long-term care are also options. Health care delivery settings are discussed in more detail later in this chapter. A person’s overall degree of health and well-being greatly influences the selection of housing in old age. Ideally, housing should be selected to promote functional independence, but safety and social interaction needs should also be priorities.
Statistics show that approximately 3.6% of all adults older than 65 are institutionalized in long-term care facilities or nursing homes. About 30% of noninstitutionalized older adults, or 10.8 million persons, live alone, according to living arrangement figures. Women comprise the majority of this group: they number 7.9 million compared with 2.9 million men. Of women older than 75, half live alone (AOA, 2012).
Persons of advanced age are more vulnerable to the multiple losses typically associated with aging, which make them frailer. These frail older adults need more intensive care in all health care settings in which they are found. Coupled with the growth of life- extending therapies and the continuous development of highly sophisticated treatment measures, the structure, services, and financing of the current health care delivery system are still not equipped to effectively manage the needs of this population segment.
As is discussed throughout the remaining chapters of this text, older adults have unique and varied responses to the interacting array of forces that affect their health status. It is well documented that advancing age is associated with more physical frailty as a result of the increased incidence of chronic disease, greater vulnerability to illness and injury, diminished physical functioning, and the increased likelihood of developing cognitive impairment. Additionally, psychologic, social, environmental, and financial factors play a significant role in the level of frailty. Nevertheless,
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not all older adults are frail. The expectation of wellness, even in the presence of chronic illness and significant impairment, must be incorporated into the consciousness and practice of nurses who interact with this population. (See Figure 1-2 for living arrangements).
FIGURE 1-2 Living arrangements of persons 65 or older: 2007. (From Administration on Aging (2013). A profile of older Americans: 2012.
Washington, DC: U. S. Department of Health and Human Services.)
In 2011, the median value of homes owned by older persons was $150,000. Sixty-five percent of homeowners had completely paid for their homes; however, older persons were more likely to lose a home as a result of property taxes and maintenance costs, which were difficult to pay on a fixed income. About 81% were homeowners (in the process of buying or already owned homes), and 19% were renters (AOA, 2012).
Geographic Distribution Older adults, as a group, are less likely to change residences compared with other age groups. For many years, this phenomenon of aging in place has been an important factor in the growth of the population that is 65 or older living in metropolitan and
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nonmetropolitan areas. Through their later years, older adults tend to remain wherever they reside, choosing not to move. However, various factors may influence the decision to move. Dependency and health status may require older persons to move to be near caregivers. Countermigration describes the move some older adults make back to their home states after a previous migration to the Sunbelt states for retirement. Dwindling financial resources may necessitate a move to a more economical location; conversely, economic stability or affluence may afford the opportunity to move to a retirement community or a location with a temperate climate and recreational offerings.
Education Although, as a group, older adults are less educated than younger persons, the educational level of the older adult population has been steadily increasing. Between 1970 and 2012, the percentage that had completed high school increased from 28% to 81%. In 2012, about 24% had gone to college for at least 4 years (AOA, 2012). Educational levels are significantly different between whites and nonwhites. In 2012, 86% of whites had completed high school, whereas only 74% of Asians, 69% of African Americans, 69% of American Indian and Alaska Natives, and 49% of Hispanics had completed the same level of education (AOA, 2012).
Low levels of education may impair older persons’ abilities to live a healthy lifestyle, access service and benefit programs, recognize health problems and seek appropriate care, and follow recommendations for care. The educational level of older adult patients also affects the nurse–patient health teaching process; thus, it is an important consideration in health promotion and illness/disability prevention. See Chapter 8 for in-depth information on this topic.
Income and Poverty The median income of older adults in 2011 was $27,707 for older men and $15,362 for older women. For all older persons reporting income in 2011, 5% reported less than $15,000 and 67% reported
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$35,000 or more. The major source of income for older individuals and couples in 2010 was Social Security (reported by 86% of older persons), a plan that was originally developed to be a supplemental source of income in old age. Other income sources in order of rank were income from assets (reported by 52%), private pensions (reported by 27%), and government employee pensions (reported by 15%) (AOA, 2012).
Family households headed by persons 65 or older had a median income of $48,538 in 2011. Nonwhites continued to have substantially lower incomes than their white counterparts. African Americans had a median income of $39,533 and Hispanics $33,809, whereas whites had a median income of $50,658. About 5% of all family households headed by an older adult had annual median incomes of less than $15,000; 67% had incomes of $35,000 or more (Figure 1-3).
FIGURE 1-3 Percentage distribution by income in households headed by persons 65 or older. (From Administration on Aging (2013). A
profile of older Americans: 2012. Washington, DC: U. S. Department of Health and Human Services.)
Approximately 3.6 million older adults were below the poverty level in 2011. Another 2.4 million older persons were classified as near-poor, with incomes between the poverty level and 125% of the level (AOA, 2012).
Gender and race are significant indicators of poverty. Older
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women had a poverty rate nearly twice as high as older men in 2011. Only 6.7% of older whites were poor in 2011 compared with 17.3% of older African Americans, 11.7% of Asians, and 18.7% of older Hispanics.
The most important factors in the relationship between income and health are the lifestyle changes imposed by reduced or dwindling financial resources. Persons unable to meet their basic needs typically reduce the amount spent on health care or avoid spending any health-related dollars.
Employment About 7.7 million older adults (18.5%) were classified as labor force participants (employed or actively seeking employment) in 2012, of which 23.6% were men and 14.4% were women. In 2012, nearly two thirds of older, self-employed workers were men. The labor force participation of older men remained fairly constant from 1900 until 2002, at which time it began increasing and has been increasing ever since. The rate in 1996 was approximately 17%. The number of older women in the labor force was steady from 1900 to the 1950s, at which time the rate was 10.8% of the total labor force. A slight decrease occurred in 1985, but it has been increasing since 2000 to over 20% now (AOA, 2012).
With the financial changes in 2008, many older men and women have continued to work past the expected retirement age of 65. Part-time work has increased past the point at which Social Security payments are received. As the age for full Social Security payments rises to 67 years or older, this trend is expected to continue. The cost of living has risen while retirement accounts have suffered losses as several major financial firms collapsed in the 2008 and 2009 financial crisis. Housing costs and equity have dropped while utility companies have raised rates in different parts of the United States. The financial outlook in 2014 looks brighter, but the recovery is still slow.
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Health status of older adults Before beginning a discussion of the health status of older adults, it is necessary to offer some words of caution: Old age is not synonymous with disease. Although selected portions of this text address disease and disability in old age by emphasizing the provision of age-appropriate nursing care of persons with various conditions, the implication is not that disease is a normal, expected outcome of aging. Clearly, risks of health problems and disability increase with age, but older adults are not necessarily incapacitated by these problems. They may have multiple, complex health problems resulting in sickness and institutionalization, but the nurse should not consider this the norm for this population.
Because of this high concentration of morbidity and frequent use of health services by certain high-risk groups of older adults, delivery systems are now being forced to more effectively manage resources. Strategies to maximize health and prevent disease in older persons are being incorporated into the emerging health care insurance plans. Incentives are prompting the development of innovative programs and services of care that improve outcomes and lower costs for healthy and chronically ill older adults. Such proactive developments hold much promise for the future care of older populations and provide opportunities to redefine gerontologic nursing practice. The notion of incorporating an expectation of wellness, even when treating those who have chronic disease and functional impairment, is one that can truly reshape the care of older adults. Accordingly, nurses are advised to remember that even older persons with disease, disability, or both may be considered healthy and well to some degree on the health–illness continuum. In fact, older adults already tend to view their personal health positively despite the presence of chronic illness, disease, and impairment.
Self-Assessed Health and Chronic Disease Noninstitutionalized older adults routinely assessed (44%) their
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own health as good or excellent. Ethnic/racial findings differ in that older African Americans rate their health as fair or poor more often than do white or Asian older adults. In financial terms, white women are twice as likely to be poor compared with white men of the same age; however, Hispanics and African American women are four times as likely to be poor when compared with those same white men (AOA, 2012).
Some older adults maintain good to excellent health without disease or disability, but many persons older than 65 have at least one chronic condition, and many have multiple conditions. The most common conditions for noninstitutionalized older adults are (1) arthritis, (2) hypertension, (3) heart disease, (4) hearing impairments, (5) cataracts, (6) orthopedic impairments, and (7) diabetes mellitus. The three leading causes of death for older persons (in order) are heart conditions, malignant neoplasms, and cerebrovascular diseases (U. S. Bureau of the Census, 2012).
Although death rates from heart disease have decreased for older adults since 1960, it remains the leading cause of death for this group. In contrast, death rates from cancer increased until 2007 and now have reached a plateau.
Functional Status The degree of functional ability is of greater concern to older adults and nurses than the incidence and prevalence of chronic disease. Functional ability is defined as the capacity to carry out the basic self-care activities that ensure overall health and well-being. Functional ability is classified in many measurement tools by activities of daily living (ADLs) such as bathing, dressing, eating, transferring, and toileting (Katz, 1963) and instrumental ADLs, which include home-management activities such as shopping, cooking, housekeeping, laundry, and handling money (Lawton & Brody, 1969). These measurement tools were identified more than 45 years ago, but they remain the most used and effective measurements available.
The use of such measurement tools or scales to determine the effect of chronic disease and normal aging on physical,
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psychological, and social function provides objective information about a person’s overall degree of health. Assessment of the impact of chronic disease and age-related decreases in functional status enables the nurse to determine needs, plan interventions, and evaluate outcomes. Chronic disease and disability may impair physical and emotional health, self-care ability, and independence. Improving the health and functional status of older adults and preventing complications of chronic disease and disability may avert the onset of physical frailty and cognitive impairment, two conditions that increase the likelihood of institutionalization.
Health Care Expenditure and Use The federal government funds the majority of health care in the United States for persons aged 65 or older. The Medicare insurance program is for people aged 65 or older, younger than 65 with certain disabilities, and any age with end-stage renal disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplantation). The different parts of Medicare include Part A (hospital insurance), Part B (medical insurance), Part C (Medicare advantage plans such as health maintenance organizations (HMOs) or preferred provider organizations [PPOs]), and Part D (Medicare prescription drug coverage) (Centers for Medicare and Medicaid Services [CMS], 2013). Some basics of these types of coverage include Part A services such as blood transfusions, home health services, hospice care, hospital stays as an inpatient, and residency in a skilled nursing facility (CMS, 2013).
The Affordable Care Act of 2010 has improved the cost of prescription drugs for more than 6.3 million seniors and people with disabilities on Medicare more than $6.1 billion since it was enacted. In 2012, nearly 3.5 million people on Medicare saved an average of more than $706 each on prescriptions (Medicare Blog, 2013). Prior to the Affordable Care Act changes to Part D, prescription drug coverage, a “donut hole” in coverage existed. This was the result of the Medicare recipient paying the first $310 toward medications and then paying 25% of the cost of the prescriptions until reaching $2800 of costs. Once this limit was attained, no benefits were applied toward the cost of prescriptions
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until $4550 was spent. Then the recipient was only responsible for about 5% of the cost of the remainder of medications for that fiscal year. From 2013 through 2020, the “donut hole” is closing with more payments being made for generic and brand-name medications each year. By 2020, the coverage gap will be closed, that is, there will be no more “donut hole,” and recipients will pay only 25% of the costs of medications until the yearly out-of-pocket spending limit is reached (Health & Human Services, 2013). For more information on the many benefits or services, go to www.medicare.gov or call 1-800-medicare (633-4227).
Implications for Health Care Delivery Although the future direction of health care is uncertain, on the basis of the demographic profile, it can confidently be surmised that nurses in a wide variety of settings and roles will be challenged to provide care to an increasingly divergent, complex group of older persons. An urgent need exists for gerontologic nurses to (1) create roles that meet the needs of the older population across the continuum of care; (2) develop models of care delivery directed at all levels of prevention, with special emphasis on primary prevention and health promotion services in community-based settings; and (3) assume positions of leadership and influence not only in institutions and settings where care is currently provided to older persons but also in the political arena. The overriding fact to remember is that the majority of problems experienced by older adults fall within the scope of nursing practice.
The following descriptions of select settings of care are given as an overview and are not intended to be inclusive. Rather, they represent the settings where the majority of older adult care is provided today (see Chapter 9 for in-depth information on health care delivery settings).
Acute Care Setting The time when the hospital was the hub of the health care delivery system has clearly passed. Political climate, market forces, technologic advances, and economics are a few of the major
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external forces that have brought about the significant changes seen in recent years in this traditional care setting. Although the shift is away from the acute care setting toward a wide array of community-based alternatives, a segment of the older adult population will continue to need care in a hospital setting. Acute conditions such as strokes, hip fractures, congestive heart failure, and infections are common in older adults and are still treated in the hospital, as are critical health problems requiring medical and surgical treatments. However, few acute care hospitals adequately manage the care of their older adult patients in terms of preventing functional decline and promoting independence, which is why the hospital setting continues to be one of the most dangerous for older persons.
Subacute care units are aimed at the high-risk hospitalized older population. Such units typically provide interventions to eliminate or shorten the expensive hospital stays that are known to be potentially hazardous for older adults. These units may be located in freestanding facilities, they may be hospital-based, or they may be part of a traditional nursing or rehabilitation facility that has upgraded the physical unit as well as the staff providing the care. The units provide such treatments as chemotherapy, wound care, intravenous therapy, and ventilator care.
Because they may be caring for a frail, high-risk older adult population, nurses in the acute care workforce of today need to recognize that they should quickly acquire the necessary knowledge and skills for delivering timely, age-appropriate care— knowledge that includes (1) an understanding of normal aging and abnormal aging; (2) strong assessment skills to detect subtle changes that indicate impending, serious problems; (3) excellent communication skills for interacting with not only well older persons but also those with delirium, dementia, and depression; (4) a keen understanding of rehabilitation principles as they apply to the maintenance and promotion of functional ability in older adults; and (5) sensitivity and patience so that older adults are treated with dignity and respect. It is imperative for acute care nurses to incorporate this knowledge and these skills into their daily practice with older adult patients because hospitalized older adults in the
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future will likely be even frailer than they are today.
Nursing Facilities As discussed, the emphasis on reducing costs in the hospital setting through more rapid discharge has led to the shift of more acutely ill residents to nursing facilities, which are traditionally referred to as nursing homes or long-term care facilities. Unfortunately, some of these facilities do not have an adequate number of qualified, professional nursing staff members to provide the complex care these residents require, or the staff does not have up-to-date knowledge and skills. In addition, the nursing staff mix may not be sufficient to meet the needs of this more acutely ill population. Finally, the physical environment and systems for delivering care in the traditional nursing facility may not be the most appropriate for meeting the needs of this more ill, more unstable population.
The segment of the population that is older than 85 and whose members have decreased functional abilities is increasing in size and represents the group typically found in nursing facilities. Their care needs, coupled with those of the more acutely ill residents who are increasingly being placed in nursing facilities, have already placed greater demands on many of these institutions. In the immediate future, these forces promise to continue putting pressure on nursing facilities. Economics, particularly as driven by health care reform, will determine the future of these institutions.
As the role of the advanced practice nurse continues to progress, opportunities for implementing various models of service delivery to nursing facility residents are growing. For example, ACAGNPs are serving as case managers and coordinators of care in this setting. PCAGNPs are also providing primary care services to residents, demonstrating the delivery of high-quality health care in nursing facilities. AGCNSs are providing staff education and training and serving as consultants to the nursing staff in assessing and planning nursing care for residents with complex health conditions. Significant gains have been made in the quality of nursing facility resident care as a result of economic and legislative reforms that have allowed nurses to practice in these innovative
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ways. Although the momentum is growing, these advanced practice nurses are challenged to continue to serve as leaders in promoting continued reform and advocating higher standards of care.
Home Care The desire and preference of most older persons to stay in their own homes for as long as possible is a major driving force influencing the need for increasing home care services. Additional factors are the recent economic, governmental, and technologic developments that have led to sicker patients going home from the hospital sooner, with needs for high-tech care and complex equipment (Gebhardt, Sims, & Bates, 2009).
Older home care patients have multiple, complex problems. In addition to possessing the knowledge and skills previously noted, home care nurses must be self-directed and capable of functioning with a multidisciplinary team that is widely dispersed throughout the community. Keen clinical judgment skills are essential because the home care nurse is often called on to make decisions about whether patients should be referred to a physician. In addition to physical and psychosocial assessments, the home care nurse is responsible for determining older patients’ functional status. Assessment of home safety factors and family dynamics, knowledge and use of community resources and environmental factors, and knowledge of the treated conditions and lifestyle implications are also the responsibility of the home care nurse. Excellent coordination and collaboration skills are necessary because it is the home care nurse who is the primary resource of older patients; home care nurses call in other resources as warranted. Finally, a genuine respect for older clients’ desires and rights to live at home is vital.
Nurses caring for homebound older adults need to become increasingly more involved in conducting community assessments that focus specifically on the aged population. The data obtained from this type of assessment may be used to plan age-specific programs and services aimed at all levels of prevention but
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specifically at refinement of health screening, health promotion, and health maintenance activities. Linking these activities to community-based programs and organizations already used by older persons is a logical place to begin.
Community-based clinics that are operated and served by nurses are becoming more prevalent as the home care movement toward keeping frail and impaired older persons at home gains momentum. The models are all capitated plans that provide Medicare benefits such as home health care, durable medical equipment, ambulance services, and outpatient therapies. They focus on health promotion and disease prevention while minimizing the need for hospitalization.
With rapidly increasing health care costs, the Independence at Home Act, which is part of the Affordable Care Act, is a demonstration project that provides primary care teams to deliver care to high-risk patients at home. If results of quality of care and cost-effectiveness ensure, this project could become a permanent program. This project ends soon. At that time, it will be reviewed for effectiveness by Congress (Landers, 2010).
Continuum of Care The shift from acute care, hospital-based organizations to fully integrated health systems has resulted in a highly competitive and intricate system of care. HMOs, PPOs, provider service organizations (PSOs), and independent practice associations (IPAs) are just a few of the current managed care systems. More health care is being delivered on an ambulatory basis, which is a trend that is well established and likely to continue. With this shift to community-based care, greater emphasis is being placed on health promotion and disease prevention so that the goals of maximum health and independence can be achieved. Gerontologic nurses must advocate for all older persons along the continuum of care, promoting interventions that result in their highest level of wellness, functionality, and independence.
Continuing efforts to restructure the health care system for the older adult population must take into account the widely ranging
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levels of care needed by this group. The health care network that evolves for this population must integrate programs into coordinated systems of care that allow for ease of movement along the continuum. As eloquently stated by Ebersole and Hess (1990), “Fragmented or superficial care is particularly dangerous to the elderly. Their functions become more and more interdependent as they age. A small disturbance is like a pebble in a still lake. The ripples extend outward in all directions.” The future is uncertain, but older adults and their caregivers are anxiously awaiting the new choices that will be presented in hopes of more effectively meeting the needs of a growing and demographically changing population.
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Impact of an aging population on gerontologic nursing Given the demographic projections presented earlier in this chapter and the development of gerontologic nursing as a specialty, the current challenge is to participate in the development of an appropriate health care delivery framework for older adults that considers their unique needs. Now is the time for all gerontologic nurses to create a new vision for education, practice, and research.
Ageism Ageism is a term that was coined by Butler in 1969 to describe the deep and profound prejudice in American society against older adults. “Ageism reflects a deep-seated uneasiness on the part of young and middle-aged—a personal revulsion and distaste for growing old, disease, disability; and fear of powerlessness, ‘uselessness,’ and death.” In a society that highly values youth and vitality, it is no surprise that ageism exists. Butler also likens ageism to bigotry: “Ageism can be seen as a process of systematic stereotyping of and discrimination against people because they are old, just as racism and sexism accomplishes this with skin color and gender. Ageism allows the younger generation to see older persons as different from themselves; thus they subtly cease to identify with their elders as human beings” (Butler & Lewis, 1977).
Butler (1993) also discusses the development of a “new ageism” in recent years caused by forces such as the economic gains of older adults, their increasing vigor and productivity, and their growing political influence. He added that, for these and even more subtle reasons, the older population is considered a threat by many who fear their ever-increasing numbers will only further drain financial resources, slow economic growth, and create intergenerational conflict. Some of the suggestions Butler proposes to fight this “new ageism” (1993) include building coalitions among advocates of all age groups; recognizing that older persons themselves are an economic market and developing ways to capitalize on it; investing
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in biomedical, behavioral, and social research as a way to eliminate many of the costly chronic conditions of old age and strengthen social networks; and fostering the development of a healthy philosophy on aging. A sense of hope, pride, confidence, security, and integrity can greatly enhance the quality of life for older adults. Persons of all ages are stakeholders in developing strategies and solutions to this end. Only then will we be able to eliminate the negative attitudes and discriminatory practices that harm us all.
Unfortunately, the nursing profession is not immune to ageism. Because generally negative attitudes about older people are held by society at large—and nurses are members of society—it follows that some nurses may have ageist views. Studies have found such attitudes among nursing recruits, which is a finding that has significant implications for practice, education, and research.
Nursing Education The need for adequately prepared nurses to care for the growing population of older adults continues to intensify. Gerontologic nursing content needs to be an intricate component throughout the nursing curricula in all nursing educational programs.
The pioneering work of Gunter and Estes (1979) defined an educational program specific to five levels of nursing: (1) nursing assistants/technicians, (2) licensed practical/vocational nurses, (3) registered nurses, (4) nurses with graduate education at the master’s degree level, and (5) nurses with graduate education at the doctoral level. Although no reports in the nursing literature describe the use of this framework for curriculum development, this work has been an invaluable reference for nurse educators and in-service education staff members in various settings because it is the first attempt to provide a conceptual framework, delineation, and definition for the specialty. Since the first publication of this work, the published literature has cited some agreement among nurse educators as to what constitutes essential gerontologic content in the baccalaureate program.
Through the Community College–Nursing Home Partnership Project, ideas about essential gerontologic nursing content in the
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associate degree program have been offered (Waters, 1991). However, despite the many recommendations that have been made, unanimous agreement as to what constituted core gerontologic nursing content at any level of nursing education was not published until 1996, with an updated text in 2002. The second edition of the NGNA Core Curriculum for Gerontological Nursing (Luggen & Meiner, 2002) set the tone for the guideline of essentials in gerontologic education. These texts were developed in conjunction with the National Gerontological Nursing Association (NGNA) and were originally conceived as a tool to prepare candidates for the ANCC Certification Examination for the Gerontologic Nurse. Gerontologic nursing educational programs in colleges, universities, and nursing schools would do well to use current texts as a content outline for development of their programs.
The American Association of Colleges of Nursing (AACN) developed a position statement in 1993, Nursing Education’s Agenda for the 21st Century, which “delineates a suggested role for nursing education in the context of Nursing’s Agenda for Health Care Reform, the goals of Healthy People 2000 & 2010, and evolutions in health care delivery.” The statement challenges nurse educators to anticipate and prepare for the changes indicated in the described documents (both of which address issues related to the care of older persons) and educate their students at the baccalaureate, master’s, and doctoral levels for this new environment. In addition, the position statement identifies the need for curricular content that prepares nurses for roles in future health care systems, which includes acute care and health promotion and maintenance in relation to chronic conditions and older adult health (AACN, 1993).
In 2008, the AACN published The Essentials of Baccalaureate Education for Professional Nursing Practice. The inclusion of geriatric nursing content and clinical experience was addressed. This document was updated in 2010, with additional information from the Hartford Institute for Geriatric Nursing, as Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults. These works have encouraged nursing educational programs at all levels to add geriatric nursing content
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with clinical experiences to enhance nurses’ responsibilities, knowledge, and skills to the practice of nursing.
In terms of program evaluation and outcomes, these documents assist in meeting the challenges set forth by evolutions in health care, nursing curricula, instructional strategies, and clinical practice models that respond to major trends in health care. Nurse educators must develop clinical practice sites for students, outside the comfort of the institutional setting, that reflect the emerging trends of community-based care with a focus on health promotion, disease prevention, and the preservation of functional abilities. Nurse faculty members with formal preparation in the field of gerontologic nursing are imperative if students are to be adequately prepared to meet the needs of the older adult population.
Assuring nursing students that they will be sufficiently prepared to practice in the future—a future that will undeniably include the care of older adults in a wide variety of settings—necessitates answering many questions concerning nursing education. The primary issue is not whether to include gerontologic nursing content but the extent of its inclusion. Until a sufficient number of nurse faculty members are prepared in the specialty, this question will remain unanswered, and students will continue to be inadequately prepared for the future of nursing.
With the introduction of the Patient Protection and Affordable Care Act in 2010, additional funding for advanced educational preparation for faculty and students in gerontologic nursing is anticipated (see http://hartfordign.org).
Nursing Practice Gerontologic nursing practice continues to evolve as new issues concerning the health care delivery system in general and the health of older adults in particular demand attention. The continuing movement of health care away from acute care hospitals, economics as a driving force in health care delivery, the changes in managed care, the expanding role of the RN, and the use of unlicensed assistive personnel (UAPs) has implications for the future of gerontologic nursing.
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Today’s older adult health care consumers are more knowledgeable and discerning and thus are better informed as they become more active decision makers about their health and well- being. Because they have greater financial resources than they have had in the past, older adult consumers are able to exercise more options in all aspects of their daily lives.
As more care shifts from hospitals to ambulatory or community- based sites, older adults are demanding more programs and services aimed at (1) health maintenance and promotion, and (2) disease and disability prevention. Gerontologic nurses will play an integral role in effecting these changes in the various emerging practice arenas. They will practice in clinics, the home care environment, and older adult living communities that range from independent homes to rehabilitation centers. Already, parish nurses are providing a wide range of services to older adults living in their service areas; this type of nursing practice is likely to continue to expand. Gerontologic nurses are also working as case managers in various practice sites, including hospitals and community-based ambulatory settings. As managed care grows, so will the opportunities associated with gerontologic nursing practice.
Some advanced practice gerontologic nurses are currently practicing independently in some areas, others work with a collaborating physician in a primary care office setting, and still others work in urgent care centers. Although practices such as these may soon become more common, gerontologic nurses must continue to educate older persons about their care options and lobby for legislation at the state and federal levels for expansion of reimbursement opportunities for advanced practice nurses who care for older adults.
In light of the increasing number of older adults requiring functional assistance to remain at home, in semi-independent living sites, or in other alternative settings, gerontologic nurses need to be vigilant as more care functions normally performed by RNs are transferred to UAPs. It is unclear whether the use of UAPs is a viable solution for providing safe, high-quality, cost-conscious care to the older population in any setting. However, with appropriate education and training, it may be possible to use UAPs in select
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situations. For this to be successful, nurses need to take a greater role in the education of such personnel within an appropriate practice framework and ensure that they meet established competency criteria. This would be an ideal role for a gerontologic nurse consultant because it would encompass advocacy, education, and a standard setting.
Additional skills required by nurses to support home care of older adults and care through community-based services include the ability to teach families and other caregivers about safe and effective caregiving techniques as well as the services and resources available. Because many of these older patients have varying degrees of functional impairment, nurses must have a comprehensive knowledge of functional assessment as well as intervention and management strategies from a rehabilitative perspective. Lifestyle counseling skills will also be needed by gerontologic nurses as the emphasis on health promotion and disease prevention grows and older persons assume more responsibility for their health. Most gerontologic nurses have had little experience with education and counseling related to preretirement planning, but they would be extremely helpful skills for assisting older adults. Gerontologic nurses could provide anticipatory guidance for the possible psychological reactions to a relevant life experience such as retirement.
Despite the aforementioned trends, the traditional medical model of care in the acute care setting and the nursing facility that focuses on the treatment of illness and disease continues to endure. Furthermore, even if older adults do have individual problems, they are likely to be intertwined with other variables. Consequently, future models of care must give greater consideration to the impact of many intervening variables on the health status of older adults. The psychological, social, and financial needs must be considered commensurate with the presenting physical needs. The ability to comprehensively assess all of these areas will require the nurse to possess refined and highly discriminating assessment skills. This will become increasingly more important as nurses take on more responsibility for the care and treatment of older adults in all settings. Equally important will
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be the development of coordination and collaboration skills, communication and human relations skills, and the ability to influence others because future practice models and sites will likely reflect a true team approach to older adult care.
Nursing Research The evolution of gerontologic nursing research can be seen in the publications and organizations that regularly review and disseminate evidence-based practice findings. In 2002, the Annual Review of Nursing Research was devoted to gerontologic nursing research (Fitzpatrick, 2002).
The leading gerontologic nursing research questions for the future should be framed within larger issues such as patient- centered outcomes, health promotion and maintenance, prevention of disease and disability, and early detection of disease and illness —all within traditional and alternative health care delivery systems. Knowledge built through research is imperative for the development of a safe and sound knowledge base that guides clinical practice as well as for the promotion of the specialty.
The incredible growth in research on aging has largely been the result of the birth of Medicare and Medicaid nearly 40 years ago. Although private funding is available for gerontologic research, it is difficult to find it. Information regarding federal funding for specific research areas may require significant research in itself. One way to shorten that search is through the use of Federal Bulletins. These bulletins list the type of research in aging that is the most likely to receive funding. Federal funding follows the type of research wanted as listed in the requests for proposals (RFPs).
Evidence-Based Practice Research in nursing practice begins with ideas that might answer hypotheses posed by questions that arise in patient care or practice. The study design, methods to be used, and type of statistical analyses to be employed are then identified. Other needs are the identification of the group of subjects who will be included or excluded from the research groups. Once the approval is obtained,
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research done, and analyses completed, the findings are disseminated to those who will implement the findings. Professional journals are one of the main sources of dissemination of information. Seminars, conferences, and webinars are used to further the dissemination process. Evidence-based practice is the result of putting the findings of the research into operational use.
When research in an area of nursing practice is sparse, other types of evidence may be supplemented. Expert opinion and case reports may be used to supplement research findings in setting up a guideline for practice (Linton & Lach, 2007).
According to the Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001), the first step is to select a topic that can originate from knowledge-focus, problem-focus, quality improvement needs, risk surveillance, financial data, benchmarking data, or recurrent clinical problems. A team or task force group is then formed to develop the protocol. This team or group needs to consist of persons who have an interest in the topic or needs so that they are viewed as stakeholders in finding the answers to the question(s). Several clearly defined questions need to be considered before the total clinical question is posed for designing the project (Linton & Lach, 2007).
In 2003, the Institute of Medicine (IOM) published a report entitled Health Professions Education: A Bridge to Quality. A mandate was given in that report. That mandate stated, “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches and informatics” (p. 3). The IOM and the Robert Wood Johnson Foundation published The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2010). One of the four major recommendations made was as follows: “Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States” (p. 3).
The Agency for Healthcare Quality and Research (AHQR, 2002) developed a list of important domains and elements for systems to rate the quality of individual articles. These are (1) study question, (2) search strategy, (3) inclusion and exclusion criteria, (4)
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interventions, (5) outcomes, (6) data extraction, (7) study quality and validity, (8) data synthesis and analysis, (9) results, (10) discussion, and (11) funding or sponsorship.
Throughout this book, boxes will appear with the title “Evidence- Based Practice.” These boxes will present research information that can be used in the development of clinical practice decision-making strategies.
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Summary Despite the slow progress that has been made, nursing care of older adults is now recognized as a legitimate specialty. The important groundwork that has been laid now serves as the basis from which the specialty will forge into the future. Gerontologic nurses at all levels of educational preparation and in all settings of care must now venture into that future with creativity, pride, and determination as they meet their professional responsibility of providing quality care to older persons everywhere. Now is the time to seize the opportunity to advance gerontologic nursing education, practice, and research for the benefit of the older adult population—a population that continues to grow.
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Key points • The growth of the nursing profession as a whole, increasing
educational opportunities, demographic changes, and changes in health care delivery systems have all influenced the development of various gerontologic nursing roles.
• Age 65 or older is widely accepted and used for reporting demographic statistics about older persons; however, turning 65 does not automatically mean a person is “old.”
• The nurse is cautioned against thinking of all older persons as similar, despite the fact that most demographic data place all persons older than 65 into a single reporting group.
• Persons 65 or older currently represent about 13.3% of the total population of the United States.
• The most rapid and dramatic growth for the older adult segment of the total U.S. population will occur between the years 2010 and 2030, when the baby boom generation reaches 65 years of age.
• About 3.6% of persons older than 65 reside in nursing facilities, but the percentage increases dramatically with advancing age.
• Gender and race are significant indicators of poverty; older women have a poverty rate twice as high as older men, and a significantly higher percentage of blacks and Hispanics are poor compared with the percentage of whites who are poor.
• Estimates indicate that the majority of persons older than 65 have one or more chronic health conditions.
• Three leading causes of death among older persons, in order of importance, are cardiovascular diseases, malignant neoplasms, and cerebrovascular diseases.
• Nurses in a wide variety of settings and roles are challenged to provide age-appropriate and age-specific care based on a comprehensive and scientific knowledge base.
• Ageism is prejudice against the old just because they are old.
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• Gerontologic nursing content should be included in all nursing education programs.
• Evidence-based practice has the potential to improve care for the older adult.
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Critical thinking exercises 1. Care of the older person today is considerably different from what it was 55 years ago (1960). Cite examples of how and why the care of older persons is different today than it was in the past.
2. When reporting for work, you note that you have been assigned to two 74-year-old women for the evening. Is it safe to assume that the care of these two women will be similar because they are the same age? Why, or why not? How would their care be enhanced or be compromised if they were treated similarly?
3. As a student, you are often assigned to care for older adults. At what point in your education do you feel care of the older adult should be included? In early classes, later in the program, or throughout your nursing program? Support your position.
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References Administration on Aging (AOA). A profile of older Americans:
2012. Washington, DC: U. S. Department of Health and Human Services, The Agency; 2012.
Agency for Healthcare Quality and Research. Systems to rate the strength of scientific evidence, summary. Report/Technology Assessment Report no. 47, pub. no. 02-E015. Bethesda, MD: U. S. Department of Health and Human Services, Agency for Healthcare Research and Quality; 2002.
American Association of Colleges of Nursing (AACN). Position statement: Nursing education’s agenda for the 21st century. Washington, DC: The Association; 1993.
American Association of Retired Persons (AARP). Images of aging in America 2004: Summary information. Washington, DC: The Association; 2004.
American Nurses Association (ANA). Nursing practice standards and guidelines. Oasis: Council on Gerontological Nursing Practice. 1991;8(4):2.
American Nurses Association (ANA). Scope and standards of gerontological nursing practice. Washington, DC: The Association; 1995.
American Nurses Association (ANA). Nursing: Scope & standards of practice. 2nd ed. Washington, DC: The Association; 2010a.
American Nurses Association (ANA). Nursing’s social policy statement: The essence of the profession. Washington, DC: The Association; 2010b.
American Nurses Association (ANA). Guide to the code of ethics for nurses: Interpretation and application. Washington, DC: The Association; 2010c.
American Nurses Association (ANA). Scope and standards of gerontological nursing practice. Washington, DC: The
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Association; 2010.
American Nurses Credentialing Center (ANCC). ANCC certification catalog: 2013. Washington, DC: The Center; 2013.
Burnside IM. Nursing and the aged: A self-care approach. 3rd ed. New York: McGraw-Hill; 1988.
Butler RN. Age-ism: Another form of bigotry. Gerontologist. 1969;9:243.
Butler RN. Why survive? Being old in America. New York: Harper & Row; 1975.
Butler RN. Dispelling ageism: The cross-cutting intervention. Generations. 1993;17(2):75.
Butler RN, Lewis MI. Aging and mental health. ed 2 St Louis: Mosby; 1977.
Centers for Medicare and Medicaid Services (CMS). Medicare basics. In: Medicare & you. Washington, DC: The Centers; 2013.
Ebersole P, Hess P. Toward healthy aging: Human needs and nursing response. 3rd ed. St Louis: Mosby; 1990.
Fitzpatrick JJ, ed. New York: Springer. Annual review of nursing research. 2002;Vol. 20.
Gebhardt MC, Sims TT, Bates TA. Enhancing geriatric content in a baccalaureate nursing program. Nursing Education Perspectives. 2009;30:245.
Gunter L, Estes C. Education for gerontic nursing. New York: Springer; 1979.
Health and Human Services (HHS). The affordable care act: Section by section (2003). Retrieved from: http://www.hhs.gov/healthcare/rights/law/index.html. Accessed September 25, 2013.
Institute of Medicine (IOM). Committee on Health Professions Education Summit. Health professions education: A bridge to quality. Washington, DC: National Academies Press; 2003.
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Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: Leading change, advancing health (Report Brief). Washington, DC: National Academies Press; 2010.
Katz L, et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA: The Journal of the American Medical Association. 1963;185:94.
Landers SJ. Why health care is going home. New England Journal of Medicine. 2010;363:1690.
Lawton MP, Brody EM. Assessment of older people: Self- maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179.
Linton AD, Lach HW. Matteson & McConnell’s gerontological nursing: Concepts and practice. 3rd ed. St. Louis: Saunders; 2007.
Luggen AS, Meiner SE. NGNA core curriculum for gerontological nursing. 2nd ed. St. Louis: Mosby; 2002.
The Medicare Blog. Retrieved from 2013. www.blog.medicare.gov/?s=prescription+savings Accessed on July 8, 2014.
Titler MG, Kleiber C, Steelman VJ, et al. The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America. 2001;13(4):497.
U. S. Bureau of the Census. Sixty-five plus in the United States: 2012, Statistical Brief. Washington, DC: Economics and Statistics Administration, U. S. Department of Commerce; 2012.
Waters V, ed. Teaching gerontology: The curriculum imperative. New York: National League for Nursing Press; 1991.
* Previous author: Annette G. Lueckenotte, MS, RN, BC, GNP, GCNS; Revisions by: Sue E.
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Meiner, EdD, APRN, BC, GNP.
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C H A P T E R 2
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Theories of aging Sue E. Meiner, EdD, APRN, BC, GNP
Learning objectives
On completion of this chapter, the reader will be able to: 1. Define aging from biologic, sociologic, and psychologic frameworks.
2. Analyze the prominent biologic, sociologic, and psychologic theories of aging.
3. Discuss the rationale for using an eclectic approach in the development of aging theories.
4. Develop nursing interventions based on the psychosocial issues and biologic changes associated with older adulthood.
5. Discuss several nursing implications for each of the major biologic, sociologic, and psychologic theories of aging.
http://evolve.elsevier.com/Meiner/gerontologic
Theories of aging have been debated since the time of the ancient Greeks. In the twelfth century, thoughts were centered on predetermination and an unalterable plan for life and death. The philosopher Maimonides thought that precautions and careful living might prolong life. In the late 1400s, Leonardo da Vinci attempted to explain aging as physiologic changes while studying the structure of the human body. Studies were few until the late 1900s when world populations began to have increasing numbers of older adults. Scholars have sought to embrace a theory that can explain the entire aging phenomenon. However, many scholars have concluded that no one definition or theory explains all aspects of aging; rather, scientists have found that several theories may be combined to explain various aspects of the complex phenomenon
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we call aging.
Theories function to help make sense of a particular phenomenon; they provide a sense of order and give a perspective from which to view the facts. Theories provide a springboard for discussion and research. Some theories are presented in this chapter because of their historical value; for the most part, they have been abandoned because of lack of empiric evidence. Other theories are the result of ongoing advances made in biotechnology and, as such, provide glimpses into our future.
Human aging is influenced by a composite of biologic, psychologic, sociologic, functional, and spiritual factors. Aging may be viewed as a continuum of events that occur from conception to death (Ignatavicius & Workman, 2013). Biologic, sociologic, and psychologic theories of aging attempt to explain and explore the various dimensions of aging. This chapter explores the prominent theories of aging as a guide for developing a holistic gerontologic nursing theory for practice application. No single gerontologic nursing theory has been accepted by this specialty, which requires nurses to use an eclectic approach from other disciplines as the basis of clinical decision making (Comfort, 1970) (Box 2-1).
Box 2-1
Theories of aging Biologic Concerned with answering basic questions regarding physiologic processes that occur in all living organisms over time (Hayflick, 1996).
Sociologic Focused on the roles and relationships within which individuals engage in later life (Hogstel, 1995).
Psychologic
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Influenced by both biology and sociology; address how a person responds to the tasks of his or her age.
Moral/spiritual Examine how an individual seeks to explain and validate his or her existence (Edelman & Mandle, 2003).
By incorporating a holistic approach to the care of older adults, nurses can view this ever-increasing portion of the population more comprehensively. Interactions between gerontologic nurses and older adults are not limited to specific diseases or physiologic processes, absolute developmental tasks, or psychosocial changes. Nurses have the ability to synthesize various aspects of the different aging theories, and they visualize older adults interfacing with their total environment, including physical, mental/emotional, social, and spiritual aspects. Therefore, an eclectic approach provides an excellent foundation as nurses plan high-quality care for older adults.
Theories of aging attempt to explain this phenomenon of aging as it occurs over the life span, which is thought to be a maximum of approximately 120 years. Several basic assumptions and concepts have been accepted over the years as guiding research and clinical practice related to aging (Hornsby, 2010). Human aging is viewed as a total process that begins at conception. Because individuals have unique genetic, social, psychologic, and economic factors intertwined in their lives, the course of aging varies from individual to individual. Senescence, defined as a change in the behavior of an organism with age, leading to a decreased power of survival and adjustment, also occurs. The recognition of the universal truths is what we attempt to discover through the theories of aging.
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Biologic theories of aging Biologic theories are concerned with answering basic questions regarding the physiologic processes that occur in all living organisms as they age chronologically. These age-related changes occur independent of any external or pathologic influence. The primary question being addressed relates to the factors that trigger the actual aging process in organisms. These theories generally view aging as occurring at molecular, cellular, and even systemic levels. In addition, biologic theories are not meant to be exclusionary. Theories may be combined to explain phenomena (Hayflick, 1996, 2007).
The foci of biologic theories include explanations of the following: (1) deleterious effects leading to decreasing function of the organism, (2) gradually occurring age-related changes that progress over time, and (3) intrinsic changes that may affect all members of a species because of chronologic age. The decreasing function of an organism may lead to a complete failure of either an organ or an entire system (Hayflick, 1996, 2004, 2007). In addition, according to these theories, all organs in any one organism do not age at the same rate, and any single organ does not necessarily age at the same rate in different individuals of the same species (Warner, 2004).
The biologic theories can be subdivided into two main divisions: stochastic and nonstochastic. Stochastic theories explain aging as events that occur randomly and accumulate over time, whereas nonstochastic theories view aging as certain predetermined, timed phenomena (Box 2-2).
Box 2-2
Biologic theories of aging
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Stochastic theories Error Theory The error theory is based on the idea that errors can occur in the transcription of the synthesis of deoxyribonucleic acid (DNA). These errors are perpetuated and eventually lead to systems that do not function at the optimal level. An organism’s aging and death are attributable to these events (Sonneborn, 1979).
Free Radical Theory Free radicals are by products of metabolism. When these byproducts accumulate, they damage the cell membrane, which decreases its efficiency. The body produces antioxidants that scavenge the free radicals (Hayflick, 1996).
Cross-Linkage Theory With age, according to this theory, some proteins in the body become cross-linked. This does not allow for normal metabolic activities, and waste products accumulate in the cells. The end result is that tissues do not function at optimal efficiency (Hayflick, 1996).
Wear and Tear Theory The wear and tear theory equates humans with machines. It hypothesizes that aging is the result of continuous use of the body over time.
Nonstochastic theories
Programmed Theory Hayflick and Moorehead demonstrated that normal cells divide a limited number of times and they hypothesized that life expectancy was preprogrammed (Hayflick, 1996).
Immunity Theory As a result of aging, changes occur in the immune system, specifically in T lymphocytes. These changes leave the individual more vulnerable to disease (Phipps et al., 2003).
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Stochastic Theories Error Theory As a cell ages, various changes occur naturally in its deoxyribonucleic acid (DNA) and ribonucleic acid (RNA), the building blocks of the cell. DNA, found in the nucleus of the cell, contains the fundamental genetic code and forms the genes on all 46 human chromosomes (Black & Hawks, 2005).
In 1963, Orgel proposed the Error Theory, sometimes called the Error Catastrophe Theory. This theory’s hypothesis is based on the idea that errors may occur in the transcription in any step of the protein synthesis of DNA, and this eventually leads to either the aging or the actual death of a cell. The error would cause the reproduction of an enzyme or protein that was not an exact copy of the original. The next transcription would again contain an error. As the effect continued through several generations of proteins, the end-product would not even resemble the original cell and its functional ability would be diminished (Sonneborn, 1979).
In recent years, the theory has not been supported by research. Although changes do occur in the activity of various enzymes with aging, studies have not found that all aged cells contain altered or misspecified proteins, nor is aging automatically or necessarily accelerated if misspecified proteins or enzymes are introduced to a cell (Hayflick, 1996, 2004; Schneider, 1992; Weinert & Timiras, 2003).
Radical Theory Free radicals are byproducts of fundamental metabolic activities within the body. Free radical production may increase as a result of environmental pollutants such as ozone, pesticides, and radiation. Normally, they are neutralized by enzymatic activity or natural antioxidants. However, if they are not neutralized, they may attach themselves to other molecules. These highly reactive free radicals react with the molecules in cell membranes, in particular, cell membranes of unsaturated lipids such as mitochondria, lysosomes, and nuclear membranes. This action monopolizes the receptor sites on the membrane, thereby inhibiting the interaction with other substances that normally use this site; this chemical reaction is
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called lipid peroxidation. Therefore, the mitochondria, for example, can no longer function as efficiently, and their cell membranes may become damaged, which results in increased permeability. If excessive fluid is either lost or gained, the internal homeostasis is disrupted, and cell death may result.
Other deleterious results are related to free radical molecules in the body. Although these molecules do not contain DNA themselves, they may cause mutations in the DNA–RNA transcription, thereby producing mutations of the original protein. In nervous and muscle tissue, to which free radicals have a high affinity, a substance called lipofuscin has been found and is thought to be indicative of chronologic age. Strong support for this theory has continued over the past 35 + years (Jang & Van Remmen, 2009).
Lipofuscin, a lipid- and protein-enriched pigmented material, has been found to accumulate in older adults’ tissues and is commonly referred to as “age spots.” As the lipofuscin’s presence increases, healthy tissue is slowly deprived of oxygen and nutrient supply. Further degeneration of surrounding tissue eventually leads to actual death of the tissue. The body does have naturally occurring antioxidants, or protective mechanisms. Vitamins C and E are two of these substances that can inhibit the functioning of the free radicals or possibly decrease their production in the body.
Harman (1956) was the first to suggest that the administration of chemicals terminating the propagation of free radicals would extend the life span or delay the aging process. Animal research demonstrated that administration of antioxidants did increase the average length of life, possibly because of the delayed appearance of diseases that may have eventually killed the animals studied. It appears that the administration of antioxidants postpones the appearance of diseases such as cardiovascular disease and cancer, two of the most common causes of death. Antioxidants also appear to have an effect on the decline of the immune system and on degenerative neurologic diseases, both of which affect morbidity and mortality (Hayflick, 1996; Weinert & Timiras, 2003; Yu, 1993, 1998).
Cross-Linkage Theory
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The cross-linkage theory of aging hypothesizes that with age, some proteins become increasingly cross-linked or enmeshed and may impede metabolic processes by obstructing the passage of nutrients and wastes between the intracellular and extracellular compartments. According to this theory, normally separated molecular structures are bound together through chemical reactions.
This primarily involves collagen, which is a relatively inert long- chain macromolecule produced by fibroblasts. As new fibers are created, they become enmeshed with old fibers and form an actual chemical cross-link. The end result of this cross-linkage process is an increase in the density of the collagen molecule but a decrease in its capacity to both transport nutrients to the cells and remove waste products from the cells. Eventually, this results in a decrease in the structure’s function. An example of this would be the changes associated with aging skin. The skin of a baby is soft and pliable, whereas aging skin loses much of its suppleness and elasticity. This aging process is similar to the process of tanning leather, which purposefully creates cross-links (Bjorkstein, 1976; Hayflick, 1996, 2004).
Cross-linkage agents have been found in unsaturated fats; in polyvalent metal ions such as aluminum, zinc, and magnesium; and in association with excessive radiation exposure. Many of the medications ingested by the older population (such as antacids and coagulants) contain aluminum, as does baking powder, a common cooking ingredient. Some research supports a combination of exercise and dietary restrictions in helping to inhibit the cross- linkage process as well as the use of vitamin C prophylactically as an antioxidant agent (Bjorkstein, 1976).
One researcher, Cerani, has shown that blood glucose reacts with bodily proteins to form cross-links. He has found that the crystallin of the lens of the eye, membranes of the kidney, and blood vessels are especially susceptible to cross-linking under the conditions of increased glucose. Cerani suggests increased levels of blood glucose cause increased amounts of cross-linking, which accelerate lens, kidney, and blood vessel diseases (Schneider, 1992). This research was more recently updated by Eyetsemitan, who identified the
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stiffening of blood vessels with an increase in thickness caused by the cross-linking of protein and glucose. The product of this effect is identified as AGEs, or advanced glycation end-products (Eyetsemitan, 2007).
Cross-linkage theory proposes that as a person ages and the immune system becomes less efficient, the body’s defense mechanism cannot remove the cross-linking agent before it becomes securely established. Cross-linkage has been proposed as a primary cause of arteriosclerosis, decrease in the efficiency of the immune system, and the loss of elasticity often seen in older adult skin.
Wear and Tear Theory This theory proposed that cells wear out over time because of continued use. When this theory was first proposed in 1882 by Weisman, death was seen as a result of tissues being worn out because they could not rejuvenate themselves in an endless manner (Hayflick & Moorehead, 1961). Essentially, the theory reflects a belief that organs and tissues have a preprogrammed amount of available energy and wear out when the allotted energy is expended. Eventually, this leads to the death of the entire organism.
According to this theory, aging is almost a preprogrammed process—a process thought to be vulnerable to stress or to an accumulation of injuries or trauma, which may actually accelerate it. “Death,” stated Weisman, “occurs because a worn out tissue cannot forever renew itself” (Hayflick, 1996; Holliday, 2004; Weinert & Timiras, 2003).
According to Carnes, Staats, and Sonntag (2008), striated muscle, heart muscle, muscle fibers, nerve cells, and the brain are irreplaceable when destroyed by wear and tear. Mechanical injury, chemical injury, or both may lead to similar permanent changes.
Proponents of this theory cite microscopic signs of wear and tear that have been found in striated and smooth muscle tissues and in nerve cells. Others question this theory in light of research demonstrating increased functional abilities in individuals who exercise daily. This effect occurs even in persons with chronic
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limiting states such as rheumatoid arthritis. If exercise has been found to increase a person’s level of functioning rather than decrease it, critics challenge, how can the wear and tear hypothesis be correct? This theory was developed during the Industrial Revolution, when people were attempting to explain and make sense of events in their world. These people were trying to equate humans with the marvelous machines they were creating. It eventually became clear just how different humans were from these machines.
Nonstochastic Theories Programmed Theory or Hayflick Limit Theory One of the first proposed biologic theories is based on a study completed in 1961 by Hayflick and Moorehead. This study included an experiment on fetal fibroblastic cells and their reproductive capabilities. The results of this landmark study changed the way scientists viewed the biologic aging process.
Hayflick and Moorehead’s study showed that functional changes do occur within cells and are responsible for the aging of the cells and the organism. The study further supported the hypothesis that a cumulative effect of improper functioning of cells and eventual loss of cells in organs and tissues are therefore responsible for the aging phenomenon. This study contradicted earlier studies by Carrel and Ebeling, in which chick embryo cells were kept alive indefinitely in a laboratory; the conclusion from this 1912 experiment was that cells do not wear out but continue to function normally forever. An interesting aspect of the 1961 study was that freezing was found to halt the biologic cellular clock (Hayflick & Moorehead, 1961).
This 1961 study found that unlimited cell division did not occur; the immortality of individual cells was found to be more an abnormal occurrence than a normal one. Therefore, this study seemed to support the Hayflick Limit Theory. Life expectancy was generally seen as preprogrammed, within a species-specific range; this biologic clock for humans was estimated at 110 to 120 years (Gerhard & Cristofalo, 1992; Hayflick, 1996). On the basis of the
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conclusions of this experiment, the Hayflick Limit Theory is sometimes called the “Biologic Clock Theory,” “Cellular Aging Theory,” or “Genetic Theory.”
Immunity Theory The immune system is a network of specialized cells, tissues, and organs that provide the body with protection against invading organisms. Its primary role is to differentiate self from non-self, thereby protecting the organism from attack by pathogens. It has been found that as a person ages, the immune system functions less effectively. The term immunosenescence has been given to this age- related decrease in function.
Essential components of the immune system are T lymphocytes, which are responsible for cell-mediated immunity, and B lymphocytes, the antibodies responsible for humoral immunity. Both T and B lymphocytes may respond to an invasion of an organism, although one may provide more protection than the other in certain situations. The changes that occur with aging are most apparent in T lymphocytes, although changes also occur in the functioning capabilities of B lymphocytes. Accompanying these changes is a decrease in the body’s defense against foreign pathogens, and this manifests itself as an increased incidence of infectious diseases and an increase in the production of autoantibodies, which lead to a propensity to develop autoimmune- related diseases (De la Fuente, 2008; Hayflick, 1996; Weinert & Timiras, 2003) (Box 2-3).
Box 2-3
Changes in cell-mediated immune function as a result of aging • Increase in autoantibodies as a result of altered immune system
regulation: This predisposes an individual to autoimmune
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diseases such as systemic lupus erythematosus and rheumatoid arthritis.
• Low rate of T-lymphocyte proliferation in response to a stimulus: This causes older adults to respond more slowly to allergic stimulants.
• Reduced response to foreign materials, resulting in an increased number of infections: This is a result of a decrease in cytotoxic or killer T cells.
• Generalized T-lymphocyte dysfunctions, which reduce the response to certain viral antigens, allografts, and tumor cells: This results in an increased incidence of cancer in older adults.
The changes in the immune system cannot be explained by an exact cause-and-effect relationship, but they do seem to increase with advancing age. These changes include a decrease in humoral immune response, often predisposing older adults to (1) decreased resistance to a tumor cell challenge and the development of cancer, (2) decreased ability to initiate the immune process and mobilize the body’s defenses against aggressively attacking pathogens, and (3) heightened production of autoantigens, often leading to an increase in autoimmune-related diseases.
Immunodeficient conditions such as human immunodeficiency virus (HIV) infection and immune suppression in organ transplant recipients have demonstrated a relationship between immunocompetence and cancer development. HIV infection has been associated with several forms of cancer such as Kaposi sarcoma. Recipients of organ transplants are 80 times more likely to develop cancer compared with the rest of the population (Black & Hawks, 2005).
Emerging Theories Neuroendocrine Control Theory or Pacemaker Theory The neuroendocrine theory examines the interrelated role of the neurologic and endocrine systems over the life span of an individual (Box 2-4). The neuroendocrine system regulates and controls many important metabolic activities. It has been observed
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that a decline, or even a cessation, occurs in many of the components of the neuroendocrine system over the life span. The reproductive system, and its changes over the life of an individual, provides an interesting model for the functional capability of the neuroendocrine system.
Box 2-4
Emerging theories of aging Neuroendocrine control or pacemaker theory The neuroendocrine system controls many essential activities with regard to growth and development. Scientists are studying the roles played by the hypothalamus and the hormones DHEA (dehydroepiandrosterone) and melatonin in the aging process (Guardiola-Lemaitre, 1997; Hayflick, 1996).
Metabolic theory of aging/caloric restriction The role of metabolism in the aging process is being investigated (Hayflick, 1996).
Research on aging related to deoxyribonucleic acid (DNA) Two developments are occurring at this time in relationship to DNA and the aging process. First, as scientists continue to map the human genome, they are identifying certain genes that play a role in the aging process (Schneider, 1992). Second is the discovery of telomeres, located at the ends of chromosomes, which may function as the cells’ biologic clocks (Hayflick, 1996).
Research has shown complex interactions take place between the endocrine and nervous systems. It appears that the female reproductive system is governed not by the ovaries or the pituitary gland but by the hypothalamus. Men do not experience a reproductive system–related event such as menopause, although
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they do demonstrate a decline in fertility. The mechanisms that trigger this decline may offer a template for understanding the phenomenon of aging (Hayflick, 1996; Weinert & Timiras, 2003).
Another hormone that has been receiving attention is dehydroepiandrosterone (DHEA). This hormone, secreted by the adrenal glands, diminishes over the lifetime of an individual. Administration of this hormone to laboratory mice showed that it increased longevity, bolstered immunity, and made the animals appear younger. These mice also ate less, so some question whether DHEA-fed mice exhibit the effect of calorie restriction (Cupp, 1997; Guardiola-Lemaitre, 1997; Hayflick, 1996, 2004).
Melatonin is a hormone being investigated for its role as a biologic clock. Melatonin is produced by the pineal gland, the function of which was a mystery until recently. Melatonin has been found to be a regulator of biologic rhythms and a powerful antioxidant that may enhance immune function. The level of melatonin production in the body declines dramatically from just after puberty until old age.
The belief that melatonin has a role in aging comes not only from its effect on the immune system and its antioxidant capability but also from studies on rodents that demonstrated an increased life span when melatonin was administered. These studies also found that rodents fed supplementary melatonin restricted their calorie intake. More research on the safety and efficacy of melatonin needs to be performed. However, in the United States, melatonin is already marketed as a dietary supplement, so little financial incentive exists for conducting research. In Europe, melatonin is considered a neurohormone, so more financial gain is possible in determining its role in the aging process. At this time, no individual should take melatonin without his or her primary health care provider’s knowledge (Guardiola-Lemaitre, 1997; Hayflick, 1996).
Metabolic Theory of Aging or Caloric Restriction This theory proposes that all organisms have a finite metabolic lifetime and that organisms with a higher metabolic rate have a shorter life span. Evidence for this theory comes from research
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showing that certain fish, when the water temperature is lowered, live longer than their warm-water counterparts. Extensive experimentation on the effects of caloric restriction on rodents has demonstrated that caloric restriction increases the life span and delays the onset of age-dependent diseases (Hayflick, 1996; Schneider, 1992).
DNA-Related Research Two major developments are occurring at the time of this writing in relation to our understanding of the role DNA plays in the aging process. The first involves the process of mapping, or identification, of the human genome, with the hope that this task will be accomplished early in the twenty-first century. It is believed that as many as 200 genes may be responsible for controlling aging in humans (Schneider, 1992). Investigation into the “aging” genes in select body systems such as the immune system may lead to greater understanding of the process of aging.
The second development that has occurred involves the discovery of telomeres, which are the regions at the ends of chromosomes that may function as biologic clocks (Figure 2-1). It has been found that with each cell division that takes place in cultured, normal human cells, part of the telomere is lost. This discovery explains why normal cells have a limited capacity to divide. Abnormal cells such as cancer cells seem to have found a way to keep from shortening at each division, which confers on them some sort of “immortality.” These “abnormal” cells produce an enzyme called telomerase. This enzyme actually adds telomere sequences to the ends of each chromosome at each cell division. The immediate benefit of this discovery was the development of tests to detect telomerase, thereby identifying abnormal cells. Research is proceeding to develop substances that would inhibit the production of telomerase in an effort to prevent cancer cells from multiplying (Gupta & Han, 1996; Hayflick, 1996; Keys & Marble, 1998; Weinert & Timiras, 2003).
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FIGURE 2-1 A deoxyribonucleic acid (DNA) model against a background of chromosomes. The light ends on the chromosomes
are telomeres. (Used with permission from The University of Texas Southwestern Medical Center at Dallas; Office of News and Publications; 5323 Harry Hines
Boulevard; Dallas, TX 75235.)
Implications for Nursing When interacting with the older population, caregivers must relate the key concepts of the biologic theories to the care being provided. Although these theories do not provide the answer, they certainly can explain some of the changes seen in the aging individual. Aging and disease do not necessarily go hand in hand, and the nurse caring for older adults needs to have a clear understanding of the
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difference between age-related changes and those that may actually be pathologic. Nurses must remember that scientists are still in the process of discovering what “normal” aging is.
Among biologic theories of aging, two concepts have gained wide acceptance: (1) The limited replicative capacity of certain cells causes overexpression of damaged genes and oxidative damage to cells; and (2) free radicals may cause damage to cells over time. On the basis of these concepts, gerontologic nurses can promote the health of older adult patients in a number of ways. Providing assistance with smoking cessation would be one example of health promotion. Cigarette smoking causes increased cell turnover in the oral cavity, bronchial tree, and alveoli. Smoking also introduces carcinogens into the body, which may result in an increased rate of cell damage that can lead to cancer. Using the same principles, nurses can develop a health promotional activity for education regarding sun exposure. Excessive exposure to ultraviolet light is another example of a substance causing rapid turnover of cells, which may lead to mutations and ultimately malignancies. In an effort to reduce free radical damage, nurses can also advise patients to ingest a varied, nutritious diet using the food pyramid as a guide and suggest supplementation with antioxidants such as vitamins C and E (Goldstein, 1993). Physical activity continues to play an important role in the lives of older adults. Daily routines need to incorporate opportunities that capitalize on existing abilities, strengthen muscles, and prevent further atrophy of muscles from disuse. Encouraging older adults to participate in activities may prove a challenge to nurses interacting with these patients (see the Evidence-Based Practice box) (Carter, 2003).
Evidence-based Practice Sample/Setting A nonrandomized study of 184 male veterans, older than 65, and not living in an institution.
Methods
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The Interaction Model of Client Health Behavior was administered. The independent variables were age, education, race, marital status, children, siblings, income, spiritual well- being, functional status, motivation, health conceptions, and loneliness. The dependent variable was Schwirian’s (1992) active composure, conceptualized as activities producing rest, relaxation, and anxiety and stress reduction. A multiple regression model explained 49% of the variance in active composure. Race, income, the religious aspect of spiritual well- being, instrumental activities of daily living (IADLs), and loneliness were significant predictors.
Findings The findings of this study demonstrated that higher levels of active composure occurred in nonwhite individuals who perceived that they had adequate incomes and who had higher religious aspects of spiritual well-being, greater independence in IADLs, and lower levels of loneliness. The ability to perform IADLs in older adulthood appears to be a better predictor of active composure than age alone. It is possible that health behaviors are more socially defined and less influenced by education than other forms of behavior. Areas that did not correlate with the findings were age, education, marital status, number of children and siblings, spiritual well-being, motivation, and health conception.
Implications Nurses are challenged to promote the health of an older, community-living population with chronic illnesses. As the cohort of older adults increases, a proactive approach to health through appropriate health promotion strategies can be an effective means of reducing health care costs and supporting community-living status. From Carter, K.F. (2003). Behaviors of older men living in the community: correlates producing active composure. Journal of Gerontological Nursing, 29(10),37.
Performing activities of daily living (ADLs) requires the functional use of extremities. Daily exercises that enhance upper
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arm strength and hand dexterity contribute to older adults’ ability to successfully perform dressing and grooming activities. Even chair-based activities such as deep breathing increase the oxygen flow to the brain, thereby promoting clear mental cognition, minimizing dizziness, and increasing stamina with activity.
Encouraging older adults to participate in daily walking, even on a limited basis, facilitates peripheral circulation and promotes the development of collateral circulation. Walking also helps with weight control, which often becomes a problem in older adults. Additional benefits of walking include (1) replacement of fat with muscle tissue, (2) prevention of muscle atrophy, and (3) a generalized increase in the person’s sense of well-being.
The health care delivery system is beginning to focus on disease prevention and health promotion, and older adults must be included in this focus. Stereotypical views that older adults are “too old to learn new things” must be replaced by factual knowledge about the cognitive abilities of older adults. It is necessary for patient teaching to stress the concept that certain conditions or diseases are not inevitable just because of advancing years. A high level of wellness is needed to help minimize the potential damage caused by disease in later years. Although aging brings with it a decrease in the normal functioning of the immune system, older adults should not suffer needlessly from infections or disease. Encouraging preventive measures such as annual influenza vaccination or a one-time inoculation with the pneumococcal vaccine is essential to providing a high-quality life experience for the older population.
Other applications of biologic theories include the recognition that stress, both physical and psychologic, has an impact on the aging process. In planning interventions, nurses should pay attention to the various stress factors in an older person’s life. Activities to minimize stress and to promote healthy coping mechanisms must be included in the patient teaching plan for older adults.
Teaching the basic techniques of relaxation, guided imagery, visualization, distraction, and music therapy facilitate a sense of control over potential stress-producing situations. Additional
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options, including heat or cold application, therapeutic touch, and massage therapy, could be explored. Being aware of individual cultural preferences and sharing these with other health care professionals will further promote positive interactions with older adults in all settings.
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Sociologic theories of aging Sociologic theories focus on changing roles and relationships (Box 2-5). In some respects, sociologic theories relate to various social adaptations in the lives of older adults. One of the easiest ways to view the sociologic theories is within the context of the societal values at the time in which they were developed. The early research was carried out largely on institutionalized and ill older persons, which skewed the information collected. Contemporary research is being conducted in a variety of more naturalistic environments, reflecting more accurately the diversity of the aging population.
Box 2-5
Sociologic theories of aging Disengagement theory As individuals age, they withdraw from society, and society encourages this withdrawal (Cumming & Henry, 1961).
Activity/developmental task theory Individuals need to remain active to age successfully. Activity is necessary to maintain life satisfaction and a positive self-concept (Havighurst, Neugarten, & Tobin,1963).
Continuity theory Individuals will respond to aging in the same way they have responded to previous life events. The same habits, commitments, preferences, and other personality characteristics developed during adulthood are maintained in older adulthood (Havighurst, Neugarten, & Tobin, 1963).
Age stratification theory Society consists of groups of cohorts that age collectively. The
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people and roles in these cohorts change and influence each other, as does society at large. Therefore a high degree of interdependence exists between older adults and society (Riley, 1985).
Person–environment fit theory Each individual has personal competencies that assist the person in dealing with the environment. These competencies may change with aging, thus affecting the older person’s ability to interrelate with the environment (Lawton, 1982).
During the 1960s, sociologists focused on the losses of old age and the manner in which individuals adjusted to these losses in the context of their roles and reference groups. A decade later, society began to have a broader view of aging as reflected in the aging theories proposed during this period. These theories focused on more global, societal, and structural factors that influenced the lives of aging persons. The 1980s and 1990s brought other changes into focus, as sociologists began to explore interrelationships, especially those between older adults and the physical, political, environmental, and even socioeconomic milieu in which they lived.
Disengagement Theory When the disengagement theory was introduced by Cumming and Henry in 1961, it sparked immediate controversy. These two theorists viewed aging as a developmental task in and of itself, with its own norms and appropriate patterns of behavior. The identified appropriate patterns of behavior were conceptualized as a mutual agreement between older adults and society on a reciprocal withdrawal. Individuals would change from being centered on society and interacting in the community to being self-centered persons withdrawing from society, by virtue of becoming “old.” Social equilibrium would be the end result (Cumming & Henry, 1961).
The idea that older adults preferred to withdraw from society and to voluntarily decrease their interactions with others was not readily accepted by the general public, much less the older persons
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themselves. Although the theory oversimplified the aging process, its lasting benefit relates to the controversy it created. The theory itself is no longer supported, but the discussion and the research stemming from its premise continue today.
Activity Theory or Developmental Task Theory Whereas one group of theorists proposed that older adults need to disengage from society, other sociologists proposed that people need to stay active if they are to age successfully. In 1953, Havighurst and Albrecht first proposed the idea that aging successfully is related to staying active. It was not until 10 years later that the phrase “activity theory” was coined by Havighurst and his associates (Havighurst, Neugarten, & Tobin, 1963).
This theory sees activity as necessary to maintain a person’s life satisfaction and positive self-concept. By remaining active, the older person stays young and lively and does not withdraw from society because of an age parameter. Essentially, the person actively participates in a continuous struggle to remain middle-aged. This theory is based on three assumptions: (1) It is better to be active than inactive; (2) it is better to be happy than unhappy; and (3) an older individual is the best judge of his or her own success in achieving the first two assumptions (Havighurst, 1972). Within the context of this theory, activity may be viewed broadly as physical or intellectual. Therefore, even with illness or advancing age, the older person can remain “active” and achieve a sense of life satisfaction (Havighurst et al., 1963).
Continuity Theory The continuity theory dispels the premises of both the disengagement and activity theories. According to this theory, being active, trying to maintain a sense of being middle-aged, or willingly withdrawing from society does not necessarily bring happiness. Instead, the continuity theory proposes that how a person has been throughout life is how that person will continue to
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be through the remainder of life (Havighurst et al., 1963).
Old age is not viewed as a terminal or final part of life separated from the rest of a person’s life. According to this theory, the latter part of life is a continuation of the earlier part and therefore an integral component of the entire life cycle. When viewed from this perspective, the theory can be seen as a developmental theory. Simply stated, the theory proposes that as people age, they try to maintain or continue previous habits, preferences, commitments, values, beliefs, and the factors that have contributed to their personalities (Havighurst et al., 1963).
Age Stratification Theory Beginning in the 1970s, theorists on aging began to focus more broadly on societal and structural factors that influenced how the older population was being viewed. The age stratification theory is only one example of a theory addressing societal values. The key societal issue being addressed in this theory is the concept of interdependence between the aging person and society at large (Riley, Johnson, & Foner, 1972).
This theory views the aging person as an individual element of society and also as a member, with peers, interacting in a social process. The theory attempts to explain the interdependence between older adults and society and how they constantly influence each other in a variety of ways.
Riley (1985) identifies the five major concepts of this theory: (1) Each individual progresses through society in groups of cohorts that are collectively aging socially, biologically, and psychologically; (2) new cohorts are continually being born, and each of them experiences their own unique sense of history; (3) society itself can be divided into various strata, according to the parameters of age and roles; (4) not only are people and roles within every stratum continuously changing but so is society at large; and (5) the interaction between individual aging people and the entire society is not stagnant but remains dynamic.
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Person–Environment Fit Theory Another aging theory relates to the individual’s personal competence within the environment in which he or she interacts. This theory, proposed by Lawton (1982), examines the concept of interrelationships among the competencies of a group of persons, older adults, and their society or environment.
All people, including older persons, have certain personal competencies that help mold and shape them throughout life. Lawton (1982) identified these personal competencies as including ego strength, motor skills, individual biologic health, and cognitive and sensory–perceptual capacities. All these help people deal with the environment in which they live.
As a person ages, changes or even decreases may occur in some of these personal competencies. These changes influence the individual’s abilities to interrelate with the environment. If a person develops one or more chronic diseases such as rheumatoid arthritis or cardiovascular disease, then competencies may be impaired and the level of interrelatedness may be limited.
The theory further proposes that as a person ages, the environment becomes more threatening and he or she may feel incompetent dealing with it. In a society constantly making rapid technologic advances, this theory helps explain why an older person might feel inadequate and may retreat from society.
Implications for Nursing It is important to remember that all older adults cannot be grouped collectively as just one segment of the population. Many differences exist within the aged population. The young-old (ages 65 to 74), the middle-old (ages 75 to 84), the old-old (more than 85), and the elite- old (more than 100 years old) are four distinct cohort groups, and the individuals within each of these cohort groups have their own history. Variation exists among even the same cohort group based on culture, life experiences, gender, and health and family status. Nurses need to be aware of the fact that whatever similarities exist among the individuals of a cohort group, they are still individuals.
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Older adults are not a homogeneous sociologic group, and care needs to be taken not to treat them as if they were.
Older adults respond to current experiences on the basis of their past life encounters, beliefs, and expectations. If their “typical” reaction to stress, challenges, or fear is to disengage from interactions, then current situations often produce the same responses. Because older adults are individuals, their responses must be respected. However, it is within the nurse’s scope of practice to identify maladaptive responses and intervene to protect the integrity of the person.
Withdrawal in older adults may be a manifestation of a deeper problem such as depression. Using assessment skills and specific tools, nurses can further investigate and plan appropriate interventions to help resolve a potentially adverse situation. Older adults may refuse to engage in a particular activity because of fear of failure or frustration at not being able to perform the activity. Planning realistic activities for particular patient groups is crucial to successful group interaction. The successful completion of a group activity provides an opportunity for increasing an older person’s self-confidence, whereas frustration over an impossible task further promotes feelings of inadequacy and uselessness.
By examining the past and being aware of significant events or even beliefs about health and illness, the health care provider can develop a deeper understanding of why these particular older adults act the way they do or believe in certain things. The health care provider can also gain insight into how a particular group of older adults responds to illness and views healthy aging. This knowledge and insight can certainly assist in planning not only activities but also meaningful patient teaching.
Another application of the sociologic theories relates to helping individuals adapt to various limitations and securing appropriate living arrangements. Following the passage of the 1990 Americans with Disabilities Act, a majority of buildings are now easily accessible to those with special needs. These special needs may include doorways that are wide enough for wheelchairs, ramps in addition to stairs, handrails in hallways, and working elevators. Although these changes assist younger members of society with
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limited physical capabilities, they also benefit older adults. In addition, older adults might consider the installation of medical alert devices, preprogrammed or large-numbered phones, and even special security systems.
Helping older adults adjust to limitations while accentuating positive attributes may enable them to remain independent and may perpetuate a high quality of life during later years. These adaptations may encourage older adults to remain in the community, perhaps even in the family home, instead of being prematurely institutionalized. Older adults continue to feel valued and viewed as active members of society when allowed to maintain a sense of control over their living environment.
In some cities in the United States, multigenerational communities are developing, fostering a sharing of different cultures as well as generations. Schools are promoting “adopt a grandparent” programs, day care centers are combining services for children and older adults, and older volunteers visit hospitalized children or make telephone calls to “latchkey” children after school. These are examples of the practical application of sociologic aging theories. Older adults are continuing to be active, engaging or disengaging as they wish, and remaining valued members of society.
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Psychologic Theories of Aging The basic assumption of the psychologic theories of aging is that development does not end when a person reaches adulthood but remains a dynamic process throughout the life span (Box 2-6). As a person passes from middle life to later life, his or her roles, abilities, perspectives, and belief systems enter a stage of transition. The nurse, by providing holistic care, seeks to employ strategies to enhance patients’ quality of life (Hogstel, 1995). The psychologic theories of aging are much broader in scope than the earlier theories because they are influenced by both biology and sociology. Therefore, psychologic aging cannot readily be separated from biologic and sociologic influences.
Box 2-6
Psychologic theories of aging Maslow’s hierarchy of human needs Human motivation is viewed as a hierarchy of needs that are critical to the growth and development of all people. Individuals are viewed as active participants in life, striving for self- actualization (Carson & Arnold, 1996).
Jung’s theory of individualism Development is viewed as occurring throughout adulthood, with self-realization as the goal of personality development. As an individual ages, he or she is capable of transforming into a more spiritual being.
Erikson’s eight stages of life All people experience eight psychosocial stages during the course of a lifetime. Each stage represents a crisis, where the goal is to integrate physical maturation and psychosocial demands. At
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each stage the person has the opportunity to resolve the crisis. Successful mastery prepares an individual for continued development. Individuals always have within themselves an opportunity to rework a previous psychosocial stage into a more successful outcome (Carson & Arnold, 1996).
Peck’s expansion of erikson’s theory Seven developmental tasks are identified as occurring during Erikson’s final two stages. The final three of these developmental tasks identified for old age are (1) ego differentiation versus work role preoccupation, (2) body transcendence versus body preoccupation, and (3) ego transcendence versus ego preoccupation (Ignatavicius & Workman, 2013).
Selective optimization with compensation Physical capacity diminishes with age. An individual who ages successfully compensates for these deficits through selection, optimization, and compensation (Schroots, 1996).
As people age, various adaptive changes help them cope with or accept some of the biologic changes. Some of the adaptive mechanisms include memory, learning capacity, feelings, intellectual functioning, and motivations to perform or not perform particular activities (Birren & Cunningham, 1985). Psychologic aging, therefore, includes not only behavioral changes but also developmental aspects related to the lives of older adults. How does behavior change in relation to advancing age? Are these behavioral changes consistent in pattern from one individual to another? Theorists are searching for answers to questions such as these.
Maslow’s Hierarchy of Human Needs According to this theory, each individual has an innate internal hierarchy of needs that motivate all human behaviors (Maslow, 1954). These human needs have different orders of priority. When people achieve fulfillment of their elemental needs, they strive to meet the needs on the next level, continuing on until the highest
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order of needs is reached. These human needs are often depicted as a pyramid, with the most elemental needs at the base (Figure 2-2).
FIGURE 2-2 Maslow’s hierarchy of needs. (From Maslow, A.H. et al. (1987). Motivation and personality (3rd ed.). Upper Saddle River, NJ: Pearson
Education. Copyright 1987, reprinted by permission of Pearson Education, Inc.)
The initial human needs each person must meet relate to physiologic needs—the needs for basic survival. Initially, a starving person worries about obtaining food to survive. Once this need is met, the next concern is about safety and security. These needs must be met, at least to some extent, before the person becomes concerned with the needs for love, acceptance, and a feeling of belonging. According to Maslow (1968), as each succeeding layer of needs is addressed, the individual is motivated to look to the needs at the next higher step.
Maslow’s fully developed, self-actualized person displays high levels of all the following characteristics: perception of reality; acceptance of self, others, and nature; spontaneity; problem-solving ability; self-direction; detachment and the desire for privacy; freshness of peak experiences; identification with other human
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beings; satisfying and changing relationships with other people; a democratic character structure; creativity; and a sense of values (Maslow, 1968). Maslow’s ideal self-actualized person is probably only attained by about 1% of the population (Thomas & Chess, 1977). Nevertheless, the person developing in a healthy way is always moving toward more self-fulfilling levels.
Jung’s Theory of Individualism The Swiss psychologist Carl Jung (1960) proposed a theory of personality development throughout life: childhood, youth and young adulthood, middle age, and old age. An individual’s personality is composed of the ego, the personal unconsciousness, and the collective unconsciousness. According to this theory, a person’s personality is visualized as oriented either toward the external world (extroversion) or toward subjective, inner experiences (introversion). A balance between these two forces, which are present in every individual, is essential for mental health.
Applying his theory to individuals as they progress through life, Jung proposed that it is at the onset of middle age that the person begins to question values, beliefs, and possible dreams left unrealized. The phrase midlife crisis, popularized by this theory, refers to a period of emotional, and sometimes behavioral, turmoil that heralds the onset of middle age. This period may last for several years, with the exact time and duration varying from person to person.
During this period, the individual often searches for answers about reaching goals, questioning whether a part of his or her personality or “true self” has been neglected and whether time is running out for the completion of these quests. This may be the first time the individual becomes aware of the effects of the aging process and the fact that the first part of the adult life is over. This realization does not necessarily signal a time of trauma. For many people, it is just another “rite of passage.”
As the person ages chronologically, the personality often begins to change from being outwardly focused, concerned about establishing oneself in society, to becoming more inward, as the
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individual begins to search for answers from within. Successful aging, according to Jung’s theory, is when a person looks inward and values himself or herself for more than just current physical limitations or losses. The individual accepts past accomplishments and limitations (Jung, 1960).
Eight Stages of Life In 1959, Erikson (1993) proposed a theory of psychologic development that reflects cultural and societal influences. The major focus of development in this theory is on an individual’s ego structure, or sense of self, especially in response to the ways in which society shapes its development. In each of the eight stages identified by Erikson, a “crisis” occurs that affects the development of the person’s ego. The manner in which a person masters any particular stage influences future success or lack of success in mastering the next stage of development.
When considering older adults, one must focus attention on the developmental tasks of both middle adulthood and older adulthood. The task of middle adulthood is resolving the conflict between generativity and stagnation. During older adulthood, the developmental task needing resolution is balancing the search for integrity and wholeness with a sense of despair (Table 2-1) (Potter & Perry, 2004).
Table 2-1 Summary of Erikson’s Theory: Middle and Older Adulthood
Modified from Potter, P.A. & Perry, A.G. (2004). Fundamentals of nursing (5th ed.). St.
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Louis: Mosby.
In 1968, Peck expanded Erikson’s original theory regarding the eighth stage of older adulthood. Erikson had grouped all individuals together into “old age” beginning at age 65, not anticipating that a person could live another 30 to 40 years beyond this milestone. Because people were living longer, an obvious need arose to identify additional stages for older adults. Peck (1968) expanded the eighth stage, ego integrity versus despair, into three stages: (1) ego differentiation versus work role preoccupation, (2) body transcendence versus body preoccupation, and (3) ego transcendence versus ego preoccupation (Ignatavicius & Workman, 2013).
During the stage of ego differentiation versus work role preoccupation, the task for older adults is to achieve identity and feelings of worth from sources other than the work role. The onset of retirement and termination of the work role may reduce feelings of self-worth. In contrast, a person with a well-differentiated ego, who is defined by many dimensions, can find other roles to replace the work role as the major defining source for self-esteem.
The second stage, body transcendence versus body preoccupation, refers to the older person’s view of the physical changes that occur as a result of the aging process. The task is to adjust to or transcend the declines that may occur to maintain feelings of well-being. This task can be successfully resolved by focusing on the satisfaction obtained from interpersonal interactions and psychosocial activities.
The third and final task, ego transcendence versus ego preoccupation, involves acceptance of the individual’s eventual death without dwelling on the prospect of it. Remaining actively involved with a future that extends beyond a person’s mortality is the adjustment that must be made to achieve ego transcendence.
Selective Optimization with Compensation Baltes (1987) has conducted a series of studies on the psychologic processes of development and aging from a life span perspective and formulated a psychologic model of successful aging. This
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theory’s central focus is that individuals develop certain strategies to manage the losses of function that occur over time. This general process of adaptation consists of three interacting elements: (1) selection, which refers to an increasing restriction on one’s life to fewer domains of functioning because of an age-related loss; (2) optimization, which reflects the view that people engage in behaviors to enrich their lives; and (3) compensation, which results from restrictions caused by aging, requiring older adults to compensate for any losses by developing suitable, alternative adaptations (Schroots, 1996).
The lifelong process of selective optimization with compensation allows people to age successfully. Schroots (1996) cited the famous pianist Rubinstein to illustrate an application of these elements. Rubinstein stated that as he grew older, he first reduced his repertoire and played a smaller number of pieces (selection); second, he practiced these more often (optimization); and third, he slowed down his playing right before fast movements, producing a contrast that enhanced the impression of speed in the fast movements (compensation). These concepts of selection, optimization, and compensation can be applied to any aspect of older adulthood to demonstrate successful coping with declining functions.
Implications for Nursing Integrating the psychologic aging theories into nursing practice becomes increasingly important as the U.S. population continues to age. Present and future generations can learn from the past. Older adults should be encouraged to engage in a “life review” process; this may be accomplished using a variety of techniques such as reminiscence, oral histories, and storytelling. Looking back over life’s accomplishments or failures is crucial in assisting older adults to accomplish developmental tasks (as in ego integrity), to promote positive self-esteem, and to acknowledge that one “did not live in vain.”
As nurses apply the psychologic theories to the care of older adults in any setting, they help dispel many of the myths about old
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age. An older person talking about retirement, worrying about physical living space, and even planning funeral arrangements are all part of the developmental tasks appropriate for this age group. Instead of trying to change the topic or telling the person not to be so “morbid,” the nurse must understand that in each stage of life, specific developmental tasks need to be achieved. Instead of hampering their achievement, the nurse should facilitate them.
Nurses also need to keep in mind that intellectual functioning remains intact in the majority of older adults. A younger person can gain much by observing older persons, listening to how they have coped with life experiences, and discussing his or her plans for the future with them.
As did other humanistic psychologists, Maslow focused on the human potential, which sets an effective and positive foundation for nurse–patient interactions. Maslow’s theory also sets priorities for the nurse in relationship to patient needs. Employing Maslow’s theory, the nurse recognizes that essential needs such as food, water, oxygen, elimination, and rest must be met before self- actualization needs. The nurse recognizes, for example, that patient education will be more successful if patients are well rested (Carson & Arnold, 1996).
In planning activities for older adults, nurses need to remember that all individuals enjoy feeling needed and respected and being considered contributing members of society. Perhaps activities such as recording oral history, creating a mural, or quilting a particular event or even an individual’s lifetime could be included. Not only would such activities demonstrate that the individual is valued, but they would also serve to pass on information from one generation to the next; this is an important task that is often overlooked.
Programs promoting interaction between older adults and young children might prove beneficial to all concerned. For some older adults, caring for small children represented a happy time in their lives. Rocking, cuddling, and playing with children might bring back feelings of being valued and needed. The touching aspects of this activity are also important in relieving stress; many older adults no longer experience any type of meaningful physical contact with others, yet all individuals need this type of contact.
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As eyesight and manual dexterity diminish, many older adults enjoy the opportunity to cook or to work in a garden. Often, the feel of dirt between the fingers is relaxing and brings back memories of growing beautiful flowers and prize vegetables in the past. For the older woman, in particular, preparing a meal may be an activity she has not been able to do for several years, and with assistance, she may find baking cookies a pleasant activity filled with memories of holidays and loved ones or prizes at the county fair. Older men may also enjoy cooking and should not be left out of this activity. Preparing muffins for a morning snack would be an activity in which everyone could participate.
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Moral and spiritual development Human beings seek to explain and validate their existence in the world. For many individuals, this occurs through their development as moral and spiritual thinkers. Kolberg has postulated a theory of moral development that is based on interviews with young persons. He recognized distinct sequential stages of moral thinking. Although he did not study older adults, parallels could be drawn between his highest stage of moral development, Universal Ethical Principles, and Maslow’s highest level of Self-Transcendent Needs. In each instance, only a small segment of the population reaches this highest level of development, where their personal needs are sublimated for the greater good of society (Edelman & Mandle, 2003; Levin & Chatters, 1998; Mehta, 1997).
It is important for the nurse to acknowledge the spiritual dimension of a person and support spiritual expression and growth (Hogstel, 1995). Spirituality no longer merely denotes religious affiliation; it synthesizes a person’s contemplative experience. Illness, a life crisis, or even the recognition that one’s days on earth are limited may cause a person to contemplate spirituality. The nurse can assist patients in finding meaning in their life crises. Research has begun to explore the relationship between patient- centered outcomes and spirituality. A correlation between successful outcomes and spirituality has been demonstrated in some of this research. Regardless of outcomes, nurses need to address spirituality as a component in holistic care (Phipps et al., 2003).
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Summary When interacting with older adults, the nurse often plays a key role as the coordinator of the health care team. Nurses have the background to incorporate information from a variety of sources when planning care for older adults. By using an eclectic approach to the aging theories, the nurse will have a broad background from which to draw specific details to provide clarity, explanations, or additional insight into a particular situation.
Biologic theories help the nurse understand how the physical body may change with advancing years and what factors may increase older adults’ vulnerability to stress or disease. The nurse will also be able to develop health promotional strategies on behalf of older patients. Understanding the sociologic theories broadens the nurse’s view of older adults and their interactions with society. The psychologic theories provide an understanding of the values and beliefs an older person may possess. These theories enable a nurse to understand the phases of the life span and the developmental tasks faced by older adults. By integrating the various components of these theories, nurses can plan high-quality care for this population. As the U.S. population continues to age, nurses with the capability to understand and apply the theories of aging from several disciplines will be the leaders of gerontologic nursing. These nurses will contribute to increasingly holistic care and an improved quality of life for older adults.
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Key points • No one theory explains the biologic, sociologic, or psychologic
aging processes.
• An eclectic approach incorporating concepts from biology, sociology, and psychology was used in developing the aging theories.
• The biologic theories address what factors actually trigger the aging process in organisms.
• Humans are thought to have a maximum life span of 110 to 120 years.
• A change in the efficiency of immune processes may predispose individuals to disease with advancing age.
• The biologic theories alone do not provide a comprehensive explanation of the aging process.
• Reminiscence is supported by the sociologic theories and assists older adults in appreciating past memories.
• Each individual, no matter what his or her age, is unique. Older adults are not a homogeneous population.
• The activity theory remains popular because it reflects current societal beliefs about aging.
• As a person ages, various adaptive changes occur that may assist the person in coping with or accepting some of the biologic changes.
• Human development is a process that occurs over the life span.
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Critical thinking exercises 1. Discuss how sociologic theories of aging may be influenced by changing societal values (e.g., advanced technology or a community health care focus) in the next decade.
2. A 64-year-old woman believes that heart disease and poor circulation are inevitable consequences of growing older and is resistant to altering her ADLs and dietary regimen. How would you respond?
3. Think of various programs and institutions in your community that care for older persons. Identify two, and discuss the sociologic aging theories represented in each example.
4. A 77-year-old man frequently talks about how he wishes he were as strong and energetic as he was when he was younger. His family consistently changes the topic or criticizes him for being so grim. How would you intervene in this situation?
5. What health promotion strategies would you recommend to encourage successful aging?
6. Imagine yourself at age 70. Describe your appearance, your health issues, and your lifestyle.
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* Previous authors: Marjorie A. Maddox, EdD, MSN, ARNP, ANP-C, and Holly Evans Madison, RN, MS
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C H A P T E R 3
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Legal and ethical issues Sue E. Meiner, EdD, APRN, BC, GNP
Learning objectives
On completion of this chapter, the reader will be able to: 1. Discuss how professional standards are used to measure the degree to which the legal duties of nursing care of patients are met.
2. State the sources and definitions of laws such as statutes, regulations, and case law, as well as the levels at which the laws were made such as federal, state, and local laws.
3. Explore why older adults are considered a vulnerable population, why this is legally significant, and the legal implications of such a designation.
4. Discuss the reasons behind the sweeping nursing facility reform legislation known as the Omnibus Budget Reconciliation Act (OBRA) of 1987 and understand its continuing significance and impact for residents and caregivers in nursing facilities.
5. Identify the OBRA’s three major parts and describe the key areas addressed in each.
6. State the rationale behind the Affordable Care Act and cite who the Act was developed to benefit.
7. Discuss the legal history of the doctrine of autonomy and self- determination and cite major laws that have influenced contemporary thought and practice.
8. Identify the three broad categories of elder abuse, define seven types of abuse, and discuss the responsibility of the nurse in responding to suspected abuse of older adults.
9. Name and state the purpose of the legal tools known as “advance directives” and list the major points that should be addressed in a
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Do Not Resuscitate policy.
10. Explain the requirements of the four major provisions of the Patient Self-Determination Act and the nurse’s responsibility with respect to advance directives.
11. Describe the values history and how it can help patients and health care professionals in preparing for end-of-life decisions.
12. Identify at least three ethical issues nurses may face in caring for older adults, with regard to the areas of care of the terminally ill, organ donation, and self-determination.
13. State the function and role, as well as the recommended membership composition, of an institutional ethics committee.
14. Relate at least three major reasons why the skillful practice of professional nursing can improve the quality of life for older adults in health care settings.
http://evolve.elsevier.com/Meiner/gerontologic
How the health needs of older adults will be met is an ongoing concern. The unique characteristics and needs of older adults pose significant questions of legal and ethical significance. Older adults depend on the health care system to deliver the care that optimizes their health status and functional capabilities. Their quality of life often depends on the type and quality of nursing care they receive. This chapter focuses on legal concerns of nurses who care for older adults, and the ethical issues that may be encountered.
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Professional standards: their origin and legal significance Health care providers have a general obligation to live up to accepted or customary standards of care, which may be determined on a regional or national basis. Nurses are responsible for providing care to the degree, skill, and diligence measured and recognized by applicable standards of care. The duty of care increases as patients’ physical and mental conditions and ability for self-care decline.
Nursing standards of practice are measured according to the expected level of professional practice of those in similar roles and clinical fields. For example, the standards of practice of a gerontologic nurse practicing at the generalist level would be measured against the practice of other nurse generalists practicing in the area of gerontology. The advanced practice gerontologic nurse, who has at least a master’s degree in an applicable field, would be expected to conform to standards established for similarly situated advanced practice nurses.
A standard of care is a guideline for nursing practice and establishes an expectation for the nurse to provide safe and appropriate care (Potter & Perry, 2004). It is used to evaluate whether care administered to patients meets the appropriate level of skill and diligence that can reasonably be expected, given the nurse’s level of skill, education, and experience.
Standards originate from many sources. Both state and federal statutes may help establish standards, although conformity with a state’s minimum standards does not necessarily prove that due care was provided. Conformity with local standards or comparison with similar facilities in the region may be considered evidence of proper care (Strauss et al., 1990). Some jurisdictions in the United States call this the community standard of care. However, the community standard of care cannot be lower or hold fewer expectations than the federal standard.
The published standards of professional organizations, representing the opinion of experts in the field, are important in
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establishing the proper standard of care. The Scope and Standards of Gerontological Nursing Practice, published by the American Nurses Association (ANA) in 1994, is one example. However, in 2004, the ANA combined the scope and standards of practice into one book for all practice areas (ANA, 2004). Nurses who care for older patients should be familiar with these standards and those from all relevant sources. In 2010, the Scope and Standards of Practice: Nursing was updated (ANA, 2010). Refer to www.nursingworld.org for additional information.
Most health care facilities, at some point, seek accreditation status. This means that they voluntarily undergo a detailed survey by an organization with the skill and expertise to evaluate their services. One of the best known accreditation organizations is The Joint Commission (TJC), previously known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Because it is a well-known and long-existing organization, the standards established and used by the TJC to review health care facilities are often referred to in court cases to ascertain the appropriate standard of care. Thus, the standards set by TJC are often considered the “industry standard,” even for facilities that are not accredited (Schreiber, 1990; The Joint Commission, 2013).
Federal and state statutes require nursing facilities to have written health care and safety policies, and these have been used successfully to establish a standard of care in court cases. Bylaws and internal rules and policies also help establish the standard of care in an organization, although, depending on the circumstances, their importance may vary. In any event, it is important for nurses to be aware of their organization’s policies; failure to follow “your own rules” clearly poses a liability risk—both to the nurse and the organization.
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Overview of relevant laws Sources of Law Statutes are laws created by legislation and are enacted at the federal and state levels. Common laws are principles and rules of action and derive authority from judgments and decrees of the court; they are also known as case law (Black, 1979). Regulations are rules of action and conduct developed to explain and interpret statutes and to prescribe methods for carrying out statutory mandates. Regulations are also promulgated at the federal and state levels.
Federal and State Laws The federal government, under the Social Security Act, has the primary responsibility for providing medical services to certain older adults, those with disabilities, or certain other classified American citizens. The government fulfills this obligation through the Medicare and Medicaid programs. These programs were enacted as part of the Social Security Amendments of 1965 (P.L. No. 89–97, July 30, 1965).1 Several amendments have been added since 1965, and the continuation or proposed modifications of amendments are still being debated at the time of publication of this text in 2014. Part C, the Medicare Advantage Plan, and Part D, related to prescription drug coverage, have been added in the 2000s.
The U.S. Department of Health and Human Services (DHHS) promulgated regulations for the Medicare and Medicaid programs until July 1, 2001. At that time, the Health Care Financing Administration (HCFA) became the Centers for Medicare and Medicaid Services (CMS). The restructured agency aims to increase emphasis on responsiveness to the beneficiaries and providers, and quality improvement is one of the goals. Then, Health and Human Services Secretary Tommy G. Thompson made the announcement on June 14, 2001, “We are making quality service the number one priority in this agency.”
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Two levels of care are generally associated with nursing facilities: skilled and intermediate. Skilled nursing facilities (SNFs) provide technical and complex care and offer more skilled levels of professional staff. Medicare pays only for skilled care, which includes nursing, physical therapy, occupational therapy, and speech therapy, for Medicare-insured persons in long-term care facilities. Medicaid pays for both intermediate and skilled care for indigent persons. Intermediate care is custodial and is supervised by professional nurses.
The Omnibus Budget Reconciliation Act of 1987 (OBRA) refers to SNFs only in relation to Medicare facilities and has merged the distinctions skilled and intermediate into the single term nursing facility for Medicaid purposes (as of the OBRA’s effective date, October 1, 1990). For survey purposes, a single set of survey requirements is used. However, these designations are used for reimbursement and survey purposes only and are presented here to assist in understanding what is meant by the terms in connection with reimbursement or survey activities.
Survey and certification procedures and the process by which the CMS evaluates and determines whether a provider is in compliance with the Medicare and Medicaid requirements are the responsibilities of the Health Standards and Quality Bureau within the CMS.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Recent changes in federal law now give additional, although limited, protections to individuals and their family members when they need to buy, change, or continue their health insurance. These important laws affect the health benefits of millions of working Americans and their families. It is important that nurses understand these new protections, as well as laws in their states, to help them make more informed choices for themselves or to inform their patients of the options available. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) may:
1. Increase a person’s ability to get health care coverage when the
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person begins a new job;
2. Lower the chance of losing existing health coverage, whether the coverage is through a job or through individual health insurance;
3. Help maintain continuous health coverage when a change of job occurs; and
4. Help purchase health insurance coverage individually if the coverage is lost under an employer’s group health plan and no other health coverage is available (HIPAA, 2004).
Among the specific protections of HIPAA, it:
1. Limits the use of preexisting condition exclusions;
2. Prohibits group health plans from discriminating by denying coverage or charging extra for coverage based on the person’s or a family member’s past or present poor health;
3. Guarantees certain small employers and certain individuals who lost job-related coverage the right to purchase health insurance; and
4. Guarantees, in most cases, that employers or individuals who purchase health insurance can renew the coverage regardless of any health conditions of individuals covered under the insurance policy (HIPAA, 2004).
Several misunderstandings exist about what HIPAA provides. Note the following:
1. HIPAA does not require employers to offer or pay for health coverage for employees or family coverage for spouses and dependents.
2. HIPAA does not guarantee health coverage for all workers.
3. HIPAA does not control the amount an insurer may charge for coverage.
4. HIPAA does not require group health plans to offer specific benefits.
5. HIPAA does not permit people to keep the same health coverage they had in their old job when they move to a new job.
6. HIPAA does not eliminate all use of preexisting condition
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exclusions.
7. HIPAA does not replace the state as the primary regulator of health insurance (HIPAA, 2004).
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Elder abuse and protective services It has already been noted that the incidence of illness and disability increases with age. Old-old adults, those older than age 85, make up the fastest growing group (Zedlewski et al., 1989), and their health status often leads to changes in living arrangements both in homes and in institutions. These changes affect not only older adults but also often their family and others who must see to their care and living needs. These conditions can lead to neglect, deliberate abuse, or exploitation of older adults.
In addition, as older adults’ abilities to manage their affairs are compromised, the necessity of turning the management of certain activities over to others may also open the door to mistreatment. The legal recognition of this vulnerability is reflected in laws enacted specifically to protect older adults.
Unfortunately, mistreatment is not defined in the same manner across state lines. However, it is known that it occurs recurrently and episodically and not usually as an isolated incident (Touhy & Jett, 2012).
The need to protect older adults from abuse is a subject of growing public policy interest. Lantz (2006) found the number of older adults who were mistreated or abused in the United States to be approximately two million. However, given the potential for hiding incidents of elder abuse in domestic settings as a “family secret,” the incidents of elder abuse are likely grossly underreported. Cultural differences have also led to poor identification of the reaction to abuse.
Elder abuse is defined by state laws, which vary from state to state. However, three basic categories of elder abuse exist: (1) domestic elder abuse, (2) institutional elder abuse, and (3) self-neglect or self- abuse (National Center for Elder Abuse [NCEA], 2013). Domestic elder abuse refers to forms of maltreatment by someone who has a special relationship with the older adult, for example, a family member or caregiver. Institutional abuse refers to abuse that occurs in residential institutions such as nursing facilities, usually
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committed by someone who is a paid caregiver such as a nursing facility staff member. Self-neglect is usually related to a diminished physical or mental decline. It is identified by a failure or refusal to provide them with adequate shelter, food, water, hygiene, safety, clothing or health care. Within the three broad categories are a number of recognized types of elder abuse.
An analysis of existing state and federal definitions of elder abuse, neglect, and exploitation conducted by the NCEA (2013) identified seven different kinds of elder abuse:
1. Physical abuse—use of physical force that may result in bodily injury, physical pain, or impairment
2. Sexual abuse—nonconsensual sexual contact of any kind with an older adult
3. Emotional abuse—infliction of anguish, pain, or distress through verbal or nonverbal acts
4. Financial and material exploitation—illegal or improper use of an older adult’s funds, property, or assets
5. Neglect—the refusal or failure of a person to fulfill any part of his or her obligations or duties to an older adult
6. Abandonment—the desertion of an older adult by an individual who has physical custody of the older adult or by a person who has assumed responsibility for providing care to the older adult
7. Self-neglect—behaviors of an older adult that threaten the older adult’s health or safety
Elder abuse generally occurs as the result of a number of complex factors. Abuse may be a result of caregiver stress. The physical and emotional demands of caring for a physically or mentally impaired person can be great, and the caregiver may not be prepared to undertake the responsibility. Supportive resources may also be lacking. It has been found that abuse tends to occur when the caregiver’s stress level is heightened by the older person’s worsening condition (Jett, 2012; NCEA, 2013).
Nurses must be alert to recognize signs and symptoms of abuse. Signs of physical abuse may be visible, for example, bruises,
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wounds, or fractures. They may also be less apparent, for example, an older adult’s report of being hit or mistreated or a sudden change in behavior. Sexual abuse may be detectable by the presence of signs such as bruises in the genital area or unexplained vaginal bleeding. But other forms of abuse such as the taking of pornographic photographs may be more difficult to detect. Signs of neglect may include unsanitary living conditions or the older adult being malnourished or dehydrated. In addition, the nurse should be alert to signs of financial or material exploitation, for example, the unexplained disappearance of funds or valuable possessions.
Because signs and symptoms of elder abuse in its many forms may be difficult to detect, the nurse must be educated in this regard and must be alert to the actions of others such as nursing attendants involved in the care of older adults. It has been shown that the primary abusers of nursing facility residents are nurse aides and orderlies who have never received training in stress management and who are working in facilities that show evidence of administrative problems such as high staff turnover (Keller, 1996).
A training program designed specifically for nurse aides in long- term care facilities, providing information about abuse, including possible causes and conflict intervention strategies, was tested on 216 nurse aides in the Philadelphia area. In this study, training was shown to bring about significant improvement in attitudes toward residents, conflict with residents, resident aggression toward staff, and self-reported abuse actions by staff (Keller, 1996). This may suggest that training may serve as an effective abuse prevention strategy, and expansion to other care settings may be important in preventing abuse of older adults.
The term adult protective services refers to the range of laws and regulations enacted to deal with abusive situations. The laws and regulations are typically administered by an agency within the state, for example, the Department of Social Services, which receives and investigates complaints. Specific responses to safeguard abused or at-risk older adults may include protective orders issued to shield older adults from abusive members of their households; elder abuse statutes that outlaw harmful acts that victimize older adults; and laws to protect older residents of
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nursing facilities from abuse (Strauss et al., 1990).
Elder abuse laws levy criminal penalties against those who commit harmful acts against older adults. Many states’ laws enhance the penalties for criminal offenses against older persons, for example, violent or property-related offenses, and some outlaw any acts that victimize older adults (e.g., see Connecticut General Statutes Annals. §46a-15). These laws typically apply to the abuse of older adults in the community.
States may also levy penalties for acts of elder abuse committed by those who are responsible for the care of older adults in nursing facilities or other institutions (Strauss et al., 1990). These laws are in addition to those already in effect to protect the rights of patients in facilities governed by federal regulation. Most states have mandatory reporting requirements for nurses, other health care workers, and facility employees who have a reasonable suspicion of elder abuse.
The definition of what constitutes elder abuse under these statutes varies. For example, emotional abuse may be in the form of acts such as “ridiculing or demeaning . . . or making derogatory remarks to a . . . resident”2; “any non-accidental infliction of physical injury, sexual abuse, or mental injury”3; and “unauthorized use of physical or chemical restraint, medication, or isolation.”4
For the purposes of these types of statutes, some states define the term older adults as those 60 years or older. It is important for nurses to know the legal requirements relating to the abuse of older adults for the state in which they practice.
Most states designate certain professionals or other caregivers as “mandated reporters.” This means that the mandated reporter is required by law to report suspected cases of abuse, neglect, or exploitation. Failure to report as required under this law may result in imposition of civil penalties, criminal penalties, or both.
A report of suspected abuse may be required on a “reasonable suspicion.” This implies that actual knowledge or certainty is not necessary. Most states provide immunity from civil liability for anyone reporting older adult abuse based on reasonable suspicion
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and in good faith, even if it is later shown that the reporter was mistaken. However, it is interesting to note that the majority of elder abuse reports are in fact substantiated after investigation (NCEA, 2013).
In most care settings, nurses are mandated reporters. To be responsive to this legal obligation and because of the great variation among the states, nurses should determine the specific reporting requirements of their jurisdictions, including where reports and complaints are received and in what form they must be made.
Nurses must be aware at all times of the responsibility to respect and to preserve the autonomy and individual rights of older adults. All people, including older adults, have the right to decide what is to be done to them, as well as the right to exercise maximum control of their personal environments and living conditions. The nurse’s responsibility in this regard emanates from both legal and professional standards.
The fact of ongoing legislative responses to the identification and preservation of these rights underscores this point. The nurse is often the health professional closest to older patients and therefore may be in the best position to communicate and understand their wishes. This presents both an unequaled opportunity and a legally recognizable and indisputable responsibility to advocate on their behalf. Thus, the need to be legally informed and professionally conscientious is greater than ever.
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Nursing facility reform In 1985, 5% of the older adult population resided in nursing facilities (1.5 million persons) (Collier, 1990). More than 1.6 million older adults and persons with disabilities receive care in approximately 16,800 nursing facilities across the United States (HCFA, 1998). In 2011, a relatively small number (1.5 million) and percentage (3.6%) of the persons 65 years or older lived in institutional settings such as nursing homes (1.3 million). However, the percentage dramatically increased to 11% for persons 85 and older (Administration on Aging [AOA], 2012).
The OBRA applies to all Medicare- and Medicaid-certified nursing facilities, including (1) beds in acute care hospitals certified to be used as long-term nursing care beds at times when they are not needed for acute care purposes (so-called swing beds), and (2) beds in acute care hospitals certified as separate units for Medicare- approved services (so-called “distinct part units”). The OBRA is the most sweeping reform affecting Medicare and Medicaid nursing facilities since the programs began.
Evidence that the health and safety of nursing facility residents have improved as a result of these tough regulations and sweeping reforms is quite evident. Such improvements, among other things, include reduction in the overuse of antipsychotic drugs, inappropriate use of restraints, and inappropriate use of indwelling urinary catheters. Since 2001, the CMS has increased the number of penalties levied on poor-quality nursing facilities (CMS, 2004).
However, the CMS has also identified areas requiring greater regulatory oversight. Nursing facility surveys are too predictable and are rarely conducted on weekends or during evening hours. Some states rarely cite nursing facilities for substandard care, which is an indication that their inspections may be inadequate. Nursing facility residents continue to suffer from pressure ulcers and skin breakdown, malnutrition and dehydration, and various forms of abuse (CMS, 2004). For these reasons, new enforcement tools are being added to the regulatory oversight of the nations’ nursing facilities. Some of these additional measures are discussed in the
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following section.
OBRA’s Three Major Parts The OBRA provisions are divided into three parts: (1) provision of service requirements for nursing facilities, (2) survey and certification processes, and (3) enforcement mechanisms and sanctions.
The provision of service requirements for nursing facilities includes resident assessments, preadmission and annual screening of residents, maintenance of minimal nurse staffing levels, required and approved nurse aide training programs and competency levels, professional social worker services in facilities with 120 or more beds, and the important focus on specifying and ensuring resident rights.
The survey and certification process was substantially revised with the enactment of the OBRA. New types of surveys were established to evaluate facilities. In brief, each facility is subject to a standard annual survey. Any change in facility management or ownership is further evaluated by a “special” survey. If any survey suggests that care may be substandard, the facility may be subject to a more detailed “extended” survey. States are also evaluated for the effectiveness of their survey process through a “validation” survey. Furthermore, the federal authorities may make an independent and binding determination of a facility’s compliance through a “special compliance” survey.
The OBRA also brought a new range of enforcement mechanisms and sanctions. Thus, a number of corrective measures may be applied to repair deficiencies, on the basis of the severity of the risk to residents. These three OBRA provisions are discussed further in the following sections.
Overall the regulations focus on the quality of life of nursing facility residents and emphasize their individual rights. The OBRA has created a new regulatory environment by empowering residents, giving them a greater say in these quality of life issues. In 2010, a report found that key government-measured quality trends are improving (AQNHC & AHCA, 2014).
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Provision of Service Requirements Quality of Care Nursing facility residents must be assessed to identify medical problems, describe their capacity to perform daily life functions, and note any significant impairment in their functional capacity. In Medicare- and Medicaid-certified long-term care facilities, physicians evaluate residents at the time of admission, at 30 days and 90 days, when a change in condition occurs, and at 1 year. The government’s final regulations permitted certified nurse practitioners to certify the necessity for skilled nursing services for residents of nursing facilities (Vaca & Daake, 1998). A state- specified instrument must be used to conduct the assessment, which is based on a uniform data set, referred to as the minimum data set (MDS), established by the DHHS.
The assessment is used to develop a written and comprehensive plan of care for each resident. The plan must quantify expected levels of functioning and must be reviewed quarterly. MDS assessment categories include resident background, daily pattern of activity, cognition, physical functioning, psychosocial status, health problems, and specific body systems. Certain responses on the MDS, called resident assessment protocols (RAPs), are designed to prompt more thorough assessment and evaluation of common clinical problems (Vaca & Daake, 1998).
A similar uniform approach to assessment of adult home care patients, known as the outcome and assessment information set (OASIS-C) is used across the country. The goal of this tool is to provide a set of essential data items necessary for measuring patient outcomes that have utility for such purposes as outcome monitoring, clinical assessment, and care planning. The CMS (2012) is likely to issue new rules relating to home health agencies that include the required collection of OASIS-C data.
The assessment and planning of care for nursing facility residents is an important role for the professional nurse. As can be seen from this discussion of nursing facility reform, it is a central point for determining the care and services that particular residents will need. Careful assessment and planning are time consuming and
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also require the professional nurse to be skilled and knowledgeable in carrying out these functions.
The advent of the OBRA and nursing facility reform has ushered in a new phase of professional accountability. It has increased the demands on nursing time and performance, has forced nursing facilities to change the structure of their operation, and has resulted in a different image of what nursing facilities are and how they care for their residents.
Medicare SNFs and Medicaid nursing facilities must have licensed nursing services available 24 hours a day, 7 days a week. A registered nurse (RN) must be on duty at least 8 hours a day, 7 days a week.
Nursing assistants must be trained according to regulatory specifications and pass state-approved competency evaluations. They must receive classroom training before any contact with residents and must receive training in areas such as interpersonal skills, infection control, safety procedures, and resident rights. They also must have 6 hours of in-service education each quarter to ensure ongoing competency (Vaca & Daake, 1998).
Resident Rights A primary thrust of the OBRA’s nursing facility reform provisions is to protect and promote the rights of residents to enhance their quality of life. Thus, the legislation contains numerous requirements to ensure the preservation of a resident’s rights.5
The OBRA imposed new disclosure obligations on nursing facilities to apprise residents of their rights; these require that residents be notified, both orally and in writing, of their rights and responsibilities and of all rules governing resident conduct. This notification and disclosure must take place before or up to the time of admission and must be updated and reviewed during the course of residents’ stays. Box 3-1 shows a sample of statements from the OBRA’s resident bill of rights, as adapted from the Code of Federal Regulations (CFR).
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Box 3-1
Resident bill of rights A facility must protect and must promote the exercise of rights for all residents.
The following are some of those rights:
1. The right to select a personal attending physician and to receive complete information about one’s care and treatment, including access to all records pertaining to the resident
2. Freedom from physical or mental abuse, corporal punishment, involuntary seclusion, and any unwarranted physical or chemical restraints
3. Privacy with regard to accommodations, medical treatment, mail and telephone communication, visits, and meetings of family and resident groups
4. Confidentiality regarding personal and clinical records
5. Residing in a facility and receiving services with reasonable accommodation of individual needs and preferences
6. Protesting one’s treatment or care without discrimination or reprisal, including the refusal to participate in experimental research
7. Participation in resident and family groups
8. Participation in social, religious, and community activities
9. The right to examine the federal or state authorities’ surveys of a nursing facility
Modified from 42 CFR §483.10.
Most facilities have developed a contract for new residents (or a family member or other responsible person) to sign at the time of admission. This is usually called the admission agreement. This agreement sets forth the rights, obligations, and expectations of each party. It is a good way to inform residents of a facility’s rules,
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regulations, and philosophy of care. This is a practical way to meet the OBRA’s notification and disclosure requirements.
As with any agreement, it can only be a valid contract if the parties entering into the agreement are capable of understanding its provisions. If a resident is not capable of doing this, then a family member or other responsible person may sign on the resident’s behalf. The laws of the particular state should be explored to determine who has standing to contract on behalf of the resident.
The OBRA only allows a facility to transfer or discharge residents in the following situations: (1) if the facility cannot meet the residents’ needs, (2) if their stay is no longer required for their medical condition, (3) if they fail to pay for their care as agreed to, or (4) if the facility ceases to operate. These provisions are designed to establish the basic right of a resident to remain in a facility and not be transferred involuntarily unless one of these conditions exists; they also ensure that a resident has been given proper notice with the opportunity to appeal the decision. This was, in part, a response to situations in which older residents of nursing facilities were “ousted” without notice and perhaps without regard to the detrimental effects (both physical and emotional) of being uprooted from familiar surroundings (AHCA, 2012).
The requirement for a bill of rights for residents is not an entirely new item on the landscape. Many states have had such provisions in their facility licensure statutes for many years. Medicare and Medicaid regulations have also included resident rights requirements for some time. The OBRA strengthened and enhanced the importance of these requirements by enforcing them as part of the facility survey process. Although the specific contents of resident’s rights laws vary considerably from state to state, both the state and federal contents have some similarities. Both are concerned with physician selection, medical decision making, privacy, dignity, the ability to pursue grievances, discharge and transfer rights, and access to visitors and services (AHCA, 2012).
Unnecessary Drug Use and Chemical and Physical Restraints
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The OBRA requires that nursing facility residents be free of unnecessary drugs of all types; chemical restraints, commonly thought of as psychotropic drugs; and physical restraints. Chemical restraints are drugs that are used to limit or inhibit specific behaviors or movements. Physical restraints are appliances that inhibit free physical movement, for example, limb restraints, vests, jackets, and waist belts. Wheelchairs, geriatric chairs, and side rails may, in some circumstances, also be forms of physical restraint (NCEA, 2013).
The OBRA’s guidelines for unnecessary drug use pertain to the use of antipsychotics, benzodiazepines, other anxiolytic and sedative drugs, and hypnotics. As of this writing, the CMS has not developed guidelines concerning antidepressant use because it is believed that depression is undertreated and underrecognized in nursing facilities.
The drug use guidelines are based on the principles that certain problems can be handled with nondrug interventions and that such forms of treatment must be ruled out before drug therapy is initiated. Furthermore, when used, drugs must maintain or improve a resident’s functional status.
An update in the OBRA regulations is in progress. This reflects an interim guidance issued by the CMS (2012) effective in May 2013 regarding clarifications to tags F309 (Quality of Care) and F329 (unnecessary drugs). The nursing facilities are being held accountable by the CMS surveyors for changes to these “F” tags. Since changes occur on an ongoing basis, the reader should go to www.medicare.gov. for up-to-the-minute approvals from Congress on OBRA regulations.
The OBRA’s guidelines detail doses but do not set maximum dosage limitations. The dosage detailing is a way to draw attention to the need for comprehensive assessment and review of drug use. Surveyors review the duration of drug therapy regimens and look for documentation of indications for the use of the drug therapy. Nurses should also carefully document observed effects of drug therapy.
This is an area in which the nurse should exercise skill and
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leadership by working with others on the resident’s care team to ensure that the resident is not overmedicated or unnecessarily medicated. For example, the nurse may work with the interdisciplinary care team to plan nondrug interventions. The nurse is also in a position to inform a resident’s physician about the OBRA’s guidelines with regard to drug use. This may not only be new information for the physician, but it may also provide a sound explanation that the physician can use when speaking with a resident’s family members who may be requesting drug interventions. In fact, the nurse is in the best position to work with residents and their families to provide information and reinforcement about this important approach to care.
Drug toxicities have been underestimated, and at times, drugs have been used to meet the desires of nurses or other facility staff for “environmental control,” for example, to settle residents down for sleep. The need to manage the environment may pose a genuine dilemma for nurses because certain resident behaviors such as yelling or wandering into other residents’ rooms may be disruptive. Such behaviors may cause family members to pressure nurses to calm down such residents or take other steps to stop the bothersome behavior. Nursing facility residents may be challenging in spite of a nursing staff’s intent to provide good care and to identify causes of residents’ disturbing behaviors (Wang, Lin, & Lee, 2006). However, drug therapy should not be used for environmental control.
Physical restraints may be used only when specific medical indications exist and when a physician has written a specific order for their use. The order must include the type of restraint, the condition or specific behavior for which it is to be applied, and a specified time or duration for its use. Orders for a restraint must be reevaluated and, if use is to be continued, periodically reassessed.
The nurse must carefully document the behavior or condition that led to the order for a restraint and monitor the resident’s ongoing condition, noting responses to the application of a restraint and changes in condition. When physical restraints are used, the resident must be observed and the restraints released at regular intervals. Records documenting these activities must be kept.
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The OBRA’s guidelines require that antipsychotic drugs be used at the minimum dose necessary. This minimization must be ensured through careful monitoring and documentation by the staff to identify why a behavioral problem may exist and whether the antipsychotic treatment is actually effecting a change in the target symptom.
Residents receiving an antipsychotic drug must have an indication for the use of the drug on the basis of one of the following conditions:
1. Schizophrenia
2. Schizoid-affective disorder
3. Delusional disorder
4. Acute psychosis
5. Mania with psychotic mood
6. Brief reactive psychosis
7. Atypical psychosis
8. Tourette syndrome
9. Huntington chorea
10. Short-term symptomatic treatment of nausea, vomiting, hiccups, or itching
11. Dementia associated with psychotic or violent features that represent a danger to the patients or others
Reasons for the use of antipsychotic drugs must be documented in the physician’s orders and in the resident care plan. They should not be used for behaviors such as restlessness, insomnia, yelling or screaming, and wandering or because of the staff’s inability to manage the resident.
The OBRA mandates a 25% reduction in dose trial, unless the drug has been tried previously and has resulted in decompensation of the resident or if the resident has one of the 11 conditions listed earlier. A “reduction in dose trial” consists of a reduction in the dose of the drug coupled with observations to note the return of
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symptoms or any adverse side effects. The dose is gradually increased until the optimal effectiveness in treatment response and the minimum necessary dose are achieved.
The physician’s order must include the following specific information: (1) the reasons for the use of antipsychotic drugs, including medical indications; (2) the target behaviors that the drug therapy is intended to treat; (3) the goals of therapy; and (4) common side effects. These notations must also be entered in the resident’s care plan. The observations and charting made by the nurse must also address these specific points.
A facility is not absolved from regulatory liability by the mere presence of a physician’s written order for restraints of any kind. The nursing staff is professionally responsible for challenging questionable orders (Johnson, 1991). For example, statement three and its interpretation in the Code for Nurses identify the nurses’ responsibility to “safeguard the patient,” and to challenge any “questionable practice in the provision of health care.” Nurses should participate in the development of problem-solving procedures that are established to provide constructive and effective ways to resolve disputes involving patient care issues. Such procedures generally provide an avenue of communication that may be used to resolve questions or disagreements that arise between health care professionals. When a question or issue does arise, the nurse must institute the dispute resolution procedure promptly (Hawes, Mor, Phillips, 1997).
Reductions in the use of physical restraints and almost universal use of CMS’s resident assessment system are indications that nursing facility reform is working (Suffering in silence, 1993). Recent studies indicate that antipsychotic drug use is down, resulting in economic benefits and improving the quality of life for nursing facility residents (CMS, 2012).
Nurses have been successful in employing practices directed toward avoiding the use of chemical or physical restraints. Some of these techniques are companionship; increased patient supervision; meeting physical needs such as toileting, exercise, or hunger; modifying staff attitudes; and other psychosocial approaches. Again, it is obvious that nurses are in a unique position to
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positively affect the quality of life of institutionalized older adults. Nurses should continue to educate others about these behavior management techniques.
Urinary Incontinence Urinary incontinence is one of three key reasons older adults enter nursing facilities (Suffering in silence, 1993). In fact, more than half of nursing facility residents are incontinent. Left untreated, this condition may lead to other physical problems such as infections and skin breakdown.
Because this is a prevalent condition and one that has implications for the quality and enjoyment of life, it may be expected to remain a major area of regulatory scrutiny. Under the OBRA, nursing facilities are required to include incontinence in the comprehensive assessment of a resident’s functions and to provide the necessary treatment.
Furthermore, surveyors of the state Division of Aging are being instructed to focus on this problem by evaluating its occurrence in the nursing facilities they survey and assessing the extent to which residents are involved in bladder training programs.
Nurses should be familiar with guidelines and procedures for management of incontinence, for example, the Agency for Health Care Policy and Research Guidelines (refer to Chapters 26 and 28 for more information). Charting should be specific to reflect the presence and extent of the problem of incontinence, and it should note the treatment plan that has been established and the effects of the treatment. From the OBRA perspective, behavioral approaches are preferable to more intense mechanical or chemical therapies.
Facility Survey and Certification The CMS is determined to see that every nursing facility implements and complies with the letter and spirit of the OBRA’s requirements. This determination is enforced through a process of surveying facilities, and the decision of the CMS (2012) is based on the results of the surveys, which certifies a facility’s compliance with the OBRA’s laws and regulations.
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The enactment of the OBRA created a new survey process. In general, the standard survey is conducted to review the quality of care by evaluation of criteria such as medical, nursing, and rehabilitative care; dietary services; infection control; and the physical environment.
Written care plans and resident assessments are evaluated for their adequacy and accuracy, and the surveyors look for compliance with residents’ rights. The OBRA’s long-term care survey processes have a renewed emphasis on the outcome of resident care rather than mere paper compliance with regulatory requirements.
By contractual arrangement with the DHHS, state survey agencies are authorized to certify the compliance of facilities. States are also required to educate facility staff regarding the survey process and are further authorized to investigate complaints of all types. On the basis of reports of persistent problems in nursing facilities, the CMS will strengthen federal oversight of nursing facility quality and safety standards. These steps will include more frequent inspections for repeated offenders or facilities with serious violations; more inspections carried out on weekends and evenings; targeting of states with weak inspections systems; and requiring the assurance that state surveyors enforce the policies of the CMS to sanction nursing facilities with serious violations (CMS, 2012).
Surveys are conducted by a multidisciplinary survey team of professionals, including at least one RN. Survey participants include facility personnel, residents and their families, and the state’s long-term care public advocate that investigates complaints, known as an ombudsman. Surveyors interview residents and ask them about facility policies and procedures. They observe staff in the performance of their duties, and staff may be asked to complete forms required by the survey team.
Enforcement Mechanisms and Sanctions The DHHS and the states may apply sanctions or penalties against a facility for failure to meet requirements and standards. Such sanctions may include civil monetary penalties, appointment of a
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temporary manager to run a facility while deficiencies are remedied, or even closure of a facility or transfer of residents to another facility (or both). In addition, the CMS plans to publish individual nursing facility survey results and violation records on the Internet to increase accountability and flag repeated offenders for families and the public (CMS, 2004).
The sanctions applied must be appropriate to the facility deficiency. This often depends on whether an immediate threat to the health and safety of residents exists. Sanctions may also be increased if there are repeated or uncorrected deficiencies. Deficiencies are analyzed on the basis of the scope of the deficiency —that is, whether it constitutes a pattern of activity or whether it is an isolated or sporadic occurrence—and the severity of the deficiency—that is, the extent to which it presents a threat to the safety and welfare of residents. To assist in analysis, the scope and severity factors are laid out on a “grid” and sanctions are applied based on the result of this analysis.
It is important for the nurse to understand that officials authorized by the state or federal agencies that oversee the operation of nursing facilities (or any licensed health care institution or setting) may enter and review activities at any time. They are not required to announce the visit in advance (in fact, the OBRA’s regulations specifically prohibit this for the annual standard survey), and the nurse must respond to their questions and requests for information and records.
The director of nursing has an important role in the survey process. If requested to do so by the surveyor, the director may participate in rounds or other activities of the surveyor; the director is also present at a closing conference in which the overall results of the survey are discussed. Often, the surveyors follow up the visit by telephone, or they may return for additional visits to a facility if further information is needed.
A written report of the survey is ultimately sent to the facility, and if deficiencies or violations are present, the director of nursing and other members of the nursing staff may participate in formulating a plan of correction to submit to the regulatory officials.
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In the course of an inspection a surveyor may find information suggesting that the practice of a licensed nurse may have been improper or may not have met the proper standard of care. For example, a particular nurse may have a high incidence of medication errors or may not have taken proper action when a patient experienced a change in condition. In such cases, the surveyor may forward the record showing the relevant findings to the appropriate state agency or board for review of the nurse’s practice, requesting a determination of whether the nurse may have violated the state’s nurse practice act. The board may find no basis for further action and not proceed, or it may require a hearing or other measures that could lead to disciplinary action. Disciplinary action could range from a reprimand, to required educational remediation, to suspension or revocation of the nurse’s license. This again underscores the need for nurses to be diligent and conscientious in their professional practice and to remember that they will be held accountable for their individual performance.
Proposed Legislative Changes The federal government, while recognizing certain improvements in the care of nursing facility residents, has also been alarmed by reports of persistent serious problems. In part, this concern is the result of a report by the DHHS, which was the subject of congressional hearings in the summer of 1998. Changes made to achieve the goals of the CMS are addressing these issues.
Congress has taken some steps to ensure a safe environment for nursing facility residents. For example, the OBRA requires all states to establish and maintain a registry of nurse aides who are unfit to provide care because of abusive or criminal histories. In addition, 33 states currently require nursing facilities to do criminal background checks on new job applicants. However, most states require only checks of the states’ own criminal database and not a national database. This permits unsuitable workers to gain employment by crossing state lines.
In July 1998, using existing authority, President Bill Clinton ordered a step-up in nursing facility survey and enforcement
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activities. Specifically, he announced steps to make facility inspections less predictable by ordering state officials to inspect the facilities at night and on weekends. He further instructed officials to focus these enforcement activities on facility operators with a history of poor performance. Furthermore, through emphasis on training of nursing assistants, he stepped up initiatives to enhance the ability to care for residents with pressure ulcers, dehydration, and nutrition problems (Pear, 1998). The CMS has continued to develop action plans to improve these areas.
Affordable Care Act The Affordable Care Act (ACA) was passed by Congress on March 21, 2010, and signed into law on March 23, 2010, by President Barack Obama. The law was challenged but was upheld by the United States Supreme Court on June 28, 2012. The ACA represents the largest change in the United States Health Care System since 1965 when Medicare and Medicaid were enacted and initiated. The main goal of the ACA is to help reduce the numbers of Americans who do not have health insurance and to further reduce the overall costs of health care in the United States. Various provisions of the ACA will be phased in over a 10-year period. Guaranteed coverage is a requirement. All Americans will be issued a health insurance policy regardless of community rating, preexisting medical conditions, or age. Everyone within the same age group and location must be charged the same premium. Failure to sign up for coverage may lead to penalties assessed by a Health Insurance Tax (HHS, 2013).
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Autonomy and self-determination The right to self-determination has its basis in the doctrine of informed consent. Informed consent is the process by which competent individuals are provided with information that enables them to make a reasonable decision about any treatment or intervention that is to be performed on them.
A great deal of legal analysis has been applied to the question “What is enough information for a person to make a reasonable decision?” It is generally accepted that for consent to be valid and legally sufficient, a standard of disclosure must be met that includes the diagnosis, the nature and purpose of the treatment, the risks of the treatment, the probability of success of the treatment, available treatment alternatives, and the consequences of not receiving the treatment.
Informed consent has developed from strong judicial deference toward individual autonomy, reflecting a belief that individuals have a right to be free from nonconsensual interference with their persons, and the basic moral principle that it is wrong to force others to act against their will (Furrow et al., 1987). The judicial system’s strong deference toward individual autonomy in the medical context was articulated long ago by Justice Benjamin Cardozo:
Every human being of adult years and sound mind has a right to determine what shall be done with his own body.6
The right to self-determination, then, has a long-standing basis in the common or case law and has roots under the right of liberty guaranteed by the U.S. Constitution. These common law rights, to a large extent, have been codified, acted on by legislatures, and enacted into statutory law. The codification of these legal rights should serve to make the legal tools of self-determination more readily available to the citizenry. Nurses should be careful, however, because sometimes the opposite effect occurs. Rather than making mechanisms for the exercise of consent more available, the codification of these rights sometimes results in a view that the
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absence of a legal, written tool or directive such as a living will or a signed consent form means that a patient’s decision has not been made. However, there may, in fact, be other sources of information that express a person’s wishes, and caregivers should not presume that the absence of a written document is the same as a lack of consent. Rather, nurses must remember that the right to decide what shall be done for and to oneself is a fundamental right and legal tools should be used to assist, not detract, from that basic human right. The nurse’s role as advocate has a high degree of importance in this regard.
The right to self-determination covers all decisions about one’s care and treatment, including the removal of life support or life- sustaining treatments and life-prolonging or lifesaving measures. These issues are particularly relevant to older adults. Although individuals of all ages are concerned with these matters and young persons do die, incapacity and infirmity are more common in old age. Therefore, more frequent discussion of the need to preserve the right to self-determination occurs among older adults.
The doctrine and standards of informed consent are intended to apply to the decision-making capability of one who is competent to make such a decision. In this context, the term competent refers to the ability to understand the proposed treatment or procedure and thereby make an informed decision.
When a person is not competent, the decision may be made by a surrogate. This is known as “substituted” judgment. More discussion on this point appears later in the chapter.
Do Not Resuscitate Orders A “Do not resuscitate” (DNR) order is a specific order from a physician, entered on the physician order sheet, which instructs health care providers not to use or order specific methods of therapy, which are referred to as cardiopulmonary resuscitation (CPR) (Lieberson, 1992).
CPR generally includes those measures and therapies used to restore cardiac function or to support ventilation in the event of a cardiac or respiratory arrest7 and to handle emergencies caused by
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sudden loss of oxygen supply to the brain as a result of lung or heart failure.
DNR orders have been used for many years. In 1974, the American Medical Association (AMA) recommended that decisions not to resuscitate a patient be formally entered into the medical record, although this was a practice that had already become widespread (Lieberson, 1992).
New York is one of only a few states that have passed specific codified procedures covering DNR orders, and this statute is useful to look to for guidelines.8 The law applies to patients in general hospitals and in nursing facilities.9 In New York, consent to CPR is presumed unless a DNR order has been issued.10 As is customary, a presumption of competency to make such a decision also exists.11 Competent individuals may choose to forego any treatment or care, even if the choice will result in death.
For a person to choose to accept or reject medical care, that person must be determined to be competent. The reluctance of courts to articulate a standard for competence has resulted in very few reported opinions that state any formal opinion of competency. Rather, courts prefer to involve physicians, often psychiatrists, and other caregivers in testifying about the mental state of a person, and the courts base the determination of competency on that information (Furrow et al., 1987).
The capacity to make decisions is applicable only to the decision being made at the time. Even if a person has appointed an agent to manage his or her affairs, this does not necessarily mean that the person is incompetent in any total sense. “It is ethically inappropriate to assign blanket ‘incapacity to decide’ to the [older adult] patient based on isolated areas of irrationality.”12
In a court determination of competency, the nurse may be called on to testify and will be asked to offer information relative to the client’s behavior or verbalizations that may give evidence of the person’s state of mind. The medical record is extremely important in this type of proceeding, and the nurse will want to use it to back up any testimony given.
Older adults are more often faced with issues concerning the
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right to self-determination, and in such matters, patients’ statements and other indications of their wishes, as well as their state of mind, are critical. Nurses should keep these points in mind when they are responsible for the care of older adults, and they should make certain that records and notations, assessments, and other ongoing observations are carefully, objectively, and accurately documented. If a time comes when a nurse needs to refer to records to testify in a court proceeding, the information provided will be used to help determine how an individual’s basic rights are being addressed. A nurse can be secure in knowing that everything has been done to see that the resident’s rights are respected.
Guidelines for DNR Policies in Nursing Facilities Nurses often raise questions and are faced with dilemmas about DNR policies because of inconsistency or uncertainty in either the existing policy or the application of procedures. Because the nurse may be the only health care professional present in the nursing facility at any given time, it is imperative for the nurse to request that the facility have a detailed and specific policy to provide the necessary guidance.
If a facility does develop a DNR policy, the following guidelines should be considered. Whatever policies are adopted should be well communicated to the staff and should be adhered to scrupulously. The policy should indicate:
• That a facility must have competently trained staff available 24 hours a day to provide CPR (Schreiber, 1990).
• Whether CPR will be performed unless a DNR order exists.
• The conditions under which the facility will issue DNR orders. These factors should be in compliance with applicable state law; thus, it is necessary to examine the DNR provisions of the jurisdiction. Considerations include required physician consultations regarding medical conditions and documented discussions with the patient and family members.
• That competency is established, again with proper documentation or medical consultation, as may be indicated by applicable state law.
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• The origin of consent for the order: via the patient, while competent; by an advance medical directive (AMD); or by a substitute or surrogate decision maker.
• Provision for renewal of DNR orders at appropriate intervals with ongoing documentation of the condition to note changes.
• As required by the TJC standards, the roles of various staff members. The policy should be approved through all appropriate channels (see Standard CP 1.5.18 and its subsections; Long Term Care Standards Manual, 1989).
Advance Medical Directives AMDs are documents that permit people to set forth in writing their wishes and preferences regarding health care. AMDs are used to indicate their decisions if the time should come when they are unable to speak for themselves. Some advance directives also permit people to designate someone to convey their wishes in the event they are rendered unable to do so. AMDs are helpful to professionals because they provide information and guidance when treatment decisions are made.
A number of issues pose problems to the professional in honoring advance directives. First, an advance directive is not operative until the patient is no longer capable of decision making (Lieberson, 1997). Therefore, the first decision must be whether a patient is capable of making a decision or whether the advance directive must be followed. At times, the patient may be awake and responsive but not clear in his or her ability to think or communicate (Lieberson, 1997). However, if a determination of incapacity is made, then an advance directive may be looked to, as it would speak when the person cannot.
Sometimes, the policy of the provider or the judgment of the treating physician may not be in accord with the patient’s wishes. In such cases, it is necessary to advise the patient of this. For example, if a nursing facility does not offer CPR and the patient desires that option, then the facility must advise the patient and offer the option of transfer. In the same way, a physician who does not agree with or cannot carry out the patient’s wishes must advise
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the patient of this and must then transfer the care of the patient to another physician as soon as it is practical to do so.
Remember, the right to self-determination is well grounded in the common law and is interpreted in the U.S. Constitution under the right of liberty. The statutory developments and codification of these principles promote communication and make it easier for individuals to exercise their right to autonomy.
Legal Tools Living Wills or Designation of Health Care Agents Living wills (LWs) are intended to provide written expressions of a patient’s wishes regarding the use of medical treatments in the event of a terminal illness or condition. Health care agent designations entail appointing a trusted person to express the patient’s wishes regarding the withholding or withdrawal of life support.
Allowing for variations among states, LWs are generally not effective until (1) the attending physician has the document and the patient has been determined to be incompetent, (2) the physician has determined the patient has a terminal condition or a condition such that any therapy provided would only prolong dying, and (3) the physician has written the appropriate orders in the medical record (Lieberson, 1992). The LW is not the same instrument as a DNR. The DNR is a medical directive, not a personal directive (Jett, 2012).
States differ in the type of written instruments used for these purposes. For example, New York does not have a living will statute as such but does have a health care proxy provision, which combines the elements of the living will and the designation of a health care agent.
General Provisions in Living Wills Living wills may be executed by any competent adult. Most statutes contain specific language excluding euthanasia and declaring that withholding care in compliance with the document does not
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constitute suicide.
Most statutes require that the patient’s signature be witnessed. The witness usually does not have to attest to the patient’s mental competence; however, many forms require that the witness indicate that the principal “appeared” to be of sound mind.
In general, it is also prohibited for an owner or employee of a facility in which a patient resides to serve as a witness to a signature, unless the owner is a relative. In some states, a person who has an interest in the patient’s estate may not serve as witness or be designated the health care agent.
Pain and comfort measures may not be withheld. A living will may be revoked at any time and by any means.
Durable or General Power of Attorney: Differences and Indications The durable power of attorney for health care (DPAHC) is a legal instrument by which a person may designate someone else to make health care decisions at a time in the future when he or she may be rendered incompetent. This is called a springing power, which comes into effect in the future on occurrence of a specific event—in this case, the incompetence of the patient.
The person delegating the power of attorney for health care is called the principal, whereas the person to whom the power is granted is known as the agent. A DPAHC is different from a general power of attorney in that a general power of attorney would become invalid upon determination of the incompetence of the principal.
Thus, the DPAHC allows the designation of a legally enforceable surrogate decision maker. The role of the designated surrogate in this situation is to make the decisions that most closely align with the patient’s wishes, desires, and values.
The DPAHC has an advantage over the LW in that the designated agent may assess the current situation, ask questions, and gather information to assist in determining the probable wishes of the patient. The living will, however, speaks for the patient who
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cannot speak for himself or herself; obviously, it cannot ask questions (Jett, 2012).
All states now have laws providing for types of LW documents, DPAHCs, or both. Because specifics of the laws vary from state to state, it is important for the nurse to be knowledgeable of the laws in the state in which he or she practices. Furthermore, because this is a developing area of the law, the nurse should keep abreast of changes. Depending on a nurse’s work environment, resources for this information may be the facility administration, risk management staff, legal counsel, or another appropriate source.
Decision Diagram The decision diagram assists in understanding the thought process that should be followed when trying to analyze end-of-life decision- making situations (Box 3-2).
Box 3-2
End-of-life decision diagram
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Right to Self-Determination • Can reject lifesaving treatment
• In a position to “speak for oneself”
Determination of Competence • Medical and family judgment
• Court determination
Right to Self-Determination • What have they told others?
• What advance directives have been prepared?
• Must they speak through writings or another person?
If patients are competent, then they are capable of making their own decisions. While competent, a person may prepare for possible future incompetence by executing an AMD and by discussing
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personal wishes with health care professionals and family members so that they fully understand that person’s specific preferences for future care and treatment.
When the time comes for an AMD to be used, a verification of incompetence will be made. This is normally accomplished through medical judgment and family discussion. Laws of any jurisdiction should be evaluated to see what documentation and procedures are required.
Once a person is deemed incompetent, substituted decision- making alternatives must be chosen. If a person has not executed an AMD, other people are looked to for their knowledge about the patient’s wishes. If all agree about the patient’s medical condition, then the statutory order of priority for surrogates can be looked to for designation of the decision maker. If an AMD has been executed and an agreement exists among health care professionals and family, then the wishes may be carried out according to the AMD.
Where lack of agreement or confusion is present, it may be necessary to seek a court-ordered conservator. (This person is sometimes referred to as a guardian; the word conservator is used here, but jurisdictions may assign varied meanings to these terms.) The conservator then acts as the surrogate and decides according to the patient’s wishes as can best be determined by available information. The conservator also makes such decisions in the best interests of the patient. This refers to a conservator of the person, as opposed to a conservator of property, who deals with matters related to an individual’s property and belongings and thus is not a subject of this discussion (see Chapter 18, for a further discussion on end-of-life issues).
The court-appointed conservator has priority over other decision makers. The conservator may be a spouse, parent, or other family member. It may also be any other person the court determines may best serve the interests of the patient. For a paradigm of end-of-life decision making, see Box 3-2.
An example of a typical LW document is presented in Box 3-3, and an example of a document concerning appointment of a health care agent is presented in Box 3-4. States usually provide forms for
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these purposes but may not require that the specific form be used. Rather, most simply require that the executed documents be in substantially the same form. In any event, the laws of the jurisdiction should be reviewed to see if a specific form or document is required.
Box 3-3
Living will: connecticut general statutes § 19a-575. form of document Any person 18 years of age or older may execute a document which shall contain directions as to specific life support systems which such person chooses to have administered. Such document shall be signed and dated by the maker with at least two witnesses and may be substantially in the following form:
Document Concerning Withholding or Withdrawal of Life Support Systems If the time comes when I am incapacitated to the point where I can no longer actively take part in decisions for my own life, and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes.
“I ………………. (NAME) request that, if my condition is deemed terminal or if it is determined that I will be permanently unconscious, I be allowed to die and not be kept alive through life support systems. By terminal condition, I mean that I have an incurable or irreversible medical condition which, without the administration of life support systems, will, in the opinion of my attending physician, result in death within a relatively short time. By permanently unconscious I mean that I am in a permanent coma or persistent vegetative state that is an irreversible condition in which I am at no time aware of myself or the environment and show no behavioral response to the environment. The life support systems that I do not want
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included, but are not limited to:
Artificial respiration
Cardiopulmonary resuscitation
Artificial means of providing nutrition and hydration (Cross out any initial life support systems you want administered.)
I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.
Other specific requests:
This request is made, after careful reflection, while I am of sound mind.
………………… (Signature)
………………… (Date)
This document was signed in our presence, by the above- named
………………… (NAME) who appeared to be 18 years of age or older, of sound mind, and able to understand the nature and consequences of health care decisions at the time the document was signed.
………………… (Witness)
………………… (Address)
………………… (Witness)
………………… (Address)
Box 3-4
Health care agent: connecticut health care agent (C.G.S. § 19A-577) (a) Any person 18 years of age or older may execute a document that may, but need not, be in substantially the following form:
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Document Concerning the Appointment of Health Care Agent I appoint..................... (NAME) to be my health care agent. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and to reach and communicate an informed decision regarding treatment, my health care agent is authorized to:
(1) convey to my physician my wishes concerning the withholding or removal of life support systems.
(2) take whatever actions are necessary to ensure that my wishes are given effect.
If this person is unwilling or unable to serve as my health care agent, I appoint..................... (NAME) to be my alternative health care agent.
This request is made, after careful reflection, while I am of sound mind.
………………… (Signature)
………………… (Date)
This document was signed in our presence, by the above- named
………………… (NAME) who appeared to be 18 years of age or older, of sound mind, and able to understand the nature and consequences of health care decisions at the time the document was signed.
………………… (Witness)
………………… (Address)
………………… (Witness)
………………… (Address)
Conflicts between Directives and Family Desires
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Families may disagree with the directives of a family member. Often, family members express the desire to have more care than is requested by a patient. The law upholds the expressed desires of a patient over those of the family, but families may try to exert influence to bring about a decision that is sometimes contrary to the patient’s expressed wishes (Lieberson, 1997). This puts physicians and nurses in confusing and conflicting situations.
Although the law consistently upholds the expressed desires of patients, families continue to exert influence over medical decisions, even when they support decisions known to be contrary to the patient’s wishes. Designated health care agents may also find themselves in conflict with family members who question the control of the agent and may not understand why the agent has been given this control (Kulkarni, Karliner, Auerbach et al., 2010).
Most AMD statutes specifically provide immunity for physicians who follow, in good faith, the wishes of a patient as expressed therein. Nurses should note that in most cases, this immunity applies only to the physician and not to the nurse because the physician is given the legal duty to put into effect the patient’s wishes. Consequently, the nurse must rely on effective communication with the physician, the patient, and the family, and on the quality of the facility’s policies and procedures, to be sure that his or her actions are consistent with the legally required steps. In addition, an effective ethical process for discussion and problem solving, discussed elsewhere in this chapter, is critical in these situations.
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The patient self-determination act The Patient Self-Determination Act13 (PSDA) came into effect on December 1, 1991. The intent of this law is to ensure that patients are given information about the extent to which their rights are protected under state law. The PSDA itself does not create any new substantive legal right for individuals regarding their decision making. Rather, its focus is on education and communication.
The PSDA requires hospitals, nursing facilities, and other health care providers who receive federal funds such as Medicare or Medicaid to give patients written information explaining their legal options for refusing or accepting treatment should they become incapacitated.
Background: The Cruzan Case On January 11, 1983, Nancy Cruzan, a healthy 25-year-old woman, was seriously injured in an automobile accident; she became comatose and remained in a persistent vegetative state. Seven years later, the U.S. Supreme Court considered whether her life support could be withdrawn. Her parents, who had also been designated her co-guardians by a judgment of the court, sought a court order to withdraw the artificial feeding and hydration equipment after it became apparent that she had virtually no chance of regaining her cognitive facilities.14
In June 1990, in a 5-to-4 decision, the Court held that because no clear and convincing evidence of Nancy’s desire to have life- sustaining treatment withdrawn under such circumstances, her parents did not have the authority to carry out such a request.14 The Court affirmed that the Missouri Supreme Court was within its rights to request more evidence to indicate what Nancy’s decision would be if she were in a position to make that decision herself. It was in this decision that the Court permitted the state of Missouri (and thus made it constitutionally permissible) to require “clear and convincing proof” as the standard needed to determine a person’s wishes regarding the withdrawal of life support.
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Most states have not adopted this rigorous standard of proof for such decisions. In fact, as of this writing, only two states—Missouri and New York—use the “clear and convincing” standard. In most jurisdictions, family members, those close to the individual, or other surrogate decision makers may make decisions for a patient who has not left specific oral or written instructions (Coleman, 1994).
Clear and Convincing Proof It is difficult, if not impossible, to come up with a precise meaning of “clear and convincing proof.” Although this standard is not applied in most states, a discussion is presented here to provide insight into the Cruzan case, to help understand the significance of the Court’s decision to initiate AMD legislation nationwide and to enact the PSDA and to provide some clarification for understanding a lesser standard of proof.
The clear and convincing standard is an intermediate standard of evidence, higher than a “preponderance of the evidence” but below “certainty beyond a reasonable doubt.” A clear and convincing presentation should provide enough facts to produce in the mind of the adjudicator a “firm belief or conviction” regarding the events to be established (Black, 1979).
An AMD may help meet this standard. However, in the absence of an AMD, the evidence required to meet this standard is somewhat cloudy. Documents such as an LW would be accorded more weight than oral statements.
In re Westchester County Medical Center on Behalf of O’Connor15 described the clear and convincing standard as “a firm and settled commitment . . . under circumstances like those presented”; it must be “more than immediate reactions to the unsettling experience of seeing or hearing another’s unnecessarily prolonged death.”16
The Cruzan decision must be examined for the areas of clarification it provides. Although it does not declare a “right to die” as such, it does provide much stimulus for the development of state legislation to clarify the existing rights to self-determination. In addition, it also served as the catalyst for the enactment of the PSDA:
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A competent person has a constitutionally protected right under the Fourteenth Amendment to refuse medical treatment, even life saving nutrition and hydration; an incompetent or incapacitated person may have that right exercised by a surrogate.17
In her concurring opinion, U.S. Supreme Court Justice Sandra Day O’Connor made the following points (the interpretation is the author’s analysis of points taken from the concurring opinion of O’Connor):
Artificial provision of nutrition and hydration involves intrusion and restraint and invokes the same due process concerns as any other medical treatment.
One does not by incompetence lose one’s due process liberty interests.
The U.S. Constitution may require the states to implement the decision of a client’s duly appointed surrogate.18
The Four Significant Provisions of the PSDA The PSDA has four significant provisions:
1. It requires hospitals, SNFs, home health agencies, hospice programs, and health maintenance organizations (HMOs) that participate in Medicare and Medicaid programs to maintain written policies and procedures guaranteeing that every adult receiving medical care is given written information regarding his or her involvement in treatment decisions. This information must include (1) individual rights under state law, either statutory or case law; and (2) written policies of the provider or organization regarding the protection of such rights. When state advance directive laws change, facilities must update their materials accordingly, but no later than 90 days after the changes in state laws.
• The information must be provided by hospitals at the time of admission, nursing facilities at the time of admission as a resident, hospice programs at the time of the initial receipt of hospice care, HMOs at the time of enrollment, and home health agencies in advance of the individual coming under the agencies’ care.
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• The PSDA further requires distribution of written information that describes each facility’s policy for protecting the rights of patients. Each patient’s medical record must document whether the patient has executed an AMD.
• The PSDA also provides protection against discrimination or refusal to provide care based on whether an individual has executed an AMD.
• A facility may engage a contractor to perform services required by the PSDA, but it retains the legal obligations for compliance with the law.
• If a patient or resident is incapacitated at the time of admission, the required information may be furnished to the family member or responsible party, but the patient or resident must be provided with the material at such time as he or she is no longer incapacitated.
2. The provider must provide for education of staff and community on issues concerning AMDs but is not required to provide the public with the same material it provides patients.
3. States are required to develop a written description of the law concerning AMDs in their respective jurisdictions and to distribute the material to providers who provide it to patients according to the requirements of the PSDA.
4. The secretary of the DHHS was also required to develop and implement a national campaign to inform the public of the option to execute AMDs and of the patient’s right to participate in and direct his or her health care decisions.
Nurses’ Responsibilities The ANA (1992) published the following statement made by its board of trustees, articulating the nurse’s important role in implementation of the PSDA: “Nurses should know the laws of the state in which [they] practice . . . and should be familiar with the strengths and limitations of the various forms of advance directive. The nurse has a responsibility to facilitate informed decision making, including but not limited to advance directives.”
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The ANA recommends that the following questions be part of the nursing admission assessment:
• Do you have basic information about advance medical directives, including living wills and durable power of attorney?
• Do you wish to initiate an advance medical directive?
• If you have already prepared an advance medical directive, can you provide it now?
• Have you discussed your end-of-life choices with your family or designated surrogate and health care team workers? (ANA, 1992)
Problems and Ethical Dilemmas Associated with Implementation of the PSDA Although public and medical professionals overwhelmingly support AMDs, patients have historically been reluctant to complete them. Even distribution of forms and information has failed to increase the participation rate.
During the first 2 years after the enactment of the PSDA, only about 5% to 15% of patients completed AMDs or were even familiar with their rights of self-determination (Parkman, 1997). By the end of 1994, 90% of Americans reportedly supported AMDs, yet only 10% to 20% had actually written one (Parkman, 1997). Overall, data suggest that despite enactment of the PSDA, most patients still do not complete AMDs (Jett, 2012; Lieberson, 1997).
Other research indicates that care of dying patients may not be keeping pace with national guidelines or legal decisions upholding patients’ rights to accept or refuse treatment. Physicians may be reluctant to discuss AMDs with their patients. The major barriers to this communication process are lack of knowledge about AMDs and the belief that AMDs are not necessary for young healthy patients. Other studies have found that patients’ personal desires do not always get attention, and physicians try to avoid discussion of grim subjects (Parkman, 1997).
Questions arise about the effectiveness of AMDs in situations where, for example, the person is away from home, a person
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changes his or her mind, or an unanticipated event occurs. Some approaches have been recommended with regard to these issues.
For example, some states have included in the language of LW provisions that a validly executed LW from another jurisdiction will be honored. However, if any uncertainty exists, it is probably wise to have people from the other state execute a new document as soon as possible.
AMD provisions appropriately allow people to change their minds at any time and by any means. Nurses need to be alert to any indications from a patient. Because of the person’s medical condition, subtle signs such as a gesture or a nod of the head may be easily overlooked.
The protocols established by facilities to comply with the PSDA may turn the “tangible indicators of extremely important and personal decisions into just another piece of paper.” AMDs must be part of a clinical process, not an administrative one (Kulkarni et al., 2010; LaPuma, Orrentlicher, & Moss, 1991). These very personal and difficult questions may be asked along with routine questions about finances and next of kin. The meaning and importance of these issues may be undermined if they become merely a routine administrative procedure.
Many have questioned whether the time of admission to a hospital or a nursing facility is the best time to discuss AMDs. At such times, patients may be fearful, uncomfortable, in pain, and anxious. These emotional states may affect a patient’s understanding and level of competence. It is important for the nurse to facilitate this process using the professional skills and understanding necessary to comply with the PSDA in such circumstances (Stillman et al., 2005).
Conflicts between medical judgment and patient choices are bound to become more common. It will be necessary to take steps to ensure that the directives of patients are accorded appropriate compliance and that the judgment of health care professionals is respected.
As discussed previously, both the PSDA and the OBRA require that a facility or a physician who is unable to comply with the
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patient’s wishes notify the patient when it is appropriate to be transferred to another facility or to the care of another physician. This ensures that the patient’s wishes are respected and preserves the integrity of the medical practitioner and provider. The medical record should reflect only the facts of such a situation. It is neither necessary nor appropriate to “make a case” in the record as to which party was right or wrong. It is appropriate only to show that proper procedures were followed and that all relevant matters were fully explained.
Many unanswered questions in the PSDA still remain and will have to be sorted out over time. For example, the exact time of admission may be unclear. How is the matter handled with those who are illiterate? What should the nurse do if patients refuse to produce their AMDs? In the case of surrogate decision makers, what about the response of a designated agent who is then called on to decide about the removal of life support? If and when the time comes, will the person be able to carry out the principal’s wishes? Will the instructions left be clear enough to ensure that those wishes are carried out? (Kulkarni et al., 2010)
The responsibility to make these truly profound decisions may arise at times of great personal difficulty and may, in fact, be more demanding than the agent ever thought possible. A realistic approach to these points at the time such instruments are executed will help resolve such dilemmas. The nurse should be alert for opportunities to gain information from both patients and their families or health agents to gauge their level of understanding. The nurse’s role in clarifying matters and in explaining information may help alleviate the emotional dilemma associated with carrying out end-of-life decisions.
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Values history AMDs such as LWs and DPAHCs are easing some of the difficult situations faced by health care professionals and families when making decisions about treatment to prolong life. However, one criticism of such documents is that they may not offer insight into the person’s own values or underlying beliefs regarding such directives (Jett, 2012).
A values history may help add this dimension to decision making regarding AMDs. The values history is an instrument that asks questions related to quality versus length of life and tries to determine what values a person sees as being important to maintain during terminal care. The instrument asks people to specify their wishes regarding several types of medical situations. It presents the types of treatment that may be available in each situation and describes the persons with whom these matters have been discussed in the past and who should be involved in the actual decision making.
As a practical matter, its use may be limited by the time required for discussion with the physician or by the physician’s discomfort or reluctance to directly address the issues. However, this should not serve as a reason to abandon this potentially useful tool.
The values history has important implications for the nurse. The values history is really more than a document with questions and answers. It is a process of reflection. These reflections add information that is gained over a lifetime. The close interpersonal relationships that nurses develop with patients and families and their high degree of communication skills speak to the critical role they can play in this process. As life-and-death situations become more complex and begin to demand real knowledge of the patient’s wishes, the values history may help preserve the autonomy of the individual.
The values history may encourage extended conversation between individuals and their physicians and other health care professionals. This type of instrument may increase autonomy by
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providing a better basis for representing the patients’ desires when they can no longer express their wishes. A copy of the values history developed at the University of New Mexico is included at the end of this chapter in Appendix 3A.
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Nurses’ ethical code and end-of-life care Ethics relate to the moral actions, behavior, and character of an individual. Nurses occupy one of the most trusted positions in society, and conforming to a code of ethics gives evidence of acceptance of that responsibility and trust. A code of ethical conduct offers general principles to guide and to evaluate nursing actions (ANA, 1995).
The role of the health care professional is to maintain patient autonomy, maintain or improve health status, and do no harm (Sabatini, 1998). The nurse–patient relationship is built on trust, and nurses’ understanding of the key ethical principles is the basis of a trusting relationship. The key ethical principles should serve as a framework for nursing decision making and application of professional judgment. These key ethical principles are autonomy or self-determination, beneficence (doing good), nonmaleficence (avoiding evil), justice (allocation of resources), and veracity (truthfulness) (Sabatini, 1998). Issues related to ageism, ethnicity, sexual orientation, gender, physical or mental disability, and race are critical areas of difference that may affect the provider–patient relationship (Sabatini, 1998). These factors must be acknowledged and addressed if the moral and ethical principles of the provider– patient relationship are to be respected.
Scope and Standards of Gerontological Nursing Practice, Professional Performance Standard V, states that a gerontologic nurse’s practice is guided by the Code for Nurses, established by the ANA as the guide for ethical decision making in the practice of nursing (ANA, 2001). The code explains the values and ideals that serve as a framework for the nurses’ ethical decision making and conduct (Rushton & Scanlon, 1998). A violation of the ethical code may not, in itself, be a violation of law. The state’s nursing association may take action against a nurse who has committed a violation of the ethical code. More important, the ethical code serves to regulate professional practice from within the profession and ensure ethical
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conduct in the professional setting. Maintaining mutual respect among practitioners in the field is arguably one of the best ways to bring respect to the profession and to oneself.
Ethical directives guide and direct the nurse who is caring for dying patients. Care of the terminally ill and dying should be done with professional and ethical deliberation. The code of ethical conduct for nurses prohibits nurses from participating in assisted suicide. The ANA’s position statement holds that “nurses, individually and collectively, have an obligation to provide comprehensive and compassionate end-of-life care which includes the promotion of comfort and the relief of pain, and at times, foregoing life sustaining treatments” (American Nurses Association praises Supreme Court for suicide ruling, [ANA], 1997; ANA, 2010).
Ethical Dilemmas and Considerations Euthanasia, Suicide, and Assisted Suicide The issue of physician-assisted suicide has become a front-burner national debate. (The debate on euthanasia was nationally renewed with the highly publicized case of Dr. Kevorkian, who invented a “suicide machine,” first used by patient Janet Adkins to take her own life in June 1990.) Opinions on this issue are varied and changing. Signs of public support for aid-in-dying are thought to be increasing. A report released in 1992 (Blendon et al., 1992) showed an increase in approval for physician aid-in-dying on request of the patient and family; approval rose from 34% to 63% between 1950 and 1991. Other polls suggested that more than 60% of Americans now support some legalized form of physician-assisted dying (Lieberson, 1997). Associated views and issues are controversial. However, efforts to change and shape public policy on this issue will continue (Death with Dignity National Center [DDNC], 2010).
The AMA has maintained its opposition to physician-assisted suicide. The ANA applauded the U.S. Supreme Court decision that found no constitutionally protected rights to physician-assisted suicide (American Nurses Association praises Supreme Court for suicide ruling, [ANA], 1997).
However, many citizens, some physicians, and some other health
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care professionals believe that doctors should be allowed to help severely ill persons take their own lives (Lieberson, 1992). In most states, assisted suicide is considered an illegal act. However, an act of affirmative euthanasia (actual administration of the instrumentality that causes death) constitutes an illegal criminal offense in all 50 states.
On November 8, 1994, Oregon voters approved ballot Measure 16, otherwise known as Oregon’s Death with Dignity Act. Despite legal challenges, the measure was reaffirmed by Oregon voters in 1997. Under the Oregon law, physicians may prescribe life-ending medication to anyone who is mentally competent and diagnosed as having less than 6 months to live. The patient may take the lethal dose only after a 15-day waiting period. The law does not specify what medications may be used (Maier, 1997). In March 1998, an Oregon woman dying of breast cancer became the first person to use the law by ingesting physician-prescribed medication to end her own life (American Nurses Association praises Supreme Court for suicide ruling, [ANA], 1997). Oregon proponents of the law cite improvements in end-of-life care since the enactment of the measure in 1994.
Precise information on the incidence of “assisted dying” type activities is not available. If such acts occur, they may be handled with subtlety and thus may be unlikely to be recognized as affirmative euthanasia. Actions such as failure to take steps to prevent a suicide, deliberate administration of a medication in a dosage that will suppress respiration and cause death, or administering heavy doses of pain medications needed to comfort a terminally ill patient may be intentional or inadvertent acts of assisting suicide or euthanasia. The nurse, in particular, may be in the middle of a conflict between the therapeutic necessity of treatment and the likely outcomes. Unlike an act of affirmative euthanasia, where the nurse’s actions are clear, in situations where there are competing interests (e.g., therapeutic necessity and likely outcomes), the nurse must rely on patients’ needs and his or her own professional judgment. The nurse should not hesitate to request assistance from the institutional ethics committee to help cope with such dilemmas.
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What about the person who, although not terminally ill or in a persistent vegetative state, is in her 80s and wishes to stop eating or drinking with the intent of causing her own death? In a 1987 case,19 the court denied the petition of a nursing facility administrator to authorize forced feeding. Although physicians disagreed with regard to the resident’s competence, the court decided that she was competent and thus had a right to determine what was to be done with her body. It found that refraining from force feeding is not abetting suicide.
In these challenging times, the nurse may be confronted by unanswered questions, ambiguity, and decisional conflicts in the clinical setting (Rushton & Scanlon, 1998). Nurses must hone their ethical and analytical skills to deal effectively with these situations and look to the learning tools and information available to them.
Reference has already been made to the Code for Nurses (ANA, 2001), which has established the ethical framework for nursing practice. In addition, nurses should look to their patient’s statements, either written or verbal. Nurses should be alert to their own visceral reaction—that is, does the situation “feel right”?—and try to identify the issues about the matter in question that are causing concern (Rushton & Scanlon, 1998). By answering such questions and by proceeding in a cautious and deliberate manner, nurses can usually determine the proper action. A most disturbing interruption to this process may emerge when disagreement or conflict exists, and the nurse may have to stop and reassess all of the factors before proceeding on the planned course of action (Rushton & Scanlon, 1998).
Experimentation and Research As previously discussed, nursing facility residents are accorded specific rights with respect to their treatments. The patient or resident bill of rights entitles them to choose a primary physician, if desired. Furthermore, they have the right to be informed about their medical conditions and proposed plans of treatment.
Nursing facility residents, or any patients, may refuse to participate in experimental research,20 and they may refuse to be
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examined, observed, or treated by students or other staff without jeopardizing their access to care.21
The goals of research are different from the goals of care. Research seeks to acquire knowledge with no intended benefit to the subjects because much of clinical research is conducted to determine effective treatments or potential benefits of new drugs and medical devices. The goal of patient care, however, is to provide benefit only to a specific patient (Brett & Grodin, 1991). This is a complex and controversial subject. Key points to consider in such issues are the goals and value of the research, conflicts between institutional interests and researchers, and the medical interests of the individual.
DHHS regulations may permit waiving the right to informed consent under the following specific circumstances: the research poses only a minimum risk; no adverse effects on the rights and welfare of the subjects will occur; or the research cannot be carried out effectively without the waiver; and whenever possible, the participants will be provided with pertinent information during or after participation.
Only a full review of the research, including legal analysis, determines whether a waiver of informed consent can be justified. It may be that the right to informed consent cannot be waived even when the research poses minimum risk.
Research involving humans should be examined by an appropriate review board (Brett & Grodin, 1991). All aspects of the proposed study must be evaluated to ensure that the research is justified and is of benefit and that the individual rights of all persons, including those of volunteer participants, are not sacrificed. Nurses, as a professional group closely involved with the clinical aspects of human research, should be represented on the review board.
Both state and federal regulatory provisions govern human research investigations. The diligent efforts of the research review board consider not only these laws and regulations but also their application to the particular benefits of the proposed research. A nurse involved in any aspect of human research should ask to see
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the details of the proposed study and the deliberations and decision of the institutional review board. It is not improper for a nurse to ask to attend a meeting of the review board if the nurse is involved in carrying out any aspect of the research or has any information that is of importance to the board’s deliberations. Furthermore, the nurse should report to the board any time issues arise with respect to the research, if it appears that individual rights are in question.
Organ Donation Technologic and medical advances have facilitated the successful transplantation of vital organs, and such procedures have become routine at many medical centers. However, this success has exacerbated the ethical questions involving the allocation of scarce donor organs (Giuliano, 1997). Which individuals should have priority for receiving donated organs? Should relatives, for example, be permitted to donate kidneys? What about the risks of such procedures to the donors? What about the psychological issues and family dynamics? Should donors be compensated, or should recipients pay for their organs? What about animal organ transplants?
Recognizing that the number of recipients who are waiting is more than that of available donors, the federal government has taken steps to promote organ donation. Hospitals in the United States are now required to report all deaths to the local organ procurement organization (OPO). This would permit the nation’s 63 OPOs, which collect organs and coordinate donations daily, to determine whether a person is a suitable donor (Neus, 1998). The DHHS believes that this measure, which is now a condition for participating in the Medicare program, will save lives by substantially increasing organ donations in the United States.
Clearly, many questions remain unanswered. However, some legal guidelines do exist. For example, the 1984 National Organ Transplant Act prohibits sale of organs in the United States (Giuliano, 1997). Standards of informed consent must be adhered to with respect to both donors and recipients. Even when an individual has signed an organ donor card, the consent of survivors
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is still needed (US HHS, 1998).
In dealing with the ethical issues faced in these situations, the answers are not clear-cut and may depend on individual values (Giuliano, 1997). However, when it is necessary to sort out conflicts or report anything believed to be illegal or unethical, the nurse should consider obtaining guidance from an institutional ethics committee or other ethical resource.
Ethics Committees Institutional biomedical ethics committees play a pivotal role in dealing with sensitive conflicts about treatment decisions. They help resolve conflicts that might otherwise force treatment decisions “from the bedside to the courtroom” (McCormick, 1991). Their objective is to carefully evaluate differing positions to achieve a consensus that is ethically and legally acceptable to all parties (Houge, 1993).
Ethics committees do not have any legal authority. Their main purpose is to create a forum where patients, patient representatives, and providers can express and consider different points of view.
Two thirds of general hospitals with more than 200 beds have panels of ethics committees. Their presence in nursing facilities is not as common. Membership on ethics committees should be diverse to minimize a group’s tendency to view the task as technical, to help maintain a balanced view among professionals and special interest groups, and to offer a variety of perspectives to those seeking guidance (Hollerman, 1991). The nurse’s role is crucial. Representation should include administrative and staff nurses, as well as nurses practicing in specialty areas. It is recommended that nurses make up approximately one third of committee members (Hollerman, 1991).
Ethics committees’ primary purposes are to (1) provide education and help guide policy making regarding ethical issues, (2) facilitate the resolution of ethical dilemmas, and (3) take an activist role in involving all interested parties in promoting the best care for patients (Houge, 1993).
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Issues and topics that might be discussed by an ethics committee include euthanasia; patient competency and decision-making capacities; guardianship issues; DNR orders and policies; patient refusal of treatment; starting, continuing, or stopping treatment; informed consent; use of feeding tubes; and use of restraints, and the list goes on.
An organization considering the establishment of an ethics committee should be prepared to make the necessary commitment of time and resources. A committee should be visible and available and should publish clear notice of means to obtain access. Ethics committees provide a process, not a decision.
Home care
• Remember that home care agencies’ standards are based on the Scope and Standards of Gerontological Nursing Practice, published by the American Nurses Association (1995).
• Assess for older adult abuse and notify the proper authorities (e.g., local older adult protective services or ombudsman program).
• On initial assessment, inform homebound older adults and their caregivers of home care patient rights. Have them sign a copy that documents that they have been informed of their rights.
• Inform caregivers and homebound older adults of their right to self-determination. Document that homebound older adults, caregivers, or both have been informed by obtaining signatures. Advance medical directives (AMDs) must be part of a clinical assessment.
• Obtain a copy of homebound older adults’ AMDs, and keep them on file in their charts. Send copies to the physicians to file.
• Remember that a do not resuscitate (DNR) order must be signed by the physician within 48 hours as specified by Medicare regulations.
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• To help caregivers and homebound older adults make decisions about treatment used to prolong life, consider using a values history. The values history is an instrument that asks questions related to quality versus length of life and the values that persons see as being important to maintain during terminal care.
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Summary This chapter presented the legal and ethical issues associated with the nursing care of older adults. Professional standards of practice were identified as the legal measure against which nursing practice is judged, and sources of such standards were identified. Laws applicable to older adults generally were presented, and because older adults who reside in nursing facilities are particularly vulnerable, nursing facility regulations were comprehensively covered, including issues involving quality of life and rights of residents.
Issues associated with autonomy and self-determination were described, including physician-assisted dying, DNR orders, AMDs, end-of-life decision making, and organ donation. Ethical considerations were discussed, including issues associated with euthanasia and human research. Nurses have an important role in assisting to meet the health care needs of older adults, whose unique characteristics, vulnerabilities, and needs present great and varied challenges. The older person’s quality of life is affected to a great extent by the quality of nursing care he or she receives.
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Key points • The nurse’s duty to patients is to provide care according to a
measurable standard. When patients’ physical and mental conditions and their ability to care for themselves decline, the duty of care increases.
• Older adults, particularly infirm older adults, are considered a vulnerable population; therefore, their treatment in licensed health care institutions and other settings (including the home) is carefully regulated.
• Evidence provided to the U.S. Congress in 1983 suggested widespread abuse of residents in nursing facilities and resulted in the enactment of the OBRA, the most sweeping reform affecting Medicare and Medicaid nursing facilities since those programs began. Results of the reforms have been mixed, and reports of continuing problems affecting quality of care for older adults persist, causing Congress to consider closer regulation and more stringent enforcement.
• The OBRA focuses on the quality of life of residents in nursing facilities and assurances of the preservation of their human rights and due process interests. The regulations address virtually every element of life in a nursing facility. The OBRA’s regulations are enforced through a survey process that focuses on the outcomes of residential care and include sanctions designed to force compliance, analyzed according to the scope and severity of violations.
• A strong judicial deference toward individual autonomy ensures that every human has the right to determine what shall be done with his or her own body. These rights are guaranteed in the U.S. Constitution and have been additionally interpreted in case law and state laws.
• Legal tools and instruments such as AMDs, DNR orders, designation of health care agents, and durable powers of attorney help people plan for future decision making so that their wishes can be carried out even when they are no longer able to speak for
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themselves. The presence of these instruments may add to the information available about an individual’s wishes, but care should be taken to avoid equating the instruments themselves with the existence of these fundamental human rights.
• The right to self-determination was given even more emphasis with the passage of the PSDA, which came into effect in December 1991. This law requires health care providers to inform and educate patients about their rights as they exist under the laws of each state.
• Physician-assisted suicide and issues surrounding the care of terminally ill older persons are subjects of national interest and debate, as well as judicial and legislative interest, and the role and obligation of the nurse in such matters must be carefully monitored.
• The technologic and medical advancements that help people live longer also contribute to the complicated ethical dilemmas that exist in the care of older adults. Ethics committees help in these matters by responding to the need for the education of and communication between caregivers and patients.
• It is preferable to resolve patient care dilemmas at the bedside rather than in the courtroom. The courts prefer such matters to be handled by patients, their families, and health care professionals. With careful guidance and discussion, this can often be achieved.
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Critical thinking exercises 1. An 85-year-old man has been able to care for himself with minimum assistance until recently. Should he and his family decide that it is time for him to move to a long-term care facility? How will his rights as an individual be protected, since he will be giving up his independence? Explain.
2. A 95-year-old man resides in a long-term care facility. He has signed an advance medical directive (AMD) in case he becomes seriously ill. A 73-year-old woman is being treated in the hospital for a recent cerebral vascular accident that has left her severely incapacitated. Her family has requested a Do Not Resuscitate (DNR) order. How do these two instruments differ? In what ways do they protect each person’s rights?
3. You are the nurse in charge of a wing of a nursing facility. During rounds one evening, an older, sometimes confused resident tells you that a nurse aide “pushed her around” during dinner that evening. What issues are presented, and what actions should you take?
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Appendix 3A Values History Form Name: ________________________________________________
Date: _________________________________________________
If someone assisted you in completing this form, please fill in his or her name, address, and relationship to you.
Name: _________________________________________________
Address: _______________________________________________
Relationship: ____________________________________________
The purpose of this form is to assist you in thinking about and writing down what is important to you about your health. If you should at some time become unable to make health care decisions for yourself, your thoughts as expressed on this form may help others make a decision for you in accordance with what you would have chosen.
The first section of this form asks whether you have already expressed your wishes concerning medical treatment through either written or oral communications and, if not, whether you would like to do so now. The second section of this form provides an opportunity for you to discuss your values, wishes, and preferences in a number of different areas, such as your personal relationships, your overall attitude toward life, and your thoughts about illness. From Center for Health and Law Ethics, Institute of Public Law, University of New Mexico, Albuquerque.
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Section 1 A Written Legal Documents Have you written any of the following legal documents?
If so, please complete the requested information.
Living Will Date written: _______________________________________
Document location: __________________________________
Comments: (e.g., any limitations, special requests, etc.)______
___________________________________________________
___________________________________________________
___________________________________________________
Durable Power of Attorney Date written: _______________________________________
Document location: __________________________________ Comments: (e.g., whom have you named to be your decision
maker?) ___________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Durable Power of Attorney for Health Care Decisions Date written: _______________________________________
Document location: __________________________________
Comments: (e.g., whom have you named to be your decision maker?) ___________________________________________
___________________________________________________
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___________________________________________________
___________________________________________________
Organ Donations Date written: _______________________________________
Document location: _______________________________
Comments: (e.g., any limitations on which organs you would like to donate) ______________________________________
___________________________________________________
___________________________________________________
___________________________________________________
B Wishes Concerning Specific Medical Procedures If you have ever expressed your wishes, either written or orally, concerning any of the following medical procedures, please complete the requested information. If you have not previously indicated your wishes on these procedures and would like to do so now, please complete this information.
Organ Donation To whom expressed: __________________________________
If oral, when? _______________________________________
If written, when? ____________________________________
Document location: __________________________________
Comments:_________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
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Kidney Dialysis To whom expressed: __________________________________
If oral, when? _______________________________________
If written, when? ____________________________________
Document location: __________________________________
Comments:_________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Cardiopulmonary Resuscitation (CPR) To whom expressed:
If oral, when? _______________________________________
If written, when? ____________________________________
Document location: __________________________________
Comments:_________________________________________
___________________________________________________
___________________________________________________
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Respirators To whom expressed: __________________________________
If oral, when? _______________________________________
If written, when? ____________________________________
Document location: __________________________________
Comments:_________________________________________
___________________________________________________
___________________________________________________
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___________________________________________________
Artificial Nutrition To whom expressed: __________________________________
If oral, when? _______________________________________
If written, when? ____________________________________
Document location: __________________________________
Comments:_________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Artificial Hydration To whom expressed: __________________________________
If oral, when? _______________________________________
If written, when? ____________________________________
Document location: __________________________________
Comments:_________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
C General Comments Do you wish to make any general comments about the information you provided in this section?
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Section 2 A Your Overall Attitude toward Your Health 1. How would you describe your current health status? If you currently have any medical problems, how would you describe them?____________________________________ ________________________________________________ ________________________________________________ ________________________________________________
2. If you have current medical problems, in what ways, if any, do they affect your ability to function?_____________________ ________________________________________________ ________________________________________________ ________________________________________________
3. How do you feel about your current health status?_________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
4. How well are you able to meet the basic necessities of life— eating, food preparation, sleeping, personal hygiene, etc.? ____________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
5. Do you wish to make any general comments about your overall health?____________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
B Your Perception of the Role of Your Doctor
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and Other Health Caregivers 1. Do you like your doctors?___________________________ ________________________________________________
2. Do you trust your doctors?___________________________ ________________________________________________ _______________________________________________
3. Do you think your doctors should make the final decision concerning any treatment you might need? ______________ ________________________________________________ ________________________________________________
4. How do you relate to your caregivers, including nurses, therapists, chaplains, social workers, etc.? __________________ ________________________________________________ ________________________________________________
5. Do you wish to make any general comments about your doctor and other health caregivers?____________________ ________________________________________________ ________________________________________________ ________________________________________________
C Your Thoughts about Independence and Control 1. How important are independence and self-sufficiency in your life? ________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
2. If you were to experience decreased physical and mental abilities, how would that affect your attitude toward independence and self- sufficiency? ___________________________ ________________________________________________ ________________________________________________ ________________________________________________
3. Do you wish to make any general comments about the value of
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independence and control in your life? ______________ ________________________________________________ ________________________________________________ ________________________________________________
D Your Personal Relationships 1. Do you expect that your friends, family, and/or others will support your decisions regarding medical treatment you may need now or in the future? ______________________ ________________________________________________ ________________________________________________ ________________________________________________
2. Have you made any arrangements for your family or friends to make medical treatment decisions on your behalf? If so, who has agreed to make decisions for you and in what circumstances? _____________________________________ ________________________________________________ ________________________________________________ ________________________________________________
3. What, if any, unfinished business from the past are you concerned about (e.g., personal and family relationships, business, and legal matters)? _____________________________ ________________________________________________ ________________________________________________ ________________________________________________
4. What role do your friends and family play in your life? ____ ________________________________________________ ________________________________________________ ________________________________________________
5. Do you wish to make any general comments about the personal relationships in your life?__________________________ ________________________________________________ ________________________________________________ ________________________________________________
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E Your Overall Attitude toward Life 1. What activities do you enjoy (e.g., hobbies, watching TV)? __ ________________________________________________ ________________________________________________
2. Are you happy to be alive? ___________________________ ________________________________________________
3. Do you feel that life is worth living? ___________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
4. How satisfied are you with what you have achieved in your life? ____________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
5. What makes you laugh/cry? _________________________ ________________________________________________ ________________________________________________ ________________________________________________
6. What do you fear most? What frightens or upsets you? _____ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
7. What goals do you have for the future? ________________ ________________________________________________ ________________________________________________ ________________________________________________
8. Do you wish to make any general comments about your attitude toward life?__________________________________ ________________________________________________ ________________________________________________
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________________________________________________
F Your Attitude toward Illness, Dying, and Death 1. What will be important to you when you are dying (e.g., physical comfort, no pain, family members present)? ____________________________________________ ________________________________________________ ________________________________________________
2. Where would you prefer to die? ______________________ ________________________________________________ ________________________________________________
3. What is your attitude toward death? __________________ ________________________________________________ ________________________________________________ ________________________________________________
4. How do you feel about the use of life-sustaining measures in the face of: Terminal illness?__________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Permanent coma? _________________________________ ________________________________________________ Irreversible chronic illness (e.g., Alzheimer’s disease)? _____ ________________________________________________
5. Do you wish to make any general comments about your attitude toward illness, dying, and death? ___________________ ________________________________________________
G Your Religious Background and Beliefs 1. What is your religious background? ___________________ ________________________________________________ ________________________________________________
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2. How do your religious beliefs affect your attitude toward serious or terminal illness?___________________________ ________________________________________________
3. Does your attitude toward death find support in your religion? _______________________________________ ________________________________________________
4. How does your faith community, church, or synagogue view the role of prayer or religious sacraments in an illness? _____ ________________________________________________ ________________________________________________
5. Do you wish to make any general comments about your religious background and beliefs?________________________ ________________________________________________ ________________________________________________ ________________________________________________
H Your Living Environment 1. What has been your living situation over the last 10 years (e.g., lived alone, lived with others)? ________________________ ________________________________________________ ________________________________________________
2. How difficult is it for you to maintain the kind of environment for yourself that you find comfortable? Does any illness or medical problem you have now mean that it will be harder in the future? _____________________________________ ________________________________________________ ________________________________________________
3. Do you wish to make any general comments about your living environment? _______________________________ ________________________________________________ ________________________________________________ ________________________________________________
I Your Attitude Concerning Finances
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1. How much do you worry about having enough money to provide for your care?______________________________ ________________________________________________ ________________________________________________
2. Would you prefer to spend less money on your care so that more money can be saved for the benefit of your relatives and/or friends? ___________________________________ ________________________________________________ ________________________________________________ ________________________________________________
3. Do you wish to make any general comments concerning your finances and the cost of health care? ___________________ ________________________________________________ ________________________________________________ ________________________________________________
J Your Wishes Concerning Your Funeral 1. What are your wishes concerning your funeral and burial or cremation? ______________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
2. Have you made your funeral arrangements? If so, with whom? _________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
3. Do you wish to make any general comments about how you would like your funeral and burial or cremation to be arranged or conducted? _____________________________ ________________________________________________ ________________________________________________
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________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
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Optional Questions 1. How would you like your obituary (announcement of your death) to read? ___________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
2. Write yourself a brief eulogy (a statement about yourself to be read at your funeral).___________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
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Suggestions for Use After you have completed this form, you may wish to provide copies to your doctors and other health caregivers, your family, your friends, and your attorney. If you have a Living Will or Durable Power of Attorney for Health Care Decisions, you may wish to attach a copy of this form to those documents.
1 42 U.S.C. §3001 (1965). 2 Delaware Title 16 § §1132 and 1135. 3 Illinois Chapter 111½¶ 4161–176. 4 California Welfare and Institutions § §15600–15637. 5 OBRA’ 87 at §4211(a), 42 U.S.C.A. § 139r(c) (West Supp 1989). 6 Schloendorf v. Society of New York Hospital, 211 N.Y. 125, 129 (1914). 7 McKinney’s consolidated laws of New York annotated, Public Health Law § § 2961(4). 8 McKinney’s consolidated laws of New York annotated, Public Health Law §§ 2960 to 2979, as amended by Ch. 370, L. 1991, effective July 15, 1991. See also Florida Statutes § 765.101(2) and Colorado Revised Statutes § 15–18.6–101(1). 9 McKinney’s consolidated laws of New York annotated, Public Health Law §§ 2800(1) and (3) (McKinney, 1993). 10 McKinney’s consolidated laws of New York annotated, Public Health Law § 2962(1) (McKinney, 1993). 11 McKinney’s consolidated laws of New York annotated, Public Health Law § 2963(1) (McKinney, 1993). 12 Lieberson AD, Advance medical directives, vol. 1, September 1997, Sec 30.3, p 453. 13 42 U.S.C. §§ 1395 and 1396 (1990), as amended, 60 FR 33262, June 27, 1995. 14 Cruzan v Director, Missouri Deptartment of Health (1990, US), 111 L Ed 2d 224, 234, 110 S Ct 2841. 15 72 NY2d 517, 534 NYS2d 886, 531 NE2d 607 (1988). 16 72 NY2d 517, 534 NYS2d 886, 531 NE2d 607 (1988) at 903. 17 Cruzan v. Director, Missouri Department of Health, 111 L Ed 2d 224, 110 S Ct 2841 (1990). 18 Modified from Cruzan v. Director, Missouri Department of Health [1990, US] 111 L Ed 2d 224, 247–251, 110 S Ct 2841. 19 In re Application of Brooks, NY Sup CT, Albany County, June 10, 1987. 20 For example, see Annotated Code of Maryland, 1957, § 19–344(f); and Vermont Statutes Annotated, Title 18 § 1852(a)(10) and Title 33 § 3781(3), as redesignated by Act 219, L. 1990, effective July 1, 1990.
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21 For example, see 1990 edition, General Laws of Massachusetts, supplemented by the 1991 Supplement, Chapter 111: 70E9h.
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C H A P T E R 4
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Gerontologic Assessment Sue E. Meiner, EdD, APRN, BC, GNP
Learning objectives
On completion of this chapter, the reader will be able to: 1. Explain the interrelationship between the physical and psychosocial aspects of aging as it affects the assessment process.
2. Describe how the nature of illness presentation and changes in homeostatic mechanisms for older adults affect the assessment process.
3. Compare and contrast the clinical presentation of delirium and dementia.
4. Describe the assessment modifications that may be necessary when assessing older adults.
5. Describe strategies and techniques to ensure collection of relevant and comprehensive health histories for older adults.
6. Identify the basic components of health histories for older adults.
7. List the principles to observe when conducting physical examinations of older adults.
8. Explain the rationale for assessing functional status in older adults.
9. Describe the elements of a functional assessment.
10. Describe the basic components of a mental status assessment.
11. Discuss the rationale for conducting affective assessments on older adults.
12. Explain the rationale for assessing social function in older adults.
13. Conduct a comprehensive health assessment on an older adult
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patient.
http://evolve.elsevier.com/Meiner/gerontologic
The nursing process is a problem-solving process that provides the organizational framework for the provision of nursing care. Assessment, the crucial foundation on which the remaining steps of the process are built, includes the collection and analysis of data and results in a nursing diagnosis. A nursing-focused assessment is crucial in determining nursing diagnoses that are amenable to nursing intervention. Unless the approach to assessment maintains a nursing focus, the sequential steps of the nursing process— diagnosis, planning, implementation, and evaluation—cannot be carried out.
A nursing focus evolves from an awareness and understanding of the purpose of nursing. This purpose was defined in the 1980 American Nurses Association (ANA) publication, Nursing: A Social Policy Statement, as “the diagnosis and treatment of human responses to actual or potential health problems.” In 1995, the ANA developed Nursing’s Social Policy Statement, which elaborated on the above-mentioned purpose of nursing based on the growth of nursing science “and its integration with the traditional knowledge base for diagnosis and treatment of human responses to health and illness.” Although providing no specific definition of nursing, this policy statement cited three “essential features of contemporary nursing practice” that are common to most definitions:
1. Attention to the full range of human experiences and responses to health and illness without restriction to a problem-focused orientation
2. Integration of objective data with knowledge gained from an understanding of the patient or group’s subjective experience
3. Application of scientific knowledge to the processes of diagnosis and treatment and provision of a caring relationship that facilitates health and healing (ANA, 1995).
It is clear from these elements that the nurse collects subjective and objective data about the patient to assist in determining the
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patient’s response to health and illness. A comprehensive, nursing- focused assessment of these responses establishes a database about a patient’s ability to meet the full range of physical and psychosocial needs. Patient responses that reveal an inability to satisfactorily meet these needs indicate a need for nursing care, or the “caring relationship that facilitates health and healing” (ANA, 1995).
In 2004, Nursing: Scope and Standards of Practice entered another review process that resulted in ANA expectations of the professional role within which all registered nurses must practice. The ANA charged those in the nursing profession to incorporate the standards into practice settings across the country. The ANA (2004) stated: “The goal is to improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nurses utilizing standards-based practice.”
In 2010, Nursing: Scope and Standards of Practice, 2nd Edition, addressed the five tenets that characterize the contemporary practice of nursing. These tenets include the following:
1. Nursing practice is individualized.
2. Nurses coordinate care by establishing partnerships.
3. Caring is central to the practice of the registered nurse.
4. Registered nurses use the nursing process to plan and provide individualized care to their health care consumers.
5. A strong link exists between the professional work environment and the registered nurse’s ability to provide quality health care and achieve optimal outcomes. (pp. 3, 4, & 5)
Nursing-focused assessment of older adults occurs in traditional settings, that is, hospitals, homes, or long-term care facilities, as well as in nontraditional settings such as senior centers, congregate living units, hospice facilities, and independent or group nursing practices. The setting dictates the way data collection and analysis should be managed to serve patients best. Although the setting may vary, the purpose of nursing-focused assessment of older adults remains that of determining the older person’s ability to meet any health- and illness-related needs. Specifically, the purpose of older
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adult assessment is to identify patient strengths and limitations so that effective and appropriate interventions can be delivered to support, promote, and restore optimal function and to prevent disability and dependence.
Gerontologic nurses recognize that assessing the older adult involves the application of a broad range of skills and abilities, as well as consideration of many complex and varied issues. Nursing- focused assessment based on a sound, scientific gerontologic knowledge base, coupled with repeated practice to acquire the art of assessment, is essential for the nurse to recognize responses that reflect unmet needs. Many frameworks and tools are available to guide the nurse in assessing older adults. Regardless of the framework or tool used, the nurse should collect the data while observing the following key principles: (1) the use of an individual, person-centered approach; (2) a view of patients as participants in health monitoring and treatment; and (3) an emphasis on patients’ functional ability.
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Special considerations affecting assessment Nursing assessment of older adults is a complex and challenging process that must take into account the following points to ensure an age-specific approach. The first is the interrelationship between physical and psychosocial aspects of aging. Next is an assessment of the nature of disease and disability and their effects on functional status. The third is to tailor the nursing assessment to the individual older adult.
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Interrelationship between physical and psychosocial aspects of aging The health of people of all ages is subject to the influence of any number and kind of physical and psychosocial factors within the environment. The balance that is achieved within that environment of many factors greatly influences a person’s health status. Factors such as reduced ability to respond to stress, increased frequency and multiplicity of loss, and physical changes associated with normal aging may combine to place older adults at high risk for loss of functional ability. Consider the following case, which illustrates how the interaction of select physical and psychosocial factors may seriously compromise function.
Mrs. M, age 83, arrived in the emergency room after being found in her home by a neighbor. The neighbor had become concerned because he noticed Mrs. M had not picked up her newspapers for the past 3 days. She was found in her bed, weak and lethargic. She stated that she had the flu for the past week, so she was unable to eat or drink much because of the associated nausea and vomiting. Except for her mild hypertension, which is medically managed with an antihypertensive agent, she had enjoyed relatively good health before this acute illness. She was admitted to the hospital with pneumonia.
Because of the emergent nature of the admission, Mrs. M does not have any personal belongings with her, including her hearing aid, glasses, and dentures. She develops congestive heart failure after treatment of her dehydration with intravenous fluids. She becomes confused and agitated, and haloperidol (Haldol) is administered to her. Her impaired mobility, resulting from the chemical restraint, has caused urinary and fecal incontinence in her, and she has developed a stage 2 pressure ulcer on her coccyx. She needs to be fed because of her confusion and eats very little. She sleeps at intervals throughout the day and night, and when she is awake, she is usually crying.
Table 4-1 depicts the many serious consequences of the interacting physical and psychosocial factors in this case
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(Lueckenotte, 1998). A word of caution is warranted: Undue emphasis should not be placed on individual weaknesses. In fact, it is imperative that the gerontologic nurse search for the patient’s strengths and abilities and build the plan of care on these. However, in a situation such as that of Mrs. M, the nurse should be aware of the potential for the consequences illustrated here. A single problem is not likely because multiple conditions are often superimposed. In addition, the cause of one problem is often best understood in view of the accompanying problems. Careful consideration, then, of the interrelationships between physical and psychosocial aspects in every patient situation is essential.
Table 4-1 Effect of Selected Variables on Functional Status
Variable Effect Visual and auditory loss Apathy
Confusion, disorientation Dependency, loss of control
Multiple strange and unfamiliar environments
Confusion, agitation Dependency, loss of control Sleep disturbance Relocation stress
Acute medical illness Mobility impairment Dependency, loss of control Sleep disturbance Pressure ulcer Inadequate food intake
Altered pharmacokinetics and pharmacodynamics
Persistent confusion Drug toxicity Potential for further mobility impairment, loss of function, and altered patterns of bowel and bladder elimination Loss of appetite, which, in turn, affects wound healing, bowel function, and energy level; dehydration Sleep disturbance (oversedation)
Adapted from Lueckenotte, A.G. (1998). Pocket guide to gerontologic assessment (3rd ed.). St. Louis, MO: Mosby.
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Nature of disease and disability and their effects on functional status Aging does not necessarily result in disease and disability. Although the prevalence of chronic disease increases with age, older people remain functionally independent. However, what cannot be ignored is the fact that chronic disease increases older adults’ vulnerability to functional decline. Comprehensive assessment of physical and psychosocial function is important because it can provide valuable clues to a disease’s effect on functional status. Also, self-reported vague signs and symptoms such as lethargy, incontinence, decreased appetite, and weight loss may be indicators of functional impairment. Ignoring older adults’ vague symptomatology exposes them to an increased risk of physical frailty. Physical frailty, or impairment of physical abilities that are needed to live independently, is a major contributor to the need for long-term care. Therefore, it is essential to comprehensively investigate the report of nonspecific signs and symptoms to determine whether underlying conditions may be contributing to the older person’s frailty.
Declining organ and system function and diminishing physiologic reserve with advancing age are well documented in the literature. Such normal changes of aging may make the body more susceptible to disease and disability, the risk of which increases exponentially with advancing age. It may be difficult for the nurse to differentiate normal age-related findings from indicators of disease or disability. In fact, it is not uncommon for nurses and older adults alike to mistakenly attribute vague signs and symptoms to normal aging changes or just “growing old.” However, it is essential for the nurse to determine what is “normal” versus what may be an indicator of disease or disability so that treatable conditions are not disregarded.
Decreased Efficiency of Homeostatic Mechanisms
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Declining physiologic function and increased prevalence of disease, particularly in the old-old (age 85 or older), are, in part, a result of a reduction in the body’s ability to respond to stress through all of its homeostatic mechanisms, most importantly the immune system. Older adults’ adaptive reserves are reduced and their homeostatic mechanisms weakened; these factors result in a decreased ability to respond to physical and emotional stress.
The immune system, as the body’s major defense against illness and disease, has a decreased ability to provide protection with aging (see Chapter 15). Although scientists have attempted to identify which age-related immune system changes cause the decline in immunocompetence, it has been difficult to do so because immunocompetence is affected by multiple factors.
Increasing consideration has also been given in recent years to the potential impact of psychosocial stress on the older adult immune system. This growing consideration, coupled with the knowledge about factors affecting physiologic immunocompetence, has potential clinical relevance that is a current source of controversy. The reader is referred to an immunology text for a more complete discussion of the effect of aging on the immune response.
The important point is that older adults often encounter profound and repeated losses; the time between the occurrences of these losses is often short, resulting in an inadequate period for resolution and return to a baseline state. Older adults have less ability than younger people to cope with assaults such as infection, blood loss, a high-technology environment, or loss of a significant person (see Chapter 18). The nurse should therefore assess older adults for the presence of physical and psychosocial stressors and their physical and emotional manifestations.
Lack of Standards for Health and Illness Norms Determining older adults’ physical and psychosocial health status is not easy because norms for health and illness are always being redefined. Established standards for what is normal versus
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abnormal are changing as more scientific studies are conducted and the knowledge base is expanded.
One area where scientific study is changing how health care providers interpret normal versus abnormal status is that of laboratory values. When analyzing older adults’ assessment data relying on established norms for laboratory values may lead to incorrect conclusions. Fasting blood glucose of 80 milligrams (mg) per 100 milliliters (mL) may be within the normal range for a young adult, but an older person with that same level may experience symptoms of hypoglycemia. Polypharmacy and the multiplicity of illness and disease are only two variables that may affect laboratory data interpretation for older adults (see Chapters 19 and 20).
In addition, no definitive aging norms exist for many pathologic conditions. For example, debate has continued over what constitutes isolated systolic hypertension in older people. Is a high systolic pressure simply a function of age, or does it require treatment? The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) states that cardiovascular morbidity and mortality in older people have been reduced with antihypertensive drug therapy (National High Blood Pressure Education Program, 2003). However, Moser (2007) identified that the lowering of systolic hypertension using drug therapy (diuretic or beta-blocker drugs) made more of a positive difference in the outcome than any specific antihypertensive medication(s). As more studies are conducted in this and other areas, norms for older adults will continue to be redefined.
Landmarks for human growth and development are well established for infancy through middlescence, whereas few norms are defined for older adulthood. Developmental norms that have been described for later life categorize all older people in the “older than 65” group. However, it could easily be argued from a developmental perspective that as great a difference exists among adults ages 65, 75, 85, and 95, as it does among children ages 2 through 5. In fact, given the demographic facts and predictions, clear delineation of the developmental characteristics of older people for each decade of life is a pressing need. This is an
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important area for scientific inquiry.
To compensate for the lack of definitive standards, the nurse should first assume heterogeneity rather than homogeneity when caring for older people. It is crucial to respect the uniqueness of each person’s life experiences and to preserve the individuality created by those experiences. The older person’s experiences represent a rich and vast background that the nurse can use to develop an individualized plan of care. Second, the nurse can compare the older person’s own previous patterns of physical and psychosocial health and function with the current status, using the individual as the standard. Finally, the nurse must have a complete, current, scientific knowledge base and skills in gerontologic nursing to apply to each individual older adult patient.
Altered Presentation of and Response to Specific Diseases With advanced age the body does not respond as vigorously to illness or disease because of diminished physiologic reserve. The diminished reserve poses no particular problems for older people as they carry out their daily routines; however, in times of physical and emotional stress, older people will not always exhibit the expected or classic signs and symptoms. The characteristic presentation of illness in older adults is more commonly one of blunted or atypical signs and symptoms.
The atypical presentation of illness may be displayed in various ways. For example, the signs and symptoms may be modified in some way, as in the case of pneumonia, when older adults may exhibit dry cough instead of the classic productive cough. Also, the presenting signs and symptoms may be totally unrelated to the actual problem, for example, the confusion that may accompany urinary tract infection. Finally, the expected signs and symptoms may not be present at all, as in the case of a myocardial infarction that includes no chest pain (Table 4-2). All these atypical presentations challenge the nurse to conduct careful and thorough assessments and analyses of symptoms to ensure appropriate treatment. Again, a simple and safe strategy is to compare the
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presenting signs and symptoms with the older adult’s normal baselines.
Table 4-2 How Illness Changes With Age
Problem Classic Presentation in Young PATIENT Presentation in Older Adult Patients Urinary tract infection
Dysuria, frequency, urgency, nocturia Dysuria often absent; frequency, urgency, nocturia sometimes present Incontinence, delirium, falls, and anorexia are other signs.
Myocardial infarction
Severe substernal chest pain, diaphoresis, nausea, dyspnea
Sometimes no chest pain; or atypical pain location such as in jaw, neck, shoulder, epigastric area Dyspnea may or may not be present. Other signs are tachypnea, arrhythmia, hypotension, restlessness, syncope, and fatigue/weakness. A fall may be a prodrome.
Bacterial pneumonia
Cough productive of purulent sputum, chills and fever, pleuritic chest pain, elevated white blood cell (WBC) count
Cough may be productive, dry, or absent; chills and fever and/or elevated WBCs also may be absent. Tachypnea, slight cyanosis, delirium, anorexia, nausea and vomiting, and tachycardia may be present.
Congestive heart failure
Increased dyspnea (orthopnea, paroxysmal nocturnal dyspnea), fatigue, weight gain, pedal edema, nocturia, bibasilar crackles
All the manifestations of young adult and/or anorexia, restlessness, delirium, cyanosis, and falls Cough
Hyperthyroidism Heat intolerance, fast pace, exophthalmos, increased pulse, hyperreflexia, tremor
Slowing down (apathetic hyperthyroidism), lethargy, weakness, depression, atrial fibrillation, and congestive heart failure
Hypothyroidism Weakness, fatigue, cold intolerance, lethargy, skin dryness and scaling, constipation
Often presents without overt symptoms; majority of cases are subclinical. Delirium, dementia, depression/lethargy, constipation, weight loss, and muscle weakness/unsteady gait are common.
Depression Dysphoric mood and thoughts, withdrawal, crying, weight loss, constipation, insomnia
Any of classic symptoms may or may not be present. Memory and concentration problems, cognitive and behavioral changes, increased dependency, anxiety, and increased sleep. Muscle aches, abdominal pain or tightness, flatulence, nausea and vomiting, dry mouth, and headaches Be alert for congestive heart failure, diabetes, cancer, infectious diseases, and anemia. Cardiovascular agents, anxiolytics, amphetamines, narcotics, and hormones may also play a role.
Modified from Henderson, M.L. (1986). Altered presentations. American Journal of Nursing, 15:1104.
Cognitive Impairment As can be seen in Table 4-2, delirium is one of the most common, atypical presentations of illness in older adults, representing a wide variety of potential problems.
Confusion, mental status changes, cognitive changes, and delirium are some of the terms used to describe one of the most common
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manifestations of illness in old age. Foreman (1986) advocated use of the term acute confusional state (ACS) to describe “an organic brain syndrome characterized by transient, global cognitive impairment of abrupt onset and relatively brief duration, accompanied by diurnal fluctuation of simultaneous disturbances of the sleep–wake cycle, psychomotor behavior, attention, and affect.” Unfortunately, the ageist views of many health care providers cause them to believe that an ACS is a normal, expected outcome of aging, thus robbing older adults of complete and thorough workups of this syndrome. The nurse, as an advocate for older adults, may need to remind other team members that a sudden change in cognitive function is often the result of illness, not aging. Knowing older adults’ baseline mental status is essential to avoid overlooking a serious illness manifesting itself as an ACS. Box 4-1 outlines the multivariate causes of an ACS that the nurse must consider during assessment.
Box 4-1
Physiologic, psychologic, and environmental causes of acute confusional states in hospitalized older adults Physiologic A. Primary cerebral disease
1. Nonstructural factors
a. Vascular insufficiency—transient ischemic attacks, cerebrovascular accidents, thrombosis
b. Central nervous system infection—acute and chronic meningitis, neurosyphilis, brain abscess
2. Structural factors
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a. Trauma—subdural hematoma, concussion, contusion, intracranial hemorrhage
b. Tumors—primary and metastatic
c. Normal pressure hydrocephalus
B. Extracranial disease
1. Cardiovascular abnormalities
a. Decreased cardiac output state—myocardial infarction, arrhythmias, congestive heart failure, cardiogenic shock
b. Alterations in peripheral vascular resistance—increased and decreased states
c. Vascular occlusion—disseminated intravascular coagulopathy, emboli
2. Pulmonary abnormalities
a. Inadequate gas exchange states—pulmonary disease, alveolar hypoventilation
b. Infection—pneumonias
3. Systemic infective processes—acute and chronic:
a. Viral
b. Bacterial—endocarditis, pyelonephritis, cystitis, mycosis
4. Metabolic disturbances
a. Electrolyte abnormalities—hypercalcemia, hyponatremia and hypernatremia, hypokalemia and hyperkalemia, hypochloremia and hyperchloremia, hyperphosphatemia
b. Acidosis and alkalosis
c. Hypoglycemia and hyperglycemia
d. Acute and chronic renal failure
e. Volume depletion—hemorrhage, inadequate fluid intake, diuretics
f. Hepatic failure
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g. Porphyria
5. Drug intoxications—therapeutic and substance abuse
a. Misuse of prescribed medications
b. Side effects of therapeutic medications
c. Drug–drug interactions
d. Improper use of over-the-counter medications
e. Ingestion of heavy metals and industrial poisons
6. Endocrine disturbance
a. Hypothyroidism and hyperthyroidism
b. Diabetes mellitus
c. Hypopituitarism
d. Hypoparathyroidism and hyperparathyroidism
7. Nutritional deficiencies
a. B vitamins
b. Vitamin C
c. Protein
8. Physiologic stress—pain, surgery
9. Alterations in temperature regulation—hypothermia and hyperthermia
10. Unknown physiologic abnormality—sometimes defined as pseudodelirium
Psychological 1. Severe emotional stress—postoperative states, relocation,
hospitalization
2. Depression
3. Anxiety
4. Pain—acute and chronic
5. Fatigue
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6. Grief
7. Sensory-perceptual deficits—noise, alteration in function of senses
8. Mania
9. Paranoia
10. Situational disturbances
Environmental 1. Unfamiliar environment creating a lack of meaning in the
environment
2. Sensory deprivation or environmental monotony creating a lack of meaning in the environment
3. Sensory overload
4. Immobilization—therapeutic, physical, pharmacologic
5. Sleep deprivation
6. Lack of temporospatial reference points Modified from Foreman, M.D. (1966). Acute confusional states in hospitalized elderly: a research dilemma. Nursing Research, 35(1):34.
One of the more challenging aspects of assessment of an older adult is distinguishing a reversible ACS from irreversible cognitive changes such as those seen in dementia and related disorders. In contrast to the characteristics of an ACS noted previously, dementia is a global, sustained deterioration of cognitive function in an alert patient. Other diagnostic features of dementia include memory impairment and one or more of the following cognitive disturbances: aphasia, apraxia, agnosia, or disturbance in executive functioning (e.g., planning, organizing, sequencing, abstracting) (American Psychiatric Association, 1994). Primary dementias include senile dementia of the Alzheimer type, Lewy body disease, Pick disease, Creutzfeldt-Jakob disease, and multiinfarct dementia. Secondary dementias that have the same presenting symptoms but that are often reversible with early diagnosis include normal pressure hydrocephalus, intracranial masses or lesions, pseudodementia, and Parkinson dementia. Table 4-3 depicts the
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distinguishing features of an ACS and dementia. See Chapter 27 for a complete description of these primary and secondary dementing diseases.
Table 4-3 Differentiating Dementia and Acute Confusional State (ACS)
Clinical Feature
ACS Dementia
Onset Acute/subacute; depends on cause; often occurs at twilight
Chronic, generally insidious; depends on cause
Course Short; diurnal fluctuations in symptoms; worse at night, dark, and on awakening
Long; no diurnal effects; symptoms progressive yet relatively stable over time
Duration Hours to less than 1 month Months to years Awareness Fluctuates, generally reduced Generally clear Alertness Fluctuates—reduced or increased Generally normal Attention Impaired, often fluctuates Generally normal Orientation Fluctuates in severity, generally impaired May be impaired Memory Recent and immediate memory impaired; unable to
register new information or recall recent events Recent and remote memory impaired; loss of recent memory is first sign; some loss of common knowledge
Thinking Disorganized, distorted, fragmented, slow, or accelerated
Difficulty with abstraction and word finding
Perception Distorted, illusions, delusions, or hallucinations Misperceptions often absent Sleep– wake cycle
Disturbed, cycle reversed Fragmented
Modified from Foreman, M.D. (1986). Acute confusional states in hospitalized elderly: a research dilemma. Nursing Research, 35(1):34.
Assessment may be complex because of the multiple associated characteristics of an ACS and dementia. In fact, it is not uncommon for an ACS to be superimposed on dementia. In this case, the symptoms of a new illness may be accentuated or may be masked, thus confounding assessment. Therefore, the nurse must have a clear understanding of the differences between an ACS and dementia and must recognize that only subtle evidence may be present to indicate the existence of a problem. Also, it may not be possible or desirable to complete the total assessment during the first encounter with the patient. In conducting the initial assessment of the course of the presenting symptoms, the nurse should remember that families and friends of the patient may be valuable sources of data regarding the onset, duration, and associated symptoms.
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Tailoring the nursing assessment to the older person The health assessment may be collected in a variety of physical settings, including the hospital, home, office, day care center, and long-term care facility. Any of these settings may be adapted to be conducive to the free exchange of information between the nurse and an older adult. The overall atmosphere established by the nurse should be one that conveys trust, caring, and confidentiality. The following general suggestions related to preparation of the environment and consideration of individual patient needs foster the collection of meaningful data (see the Cultural Awareness box).
Cultural awareness
Cultural assessment Cultural or culturologic nursing assessment refers to a systematic appraisal or examination of older adult individuals, groups, and communities in relation to their cultural beliefs, attitudes, values, behaviors, and practices to determine explicit nursing needs and interventions within the cultural context of the people being evaluated. Because they deal with cultural values, belief systems, and lifestyles, cultural assessments tend to be broad and comprehensive, although it is possible to focus on a smaller segment.
Cultural assessment consists of both process and content. The process aspect concerns the nurse’s approach to patients, taking into account verbal and nonverbal communication, meaning and context of speech, spatial behavior and spatial needs, relevance of social versus clock time, environmental control issues, and biologic variations. The sequence or order in which data are gathered is often critical, and the order of the assessment may
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need to be varied, depending on the cultural group and the patients’ individual needs. The content of the cultural assessment consists of the actual data categories in which information about patients is gathered.
Environmental modifications made during the assessment should take into account sensory and musculoskeletal changes in the older adult. The following points should be considered in preparation of the environment:
• Provide adequate space, particularly if the patient uses a mobility aid.
• Minimize noise and distraction such as those generated by a television, radio, intercom, or other nearby activity.
• Set a comfortable, sufficiently warm temperature and ensure no drafts are present.
• Use diffuse lighting with increased illumination; avoid directional or localized light.
• Avoid glossy or highly polished surfaces, including floors, walls, ceilings, and furnishings.
• Place the patient in a comfortable seating position that facilitates information exchange.
• Ensure the older adult’s proximity to a bathroom.
• Keep water or other preferred fluids available.
• Provide a place to hang or store garments and belongings.
• Maintain absolute privacy.
• Plan the assessment, taking into account the older adult’s energy level, pace, and adaptability. More than one session may be necessary to complete the assessment.
• Be patient, relaxed, and unhurried.
• Allow the patient plenty of time to respond to questions and directions.
• Maximize the use of silence to allow the patient time to collect thoughts before responding.
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• Be alert to signs of increasing fatigue such as sighing, grimacing, irritability, leaning against objects for support, dropping of the head and shoulders, and progressive slowing.
• Conduct the assessment during the patient’s peak energy time.
Regardless of the degree of decrement and decline an older adult patient may exhibit, he or she has assets and capabilities that allow functioning within the limitations imposed by that decline. During the assessment, the nurse must provide an environment that gives the older adult the opportunity to demonstrate those abilities. Failure to do so could result in inaccurate conclusions about the patient’s functional ability, which may lead to inappropriate care and treatment:
• Assess more than once and at different times of the day.
• Measure performance under the most favorable of conditions.
• Take advantage of natural opportunities that would elicit assets and capabilities; collect data during bathing, grooming, and mealtime.
• Ensure that assistive sensory devices (glasses, hearing aid) and mobility devices (walker, cane, prosthesis) are in place and functioning correctly.
• Interview family, friends, and significant others who are involved in the patient’s care to validate assessment data.
• Use body language, touch, eye contact, and speech to promote the patient’s maximum degree of participation.
• Be aware of the patient’s emotional state and concerns; fear, anxiety, and boredom may lead to inaccurate assessment conclusions regarding functional ability.
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The health history The nursing health history and interview, as the first phase of a comprehensive, nursing-focused health assessment, provide a subjective account of the older adult’s current and past health status. The interview forms the basis of a therapeutic nurse–patient relationship, in which the patient’s well-being is the mutual concern. Establishing this relationship with the older adult is essential for gathering useful, significant data. The data obtained from the health history alert the nurse to focus on key areas of the physical examination that require further investigation. By talking with the nurse about health concerns, the older adult increases his or her awareness of health, and topics for health teaching can be identified. Finally, the process of recounting a patient’s history in a purposeful, systematic way may have the therapeutic effect of serving as a life review.
Although a number of formats exist for the nursing health history, all have similar basic components (Figure 4-1) (Lueckenotte, 1998). In addition, the nursing health history for the older adult should include assessment of functional, cognitive, affective, and social well-being. Specific tools for the collection of these data are addressed later in this chapter.
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FIGURE 4-1 Sample older adult health history format. (From Lueckenotte, A.G. (1998). Pocket guide to gerontologic assessment (3rd ed.). St.
Louis: Mosby.)
The physical, psychosocial, cultural, and functional aspects of the older adult patient, coupled with a life history filled with people, places, and events, demand adaptations in interviewing styles and techniques. Making adaptations that reflect a genuine sensitivity toward the older adult and a sound, theoretic knowledge base of aging enhances the interview process.
The Interviewer The interviewer’s ability to elicit meaningful data from the patient depends on the interviewer’s attitudes and stereotypes about aging and older people. The nurse must be aware of these factors because they affect nurse–patient communication during the assessment (see Cultural Awareness boxes).
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Cultural awareness
Cultural considerations during the interview: introductions and names Because initial impressions are important in all human relationships, if a mutually respectful relationship is to be established, nurses should introduce themselves and should indicate to patients how they prefer to be addressed (by first name, last name, or title). They should then elicit the same information from the patients because this enables nurses to address persons in a manner that is culturally appropriate; this could actually spare considerable embarrassment. For example, because it is the custom among some Asian and European cultures to write the last name first, the nurse must make sure to have a patient’s name correct. Avoid the use of nicknames (e.g., Grandma, Pop, Dear) that may be offensive to older adult patients. Regardless of the nurse’s good intentions, older adults may construe the use of such terms as overly familiar, ill mannered, or inappropriate.
Attitude is a feeling, value, or belief about something that determines behavior. If the nurse has an attitude that characterizes older adults as less healthy and alert and more dependent, then the interview structure will reflect this attitude. For example, if the nurse believes that dependence in self-care normally accompanies advanced age, the patient will not be questioned about strengths and abilities. The resulting inaccurate functional assessment will do little to promote patient independence. Myths and stereotypes about older adults also may affect the nurse’s questioning. For example, believing that older adults do not participate in sexual relationships may result in the nurse’s failure to interview the patient about sexual health matters (see Chapter 13). The nurse’s own anxiety and fear of personal aging, as well as a lack of knowledge about older people, contribute to commonly held negative attitudes, myths, and stereotypes about older people. Gerontologic nurses have a responsibility
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Cultural awareness
Cultural considerations and the interviewer • Be respectful of, interested in, and understanding of other
cultures without being judgmental.
• Avoid stereotyping by race, gender, age, ethnicity, religion, sexual orientation, socioeconomic status, and other social categories.
• Know the traditional health-related beliefs and practices prevalent among members of a patient’s cultural group, and encourage patients to discuss their cultural beliefs and practices.
• Learn about the traditional or folk illnesses and folk remedies common to patients’ cultural groups.
• Try to understand patient perceptions of appropriate wellness and illness behaviors and expectations of health care providers in times of health and illness.
• Study the cultural expressions and manifestations of caring and noncaring behaviors expected by patients.
• Avoid stereotypical associations with violence, poverty, crime, low level of education, “noncompliant” behaviors, and nonadherence to time-regimented schedules, and avoid any other stereotypes that may adversely affect nurse–patient relationships.
• Be aware that patients who have lived in the United States for a number of years may have become increasingly westernized and have fewer remaining practices of their birth culture.
• Learn to value the richness of cultural diversity as an asset rather than a hindrance to communication and effective intervention.
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to themselves and to their older adult patients to improve their understanding of the aging process and aging people.
To ensure a successful interview, the nurse should explain the reason for the interview to the patient and should give a brief overview of the format to be followed. This alleviates anxiety and uncertainty, and the patient can then focus on telling the story. Another strategy that can be employed in some settings is to give the patient selected portions of the interview form to complete before meeting with the nurse. This allows patients sufficient time to recall their long life histories, thus facilitating the collection of important health-related data.
Older people have lengthy and often complicated histories. A goal-directed interviewing process helps the patient share the pertinent information, but the tendency to reminisce may make it difficult for the patient to stay focused on the topic. Guided reminiscence, however, can elicit valuable data and can promote a supportive therapeutic relationship. Using such a technique helps the nurse balance the need to collect the required information with the patient’s need to relate what is personally important. For example, the patient may relate a story about a social outing that seems irrelevant but may reveal important information about available resources and support systems. The interplay of the previously noted factors may necessitate more than one encounter with the patient to complete the data collection. Setting a time limit in advance helps the patient focus on the interview and aids with the problem of diminished time perception. Keeping a clock that is easy to read within view of the patient may be helpful.
Because of the need to structure the interview, nurses tend to exhibit controlling behavior with patients. To promote patient comfort and sharing of data, the nurse should work with the patient to establish the organization of the interview. In addition,
Cultural awareness
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Space and distance Both the older adult and the nurse’s sense of spatial distance is significant in cross-cultural communication, and the perception of appropriate distance zones varies widely among cultural groups. Although individual variations exist in spatial requirements, persons of the same culture may act similarly. For example, white nurses may find themselves backing away from patients of Hispanic, East Indian, or Middle Eastern origins, who often invade the nurse’s personal space in an attempt to bring the nurse into the space that is comfortable to them. Although nurses may be uncomfortable with the physical proximity of these patients, the patients may be perplexed by the nurse’s distancing behaviors and may perceive the nurse as aloof and unfriendly.
Because individuals are usually not consciously aware of their personal space requirements, they often have difficulty understanding a different cultural pattern. For example, sitting closely may be perceived by one patient as an expression of warmth and friendliness but by another as a threatening invasion of personal space. Findings from some research suggest that American, Canadian, and British patients require the most personal space, whereas Latin American, Japanese, and Middle Eastern patients need the least.
the nurse should seek the patient’s permission to take notes during the interview. The patient should feel that the nurse is a caring person who treats others with respect. Self-esteem is enhanced if the patient feels included in the decision-making process.
At the beginning of the interview, the nurse and patient need to determine the most effective and comfortable distance and position for the session. The ability to see and hear within a comfortable territory is critical to the communication process with an older adult, and adaptations to account for any deficits must include consideration of personal space requirements (see Cultural Awareness boxes).
Also, the appropriate use of touch during the interview may reduce the anxiety associated with the initial encounter. The importance and comfort of touch is highly individual, but older
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persons need and appreciate it. Burnside (1988) advises that the nurse does not have to be overly professional and cautious about the use of touch with the older adult patient. However, a word of caution: Do not use touch in a condescending manner (review Cultural Awareness box, Culture and Touch). Touch should always convey respect, caring, and sensitivity. Nurses should not be surprised if an older person reciprocates because of an unmet need for intimacy.
Finally, the nurse does not have to obtain the entire history in the traditional manner of a seated, face-to-face interview. In fact, this technique may be inappropriate with the older adult, depending on the situation. The nurse should not overlook the natural opportunities available in the setting for gathering information. Interviewing the patient at mealtime, or even while participating in a game, hobby, or other social activity, often provides more meaningful data about a variety of areas.
The Patient Several factors influence the patient’s ability to participate meaningfully in the interview. The nurse must be aware of these factors because they affect the older adult’s ability to communicate all the information necessary for determining appropriate, comprehensive interventions. Sensory–perceptual
Cultural awareness
Culture and touch Although recognizing the many reported benefits of establishing rapport with patients through touch (including the promotion of healing through therapeutic touch), nurses must understand that physical contact with patients conveys various meanings cross- culturally. In many cultures (e.g., Middle Eastern, Hispanic), male health care providers may be prohibited from touching or
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examining either all or certain parts of the female body. Older women (e.g., those having a gynecologic examination) may prefer female health care providers over male ones and may actually refuse to be examined by a man. Nurses should be aware that patients’ significant others may also exert pressure on nurses by enforcing these culturally meaningful norms in the health care setting.
The following beliefs concerning touch are stereotypes that should be validated with patients to ascertain individual beliefs, practices, and preferences.
Hispanics Highly tactile.
Very modest (men and women).
May request health care provider of same gender.
Women may refuse to be examined by male health care providers.
Asian/Pacific Islanders Avoid touching (patting the head is strictly taboo).
Touching during an argument equals loss of control (shame).
Putting feet on furniture is both impolite and disrespectful.
Public displays of affection toward members of the same gender are permissible but not toward members of the opposite gender.
Blacks Should not be touched without permission.
Native Americans Usually shake hands lightly.
Should not be touched without permission.
deficits, anxiety, reduced energy level, pain, multiple and interrelated health problems, and the tendency to reminisce are the major patient factors requiring special consideration while the
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nurse elicits the health history (see Cultural Awareness boxes). Table 4-4 contains recommendations for managing these factors (Lueckenotte, 1998).
Table 4-4 Patient Factors Affecting History Taking and Recommendations
Factor Recommendations Visual deficit Position self in full view of patient.
Provide diffused, bright light; avoid glare. Ensure patient’s glasses are worn, in good working order, and clean. Face patient when speaking; do not cover mouth.
Hearing deficit Speak directly to patient in clear, low tones at a moderate rate; do not cover mouth. Articulate consonants with special care. Repeat if patient does not understand question initially, and then restate. Speak toward patient’s “good” ear. Reduce background noises. Ensure patient’s hearing aid is worn, turned on, and working properly.
Anxiety Give patient sufficient time to respond to questions. Establish rapport and trust by acknowledging expressed concerns. Determine mutual expectations of interview. Use open-ended questions that indicate an interest in learning about the patient. Explain why information is needed. Use a conversational style. Allow for some degree of life review. Offer a cup of coffee, tea, or soup. Address the patient by name often.
Reduced energy level Position comfortably to promote alertness. Allow for more than one assessment encounter; vary the meeting times. Be alert to subtle signs of fatigue, inability to concentrate, reduced attention span, restlessness, posture. Be patient; establish a slow pace for the interview.
Pain Position patient comfortably to reduce pain. Ask patient about degree of pain; intervene before interview, or reschedule. Comfort and communicate through touch. Use distraction techniques. Provide a relaxed, “warm” environment.
Multiple and interrelated health problems
Be alert to subjective and objective cues about body systems and emotional and cognitive function. Give patient opportunity to prioritize physical and psychosocial health concerns. Be supportive and reassuring about deficits created by multiple diseases. Complete full analysis on all reported symptoms. Be alert to reporting of new or changing symptoms. Allow for more than one interview time. Compare and validate data with old records, family, friends, or confidants.
Tendency to reminisce Structure reminiscence to gather necessary data. Express interest and concern for issues raised by reminiscing. Put memories into chronologic perspective to appreciate the significance and span of patient’s life.
From Lueckenotte, A.G. (1998). Pocket guide to gerontologic assessment (3rd ed.). St. Louis: Mosby.
The Health History Format The components of the sample format for collecting a health history
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(see Figure 4-1) are extensive, and they focus on the special needs and concerns of the older adult patient. Although the entire format may seem overwhelming and repetitive in places, remember that this population may have many physical and psychosocial conditions, some of which may overlap. Depending on the setting and purpose, not every patient needs to be asked every question. The suggested format may be used as a reference from which to proceed in collecting data from each patient. The order of the components enables the nurse to begin with the less threatening “get-acquainted” type of questioning, which eases the tension and anxiety and builds trust. The nurse then gradually moves to the more personal and sensitive questions. Box 4-2 is a discussion of each of the components. When
Box 4-2
Basic components of a nursing health history Patient Profile/Biographic Data: Address and telephone number; date and place of birth, age; gender; race; religion; marital status; education; name, address, and telephone number of nearest contact person; advance directives
Family Profile: Family members’ names and addresses, year and cause of death of deceased spouse and children
Occupational Profile: Current work or retirement status, previous jobs, source(s) of income and perceived adequacy for needs
Living Environment Profile: Type of dwelling; number of rooms, levels, and people residing; degree of privacy; name, address, and telephone number of nearest neighbor
Recreation/Leisure Profile: Hobbies or interests, organization memberships, vacations or travel
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Resources/Support Systems Used: Names of physician(s), hospital, clinics, and other community services used
Description of Typical Day: Type and amount of time spent in each activity
Present Health Status: Description of perception of health in past 1 year and 5 years, health screenings, chief complaint and full symptom analysis, prescribed and self-prescribed medications, immunizations, allergies, eating and nutritional patterns
Past Health Status: Previous illnesses throughout life, traumatic injuries, hospitalizations, operations, obstetric history
Family History: Health status of immediate and living relatives, causes of death of immediate relatives, survey for risk of specific diseases and disorders
Review of Systems: Head-to-toe review of all body systems and review of health promotion habits for same
Cultural awareness
Overcoming language barriers: use of an interpreter • Before locating an interpreter, find out what language the
patient speaks at home because it may be different from the language the patient speaks in public (e.g., French is sometimes spoken at home by well-educated and upper-class members of certain Asian or Middle Eastern cultures).
• Avoid interpreters who are not actually from the patient’s native state, region, or nation (e.g., a Palestinian who knows Hebrew may not be the best interpreter for a Jewish patient).
• Be aware of gender differences between interpreter and patient. In general, the same gender is preferred.
• Be aware of age differences between interpreter and patient. In
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general, for older adult patients, an older, more mature interpreter is preferred to a younger, less experienced one.
• Be aware of evident socioeconomic differences between interpreter and patient.
• Ask the interpreter to translate as closely to verbatim as possible.
• An interpreter who is a nonrelative may seek compensation for services rendered.
• An interpreter who is a relative may change the meaning of what is said out of concern for the older family member’s well- being.
Recommendations for Institutions • Maintain a computerized list of interpreters who may be
contacted as needed.
• Network with area hospitals, colleges, universities, and other organizations that may serve as resources.
• Use the translation services provided by telephone companies (e.g., AT&T).
possible, refer to old records to obtain information that will lessen the time required of both the patient and the interviewer.
Patient Profile or Biographic Data This profile is basic, factual data about the older adult. In this section, it is often useful to comment on the reliability of the information source. For example, if the patient’s cognitive ability prevents giving accurate information, secondary sources such as family, friends, or other medical records should be consulted. Knowledge of the source of the data alerts the reader or user to the context within which he or she must consider the information. Take time to clarify advance directives such as the existence of a living will, powers of attorney for health care and finances, and code status.
Family Profile
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This information about immediate family members gives a quick overview of who may be living in the patient’s home or who may represent important support systems for the patient. These data also establish a basis for a later description of family health history.
Occupational Profile Information about work history and experiences may alert the nurse to possible health risks or exposures, lifestyle or social patterns, activity level, and intellectual performance. Retirement concerns may also be identified. Obtaining the
Cultural awareness
Overcoming language barriers: no interpreter • Be polite and formal.
• Greet the person using the appropriate title (e.g., Mr., Mrs., Ms., Dr., Rev., Col.) and last or complete name. Gesture to yourself, and say your name. Offer a handshake or nod. Smile.
• Proceed in an unhurried manner. Pay attention to any effort by the patient or family to communicate.
• Speak in a low, moderate voice. Avoid talking loudly. Be aware of your tendency to raise the volume and pitch of your voice when the listener either speaks another language or appears not to understand. The listener may perceive that the nurse is shouting or is angry.
• Use any words known in the patient’s language. This indicates that the nurse is aware of and respects the patient’s culture.
• Use simple words such as “pain” instead of “discomfort.” Avoid medical jargon, idioms, and slang. Avoid using contractions (e.g., don’t, can’t, won’t). Use nouns repeatedly instead of using pronouns.
• Avoid negative interrogatives. Example: Do not say, “He has not
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been taking his medicine, has he?” Say, “Does Juan take medicine?”
• Mime words by using simple actions while verbalizing them.
• Give instructions in the proper sequence. Example: Do not say, “Before you rinse the bottle, sterilize it.” Say, “First, wash the bottle. Second, rinse the bottle.”
• Discuss one topic at a time. Avoid using conjunctions. Example: Do not say, “Are you cold and in pain?” Say, “Are you cold (while miming)? Are you in pain?”
• Validate the patient’s understanding by having him or her repeat instructions, demonstrate the procedure, or act out the meaning.
• Write out several short sentences in English, and determine the person’s ability to read them.
• Try a third language. Many Southeast Asians speak French. Europeans often know three or four languages. Try Latin words or phrases if you are familiar with that language.
• Ask if anyone among the patient’s family and friends could serve as an interpreter.
• Obtain phrase books from a library or bookstore, or make or purchase flash cards with words commonly used by the patient’s group.
patient’s perception of the adequacy of income for meeting daily living needs may have implications for designing nursing interventions. Financial resources and health have an interdependent relationship.
Living Environment Profile Any nursing interventions for the patient must be planned with consideration of the living environment. The degree of function, safety and security, and feelings of well-being are a few of the areas affected by a patient’s living environment.
Recreation or Leisure Profile
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Identifying what the patient does to relax and have fun and how the patient uses free time may provide clues to some of the patient’s social and emotional dimensions.
Resources or Support Systems Used Obtaining information about the various health care providers and agencies used by the patient may alert the nurse to patterns of use of health care and related services, perceptions of such resources, and attitudes about the importance of health maintenance and promotion. The importance of religion in all its dimensions, including participation in church-related activities, is an important area to assess. Frequently, the church “family” is a significant source of support for the older adult.
Description of a Typical Day Identifying the activities of a patient during a full 24-hour period provides data about practices that either support or hinder healthy living. Analysis of the usual activities carried out by the patient may serve to explain symptoms that may be described later in the Review of Systems section (see Figure 4-1). Clues about the patient’s relationships, lifestyle practices, and spiritual dimensions may also be uncovered.
Present Health Status The patient’s perception of health in both the past year and the past 5 years, coupled with information about health habits, reveals much about his or her physical integrity. On the basis of how the patient responds, the nurse may be able to ascertain whether the patient needs health maintenance, promotion, or restoration.
The chief complaint, stated in the patient’s own words, enables the nurse to identify specifically why the patient is seeking health care. It is best to ask about this using terms other than chief complaint because patients may take offense at that choice of words. If a symptom is the reason, usually its duration is also included. A complete and careful symptom analysis may be carried out for the chief complaint by collecting information on the factors identified
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in Table 4-5 (Barkauskas et al., 1998). When the patient does not display specific symptomatology but instead has broader health concerns, the nurse should identify those concerns to begin establishing potential nursing interventions.
Table 4-5 Symptom Analysis Factors
Dimensions of a Symptom Questions to Ask 1. Location “Where do you feel it?
Does it move around? Does it radiate? Show me where it hurts.”
2. Quality or character “What does it feel like?” 3. Quantity or severity On a scale of 1 to 10, with 10 being the worst pain you could have, how would you rate the
discomfort you have now? How does this interfere with your usual activities? How bad is it?”
4. Timing “When did you first notice it? How long does it last? How often does it happen?”
5. Setting “Does this occur in a particular place or under certain circumstances? Is it associated with any specific activity?”
6. Aggravating or alleviating factors
“What makes it better? What makes it worse?”
7. Associated symptoms “Have you noticed other changes that occur with this symptom?”
From Barkauskas, V.H., et al. (1998). Health and physical assessment (2nd ed.). St. Louis: Mosby.
Information about the patient’s knowledge and understanding of his or her current health state, including treatments and management strategies, helps the nurse to focus on possible areas of health teaching and reinforcement, identify a patient’s access to and use of resources, discover coping styles and strategies, and determine health behavior patterns. Data about the patient’s perception of functional ability in light of perceived health problems and medical diagnoses provide valuable insight into the individual’s overall sense of physical, social, emotional, and cognitive well-being.
Medications Assessment of the older adult’s current medications is usually accomplished by having the patient bring in all prescription and over-the-counter drugs, as well as regularly and occasionally used home remedies. The nurse should also inquire about the patient’s use of herbal and other related products and also ask how each
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medication is taken—by the oral, topical, inhaled, or other route. Obtaining the medications in this manner allows the nurse to examine medication labels, which may show the use of multiple physicians and pharmacies. Also, this helps the nurse determine the patient’s pattern of drug taking (including compliance), his or her knowledge of medications, the expiration dates of medications, and the potential risk for drug interactions.
Immunization and Health Screening Status The older adult’s immunization status for specific diseases and illnesses is particularly important because of the degree of risk for this age group. More attention is increasingly being paid to the immunization status of the older adult population, primarily because of inappropriate use and underuse of vaccines in the past, especially the influenza and pneumococcal vaccines. (See Chapter 22 for a more complete discussion of influenza and pneumonia.) Tetanus and diphtheria toxoids (Td) boosters are recommended at 10-year intervals for those who have been previously immunized as adults or children. Herpes zoster immunizations are frequently recommended. Older adults should still participate in health screenings for the most recent recommendations. Tuberculosis, a disease that was once fairly well controlled, is now resurfacing in this country. Older adults who may have had a tubercular lesion at a young age may experience a reactivation as a result of age-related immune system changes, chronic illness, and poor nutrition. Frail and institutionalized older adults are particularly vulnerable and should be screened for exposure or active disease through an annual purified protein derivative (PPD) test.
Allergies Determining the older adult’s drug, food, and other contact and environmental allergies is essential for planning nursing interventions. It is particularly important to note the patient’s reaction to the allergen and the usual treatment.
Nutrition A 24-hour diet recall is a useful screening tool that provides
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information about the intake of daily requirements, including the intake of “empty” calories, the adherence to prescribed dietary therapies, and the practice of unusual or “fad” diets. The nurse should also assess the time meals and snacks are eaten. If a 24-hour recall cannot be obtained or the information gleaned raises more questions, having the patient keep a food diary for a select period may be indicated. The diets of older adults may be nutritionally inadequate because of advanced age, multiple chronic illnesses, lack of financial resources, mobility impairments, dental health problems, and loneliness (see Chapter 10). The diet recall and diary provide nutritional assessment data that reflect the patient’s overall health and well-being (see Cultural Awareness box).
Past Health Status Because a person’s present health status may depend on past health conditions, it is essential to gather data about common childhood illnesses, serious or chronic illnesses, trauma, hospitalizations, operations, and obstetric history. The patient’s history of measles, mumps, rubella, chickenpox, diphtheria, pertussis, tetanus, rheumatic fever, and poliomyelitis should be obtained to identify potential risk factors for future health problems.
An older adult patient may not know what diseases are considered major or may not fully appreciate why it is important to screen for the presence of certain diseases. In such cases, the nurse should ask the patient directly about the presence of specific
Cultural awareness
Cultural assessment of nutritional needs • What is the meaning of food and eating to the patient?
• What does the patient eat during:
• A typical day?
• Special events such as secular or religious holidays? (e.g.,
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Muslims fast during the month of Ramadan; some blacks may eat moderately during the week but consume large, heavy meals on weekends.)
• How does the patient define food? (e.g., Unless rice is served, many from India do not consider other food to be a proper meal; some Vietnamese patients consume large quantities of calcium-rich pork bones and shells, which offsets their lower intake of milk products)
• What is the timing and sequencing of meals?
• With whom does the patient usually eat? (e.g., alone, with others of the same gender, with spouse)
• What does the patient believe constitutes a “healthy” versus “unhealthy” diet? Any hot/cold or yin/yang beliefs? (see Chapter 5)
• From what sources (e.g., ethnic grocery store, home garden, restaurant) does the patient obtain food items? Who usually does the grocery shopping?
• How are foods prepared (e.g., type of preparation; cooking oil used; length of time foods are cooked; amount and type of seasoning added before, during, and after preparation)?
• Has the patient chosen a particular nutritional practice such as vegetarianism or abstinence from alcoholic beverages?
• Do religious beliefs and practices influence the patient’s diet or eating habits (e.g., amount, type, preparations, or designation of acceptable food items or combinations)? Ask the patient to explain the religious calendar and guidelines that govern these dietary practices, including exemptions for older adults and the sick.
diseases. It is also important to note the dates of onset or occurrence and the treatment measures prescribed for each disease.
For the older adult the history of traumatic injuries should be completely described, and the date, time, place, circumstances surrounding the incidents, and impact of the incidents on the patient’s overall function should be noted. On the basis of the
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information gathered about previous hospitalizations, operations, and obstetric history, additional data may be needed to gain a complete picture of the older adult’s health status. The patient may need to be guided through this process because of forgetfulness or because of a lengthy, complicated personal history.
Family History Collecting a family health history provides valuable information about inherited diseases and familial tendencies, whether environmental or genetic, for the purposes of identifying risk and determining the need for preventive services. In surveying the health of blood relatives, the nurse should note the degree of overall health, the presence of disease or illness, and age (if deceased, the cause of death). By collecting these data, the nurse may also be able to identify the existence and degree of family support systems. Data are usually recorded in a family tree format.
Review of Systems The review is generally a head-to-toe screening to ascertain the presence or absence of key symptoms within each of the body systems. It is important to question the patient in lay terminology and, if a positive response is elicited, conduct a complete symptom analysis to clarify the course of the symptomatology (see Table 4-5). To reduce confusion and to ensure the collection of accurate data, the nurse should ask the patient for only one piece of information at a time. Information obtained here alerts the nurse about what to focus on during the physical examination.
The Physical Assessment Approach and Sequence The objective information acquired in the physical assessment adds to the subjective database already gathered. Together, these components serve as the basis for establishing nursing diagnoses and planning, developing interventions, and evaluating nursing care.
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Physical assessment is typically performed after the health history. The approach should be a systematic and deliberate one that allows the nurse to (1) determine patient strengths and capabilities, as well as disabilities and limitations, (2) verify and gain objective support for subjective findings, and (3) gather objective data not previously known.
No single right way to put together the parts of the physical assessment exists, but a head-to-toe approach is generally the most efficient. The sequence used to conduct the physical assessment within this approach is a highly individual one, depending on the older adult patient. In all cases, however, a side-to-side comparison of findings is made using the patient as the control. To increase mastery in conducting an integrated and comprehensive physical assessment, the nurse should develop a method of organization and should use it consistently.
The Minimum Data Set (MDS) is a comprehensive tool established by the CMS for use in long-term-care settings. The current revision is called the MDS 3.0. This current form includes evidence-based measures for pain, cognition, delirium, and depression as well as other expert tools of choice to complete the multi-page form (Augustine & Capitosti, 2010). Payment for services provided to a resident need to have a correlation with findings on the MDS 3.0 (Shephard, 2010). This form is completed at different points in time during a single admission or readmission to a facility.
Ultimately, the practice setting and patient condition together determine the type and method of examination to be performed. For example, an older adult admitted to an acute care hospital with a medical diagnosis of congestive heart failure initially requires respiratory and cardiovascular system assessments to plan appropriate interventions for improving activity tolerance. In the home care setting, assessment of the patient’s musculoskeletal system is a priority for determining the potential for fall-related injuries and the ability to perform basic self-care tasks. The frail, immobile patient in a long-term care setting requires an initial skin assessment to determine the risk for pressure ulcer development and preventive measures required. Regular examination of the skin thereafter is necessary to assess the effectiveness of the preventive
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measures instituted.
In all the aforementioned situations, complete physical assessments are important and should eventually be carried out, but the patient and setting dictate priorities. Consider the subjective patient data already obtained in terms of the urgency of the situation, the acute or chronic nature of the problem, the extent of the problem in terms of body systems affected, and the interrelatedness of physical and psychosocial factors in determining where to begin.
Two basic tools recommended by Touhy and Jett (2012) are the acronyms FANSCAPES and SPICES. These are especially helpful when doing a basic assessment of older adults who are medically compromised. The acronym FANSCAPES refers to reviews of Fluids, Aeration, Nutrition, Communication, Activity, Pain, Elimination, and Social skills or Socialization. The mnemonic SPICES stands for Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown. When using these tools, alterations in any area should lead to additional assessment in the area indicated (Montgomery et al, 2008; Touhy & Jett, 2012).
General Guidelines Regardless of the approach and sequence used, the following principles should be considered during the physical assessment of an older adult:
• Recognize that the older adult may have no previous experience with a nurse conducting a physical assessment; an explanation may be warranted. The examiner needs to project warmth, sincerity, and interest to allay any anxiety or fear.
• Be alert to the older patient’s energy level. If the situation warrants it, complete the most important parts of the assessment first, and complete the other parts of the assessment at another time. Generally, it should take approximately 30 to 45 minutes to conduct the assessment.
• Respect the patient’s modesty. Allow privacy for changing into a gown; if assistance is needed, assist in such a way as to not
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expose the patient’s body or cause embarrassment.
• Keep the patient comfortably draped. Do not unnecessarily expose a body part; expose only the part to be examined.
• Sequence the assessment to keep position changes to a minimum. Patients with limited range of motion and strength may require assistance. Be prepared to use alternative positions if the patient is unable to assume the usual position for assessment of a body part.
• Develop an efficient sequence for assessment that minimizes both nurse and patient movement. Variations that may be necessary will not be disruptive if the sequence is consistently followed. Working from one side of the patient, generally the right side, promotes efficiency.
• Make sure the patient is comfortable. Offer a blanket for added warmth or a pillow or alternative position for comfort.
• Explain each step in simple terms. Give clear, concise directions and instructions for performing required movements.
• Warn of any discomfort that might occur. Be gentle.
• Probe painful areas last.
• For reassurance, share findings with the patient when possible. Encourage the patient to ask questions.
• Take advantage of “teachable moments” that may occur while conducting the assessment (e.g., breast self-examination).
• Develop a standard format on which to note selected findings. Not all data need to be recorded, but the goal is to reduce the potential for forgetting certain data, particularly measurements.
Equipment and Skills Because the older adult patient may become easily fatigued during the physical assessment, the nurse should ensure proper function and readiness of all equipment before the assessment begins to avoid unnecessary delays. Place the equipment within easy reach and in the order in which it will be used. The traditional techniques
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of inspection, palpation, percussion, and auscultation are used with older adults, with age-specific variations for some areas. See Chapters 21 through 29 for these variations.
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Additional assessment measures Obtaining the health history as described previously does not always provide sufficient data for planning nursing care for the older adult. Assessment of all the dimensions of the older adult is essential to establish baseline functional ability and provide individualized care.
The extremely delicate balance of homeostatic mechanisms that the older adult is able to achieve is vulnerable to assault from a variety of sources, thus increasing the risk of impairment or disability. The primary reason for such a precarious situation is that the physical, mental, emotional, and social well-being of the older adult are all closely interrelated. Medical diagnoses alone do not provide a reliable measure of functional ability. In fact, a lengthy medical problem list may not correlate at all with any degree of functional loss. Therefore, what is crucial for the nurse to know is how the older person has adapted to manage all dimensions of life with the diagnosed illnesses and medical problems. The use of standardized tools and measures of functional status are important adjuncts to traditional assessment, as they enable health care providers to objectively determine the older person’s ability to function independently despite disease and mental, emotional, and social disability. These assessments include determination of the patient’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), as well as the patient’s cognitive, affective, and social levels of function. Obtaining these additional data provides a more comprehensive view of the impact of all the interrelated variables on the older adult’s total functioning.
Functional Status Assessment Functional status is considered a significant component of an older adult’s quality of life. Assessing functional status has long been viewed as an essential piece of the overall clinical evaluation of an older person. Functional status assessment is a measurement of the
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older adult’s ability to perform basic self-care tasks, or ADLs, and tasks that require more complex activities for independent living, referred to as IADLs (Kane & Kane, 1981). Determination of the degree of functional independence in these areas helps identify a patient’s abilities and limitations, leading to appropriate interventions.
The patient’s situation determines the location and time when any of the scales or tools should be administered, as well as the number of times the patient may need to be tested to ensure accurate results. Many tools are available, but the nurse should use only those that are valid, reliable, and relevant to the practice setting. A description of the tools appropriate for use with older adults in most settings is given below.
The Katz Index of ADLs (Katz et al., 1963) is a tool widely used to determine the results of treatment and the prognosis in older and chronically ill people. The index ranks adequacy of performance in six functions: bathing, dressing, toileting, transferring, continence, and feeding. A dichotomous rating of independence or dependence is made for each of the functions. One point is given for each dependent item. Only people who can perform the function without any help at all are rated as independent; the actual evaluation form merely shows the rater how a dependent item is determined. The order of items reflects the natural progression in loss and restoration of function, based on studies conducted by Katz and his colleagues (Kane & Kane, 1981). The Katz Index is a useful tool for the nurse because it describes the patient’s functional level at a specific point in time and objectively measures the effects of the treatment intended to restore function. The tool takes only about 5 minutes to administer and may be used in most settings. A copy of the Katz Index of ADLs can be obtained by contacting the American Medical Association at www.AMA.org.
The Barthel Index (Mahoney & Barthel, 1965), another tool used for measuring functional status, rates self-care abilities in the areas of feeding, moving, toileting, bathing, walking, propelling a wheelchair, using stairs, dressing, and controlling bowel and bladder (Figure 4-2). For each item, the individual is rated on the basis of ability to perform the task independently or with help;
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more points are scored for independence, and a maximum score of 100 indicates independence on all items. However, the instrument developers note that a score of 100 does not necessarily mean one could live alone or without assistance. The Barthel Index is most appropriate for use in rehabilitation settings for documenting improvement in performance and ability.
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FIGURE 4-2 Barthel Index. (Modified from Mahoney, F.I. & Barthel, D.W. (1965). Functional evaluation: the Barthel Index. Maryland State Medical Journal,
14:61.)
IADLs represent a range of activities more complex than the self- care tasks described in the aforementioned tools (Kane & Kane, 1981). Lawton and Brody (1969) described the Philadelphia Geriatric Center Instrumental Activities of Daily Living Scale as one that measures complex activities such as using a telephone, shopping, preparing food, housekeeping, doing laundry, using transportation, taking medication, and handling finances (Figure 4- 3). The scale’s limitations include an absence of instructions for summing up the items and an emphasis on tasks traditionally performed by women, especially given today’s cohort of older people (Kane & Kane, 1981). Its usefulness is that it may identify people living in the community who need help, which enables the nurse to match services and other sources of support for patients.
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FIGURE 4-3 Instrumental Activities of Daily Living Scale. (From Lawton, H.P. & Brody, E.M. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist, 9:179. Copyright by The
Gerontological Society of America.)
Older adults in most health care settings may benefit from functional status assessment, but those in acute care settings are particularly in need of such an assessment because of their typically advanced age, level of acuity, comorbidity, and risk for iatrogenic conditions such as urinary incontinence, falls, delirium, and polypharmacy. The hospitalization experience for older adults may cause loss of function and self-care ability because of the many extrinsic risk factors associated with this setting, including aggressive treatment interventions, forced bed rest, restraint use, lack of exercise, insufficient nutritional intake, and iatrogenic infection. Box 4-3 provides a clinical practice protocol to guide acute care nurses in the functional assessment process for older adults (Kresevic & Mezey, 1997). Nurses in this setting are in a key position to assess the older adult’s function and implement interventions aimed at preventing decline. Specialized care units known as acute care for elders (ACE) units have been developed in hospitals around the country to better address these issues.
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Research is being conducted to determine the impact of this age- specific, comprehensive approach on reducing morbidity and mortality associated with hospitalizing older adults.
Box 4-3
Nursing standard of practice protocol: assessment of function in acute care The following nursing care protocol has been designed to assist bedside nurses in monitoring function in older patients, preventing decline, and maintaining the function of older adults during acute hospitalization.
Objective: The goal of nursing care is to maximize the physical functioning and prevent or minimize declines in ADL function.
I Background A. The functional status of individuals describes the capacity to
safely perform ADLs. Functional status is a sensitive indicator of health or illness in older adults and therefore a critical nursing assessment.
B. Some functional decline may be prevented or ameliorated with prompt and aggressive nursing intervention (e.g., ambulation, enhanced communication, adaptive equipment).
C. Some functional decline may occur progressively and is not reversible. This decline often accompanies chronic and terminal disease states such as Parkinson disease and dementia.
D. Functional status is influenced by physiologic aging changes, acute and chronic illness, and adaptation. Functional decline is often the initial symptom of acute illness such as infections (pneumonia, urinary tract infection). These declines are usually reversible.
E. Functional status is contingent on cognition and sensory
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capacity, including vision and hearing.
F. Risk factors for functional decline include injuries, acute illness, medication side effects, depression, malnutrition, and decreased mobility (including the use of physical restraints).
G. Additional complications of functional decline include loss of independence, loss of socialization, and increased risk for long- term institutionalization and depression.
H. Recovery of function can also be a measure of return to health such as in those individuals recovering from exacerbations of cardiovascular disease.
II Assessment parameters A. A comprehensive functional assessment of older adults
includes independent performance of basic ADLs, social activities, or IADLs; the assistance needed to accomplish these tasks; and the sensory ability, cognition, and capacity to ambulate.
1. Basic ADLs
a. Bathing
b. Dressing
c. Grooming
d. Eating
e. Continence
f. Transferring
2. IADLs
a. Meal preparation
b. Shopping
c. Medication administration
d. Housework
e. Transportation
f. Accounting
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B. Older adult patients view their health in terms of how well they can function rather than in terms of disease alone.
C. The clinician should document functional status and recent or progressive declines in function.
D. Function should be assessed over time to validate capacity, decline, or progress.
E. Standard instruments selected to assess function should be efficient to administer and easy to interpret and provide useful, practical information for clinicians.
F. Multidisciplinary team conferences should be scheduled.
III Care strategies A. Strategies to maximize function
1. Maintain individual’s daily routine. Help the patient to maintain physical, cognitive, and social functions through physical activity and socialization: encourage ambulation; allow flexible visitation, including pets; and encourage reading the newspaper.
2. Educate older adults and caregivers on the value of independent functioning and the consequences of functional decline.
a. Physiologic and psychological value of independent functioning
b. Reversible functional decline associated with acute illness
c. Strategies to prevent functional decline—exercise, nutrition, and socialization
d. Sources of assistance to manage decline
3. Encourage activity, including routine exercise, range of motion exercises, and ambulation to maintain activity, flexibility, and function.
4. Minimize bed rest.
5. Explore alternatives to physical restraint use.
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6. Judiciously use psychoactive medications in geriatric dosages.
7. Design environments with handrails, wide doorways, raised toilet seats, shower seats, enhanced lighting, low beds, and chairs.
8. Help individuals regain baseline function after acute illnesses by the use of exercise, physical therapy consultation, and increasing nutrition.
9. Obtain assessment for physical and occupational therapies needed to help regain function.
B. Strategies to help individuals cope with functional decline
1. Help older adults and family determine realistic functional capacity with interdisciplinary consultation.
2. Provide caregiver education and support for families of individuals when decline cannot be ameliorated in spite of nursing and rehabilitative efforts.
3. Carefully document all intervention strategies and patient responses.
4. Provide information to caregivers on causes of functional decline related to the patient’s disorder.
5. Provide education to address safety care needs for falls, injuries, and common complications. Alternative care settings may be required to ensure safety.
6. Provide sufficient protein and calories to ensure adequate intake and prevent further decline.
7. Provide caregiver support and community services such as home care, nursing, and physical and occupational therapy services to manage functional decline.
IV Expected outcomes A. Patients can
1. Maintain a safe level of ADLs and ambulation.
2. Make necessary adaptations to maintain safety and
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independence, including assistive devices and environmental adaptations.
B. Provider can demonstrate
1. Increased assessment, identification, and management of patients susceptible to or experiencing functional decline.
2. Ongoing documentation of capacity, interventions, goals, and outcomes.
3. Competence in preventive and restorative strategies for function.
C. Institution can demonstrate
1. Decrease in incidence and prevalence of functional decline in all care settings.
2. Decrease in morbidity and mortality rates associated with functional decline.
3. Decreased use of physical restraints.
4. Decreased incidence of delirium.
5. Increase in prevalence of patients who leave hospital with baseline functional status.
6. Decreased readmission rate.
7. Increased use of rehabilitative services (occupational and physical therapy).
8. Support of institutional policies and programs that promote function.
a. Caregiver educational efforts
b. Walking programs
c. Continence programs
d. Self-feeding initiatives
e. Elder group activities
ADL, Activities of daily living; IADL, instrumental activities of daily living.
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Modified from Kresevic, D.M., & Mezey, M. (1997). Assessment of function: Critically important to acute care of elders. Geriatric Nursing, 18(5):216.
Nurses practicing in all settings should begin incorporating the tools already noted, as well as others described in the comprehensive text by Kane and Kane (1981), into routine assessments to determine a patient’s baseline functional ability. However, with all the previously mentioned tools, the nurse should remember the following points:
• Scores will be affected by the environment in which the tool is administered.
• The patient’s affective and cognitive state will affect performance.
• The result represents but one piece of the total assessment.
Cognitive or Affective Assessment The purpose of mental status assessment in the older adult is to determine the patient’s level of cognitive function (which implies all those processes associated with mentation or intellectual function) and the effect of the assessed degree of impairment on functional ability. This assessment is usually integrated into the interview and physical examination, and testing is conducted in a natural, nonthreatening manner with consideration of ethnicity. Table 4-6 identifies typical areas to assess in a mental status assessment. Note that this mental status assessment provides a baseline that identifies the need for the administration of one of the standardized mental status examinations.
Table 4-6 Mental Status Assessment
Exam Component Area to Assess General appearance Observe physical appearance, coordination of movements, grooming and hygiene, facial
expression, and posture as measures of mental function. Alertness Note level of consciousness (alert, lethargic, obtunded, stuporous, or comatose). Mood or affect Note verbal and nonverbal behaviors for appropriateness, degree, and range of affect. Speech Evaluate comprehension of and ability to use the spoken language; note volume, pace, amount, and
degree of spontaneity. Orientation Note awareness of person, place, and time. Attention and concentration
Note ability to attend to or concentrate on stimuli.
Judgment Note ability to evaluate a situation and determine appropriate reaction or response. Memory Note ability to accurately register, retain, and recall data or events (may need to verify with
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collateral sources). Perception Note presence or absence of delusions or visual and auditory hallucinations. Thought content and processes
Observe for organized, coherent thoughts; note ability to relate history in a clear, sequential, and logical manner.
The multiple physiologic, psychological, and environmental causes of cognitive impairment in older adults, coupled with the view that mental impairment is a normal, age-related process, often lead to incomplete assessment of this problem. Standardized examinations test a variety of cognitive functions, aiding the identification of deficits that affect overall functional ability. Formal, systematic testing of mental status may help the nurse determine which behaviors are impaired and warrant intervention.
The Short Portable Mental Status Questionnaire (SPMSQ) (Figure 4-4), which is used to detect the presence and degree of intellectual impairment, consists of 10 items to assess orientation, memory in relation to self-care ability, remote memory, and mathematic ability (Pfeiffer, 1975). The simple scoring method rates the level of intellectual function, which aids in making clinical decisions regarding self-care capacity.
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FIGURE 4-4 Short Portable Mental Status Questionnaire (SPMSQ). (From Pfeiffer, E. (1975). A short portable questionnaire for the
assessment of organic brain deficit in elderly patients. Journal of the American Geriatric Society, 23:433.)
Because the SPMSQ is given orally, it is easy to memorize. It may be administered as a screening assessment for older people in acute, community-based, and long-term care settings. On the basis of the score, a more complete mental status assessment and neuropsychiatric evaluation may be warranted.
The Mini-Mental State Examination (MMSE) tests the cognitive aspects of mental functions: orientation, registration, attention and calculation, recall, and language (Folstein, Folstein, & McHugh, 1975). The highest possible score is 30; a score of 21 or less generally indicates cognitive impairment requiring further investigation. The examination takes only a few minutes to complete and is easily
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scored, but it cannot be used alone for diagnostic purposes. Because the MMSE quantifies the severity of cognitive impairment and demonstrates cognitive changes over time and with treatment, it is a useful tool for assessing patient progress in relation to interventions (Wattmo et al., 2010). As with the SPMSQ, if the MMSE score demonstrates the patient has impaired mental function, additional diagnostic testing and mental status examination are indicated.
The Mini-Cog (Figure 4-5) is an instrument that combines a simple test of memory with a clock drawing test. It was created by researchers at the University of Washington led by Soo Borson. The Mini-Cog is both quick and easy to use and has been found to be as effective as longer, more time-consuming instruments in accurately identifying cognitive impairment (Borson et al., 2003). It is relatively uninfluenced by education level or language.
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FIGURE 4-5 Mini-Cog test. (Mini-Cog [Versions 1.0 and 2.0], Copyright 2000 and 2003, Soo Borson and James Scanlan. All rights reserved. Reprinted under license from the University of Washington solely for use as a clinical or
teaching aid. Any other use is strictly prohibited without permission from Dr. Borson, [email protected].)
Affective status measurement tools are used to differentiate serious depression that affects many domains of function from the low mood common to many people. Depression is common in older adults and is often associated with confusion and disorientation, so older people with depression are often mistakenly labeled as having dementia. It is important to note here that people who are depressed usually respond to items on mental status examinations by saying, “I don’t know,” which leads to poor performance. Because mental status examinations are not able to distinguish
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between dementia and depression, a response of “I don’t know” should be interpreted as a sign that further affective assessment is warranted.
The Beck Depression Inventory contains 13 items describing a variety of symptoms and attitudes associated with depression (Beck & Beck, 1972). Each item is rated using a four-point scale to designate the intensity of the symptom. The tool is easily scored and may be self-administered or given by the nurse in about 5 minutes. Depending on the degree of impairment, the number of responses for each item could be confusing or could create difficulty for the older patient. The nurse may need to assist patients experiencing this problem with the tool. The scoring cutoff points aid in estimating the severity of the depression. This scale is not represented here.
The short form Geriatric Depression Scale (Box 4-4), derived from the original 30-question scale, is a convenient instrument designed specifically for use with older people to screen for depression (Yesavage & Brink, 1983). Questions answered as indicated score one point. A score of 5 or more may indicate depression.
Box 4-4
Yesavage geriatric depression scale, short form 1. Are you basically satisfied with your life? (no)
2. Have you dropped many of your activities and interests? (yes)
3. Do you feel that your life is empty? (yes)
4. Do you often get bored? (yes)
5. Are you in good spirits most of the time? (no)
6. Are you afraid that something bad is going to happen to you? (yes)
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7. Do you feel happy most of the time? (no)
8. Do you often feel helpless? (yes)
9. Do you prefer to stay home at night, rather than go out and do new things? (yes)
10. Do you feel that you have more problems with memory than most? (yes)
11. Do you think it is wonderful to be alive now? (no)
12. Do you feel pretty worthless the way you are now? (yes)
13. Do you feel full of energy? (no)
14. Do you feel that your situation is hopeless? (yes)
15. Do you think that most persons are better off than you are? (yes)
Score 1 point for each response that matches the yes or no answer after the question. A score of 5 or more may indicate depression. From Yesavage, J.A., & Brink, T.L. (1983). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17:37, Elsevier Science Ltd., Pergamon Imprint, Oxford, England.
The instruments described here for assessing cognitive and affective status are valuable screening tools that the nurse may use to supplement other assessments. They may also be used to monitor a patient’s condition over time. The results of any mental or affective status examination should never be accepted as conclusive; they are subject to change on the basis of further workup or after treatment interventions have been implemented.
Social Assessment Several legitimate reasons exist for the need for health care providers to screen for social function in older people, despite the diverse concepts of what constitutes social function (Kane & Kane, 1981). First, social function is correlated with physical and mental function. Alterations in activity patterns may negatively affect physical and mental health, and vice versa. Second, an individual’s
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social well-being may positively affect his or her ability to cope with physical impairments and the ability to remain independent. Third, a satisfactory level of social function is a significant outcome in and of itself. The quality of life an older person experiences is closely linked to social function dimensions such as self-esteem, life satisfaction, socioeconomic status, and physical health and functional status.
The relationship the older adult has with family plays a central role in the overall level of health and well-being. The assessment of this aspect of the patient’s social system may yield vital information about an important part of the total support network. Contrary to popular belief, families provide substantial help to their older members (see Chapter 6). Consequently, the level of family involvement and support cannot be disregarded when collecting data.
Support for people outside the family plays an increasingly significant role in the lives of many older persons today. Faith- based community support, especially in the form of the parish nurse program, is evolving as a meaningful source of help for older persons who have no family or who have family in distant geographic locations (see Chapter 7). The nurse must regard these “nontraditional” sources of social support as legitimate when assessing the older adult’s social system.
One of the components of the Older Adults Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire, developed at Duke University, is the Social Resource Scale (Duke University Center for the Study of Aging and Human Development, 1988) (Figure 4-6). This scale is one of the better- known measures of general social function in older adults. The questions extract data about family structure, patterns of friendship and visiting, availability of a confidant, satisfaction with the degree of social interaction, and availability of a helper in the event of illness or disability. Different questions (noted in italics in Figure 4- 6) are used for patients residing in institutions. The interviewer rates the patient using a six-point scale ranging from “excellent social resources” to “totally socially impaired” based on the responses to the questions.
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FIGURE 4-6 OARS Social Resource Scale. (Reprinted with permission from the OARS Multidimensional Functional Assessment Questionnaire. [1988]. Center for the Study of Aging and Human Development, Duke University Medical
Center, Durham NC).
Many other measures of social function can be found in the literature, but a lack of consensus by experts as to which are most
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suitable for use with older adults makes it difficult to recommend any one with confidence. Therefore, the nurse should use these tools with caution and care, remembering that it is crucial to attempt to screen for those older people at social risk.
For all the additional assessment measures discussed previously, the nurse should bear in mind that these are meant to augment the traditional health assessment, not replace it. Care needs to be taken to ensure the tools are used appropriately with regard to purpose, setting, timing, and safety. Doing so leads to a more accurate appraisal on which to base nursing diagnostic statements and to plan suitable and effective interventions.
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Laboratory data The last component of a comprehensive assessment is evaluation of laboratory tests. The results of laboratory tests validate history and physical examination findings and also identify potential health problems not pointed out by the patient or the nurse. Data are considered with regard to established norms based on age and gender. See Chapter 19 for a comprehensive discussion of age- related changes in laboratory tests.
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Summary This chapter presented the components of a comprehensive nursing-focused assessment for an older adult, including special considerations to ensure an age-specific approach, as well as pragmatic modifications for conducting the assessment with this unique age group. Components of the health history and physical assessment were discussed, and consideration was given to additional functional status assessment measures that can be used with older adults. Compiling an accurate and thorough assessment of an older adult patient, which serves as the foundation for the remaining steps of the nursing process, involves the blending of many skills and is an art not easily mastered.
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Key points • The less vigorous response to illness and disease in older adults
as a result of diminished physiologic reserve, coupled with the diminished stress response, causes an atypical presentation of and response to illness and disease.
• Standards for what constitutes normal and abnormal in health and illness for older adults are constantly changing as the scientific knowledge base grows.
• Cognitive change is one of the most common manifestations of illness in old age.
• An abrupt-onset ACS in the older adult requires a complete workup to identify the cause so that appropriate interventions can be developed to reverse it.
• Conducting a health assessment with an older adult requires modification of the environment, consideration of the patient’s energy level and adaptability, and the observance of the opportunity for demonstrating assets and capabilities.
• Sensory-perceptual deficits, anxiety, reduced energy level, pain, multiple and interrelated health problems, and the tendency to reminisce are the major factors requiring special consideration by the nurse while conducting the health history with the older adult.
• An older adult’s physical health alone does not provide a reliable measure of functional ability; assessment of physical, cognitive, affective, and social function provides a comprehensive view of the older adult’s total degree of function.
• The purpose of a nursing-focused assessment of the older adult is to identify patient strengths and limitations so that effective and appropriate interventions can be delivered to promote optimum function and to prevent disability and dependence.
• An older adult’s reduced ability to respond to stress, the increased frequency and multiplicity of loss, and the physical
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changes associated with normal aging combine to place the older adult at high risk of loss of functional ability.
• A comprehensive assessment of an older adult’s report of nonspecific signs and symptoms is essential for determining the presence of underlying conditions that may lead to a functional decline.
• To compensate for the lack of definitive standards for what constitutes “normal” in older adults, the nurse may compare the older patient’s own previous patterns of physical and psychosocial health and function with the patient’s current status.
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Critical thinking exercises 1. You are interviewing a 79-year-old man, who was just admitted to the hospital. He states that he is hard of hearing; you note that he is restless and apprehensive. How would you revise your history- taking interview based on these initial observations?
2. Three individuals, 65, 81, and 95 years of age, have blood pressure readings of 152/88, 168/90, and 170/92 mm Hg, respectively. The nurse infers that all older people are hypertensive. Analyze the nurse’s conclusion. Is faulty logic being used in this situation? What assumption(s) did the nurse make with regard to older people in general?
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References American Nurses Association (ANA). Nursing’s social policy
statement. Washington, DC: The Association; 1995.
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Beck AT, Beck RW. Screening depressed patients in family practice: A rapid technique. Postgraduate Medicine. 1972;52:81.
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Foreman MD. Acute confusional states in hospitalized elderly: A research dilemma. Nursing Research. 1986;35(1):34.
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Kane RA, Kane RL. Assessing the elderly: A practical guide to measurement. Lexington, MA: Lexington Books; 1981.
Katz S, Ford AB, Moskowitz RW. Studies of illness in the aged: The index of ADL—A standardized measure of biological and psychosocial function. JAMA. 1963;185:914.
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Lueckenotte AG. Pocket guide to gerontologic assessment. 3rd ed. St. Louis: Mosby; 1998.
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Montgomery J, Mitty E, Flores S. Resident condition change: Should I call 911?. Geriatric Nursing. 2008;29:159.
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Shephard R. MDS 3.0 are you ready?. Advance For Health Information Professionals. 2010.
Touhy TA, Jett K. Ebersole & Hess’ toward healthy aging: Human needs & nursing response. 8th ed. St. Louis: Elsevier; 2012.
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* Original author: Annette G. Lueckenotte, MS, RN, BC, GNP, GCNS; Revisions by: Sharon Roth Maguire, MS, APRN-BC, GNP, APNP; and Sue E. Meiner, EdD, APRN, BC, GNP.
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PA R T 2 Influences on Health and Illness
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C H A P T E R 5
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Cultural Influences Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD(c)
Learning objectives
On completion of this chapter, the reader will be able to: 1. Discuss the major demographic trends in the United States in relation to the various older adult ethnic populations.
2. Analyze the nursing implications of ethnic demographic changes.
3. Differentiate among culture, ethnicity, and race.
4. Identify potential barriers to care for the ethnic older person.
5. Discuss cultural variations in beliefs about health, illness, and treatment.
6. Describe how differences in cultural patterns may result in a potential conflict between a gerontologic nurse and an older person or his or her family member.
7. Propose how to increase the quality of the interaction between the nurse and the older adult through the nurse’s knowledge of the concept of context as it relates to relationships and behavior.
8. Apply linguistically appropriate techniques in communicating with an ethnic older person.
9. Discuss ways in which planning and implementation of nursing interventions can be adapted to older adults’ ethnicity.
http://evolve.elsevier.com/Meiner/gerontologic
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Diversity of the older adult population in the united states The United States has seen a significant shift in the percentage of persons who identify with ethnic groups other than those classified as white and of Northern European descent. It is projected that by 2050, those persons from groups that have long been counted as statistical minorities will assume membership in what has been called the emerging majority.
Although older adults of color will still be outnumbered by their white counterparts for years to come, tremendous growth is anticipated (Gelfand, 2003). Between 2012 and 2050, the percentage of older African Americans is projected to grow from 8.3% to 13%; Asian/Pacific Islanders from 2.3% to 8.5%; American Indians/Alaskan Natives from 0.6% to 1.0%. Finally, Hispanics of any race will increase from 6.6% to 19.7% (Administration on Aging [AOA], 2011). By 2030, the number of older Hispanics is expected to be the largest of any other group described as a minority (Figure 5- 1).
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FIGURE 5-1 Projected Population of Persons 65 and Older by Race, 2000-2050. (From U.S. Bureau of the Census, 2011.)
It must be noted, however, that these and many of the figures we have today are drawn from the U.S. Census, in which persons of color are often underrepresented and those who are in the United States illegally are not included at all. In reality, the numbers of ethnic older adults in the United States may be or may become substantially higher.
Furthermore, within the broad census categories, considerable diversity exists. A person who identifies himself or herself as a Native American or Alaskan Native is a member of one of more than 500 tribal groups and may prefer to be referred to as a member of a specific tribe such as Navaho. Although commonalities exist, each tribe also has unique cultural features and practices. Similarly, older adults who consider themselves Asian/Pacific Islanders may be from one of more than a dozen countries from the Pacific Rim and speak at least one of the thousand or more languages or dialects.
Adding to the diversity in the United States is the influx of immigrants. The immigrant population is growing at a faster rate
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than that of the native born. Although access to the United States varies with global politics, older adults are continually being reunited with their adult children; they may live in their adult children’s households, where they assist with homemaking and care for younger children in the family and are cared for in return. It is becoming increasingly common for communities to support senior centers with activities and meals reflective of their diverse participants (McCaffrey, 2007).
Certain communities and regions in the United States are decidedly more diverse than others. Figures 5-2 through 5-5 provide information about the geographic distribution of older persons from each census group. Today and in the future, nurses may provide care to older adults from multiple ethnic groups in the course of a single day. It is likely that many of these older adults will not speak the same language as the nurse.
FIGURE 5-2 Percent of persons 65 years or older (black or African American alone). (From U.S. Bureau of the Census, 2011.)
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FIGURE 5-3 Percent of persons 65 or older (Asian alone). (From U.S. Bureau of the Census, 2011.)
FIGURE 5-4 Percent of persons 65 or older (American Indian or Alaskan native only). (From U.S. Bureau of the Census, 2011.)
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FIGURE 5-5 Percent of persons 65 or older (Hispanic or Latino, any race). (From U.S. Bureau of the Census, 2011.)
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Culturally sensitive gerontologic nursing care The diversity of values, beliefs, languages, and historical life experiences of older adults today challenges nurses to gain new awareness, knowledge, and skills to provide culturally and linguistically appropriate care. When language becomes a barrier to care, working with interpreters may be helpful. To give the most sensitive care, it is necessary to step outside of cultural bias and accept that other cultures have different ways of perceiving the world that are as valid as one’s own. Increasing awareness, knowledge, and skills are the tools needed to begin to overcome the barriers to culturally compassionate care and, as a consequence, to reduce health disparities (see Evidence-Based Practice box).
Awareness Providing culturally appropriate care begins with increasing an awareness of our own beliefs and attitudes and those commonly seen in the community at large and in the community of health care. Awareness of one’s thoughts and feelings about others who are culturally different from oneself is necessary. These thoughts and feelings may be hidden from you but may be evident to others. To be aware of these thoughts and feelings about others, you can begin to share or write down personal memories of those first experiences of cultural differences. A good starting point to begin the process of discovery is to conduct a cultural self-assessment such as the one found in the Cultural Awareness box on self- assessment.
Awareness is also enhanced through the acquisition of new knowledge about cultures and the common barriers to high-quality health care too often faced by persons from ethnically distinct groups.
Knowledge
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Increased knowledge is a prerequisite for culturally appropriate care given to all persons, regardless of race or ethnicity. Developing cross-cultural knowledge is essential for the delivery of sensitive care. Frustration and conflict among older adult patients, nurses, and other health care providers can be lessened or avoided. Courses in anthropology (political, economic, and cultural), world religions, intercultural communication, scientific health and folk care systems, cross-cultural nutrition, and languages are relevant. Such information helps students, practitioners, and health care institutions become more culturally sensitive to the diversity of their present and potential patient populations. It will allow the nurse to improve patient health outcomes and, in doing so, reduce persistent health disparities (Purnell, 2012).
Cultural Concepts Several key terms and concepts are discussed here in an attempt to clarify those that are often used incorrectly or interchangeably in any discussion related to culture and ethnicity.
Culture is a universal phenomenon. It is the shared and learned beliefs, expectations, and behaviors of a group of people. Style of dress, food preferences, language, and social systems are expressions of culture. Cultures may share similarities, but no two are exactly alike. Cultural knowledge is transmitted from one member to another through the process called enculturation. It provides individuals with a sense of security and a blueprint for interacting within the family, community, and country. Culture allows members of the group to predict each other’s behavior and respond appropriately, including during one’s own aging and that of community members. Culture is universal, adaptive, and exists at the microlevel of the individual or family and at the macrolevel in terms of a region, country, or a specific group. Review Boxes 5-1 through 5-4.
Box 5-1
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Anglo-american (european american) culture (mainly u.s. middle and upper class) Cultural Values • Individualism—focus on a self-reliant person
• Independence and freedom
• Competition and achievement
• Materialism (items and money)
• Technologic dependence
• Instantaneous actions
• Youth and beauty
• Equal rights to both sexes
• Leisure time
• Reliance on scientific facts and numbers
• Less respect for authority and older adults
• Generosity in time of crisis
Culture Care Meanings and Action Modes • Alleviating stress:
• Physical means
• Emotional means
• Personalized acts:
• Doing special things
• Giving individual attention
• Self-reliance (individualism) by:
• Reliance on self
• Reliance on self (self-care)
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• Becoming as independent as possible
• Reliance on technology
• Health instruction:
• Explaining how “to do” this care for self
• Giving the “medical” facts From Leininger, M (Ed.). (1991). Culture care diversity and universality: A theory of nursing. Sudbury, MA: National League for Nursing, Jones and Bartlett.
Box 5-2
Appalachian culture Cultural Values • Keeping ties with kin from the “hollows”
• Personalized religion
• Folk practices as “the best lifeways”
• Guarding against “strangers”
• Being frugal; always using home remedies
• Staying near home for protection
• Mother as decision maker
• Community interdependency
Culture Care Meanings and Action Modes • Knowing and trusting “true friends”
• Being kind to others
• Being watchful of strangers or outsiders
• Doing for others; less for self
• Keeping with kin and local folks
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• Using home remedies “first and last”
• Taking help from kin as needed (primary care)
• Helping people stay away from the hospital—”the place where people die”
From Leininger, M (Ed.). (1991). Culture care diversity and universality: A theory of nursing. Sudbury, MA: National League for Nursing, Jones and Bartlett.
Box 5-3
Black culture Cultural Values • Extended family networks
• Religion (many are Baptists)
• Interdependence with blacks
• Daily survival
• Technology (e.g., radio, car)
• Folk (soul) foods
• Folk healing modes
• Music and physical activities
Culture Care Meanings and Action Modes • Concern for “my brothers and sisters”
• Being involved
• Providing a presence (physical)
• Family support and “get-togethers”
• Touching appropriately
• Reliance on folk home remedies
• Reliance on Jesus to “save us” with prayers and songs
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From Leininger, M (Ed.). (1991). Culture care diversity and universality: A theory of nursing. Sudbury, MA: National League for Nursing, Jones and Bartlett.
Box 5-4
Arab-american muslim culture Culture Care Meanings and Action Modes • Providing family care and support—a responsibility
• Offering respect and private time for religious beliefs and prayers (five times each day)
• Respecting and protecting cultural differences in gender roles
• Knowing cultural taboos and norms (e.g., no pork, alcohol, or smoking)
• Recognizing honor and obligation
• Helping others to “save face” and preserve cultural values
• Obligation and responsibility to visit the sick
• Following the teachings of the Koran
• Helping children and elderly when they are ill From Leininger, M (Ed.). (1991). Culture care diversity and universality: A theory of nursing. Sudbury, MA: National League for Nursing, Jones and Bartlett.
Evidence-based practice Lack of health care information is one possible reason for racial differences in the prevalence of hysterectomy Background Anecdotal reports continue to suggest that women of color receive a disproportionate degree of invasive gynecologic
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surgeries related to socioeconomic or psychosocial factors. This study sought to examine the association between race and the prevalence of hysterectomy surgeries.
Sample/Setting A cohort of 1863 black and white women served as the study population.
Methods Through the utilization of logistic regression, multivariate analysis demonstrated that significant predictors among all study participants for hysterectomy rates were increased age and access to medical care.
Findings Black women had an increased chance (22%) of undergoing hysterectomy over their white counterparts when all factors except race where held equal.
Implications The gerontologic nurse should be aware of such discrepancies in health care treatment. The study authors speculated that the subjects’ individual knowledge of alternative treatments to radical hysterectomy might be an additional compounding factor. Helping patients gain access to health care information needs to be a priority for those working with minority elderly patients. From Bower, J. K. et al. (2009). Black-white differences in hysterectomy prevalence: the CARDIA study, Am Journal of Public Health 99(2):300.
Cultural awareness
Cultural Self-Assessment • What are my personal beliefs about older adults from different
cultures?
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• What experiences have influenced my values, biases, ideas, and attitudes toward older adults from different cultures?
• What are my values as they relate to health, illness, and health- related practices?
• How do my values and attitudes affect my clinical judgments?
• How do my values influence my thinking and behaving?
• What are my personal habits and typical communication patterns when interacting with others? How would these be perceived by older adults of different cultures?
Cultural beliefs about what is right and wrong are known as values. Values provide a standard from which judgments are made, are learned early in childhood, and are expressed throughout the life span. An example of this is the importance of filial responsibility in many cultures outside those of Northern European origins. This is the expectation that the needs of older adults will be met by their children.
Acculturation is a process that occurs when a member of one cultural group adopts the values, beliefs, expectations, and behaviors of another group, usually in an attempt to become recognized as a member of the new group. Issues surrounding acculturation are particularly relevant for ethnic older persons. Many emigrate to join their children’s families who have established themselves in a new homeland. They may live in ethnically homogeneous neighborhoods such as “Little Italy,” “Little Havana,” “Chinatown,” or other such locations. They may have little interest or need to adopt the mainstream culture of the new country and may retain practices and expectations of the “old country.” Their children, on the other hand, may live in two cultures, that of their parents and that of the community, including their workplaces. This phenomenon has produced a considerable amount of intergenerational conflict. The book The Spirit Catches You and You Fall Down by Anne Fadiman (2012) provides an excellent example of this.
Race is the outward expression of specific genetically influenced, hereditary traits such as skin color and eye color, facial structures,
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hair texture, and body shape and proportions. Many older adults would have married members of their same ethnic or racial group, but this is becoming less common among younger persons. This, too, may serve as a source of familial conflict as traditions and expectations clash.
Ethnicity is defined as a social differentiation of people based on group membership, shared history, and common characteristics. For example, the term Hispanic or Latino is often applied to persons who speak the Spanish language and practice the Catholic religion. However, those who identify themselves as Latino may have been born in any number of countries and be of any race.
Ethnic identity refers to an individual’s identification with a particular group of persons who share similar beliefs and values. Ethnic identity cannot be assumed by appearance, language, or other outward features. I once asked an older black woman, “May I assume you identify yourself as an African American?” To which she replied, “Well, no—I have always thought of myself as just an American and don’t think in terms of ‘African American’.”
Gerontologic nursing care is provided to all persons in all settings, without regard to personal characteristics (see Home Care box).
Home care
1. Ascertain whether the older adult was born in America or came to the United States as a child, young adult, or already in late life because this may affect his or her level of knowledge of Western medicine and care, as well as his or her eligibility for benefits and services. Adapt communication styles as needed to reduce the potential for conflict. Refer to the appropriate agency or social worker for assistance, if necessary.
2. Assess the caregiver’s and patient’s own concepts of health and illness.
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3. Communicate with persons with different linguistic or cultural patterns (e.g., eye contact) in a way in which information may be clear and understandable.
4. Assess the home environment for evidence of cultural values, and determine views on health and illness concepts. Incorporate these data into the care plan to meet the cultural needs of the individual and family.
However, evidence of racial and ethnic disparities in health care and health outcomes exists across the range of illness and services and all age groups (Smedley, Stith, & Nelson, 2003). Socioeconomic factors account for some of these differences, but so do racism and ageism in the health care encounter. Significant for older adults, alarming differences are seen in the rate of angioplasty, use of pain medication, timing of mammography, and mortality associated with prostate cancer, to name only a few (Betancourt & Maina, 2004; Chatterjee, He, & Keating, 2013; Davis, Buchanan, & Green, 2013; Smedley, Stith, & Nelson, 2003).
Gerontologic nurses who provide culturally sensitive care can contribute to the reduction of health disparities through awareness of, sensitivity to, and knowledge of, both overt and covert barriers to our caring (Galanti, 2008). Among these barriers are ethnocentrism and racism. Both are triggers to cultural conflict in the nursing situation. In gerontologic nursing, the barriers are reinforced by ageism.
Ethnocentrism is the belief that one’s own ethnic group, race, or nation of origin is superior to that of another’s. In nursing, we have a unique culture and expect our patients to adapt to us. On the basis of a Western model, nurses and the health care system expect patients to be on time for appointments and follow instructions, among other requirements. If we are caring for older adults in an institutional setting, we expect they will agree to the frequency of prescribed bathing, eating (and timing of this), and sleep and rest cycles. The more an individual is accepting of the institution’s culture, the more content he or she will appear to be. The individual most likely will be identified as “compliant” or a “good patient.” Such a nursing home resident will eat the meals provided even if
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the food does not look like or taste like what he or she has always eaten. A non–English-speaking resident will cooperate with the staff, with or without the help of an interpreter. Those who resist may be considered “noncompliant,” “combative,” or “a difficult patient.” However, some of the emerging models of care such as the Green House Model and the Eden Alternatives in nursing facilities are attempting to reverse this care trend and create homelike environments (Sharkey, Hudak, Horn, James, & Howes, 2010).
Racism is having negative beliefs, attitudes, or behavior toward a person or groups of persons based solely on skin color. Racism results in hostile attitudes of prejudice and the differential treatment and behavior of discrimination and is directed at a specific ethnic or minority group. It has also been found to be a factor in reduced health outcomes in persons from those groups considered “minorities.” The same description may be applied to discrimination based on age. The following example illustrates racism.
A gerontologic nurse responded to a call from an older patient’s room. For some unknown reason, the patient, repeatedly and without comment, dropped his watch on the floor while talking to the nurse. She calmly picked it up, handed it back to him, and continued talking. During one of the droppings, an aide walked in the room, picked up the watch, and attempted to hand it back to him. The patient immediately started yelling and cursing at the aide for attempting to steal his watch. When telling this story, the nurse thought the whole situation odd but not too remarkable. It was not until she learned about subtle racism in health care settings that she recognized the patient’s harmful, racist behavior: He was white and so was she, but the aide was black.
Cultural conflict is the anxiety experienced when people interact with individuals who have beliefs, values, customs, languages, and ways of life different than their own. Consider this example:
An immigrant Korean nurse was instructed to walk with an 80-year- old black patient. The patient complained that he was tired and wanted to remain in bed. The nurse did not insist. The European
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American nurse manager reprimanded the immigrant Korean nurse for not walking with the patient as ordered. The immigrant Korean nurse commented to another Korean nurse, “These Americans do not respect their elders; they talk to them as if they were children.”
Older adults are revered by the Korean culture. Cultural conflicts may occur when caregivers apply their own cultural norms to others without understanding the rationale for the action.
Beliefs about Health and Illness Beliefs about health, disease causation, and appropriate treatment are grounded in culture. The significance attached to illness symptoms and the expectation of outcomes are influenced by past experiences. Knowledge about a person’s beliefs about health and illness is especially important in gerontologic nursing because elders have had a lifetime of experience with illness of self, family, and others within their ethnic and cultural groups (Spector, 2012). Beliefs about health, illness, and treatment can be loosely divided into three theoretical categories: magico-religious, balance and harmony, and biomedical.
In the magico-religious theory, health, illness, and effectiveness of treatment are believed to be caused by the actions of a higher power (e.g., God, gods, or supernatural forces or agents). Health is viewed as a blessing or reward from a higher source and illness as a punishment for breaching rules, breaking a taboo, or displeasing the source of power. Beliefs that illness and disease causation originate from the wrath of God are prevalent among members of the Holiness, Pentecostal, and Fundamental Baptist churches.
Examples of magical causes of illness are voodoo, especially among persons from the Caribbean; root work among southern black Americans; hexing among Mexican Americans; and Gaba among Filipino Americans. For other religious beliefs of different groups, see Box 5-5.
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Box 5-5
Religious beliefs of 23 different groups that can affect nursing care Adventist (Seventh Day Adventist; Church of God) • May believe in divine healing and practice anointing with oil;
use of prayer
• May desire communion or baptism when ill
• Believe in human choice and God’s sovereignty
• May oppose hypnosis as therapy
Baptist (27 Groups) • Laying on of hands (some groups)
• May resist some therapies such as abortion
• Believe God functions through physician
• May believe in predestination; may respond passively to care
Black Muslim • Faith healing unacceptable
• Always maintain personal habits of cleanliness
Buddhist Churches of America • Believe illness to be a trial to aid development of soul; illness
because of karmic causes
• May be reluctant to have surgery or certain treatments on holy days
• Believe cleanliness to be of great importance
• Family may request Buddhist priest for counseling
Church of Christ Scientist (Christian Science) • Deny the existence of health crisis; see sickness and sin as errors
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of the mind that can be altered by prayer
• Oppose human intervention with drugs or other therapies; however, accept legally required immunizations
• Many believe that disease is a human mental concept that can be dispelled by “spiritual truth” to the extent that they refuse all medical treatment
Church of Jesus Christ of Latter Day Saints (Mormon) • Devout adherents believe in divine healing through anointment
with oil, laying on of hands by certain church members holding the priesthood, and prayers
• Medical therapy not prohibited; members have free will to choose treatments
Eastern Orthodox (in Turkey, Egypt, Syria, Romania, Bulgaria, Cyprus, Albania, and Other Countries) • Believe in anointing of the sick
• No conflict with medical science
Episcopal (Anglican) • May believe in spiritual healing
• Rite for anointing sick available but not mandatory
Friends (Quakers) • No special rites or restrictions
Greek Orthodox • Each health crisis handled by ordained priest; deacon may also
serve in some cases
• Holy Communion administered in hospital
• May desire Sacrament of the Holy Unction performed by priest
Hindu • Illness or injury believed to represent sins committed in
previous life
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• Accept most modern medical practices
Islam (Muslim/Moslem) • Faith healing not acceptable unless patient’s psychological
condition is deteriorating; performed for morale • Ritual washing after prayer; prayer takes place five times daily
(on rising, midday, afternoon, early evening, and before bed); during prayer, face Mecca and kneel on prayer rug
Jehovah’s Witness • Generally, absolutely opposed to transfusions of whole blood,
packed red blood cells, platelets, and fresh or frozen plasma, including banking of own blood; individuals may sometimes be persuaded in emergencies
• May be opposed to use of albumin, globulin, factor replacement (hemophilia), and vaccines
• Not opposed to non–blood plasma expanders
Judaism (Orthodox and Conservative) • May resist surgical procedures on Sabbath, which extends from
sundown Friday until sundown Saturday
• Seriously ill and pregnant women exempt from fasting
• Illness as grounds for violating dietary laws (e.g., patient with congestive heart failure does not have to use kosher meats, which are high in sodium)
Lutheran • Church or pastor notified of hospitalization
• Communion may be given before or after surgery or similar crisis
Mennonite (Similar to Amish) • No illness rituals
• Deep concern for dignity and self-determination of individual; would conflict with shock treatment or medical treatment
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affecting personality or will
Methodist • Communion may be requested before surgery or similar crisis
Nazarene • Church official administers communion and laying on of hands
• Believe in divine healing but without excluding medical treatment
Pentecostal (Assembly of God, Four-Square) • No restrictions regarding medical care
• Deliverance from sickness provided for by atonement; may pray for divine intervention in health matters and seek God in prayer for themselves and others when ill
Orthodox Presbyterian • Communion administered when appropriate and convenient
• Blood transfusion accepted when advisable
• Pastor or elder should be called for ill person
• Believe science should be used for relief of suffering
Roman Catholic • Encourage anointing of sick, although older members of the
church may see this as equivalent to “extreme unction,” or “last rites”; may require careful explanation if reluctance is associated with fear of imminent death
• Traditional church teaching does not approve of contraceptives or abortion
Russian Orthodox • Cross necklace is important and should be removed only when
necessary and replaced as soon as possible
• Believe in divine healing but without excluding medical treatment
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Unitarian Universalist • Most believe in general goodness of fellow humans and
appreciate expression of that goodness through visits from clergy and fellow parishioners during times of illness
Adapted from Leininger, M. & McFarland, M. (2002). Transcultural nursing: Concepts, theories and practice (3rd ed.). New York: McGraw-Hill; Purnell, L. (2012). Transcultural health care: A culturally competent approach (4th ed.). New York: FA Davis; Spector, R. (2012). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Prentice- Hall.
Treatments may involve religious practices such as praying, meditating, fasting, wearing amulets, burning candles, establishing family altars, or all of these practices. Such practices may be used both curatively and preventively.
Significant conflict with nurses may result when a patient refuses biomedical treatments because accepting treatment is viewed as a sign of disrespect for God or their source of power and as challenging God’s will. Although this belief is more common in certain groups, many nurses have engaged in magico-religious healing practices such as joining the patient in prayer. Other practices such as “laying on of hands,” or Reiki, are also becoming more widely accepted.
Others view health as a sign of balance—of the right amount of exercise, food, sleep, evacuation, interpersonal relationships, or geophysical and metaphysical forces in the universe, for example, chi. Disturbances in balance are believed to result in disharmony and subsequent illness. Appropriate interventions, therefore, are methods that restore balance, for example, following a strict American Dietetic Association diet, following a diet in which the sodium intake does not upset the fluid balance, or balancing sleep with activity. Historical manifestations of philosophies of balance are the “yin and yang” of ancient China and the “hot and cold theory” common throughout the world.
The yin and yang theory is an ancient Chinese theory that has been used for the past 5000 years. It is common throughout Asia. Many Chinese and other Asian groups apply it in their lives along with practices of Western medicine. The theory posits that all organisms and things in the universe consist of yin or yang energy forces. The
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seat of the energy forces is within the autonomic nervous system. Health is a state of perfect balance between yin and yang. When a person is in balance, he or she experiences a feeling of inner and outer peace. Illness represents an imbalance of yin and yang. Balance may be restored by herbs, acupuncture, acupressure, or massage to specific points on the body called meridian points.
According to the hot and cold theory, illness may be classified as either “hot” or “cold.” The treatments (including food) provided must be balanced with the illness to be effective. Hot foods and treatments are needed for “cold” illnesses, and cold foods and treatments are needed for “hot” illnesses. The culturally caring nurse would ask older adults whether they have a belief about the hotness or coldness of a condition and what accommodations are needed.
Another theoretical perspective on health, illness, and treatment is called the biomedical or Western perspective. The body is viewed as a functioning machine. A part may fall into disrepair and need adjustment or become susceptible to infection. Health is a state of optimal functioning as well as the absence of disease-causing microorganisms such as bacteria or viruses. When microorganisms enter the body, they overpower its natural resistance. Treatment is directed at repair or removal of the damaged part or administration of drugs to kill or retard the growth of the causative organism. The biomedical perspective is the one that is most prevalent in what are called “Western cultures.”
In most cultures, older adults are likely to treat themselves informally for familiar or chronic conditions they have successfully treated in the past, based on one or several of the beliefs just described. When self-treatment fails, a person may consult with another known to be knowledgeable or experienced with the problem, for example, a community healer. Only when this fails do most people seek professional help within a formal health care system. This is especially true of older adults who were born in a (non-Western) country other than the one in which they are aging or residing. Older immigrants may be accustomed to brewing certain herbs, grasses, plants, and leaves to make herbal teas, drinks, solutions, poultices, decoctions, and medicines to prevent
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and treat illness. Many of the same drugs prescribed by physicians are prepared by older adult immigrants at less expense than buying the drug at the pharmacy. These products may be available in ethnic neighborhood grocery stores or botanicas. Others grow their own treatments in potted plants and backyard herb and vegetable gardens (Spector, 2012).
Transcending Cultural Concepts As with health beliefs, a number of concepts may transcend cultures and may have significant influence in the seeking and receiving of health care. As older adults acquire more and more chronic diseases, these concepts may become more important in the effort to provide the highest quality and most sensitive care.
Time Orientation Time orientation refers to one’s primary focus—toward the past, present, or future. The focus of a person who is future oriented is consistent with the biomedical practices of Western medicine. Holders of a future orientation accept that what we do now affects our future health. This means that a problem noted today can “wait” until an office appointment with a health care provider tomorrow—that the problem will still be there and that the delay will not necessarily affect the outcome. This also means that health screenings will help detect a problem today for potentially better health at a later time, days, weeks, or years ahead; it means that prevention may be worth pursuing.
Quite different from individuals with a future perspective, persons oriented to the present perceive a new health problem to need attention in the immediate present. The outcome is seen as occurring in the present, not the future. Preventive actions are not consistent with this approach. This may be a partial explanation of the use of emergency departments when same-day appointments are not available from one’s providers. This difficulty with same- day access may partially explain the new industry known as “retail health clinics.”
Persons oriented to the past perceive present health and health
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problems as the result of past actions, from a past life, earlier in this life, or from events and circumstances related to one’s ancestors. Illness may also be viewed as a punishment for past deeds. For example, dishonoring ancestors by failing to perform certain rituals may result in illness. An older adult who is used to maintaining traditional customs may refuse preventive services while receiving care in a future-oriented system or may resist present orientations seen in nursing facilities.
Conflicts between the future-oriented, westernized world of the nurse and persons with past or present orientations are not hard to imagine. Patients are likely to be labeled as noncompliant for failure to keep appointments or for failure to participate in preventive measures such as immunizations or even a turn schedule to avoid pressure ulcers.
The nurse should, however, listen closely to the older adult, find out which orientation he or she values most, and figure out ways to work with it rather than try (often unsuccessfully) to continue to expect the person to conform. In this way, we reach beyond our ethnocentrism to improve the quality of the care we provide.
Individualist and Collectivist Orientations From the individualist orientation of white “mainstream” Americans and Northern Europeans, autonomy and individual responsibility are paramount. Identity and self-esteem are bound to the self rather than to a group. In a large, classic study Rathbone- McCune (1982) found that older adults of European descent would go to great lengths to try to live with significant discomfort rather than ask for help. To seek or receive help is considered a sign of weakness and dependence, which are things to be avoided at all costs.
Decisions should be made autonomously. This cultural value was put into law through the passing of the Patient Self-Determination Act (PSDA) of 1990 in the United States (American Bar Association). The PSDA formalized the concept that the individual, without the help of family or friends, makes all decisions about his or her health care. The Health Insurance Portability and Accountability Act
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(HIPAA) further codified the role of the individual as the ultimate “owner” of health information (National Institutes of Health, 2014). Others may only have access to this private information with the express permission of the owner.
This approach is in sharp contrast to that held by most or all persons from non-Western cultures, including Native Americans and persons from Mediterranean Europe. Those from a collectivist perspective derive their identity from affiliation with and participation in a social group such as a family or clan. The needs of the group are more important than those of the individual, and decisions are made with consideration of the effect on the whole. Health care decisions may be made by a group such as tribal elders or by a group leader such as the oldest son. This means that neither the PSDA nor the HIPAA are appropriate. For example, in some Latino culture groups, it is inappropriate to inform an older adult of his or her diagnosis or prognosis. Instead, it is expected that this information be conveyed to the oldest male in the family, for example, the husband or the son. To do otherwise shows disrespect of the older adult and thus the family.
When a nurse who values individuality provides care for one who has a collectivist perspective, the potential for cultural conflict exists, as illustrated by the following scenario:
An older Filipino woman is seen in her home by a public health nurse and is found to have a blood pressure of 210/100 mm Hg and a blood glucose level of 380 milligrams per deciliter (mg/dL). The nurse insists on arranging immediate transportation to an acute care facility. The older Filipino woman insists that she must wait until her only child returns home from work to make a decision about her disposition and treatment. She is concerned about the family’s welfare and wants to ensure that income is not lost by her child leaving work early. The family also jointly decides if they can afford a doctor’s visit and a possible hospitalization because the patient does not have health insurance. The nurse’s main concern is the health of the woman, and the woman’s concern is her family. The nurse is operating from the value that dictates that an individual be independent and responsible for personal health care decisions.
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Context A final perspective is that of context. In the 1970s, E.T. Hall described the interactional patterns of high context (universalism) and low context (particularism). This theory has stood the test of time and is very useful when relating to another person cross- culturally; the theory refers to the characteristics of relationships and behaviors toward others (Hall, 1977; Hall, 1990). When a person from a high-context culture interacts with the nurse, a more personal relationship is expected. For example, the nurse is expected to ask about family members and should appear friendly and genuinely interested in the person first and concerned with what might be called nursing tasks second. Body language is more important than spoken words because it is there that the true meaning of the communication is considered to reside.
In stark contrast are those whose relationships and behaviors are of low context such as those from the culture of health care drawn from primarily English and German roots. Low-context health care encounters are task oriented and only secondarily concerned about the relationship between the nurse and the older adult. Individual identity is not as important: Ms. Gomez is not the 82-year-old recent immigrant from Mexico, mother of seven, and grandmother of 30 but is the “fractured hip in 203.” For the person who is from a low- context culture, small talk may be considered a waste of time; a direct approach is expected, with the literal message, “Just tell me what is wrong with me!” Negligible attention is given to nonverbal communication, and verbal communication is kept to only what is necessary.
Most cultures across the globe are high-context cultures. The culturally sensitive nurse is skilled enough to assess the patterns of those cared for and is able to move between contexts in the provision of caring. For more information, see http://changingminds.org/explanations/culture/hall_culture.htm.
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Skills The most important skills are those associated with sensitive intercultural communication. The linguistically competent gerontologic nurse will be able to appropriately use the conventions of the handshake, silence, and eye contact. He or she will also have fundamental skills related to working with interpreters.
Handshake The customary greeting in the business world in the United States consists of smiling, extending the hand, and grasping the other person’s hand. The quality of the handshake is open to varied interpretation. A firm handshake in European American culture is considered a sign of good character and strength. A weak handshake may be viewed negatively.
Traditional Native American older adults may interpret a vigorous handshake as a sign of aggression. They may offer a hand, but it is more of a passing of the hand with light touch, which could be misinterpreted as a sign of not being welcome or of weakness.
In some situations, any type of handshake may be inappropriate. For example, older Russian immigrants may interpret a handshake as insolent and frivolous. Handshakes also raise gender issues with older adults from the Middle East and those from a traditional Muslim background. Same-gender individuals may shake hands, but cross-gender touch outside of marriage is forbidden (Mebrouk, 2008).
The effective nurse is careful to follow correct etiquette with his or her patients, whenever possible. The best way to know the appropriate response is to follow the lead of the patient; waiting for the patient to extend a hand or asking permission for any physical contact are also good rules to follow.
Eye Contact In the European American culture, direct eye contact is a sign of
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honesty and trustworthiness. Nursing students are taught to establish and maintain eye contact when interacting with patients. However, this was not the expected behavior for many older adults in their youth, when avoiding direct eye contact was interpreted as a sign of deference. This pattern continues to be the norm in other countries. Traditional Native American older adults may avoid eye contact with the nurse. They may move their eyes slowly from the floor to the ceiling and around the room. This behavior may lead the nurse to erroneous conclusions but may also cause the nurse to reflect the apparent appropriate behavior with this patient.
In many Asian cultures, looking one directly in the eyes implies equality. Older adults may avoid eye contact with physicians and nurses because health care professionals are viewed as authority figures. Direct eye contact is considered disrespectful in most Asian cultures.
Gender issues are also present in maintaining eye contact. In Middle Eastern Muslim cultures, direct eye contact between the sexes, like touch, may be forbidden except between husband and wife. It is interpreted as a sexual invitation. Nurses may want to avoid direct eye contact with patients and physicians of the opposite gender from a Middle Eastern culture if this is what is observed.
Interpreters The gerontologic nurse can increase the linguistic competence of care through the appropriate use of interpreters. Interpretation is the processing of oral language in a manner that preserves the meaning and tone of the original language without adding or deleting anything. The interpreter’s job is to work with two different linguistic codes in a way that will produce equivalent messages (Bramberg & Sandman, 2012). The interpreter tells the older person what the nurse has said and the nurse what the older person has said, without altering meaning or adding opinion.
An important distinction exists between the terms “interpreter” and “translator.” An interpreter decodes the spoken word, whereas a translator decodes the written word. The translator must further
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decode meaning and therefore may use different words when translating a written document from what the interpreter uses. This is why computer-generated translations such as Google are not recommended for translating full documents (Upadhyaya & Kautz, 2009).
An interpreter is needed any time the nurse and the patient speak different languages, when the patient has limited English proficiency, or when cultural tradition prevents the patient from speaking directly to the nurse. In the United States, as in many other countries, people who do not understand English have the right to an interpreter when dealing with health care providers (Hadziabdic, Heikkila, Albin, & Hjelm, 2011). The more complex the decision making, the more important it is to have an interpreter present, as when determining an older person’s wishes regarding life-prolonging measures (Bramberg & Sandman, 2012).
It is ideal to engage persons who are trained in medical interpretation and are of the same sex and social status of the older person. Ideally, the interpreter should be a mature individual so that potential problems of age differentials are avoided. However, children are often called on to act as interpreters for family members. In such cases, the nurse must realize that the child or the older person may “edit” his or her comments because of cultural restrictions about the content (i.e., what is or is not appropriate to speak to parent or child about) (Ngo-Metzger, Sorkin, & Phillips, 2007).
When working with an interpreter, the nurse first introduces herself or himself to the patient and the interpreter and sets down guidelines for the interview. Sentences should be short, employ the active voice, and avoid metaphors and other idioms because they may be impossible to translate from one language to another. The nurse asks the interpreter to say exactly what is being said and directs all conversation to the patient (Gurman & Moran, 2008).
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Putting it together A number of nursing frameworks are available to assist in providing culturally competent care. The website of the Transcultural Nursing Society (www.tcns.org) provides information about six different theories and models. The models include those by Margaret Andrews and Joyceen Boyle, Josepha Campinha-Bacote, Joyce Giger and Ruth Davidhizar, Madeline Leininger, Larry Purnell, and Rachel Spector (Upadhyaya & Kautz, 2009).
Leininger Leininger’s theory of cultural care diversity and universality is unique and has been recommended for use with the older adult population; it was designed primarily to assist nurses in discovering ways to provide culturally appropriate care to people who have different cultural perspectives than those of the professional nurse (Leininger & McFarland, 2002).
Leininger’s theory uses worldview, social structure, language, ethnohistory, environmental context, folk systems, and professional systems as the framework for looking at the influences on cultural care and well-being. The components of cultural and social structure dimensions are technologic, religious, philosophical, kinship, social, political, legal, economic, and educational factors, as well as cultural values and lifeways.
Leininger theorizes three modes of action for the professional nurse to provide culturally congruent care: (1) cultural care preservation or maintenance, (2) cultural care accommodation or negotiation, and (3) cultural care repatterning or restructuring. Leininger defines the three modes of nurse decisions and actions as follows:
1. Cultural care preservation or maintenance refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a particular culture to retain and to maintain their well-being, to recover from illness, or face handicaps
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or death.
2. Cultural care accommodation or negotiation refers to those assistive, supportive, facilitative, or enabling creative professional actions and decisions that help people of a designated culture adapt to or negotiate with others for a beneficial or satisfying health outcome.
3. Cultural care repatterning or restructuring refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help patients reorder, change, or greatly modify their lifeways for new, different, and beneficial health care patterns while respecting their cultural values and beliefs and still providing beneficial or healthier lifeways than existed before the changes were established (Leininger, 1991).
This theory may be used with individuals, families, groups, communities, and institutions in diverse health care delivery systems. Leininger developed the Sunrise Model (Figure 5-6) to depict the components of the theory and the interrelationship of its components (Leininger & McFarland, 2002). This model may be used as a visual and cognitive map to guide the nurse in teasing out essential data from all the dimensions of the influencers so as to gain clues for providing culturally sensitive care.
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FIGURE 5-6 Leininger’s model for discovering transcultural nursing care and performing cultural assessments. (From Leininger, M. (Ed.). [1991]. Culture care diversity and universality: A theory of nursing. New York: National League for Nursing, Jones and Bartlett. Reprinted with permission from the
National League for Nursing [NLN].)
The Explanatory Model Kleinman, Eisenberg, and Good (1978) presented an alternative far- reaching proposition. They suggested that to provide culturally sensitive and competent care, the gerontologic nurse should explore the meaning of the health problem from the patient’s perspective. This was a radical approach at the time but one that is becoming more relevant as global diversity continues to grow.
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See Box 5-6 for an assessment approach that the gerontologic nurse might use in coming to know the older adult from a culture different from that of the nurse.
Box 5-6
The explanatory model Cultural Care Questions • How has this problem or change affected your life?
• Do you know anyone else who has had this problem or change? What did he or she do about it? What kinds of treatments were used?
• Do you think there is any way to keep this from happening again?
• What treatments have you tried?
• What do you think I (or we) can do for you?
• Is there someone in your family whom you would like to be involved in conversations about this problem or the plan for what to do about the problem?
• Does anyone else need to be involved in your healing? Adapted from Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness and care: clinical lessons from anthropological and cross-cultural research, Annals of Internal Medicine, 88:251.
The Learn Model The LEARN Model (Berlin & Folkes, 1992) uses the same approach as the Explanatory Model. The LEARN Model is a useful tool in guiding the nurse who is interacting with older adults of any ethnicity in the clinical setting. Through it, the nurse increases his or her cultural sensitivity, becomes instrumental in providing more culturally competent care, and consequently contributes to the
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reduction of health disparities. The model consists of these steps:
L Listen carefully to what the older person is saying. Attend not just to the words but to the nonverbal communication and the meaning behind the stories. Listen to the person’s perception of the situation, desired goals, and ideas for treatment.
E Explain your perception of the situation and the problem(s). A Acknowledge and discuss both the similarities and the differences between your perceptions and goals and those of
the older person. R Recommend a plan of action that takes both perspectives into account. N Negotiate a plan that is mutually acceptable.
The nursing skills required to work across cultures include the application of new knowledge. Leininger’s Sunrise Model (Leininger, 1991; Leininger & McFarland, 2002) provides a complex framework for a comprehensive assessment of the culture and the person. However, the Explanatory Model offered by Kleinman and colleagues (1978) and the LEARN Model (Berlin & Folkes, 1992) may be more useful in the day-to-day interactions with persons from diverse backgrounds.
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Summary Gerontologic nurses develop awareness, sensitivity, knowledge, and skills in the delivery of culturally sensitive and linguistically competent care to a steadily diversifying older adult population. Conducting a self-assessment enables nurses to become aware of their strengths and weak areas in their knowledge and skills needed in cross-cultural caring and communication. The positive stereotypical information provided in this chapter, for example, common health beliefs or death practices, may be used as a starting point for communication. For example, the nurse might ask, “It is my understanding that remaining active in the church is important to many in the black community. Is this important to you? If so, how is your stroke affecting this aspect of your life?”
Culturally sensitive care for the patient, resident, or patient begins with an understanding of the health care practices, values, and beliefs of the older adult and his or her family. The Sunrise, Explanatory, and LEARN models may be useful approaches in identifying the health care needs and preferences of persons from cultures different from the nurse’s.
Members of distinct ethnic and racial groups across the globe are suffering from compromised outcomes in their pursuit and receipt of health care. Gerontologic nurses are in a unique position to take the lead in providing culturally and linguistically appropriate care. In doing so, they can contribute to the national agenda to reduce health disparities.
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Key points • The current older adult population in the United States is
becoming more culturally diverse.
• Culture is a universal phenomenon that is learned and transmitted from one generation to another, providing the blueprint for a person’s beliefs, behaviors, attitudes, and values.
• Culture affects all dimensions of health and well-being, so the nurse must consider patients’ cultures when planning, delivering, and evaluating nursing care.
• Ethnocentrism, discrimination, and racism contribute to health disparities.
• Providing culturally appropriate care requires awareness, new knowledge, and new skills.
• The nurse should be knowledgeable about the predominant health practices of the cultural groups for which care is provided, but he or she should still individualize the care rather than generalize about all patients in any given group.
• Cultural assessment tools and instruments need to be free from bias and previously tested on the ethnic group for whom they are intended.
• Nurses caring for older adults from diverse ethnic and cultural backgrounds should be aware that nurse–patient relationships may be based on different orientations to communication than the typical Western mode.
• Nurses should conduct a cultural self-assessment to determine how they are influenced by their own cultures and how their cultures affect their interactions with people of different cultures.
• Nursing interventions should be adapted to meet the cultural needs of older adult patients.
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Critical thinking exercises 1. In what ways do you value diversity in the world around you?
2. What are the limitations of using only race or ethnicity in identifying older patients?
3. Interview two or more older patients from the same ethnic group and discuss their cultural adaptation.
4. Identify your ethnocentric views toward certain groups and the basis on which you have formulated them.
5. What knowledge must the nurse possess to avoid stereotyping or generalizing about older patients?
6. How would you respond to a colleague who just made a racist remark or joke?
7. How would you recognize cultural conflict? How would you respond to it?
8. What are the nurse’s responsibilities when discussing the use of alternative healing practices, medicines, and nutrition with older patients?
9. What responsibilities do you have with an older patient who does not speak English?
10. Discuss the ethical conflicts that may arise among older patients whose values and beliefs are different from yours.
11. What specific cultural nursing skills are needed in caring for older patients from another ethnic group?
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References Administration on Aging. Minority aging. June 6, 2011.
Retrieved September 24, 2013 from http://www.aoa.gov/AoARoot/Aging_Statistics/minority_aging/Index.aspx
American Bar Association (ABA). Patient self determination act. Retrieved from: www.americanbar.org/groups/public_education/resources/law_issues_for_consumers/patient_self_determination_act.html 2014 Accessed on July 11, 2014.
Berlin E, Folkes W. A teaching framework for cross-cultural health care: Application in family practice. The Western Journal of Medicine. 1992;39:934.
Betancourt JR, Maina AW. The Institute of Medicine report “Unequal treatment”: Implications for academic health centers. Mt Sinai J Med. 2004;71(5):314.
Bower JK, Schreiner PJ, Sternfeld B, Lewis CE. Black-white differences in hysterectomy prevalence, the CARDIA study. American Journal of Public Health. 2009;99(2):300.
Bramberg EB, Sandman L. Communication through in-person interpreters: A qualitative study of home care providers’ and social workers’ views. Journal of Clinical Nursing. 2012;22:159–167.
Chatterjee NA, He Y, Keating NL. Racial differences in breast cancer stage at diagnosis in the mammography era. American Journal of Public Health. 2013;103(1):170–176.
Davis JL, Buchanan KL, Green L. Racial/ethnic differences in cancer prevention beliefs: Applying the health belief model framework. American Journal of Health Promotion. 2013;27(6):384–389.
Fadiman A. The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus and Giroux; 2012.
Galanti G-A. Caring for patients from different cultures. 4th ed.
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Gelfand D. Aging and ethnicity: Knowledge and service. 2nd ed. New York: Springer; 2003.
Gurman T, Moran A. Predictors of appropriate use of interpreters: Identifying professional development training needs for labor and delivery clinical staff serving Spanish- speaking patient. Journal of Health Care for the Poor and Underserved. 2008;19(4):1303.
Hadziabdic E, Heikkila K, Albin B, Hjelm K. Problems and consequences in the use of professional interpreters: Qualitative analysis of incidents from primary healthcare. Nursing Inquiry. 2011;18:253–261.
Hall ET. Beyond culture. Garden City, NY: Anchor Press; 1977.
Hall ET. Understanding cultural differences. Yarmouth, ME: Intercultural Press; 1990.
Kleinman A, Eisenberg L, Good B. Culture, illness and care: Clinical lessons from anthropological and cross-cultural research. Annals of Internal Medicine. 1978;88:251.
Leininger M. The theory of culture care diversity and universality. In: Leininger M, ed. Culture care diversity and universality: A theory of nursing. Sudbury, MA: National League for Nursing, Jones and Bartlett; 1991.
Leininger M, McFarland M. Transcultural nursing: Concepts, theories and practice. 3rd ed. New York: McGraw-Hill; 2002.
McCaffrey RG. Integrating Haitian older adults into a senior center in Florida. Journal of Gerontological Nursing. 2007 Dec;33(12):13.
Mebrouk J. Perception of nursing care: Views of Saudi Arabian female nurses. Contemporary Nurse. 2008 Apr;28(1– 2):149–161.
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Ngo-Metzer Q, Sorkin DH, Phillips RS. Providing high- quality care for limited English proficient patients: The importance of language concordance and interpreter use. Journal of General Internal Medicine. 2007;22(Suppl. 2):324.
Purnell L. Transcultural health care: A culturally competent approach. 4th ed. New York: FA Davis; 2012.
Rathbone-McCune E. Isolated elders: Health and social intervention. Rockville, MD: Aspen; 1982.
Sharkey SS, Hudak S, Horn SD, James B, Howes J. Frontline caregiver daily practices: A comparison of traditional nursing homes and the green house project sites. Journal of the American Geriatrics Society. 2010;59:126–131.
Smedley B, Stith S, Nelson. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Institute of Medicine, National Academy Press; 2003 Special report.
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Upadhyaya RC, Kautz DD. Appreciating diversity and enhancing intimacy. In: Mauk K, ed. Introduction to gerontological nursing. Boston: Jones & Bartlett; 2009.
* Original authors: Alice Welch, PhD, RN, CTN, and Kem Louis, PhD, RN, CS, FAAN; and Kathleen F. Jett, MSN, PhD, GNP-BC.
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C H A P T E R 6
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Family Influences Elizabeth C. Mueth, MLS, AHIP
Learning objectives
On completion of this chapter, the reader will be able to: 1. Gain an understanding of the role of families in the lives of older adults.
2. Identify demographic and social trends that affect families of older adults.
3. Understand common dilemmas and decisions older adults and their families face.
4. Develop approaches that can be suggested to families faced with specific aging-related concerns.
5. Identify common stresses that family caregivers experience.
6. Identify interventions to support families.
7. Plan strategies for working more effectively one-on-one with families of older adult patients.
What would you do if you were faced with the following situations?
• You have been married 45 years. Your husband recently had a severe stroke and cannot communicate. He managed the family finances and made all the family decisions. You do not know anything about your financial affairs.
• Your parents, in their late 70s, are mentally competent, but their physical condition means they cannot manage alone in their home. They require all kinds of help and reject any other living situation or paying outsiders for services.
• Your father is dying. You promised that no heroic measures
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would be taken to prolong his life; he did not want to die “with tubes hooked up to my body.” Your brother demands the physician use all possible measures to keep your father alive.
• Your father’s reactions and eyesight are poor. You do not want your children with him when he is driving. He always takes the grandchildren to get ice cream and will be hurt if you say the children cannot ride with him.
Although each situation involves medical considerations, these are tough issues and decisions that extend beyond medical aspects (Schmall, 1994):
• How much independence do I allow my family member to have, and how much risk do I allow him or her to take?
• Is my family member fully capable of making his or her own decisions?
• When, if ever, should I step in and take control of the situation?
• What should I do if my family member refuses help or refuses to make a change?
• What should I do if my family member’s actions are putting himself or others at risk?
The nurse needs to be aware of the various roles families play in the lives of older adults, to be sensitive to family needs as well as to those of the older person, and to recognize and accept that some families are limited in the level of support and caregiving they can provide.
http://evolve.elsevier.com/Meiner/gerontologic
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Role and function of families Families play a significant role in the lives of most older persons. When family is not involved, it generally is because the older person has no living relatives nearby or there have been long- standing relationship problems; 85% of senior citizens will need in- home assistance at some point in their lives. About 78% of in-home care is provided by unpaid family members and friends, and about 79% of people who need long-term care remain at home (Society of Certified Senior Advisors [CSA], 2013). This means that the majority of care for older adults is provided in the home environment. Community services generally are used only after a family’s resources have been depleted. However, several demographic and social trends have affected families’ abilities to provide support. These trends include the following:
• Increasing aging population. Since 1900, the percentage of Americans 65 + has more than tripled (from 4.1% in 1900 to 13.3% in 2011), and the number has increased over 13 times (from 3.1 million to 41.4 million). The older population itself is increasingly older. In 2011, the 65- to 74-year age group (21.4 million) was almost 10 times larger than in 1900; the 75- to 84-year group (12.8 million) was 16 times larger and the 85 + group (5 million) was 40 times larger. About three million persons celebrated their 65th birthdays in 2011. In the same year, approximately 1.8 million persons 65 or older died. Census estimates showed an annual net increase between 2010 and 2011 of 916,837 in the number of persons 65 and over. Between 1980 and 2010, a larger percentage increase occurred in the centenarian population than in the total population. Persons age 100 or older numbered 53,364 in 2010 (0.13% of the total 65 + population). This is a 66% increase from the 1980 figure of 32,194.
• Living arrangements. In 2012, 57% of noninstitutionalized persons age 65 and older lived with their spouses. About 28% lived alone. As of 2011, a total of two million older people lived in a household that included at least one grandchild. Of these, 497,000 were the primary caregivers for their grandchildren.
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Approximately 3.6% of the 65 + group lived in some sort of institutional setting such as a nursing home or assisted living. This percentage increases with age (1% for 65–74 years to 11% for 85 and older). As of 2009, 2.7% of older adults lived in senior housing with support services available (Administration on Aging [AOA], 2013).
• Disability and activity. The AOA measures disability on the basis of limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs include activities such as bathing, dressing, eating, and ambulation. IADLs include preparing meals, shopping, managing money, using the telephone, housework, and taking medication. According to data collected in 2011, 28% of noninstitutionalized Medicare beneficiaries reported difficulty performing one or more ADLs, and 12% reported difficulty with one or more IADLs (AOA, 2013a).
• Decrease in birth rate. Birth rates have declined from 30.1% in 1910, to 25.3% in 1957, the height of the baby boom, to 13.8% in 2009 (Live Births, 2013). Declining birth rate means fewer adult children are available to share in the support of aging parents.
• Increase in employment of women. Traditionally, women have been the primary caregivers. However, in 2010, women comprised 46.8% of the workforce and are projected to comprise 46.9% by 2016. Approximately 73% of women work full time, and 27% work part time. Although employed women often provide as much support as their unemployed counterparts, they often sacrifice personal time. Women aged 55 to 67 reduced their at- work hours by an average of 367 hours, or 41%, to provide some level of care to their parents. A fairly small percentage (14%) leave the workforce or take an early retirement to provide care (U.S. Department of Labor, 2013), but many rearrange work schedules, reduce work hours, or take a leave of absence without pay. Changes in employment status have implications for the financial security of these women in their own later years.
• Mobility of families. Families today may live not only in different cities from those of their older relatives but also in different states, regions, or countries. In fact, according to 2010
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U.S. Census Bureau data (U.S. Census Bureau, 2012), 13% of the U.S. population has migrated since the last census. Geographic distance makes it more difficult to directly provide the ongoing assistance an older family member may need.
• Increase in blended families. While the divorce rate per 1000 people has been declining since 1980, approximately 31% of people, aged 35 to 54, who are married, engaged, or cohabitating have been previously married. First marriages, among young couples, currently have a lifetime 40% risk of divorce, whereas married couples of 35 or more years have almost zero chance of divorce (U.S. Divorce Rates and Statistics, 2013). Divorce and remarriage may increase the complexity of family relationships and decision making and may affect helping patterns. Difficulties may arise from family conflicts, the different perspectives of birth children and stepchildren, and the logistics of caring for two persons who do not live together. However, in some situations, remarriage increases the pool of family members available to provide care.
• Older adults providing as well as receiving support. Many older adults receive financial help from adult children, but many give support (money, child care, shelter) to their adult children and grandchildren.
• The state of the senior housing industry. About 95% of Americans age 65 or older have incorporated elements for aging into their homes. The most common are main level bathrooms and bedrooms. The aging-in-place model remains strong, as 90% of the 65 + age group plans to stay in their current homes as long as possible. Assisted living is becoming more popular, as adult children need more support in caring for their aging parents. Although 90% of institutionalized seniors still reside in nursing homes, the rapidly increasing number of alternatives has caused the number of nursing homes to decrease. The number of older adults living in continuing care retirement communities (CCRCs) nearly doubled from 1997 to 2007, although occupancy rates have begun to decline with the decline in the housing market (CSA, 2013).
• Caregiver workplace issues. Caring for older adult family
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members is becoming the new normal for American families. Employers lose close to $25 billion annually from employees missing work to care for loved ones. Often, employers interpret this as a lack of commitment to career. “Family responsibilities discrimination (FRD)” is becoming a public policy issue. No law exists to protect caregivers as a group (Krooks, 2013). The Family Medical Leave Act (FMLA) allows eligible employees up to 12 weeks of unpaid leave to care for a parent, spouse, or child, but caregiving for an older adult parent may take up to 20 hours per week for as many as 5 years. Another limitation of the law is that family members with a different relationship (grandchild, niece, etc.) to the older adult are not protected by the law. Also, less than half of American employees are considered “eligible” under the law (Yang & Grimm, 2013).
For more on the family views of various cultures regarding older adults, see the Cultural Awareness box.
Cultural Awareness
Cultural Attitudes toward Older Adults
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Common late-life family issues and decisions When changes occur in an older person’s functioning, family members are often involved in making decisions about the person’s living situation, arranging for social services and health care, and caregiving. They also can facilitate, obstruct, or prohibit the older family member’s access to care and services.
Some of the most common issues and difficult decisions families face include changes in living arrangements, nursing facility placement, financial and legal concerns, end-of-life health care decisions, vehicle driving issues, and family caregiving.
Changes in Living Arrangements Many families face the question, “What should we do?” when an older family member begins to have problems living alone. Common scenarios heard from families include the following (Schmall, 1994):
• “Dad is so unsteady on his feet. He’s already fallen twice this month. I’m scared he’ll fall again and really injure himself the next time. He refuses help, and he won’t move. I don’t know what to do.”
• “Mom had a stroke, and the doctor says she can’t return home. It looks like she will have to live with us or go to a nursing facility. We have never gotten along, but she’ll be very angry if we place her in a nursing facility.”
• “Grandmother has become increasingly depressed and isolated in her home. She doesn’t cook, and she hardly eats. She has outlived most of her friends. Wouldn’t she be better off living in a group setting where meals, activities, and social contact are provided?”
Family members are often emotionally torn between allowing a person to be as independent as possible and creating a more secure environment. They may wonder whether they should force a
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change, particularly if they believe the person’s choice is not in his or her best interests. The family may be focused on the advantages of a group living situation (e.g., good nutrition, socialization, and security). However, an older person may view a move as a loss of independence or as being “one step closer to the grave.”
The nurse plays an important role in the following:
• Providing an objective assessment of an older person’s functional ability
• Exploring with families ways to maintain an older relative in his or her home and the advantages and disadvantages of other living arrangement options
• Helping families understand the older person’s perspective of the meaning of home and the significance of accepting help or moving to a new environment
It can be particularly frustrating when a family knows an older relative has difficulty functioning independently yet refuses to accept help in the home. However, as long as the older person has the mental capacity to make decisions, he or she cannot be forced to accept help. To deal successfully with resistance, a family first must understand the reasons underlying the resistance. Encourage family members to ask themselves these questions:
• Is my family member concerned about the impact of costs on his or her or my personal financial resources?
• Does my relative think he or she does not need any help?
• Does my family member view agency assistance as “welfare” or “charity”?
• Is my family member concerned about having a stranger in the house?
• Does my relative believe that the tasks I want to hire someone to do are ones that he or she can do or that “family should do,” or does he or she feel that it would not be done to his or her standards?
• Does my family member view accepting outside help as a loss of control and independence?
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• Are the requirements of community agencies—financial disclosure, application process, interviews—overwhelming to my family member?
Depending on the answers to these questions, it may be helpful to share one or more of the following suggestions with the family (Schmall, Cleland, & Sturdevant, 1999):
• Deal with your relative’s perceptions and feelings. For example, if your older mother thinks she does not have any problems, be objective and specific in describing your observations. Indicate that you know it must be hard to experience change. If your father views government-supported services as “welfare,” emphasize that he has paid for the service through taxes.
• Approach your family member in a way that prevents him or her from feeling helpless. Many people, regardless of age, find it difficult to ask for or accept help. Try to present the need for assistance in a positive way, emphasizing how it will enable the person to live more independently. Generally, emphasizing the ways in which a person is dependent only increases resistance.
• Suggest only one change or service at a time. If possible, begin with a small change. Most people need time to think about and accept changes. Introducing ideas slowly rather than pushing for immediate action increases the chances of acceptance.
• Suggest a trial period. Some people are more willing to try a service when they initially see it as a short-term arrangement rather than a long-term commitment. Some families have found that giving a service as a gift works.
• Focus on your needs. If an older person persists in asserting, “I’m okay. I don’t need help,” it may be helpful to focus on the family’s needs rather than the older person’s needs. For example, saying, “I would feel better if . . .” or “I care about you and I worry about . . ., or “Will you consider trying this for me so I will worry less?” sometimes makes it easier for a person to try a service.
• Consider who has “listening leverage.” Sometimes an older person’s willingness to listen to a concern, consider a service, or
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think about moving from his or her home is strongly influenced by who initiates the discussion. For example, an adult child may not be the best person to raise a particular issue with an older parent. An older person may “hear” the information better when it is shared by a certain family member, a close friend, or a doctor (Box 6-1) (Hartford Institute for Geriatric Nursing, 2014).
Box 6-1
Hartford institute for geriatric nursing at new york university Mission “Since its start in 1996, the singular mission of the Hartford Institute has been to shape the quality of health care of older adults through excellence in nursing practice. The commitment to this mission exhibited by the dedicated Hartford Institute leadership, staff and affiliate organizations has made the HIGN today a globally recognized geriatric presence. The Hartford Institute for Geriatric Nursing is the geriatric arm of the NYU College of Nursing, and has become, over the years, a beacon for all those who wish to advance geriatrics in nursing.”
Vision “People age with health care that is respectful, competent, coordinated and accessible.”
Values • Interdisciplinary approaches
• Quality care
• Knowledge
• Respect for older adults and the people who care for them”
The nurse will find resources and links to the following:
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• Try This® Assessment Tool Series: General Practice, Specialty Practice and Dementia Series
• How To Try This Series
• Nurses Improving Care to Healthsystem Elders (NICHE)
• National Geriatric Nursing Hospital Competencies
• Evidence-Based Geriatric Nursing Protocols
• Geriatric Nursing Certification Review Course
• Advanced Practice Curriculum Case Studies
Additional programs & their correct titles can be found here: http://www.hartfordign.org/spotlight From Hartford Institute for Geriatric Nursing. (2014). <http://www.hartfordign.org> Accessed 08/24/2014.
Making a Decision About a Care Facility Until about 25 years ago, only two options were available to older adults who could no longer live alone: move in with their children or move into a long-term care facility. In the mid-1980s, a new option was born: assisted living. Many older people needed help with things such as housekeeping, meals, laundry, or transportation, but otherwise, they were able to function on their own. Baby boomers latched onto this concept, and the industry has grown exponentially. Perhaps the fastest-growing care facility option is the CCRCs, which often look a lot more like four-star resorts than long-term care facilities. Amenities may include restaurants, pools, fitness centers, and spas. Nonetheless, the attraction of CCRCs is health care for life. This type of community typically allows residents to live independently as long as they can and gives them access to more care, in the same location, when, and if, they need it. Today, 1800 CCRCs exist nationwide, and they have been growing at a rate faster than nursing homes and assisted living facilities combined (Gengler & Crews, 2009).
The decision to move an older family member into any type of care facility is difficult for most families. It is often a decision filled with guilt, sadness, anxiety, doubt, and anger—even when the
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older person makes the decision. The difficulty of the decision is reflected in these comments:
• “It was easier to bury my first husband than to place my second husband in a nursing home.”
• “My parents have lived together in the same house for more than 50 years. Even though they know that they need more help and have agreed that they need to move where they can get more help, they are having a very difficult time coming to grips with the necessity to downsize into a retirement apartment.”
Dealing with the family’s feelings about placement is as important as stressing the need for long-term care. Many families view facilities negatively because of what they have seen in the media concerning neglect, abuse, and abandonment. Cultural considerations may also affect feelings about placement
A common feeling family’s express when faced with care facility placement is guilt. Guilt may come from several sources, including (1) pressures and comments from others (“I would never place my mother in a care facility,” or “If you really loved me, you would take care of me”); (2) family tradition and values (“My family has always believed in taking care of its own—and that means you provide care to family members at home”); (3) the meaning of nursing facility placement (“I’m abandoning my husband,” “I should be able to take care of my mother. She took care of me when I needed care,” or “You do not put someone you love in a nursing facility”); and (4) promises (“I promised Mother I would always take care of Dad,” or “When I married, I promised ‘till death do us part’”).
It may help to talk with family members about the potential benefits of a care facility. For many people, it is not easy walking into a care facility for the first time. It is helpful to prepare families about what to expect and to give guidelines for evaluating facilities, moving an older family member into a care facility, and helping an older family member adjust to the changes.
For more information, see Questions to Consider When Moving from Independent Living to a Supervised Living Facility (Boxes 6-2 and 6-3) and Internet Resources (Table 6-1).
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Box 6-2
Should I move my parents into my home?
How can I help my folks decide if it’s time for them to move? I don’t think they can stay in their own home much longer. Should I suggest that they move to my home? Move to assisted living? I’m at a loss.
Consider the following issues before deciding whether or not to move your parent to your home:
• What kind of care will your parent need?
• How much assistance and supervision can you provide?
• How well do you get along?
• Is your home parent-friendly, and if not, can you make it so?
• Will your parent contribute financially?
• How do your spouse and children feel about the move-in?
• Will your parent be able to live by the rules of your house?
• Will you and your family be able to adjust to the lifestyle changes involved in having a parent in the house?
• Do you have the time to take this on?
• Will your parent have a social network available? From Should you move your parent into your home? (2013). <http://www.caring.com/articles/moving-in-aging-relative-or-parent> Accessed October 9, 2013.
Box 6-3
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Questions to consider when moving from independent living to a supervised living facility 1. Is the move permanent or temporary?
2. Does the patient view the facility as a safety net or dumping ground?
3. Who is in control of the patient’s finances?
4. What are the personal space needs of the patient?
5. Will these needs be met in the facility?
6. Does the patient understand the diagnosis and prognosis of the illness that is precipitating the placement?
7. What has the patient’s living situation been (did the patient live alone or with others)?
8. Does the patient have long-term friends and associates in reasonable proximity to the facility to allow visiting?
9. Does the patient have a pet or pets whose care must be arranged, or does the facility allow pets?
From Baldwin, K. & Shaul, M. (2001). When your patient can no longer live independently: a guide to supporting the patient and family. Journal of Gerontological Nursing, 27(11):10.
Table 6-1 Internet Resources for Caregivers
Organization URL Resources Administration on Aging (AOA)
http://www.aoa.gov Information about insurance, lifestyle management, finances, nursing homes, assisted living, and living independently.
American Association of Retired Persons (AARP)
http://www.aarp.org An excellent site with many topics and links of interest to older persons and their families.
American Health Care Association (AHCA)
http://www.ahcancal.org Association for long-term care includes guide to choosing a nursing facility. The guide is similar to the one from Medicare but has an extensive assessment guide to help in the decision.
Centers for Medicare and Medicaid Services (CMS)
http://www.cms.gov Information on navigating insurance, regulations, care coordination, data and statistics. Includes links to websites for Medicare and Medicaid.
National Association of Professional Geriatric Care Managers
http://www.caremanager.org Describes role, qualifications, and education of care managers; guidance on selection of a qualified person; and search for care manager by zip code function.
National Family Caregivers Association
http://www.caregiveraction.org Information about caregiving and chat rooms for caregivers.
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Where to Turn http://www.where-to-turn.org Information on where to get help for any type of situation, including a section entitled “Senior Circuit”
Financial and Legal Concerns Major financial issues some families face include paying for long- term care, helping an older person who has problems managing money, knowing about and accessing resources for the older family member whose income is not sufficient, and planning for and talking about potential incapacity.
One of the most important things a nurse can do is to become knowledgeable about the community resources that can help families who are faced with financial and legal concerns, eligibility requirements for programs, program access issues, and options for older persons who need assistance in managing their finances. If a family and their older relative have not already discussed potential financial concerns, encourage them to do so.
Many families do not discuss finances before a crisis—and then it is often too late. Sometimes, adult children hesitate to discuss financial concerns for fear of appearing overly interested in inheritance. This is the last subject that parents want to talk about with their children, but it is also the most important. Children should convey that they do not want to know how much their parents have—or might leave in their will; rather, they want to make sure that a current and complete plan exists. When a person has been diagnosed with Alzheimer disease or a related disorder, it is critical that the family make financial and legal plans while the older person is able to participate. At this point, it would be appropriate to execute a general durable power of attorney, which appoints someone to act as agent for legal, financial, and sometimes health matters when the person is no longer able to do so. Once the person becomes incapacitated, if plans have not been made, the options are fewer, more complex, and more intrusive. A family may need to seek a conservatorship, which requires court action (Levy, 2013).
Older persons with limited mobility, diminished vision, or loss of hand dexterity may need only minimum assistance with finances (e.g., help with reading fine print, balancing a checkbook, preparing
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checks for signature, or dealing with Medicare or other benefit programs). Others who are homebound because of poor health but who still are able to direct their finances may need someone to implement their directives. In such situations, a family’s objective should be to assist, not to take away control. The goal is to choose the least intrusive intervention that will enable the older person to remain as independent as possible.
End-of-Life Health Care Decisions The use of life-sustaining procedures is another difficult decision, especially when family members are uncertain about the older person’s wishes or they disagree about “what Mom (or Dad) would want.” The main interests of patients nearing the end of life are pain and symptom control, financial and health decision planning, funeral arrangements, being at peace with God, maintaining dignity and cleanliness, and saying goodbye (Auer, 2008).
It is important for the nurse to realize that life’s final developmental stage ultimately ends in death. Thus, end-of-life decisions are common for most patients and their families. Often, this process does not begin until after the patient has lost the ability to participate in the decision. Some patients and families may need repeated reminders to handle these decisions. Goal setting is a useful tool to help them along. In addition, caregivers could mention that they have completed some of the same planning for themselves (Auer, 2008) (Table 6-2).
Table 6-2 Common End-of-Life Documents
Type of Document
Definition Signature
Do-Not- Resuscitate Order
Executed by a competent person indicating that if heartbeat and breathing cease, no attempts to restore them should be made.
Physician or Nurse Practitioner or patient (state law dependent)
Health Care Proxy or Medical Power of Attorney
Designates a surrogate decision maker for health care matters that takes effect on one’s incompetency. Decisions must be made following the person’s relevant instructions or in his or her best interests.
Patient or witnesses (state law dependent)
Living Will Directs that extraordinary measures not be used to artificially prolong life if recovery cannot reasonably be expected. These measures may be specified.
Patient or witnesses (state law dependent)
Advanced Health Directive
Explains person’s wishes about treatment in the case of incompetency or inability to communicate. Often used in conjunction with a Health Care Proxy or Power of Attorney.
Patient or witnesses (state law dependent)
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A useful tool to help with end-of-life planning is “Five Wishes,” an easy to use legal document written in everyday language. It is “America’s most popular living will.” “Five Wishes” meets the legal requirements for a living will in all but eight states. The wishes are (Aging with Dignity, 2013):
1. The Person I Want to Make Health Care Decisions for Me When I Cannot
2. The Kind of Medical Treatment I Want or Do Not Want
3. How Comfortable I Want to Be
4. How I Want People to Treat Me
5. What I Want My Loved Ones to Know
End-of-life caregiving by health care professionals differs greatly from that provided by family members. For health care professionals, usually, a wealth of experience is available to draw from and support from colleagues to share in the burdens. Families generally do not have the same life experiences to draw from in these situations. In a study by Phillips and Reed (2009), eight themes were identified to form the core characteristics of end-of-life caregiving:
1. It is unpredictable. Each crisis could be the last or just the next in a series of crises.
2. It is intense. It is constant and engulfing. A feeling of overwhelming responsibility exists and cannot be shared.
3. It is complex. Complex treatment regimens must be balanced with complex interpersonal relationships with the patient and other family members.
4. It is frightening. Situations such as falls, bleeding, behavior problems, or medication reactions frighten many caregivers.
5. It is anguishing. Watching the suffering of a beloved family member causes many caregivers severe angst.
6. It is profoundly moving. Many precious moments have spiritual or sacred overtones.
7. It is affirming. Bonding with the older patient is a moving
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experience.
8. It involves dissolving familiar social boundaries. Caregivers and older adults share intimacies such as toileting, changing diapers, or catheter care, which would otherwise not be shared.
The Issue of Driving Driving is a critical issue for seniors—and for this country. Older drivers are more likely to get into multiple-vehicle accidents than are younger drivers, including teenagers. Older adults are also more likely to get traffic citations for failing to yield, turning improperly, and running red lights and stop signs, which are indications of decreased driving ability. Car accidents are more dangerous for seniors than for younger people. A person 65 or older who is involved in a car accident is more likely to be seriously hurt, more likely to require hospitalization, and more likely to die than younger people involved in the same crash. In particular, fatal crash rates rise sharply after a driver has reached the age of 70 (Help Guides, 2013).
Obviously, safe driving is an important issue for our country’s older adults. Everyone ages differently, so some people are perfectly capable of continuing to drive in their 70s, 80s, and beyond. Many older adults, however, are at higher risk for road accidents. A few of the factors that contribute to increased risk are as follows:
• Loss of hearing acuity
• Loss of visual acuity
• Limited mobility and increased reaction time
• Medications
• Dementia or mental impairment
Driving symbolizes autonomy, control, competence, self-reliance, freedom, and belonging to the mainstream of society, so older persons alter their driving when their abilities decline. They may drive only during daylight hours, avoid heavy traffic times, limit the geographic area in which they drive, or limit driving to less
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complicated roadways. Some couples begin driving in tandem with the passenger acting as co-pilot. Sometimes, after the death of a spouse, family members notice that “for the first time, Dad is having problems with driving.” What they may not realize is that Dad had problems with driving before his wife died, but she had served as his eyes and ears when he was behind the wheel.
Families face a difficult time when an older relative shows signs of unsafe driving. They may be both worried about safety and reluctant to raise concerns with their family member or to take action. The issue is even more complicated when the older person is cognitively impaired and does not perceive his or her deterioration and potential driving risk. Studies show that persons with Alzheimer disease are likely to rate themselves as highly capable of driving when they are not.
Sometimes, a family member may rationalize that “Mom only drives short distances in the neighborhood” or may think “I just can’t ask Dad not to drive. The car is too important to him.” Some families are continually faced with a cognitively impaired person who cannot remember from day to day that he or she cannot drive and insists on driving. Older Driver Safety from Helpguides.com (Help Guides, 2013) offers tips on talking to a loved one about driving:
1. Be respectful, but do not back down if you have a legitimate concern.
2. Give specific examples. Instead of “You are not a safe driver,” try “You have a harder time turning your head than you used to.”
3. Find strength in numbers. If more than one person has noticed, it becomes more believable.
4. Help find alternatives. Offer rides or set up an account with a senior transit or taxi company.
5. Understand the difficulty of the transition. If it is safe to do so, try “weaning” the senior from driving. Start with only driving in daylight, or only to familiar places. Perhaps set up transportation to specific appointments to get them used to the idea.
Families may need assistance in assessing a person’s driving
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ability and how to best carry out a recommendation that their relative should limit or discontinue driving. Health care professionals play a critical role in discussing the issue of driving with older persons. Some older persons view health care professionals as being more objective than the family and thus are more willing to listen to their advice and recommendations. Many participants in focus groups indicated that family advice alone would not influence their decision to quit driving. A written prescription from a physician or other health care professional that simply states “no driving” may remind the cognitively impaired person and divert blame from the family. Families also may need information about how to make a car inoperable for the cognitively impaired person.
If family members will be addressing the issue of driving with an older relative, the nurse could suggest they first check some of the resources in Table 6-3.
Table 6-3 Online Resources for Seniors who Drive
Program URL Features American Association of Retired Persons (AARP) Driver Safety
http://www.aarp.org AARP Driver Safety courses designed for older drivers; helps them hone their skills and avoid accidents and traffic violations. Features information on classes and on senior driving in general, including FAQs, driving IQ test, and close call test.
Senior Driving from American Automobile Association (AAA)
http://seniordriving.aaa.com Features videos, pictures, and text presentations to help seniors learn to drive more safely. Topics include exercising for driving safety, adjusting your car for driving safety, handling common and difficult driving situations, and handling emergencies.
Older Drivers Education
http://www.nhtsa.gov/Senior- Drivers
(National Highway Traffic Safety Administration) Resources for people around older drivers.
Physician’s Guide to Assessing and Counseling Older Drivers
http://www.ama-assn.org Guide includes checklists for vision and motor skills to assist physicians in evaluating the ability of their older patients to operate a motor vehicle safely.
Family Caregiving Family caregiving is primarily provided by the adult children of the older person. Often, the varying levels of participation among siblings may cause stress within the family. It is important for the nurse to recognize the types and levels of family caregiving (Willyard, Miller, Shoemaker, & Addison, 2008):
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Routine Care—regular assistance that is incorporated into the daily routine of the caregiver
Back-up Care—assistance with routine activities that is provided only at the request of the main caregiver
Circumscribed Care—participation that is provided on a regular basis within boundaries set by the caregiver (i.e., taking Mom to get her hair and nails done every Saturday)
Sporadic Care—irregular participation at the caregiver’s convenience
Dissociation—potential caregiver does not participate at all in care
Providing care to frail, dependent older adults is becoming increasingly common because of the rapidly aging population. Although many caregivers are spouses, 52% of all parental caregiving is still provided by daughters or daughters-in-law (Wang, Yea-Ing & Yang, 2010). In addition, the type of care provided for parents by women is different from that provided by men. Just as the age-old concepts of “women’s work” and “men’s work” imply, a division of labor exists in family caregiving. Women are most likely to handle the more time-consuming and stressful tasks such as housework, hygiene, medications, and meals. Men are more likely to handle matters such as home maintenance, yard work, transportation, and finances (Willyard et al., 2008).
Caregiving may evolve gradually as a family member becomes frail and needs more assistance, or it may begin suddenly as the result of a stroke or accident. A family may adjust better to the demands of caregiving when a relative’s need for support gradually increases rather than when the person’s functional ability declines rapidly.
A family member with a dementing illness such as Alzheimer disease will require increasing levels of support and assistance as the disease progresses (see the Evidence-Based Practice box). The need may progress to where help is required 24 hours a day. Caregivers of patients with dementia often exhibit symptoms of tiredness and depression because of the high levels of stress (Clark & Diamond, 2010).
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Losing the person that family members have always known is one of the most difficult aspects of coping with a progressive, dementing illness. As one woman said, “I’ve already watched the death of my husband. Now I’m watching the death of the disease.” Another stated, “The personality that was my husband’s is no longer present. I feel as though I am tending the shell of who he was—that is, his body. That is all that remains.”
More and more families are faced with long-distance caregiving. They may find themselves driving or flying back and forth to repeated crises, spending long weekends “getting things in order,” or “constantly checking on Mom and Dad.” Such long-distance managing not only takes time and money but may also be emotionally and physically exhausting. Trying to connect with and coordinate services from a distance may be frustrating, especially if older persons cancel the arrangements made by their families.
Care managers, many of whom are nurses, may be particularly helpful to long-distance caregivers. A care manager can evaluate an older person’s situation and needs, establish an interface with health care providers and arrange for needed services, monitor the older person’s status and compliance with treatment plans, provide on-the-spot crisis management, and keep the family informed about progress and changes in the older person’s condition and situation. Care management services are offered by local Area Agencies on Aging (AAAs), hospitals, and private agencies and practitioners. AAAs can connect families with publicly funded care management services.
Placing the family member in a long-term care facility may merely change the kind of stress felt by the caregiver rather than alleviating it. The caregiver may feel a sense of failure—even when placement is the best decision. Stress also may result from difficult visits, travel to and from the care facility, worry about the quality of the care, family conflicts regarding placement, and the cost of the care. Some family members continue to do tasks in care facilities that they performed when providing care at home (e.g., providing assistance with eating, walking, and personal care).
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Evidence-based practice Cultural Issues in Care Giving: Personal and Family Dynamics Involved in Decision Making When Nursing Home Placement Is an Issue Sample or Setting The study consisted of 12 Korean Americans in the Chicago area age 65 or older who did not have dementia.
Methods Face-to-face interviews were conducted in Korean with specific questions centered on what type of care they desired if they were to become bedridden. The first question was who would they desire to care for them or where would they prefer to be cared for if they were to become bedridden. The next questions were: “Where did they realistically expect to go if bedridden, or who would they actually expect to care for them?” The last question was: “What, if any, was the discrepancy between what was desired and what was likely to happen if they were to become bedridden?”
Findings Most (8 of 12) study participants preferred to live with their family while the other 4 preferred senior housing in the event they were to become bedridden. The reasons for their preferences were divided into three domains. The first domain wanted to maintain independence over decision making regarding money or personal time. The next domain was family issues. Korean Americans usually lived with the oldest son, but the participants acknowledged that these cultural norms were changing now that they lived in America and maintaining good relationships sometimes meant living apart. The last domain was services available to them. Korean American senior living and nursing home care options in the area were acceptable to the older adults in the study.
All acknowledged that if bedridden, they would most likely be
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placed in a nursing home.
Implications When nursing home placement becomes a reality for older adults, nurses must be aware of the personal and family dynamics involved in the decision-making process. The norms associated with caregiving in different cultures are also important. Addressing these issues early may make the transition easier for the older adults and may provide culturally harmonious care during their stay.
From Shin, D. (2008). Residential and care giving preferences of older Korean Americans. Journal of Gerontological Nursing, 34(6):48.
Challenges and Opportunities of Caregiving Few families are prepared to cope with the physical, financial, and emotional costs of caregiving. Most sons and daughters have not anticipated the possible need to provide care to their aging parents. Caregivers may become frustrated and exhausted because of unrealistic expectations or lack of knowledge and time. When caregiving is combined with other family responsibilities, the caregiver may feel that he or she does not have sufficient time in the day to complete all the tasks (Hendriksson & Arestedt, 2013).
The two types of patients in American nursing homes are as follows (Eskildsen & Price, 2009):
Long-term care—patients needing help for coping with ADLs, incontinence, and dementia. This care is not reimbursed by Medicare. These patients pay out of pocket for their stay until they become impoverished enough to qualify for Medicaid.
Subacute (or postacute) care—patients released from the hospital who are undergoing rehabilitation after stroke, joint replacement, or wound care. This care is reimbursed by Medicare; however, the number of days that will be covered is limited.
The cost of caregiving may place a burden on the finances of many families. It is generally less expensive to provide care at home. LongTermCare.gov estimates some average costs for long-
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term care in the U.S. for 2010:
• $205 per day or $6235 per month for a semi-private room in a nursing home
• $229 per day or $6965 per month for a private room in a nursing home
• $3293 per month for care in an assisted living facility (1-bedroom unit)
• $21 per hour for a home health aide
• $19 per hour for homemaker services
• $67 per day for adult day care center
As part of their study of the Aging-In-Place model, Marek and coworkers (2010) determined that remaining at home with the use of a Nurse Care Coordinator, the costs to Medicare and Medicaid in Missouri were lower for those who remained at home.
If the caregiver is employed, work relationships may be compromised. The caregiver may be interrupted often at work or may need to miss work completely. Caregiving activities may be viewed as “lack of career commitment” (Krooks, 2013). Adult day care is one alternative available to the working caregiver; however, programs are limited in number, availability, and hours and are often costly.
Chronic stress is another challenge to family caregivers. The family’s normal routine may be disrupted. If the family providing care is from another locality, the time commitment of coordinating services and care providers may disrupt the family routine. Many families expect the daughter (either the oldest or the one living closest) to be the caregiver, regardless of her other commitments to her household or employer.
Many adult caregivers express frustration regarding the inequality of the contributions by their siblings. The siblings providing the majority of the care may resent those who are perceived to do less, whereas those who do less may feel guilt or frustration that their suggestions or offers of help are rejected.
Caregiving may also be regarded as a beneficial opportunity.
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Close-knit families may view the caregiving situation as a way to demonstrate love and commitment. Frail older persons in this situation are reportedly less depressed and more satisfied with their care. Bonds between grandparents and grandchildren may be strengthened, along with other family relationships. Depending on the situation, the younger family may move in with their older relative and as a result may receive room and board, childcare, or financial assistance while they help out with the household chores.
Long-Distance versus Nearby Family Conflict may arise between family members who live near an older person and those who live at a distance because of their different perspectives (National Institute on Aging, 2013). To the family member who lives at a distance and sees the older person for only a few days at a time, the care needs may not seem as great as they do to the family member who has daily responsibility. In addition, the person may “perk up” in response to a visit by a rarely seen family member and may not display the symptoms and difficult behavior that he or she exhibited before the visit. Some older persons “dump” on one family member and show a cheerful side to another. Others take out feelings of frustration and loss on those providing day-to-day support and talk in glowing terms about sons and daughters who live at a distance.
Family members who are unable to visit regularly sometimes are shocked at the deterioration in their older relative. They may become upset because they have not been told “just how bad Mom or Dad is.” However, they may have only two points of reference: the last time they saw their older relative (which may have been several months or a year earlier) and now. On the other hand, when changes have occurred gradually, family members who have regular contact with the person often are not aware of the degree of change because they have adjusted gradually.
Family conflict may occur because of these different experiences. The nurse often can help family members understand the reasons for different perceptions. It also may be helpful to remind distant family members not to let apparent differences in behavior between what they see and what the local caregiver has said discredit the
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caregiver. They also need to know that local caregivers often have to compromise with the older person and accept imperfect solutions to problems.
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Interventions to support family caregivers Education Many caregivers are unprepared for their new role, which may prove detrimental to both the caregiver and the patient. It is important that health care professionals ask the family what they want to know, as well as providing them with information they need to know (Table 6-4). The TRAC Study, in the United Kingdom (Forster et al., 2011) evaluated a structured, competency-based training program for caregivers of patients who had suffered a stroke. The preliminary results of the study found that both physical and psychological outcomes for both caregivers and patients were improved. The program appears to be cost effective when compared with additional health care costs incurred by those who did not participate in the program.
Table 6-4 Managing Stress
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From Alzheimer’s Association. (2013). Take care of yourself. <www.alz.org> Accessed March 9, 2013.
One advantage of education—whether provided one-on-one or in group settings—over other intervention strategies is its nonintrusive nature. Many people who would not attend a support group or seek counseling may attend a program labeled “education.” An educational program also may be a springboard for a person to seek other intervention programs. As one woman said:
I avoided going to a support group because I didn’t want to air my “dirty laundry.” It was not until after I attended an educational program that I realized my concerns and fears were not abnormal. It was then I felt more comfortable talking to others and joining the support group.
Most caregivers do not have the opportunity for extensive
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education or training before assuming their role. Often, education programs from rehabilitation services or brochures and booklets from other sources do not adequately prepare the caregiver for the many varied issues they will face at home (Elliott & Pezent, 2008). Although a caregiver’s needs for information are diverse, they fall into six general categories (Schmall, 1994):
1. Understanding the family member’s medical condition. Caregivers need information about the progression, signs, symptoms, and outcomes of medical conditions; common medical treatments; a condition’s impact on an older adult’s functional abilities; and implications for the caregiver and family. It is important to dispel any myths, misinformation, and unrealistic expectations. For example, when caregivers do not understand behavior caused by a dementia, they often view the person’s behavior as intentional.
2. Improving coping skills. Coping skills may include stress management, social network-building skills, behavioral management skills, problem-solving skills, and the ability to perform specific tasks of caregiving—such as managing incontinence, feeding a person with swallowing difficulties, or meeting an older adult’s emotional needs.
3. Dealing with family issues. Family issues often involve getting support from other family members, identifying how much and what type of help family members can give, and dealing with conflicting feelings toward family members who do not help. Decisions about older adult care and caregiving generally affect not only caregivers and care receivers but also other family members. Anger and family dissension may occur when caregivers do not attend to the thoughts and feelings of family members.
4. Communicating effectively with older persons. Family members often need to know how to effectively communicate their concerns to older persons who are competent as well as how to communicate with those who are unable to understand or communicate. Communicating effectively with cognitively impaired persons often requires learning communication skills contrary to those learned over a lifetime; yet using appropriate techniques may reduce stress for everyone. The benefits of such
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information are reflected in the following adult son’s comments:
The hardest thing about dealing with Alzheimer disease is learning to relate in new ways and accepting my Dad as he is today. What a difference it made for me when I learned in the caregiver class to “step into my Dad’s world,” rather than keep asking him questions about things he simply could not remember. Our times together are now much more enjoyable for the both of us.
5. Using community services. Many caregivers need information about the range of community services, the types of help that are available, how to access services, and care facility options.
6. Long-term planning. This includes making legal and financial plans and considering changes in the current caregiving situation, including possible nursing facility placement.
Two major goals of caregiver education should be to (1) empower caregivers and (2) increase caregiver confidence and competence (Elliott & Pezent, 2008). Feeling powerless may have a significant impact on a caregiver’s physical and emotional health. Although the factors that affect feelings of powerlessness are complex and vary from person to person, it is helpful if health care professionals use approaches that do the following (Schmall, 1994):
• Help caregivers set realistic goals and expectations. Failing to achieve goals reinforces feelings of powerlessness. Achieving goals increases morale. A caregiver whose goal is to “make Mother happy” is less likely to experience “success” than a caregiver whose goal is to plan one enjoyable activity each week with her mother.
• Provide caregivers with needed skills. Being able to do the tasks that need to be done, get needed support, or access community resources enhances feelings of being in control.
• Enhance caregivers’ decision-making skills. This includes sharing information about options and their potential consequences for older persons, caregivers, and other family members.
• Help caregivers solve problems. The ability to solve problems in
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managing care reduces feelings of powerlessness and stress.
One of the goals of education should be to provide caregivers with the confidence that they need to do a task or take an action. This means it is critical to give caregivers an opportunity to practice skills in a learning environment that is nonthreatening and psychologically safe. Skill building is enhanced when caregivers have the opportunity to practice skills in an educational setting and receive feedback, apply skills in the home environment, and then return to discuss how well the techniques worked, the problems that were encountered, and what they might do differently the next time in applying the skills.
It is important to discuss the barriers caregivers may confront in the real world and ways to overcome these barriers. For example, professionals often talk about the importance of caregivers setting limits, but they do not always prepare caregivers for the possible consequences of doing so. For instance, an older person’s manipulative behavior may worsen for a time after a caregiver begins setting limits, particularly if in the past such behavior generally resulted in the older person getting what he or she wanted.
Family members also need to know that at times they may have to step back and wait until a crisis occurs before they can act (e.g., when a mentally intact older family member refuses to go to a physician or refuses to stop drinking despite attempts at intervention). In such situations, however, family members often feel they have failed. They may need help to recognize that “failures” are the result of a challenging situation and not their performance.
Sharing printed information (e.g., handouts the nurse has prepared, pamphlets, articles) and programs is another important way to provide education. Adults also learn independently. Workbooks can provide caregivers with a step-by-step guide for taking action.
Educational materials should be easy to read, with bullet points, definitions of difficult terms, illustrations, and enough white space to keep them from being intimidating. People will not read
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something that looks like it will be complicated or difficult to understand. Materials should be written in plain language that is designed to flow, and the materials should avoid medical jargon (Make written material, 2009).
Print materials provided to caregivers, when shared with other family members, may help create a common base of information and understanding (Schmall, 1994). Sometimes, other family members “listen” more readily to information in a handout developed by a professional than to the same information shared verbally by caregivers. Printed materials are beneficial for another reason. It is difficult for people who are anxious or in crisis to hear and remember everything that is said. Written information gives them a reference for later use.
Another resource for families is the Internet. Many health and caregiving organizations offer a variety of helpful information through their websites. See Table 6-1 for more information. If families do not have access to the Internet, encourage them to ask the local library for help in locating appropriate websites.
Respite Programs Respite programs are one of the few services designed specifically to benefit the caregiver. The programs allow caregivers planned time away from their caregiving role. Researchers agree that respite care could potentially improve the well-being of the caregiver as well as possibly delaying the institutionalization of the older person in their care. The two basic premises to respite care are (1) shared responsibility for caregiving and (2) caregiver support (Alzheimer’s Association, 2013a).
The nurse can help the caregiver to understand that it is normal to need a break and that seeking respite care will not label them as a failure. According to the Alzheimer’s Association, respite services also benefit the patient. Caregivers need time to spend with family and friends, run errands, get a haircut, or see a doctor while still having the comfort of knowing that their loved one is well cared for. Benefits to the patient may include interactions with others in a similar situation; safe, supportive environment; and activities that
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will match their needs and abilities (Alzheimer’s Association, 2013).
Respite services may be provided in-home or out-of-home and for a few hours, a day, overnight, a weekend, or longer. In-home respite care can include companion sitter programs or the temporary use of homemaker or home health services. Out-of-home respite services include adult day programs or short stays in adult foster care homes, long-term care facilities, or hospitals.
Respite services often are underused by caregivers. Barriers to access and use of services include the following (Schmall & Nay, 1993):
• Lack of awareness. Often, families are not aware of the availability of respite services or of program eligibility, or they are not familiar with the provider agency.
• Apprehension. With in-home respite services caregivers may be apprehensive about leaving a family member with a “stranger” or nonprofessional.
• Caregiver attitudes. Some caregivers think “I can care (or should be able to care) for my family member myself” or “No one can care for my family member like I can.” Others feel guilty and selfish for leaving ill family members in the care of someone else so that they can meet their own needs.
• Timing. Caregivers often view respite services as “a last resort.” They seek help much too late—when they are in crisis or a family member is severely debilitated and requires care beyond what a program can provide.
• Finances. The cost of respite care, or the anticipation of future expenses, is another reason some caregivers may be unwilling to use or delay using such programs. Others are unwilling to pay for a program they view as a “babysitting service.”
• Care receiver resistance. Negative reactions by care receivers such as resentment toward someone coming into the house or a caregiver’s leaving may keep caregivers from using respite programs.
• Energy required to use the program. The time and energy
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required to prepare and transport care receivers may limit use of adult day programs.
• Program inflexibility and bureaucracy. Program inflexibility may contribute to caregivers’ low usage of respite care.
These are issues the nurse may need to address when working with a caregiver who hesitates or refuses to use a respite program. It is important to first identify the reasons a caregiver is reluctant to use a program and then work with the caregiver to reduce or eliminate the identified barriers.
In general, female caregivers appear to have more difficulty using respite and adult day programs. Because they have been socialized as nurturers and caregivers, women may buy into the view that “caregiving is women’s work” and may believe caregiving is something they should do. As a result, they may be more reluctant to let go of the caregiver role and to accept outside help. Men, on the other hand, may feel less secure in the caregiver role and may perceive that they lack the necessary skills to take care of someone else. Thus, they tend to be more willing to use services.
The nurse should help caregivers recognize that caregiving is a job. Just as employees benefit from regular breaks and vacations, caregivers benefit from a “break” in the job. The nurse should emphasize that the need for respite care begins with the onset of caregiving.
The message a nurse conveys about respite to caregivers may be important. Although respite programs are designed primarily to benefit the caregiver, some caregivers are reluctant to take advantage of services for themselves. Resistance to respite and day care programs may decrease if the nurse emphasizes how a program can benefit care receivers by keeping the caregiver fresh and relaxed.
It is generally assumed that respite is inherently beneficial to caregivers. However, different uses of respite time may lead to different outcomes (Lund et al., 2009). Caregivers who use respite time primarily for discretionary activities such as socializing, rest, and exercise experience more favorable outcomes than caregivers who spend the time primarily in obligatory activities such as doing
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housework, performing other domestic chores, or providing care to another person. As a nurse, it may be worthwhile to discuss with caregivers how they plan to use respite time and encourage caregivers to engage in discretionary activities that they enjoy.
Even when formal respite services are not available, the nurse plays a vital role in encouraging caregivers to take breaks in caregiving and helping them identify and overcome barriers to obtaining respite. Members of a caregiver’s informal support system may be able to provide respite when formal services are unavailable or inaccessible. Some caregivers need help to reach out and ask for assistance, particularly if they view asking for help as a sign of weakness, helplessness, inadequacy, or failure. A written “prescription for respite” by a health care provider for certain hours of respite per week or month may provide the authority a caregiver needs to begin taking breaks from the demands of caregiving (Box 6-4).
Box 6-4
Video respite: an innovative caregiver resource
“I can’t seem to find any time for myself. I’m suffocating.”
“I never have time alone, not even in my own home. I can’t even take a bath, fix dinner, or make a phone call without interruption. I have no privacy.”
“I’m tired of my mother following me around and asking questions constantly, like a broken record. I need some time and space to breathe.”
Such comments are common from caregivers of persons with dementia. One of their greatest needs is for regular breaks from caregiving. Although adult day care and respite programs provide family caregivers with much needed time away from the demands of caregiving, they often need 15-minute or half-hour
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breaks to take a short rest, to have time alone, to attend to personal matters, to make telephone calls, or to do household chores without interruption. Video Respite, developed by researchers at the University of Utah Gerontology Center after 10 years of research on caregiving, is a unique, innovative approach to making it possible for caregivers to get these brief “breaks” in caregiving without leaving home.
Video Respite consists of a series of programs simulating a personal and friendly visit. Each program actively engages persons who have moderate to advanced memory and cognitive impairments in an enjoyable and meaningful interaction. As the memory-impaired individual “interacts” with the person on the DVD, a caregiver can take some time for himself or herself.
Video Respite currently includes thirteen programs, ranging from 25 to 59 minutes in length. Each captures and maintains the attention of persons with dementia through the recollection of pleasant memories and music and involvement in singing and in doing simple hand, arm, and leg movements. Although some persons may not be able to do all of the physical exercises, the programs do hold the attention of memory-impaired persons, as evidenced by their participatory actions such as toe-tapping. Brief descriptions of the programs follow:
Gonna Do a Little Music. While playing the guitar and autoharp, Marianne engages the viewer in singing familiar songs. She discusses memories related to love, music lessons, family gatherings, and childhood friends.
Remembering When. This tape includes memories of school days, for example, songs and routines such as reciting the Pledge of Allegiance; city and country life; and a brief recollection of the Roaring Twenties. Kyle, a toddler, visits.
A Yankee Doodle Dandy Time. Becky recalls and prepares for a Fourth of July celebration. Becky’s cat joins her in recollections about the American flag, marching bands, and parades.
Movement, Music, and Memories. Cathy encourages viewers to stretch, walk, and march in place through the use of favorite songs. This tape also includes a visit by a boy playing kickball
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and a lamb.
Sharing Christmas Cheer. George discusses the traditions of Christmas trees, gifts, and stockings, and many familiar carols are sung.
Sharing Favorite Things. Joyce discusses pleasant memories of growing up. A dog visits, as does a 1-year-old baby, to whom the viewer is invited to sing “Happy Birthday.”
Those Good Ole School Days. This tape involves recollections of early school days—long walks to school, games, trips to the candy store—and the singing of familiar school-related songs.
Two of the DVDs were developed to be more gender specific:
Ladies … Let’s Chat. Diane chats about topics from family gatherings and meal preparation to dressing up with hats and courtship days. Her two grandchildren visit.
Lunchbreak with Tony. On his work break, Tony discusses work days, jobs, co-workers, baseball, first cars, and first loves. Tony’s dog, Sparky, visits.
Four programs are more culture specific:
Favorite Canadian Memories. Dawn, her baby, and others share early memories of growing up in Canada, including Expo ’67, ice skating, and hockey nights. Dawn’s brother, dressed in a hockey uniform, visits.
A Kibitz with David. David, a Jewish man, recalls weddings, Passover, Chanukah, and other holiday celebrations. David’s wife and children help light the Shabbos candles and sing favorite Yiddish songs.
Celebrating African-American Culture. This is a look at the celebrations and personal memories of African Americans. It includes “good old home cooking” and singing traditional songs.
A Visit with Maria. Recorded in Spanish, Maria invites viewers to sing along with old favorite songs and share memories of childhood days and festivals.
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It is exciting to observe a person with Alzheimer disease “converse” with Marianne, Joyce, Tony, and others on the programs and, even more important, feel good about his or her “visit.” Strengths of these DVDs for the person with Alzheimer disease include the following:
A personalized approach. The people on the DVDs are friendly and present themselves and the content in such a way that it feels as though the viewer is being talked to directly.
An opportunity for positive interaction. Questions, pauses, and feedback from “the visitor” encourage involvement and conversation from the person with memory impairment.
A focus on long-term memory. Through familiar images and childhood songs, the DVDs capture the attention and trigger long-term memories for persons with dementia. The objects, people, events, and early life experiences that are discussed are familiar to most of today’s older persons.
A way to help the person “feel good.” The “visitors” give a lot of positive feedback. For example, in one DVD, viewers hear comments such as “You did a great job,” “That was great,” “You have wonderful eyes,” “Do whatever feels best to you. If you want to just sing or hum along, that’s okay,” and “Thank you for spending this time with me. You have given me joy today.”
A slow pace and visually uncluttered screen. The slower pace gives persons with memory impairment the necessary time to understand and respond to information. The visual simplicity helps to keep the viewer focused and reduces distraction. The faster pace and content of most television programs are not optimum for sustaining the attention of most persons with Alzheimer disease.
Studies conducted by University of Utah researchers also show that the DVDs may be useful in calming the person who is agitated. One caregiver stated:
When Herb is agitated and I’m at my wit’s end is when I need the tape the most, and I forget to use it. And then I’ll
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call my son, and he’ll say, “Put the tape in first. If that doesn’t work, then I’ll be over.” But it always works. He’s not attentive to TV, but he is to the tape.
Because the older adult is subject to loss of recent memory with Alzheimer disease, the Video Respite tapes can be used again and again. Another caregiver reported:
This kept Mother entertained like nothing else has for years. I could use it every day, or back-to-back, because it’s like a new tape each time. If she is depressed or irritable, it will get her out of it. She won’t watch TV, but she is glued to the tape.
Because Video Respite tapes engage the person with Alzheimer disease, caregivers can get short breaks in caregiving whenever needed. For a caregiver, 30 to 50 minutes of uninterrupted time may be significant. The tapes are also (1) quick, convenient, and easy for a caregiver to incorporate into the daily routine, (2) portable so that they can be used in many different settings or places, and (3) appropriate for repeated use. The DVDs also may help to give caregivers who feel helpless a greater sense of control. As one caregiver said, “The DVDs help me to feel as though I am doing something positive for Mother.”
Considerable research and evaluation, including a 2-year grant from the national Alzheimer’s Association, went into the development of these Video Respite tapes. Tests of Video Respite in nursing facilities, special care units, and adult day care programs also show favorable results.
Video Respite is not a panacea or a substitute for a caregiver or other services; however, it does offer considerable promise in providing caregivers with an opportunity for respite time. From Video Respite. (2013). <http://www.videorespite.com/> Accessed October 9, 2013.
Support Groups In many communities, caregiver support groups have developed. Some support groups are oriented to specific diseases such as
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cancer, Parkinson disease, lung disease, stroke, or Alzheimer disease and related dementia. Others are for family caregivers in general.
A support group may be a place where caregivers get advice, gain knowledge about their older relatives’ medical conditions and problems, share experiences and feelings, develop new coping strategies, and learn about community resources and care alternatives. A support group may help normalize a caregiver’s experience. Discovering that they are not alone may provide much- needed emotional relief to some caregivers. For the isolated caregiver deprived of intimacy and support from the care receiver, a support group also may provide an acceptable outlet for socializing. Although many caregivers benefit from support groups, they are not for everyone.
Research on support group effectiveness has yielded several broad themes (Golden & Lund, 2009):
Balance—support group members learn to balance their own needs against those of their relatives
Sameness—caregivers realize that others are facing the same issues
Individuality—group members realize that although some issues are the same, each person’s circumstances may be unique
Family Meetings Although one family member is generally responsible for caregiving, other family members are important in providing support. However, each family member may have a different idea about what the problem is or how to handle it. For example, one brother might not want a parent’s resources—his potential inheritance—spent for in-home care; he may prefer that the family provide the needed care. Another brother may believe “Mom’s money is there to spend on her” and prefer to purchase services. Beliefs about what is best often differ, creating family dissension. One person may be adamant that the older person should be kept at home at all costs; another may think a care facility is the best setting. Intense conflicts may result.
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Unless differences are discussed and resolved, disagreements among family members usually magnify. A family meeting should be held as early as possible after the need for caregiving arises. Everyone who is concerned or who may be affected by decisions should be involved, including the older person (if possible) for whom plans are being made. Calling distant family members to get their input and keeping them informed may help them feel involved in the decision making. A family member should not be excluded because of distance, personality, family history, or limited resources. It is just as important to invite the difficult, argumentative family member or the one who seldom visits as it is to involve those who are supportive. Such involvement ensures greater success and support for any plans that are developed and may help prevent later undermining of decisions.
Sometimes, families find it helpful to hold a two-step meeting. The first meeting is held without the older person to discuss ideas and feelings, raise concerns, and identify needed information. The purpose is not to make the decision or to “gang up” on the older person. A second meeting is then held in which the older person is actively involved in identifying and evaluating options and making decisions.
A family meeting is not always easy. It is most difficult for family members who have never discussed emotion-laden concerns, who hold differing values and outlooks in regard to the situation, or who have a history of poor relationships and conflict. A family in conflict may become angry and get side-tracked from current issues and the decisions that need to be made. Old resentments and conflicts that have been dormant since childhood can reemerge with regard to relationships, family roles, expectations, the authority to make decisions, and even inheritance. A family meeting often is even more important in these situations.
If family conflicts or hidden resentments prevent rational discussion, it often helps to have a health care professional skilled in working with older adults and their families facilitate the family meeting. The professional, whether a nurse, social worker, member of the clergy, or counselor, should be well versed in aging-related issues and family dynamics and have group facilitation skills. The
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mere presence of an “outsider” often keeps the atmosphere calm and the discussion focused and objective. An objective third party also can help move the family past emotions to common interests and can handle many difficult situations. Some practitioners and agencies offer family consultation services that include facilitation of family meetings.
A family meeting is more likely to be successful if the following are considered (Schmall & Stiehl, 1998):
• Hold the family meeting in a neutral setting. However, a family meeting in the older person’s home may help give him or her a greater sense of control, especially if the person is feeling a loss of control over his or her life.
• Create a feeling of support and confidentiality.
• Acknowledge that everyone has a different relationship with each other and that current life circumstances vary. These factors need to be respected and considered as decisions are discussed and made.
• Have each family member address the problem from his or her perspective. This increases commitment to the process and contributes to defining “the problem” and reaching agreement on and possible solutions.
• Give everyone the opportunity to express feelings, voice preferences, and offer suggestions without being criticized.
• Keep the family meeting focused on current concerns rather than on other issues, past conflicts, personalities, or resentments.
• Focus on the positive things family members do, or are willing and able to do, and encourage everyone to be honest about their limitations. Sharing information about other responsibilities may help others understand the reasons support might be limited.
• Prepare a written plan about decisions made, what each person will do, and when he or she will do it. A written plan may prevent later disagreements.
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Working with families of older adults: considerations and strategies Identifying Who the Patient Is and Who the Family Is Critical questions to ask when working with older adults include the following: Who is the patient? Is it just the older person? Should the older person’s family also be considered the “patient”?
Although the older person is generally identified as the patient, sometimes it is also appropriate to consider the family as the patient. Family members are often intimately involved in the decisions to be made, affected by potential decisions, or actively involved in caregiving for the older person. If only the needs of the older person are considered and not the needs and situation of the family, the care plan may have less chance for success, particularly if family members will be responsible for carrying it out.
Another significant question to ask is, “Who is family, as defined by the older person?” Many older persons are connected to others by love and friendship and function as a family to each other. These relationships often extend into caregiving. The following are examples of such “families” (Schmall, 1994):
• Red, who divorced in his early 70s, never had children. His only blood relatives were his nieces, nephews, and older adult sisters, all of whom lived hundreds of miles away. During the last 12 years of his life, nearly all support was provided by a person Red referred to as “my adopted granddaughter.” When medical crises occurred and care arrangements were needed, Red looked to his “granddaughter” to make the necessary arrangements.
• Florence’s son divorced his first wife, Jane, and remarried. The divorce, however, did not end the relationship between Florence and Jane. Florence continued to view Jane as “the daughter I never had,” not as her “ex-daughter-in-law.” When Florence became frail, she did not turn to her sons or the current
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daughters-in-law for help; she turned to Jane for both day-to-day assistance and emotional support.
• Elizabeth and Mary had lived together as a couple for 30 years when Elizabeth was diagnosed with cancer. Although Elizabeth’s “blood relatives” were supportive during the downhill course of the disease, Mary was the primary caregiver, the person Elizabeth consulted when she faced medical decisions, and the one who made decisions when Elizabeth was no longer able to do so.
In created but not legally recognized families, it may be important to help individuals take steps—such as completing an advance medical directive (AMD), power of attorney for health care, or durable power of attorney for financial decisions—to ensure that the relationships continue into caregiving, especially if one person loses the capacity to make decisions. As Mary stated, “Elizabeth’s giving me power of attorney for health care ensured that our relationship could continue as it had been for 30 years. We knew another couple who were in a similar situation, and the [blood] relatives stepped in and took over control, disregarding the relationship Jim and Bill had for 20 years.”
In the health care setting, it may be important to reevaluate the definition of family. If “blood relatives only allowed in intensive care” and other rules are followed, some older persons may be deprived of their most significant sources of support.
Other important questions for the nurse to ask are, “Who is the decision maker?” and “Who owns the care plan?” The nurse’s primary role is to empower older persons and their families. This means giving the information, guidelines, options, and skills that will enable them to make the best decisions possible and to better manage a medical condition or their situation. However, it is easy to become frustrated and angry—and eventually experience burnout—if older persons or families choose a course of action that the nurse feels is not the best. Remember, nurses have not failed when an older person or family selects an option different from the nurse’s recommendation. Depending on the situation, the primary responsibility for implementation lies with the older person or the family.
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Assessing the Family When an older person’s life situation or physical or mental status changes, no easy answers exist. What may be the best answer for one older person and his or her family may be inappropriate for another family whose situation seems exactly the same.
Each older person and family system is different. It may be just as important to understand the family’s history, current life circumstances, and needs as it is to know about an older person’s needs and level of functioning. A family’s willingness to provide care, for example, says nothing about their actual ability to do so. Sometimes, the care an older person needs exceeds that which an individual or family can provide, and the caregiver becomes the “hidden patient.” As one adult daughter stated, “My father was the person with Alzheimer disease, but his illness also killed my mother.” Failing to evaluate the ability of family members to provide caregiving is a disservice to older patients.
Information from a family assessment may result in more effective older adult care planning and decision making. Another benefit of assessing how well a caregiver is doing is that it validates a person’s caregiving efforts and sends a message that the nurse is concerned about the caregiver’s well-being, as well as the older adult’s health.
Depending on the family, the older adult, and the decisions to be made, the following may be among the important factors to consider in conducting a family assessment.
Past Relationships Lifetime relationships may influence the family’s ability to plan, to make decisions together, and to provide support. Remember, every adult child has a different history with an aging parent, even if they shared the same family events. Families with a history of alcoholism, poor relationships, or abusive behavior cannot always be expected to provide the assistance an older person needs.
Consider the degree of emotional intensity—the closeness, affection, and openness—in the relationships among family
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members. Parental or spousal disability sometimes threatens a person’s identity or the level of emotional relationship that has been established. For example, some married couples, parents, and children have been emotionally distant for many years. Some spouses have shared the same household but have lived separate lives. Some adult children have maintained emotional distance from a parent by living and working at a geographic distance. People in these situations may be reluctant to enter the care system or may have more difficulty with caregiving. It may be unrealistic to expect such family members to meet the emotional needs of the older person; they may feel more comfortable with meeting a person’s instrumental needs, that is, doing tasks.
Family Dynamics Family dynamics are the ways family members interact with one another, including their communication patterns, family alliances, and symbiotic relationships. What are family members’ views about how decisions should be made? How do they view the older adult’s role in decisions about his or her life? To what degree are family members paternalistic, that is, to what degree do they expect the older person to submit to their decisions or a health care professional’s recommendations?
Roles It is useful to know whether individual family members have distinctive roles. If so, what role or roles does each person have? What expectations are held by the person fulfilling the role and by other family members? Do any of the roles generate conflict for the people who bear them? For example, family members may have always assumed that if a parent needed care, a particular daughter would provide the care because she is the oldest, lives the closest, is a nurse, or has always taken care of everyone who needed help. The daughter also may have viewed caregiving as her role. However, this “assigned” role may or may not be realistic, given the daughter’s current life situation or the parent’s needs. Sometimes, an older person or a family member may not make a decision until the “decision maker” in the family is consulted. The importance of
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considering who plays which roles is exemplified by this daughter’s comments:
I lived in the same town as my Dad, so when he needed help, I was the one who provided it on a daily basis. Dad expected me to help because I was his daughter. But when it came to making decisions, my opinions never counted with him. His son’s opinions, however, mattered, and he would listen to them. I think his basic view throughout his life was “women are there to serve men” and “men are, by far, more knowledgeable than women.” It didn’t matter that I had a college education, and my brother didn’t.
Knowing who does what for the older person makes for more effective planning. Old family roles may also come to the foreground when brothers and sisters are brought together to address the care needs of a parent. One daughter stated:
I lived in the same community as my parents, so when they became ill, I did everything that needed to be done and arranged for support services. Both of my sisters lived hundreds of miles away. Although I am a competent business woman, it seemed that when both of my sisters, who are older, came home, I immediately became the “baby of the family” again.
The roles of family members vary. Examples of potential roles include the “prime mover,” the person who gets things done in the family; the “scapegoat,” the person who becomes the focus of attention when problems arise; the “decision maker,” a role that may vary depending on whether the decision to be made regards finances, living arrangements, or health care; the “peacemaker,” the person who always tries to create peace when family dissension arises; the “pot-stirrer,” the person who seems to keep things “stirred up” in the family; the “black sheep”; the “burden bearer”; the “favorite child”; the “model child”; and the “escapee,” the person who disappears when there are tough decisions to be made or work to be done.
It may be helpful to identify how family roles, especially those of the older person, are affected as a result of the older adult’s increased frailty. What are the perceptions of family members
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regarding the role of the older person? Do any adult children perceive that their role is now to “parent their parent”?
Sometimes people talk about “role reversal.” Although a family member may take on “parentlike” responsibilities, in the emotional sense a parent is still a parent and a spouse is still a spouse, no matter how dependent a person has become. Decades of adult experiences cannot be repressed. If family members think of an older family member as a child, they are more likely to treat that person as they would treat a child and, in return, get childish behavior.
Consider the older adult’s view of his or her role with respect to the rest of the family. For example, does the older person believe he or she is still a contributing family member, or does he or she feel a loss of role? Does the person think he or she is entitled to care from family members, for example, “just because I am your parent?” Paulette tells her story:
I could see Dad deteriorating. When Dad could no longer live alone at home, he refused to consider anyone but “his daughter helping him.” When the time came that Dad had to move from his home, he said to me adamantly, “Your mother took care of her mother and my father until they died,” implying that I also should do the same with him. To Dad, “taking care of” meant he would live in our home. He felt that this is “what daughters are supposed to do.”
Loyalties and Obligations This refers to interpersonal allegiances. Family members often struggle with two questions: (1) What should be my primary priority: meeting the needs of my aging family member? my spouse and children? my career?; and (2) How much do I owe to whom? Caregivers who have not been able to deal with these questions may find themselves stressed by trying to do too much. They may feel guilty because they feel they are not doing enough.
Sometimes, family members, in looking at older adult care issues, also weigh how much various family members “owe” to the person who needs assistance. Is any particular family member viewed as being more obligated or more indebted to providing care because of
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how much the older person has given him or her in the past? In other words, which family members are viewed as “creditors” and which as “debtors,” and to whom do they owe? For example:
Ann did not feel obligated to provide hands-on care to her mother. She thought that “Mother never did anything to help me. All I got from her was criticism—about everything!” On the other hand, Louise (Ann’s younger sister) said, “Mother has always been there for me. I don’t know what I would have done after my divorce if Mom hadn’t opened her doors to me and my three children for those 2 years.” Ann also believed Louise “owed” their mother more than she did.
It is important to be aware that levels of stress tend to be higher for the person who provides caregiving only out of a sense of obligation.
Dependence and Independence Some families accept and adjust more easily than other families to the increased dependence of a family member. Answers to the following questions can help determine how well family members are dealing with or will deal with increased frailty in an older family member:
• What are the attitudes and expectations of family members, including the older person, about dependency?
• Has the family experienced a shift in who is dependent? If so, what is the response of individual family members to this shift?
• Are any family members threatened by the increased dependence of the older person?
• Is the older person giving family members mixed messages about how independent or dependent he or she is?
• Do family members perceive the dependency needs of the person realistically? Is anyone denying, minimizing, or exaggerating the dependence? Is anyone overprotecting or forcing dependency?
Providing caregiving to a family member may be more difficult if the caregiver has been the dependent person in the relationship.
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The care receiver also may resent the caregiver exercising more control.
Caregiver Stress It is critical to assess the nature and extent of caregiver stress. In addition to identifying actual stressors—which may or may not be a direct result of caregiving—the nurse must assess their significance to the caregiver. Other useful areas to assess are a caregiver’s style of coping; the caregiver’s support system; the caregiver’s evaluation of the adequacy of his or her support system; the care needs of the older person, including behavioral and emotional problems, and the caregiver’s perception of those care needs; and financial resources.
Just as an older adult’s situation can change and require reassessment, so can a family’s situation and a caregiver’s ability to provide care. The following factors should be considered:
• Change in the older adult’s condition
• Change in family structure (marriage, divorce, birth, death)
• Change in employment status of the caregiver
Encouraging Families to Plan in Advance of Need Families tend not to discuss age-related issues until faced with a crisis (Hebert et al., 2009). As a result, many adult children are often unaware of parental preferences, views about care arrangements, or the existence and location of important documents.
Planning requires anticipating negative situations—dependency, disability, incapacity, and death—and exploring actions to be taken. Discussing such subjects may be uncomfortable for all family members. For some people, talking about potential incapacity and inability to manage finances is more difficult than talking about death.
A critical time for discussion is when a family member shows signs of deterioration or has been diagnosed with a degenerative
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disease such as Alzheimer disease. Waiting for a situation to worsen reduces the options. Although planning does not prevent all problems, it does prepare families to act more effectively if a crisis occurs. Planning may also do the following:
• Help avoid crisis decision making and make decisions easier in difficult times
• Reduce emotional and financial upheaval later
• Ensure that the older person’s lifestyle, personal philosophies, and choices are known should a time come when the person is unable to participate in making decisions
• Decrease the possibility that the family will have to take more intrusive, restrictive actions such as petitioning the court for guardianship or conservatorship if their older family member becomes incapacitated
• Reduce disagreements and misunderstandings among family members
Families may find the following suggestions helpful in opening up discussion with a reluctant older family member (Schmall et al., 1999).
Looking for Natural Opportunities to Talk A natural opportunity might be a life event such as when a friend or another family member experiences a health crisis, is diagnosed with Alzheimer disease, or moves into a care facility; a situation reported in the media, for example, a person dying without a will; or when the older person is recovering from an illness. If a parent says, “When I die . . .,” family members should listen and encourage the expression of feelings. Too often, families discourage discussion by saying things like, “Don’t be so morbid,” “You’ll probably out-live all of us,” or “We have lots of time to talk about such things.”
Talking about “What Ifs” A family member might say, “If a time came when you could no longer make decisions about your own health care, who would you
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want to make decisions for you?” or “If you could no longer care for yourself at home, even with the help of community services, what would you want to happen?”
Sharing Personal Preferences and Plans in the Event of One’s Own Illness or Death It is important for adult children to remember that incapacity is not always a function of getting older. Some parents are more open to discussion when their adult children also have planned for future possibilities, for example, prepared a will, an AMD, or a durable power of attorney.
Expressing Good Intentions and a Willingness to Listen The objective is to set the right tone for discussion. A loving, caring approach moves a discussion farther than an “I know what’s best for you” attitude. A paternalistic approach is likely to create resistance.
An appropriate role for the nurse is to educate older patients about the benefits of planning and the importance of making plans while their capacities are intact. A positive approach is to emphasize that making plans in advance of need gives people greater control and provides greater assurance that their preferences will be known and honored.
Helping Family Members Communicate Their Concerns Honestly and Positively Open, honest communication helps build and maintain relationships, but such communication is not easy if family communication has been about “game playing.” Adult sons or daughters may say only what they think a parent wants to hear or what they think will not upset a parent. However, this tends to create mistrust and wastes energy as family members “walk on eggshells” around each other.
Family members often express concerns using “you” messages, that is, telling the person what to do or not to do. An example of
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such a message is, “Mother, you are no longer safe living in your home. It’s time for you to move into a retirement facility.” The worst “you” message is a threat: “If you don’t … then I will …” “You” messages sound dictatorial, create defensiveness and resistance, and close off communication.
An older person is more likely to listen to family members who express their concern about an issue rather than family members who talk as if it is the older person who has the problem. The nurse can suggest they use “I” messages. With a good “I” message, a person states his or her feeling, describes the specific behavior or situation of concern, and gives a concrete reason for the concern. “I” messages are specific rather than general and focus attention on problems, not personalities. An example of an “I” message is, “Mom, because of your recent fall, I’m concerned about your safety living in this house. I’m afraid you might fall again, and the next time, you might not be found for several hours or longer. Can we talk about my concern?”
The words “I am concerned about . . .” sound quite different to a person from “You should . . . .” When done correctly, “I” messages come across as “speaking from the heart.” “I” messages also communicate that the person bringing up the issue or concern recognizes that what is being said is his or her belief; this leaves room for other perceptions. It also is more difficult for another person to argue with an “I” message because the speaker merely shared his or her feelings.
Adequately expressing one’s concerns to an older family member is only one part of effective communication. Family members also may need help to listen actively and to empathize, that is, to understand the feelings and emotional needs of the older person. Sometimes, when family members think an older person needs to make a change, for example, move to a group-living situation or give up driving, they focus only on the change as being “for the best” and fail to acknowledge the older person’s losses and feelings. The older person may experience a wide range of feelings: fear, anger, grief, helplessness, frustration, and relief. It is easier for many older persons to talk openly about their situations, concerns, and feelings if the family member listens, acknowledges, and
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accepts these feelings.
It is helpful if family members try to imagine how a situation looks and feels from the perspective of the older person. The nurse should encourage adult children to ask themselves, “How would I feel if I were in Dad’s shoes?” Older persons who sense empathy and understanding are more willing to listen to concerns expressed by family members.
Additional communication techniques to help caregivers communicate more effectively can be found in Taking Care of You: Powerful Tools for Caregiving (Schmall et al., 1999).
Involving the Older Person in Decision Making Too often, the older person, especially if he or she is frail, is excluded from decisions being made about his or her own life. Family members may fail to tell the person about the decisions under consideration or what is happening. A person who is excluded from decision making is more likely to become angry, demanding, helpless, or withdrawn. Plans also are more likely to backfire.
Involvement in decision making provides greater assurance that a person will accept and adapt to a change, even if the change is not the person’s preferred choice. A person who is railroaded into a new situation usually adjusts poorly. Change produces anxiety, but not being involved in decisions about a potential change creates even more anxiety and an atmosphere of distrust. Even a person who cannot actively participate in making or carrying out decisions should still be informed about alternatives and plans that are being made.
Only in a few extreme cases, as when people are afflicted with advanced Alzheimer disease or suffering from a massive stroke, are they unable to make decisions. It is critical for a family to understand that an older family member with memory impairment may be unable to remember discussions or agreements made. However, the person often feels a sense of being involved in what is
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happening. One son stated:
Talking to a parent about a potential move is good advice, even if it does not always work out. I talked to my mother many times concerning her condition (in response to her own concerns), and we agreed on the appropriate plan. She could not remember even 30 minutes later.
Health care providers need to avoid taking a paternalistic approach, that is, communicating primarily with the family about an older person’s condition, care plans, and the decisions to be made even though the older person is present and capable of participating in and making decisions.
Families usually must take greater control in making and carrying out decisions regarding older relatives with Alzheimer disease or other dementia. It is unrealistic to expect the person with the disease to be able to do so. However, the older person may express anger, hostility, and rejection toward family members. A nurse should prepare family members for such reactions and help them understand that these feelings really are the result of the “pain of the situation.” One person wrote about her difficult situation:
My grandmother and I had always been close. As a result of a series of small strokes, changes occurred, which included her driving down streets in the wrong lanes. We tried talking with my grandmother about her unsafe driving, but to no avail. Finally, I had to remove her car from the premises. We talked with her about the reasons she could no longer drive and made plans for meeting her transportation needs. For weeks, my grandmother was angry and accused me of stealing her car. Of course, it hurt, but I also realized that it probably felt to my grandmother as though her car had been stolen, and because of the disease process (and her lifelong personality), it was unrealistic for me to expect her to fully comprehend the true situation.
Validating Feelings Families experience many emotions when faced with difficult
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decisions and caregiving. These emotions may include grief, frustration, anger, resentment, embarrassment, or guilt. At times, caregivers may wish that care receivers would die. The increasing frailty of an older family member may become a daily reminder of that person’s mortality—and a caregiver’s own mortality.
Family members may also need to adjust their perception of the ill person, and this may be emotionally painful. It may not be easy to accept that “my husband is no longer the strong and powerful man he once was,” or “my mother who crocheted beautifully now no longer recognizes what to do with a crochet hook.” It is particularly painful when a family member is no longer recognized by the person with Alzheimer disease or a related disorder. In The Loss of Self, Eisdorfer and Cohen (1987) discuss the importance of caregivers “setting emotional distance,” that is, creating some detachment by viewing the family member as a person with a disease over which neither the person nor the caregiver has any control, while at the same time maintaining a closeness to the person.
Because feelings, beliefs, and attitudes influence behavior, it is important to address the belief systems and feelings of family members. When feelings are not dealt with, decisions are more likely to be made on the basis of guilt, promises, and “should’s and should not’s” rather than on the circumstances and what is best for everyone.
Feelings are validated by bringing them up for discussion and acknowledging their commonality. A nurse should emphasize that feelings are neither good nor bad; it is how family members act on their feelings that makes a difference.
Addressing Feelings of Guilt It is important to deal with feelings of guilt family members may have. Guilt reduces objectivity and the ability to make decisions that are best for everyone. In addition, decisions made on the basis of guilt are likely to create feelings of resentment. For example, family members who feel guilty about moving a relative into a care facility are more likely to be critical of staff, overprotective of their
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older relative, or reluctant to visit.
Feelings of guilt generally result from the feeling that one has broken a “rule.” Most guilt “rules” are black-and-white, inflexible, and impossible to conform to completely. Examples of rules include the following:
• “A good daughter provides care to an ailing parent.”
• “You should always keep a promise.”
• “I vowed we would be together for better or for worse.”
• “A son does not tell his father what to do.”
• “A loving person would never put a family member in a nursing facility.”
Telling people they have no reason to feel guilty generally does not lessen the feelings of guilt. It is more desirable to help people (1) identify and examine the rules that are causing the guilt feelings; (2) evaluate the impact of that rule (a critical question to ask is, “Does the rule work to the detriment of anyone—yourself, the person receiving care, or other family members?”); and (3) rewrite the rule, often with qualifiers, to make it more realistic and appropriate to the current situation.
If a promise is the source of guilt feelings, explore with the person the conditions under which the promise was made and the current situation. Usually, the conditions are quite different. Comparing “what was” with “what is” often helps a family member look more objectively at the current situation.
Emphasizing Goodness of Intent of Actions Sometimes, a family member may say, “I wish I had known this information earlier. I would have done things differently.” In most cases, families are trying to make good decisions and do what is best. Actions are generally based on good intentions. For example, after a workshop, one woman wrote:
A year ago, we moved Mother from Texas to Oregon. She had lived in the small Texan community all of her life, and, of course, everyone
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knew Mom. I now realize why the move has been so difficult for Mom and that she probably would have been less lonely living in Texas, even though it would have meant moving her into a care facility. I came to the workshop feeling guilty, and I could have left the workshop feeling an even heavier load of guilt except that [the nurse] emphasized the goodness of intent behind actions. For me, this was to give Mom the help she needed, to keep Mom out of a nursing facility and in a home environment, and to add the “pleasure of family” to her life.
In working with families, it is important to start with the premise that most families are doing their best. Then a nurse can help them discuss and reinforce the “goodness of intent” underlying their actions when the actual action taken may turn out not to be the best choice.
Recognizing the Nurse’s Role as Permission Giver Because health care professionals are often looked to as “experts,” their messages may carry a lot of power and authority with families. The following are 10 important messages that may be helpful for nurses to share, as appropriate, with family caregivers (Ostwald, 2009; Petch & Shamian, 2008):
1. Take care of yourself. Providing care to an older family member at the expense of the caregiver’s own health or relationships with spouse or children does not benefit anyone, including the person who needs care. Although a caregiver may be unable to mitigate the impact of an illness on the older person, it is critical that the caregiver does not allow a family member’s illness to destroy him or her or other family members.
2. Maintain contact with friends and involvement in outside activities. This is critical to caregiver well-being. Studies show that caregivers who sacrifice themselves in the care of others and remove pleasurable events from their lives may become emotionally exhausted, depressed, and physically ill. Caregivers should ask, “What happens if my family member enters a care
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facility or dies? Will I have been so wrapped up in caregiving that I will be ‘used up’ and without a life separate from caregiving?”
3. Caregiving to adults is more stressful than child-rearing. With a baby, a person looks forward to the child’s increasing independence. However, with older adult caregiving, the prognosis generally involves decline and increasing dependence, not recovery. In addition, it is generally difficult to predict how long caregiving will be needed.
4. It is all right not to love (or like) the older person who needs care. Not all older family members have been lovable or likable. It is important for caregivers to take into consideration personalities and past relationships as they consider their level of involvement in caregiving.
5. Asking for help is a sign of strength. Asking for help is not a sign of weakness, inadequacy, or failure. Knowing the limits and reaching out for assistance before a caregiver is beyond them is characteristic of a strong individual and family. It also helps to ensure high-quality care for the care receiver.
6. Caregivers have a right to set limits and to say no. Trying to do it all or to do it alone only makes caregivers physically and emotionally exhausted.
7. Begin taking regular breaks early in caregiving—it is not selfish. Breaks from the demands of caregiving are a must. They are as important to health as diet, rest, and exercise. Respite benefits the care receiver as well as the caregiver: caregivers are likely to be more loving and less exhausted. Caregivers should ask, “If my health deteriorates or I die, what will happen to my family member?” If caregivers wait until they are “burnt out,” these breaks will not be enough.
8. Make caregiving decisions based on the needs of everyone involved. Decisions should not be made only on the basis of the needs and desires of the older person.
9. Moving a family member into a care facility can be the most loving step to take. It does not mean an end to a caring relationship. Being a manager and coordinator of a family
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member’s care is just as important as providing hands-on care. When a caregiver is no longer devoting time to meeting the person’s physical and safety needs, he or she will be better able to meet the person’s emotional and social needs. Having these needs met adds immensely to a person’s quality of life.
10. Caregivers should focus on what they have done well—and forgive themselves. Too often, caregivers focus only on what they have not done or have done poorly. They should remind themselves of the many things they have done well. They should ask, “What are my personal strengths? How have I made a difference for my family member? What have I done that I feel good about?” Not everything will be as caregivers would like. At times, caregivers will wish they had done things differently. They are only human. If they make a mistake, they should admit it, learn from it, and then go on. Although family members and friends may have given these messages, many caregivers do not take such messages to heart until they hear them from a health care professional.
Recommending a Decision-Making Model to Families Many times, families find it helpful to have a model to follow as they make decisions or solve problems. One six-step model details the importance of gathering information, formulating options, evaluating options, creating a plan, implementing a plan, and reassessing (Schmall et al., 1999).
Step 1. Gathering Information The goal is for the family to make an informed decision; therefore, the first step is for them to clearly identify the issue and to gather pertinent information. Families are often so concerned about making a decision or handling a difficult situation that questions that could provide a better base for decision making go unasked and unanswered. A professional assessment of the older person’s health and level of function also may be needed.
Step 2. Formulating Options
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Once the issue has been identified, the nurse should help the family see all possible options for resolving it. This involves considering the resources of the older person, the family, and the community.
This should be the brainstorming portion of decision making. By generating a variety of possible options, families increase the chances of a successful outcome. In addition, keeping the decision separate from the possible options or solutions tends to take pressure away from people defending positions.
Step 3. Evaluating Options After all options have been identified, the next step is for the family to assess the advantages and limitations of each option. It is helpful to first identify criteria or standards by which potential options will be evaluated. These may include financial constraints and personal preferences.
Agreeing on the criteria makes it easier to identify the best of the options. A good guideline to follow is: “Be easy on people; be tough on issues.” Keeping the focus on the issue, not the positions people take, increases effective decision making. Nurses can help families identify potential consequences of various options.
It is critical that family members be open and honest about their abilities to fulfill any responsibilities associated with an identified alternative. Honest communication helps prevent unrealistic expectations and keeps people from feeling overwhelmed or burdened.
Step 4. Creating a Plan Sometimes, this is the most difficult aspect of decision making, especially if a single best choice does not seem to exist. However, identifying and evaluating all possible alternatives helps families avoid unsatisfactory decisions that may be regretted later. Also, families sometimes think that a good choice simply does not exist and that they must select “the best of the worst.” It is important for the professional to recognize that a plan developed by one family may be quite different from a plan developed by another family whose “problem” appears to be the same.
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Some families find that writing down the plan and indicating who has agreed to do which tasks by when help reduce disagreements. A written plan also may be useful later when the plan is reevaluated.
Step 5. Implementing the Plan The fifth step in decision making is to put the plan into action. As with any decision, a plan should not be considered “final and forever” because situations do change. If possible, it may be helpful to establish a trial period, approaching the decision from the perspective of “This seems like the best decision for now. Let’s give it a try for 1 month, and then evaluate the situation and how well our plan is working.” This may be difficult to do, especially if the family wants closure to a difficult situation. However, flexibility is a key to high-quality decision making.
Step 6. Reassessing It is important that the family makes plans for assessing the outcomes of the decision by asking, “How well is the plan working?” and then adjusting the plan as necessary.
Decision making is seldom easy. It is influenced by many factors such as the specific decision being faced, the personalities of family members, the quality of family relationships and communication, whether the older person is mentally intact and capable of full participation in making the decision, whether decisions are being made in advance of need or at a time of crisis, and whether family members are living nearby or at a great distance. However, a model for decision making may provide families with a method for approaching decisions.
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Summary Providing high-quality care to older adults requires recognizing the family’s role and assessing and responding to the needs of family members, particularly the caregivers. Family members should be considered a part of the care team, not outsiders. The nurse should invite families to share the knowledge they have gained through caregiving, particularly when placing an older relative in a care setting.
It is also important to be nonjudgmental and to remember that each family has its own history and values. Nurses need to be aware of their own values regarding what constitutes a family and their feelings about family behavior and relationships. It is important that nurses not allow personal values to prevent them from working effectively with families whose values or relationships with each other may be different. Nurses should not label such families as “dysfunctional.” It is necessary to identify the strengths within each family and to build on those strengths while recognizing the family’s limitations in providing support and caregiving.
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Key points • Families are significant in the lives of older persons and provide
80% of the support to older adults.
• Common dilemmas and decisions families face in later life involve changes in living arrangements, nursing facility placement, financial and legal issues, end-of-life medical treatments, the safety of an older family member’s driving, and caregiving.
• Moving an older family member to a nursing facility is a difficult decision for most families.
• When working with older adults, it is as important to address the family’s needs as to focus on the older person’s needs. If only the older person’s needs are considered, a care plan is less likely to be successful, particularly if the family is responsible for implementing it.
• Caregiving tends to be more stressful if the care receiver has a dementing illness, behavioral problem, or emotional disturbance than if a care receiver is only physically disabled.
• The meaning a caregiver ascribes to a stressor is a stronger predictor of its impact than the actual stressor.
• Family caregivers often experience restriction of personal activities and social life, emotional strain, competing demands, role conflict, and financial stress. They may need to adjust their expectations in regard to their ill family member, themselves as caregivers, and their stage of life.
• Caregiving for frail older adults differs from providing care to children.
• Education—whether provided one-on-one or in a group setting— should be designed to empower caregivers and to increase their confidence and competence in problem solving, decision making, and applying skills.
• Respite is most effective when a caregiver begins to use it early to
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prevent physical and emotional exhaustion rather than later to treat it.
• The family meeting is one strategy for a family to use to decide how to share caregiving responsibilities and to reach a consensus about problems, needs, and decisions.
• Family is more than relationships determined by blood and marital ties.
• Factors to consider in conducting a family assessment include a history of relationships, family dynamics, family roles, the impact of increased dependence of an older person on all family members, the family’s ability to provide the needed care, and the nature and degree of caregiver stress.
• Strategies and considerations for nurses working with families of older adults include the following:
• Identifying who the patient is and who the family is
• Conducting an assessment of the family as well as the older person
• Encouraging families to plan in advance of need
• Helping families communicate their concerns to older relatives honestly and in positive ways
• Involving the older person in decisions to be made about his or her life
• Validating the feelings and experiences of family members
• Addressing feelings of guilt
• Emphasizing the goodness of intent of actions
• Recognizing the nurse’s role as “permission giver”
• Recommending a decision-making model
• The nurse should try to “step into the shoes” of family members. Nurses who look at the situation from the perspective of a family member can increase their understanding of “where a person is coming from” and thus can improve their insight and sensitivity.
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Critical thinking exercises 1. Think about your own family relationships. What individual and family values might influence your care of an older adult and his or her family members? How might your current perceptions change over the next decade?
2. An 83-year-old woman is recovering from pneumonia. She has Alzheimer disease and has become increasingly hostile and unmanageable in the home setting. Her 65-year-old daughter is distraught about the idea of placing her mother in a long-term care facility but feels she is not able to care for her. What is your role as nurse in this situation?
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Aging with Dignity. Five wishes. 2013. Retrieved September 5, 2013 from http://www.agingwithdignity.org/catalog/product_info.php? products_id=28.
Alzheimer’s Association. Take care of yourself. 2013. Retrieved September 3, 2013 from www.alz.org.
Alzheimer’s Association. Respite care. 2013a. Retrieved September 6, 2013, from http://www.alz.org/care/alzheimers-dementia-caregiver- respite.asp.
Auer P. Primary care end-of-life planning for older adults with chronic illness. The Journal for Nurse Practitioners. 2008;4(3):185.
Baldwin K, Shaul M. When your patient can no longer live independently: A guide to supporting the patient and family. Journal of Gerontological Nursing. 2001;27(11):10.
Clark M, Diamond P. Depression in family caregivers of elders: A theoretical model of caregiver burden, sociotrophy, and autonomy. Research in Nursing & Health. 2010;33:20.
Eisdorfer C, Cohen D. The loss of self. New York: Penguin; 1987.
Elliott T, Pezent G. Family caregivers of older persons in rehabilitation. NeuroRehabilitation. 2008;23(5):439.
Eskildsen M, Price T. Nursing home care in the U.S.A.
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Geriatrics & Gerontology International. 2009;9:1.
Forster A, et al. A cluster randomized controlled trial of a structured training programme for caregivers of inpatients after stroke (TRACS). International Journal of Stroke. 2011;7(1):94.
Gengler A, Crews V. Live like us. Money. 2009;38(3):86.
Golden M, Lund D. Identifying themes regarding the benefits and limitations of caregiver support group conversations. Journal of Gerontological Social Work. 2009;52(2):154.
Hartford Institute for Geriatric Nursing. (2014). Retrieved September 10, 2013, from http://www.hartfordign.com.
Hebert R, Schulz R, Copeland VC, Arnold RM. Pilot testing of a question prompt sheet to encourage family caregivers of cancer patients and physicians to discuss end-of-life issues. The American Journal of Hospice & Palliative Care. 2009;26(1):24.
Help Guides. Older driver safety. 2013. Retrieved September 5, 2013 from http://www.helpguide.org/elder/senior_citizen_driving.htm.
Hendricksson A, Arestedt K. Exploring factors and caregiver outcomes associated with feelings of preparedness for caregiving in family caregivers in palliative care: A correlational, cross-sectional study. Palliative Medicine. 2013;27(7):639.
Krooks B. Elder care emerging as workplace issue. Westchester County Business Journal. 2013;49(25):15.
Levy D. U.S. Department of State: Legal & financial issues in caregiving for older adults. 2013. Retrieved September 5, 2013 from http://www.state.gov/m/dghr/flo/142266.htm.
Live Births and Birth Rates, by Year. (2013). Retrieved September 3, 2013 from http://www.infoplease.com/ipa/A0005067.html.
Lund D, Utz R, Caserta M, Wright S. Examining what caregivers do during respite time to make respite more
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effective. Journal of Applied Gerontology. 2009;28(1):109.
Make written material easy to read, understandable. Hospital Home Health. 2009;26(1):9.
Marek K, Adams S, Stetzer F, Popejoy L, Rantz M. The relationship of community-based nurse care coordination to costs in the Medicare and Medicaid programs. Research in Nursing & Health. 2010;33:235.
National Institute on Aging. So far away: Twenty questions for long distance caregivers. 2013. Retrieved September 6, 2013, from http://www.nia.nih.gov/health/publication/so-far- away-twenty-questions-andanswers-about-long-distance- caregiving-o.
Ostwald S. Who is caring for the caregiver? Promoting spousal caregiver’s health. Family & Community Health. 2009;32(1S):S5.
Petch T, Shamian J. Tapestry of care: Who provides care in the home?. Healthcare Quarterly. 2008;11(4):79.
Phillips L, Reed P. Into the abyss of someone else’s dying: The voice of the end-of-life caregiver. Clinical Nursing Research. 2009;18(1):80.
Schmall V. Family caregiving: A training and education perspective. In: Cantor MH, ed. Family caregiving: An agenda for the future. San Francisco: American Society on Aging; 1994.
Schmall V, Cleland M, Sturdevant M. Taking care of you: Powerful tools for caregiving. 1st ed. Portland, OR: Legacy Health Systems; 1999.
Schmall V, Nay T. Helping your older family member handle finances. Corvallis, OR: Oregon State University Extension Service; 1993.
Schmall V, Stiehl R. Coping with caregiving: How to manage stress when caring for elderly relatives, Pacific Northwest Extension Publication, PNW 315. Corvallis, OR: Oregon State University Extension Service; 1998.
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Shin D. Residential and care giving preferences of older Korean Americans. Journal of Gerontological Nursing. 2008;34(6):48.
Should you move your parent into your home? Retrieved September 10, 2013 from http://healthyliving.msn.com/diseases/caregiving/should- you-move-your-parent-into-your-home-1
Society of Certified Senior Advisors (CSA). State of the senior housing industry (white paper). 2013. Retrieved September 5, 2013 from www.csa.us.
U.S. Bureau of Labor Statistics. Women in the labor force: A databook. Retrieved September 3, 2013 from www.bls.gov
U.S. Census Bureau: Current population survey 1948–2012. (2012). Retrieved September 3, 2013 from http://www.census.gov/hhes/migration/data/cps/historical/Figure%20A- 1.1.png
U.S. Department of Labor. Women’s bureau: Data & statistics. 2013. Retrieved September 3, 2013 from http://www.dol.gov/wb/stats/stats_data.htm.
U.S. Divorce Rates and Statistics. Divorce by the statistics: It doesn’t add up. 2013. Retrieved September 3, 2013 from http://www.divorcesource.com/ds/main/u-s-divorce-rates- and-statistics-1037.shtml.
Video Respite. Retrieved September 10, 2013 from http://www.videorespite.com/
Wang Y, Yea-Ing L, Chen M, Yang P. Reconciling work and family caregiving among adult-child family caregivers of older people with dementia: Effects on role strain and depressive symptoms. Journal of Advanced Nursing. 2010;67(4):829.
Willyard J, Miller K, Shoemaker M, Addison P. Making sense of sibling responsibility for family caregiving. Qualitative Health Research. 2008;8(12):1673.
Yang Y, Grimm G. Caring for elder parents: A comparative
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evaluation of family leave laws. Journal of Law, Medicine, and Ethics. 2013;41(2):501.
* Original author: Vicki L. Schmall, PhD; Revisions by Elizabeth C. Mueth, MLS, AHIP.
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C H A P T E R 7
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Socioeconomic and Environmental Influences Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Identify the major socioeconomic and environmental factors that influence the health of older adults.
2. Explain the importance of age cohorts in understanding older adults.
3. Describe the economic factors that influence the lives of older persons.
4. Identify components of the Medicare health insurance programs.
5. Discuss the influence of support systems on the health and well- being of older adults.
6. Distinguish between a conservator, guardian, and durable power of attorney.
7. Discuss environmental factors that affect the safety and security of older adults.
8. Compare and contrast the housing options available for older adults.
9. Compare the influences of income, education, and health status on quality of life.
10. Relate strategies for protecting older persons in the community from criminal victimization.
11. Assess the ability of older adults to be their own advocate.
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http://evolve.elsevier.com/Meiner/gerontologic
Each person is a unique design of genetic inheritance, life experiences, education, and environment. Social status, economic conditions, and environment influence our health and response to illness. This chapter discusses the socioeconomic and environmental conditions that influence the way older adults interact with the health care system.
Socioeconomic factors such as income, level of education, present health status, and availability of support systems all affect the way older adults perceive the health care system. Benefits and entitlements may influence the availability of high-quality health care. A small number of older adults may not be competent to manage their own health care; they need the protection of a conservator or guardian.
Environmental factors such as geographic area, housing, perceived criminal victimization, and community resources make a difference in older adults’ abilities to obtain the type and quality of health care that is appropriate. One of the strongest and most consistent predictors of illness and death is socioeconomic status (Krause, 1997). The environment also influences safety and well- being. Therefore, it is imperative that health care professionals understand the socioeconomic and environmental status of older adults. Although, in some cases, illness may lead to poverty, more often poverty causes poor health by its connection with inadequate nutrition, substandard housing, exposure to environmental hazards, unhealthy lifestyles, and decreased access to and use of health care services.
In 2008, research found that the nation’s health has continued to improve overall, in part because of the resources that have been devoted to health education, public health programs, health research, and health care. The United States spends more per capita on health care than any other country, and the rate at which spending increases is going up. Much of this spending is on health care that controls or reduces the impact of chronic diseases and conditions affecting an increasingly older population; notable examples are prescription drugs and cardiac disease. Adults over the age of 65 average twice as many physician visits than persons
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younger than 65 (O’Hara & Caswell, 2013).
Older adult health care consumers often depend on the health care professional for advocacy. To be an effective advocate, the nurse must understand the factors that shape the older consumer’s perceptions of environment, socioeconomic status, and access to health care.
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Socioeconomic factors Age Cohorts Persons who share the experience of a particular event or time in history are grouped together in what is called a cohort. They shared certain experiences at similar stages of physical, psychological, and social development that influenced the way they perceive the world. Therefore, they develop attitudes and values that are similar (Cox, 1986; Richardson, 1996). By understanding cohorts, the nurse develops a greater understanding of older adults’ value systems. For example, persons who reached maturity during the Great Depression of the 1930s learned the value of having a job and working hard to keep it. Generally, persons in this cohort have been loyal workers. They feel better if they are “doing their jobs.” The nurse might increase adherence with a treatment regimen by referring to the need for adherence as an older adult’s “job.”
Cohort classifications include age, historical events, and geographic area of residence. Today’s older Americans have shared many momentous experiences. The “Roaring Twenties,” the Great Depression, World War II, and the Korean War made impressions on everyone who lived through those events, but especially on those who were young at the time. Values and the pace of life, which vary between communities and regions of the country, influence the perceptions of the residents of each region.
The age cohort that reached young adulthood in the post-World War II and Korean War era benefited from a very productive time in American history. The late 1940s, 1950s, and 1960s were times of rapidly increasing earnings and heavy spending. Strong unions negotiated for better pension plans and medical benefits. This cohort became accustomed to contacting professionals for services, thereby becoming more conscious of preventive health care compared with previous generations. This group has become aware of wellness techniques and self-care strategies that improve health. Members of this cohort usually have at least a high school education and often have some form of higher education. Many
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pursued further educational opportunities. As a group, however, they experience a less cohesive family life. Many have moved from their home communities and have experienced divorce, remarriage, or other circumstances that complicate family support (Johnson, 1992).
The age cohort that matured just before and during World War II was strongly influenced by the war. Those who served in the armed forces were shaped by their direct involvement, while most of those at home worked in the defense industry, experienced rationing of food, clothing, and fuel, and waited for the men and women in the service to come home. Life revolved around the war. Movies and music featured war themes, and rationing was a reminder that all resources were needed primarily for the war effort. Signs and billboards urged people to sign up or to purchase war bonds. Windows of houses displayed stars to honor family members who were serving or who had died in the war; resurgence in popularity of this symbol began with Operation Desert Storm in 1991 and continues today in the homes of families whose loved ones serve in the War in Afghanistan.
The workforce was expanded to include more women, many of whom continued to work after the war. In 1940, 12 million women were working; by 1945, 19 million women were working (Wapner, Demick, & Redondo, 1990). Men and women serving in the armed forces became accustomed to regular physical and dental checkups, and they extended these practices to their families after the war. Veterans took advantage of the G.I. Bill to pursue a college education, which would have been unobtainable otherwise. With the help of veterans’ benefits, they purchased houses for little or no money as down payment. Having experienced the trauma of war, this group developed an appetite for the good things in life and willingly paid for them.
Today, the oldest Americans are strongly influenced by having lived through the Great Depression of the 1930s. At the time, today’s oldest-old (95 years or older) were struggling to keep families together, and today’s younger older adults were attempting to find work and start families. The struggles of those times have shaped the lives of Americans older than 80 years.
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Persons of this era are generally frugal and often do not spend money, even if they have it. The oldest-old believe they will outlive their money because they remember what it was like to have nothing. In addition, this age cohort did not have the experience of receiving regular health care. Visits to the doctor or dentist occurred only when absolutely necessary, and home remedies were used as the first line of defense. Education often ended with the eighth grade so that children could help support the family. A college education was rare.
During this era, families were close and supportive. However, the family was a closed unit, and personal matters remained within the family. Unhappy family situations, mental illness, family finances, and abusive situations were not usually discussed outside the family. Gender roles were well defined.
Many of today’s conveniences, including antibiotics, were not available during the 1930s. The technology now used in health care settings, ranging from electronic thermometers to computed tomography (CT) and positron emission tomography (PET) scanners, represents a true technologic explosion to persons who have witnessed its development. Today’s older adult cohort has survived many significant changes. Among those changes is the family living arrangement of grandparents aged 65 or older having the primary responsibility for their grandchildren who live with them; over 1.5 million children in the United States live with their grandparents (Jayson, 2011).
Income Sources Older adults report income from five sources: (1) Social Security (86%), (2) assets (52%), (3) retirement funds (27%), (4) government pensions (15%), and (5) wages (26%). The median income in 2011 was $27,707 for men and $15, 362 for women. In 2011, 8.7% of older adults lived below the poverty level (Administration on Aging [AOA], 2012). Social Security is a benefit package for retired individuals, survivors of participants, and those with disabilities. Funds for Social Security are derived from payroll taxes, and benefits are earned by accumulating credits based on annual
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income.
Retirement age in the United States is currently 66; by the time those born in 1960 reach retirement age, it will have risen to 67 (Rosnick & Baker, 2012). However, a person may begin receiving Social Security retirement benefits as early as age 62, but at a reduced percentage. Those born before 1938 are eligible for full Social Security benefits at age 65. However, beginning in 2003, the age at which full benefits are payable began increasing in gradual steps from 65 to 67 (Table 7–1). For those who wish to delay retirement, the benefit increases by a certain percentage depending on the year of birth. The yearly rate of increase varies from 3% for those born before 1924 to 8% for those born in 1943 or later (American Association of Retired Persons [AARP], 1997).
Table 7–1 Age to Receive Full Social Security Benefits
Year of Birth Full Retirement Age 1937 or earlier 65 1938 65 and 2 months 1939 65 and 4 months 1940 65 and 6 months 1941 65 and 8 months 1942 65 and 10 months 1943–1954 66 1955 66 and 2 months 1956 66 and 4 months 1957 66 and 6 months 1958 66 and 8 months 1959 66 and 10 months 1960 or later 67
(From Social Security Online. (2009). Retirement age. Baltimore, MD: U.S. Department of Health and Human Services, Social Security Administration: <http://www.ssa.gov/pubs/retirechart.htm> Accessed 02/01/10.)
Very poor older adults depend on another federal government program. Supplemental Security Income (SSI) pays monthly checks to persons who are aged, disabled, or sight impaired and who have few assets and minimal income. This program is also regulated by the Social Security Administration, but the money to provide benefits is from income tax sources rather than Social Security payroll taxes. Eligibility depends on income and assets. Additional information is obtainable through the government’s website www.socialsecurity.gov.
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Ages 55 to 64 Those in the preretirement age cohort of 55 to 64 are generally in their peak earning years. Most are married, but few have children younger than 18 still residing in the family home. The heavy expenses of child rearing are over, and homeowners have completely or nearly paid for their homes. This age cohort tends to have increased disposable income yet is acutely aware of impending retirement; thus, priorities change and spending begins to decrease.
The recession beginning December 2007 changed the economic picture of this age cohort. In February of 2010, the jobless rate was at 7%, nearly reaching the record high of December 2009 (7.2%). Older adults who lose their jobs have a harder time finding gainful employment (an average of 35.5 weeks). Despite the jobless rate, 40% of older adults 55 and over still remain employed. The increase in the number of older adults in the labor force began with changes to retirement savings beginning in the 1990s, when the burden of retirement funding shifted from the employer to the worker. Although older adult workers took financial losses in their retirement portfolios, this had a negligible impact on the number of adults over the age of 55 entering the labor force (Sok, 2010).
Persons in this age group are generally healthy and have resources to maintain housing. The average annual income of families ages 55 to 64 is over $55,000 (DeNavas-Walt, Proctor, & Smith, 2013). Because of higher earnings, they have contributed more to Social Security than older age groups. Many held jobs with disability benefits, which now may be contributing to income. Those who served in the armed forces may be eligible for veterans’ benefits.
Ages 65 to 74 Retirement ordinarily causes income to decrease, most recently by over 40%. The median income before taxes for households ages 65 and older is a little over $33,000, which is approximately $22,000 less than the median income of households in the 55 to 64 cohort (DeNavas-Walt et al., 2013). Although spending continues to
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decrease in this age group, especially for such items as clothing, electronics, furniture, and appliances, expenses related to medical care and prescription drugs increase. Additionally, persons in this age group face funeral expenses.
Today, this age group includes many veterans from World War II and the Korean War. Veterans’ benefits are important to this age group because of the increased risk of chronic disease and other acute health problems. Eligibility for veterans’ benefits is based on military service, service-related disability, and income. Benefits are considered on an individual basis (Federal benefits for veterans and dependents, 1993) (Box 7–1).
Box 7–1
Veterans’ benefits Benefits for eligible veterans include the following:
• Disability compensation
• Pension
• Education and training
• Home loan guaranties
• Life insurance
• Burial benefits
• Health care benefits (From: Federal Benefits for Veterans, Dependents and Survivors 2013 Edition. Retrieved May 1, 2014 from http://www.va.gov/opa/publications/benefits_book/2013_Federal_Benefits_for_Veterans_English.pdf
Ages 75 to 84 After age 75, women outnumber men in American society. Many persons in this age group live alone, which affects their average household income. Although this age group has shown a slight
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increase in employment the past few years, they still make up less than 1% of the total workforce. Most women in this age group did not work outside the home, so their income depends on their spouses’ pensions or Social Security benefits. Surviving spouses with no work experience receive about two thirds of the overall income earned before the death of their spouses (Wapner et al., 1990). These findings have not been disputed in the years since this study was published. When persons in this age group were working, salaries and wages were much lower; thus, they contributed less to Social Security. Pensions were less generous or nonexistent. These factors combine to reduce the income range of most persons in this age group.
As health problems increase with age, so do expenses for prescriptions and assistive devices such as eyeglasses, hearing aids, and dentures. The quality of housing deteriorates as houses age and less money is available for maintenance. Decreased strength and endurance reduce the ability to perform household chores.
Ages 85 and Older This group is the fastest growing segment of our population (Table 7–2), with over 5.5 million persons 85 years and over in 2008. By 2050, those over 85 years old are expected to account for over 4% of the population. Although medical and social advances have prolonged the life span of Americans, this age cohort is at risk for increased chronic disease, resulting in decreased ability to perform activities of daily living (ADLs) and increased expenses for assistance, assistive devices, and medication (DeNavas-Walt et al., 2013; Federal Interagency Forum on Aging-Related Statistics, 2012).
Table 7–2 Population 65 Years or Older by Gender and Age Group: 1980 to 2008
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(From U.S. Census Bureau. (2012). The 2012 statistical abstract: <http://www.census.gov/population/www/socdemo/educ-attn.html> Accessed 04/30/14.)
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This group has the lowest average annual income level of all older Americans; nearly 13% live in poverty (Federal Interagency Forum on Aging-Related Statistics, 2012). Social Security is the primary source of income for this age group, although investments and pensions provide a significant source of additional income. Members of this age group may receive assistance from family, but the amount is small and often sporadic. Few receive wages, salary, or self-employment income (Wu, 2009).
The 85 or older group is more likely to need assistance with ADLs. They are also more likely to need institutional and home care (U.S. Census Bureau, 2004–2005; Van Nostrand, Furner, & Suzman, 1993). Dependence on medication and assistive devices increases.
If persons in this age group live independently, their housing is likely to be old and in need of repairs and maintenance (Mack, Salmoni, & Viverais-Dressler, 1997). Adaptations to compensate for decreasing abilities help older adults remain in their homes, but these changes may be costly. Some older adults choose to move in with family or to facilities offering assistance; 11% live in long-term care settings; and 2.7% live in retirement housing (AOA, 2012).
The nation’s political climate and financial stability affect the sources of income for older adults at any time. Decreased interest earnings, for example, affect those with money market investments or certificates of deposit; stock market fluctuations affect the value of stock portfolios and mutual funds; and the political climate affects the type and amount of taxes paid. The dramatic drop in home values beginning in 2008 reduced home equity that was part of many older adults’ portfolio of investments for their retirement years; however, since 2011, the housing market has begun to recover, and home equity has risen over 3%.
Poverty The following information looks at poverty at various times over the past 20 to 30 years. Updates to all statistics take place periodically and can be found by checking with the U.S. Census Bureau at http://www.census.gov/ or with the AOA at
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http://www.aoa.gov/.
In 2011, 8.7% of those age 65 or older were classified as poor, with income at or below the poverty level ($11,400 for family of one; $15,500 for family of two). Nearly 18% of African Americans over 65 are poor compared with 6.7% of older Caucasians, 18.7% of older Hispanics, and 11.7% of older Asians. The poverty rate for older women is 10.7%, whereas the rate for older men is 6.2%. Nearly a third (32.2%) of older African American women who live alone are poor. Hispanic women over the age of 65 who live alone have the highest rate of poverty (38.8%) (AOA, 2012).
Low income may affect the quality of life for older adults. For example, basics such as housing and diet may be inadequate. A worn out wardrobe and lack of transportation may cause the older adult to avoid social contact, leading to isolation. Older adults may delay seeking medical help or may not follow through with the prescribed treatment or medications because of limited income. Eyeglasses, hearing aids, and dental work may become unaffordable luxuries. Identifying an older patient’s income level enables the nurse to direct the patient to agencies and services that are available to those with limited resources (Figures 7-1A and 7- 1B).
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FIGURE 7–1 A, Poverty rates by age: United States, 1959-2012. B, Low-income population by age, race, and Hispanic origin: United
States, 2006. Notes: Data shown are the percentage of persons with family income below the poverty level. Percent of poverty level is based on family income and family size and composition using
U.S. Census Bureau poverty thresholds. Persons of Hispanic origin may be of any race. Black and Asian races include persons of Hispanic and non-Hispanic origin. (From National Center for Health
Statistics. (2009). United States, 2008 with chartbook, Hyattsville, MD: National Center for Health Statistics Health.)
Education Education has been shown to have a strong relationship to health risk factors (Brown, 1995). The level of education influences earning ability, information absorption, problem-solving ability, value systems, and lifestyle behaviors. The more educated person often has greater access to wellness programs and preventive health options (Land, Guralnik, & Blater, 1994).
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The educational level of the older population has increased steadily between 1970 and 2012, reflecting increased mandatory education and better educational opportunities in the last 40 years. The percentage of individuals who completed high school varies by race and ethnic origin; however, 81% of older adults have completed high school, and 24% have earned a bachelor’s degree or higher (AOA, 2012).
Many older adults continue their education in their later years. Some complete high school or take college courses. The Servicemen’s Readjustment Act of 1944 (known as the GI Bill) fostered this trend. This bill offers, in part, tuition assistance and defrayment of living expenses. It has been used by the Vietnam war–era veterans more than any previous generation. Revision of this bill, known as the Montgomery GI Bill, extended benefits to military veterans through 2008; in 2008, Congress extended benefits to ensure those serving in the military following the September 11, 2001, terrorist attacks have the opportunity to further their education. Other older adults take advantage of continuing education programs such as Road Scholar (for more information, go to http://www.roadscholar.org/) to explore subjects of interest. Seeking educational opportunities in later life has many benefits for older adults. Lifelong learning promotes intellectual growth, increases self-esteem, and enhances socialization. Older adults have an opportunity to stimulate creativity and to remain alert and involved with the world.
Erikson’s seventh stage of development stresses how important generativity versus stagnation is to the individual’s sense of achievement and fulfillment in life (Cox, 1986). Education provides an opportunity to avoid stagnation and isolation and adds to the enjoyment of later life. Teaching older adults with disabilities may be a challenge for nurses when the teaching is a part of health education. See Box 7–2 for suggestions related to the learning environment of those with memory, vision, or adherence issues.
Box 7–2
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Patient teaching strategies Older adults often have short-term memory deficits or limited vision or hearing abilities that affect teaching. To improve comprehension and adherence, consider the following suggestions:
• Provide a comfortable environment with adequate lighting and minimal distractions.
• Repeat important information at least three times.
• Present information in several forms: written material, discussion, videotape and audiotape, and photos and pictures.
• With written material, use large print and clear black letters on a contrasting background.
• Speak at a moderate pace and volume with a low tone of voice. Check for understanding by asking the patient to explain in his or her own words.
• Use appropriate gestures to enhance understanding.
• Check back later to assess understanding.
Health Status The health status of older adults influences their socioeconomic status. Eighty percent of older adults have at least one chronic health condition; 50% have two. The most common chronic health problems leading to death in 2011 were heart disease, cancer, stroke (accounting for 50% of deaths), followed by chronic obstructive pulmonary disease (COPD), Alzheimer disease, and diabetes (Centers for Disease Control and Prevention [CDC], 2011). Many add obesity to this list as well. The influence health problems exert often depends on the older person’s perception of the problem. Among noninstitutionalized persons, 44% of those 65 and older consider their health to be excellent or very good (AOA, 2012). Some approach health problems with an attitude of acceptance, whereas others find that chronic problems require considerable energy, and they spend extensive time and resources finding ways
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to cope or adapt (Burke & Flaherty, 1993).
Functional status is affected by chronic conditions. The CDC reports in Healthy Aging for Older Americans (CDC, 2004) that functional status is important because it serves as an indicator of an older adult’s ability to remain independent in the community. Functional ability is measured by the individual’s ability to perform ADLs and instrumental activities of daily living (IADLs). ADLs include six personal care activities: (1) eating, (2) toileting, (3) bathing, (4) transferring, (5) dressing, and (6) continence. A quarter of persons with at least one chronic disease experience a decrease in the ability to perform one or more ADLs. The term IADLs refers to the following home-management activities: preparing meals, shopping, managing money, using the telephone, doing light housework, doing laundry, using transportation, and taking medications appropriately. Data concerning the ability to perform ADLs and IADLs were gathered through the National Health Interview Survey. Nurses work with older adults to prolong independence by encouraging self-management of chronic conditions. Self-management is defined as learning and practicing the skills necessary to carry on an active and emotionally satisfying life in the face of a chronic condition (Lubkin & Larsen, 2002). Education and support help older adults make informed choices, practice positive health behaviors, and take responsibility for the care of a chronic condition.
The amount of money available for food, shelter, clothing, and recreation may be greatly affected by the cost of medication, health care equipment, glasses, hearing aids, dental care, medical care, home care assistance, and nursing facility care, some of which may not be covered by insurance programs. In addition, the insurance premiums themselves may cause financial distress. Restricted finances may affect an older adult’s safety, nutritional status, and social opportunities, which may result in an altered quality of life.
By making older adults aware of programs such as equipment loan programs, as well as optical, auditory, and dental assistance programs, the nurse can help them receive services necessary to maintain their health status, thus maximizing their quality of life in spite of finances being restricted.
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An integrated health care delivery system built on capitated benefits through Medicare and Medicaid funding is called the Program of All-inclusive Care for the Elderly (PACE). The program is a state option under Medicare with additional funding from Medicaid; eligible participants receive primary, acute, and long- term care services in the community. States certify the eligibility of frail individuals who are older than 55 and require the level of care provided at nursing facilities. Full financial responsibility is assumed by the providers of care regardless of the duration of care, amount of services used, or the scope of services provided (The Official U.S. Government Site for Medicare, 2012).
Insurance Coverage Older Americans should review their insurance coverage often to determine whether the coverage they have is necessary, appropriate, and adequate. Residential insurance purchased several years ago may be inadequate today. For example, home insurance should cover at least 80% of the replacement cost; however, many older adult homeowners are insured for the assessed value of the home at the time of purchase. Content and liability coverage may also be inadequate. Older homeowners may be unaware that policies are outdated, or they may not be able to afford the premiums an update would require. Insurance checkups reveal inadequacies. Older adults may wish to investigate several insurance companies to find the best coverage for the least cost.
Many older adults have automobiles that have reached maximum depreciation. These automobile owners may still be carrying full coverage when all they need is liability insurance. They may also be able to save money by investigating senior discounts, choosing higher deductibles, and comparing premiums from several companies. Completion of a defensive driving course such as the American Association of Retired Persons (AARP) Driver Safety Program (offered both online and in person; see http://www.aarpdriversafety.org/), may help older adults qualify for lower insurance rates (AARP, 2005).
Life insurance is valuable when providing for dependents. In old
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age, the primary reason for life insurance is to cover burial expenses. Term life insurance accomplishes this purpose. Many older adults can substantially reduce life insurance coverage. Proceeds from those policies and premium payments that are no longer due may be redirected for greater benefit.
Health insurance is a necessity for older adults because medical problems—and therefore medical expenses—increase with age. As persons age, they visit the doctor more often (U.S. Census Bureau, 2004–2005). Older adults spend more time in the hospital—an average of 5.4 days—compared with the average of 4.8 days spent by those younger than 65 (AOA, 2012).
Medicare is a federal health insurance program for persons older than 65, or persons of any age who are disabled or who have chronic kidney disease. Medicare has several parts to provide multiple benefits to older adults.
Part A, the hospital insurance, helps pay for inpatient hospital care and some follow-up care such as a skilled nursing facility, home health services, and hospice care. A person is eligible for Medicare Hospital Insurance if he or she is age 65 or older and (1) is eligible for any type of monthly Social Security benefit or railroad retirement system benefit or (2) is retired from or the spouse of a person who was employed in a Medicare-covered position. It costs nothing for those who contributed to Medicare taxes while they were working. If the person is not eligible for premium-free Part A, a monthly premium may be paid, as long as the person meets citizenship or residency requirements and is age 65 or older or disabled. The 2014 premium amount for people who buy Part A is $426 each month (“Medicare 2014 costs at a glance,” n.d.).
Part A, the hospital insurance, helps pay for the following:
• Home health care (including durable medical equipment)
• Hospice care
• Hospital inpatient stay
• Mental health inpatient stay
• Skilled nursing facility stay
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Part B is medical insurance coverage. Most Medicare recipients pay a premium that is deducted from monthly Social Security income. In addition, they pay an annual deductible on hospital and skilled nursing care benefits. The 2014 premium amount for Part B ranges from $104.90 to $335.70 each month, based on income, with a $147 deductible per year (“Medicare 2014 costs at a glance,” n.d.).
Part B, the medical insurance, helps pay for the following:
• Home health services (including durable medical equipment)
• Medical and other services (including inpatient doctor services and outpatient therapies)
• Outpatient mental health services and partial hospitalization for mental health services
• Outpatient hospital services
Medicare Part D refers to the prescription drug program that began in 2004. Eligibility requires that the person have Medicare. Older adult who have Medicaid are still eligible; however, they must sign up for a Medicare Prescription Drug Plan to receive their medications. These individuals do not have to co-pay. Medicare Part D is available regardless of income level. Older adults with limited income may qualify for Extra Help. Refer to http://www.medicare.gov for more information on the Extra Help program (Drug coverage [Part D], n.d.).
Medicare Part A covers medically necessary skilled nursing care for a limited period; custodial care is not covered. In 2012, average daily cost for 1 day in a nursing facility was $222 for a semi-private room (Mullin, 2013). In the case of most of the older adults, savings and other assets are exhausted after 6 months or less of nursing facility care. Therefore, some persons purchase long-term care insurance. Premiums depend on age at time of purchase and the extent of benefits chosen by the purchaser.
Medicare rules and benefits change often. Medicare Advantage plans (“Medicare Advantage Plans,” n.d.) were introduced as a result of the Balanced Budget Act of 1997; until the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, these were known as Medicare + Choice programs, or Medicare
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Part C. These programs provide comprehensive care through a variety of health care delivery models, including Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans (Balanced Budget Act of 1997; The Official U.S. Government Site for Medicare, n.d.).
Many older adults do not understand how Medicare works and are often confused by the paperwork, billing, and notices they receive regarding claims. They are encouraged to contact the Social Security Administration or the insurance departments of their local medical facilities if they have questions.
Those older adults who are still working may continue to be covered by their employers’ health insurance plans. A retiree is sometimes covered by a former employer’s health plan or their spouse’s employer health plan. If covered by an employer- sponsored insurance policy and enrolled in Medicare, the employer’s insurance becomes “primary” and the Medicare insurance is “secondary.” Some older adults choose to purchase supplemental insurance to cover co-pays and deductibles, often referred to as Medigap policy. The supplemental insurance is then secondary to Medicare, which is primary. This is very important to know if hospitalization or outpatient surgery centers are to be used. A significant delay in payment processing will occur with any mixing of primary and secondary insurance. Refer to http://www.medicare.gov/Publications/Pubs/pdf/02179.pdf for a patient handout on this topic.
Medicaid is a federally funded, state managed program for low- income individuals and their families. For eligible older adults residing in nursing facilities , it covers health-related care and other services not available in the community because of their mental or physical conditions. Each state has different coverage and requirements; however, general, up-to-date information can be obtained at http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Delivery-Systems/Institutional- Care/Nursing-Facilities-NF.html.
The AARP provides information to explain insurance policies in a language that most people can understand (please see:
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http://www.aarp.org/health/health-insurance/). The Official U.S. Government Site for Medicare (please see: https://www.medicare.gov/) provides information to explain Medicare. Insurance trade associations such as the Health Insurance Association of America (HIAA), the Insurance Information Institute (III), and the American Council of Life Insurance (ACLI) publish a variety of free educational materials to help people understand insurance.
Support Systems Throughout life people make new acquaintances, develop friendships, and form family circles. People identify with schools, churches or synagogues, clubs, neighborhoods, and towns. These are the places and people they turn to when they need advice or help, want to celebrate, or are grieving. With age a person loses some of these support systems. Family and friends move away or die, and organizations and neighborhoods change. Changing work roles and financial status may require changes in the groups with whom a person associates. To cope with losses of family members and friends and a decline in health and independence, individuals need a large social network.
In a study of poor, frail older adults, Mor-Barak, Miller, and Syme (1991) found that social networks act as buffers against the harmful effects that major life events have on the health of older adults; that is, social networks may help relieve the harmful consequences of life events on health. Krause (1997) found that anticipated support is associated with lower mortality risk in the upper social classes. These individuals are more likely to believe that others will help if the need arises.
Marital status affects older persons in several ways. A married person is likely to live in a household with more income compared with an older adult who lives alone. Nutritional status is likely to be better for the married person than for the person living alone. Men benefit most from marriage. They do not cultivate the close friendships that women do outside the marriage, so the spouse is a vital friend and supporter (see Figure 7–2 for information on
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population numbers from 1950 to 2050).
FIGURE 7–2 Total population and older population: United States, 1950–2050. (From National Center for Health Statistics. (2009). United States,
2008 with chartbook, Hyattsville, MD: National Center for Health Statistics Health.)
In a study of how age and gender affect the perception of quality of support, Lynch (1998) found that men appear to perceive spousal support as the most positive, whereas women perceive the support received from children as the most positive. Traditionally, men have not engaged in cooking, cleaning house, mending clothes, and doing the laundry and thus miss these services when they lose their spouses. Also, older women outnumber older men, so many men marry again. In 2010, about 78% of men ages 65 to 74 were living with their spouses; 58% of those older than 85 were living with their spouses. For women, these numbers are much lower. Among women 65 to 74, 56% were married; the number dropped to 18% among those over 85 (“Population,” n.d.).
A male older adult sees his role in marriage as the provider and
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protector. A woman feels responsible for her family’s comfort and happiness. These roles may be blurred in the marriages of older adults as disease and disability increase, forcing role changes. When the older adult loses his or her traditional role, self-esteem and satisfaction with life may be affected.
Children continue to provide support to their older parents. About one half of older adults in the United States live within 25 miles of a child; although this number varies, depending on marital status and employment (Pollak, 2010). Many visit at least weekly with children, and most talk on the phone at least once a week with a child. Female children are more likely to assist with hands-on care, whereas male children are more likely to provide business and financial support (Miller & Montgomery, 1990; U.S. Census Bureau, 1996). Although many families are separated by miles, children are concerned about their parents and attempt to arrange needed services for them. Area Agencies on Aging (AAAs), local social service organizations, and private care managers are some resources available.
Often, older adult siblings draw closer and may live together, providing support for each other as they grow older. Many older adults develop extended families of younger neighbors or fellow church members. These extended families provide both emotional and practical support.
The financial status of older adults may affect their support systems. Older adults tend to feel an obligation to return favors. If someone does something for them, they want to be able to reciprocate. If they are financially unable to do this, they might withdraw so as not to place themselves in an embarrassing position. In addition, the inability to afford suitable clothing or to maintain clean clothing may cause them to withdraw or cause others to avoid them.
The emotional status of older adults may also affect support systems. It may be difficult for friends and family of depressed or negative older persons to maintain contact with them because of the exhibited behaviors of these older adults. A complete health history and physical examination should be conducted to rule out physical causes of emotional problems. Peer counseling, support groups, or
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professional assistance from mental health professionals, clergy, or a community nursing service may help them express feelings and concerns. Close friends may be able to help the person find the positive aspects of life. Spirituality and religious practice provide positive support for older adults. Participation in religious community events helps eliminate feelings of isolation and diminishes depression. Many older adults use song, prayer, or meditation to express feelings. For many, faith is an effective coping mechanism and provides hope and support through illness and loss (Cramer, 1994; Forbes, 1994; Koenig & Weaver, 1998).
Benefits and Entitlements In addition to Social Security, Supplemental Security Income, Medicare, and Medicaid, a variety of other benefits and entitlements are available to older Americans, and these affect their socioeconomic status. Entitlement programs require the beneficiary meet certain guidelines of income or disability, whereas all older Americans may enjoy other benefits such as senior discounts.
Subsidized housing is available in almost every community in the nation. Most programs are supervised by the U.S. Department of Housing and Urban Development, but one major program is under the authority of the Farmers Home Administration of the U.S. Department of Agriculture. Once a person establishes eligibility, he or she may find suitable housing in existing rental buildings or public housing developments. The housing authority then contracts with the building owner for rent payments on the unit, or the renter pays a portion of the rent and the housing authority pays the rest. Eligibility standards differ for each program. An individual’s income, assets, and expenses are all considered in determining eligibility.
Another entitlement program available to older adults is food stamps. Food stamp programs are usually administered by a state’s Department of Health and Human Services. Eligibility and the amount of food stamps a family may receive are based on family size, available income, and other resources. Nutritious meals are available at congregate meal sites throughout the country. A small
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donation is requested for each meal. If older adults are homebound, home delivered meals are available in many communities.
Energy assistance is also available. This program is administered differently in each community. Information on the program can be obtained at the local senior center or utility company. Again, income requirements must be met.
In 2012, veterans older than age 65 numbered 9.2 million in the United States (“American veterans by the numbers,” n.d.). Many of these veterans are eligible for veterans’ benefits. The benefit used most often is access to Veterans Affairs (VA) health care. As the population has aged, the large number of veterans from World War II has put a strain on VA health care facilities. As a result, the VA has tightened the rules, making it more difficult to qualify for care. Veterans who require health care because of a war-related injury or disease are given priority. Those needing long-term care are now being referred back to their communities for that care until an opening is available in a VA health care facility. The influx of thousands of veterans of the Middle East wars has reopened the need for acute, subacute, and rehabilitation services for veterans. With the large numbers of amputees with loss of one or multiple limbs, this group of veterans will become another large group needing senior care in the future (Figure 7–3).
FIGURE 7–3 Percent of population in five age groups: United States, 1950, 2004, and 2050. (From National Center for Health Statistics. (2009). United States, 2008 with chartbook, Hyattsville, MD: National Center for
Health Statistics Health.)
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Area Agencies on Aging Local AAAs provide several services for older adults. AAAs were created in 1973 as an amendment to the Older Americans Act. The purpose of the agencies is to plan and implement social service programs at the local level. Benefits available through these agencies include the following:
• Nutrition services through congregate meal sites and home- delivered meals
• Recreational opportunities
• Chore service
• Legal assistance
• Transportation
• Information and referral
It is not the purpose of the AAAs to duplicate the services of other agencies. In fact, these agencies try to encourage community- based services. However, if a service is not available, the AAA attempts to provide it.
Conservators and Guardians When older adults are unable to handle their own financial affairs, a conservator may be appointed. This does not necessarily indicate that older persons are incompetent. For example, if a person is visually impaired, he or she may voluntarily select a conservator. However, if an older person is incompetent, the court selects the conservator. In either case, the conservator is legally appointed and court supervised.
A guardian may be appointed to handle decisions not related to financial matters. The guardian makes decisions about housing, health care, and other similar matters. This may be the same person as the conservator or a different person.
A guardian or conservator may affect a person’s socioeconomic status. By handling his or her assets wisely, a conservator may help an older person remain at least financially independent for longer
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than he or she could have otherwise. By supervising housing and health matters, the knowledgeable guardian may assist the older person in functioning at the highest possible level (Box 7–3).
Box 7–3
Definitions Conservator—manages an older person’s financial resources. An
annual report must be filed with the court detailing how the funds were spent on the person’s behalf.
Guardian—is appointed to make personal care decisions for the disabled individual. Personal care includes medical treatment and other decisions promoting comfort, safety, and health. The guardian must file an annual report with the court on the individual’s condition.
Durable power of attorney—is a document by which one person (the principal) gives legal authority to another (the agent or attorney-in-fact) to act on behalf of the principal. It is called durable because it continues to be effective even after the principal has lost capacity as a result of illness or injury. The two types of durable power of attorney are:
• Durable power of attorney for financial matters—this authority to handle financial affairs may be as broad or limited as the parties agree upon.
• Durable power of attorney for health care decisions—the agent or attorney-in-fact is not required to report actions on behalf of the principal to the court.
(From American Association of Retired Persons. (1991). A matter of choice. Washington, D.C.: The Association; Hamilton, A. (Ed.). (1991). Legal guide for senior citizens. Topeka, KS: Kansas Department on Aging.)
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Environmental influences Environment contributes to a person’s perception of life. Although the environment might not be noticeable unless it is uncomfortable, it does significantly affect emotional and physical health and well- being. Environment may be described as hot or cold, dark or light, hard or soft, and safe or dangerous. Environmental factors such as adequate shelter, safety, and comfort contribute to a person’s ability to function well. These factors take on added importance to older adults with decreased functional abilities. Geographic location, transportation, housing, and safety issues as they relate to the environment of the older person are discussed in the following sections.
Geographic Location of Residence Geographic factors influence individuals differently. Climate is important to older adults because they are susceptible to temperature extremes. Those who live in cold climates need adequate heat and clothing; those in temperate areas need cooling systems during warm seasons. Because older adults are concerned about accidental injuries, weather extremes such as snow and ice may contribute to isolation.
Whether a person lives in an urban or rural location may affect access to services, availability of support systems, and safety perceptions. Urban neighborhoods tend to be older and subject to change because of suburban migration. The notion of a friendly and convenient neighborhood in larger urban areas is rapidly declining. Such changing neighborhoods may affect the socialization of older adults because of the foreign and frightening atmosphere created. The majority of older Americans have lived in the same geographic area for more than 30 years and do not plan to move.
Older adults residing in rural areas have different problems. Geographic isolation may result in long distances between social contacts and services and inadequate availability of transportation. However, the social supports obtained through churches, friends,
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and neighbors are often strong and reliable. Although a larger percentage of older adults in rural areas own their own homes compared with those in metropolitan areas, they occupy a disproportionate share of the nation’s substandard housing. Also, fewer formal services are available for older adults living in rural areas (Coward, 1993). Neighbors helping neighbors, local clubs or groups, and church congregations often support older adults living in rural areas. However, some individuals enjoy being left alone and away from others and do not want outside involvement. Each community should set standards for being available if needed while permitting personal privacy for the older adults in their area.
Transportation For many older adults, an automobile is a symbol of independence. In 2009, 33 million older adults still had their drivers’ licenses (“Older adult drivers,” 2013). In some areas, an automobile is necessary for transportation to shopping areas, medical facilities, and social centers. Using data from the Public Use Microdata Sample, Cutler and Coward (1992) found that 76% of older adults live in households where personal transportation is available. However, these data do not indicate whether the older adults actually use available vehicles. Advancing age, female gender, and residing in inner cities were associated with a greater likelihood of lack of transportation.
Low-cost transportation is an objective of the Older Americans Act and is the responsibility of the Administration on Aging. Each AAA is charged with ensuring that transportation is available in its area. Obstacles preventing public transportation use include cost, scheduling, distance from home, availability in rural areas, lack of awareness of the service, and reluctance of some older adults to use public transportation.
Housing A person’s home is a true reflection of the individual, and for the older person it signifies independence (see Evidence-Based Practice box).
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Evidence-based practice Benefits of Teaching Personal Safety to Independent Older Women Living Alone
Sample/Setting Midwestern older adult women living alone and homebound were invited to participate in a study. Fourteen women with a mean age of 89.9 years ultimately participated. Nine participants wore a personal emergency response system (PERS) device.
Method In-person interviews were conducted every few months over an 18-month period. A descriptive phenomenologic method was used for the study. Interview questions sought to obtain responses to identify what were the concerns in reaching help quickly and what the intentions of these women were in event an intruder got into their homes.
Findings The phenomenon theme identified by the study was “contemplating what I would do if an intruder got in my house.” Five overall concerns emerged from the interviews. These were (1) reducing my risk on intrusion, (2) having a device that I could use to reach help quickly, (3) feeling safe/unsafe living in this neighborhood, (4) detecting my deterioration—seeing myself as able, and (5) being uncertain what I would do if an intruder got in.
Four themes regarding these women’s intentions once an intruder got in were identified: (1) outsmarting the intruder, (2) escaping from the intruder, (3) disabling the intruder, and (4) alerting someone that the intruder got in. Many times, the participants did not think to use the PERS in the case of an intruder but instead wanted to use the phone to call for help. Participants had not thought out how they would react to the
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event or how they would get away. Some thought of themselves as able to defend against an intruder using their own strength or a walking cane. At the beginning of the study, the participants were more likely to be unrealistic in how they would respond to an intruder. By the end of the study, the women had begun to identify more realistic means of handling such an event.
Implication Older women living alone may be unable to ward off an intruder because of their frailty. Discussion of personal safety may help these women feel confident living at home alone. Nurses come in contact with older women during home health visits or hospitalization. These opportunities allow time for nurses to engage elderly women in open-ended discussions that may prompt women to consider how they would handle such a situation and move toward realistic interventions. It would be of value to determine whether access to a PERS or other security device is available. Teaching older women that this device can be used to contact the police is an example of one such realistic intervention to use in case of home intrusion. (From Porter, E. (2008). Contemplating what I would do if someone got in my house: intentions of older homebound women living alone. Advances In Nursing Science, 31(2), 106.)
After World War II, home ownership was encouraged by offers of insured mortgages and reductions in property taxes and mortgage interest to stimulate the postwar economy. Therefore, home ownership was a goal many in the older generation sought to achieve (Burke & Flaherty, 1993). A person’s house is often his or her major asset and, in fact, may be the only asset. The older person may have been born and raised there and then raised his or her own children. More often, a young married couple would have bought the house, raised the family in that same house, then continued to live there as a couple or after the death of the spouse.
The availability of features that support older adults’ abilities to function in their homes is often a concern. Most homes occupied by older adults were designed for younger, more active individuals. Many older Americans have made modifications in their houses to
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adapt the environment to specific needs, but many others have yet to do this. For those who wish to remain in their homes but need funds for maintenance and repairs or even extra income, home equity conversion, also known as reverse mortgage, might be an alternative. In a reverse mortgage, the homeowner arranges for regular payments from a bank in exchange for the future transfer of the property to the bank.
Older adults who rent face the problem of locating affordable rental property. Once it is located, increases in rental cost may outpace older adults’ fixed income. The tenant–property manager relationship may change as property management changes hands. Building structure and appliances may be inadequate to support independent functioning in many rental properties.
In urban areas, some older adults live in single-room-occupancy (SRO) hotels. SRO hotels offer single, sparsely furnished rooms with limited cooking facilities and communal bathrooms. Tenants are traditionally single persons with limited incomes, mental illness, or substance abuse problems. Typically, they have few contacts with other tenants and no family to provide support. An increasing incidence of chronic disease and disability may keep individuals from leaving their rooms and may further restrict the person’s living environment. This may affect tenants’ physical and mental health by isolating them and preventing access to services.
Safety may be a problem in all these living arrangements. Aging furnaces and appliances, worn linoleum or carpeting, poor lighting, unprotected stairs, lack of smoke alarms and assistive grab bars, and aging, sagging, or broken furniture all pose hazards for older adults. For those who decide to give up their houses, several options are available (Figure 7–4). Independent housing options may include mobile homes, condominiums, and cooperatives. Increasingly, older adults are sharing houses. They may move in with family into a single room, an accessory apartment, or a portable housing unit on the family property. Others team up with a group of older adults to buy or rent a house. Typically, in this situation, each person has a private room, and the living, dining, and kitchen areas are shared. Chores are also shared, and in some instances, a housekeeper or manager for the house is hired. Some
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older adults take in boarders to help with expenses and household chores. The boarder is often a younger person who can do the “heavy” housework.
FIGURE 7–4 Living situation by age: 2002. Note: “Other” includes living rent-free with a relative and a small number of respondents in
miscellaneous living arrangements. (From National Institute on Aging/National Institutes of Health. (2007). Growing older in America: The health and
retirement study, Washington, D.C.: U.S. Department of Health and Human Services.)
Home matching programs are gaining in popularity. These agencies locate and match persons who can share a home. Through interviews and screenings conducted by the agency, applicants are able to locate a compatible housemate. With home sharing, common areas of the house such as the kitchen and living room are always available for use. However, personal spaces such as bedrooms and bathrooms are private. Home sharing is not for everyone. Agreements need to be in writing with regard to expectations from both renter and owner before entering into the arrangement.
A growing number of older adults are living a mobile life. These are usually the young-old who live in warmer climates in the winter and in cooler climates in the summer. They may own a home in one area and rent in another, or they may use a recreational vehicle as a second home. The real nomads are those who travel all
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year from place to place in recreational vehicles. As these older adults age and begin to have health problems, they often return to their home communities where long-established support systems of family and friends are available.
Retirement communities appeal to some. In a survey of older Americans, 10% of respondents lived in retirement housing (U.S. Census Bureau, 2004–2005). These communities may have facilities for independent persons only, or they may include a variety of housing alternatives for those with various levels of dependency. Separate housing units for independent residents, congregate apartment units for those who need meals or housekeeping help, and nursing facilities for those who need more care may be found in a continuing care community. Residents may move from one level to another as their needs change. Most such communities require a substantial entrance fee in addition to monthly charges. Benefits include activity programs and assistance with housekeeping and chores. Transportation is often included.
For those who require increasing assistance but are still able to function independently, assisted living facilities are viable options. These facilities have separate living units with common dining facilities and social rooms. Meals, transportation, housekeeping, and some laundry services are provided. Most have activity programs and encourage residents to socialize. Staff are present around the clock should a resident need help.
Board and care homes (also known as sheltered housing, personal care homes, residential care facilities, and domiciliary care) provide a home to a small number of older adults (usually four to six). Services vary widely. Basic rent usually includes room, board, laundry, and housekeeping. Some offer other services such as assistance with personal care for an additional fee. Board and care homes try to create a homelike atmosphere by remaining small and friendly.
Nursing care facilities are another housing option for persons who are no longer able to function independently. Residents of nursing care facilities depend on assistance with ADLs for survival. The resident occupies a single room or shares a room with one or more persons. The facility is staffed 24 hours a day with nursing
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professionals and trained personnel who provide needed assistance. The services on the premises generally include meals, personal laundry services, and a hair salon. Activity programming is provided to meet the needs of individual residents. Rehabilitation services are available as required by the residents.
In any assistive facility, it should be noted that residents are renting their room or part of their room, and to them, it is home. It should be arranged as residents wish and furnished with as many personal possessions as possible to provide a sense of historical continuity, belonging, identity, and comfort (Johnson, 1996). Staff should treat residents in a courteous and respectful manner. For example, a person would not go to a friend’s house and turn on the television or rearrange the furniture without permission. By recognizing the importance of personal space, staff members reaffirm older adults’ rights and enhance their sense of dignity.
When older persons change environments, stress caused by relocation is a possibility. Moving to any new setting is often associated with loss. Older persons may move because of loss of the spouse, health, home, or functional independence. Depression, withdrawal, confusion, increased dependency, lowered life satisfaction, and increased health problems may result from a move, especially if older adults are not prepared or the move is abrupt. If older persons make the decision to move after careful consideration over time, if they are familiar with the new environment, and if they are able to take cherished possessions with them, the move is made with minimum stress. Preadmission and ongoing assessments of residents and their spouses and family help ease the adjustment (Rosenkoetter, 1996). When the move is precipitous, with little or no input from the older adults, it may have negative effects on health and may possibly increase the risk of death (Johnson, 1996; Manion & Rantz, 1995).
A segment of the older population is homeless. Data about homelessness are difficult to quantify because of the nature of the problem. Older adults in the homeless population are defined as those older than 50 because they tend to look and act 10 to 20 years older (DeMallie, North, & Smith, 1997). In 2008, 30.6% of the individuals residing in shelters were over the age of 50 (National
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Coalition for the Homeless, 2009). Women are increasing in numbers among the homeless older adult communities. Some have some source of income (Social Security Insurance [SSI]), but it is usually insufficient to obtain adequate housing. However, a significant number of homeless are between the ages of 50 and 62; they are not old enough for Medicare. Approximately 30% of homeless older adults have mental illness or dementia. Many may also suffer from chronic illnesses and visual and hearing problems. Impaired judgment may lead to financial mismanagement, eviction, or exploitation of property by others, leading to a loss of residence. Locating a new residence is difficult because of limited income, mental and physical health problems, and a lack of information about affordable housing (Cohen, 1997) (see Evidence-Based Practice box).
Evidence-based practice Older homeless women
Sample/Setting The sample included 201 homeless women ages 50 or older. The sampling was stratified into four overlapping sectors: (1) persons using eight public shelters that housed homeless women, (2) women using five homeless shelters operated by religious or voluntary agencies, (3) women using four drop-in centers, and (4) women using various public areas such as parks and bus, ferry, and train terminals. Interviews were conducted over a 2-year period. The mean age of the sample was 59 years; 51% were black, 34% were white, 10% were Hispanic, and 5% were from other racial groups.
Methods Interviews were conducted with the use of two instruments: audiotapes and videotapes. The interviews took approximately 2 hours.
Findings
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Of the variables examined, only two variables—perceived support and number of community facilities attended—were significant predictors of being domiciled on follow-up. Three additional variables—absence of psychosis, a lifetime history of less than 1 year of homelessness, and number of entitlements— attained near-significance. However, what is most striking was the apparent lack of suitable housing options for older homeless women as evidenced by the high percentage of women who received no housing offers and the large number who rejected offers that were made. This was also reflected in a survey of directors of homeless programs.
Implications Older homeless women may require more intensive case management to assist in the process of leaving shelters and finding suitable housing. The nurse who becomes aware that a patient is homeless should collaborate with the case management team to help find suitable housing. (From Cohen, C. (1997). Predictors of becoming redomiciled among older homeless women. Gerontologist, 37(1), 67.)
Homeless older adults require interventions that can connect them with needed services. Medical and mental assessments, emergency shelter, and long-term supervision may be required. In a study by Harris and Williams (1991), homeless men identified needs such as clean water, healthful food, adequate rest and exercise, medications and health care, adequate clothing, a safe place to stay at night, and money and facilities for bathing and washing clothes.
Whatever the housing status of the older person, it must be remembered that each person has a right to determine where to live unless he or she is proven incompetent for self-care. Nurses, as health care professionals, must respect that right and work with the person to maintain as much independence and dignity as possible.
The AARP provides many books on housing options, adaptations, and safety. Many are free or available at minimum cost. The federal government also provides materials on housing options through the Consumer Information Center.
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Criminal Victimization Elder victimization frequently goes unreported. Often, the perpetrator of the crime is someone known to the older adult: an acquantance, family member, or friend (Box 7–4). While older adults experience the lowest rates of victimization (2.4 victims per 1000 population, compared to 33.9 per 1000 population of 18-20 year olds in 2010), older adults appear to be particularly susceptible to crimes motivated by economic gain. Older adults are more likely to be injured in a violent crime. Among violent crime victims ages 65 or older, 6.5% suffer serious injuries such as death or sexual assault. When injured, almost half the older victims receive medical care in a hospital (The National Center for Victims of Crime, n.d.) (Box 7–5).
Box 7–4
Types of crimes committed against older adults The types of crimes most often committed against older adults include the following:
Financial/Material exploitation: illegal or improper use of funds, property, or assets
Sexual abuse or assault: sexual contact without consent
Murder/Homicide: taking of another person’s life
Internet crime: illegal activity committed through the Internet (cybercrime)
Identity theft: stealing anothers identiy or personal data
Emotional/Psychological abuse: verbal or nonverbal means of inflicting pain and suffering
Physical abuse: physical force resulting in injury
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Neglect: intentional or unintentional failure to fulfill obligations
Abandonment: desertion From The National Center for Victims of Crime. Accessed May 1, 2014 from http://www.victimsofcrime.org/library/crime-information-and-statistics/elder- victimization; and Department of Health and Human Services, National Center on Elder Abuse. Accessed May 1, 2014 from http://www.ncea.aoa.gov/FAQ/Type_Abuse/index.aspx.
Box 7–5
Older adult crime victims • Victimization rates are higher among older men than among
older women. However, the rates of personal larceny with contact such as purse snatching are higher among older women.
• The rates of victimization are higher among older adults ages 65 to 74 than among those ages 75 or older.
• Older blacks are more likely than older whites to be victims of crime. However, rates of personal larceny that do not involve contact between the victim and offender are greater among whites.
• Older adults with the lowest incomes experience higher violence than those with higher family incomes. The highest rates of personal theft or household crime are seen among older adults with the highest family income.
• The highest rates of victimization for all types of crime are seen among older persons who are either separated or divorced (from among all marital statuses).
• Rates of victimization for all types of crime are highest among older residents in cities compared with suburban or rural older adults.
• Older renters are more likely than owners to experience both
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violence and personal theft. However, older homeowners are more likely than renters to be victims of household crime.
From U.S. Department of Justice. (1994). Elderly crime victims: National crime victimization survey. Annapolis Junction, MD: Bureau of Justice Statistics Clearinghouse.
Whatever the actual risk, it is the perception of risk by older adults that affects their lifestyles (Fattah & Sacco, 1989). Declining health and limited finances contribute to feelings of vulnerability. As a result, older persons may withdraw behind locked doors, becoming isolated. They may rarely leave home and may even refuse to permit services within the home. Such self-imposed social isolation has a negative effect on older adults’ overall health and well-being.
Older adults are often victims of fraud and scams. Just how often they are victimized is not known because older adults may not realize what has happened or may be too embarrassed to admit to victimization. After accounting for women being a higher proportion of the older population, they are abused at a higher rate than men. The nation’s oldest-old (85 years or older) are abused and neglected at two to three times their proportion of the older adult population (Box 7–6).
Box 7–6
Consumer frauds perpetrated most against older adults • Health and medical frauds—quackery or merchandising of
drugs, health aids, or insurance
• Mail order frauds—merchandising through the mail that includes false or misleading information about the product
• Income creation and investment frauds—get-rich-quick schemes such as pyramid selling, work-at-home scams, the sale of fraudulent franchises, and real estate investment opportunities
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• Social psychological frauds—merchandising of products and services that exploit fears by promising solutions to problems and loneliness
• Con games—schemes such as “pigeon drop,” vacation lure, bank swindle, or oil well investment; usually perpetrated by professional con operators
• Telemarketing scams—sweepstakes or contests that require payment in advance to enter or claim a prize, with payment usually by credit card; merchandising that pressures people to buy without being sent written information about the products or services that are being sold
In nearly 90% of elder abuse and neglect cases with a known perpetrator, it is a family member such as an adult child or a spouse (National Center on Elder Abuse, 1998).
Older adults become victims for several reasons (Box 7–7). They are perceived as vulnerable. The ageist views of society often portray older adults as weak and gullible; older adults may even see themselves this way.
Box 7–7
Reasons older adults are victims of fraud 1. Older adults are often lonely and isolated. They are more likely
to be at home and therefore available to both door-to-door and phone scams. They welcome con artists who are willing to spend time visiting.
2. Older adults have fewer resources to turn to for advice. They may be reluctant to “bother” friends, family, or professionals.
3. Older adults may be more susceptible to con artists who are polite, who appear knowledgeable, or who represent authority.
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4. Older adults often have concerns about maintaining a comfortable lifestyle on a fixed income, affording good medical and long-term care, and providing for spouse and children.
5. Chronic illness leads many older adults to consider medical remedies offered by health fraud promoters.
6. Many older adults believe it is impolite to hang up on a caller or turn someone away at the door.
Older adults are highly visible. Appearance advertises age. Predictability of daily routines and movements make older adults more vulnerable to criminals. They tend to rely on public transportation, and if they live in undesirable urban areas, they are vulnerable when walking to and from public transportation.
The level of dependency is an indicator for victimization. The more dependent an individual is, or appears to be, the greater the risk of victimization. Some older adults have a diminished sense of sight or hearing. They may be unable to see well enough to recognize danger in the immediate area. They may not hear well enough to understand what is being said and may not ask for clarification. Loss of physical strength reduces the ability to fight back. With loss of cognitive ability, older adults are less able to reason rationally and are therefore vulnerable to fraud and abuse.
Con artists commonly prey on older adults. A study funded by AARP categorized one third of those older than age 75 as “highly vulnerable” to fraud compared with 24% among those ages 65 to 75 and 7% of those younger than 65 (Fleming & Curti, 1994). Loneliness and a life of trusting others leave older adults vulnerable. Con artists go door to door and use friendliness to gain the trust of the older person. They visit for as long as it takes to accomplish their goal. They rely on older adults’ fears related to safety and health to sell their products. They convince older adults that the roof needs repair, the driveway needs sealing, or a burglar alarm system should be installed. Other older adults respond to appeals and advertising seen on the television, in newspaper supplements, or in the mail. They may order products that turn out to be different from what was advertised, for example, a “solar clothes dryer” for $39.99 that turned out to be just a clothesline and
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clothespins (Bekey, 1991). Illegal telemarketing is increasingly claiming older victims.
TV sales spots with call-in phone numbers or Web addresses have brought another level of crime to the home of the vulnerable older adult. When the call or connection with the phone number is made, the seller tries multiple offers of “better” products or even the “best” product available similar to the one advertised for a very low price. The seller talks fast during the interaction, which is confusing to the older adult buyer. As the word yes is said, the amount on the bill increases. The wording of the dialogue is done to deliberately create confusion and doubt over the original item in favor of the “better” or the “best” item. Then, when it seems as if the sale is done, more offers are made on the basis of the information that was gained by talking while inventory was taken or shipping and handling were being added to the bill. When the product arrives, the return cost is high, and most people just keep the items even if they get two to four times as many as they wanted.
Older adults who have been victimized are likely to be confused, disoriented, fearful, or angry. When trying to assist older adult victims, the nurse should give the impression of nonhostile authority. Firm direction should be tempered with empathy. It is important to listen carefully to victims. This conveys an attitude of empathy and respect and helps the victims sort out the facts. The nurse must remain calm and reassure them that help will be provided throughout this crisis.
The nurse may need to allow time for victims to regain composure. One way to accomplish this is to distract them by asking for demographic information. Inquire about address, phone number, family, and other support systems to help calm them.
Follow-up procedures such as referral to a social service agency or victim support group or a phone call to let a victim know how the case is progressing help victims know that the professional cares. However, precautions must be taken to avoid encouraging excessive dependency.
Community resources for crime victims vary from one area to another. In some communities, victim and witness assistance
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programs may offer short-term immediate help. Support groups may help victims work through feelings of anger and fear. Volunteer action programs, such as a neighborhood watch, aid prevention and also help older adults feel safer. The AAA is a good resource for information about assistance programs for older persons. Local law enforcement agencies are also available for help.
Every state has older adult abuse laws that include methods for reporting suspected abuse. Most state laws define abuse and provide a system of investigation. Many states maintain a registry of reports on suspected abuse. Some states mandate professionals working with older adults to report suspected abuse. In other states, reporting is voluntary. The local department of social services or AAA may provide information on reporting requirements.
It is important for older adults to have control over their environment and a voice in the community. Educational programs help older adults identify potential crime situations and ways to protect themselves. AARP has programs in place to address elder victimization. These programs are available for professionals, older adults, and families (please see: http://www.aarp.org/). Such groups are also identifying and recommending programs, as well as assisting in planning and integrating law enforcement concerns with other social service needs throughout the community (Miller, 1992). Older adults who take responsibility for their own environment feel in control, and those who would victimize older adults recognize that attitude.
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Advocacy Older adults as a group are good advocates for their own special needs and interests. They write to legislators, consumer protection groups, government agencies, and other groups that control issues affecting older adults. By advocating for themselves, older adults are taking charge of their environment, their resources, their mental and physical health, and the future of all older adults. Older adults know from experience that they can make a difference.
Some older adults, however, are not able to plead their case. For example, older women were not taught to be assertive and to stand up for themselves. The physically or mentally disabled, the undereducated, minority groups, those who do not speak the local language, and the financially disadvantaged all need assistance to take advantage of services and programs that may benefit them.
Advocacy is basic to professional nursing because it seeks to protect the human rights of patients within the health care system (Segesten & Fagring, 1996). Advocacy is an ongoing process as opposed to a single isolated event. As a moral concept, advocacy requires the nurse to speak up for the patient’s rights and choices, to help the patient clarify his or her decision, and to protect the patient’s privacy and autonomy in decision making (Hamic, 2000). The nurse is often the best person to initiate and provide that assistance. The nurse is trained to listen and assess, is aware of aging physiology and psychology, is familiar with community resources, and is motivated to serve older adults. The nurse may be the one member of the formal support group with the most complete information about older adults.
By listening to and consulting with older adults, the nurse develops an understanding of the values and perceptions that guide older adults’ thoughts and feelings about life. The nurse forms partnerships with older adults to defend and promote their rights.
The nurse advocate determines what older adults want and then helps find ways to satisfy those desires. If staying at home is
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important to an older adult, the nurse can assist in enabling the person to stay home. By involving older persons in planning from the start, the nurse establishes partnerships that strengthen older adults’ self-esteem, promote dignity, and enhance satisfaction with life.
Within the hospital or nursing facility the nurse can advocate for older adults by clearly documenting their concerns and problems and any nursing care approaches. The nurse is in a key position to advocate for older adults by bringing problems to the attention of the physician, social services department, or administrator, as appropriate. In cases in which patient competency is questioned, it may be appropriate for the nurse to encourage the patient to obtain legal counsel or to insist on comprehensive evaluations by a qualified geriatric specialist to determine the cause of symptoms.
Whatever the setting, the nurse’s advocacy for older adults is important to ensure older adults continue to control their lives. There are many organizations in the United States that advocate for older adults (see Appendix 7A at the end of this chapter). Local and regional organizations also advocate for older adults, including state departments of aging and the local AAA.
Home care
Socioeconomic Influences • Assess older adults’ outside sources of income. Many
supplemental policies cover excess costs that Medicare does not cover, thus ensuring more equipment and supplies for older adults.
• The goal of home care is to restore older adults’ independence by teaching self-management of chronic conditions.
• Use social workers to identify community resources for financial assistance for homebound older adults.
• Arrange for meals to be delivered to homebound older adults, if
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necessary.
• Contact the Area Agency on Aging for referral to employment and legal services and social opportunities for older adults.
Environmental Influences • Many meal delivery services provide food that has been
prepared and frozen. Assess the functional ability and environment of older adults to ensure they can prepare the food that has been delivered (e.g., make certain they have a stove or microwave and electricity).
• Use a social worker to identify community resources for housing options for homebound older adults with multiple problems.
• Refer to the Area Agency on Aging for resources for home repair and transportation.
• Assess for signs of older adult abuse that may be manifested by consumer frauds. Report any suspicion of consumer fraud.
• Reduce potential for consumer fraud by decreasing social isolation in homebound older adults.
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Summary Older adults’ perceptions of the health care system in its entirety are influenced by experience. The nurse needs knowledge about the major historical events that have influenced the perceptions of today’s older adults to understand their response to health care issues.
Socioeconomic issues, including income sources, prosperity or poverty, educational level, health status, and formal and informal support systems, affect the ability of older adults to comprehend and comply with health care regimens.
Older adults and their families may not be aware of community resources. The nurse should be aware of housing options, nutrition programs, transportation opportunities, respite programs, and legal assistance programs that are available in the community.
By understanding the eligibility requirements for benefits and entitlements, the nurse can assist older adults in receiving optimum services. By understanding the necessity for and the availability of conservatorship or guardianship, the nurse can help older adults and their families cope with diminishing abilities.
The sensitive nurse understands the concerns of older adults and supports and reassures them. The nurse can also encourage the older adults’ informal support systems of friends and family. Often, the nurse can coordinate the formal and informal support systems for the maximum positive effect on the health and well-being of older adults.
Advocates for older persons, whether the older adults themselves or professionals in the field of aging, can help make socioeconomic and environmental factors a positive influence on older adults.
To provide maximum benefits to aging health care consumers, the nurse must understand the factors that influence health perception. To successfully work with older adults, the nurse must understand not only where they are but also where they have been.
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Key points • Socioeconomic factors such as income level, income sources,
insurance coverage, benefits and entitlements, and educational level influence older adults’ perceptions of their health and approach to health care.
• Environmental factors such as geographic location, housing, transportation, and perception of safety influence the availability of services, as well as older adults’ knowledge and use of those services.
• The strength of the formal and informal support systems, including community services, medical care, spiritual resources, and family and friends, may affect the maintenance of independence for older adults.
• Experience has a strong influence on shaping value systems, coping skills, and perceptions. It is important to understand the events that occurred early in older adults’ lives to understand their values and perceptions.
• Education has a strong positive influence on economic well-being and health status. Education prepares persons to make positive decisions that contribute to a higher perceived quality of life.
• Medicare is a federal program that provides health insurance for older adults. It consists of two parts: Part A is hospital insurance that helps pay for inpatient care and some follow-up care, and Part B is medical insurance that helps pay for physician services and some outpatient services.
• Medicaid is a state-administered program that uses federal funds to provide some medical expenses not covered by Medicare. Each state has different coverage and requirements. Medicaid is designed for persons with very low incomes and minimal assets.
• Older adults who are no longer able to handle their affairs or make decisions about their lives may benefit from a conservator, guardian, or durable power of attorney. A conservator manages financial resources, a guardian makes personal decisions, and a
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durable power of attorney is a document that names an agent to act on behalf of a person for a specific function, such as in making financial or health care decisions.
• The condition of homes and furnishings, the composition of neighborhoods, and the availability and type of transportation affect the security and safety of older adults. Aging and outdated homes and appliances, worn furniture, and unreliable transportation may lead to accidents and injury. Deteriorating neighborhoods with changing populations may foster feelings of insecurity in older adults.
• Most communities in America have a variety of housing options to meet the needs of older adults, including single family residences, apartments, congregate housing, shared housing, retirement communities, assisted living facilities, and nursing facilities. Each option provides a different level of service to help older adults maintain maximum independence.
• Perceived victimization in older adults may result in increased suspicion and eventual withdrawal and isolation, which may have negative effects on health and well-being.
• A strong support system helps protect older adults from criminal victimization. Professional service providers, friends, and family may monitor older adults’ environments and offer guidance when necessary. Community programs such as neighborhood watch programs and educational programs on victimization help older adults actively participate in crime prevention.
• Through advocacy, nurses can protect the dignity of older adults and improve their quality of life.
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Critical thinking exercises 1. A 69-year-old chronically ill woman has few financial resources, no formal education, and only one child who can assist her. Her son is married, has four children, and has a job that barely manages to support him and his family. Speculate how the woman’s situation may affect her perception of her health care. In what ways can the nurse intervene to assist her?
2. A 78-year-old man is a retired banker whose wife died several years ago. He is able to perform all ADLs but needs help with meal preparation and transportation. He lives in a deteriorating neighborhood and no longer feels safe. He does not want to live with family members or completely give up his independence. What housing options would be appropriate for him? What advantages would such housing options offer over living alone?
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Appendix 7A Resources Organizations of Older Adults AARP
601 E Street NW
Washington, DC 20049
(202) 434–2277
Older Women’s League (OWL)
666 11th Street NW
Washington, DC 20001
(202) 783–6686
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Organizations of Professionals Working in the Field of Aging American Health Care Association
1201 L Street NW
Washington, DC 20005–4014
(202) 842–4444
Gerontological Society of America
1275 K Street NW
Suite 350
Washington, DC 20005–4006
(202) 842–1275
Hispanic Council on Aging
2713 Ontario Road NW
Washington, DC 20009
(202) 265–1288
National Association of Professional Geriatric Care Managers
1604 North Country Club Road
Tucson, AZ 85716–3102
(520) 881–8008
National Association of Social Workers
750 First Street NE
Washington, DC 20002
(202) 408–8600
National Gerontological Nursing Association
7794 Grow Drive
Pensacola, FL 32514
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1 (800) 723–0560
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Organizations of Both Professionals and Older Adults Alzheimer’s Disease and Related Disorders Association
919 North Michigan Avenue
Chicago, IL 60611–1676
(312) 335–8700
American Society on Aging
833 Market Street
Suite 511
San Francisco, CA 94103–1824
(415) 882–2910
National Council on Aging (NCOA) (includes National Institute of Senior Citizens and National Institute on Adult Day Care)
1901 L Street, NW 4th Fl.
Washington, DC 20036
(202) 479–1200
* Original author: Carol Will, RN, MA; Revised by: Sue E. Meiner, EdD, APRN, BC, GNP.
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C H A P T E R 8
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Health Promotion and Illness/Disability Prevention Sue E. Meiner, EdD, APRN, BC, GNP; , DrJean Benzel-Lindley, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Define health promotion, health protection, and disease prevention.
2. Identify models of health promotion and wellness.
3. Describe health care provider barriers to health promotion activities.
4. Describe patient barriers to health promotion activities.
5. Describe primary, secondary, tertiary, and quaternary prevention.
6. Plan strategies for nursing’s role in health promotion and public policy.
7. Develop approaches to support the empowerment of older adults.
http://evolve.elsevier.com/Meiner/gerontologic
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Essentials of health promotion for aging adults The purpose of health promotion and disease prevention is to reduce the potential years of life lost in premature mortality and ensure a higher quality of remaining life. As Americans live longer, health promotion activities are all the more important because these individuals will have more years to benefit from preventive services. Health promotion and disease prevention activities include primary prevention, or the prevention of disease before it occurs, and secondary prevention, which is the detection of disease at an early stage. Some evidence suggests that seniors benefit just as much from primary and secondary health promotion activities as those who are middle-aged. Exercise and reducing cholesterol levels improve overall health status and physical fitness, including aerobic power, strength, balance, and flexibility and help prevent acute medical problems such as fractures, myocardial infarctions, and cerebrovascular accidents (Moser & Watkins, 2009; Parker et al., 2012; Thompson et al., 2007). Appropriate screening with mammography, Papanicolaou (Pap) test, digital examination for monitoring prostate size, yearly evaluation of stool specimens for occult blood, or a combination of some of these measures may help reduce mortality and morbidity among older adults (Resnick & McLeskey, 2008).
The incidence of ineffective health maintenance is high among older adults, as evidenced by the lack of participation in healthy behaviors such as exercise. Approximately, 22% to 47% of older women and 18% to 37% of older men do not engage in regular exercise (Koestner, Walters, Mattice, Manion, & Sequin, 2009; Rosamond et al., 2008). According to the National Health and Nutrition Examination Survey, 11.2% to 63.3% of adults met healthy diet parameters. Meanwhile, 20% to 60% of older adults do not adhere to prescribed medications (Anderson et al., 2011).
Many factors put older adults at risk for having ineffective health maintenance (Table 8-1). Theoretically, reasons and decisions
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associated with engaging in health maintenance behaviors are best explained with the use of a social–ecologic model. This model incorporates intrapersonal and interpersonal factors, the environment, and policy. Intrapersonal factors include physical health, function, cognition, age, gender, and other relevant physiologic factors. Interpersonal factors include motivation and social supports. Environment includes both the physical environment, which might serve as a barrier or facilitator (being able to walk in a park for exercise or have access to an exercise room) of health behaviors, and the social environment. Lastly, policy can enforce and facilitate health behaviors through laws that require such things as bike helmets and seatbelts or that allow access through reimbursement.
Table 8-1 Factors that influence health behaviors in older adults
Factor Description Cognitive impairment
May result in a lack of understanding of the health behavior and rationale for engaging in the behavior (e.g., does not understand the impact of not taking medications, not exercising), may result in the individual simply not remembering to engage in the activity, or both.
Function Inability to physically engage in the health maintenance recommendations (e.g., cannot tolerate preparation for a colonoscopy, cannot complete stool cards, and cannot see to read medication directions).
Access to care
Inability to get to grocery stores with appropriate food options, inability to access health care providers because of transportation challenges, insufficient numbers of providers, etc.
Resources Cannot afford health food options, medications, etc. Social supports
Social supports may verbally encourage and reinforce healthy behaviors and may help individuals increase access to healthy options.
Sensory changes
Inability to see or hear adequately to engage in a behavior (e.g., cannot hear or see the directions).
Environment Living space that facilitates physical activity and exercise or does not allow for physical activity. Unpleasant sensations
Pain, fear, boredom, and fatigue are common uncomfortable sensations that decrease willingness to engage in a behavior such as exercise or getting a screening test done.
Competing priorities
Lack of time because of competing responsibilities is frequently used as an excuse for not engaging in healthy behavior.
The interpersonal aspects of health behaviors are most often where nursing interventions can impact behavior. These are best guided by social cognitive theory. According to social cognitive theory (Boston University School of Public Health, 2013), human motivation and action are regulated by forethought. This cognitive control of behavior is based on two types of expectations: (1) self- efficacy expectations, which are individuals’ beliefs in their capabilities to perform a course of action to attain a desired outcome, and (2) outcome expectancies, which are the beliefs that a certain consequence will be produced by personal action. The
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theory of self-efficacy suggests that the stronger the individual’s self-efficacy and outcome expectations, the more likely he or she will initiate and persist with a given activity. The factors that influence self-efficacy and outcome expectations include successfully performing the behavior, verbal encouragement from others to perform the behavior, seeing similar persons perform the behavior, individualized caring and approaches to facilitate performance of the behavior, decreasing unpleasant sensations around the behavior (e.g., the pain associated with mammography; unpleasant drug side effects), and education about the benefit of the behavior (Eysenbach 2010; Resnick, Luisi, & Vogel, 2008).
Terminology Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health (O’Donnell, 2009). The promotion of health provides the pathway or process to achieve this balance. Box 8-1 lists areas of health promotion most relevant to older adults. A distinction should be made between health promotion and disease prevention. Health promotion addresses individual responsibility, whereas preventive services are fulfilled by health care providers. Disease prevention focuses on protecting as many people as possible from the harmful consequences of a threat to health (e.g., through immunizations).
Box 8-1
Areas of health promotion most relevant to physical fitness of older adults • Increasing physical activity
• Smoking control
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• Medication safety/drug safety
• Spiritual health
• Cardiac health: heart healthy diet, exercise, and preventive medication use
• Medical self-care
• Environmental health
• Nutrition
• Social health
• Weight maintenance
• Driving safety
Primary prevention is defined as measures provided to individuals to prevent the onset of a targeted condition (U.S. Preventive Services Task Force [USPSTF], 2008). Specifically, primary prevention measures include activities that help prevent a given health care problem. Examples include passive and active immunization against diseases, health-protecting education and counseling, promotion of the use of automobile passenger restraints, and fall prevention programs. Because successful primary prevention helps avoid the suffering, cost, and burden associated with injury or disease, it is typically considered the most cost-effective form of health care.
Secondary prevention is defined as those activities that identify and treat asymptomatic persons who have already developed risk factors or preclinical disease but in whom the condition is not clinically apparent (USPSTF, 2008). These activities are focused on early case finding of asymptomatic disease that occurs commonly and has significant risk of a negative outcome without treatment. Screening tests for cancer are examples of secondary prevention activities. With early case finding, the natural history of the disease, or how the course of an illness unfolds over time without treatment, can often be altered to maximize well-being and minimize suffering.
Tertiary prevention is defined as activities that involve the care of
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established disease; attempts are made to restore the person to highest function, minimize the negative effects of disease, and prevent disease-related complications.
Quaternary prevention involves limiting disability caused by chronic symptoms while encouraging efforts to maintain functional ability or reduce any loss of function through adaptation. For additional information regarding quaternary measures of prevention, see the specific disorders in Part 6 and Chapter 16.
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Models of health promotion This section provides a brief overview of four models of health promotion. The models selected represent different focus areas or constituents of health promotion programs.
The first is the ONPRIME Model, and the acronym stands for organizing, needs resources assessment, priority setting, research, intervention, monitoring, and evaluation. This is intended as an instructional model aimed at “change technology” within health promotion programs, agencies, and organizations. The change technology focuses on behavior modification to achieve national goals of improved health across the life span.
The second example is the Health Belief Model, developed to determine the likelihood of an individual’s participation in health promotion, health protection, and disease prevention services. Three basic components of this model are (1) the individual’s perception of his or her susceptibility to and the severity of an illness or disease, (2) modifying factors such as knowledge of the disease, various personal psychosocial and demographic variables, and cues or triggers to action, and (3) a cost–benefit ratio that is acceptable to the individual (Rosenstock, 1974).
The PRECEDE/PROCEED Model (Li et al., 2009), the third example, is complex and incorporates community involvement in most aspects of its direction. It is firmly based on multidisciplinary scientific designs and studies from epidemiologic, educational, and psychosocial sciences. The PRECEDE phase, which stands for predisposing, reinforcing, and enabling constructs in education/environmental diagnosis and evaluation, examines life quality, health goals, and health problems. The PROCEED phase, which stands for policy, regulatory, and organizational constructs in educational and environmental development, examines implementation and evaluation. This model is particularly useful in planning health education programs.
The fourth and final model is the Health Promotion Model. This model presumes an active role by the participant in developing and
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deciding the context in which health behaviors will be modified. Three basic categories are older adults’ characteristics and life experiences, their perceived personal decision making (self- efficacy), and the effect of the plan of action on health-promoting behaviors (Dehdari, Rahimi, Aryaeian & Gohari, 2013).
To fully understand these relatively complex models, additional reading is recommended. The reference list at the end of this chapter provides full citations for students wishing to learn more about each model that is briefly overviewed in this section.
The use of a model in the study, research, or practice of nursing provides a foundation and direction for the planning of one or more interventions. Note that the terms conceptual model and functional model are not interchangeable. A conceptual model is synonymous with a conceptual framework and is generally defined as a meaningful configuration of concepts that may be abstract or general. A functional model is a construct that provides an organizational plan using a systematic process designed for testing by other members of the profession. It is a blueprint based on the author’s ideas and research.
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Barriers to health promotion and disease prevention Lack of participation in health promotion activities continues to exist among older adults. For example, the incidence of coronary vascular disease (CVD) is approximately 40% per 1000 person-years in older men and 22% in older women (Shankar, McMunn, Banks, & Sfeptoe, 2011). The prevalence of inactivity, high-fat and high- sodium diets, and poor adherence to medication regimens among older adults is likewise high (Ahmed & Haboubi, 2010; Artinian et al., 2010; Ford et al., 2013; Hekler et al., 2008; Rejeski et al., 2011).
Health Care Professionals’ Barriers to Health Promotion Health care professionals are often a contributing cause of lack of participation in health promotion among older adults. Although the guidelines are clear with regard to prevention of cardiovascular disease and the benefits of regular physical activity (American College of Sports Medicine and the American Heart Association, 2008; Borjesson et al., 2011; Kumanyika et al., 2008; Shiroma, Sesso, & Lee, 2012; Zhao, Ford, Li, & Balluz, 2011), the guidelines around secondary prevention are not always clear. The USPSTF (2008) evidence-based guidelines were created on the premise that screening will improve patient outcomes. However, screening for those 85 years or older seems contradictory because data that provide evidence of cancer screening tests being of any benefit for this age group are limited. The USPSTF does address old age and gives upper age limits for the prostate-specific antigen (PSA) test, mammography, Pap test, and most recently, colorectal cancer screening (USPSTF, 2008).
Older Adults’ Barriers to Health Promotion A number of variables affect older adults’ willingness to engage in specific primary and secondary health-promoting activities. These
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include socioeconomic factors, beliefs and attitudes of both patients and providers (Wilcox et al., 2009), encouragement by a health care provider, specific motivation based on efficacy beliefs (Kostka & Jachimowicz, 2010), and access to resources. Generally, individuals who are younger, married, have fewer health problems, and have better cognitive status are more likely to participate in primary and secondary health-promoting activities. These findings, however, are not consistent. Specifically, Gallant, Spitze, and Grove (2010) reported that the factors influencing health behaviors varied by behavior, gender, and race. Therefore, it seems that sample-specific differences may exist with regard to what factors influence health promotion behaviors.
Patient barriers unrelated to health beliefs include lack of transportation and financial limitations. Transportation is not readily available to many urban and rural older adults, or it is cost prohibitive (see Chapter 7). In addition, older adults incur the cost of many preventive services because Medicare does not cover them all (Table 8-2). This may be hard on the fixed, limited income of many older adults.
Table 8-2 Secondary prevention: Medicare reimbursement
Screening/Preventive Procedure
Medicare Guidelines for Reimbursement
Pneumococcal infection vaccination
For all older adults at least once in a lifetime and then every 5 years as recommended.
Influenza vaccination For all older adults annually. Hepatitis B vaccination
Older adults at intermediate or high risk of contracting hepatitis B: once per lifetime (co-payment required).
Mammography Women older than 40 years are covered for one screening every 12 months. The usual Part B deductible is waived. Coverage includes the radiologic procedure and physician’s interpretation.
Papanicolaou test and pelvic examination
Pap test and screening pelvic examination (including clinical breast examination) are covered at 3- year intervals. Annual examinations are covered for women identified as high risk. The usual Part B deductible is waived.
Colorectal screening Annual fecal occult blood test for those older than 50 years until age 85. Flexible sigmoidoscopy every 4 years for those older than 50 years until age 85. Colonoscopy every 2 years for those at high risk until age 85. Screening barium enemas every 4 years for those older than 50 years (not high risk) and every 2 years for those who are at high risk until age 85.
Osteoporosis Bone density scan every 2 years (co-payment required). Diabetes screening Up to twice a year for those at high risk (co-payment required) Glaucoma screening Annually for those at high risk (co-payment required). Smoking cessation Two attempts annually if so indicated by the primary health care provider (co-payment required). Physical examination Within the first 6 months of joining Medicare Part B (co-payment required).
Ethnic and cultural factors may have a negative effect on health care–seeking behaviors. The cultural diversity issue is complex and
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varies from one location to another throughout the United States (see Chapter 5). The diversity among communities has not been adequately considered by health policy makers. This creates barriers to programs; for example, some programs require older adults to forfeit personal and family privacy to obtain individual services. In some cultures, fear of reporting health screening results that could serve as the impetus for additional protective or preventive services limits program development. Another problem in culturally diverse areas is lack of coordination of preventive health services because of the differing ideas and beliefs held by health policy makers concerning the delivery of services.
Older adults differ in their willingness to engage in health- promoting activities. With advancing age, they may have less interest in engaging in health promotion activities for the purpose of lengthening life and a greater interest in engaging in these activities only if they improve their current quality of life. It is useful, therefore, to use an individualized approach to health promotion with older adults (Resnick & McLeskey, 2008).
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Health protection Health protection is a classification of the Healthy People 2020, which is in development by the U.S. Department of Health and Human Services (U.S. Department of Health and Human Services, 2009). Healthy People 2020, a revision of Healthy People 2010, will provide our country with guidelines for how to achieve a wide range of public health benefits.
The underlying premise of Healthy People 2020 is that the health of the individual is almost inseparable from the health of the larger community and that the health of every community in every state determines the overall health status of the country. The overarching goals are to attain high-quality, long lives that are free of preventable disease, disability, and injury, to eliminate disparities, create social and physical environments that promote health, and optimize quality of life across the entire life span.
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Disease prevention Primary Preventive Measures Primary prevention refers to some specific action taken to optimize the health of the older individual by helping him or her be more resistant to disease or to ensure that the environment will be less harmful. Overall guidelines for reimbursable primary prevention are reviewed in Tables 8-2 and 8-3. Many of these behaviors require ongoing behavior changes and thus should be incorporated into all interactions with older individuals.
Table 8-3 United states preventive services task force guidelines for primary and secondary health promotion activities for older adults
Health Promotion Activity
Recommendation Supportive Evidence
Mammography Annually starting at age 40 and continue every 1–3 years until ages 70– 85
Based on randomized trials; evidence for age to stop screening not well established
Pelvic examination or cervical smear test
Every 1–3 years after 2–3 negative annual examinations; can discontinue after age 65 if prior testing was normal and not high risk
Based on randomized trials and evidence that harm outweighs benefit
Fecal occult blood test
Annually after the age of 50 until age 85 Evidence from nonrandomized or retrospective studies; fair evidence to support recommendation
Prostate examination
Evidence is insufficient to support screening with prostate-specific antigen (PSA) testing; men older than 75 years of age should not be offered a PSA test routinely
Based on insufficient evidence to support the benefits of screening
Exercise Encourage aerobic and resistance exercise as tolerated; ideally 30 minutes of moderate exercise daily
Based on randomized trials
Low- cholesterol diet
Keep daily fat intake at less than 35% of total calories and saturated fat and trans fatty acid intake at less than 7% of calories
Guidelines established, although not clear about guidelines for those age 85 years or older
Routine aspirin use
Low-dose aspirin therapy should be discussed with patients and benefits and risks evaluated.
Based on randomized controlled trials
Alcohol intake Moderate alcohol use, defined as 1 drink daily that does not exceed 1.5 ounces (45 milliliters [mL]) of liquor, 5 ounces (180 mL) of wine, or a standard can of beer (National Institute on Alcohol Abuse and Alcoholism, 2012)
Guidelines and safety not well established
Generally, immunizations are strongly recommended for older adults and include an annual influenza vaccination in the early fall season of each year and a regular tetanus vaccination every 10
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years. All older adults should receive a vaccination against pneumococcal infection at or immediately after the 65th birthday, and an additional vaccination after 5 years or more is recommended for high-risk persons. Adults with high-risk status include those living in institutions and those with chronic medical conditions such as heart or lung disease, diabetes mellitus, or cancer. It should be noted, however, that the Centers for Disease Control and Prevention (CDC) does not recommend routine revaccination of immunocompetent older adults; persons ages 65 or older should only be administered a second vaccination if they received the vaccine more than 5 years previously and were younger than age 65 at the time of primary vaccination (CDC, 2008).
Smoking cessation increases life expectancy and improves the quality of the remaining life span. Alcohol consumption, although providing some positive cardiovascular benefits when done in moderation, results in increased accident risks while ambulating or driving a motor vehicle or engaging in other types of physical activity or equipment use.
Another risk factor for older adults is polypharmacy (see Chapter 20). Polypharmacy is the use of large quantities of different drugs to relieve symptoms of health deviation or symptoms resulting from drug therapy (Lacasse, 2011). Polypharmacy is compounded by the use of generic drugs or the substitution of over-the-counter drugs that are less potent than their prescription counterparts. Increased focus has been placed on medications during care transitions, and nurses need to continue to completely review all medications taken routinely, randomly, by prescription, from friends, and over-the- counter during all medication reviews. The list of medications should be reviewed for interactions, contraindications, and overmedication or overdosing.
Prevention should also focus on bone health through optimization of calcium and vitamin D intake and exercise. Oral health is maintained through daily oral care and monitoring (American Dental Health Association, 2009). The prevention of cardiovascular disease includes exercise (American College of Sports Medicine and the American Heart Association, 2008), heart
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healthy diets (American Heart Association, 2008), and adherence to appropriate medications.
Secondary Preventive Measures Secondary prevention focuses on screening or early detection of asymptomatic disease or early disease. The idea here is that finding a problem early allows more effective treatment. In addition, secondary prevention includes techniques of primary prevention that are used on older adults who already have the disease in an effort to delay progression, for example, getting people who have had a heart attack to stop smoking and start exercising.
Annual screening recommendations for older adults should be made on an individual basis with the use of the guidelines and evidence-based recommendations from USPSTF. Screening for prostate cancer, for example, is not recommended for men 75 years or older and cervical cancer screening is not recommended for women after the age of 65 if they have had negative testing previously. Evidence for the need to routinely screen for lung, ovarian, or skin cancers is insufficient.
The USPSTF also provides guidelines regarding screening for cardiovascular disease, osteoporosis, diabetes, and obesity (USPSTF, 2008). Some evidence supports screening for osteoporosis, hyperlipidemia, depression, and obesity. Evidence to support screening for triglycerides or dementia is, however, insufficient. Decisions about screening should only be made after carefully weighing the benefits against the possible risks; knowledge about how the information will be used should also be obtained (Table 8- 4). For example, screening for breast cancer should probably not be done if the older individual would refuse any further treatment.
Table 8-4 Advantages and disadvantages to health promotion activities: focus of both formal and informal teaching intervention
Activity Advantages Disadvantages Alcohol use Social benefit
Protective effect on heart Increases high-density lipoprotein (HDL) cholesterol Decreased mortality after heart attack
Health complications: gastrointestinal, cardiac, dermatologic, cognitive, and neurologic; impairment of nutritional state Risk of depression
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Decreased risk of congestive heart failure Risk of falls Drug interactions
Cervical smear test
Increased risk of cervical cancer occurs with age and may result in unpleasant symptoms (foul-smelling discharge) if untreated
Cervical cancer develops slowly and is unlikely to be the cause of death in those 90 years or older
Older women may not have had regular cervical smear tests done and may want this early screening
Less risk if the patient is not sexually active
Only pursue, as per United States Preventive Services Task Force (USPSTF) guidelines, if woman is willing to undergo treatment if disease is identified
Testing is difficult and uncomfortable in older women, particularly those who are no longer (or never were) sexually active
Mammography Increased risk of breast cancer occurs with age New-onset breast cancer is not likely to cause death in those 90 years or older
If detected, these tumors are generally estrogen-receptor positive and treatable
Tumors in older women tend to be slow growing
Only pursue if woman is willing to undergo treatment if disease is identified
Discomfort associated with mammography
Stress and anxiety over investigations Multiple complications of treatment (e.g., lumpectomy, radiation, or hormone treatment)
Prostate test Increased risk for prostate cancer occurs with age Only pursue if man is at increased risk and is willing to undergo treatment if disease is identified
Controversy persists with regard to effectiveness of treatment, options and usefulness of treatment
Fecal occult blood test (FOBT)
Early detection of a growth that could cause the older adult discomfort and affect quality of life if left untreated
False-positive results may cause additional testing and anxiety for patient
Easily performed with no discomfort to patient FOBT has better predictive value in older adults than in the young adult population
Diet monitoring
Decreasing cholesterol with dieting reduces morbidity and mortality from cardiovascular disease
Restriction in diet may affect quality of life
Restricted diets can result in weight loss and failure to thrive
Focus should be on eating a healthy diet low in fat and high in fruits, vegetables, and grains, which can facilitate maintenance of ideal weight
The impact of severe dietary restrictions is not well substantiated in those older than 90 years
Reducing nicotine
Smoking is associated with increased risk of sudden cardiac death and myocardial infarction
None
Financial incentive May decrease peripheral vascular problems and chronic obstructive pulmonary disease and may prevent further lung disease
Exercise Positive physical health benefits None Positive mental health benefits Decreased fatigue Decreased pain Maintain weight Maintain physical function
Tertiary Preventive Measures Tertiary prevention involves efforts to improve care to avoid later complications. All three areas are relevant to geriatric care. Tertiary level activities aim to prevent progression of symptoms. A good example of tertiary prevention is rehabilitation. Common conditions encountered by older adults that require tertiary care include arthritis, osteoporosis, stroke, Parkinson disease, and urinary or fecal incontinence. For additional information regarding tertiary measures of prevention, see the specific disorders in Part 6.
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The nurse’s role in health promotion and disease prevention Nursing education is a dynamic process in which nurses are involved throughout their career. Knowledge concerning health care issues, practices, and innovations is ever changing. This evolution of science and technology must be tempered by the art of caring. Nursing as a caring profession is in a unique position to make human changes through self-development and the active sharing of information with individuals and the lay community.
Requisite Knowledge The knowledge needed for health promotion and disease prevention activities includes an understanding of basic human needs, human behavior, human growth and development, ethnic and cultural diversity in aging, economic patterns, basics of political action, and, most important, behavior change and the challenges associated with behavior change among adults. Moreover, the nurse must have a comprehensive understanding of health policy and the impact of advocacy in obtaining needed care for older individuals. Specifically, knowing what services are covered under Medicare for older adults and understanding and participating in advocacy for appropriate services is essential to providing optimal nursing care.
Health promotion activities on behalf of older adults are performed at local, regional, or national levels. At the local level, case finding is an initial step toward individualizing the needs unique to the older adults in a single community. Case finding may be initiated through the case managers in acute care facilities, Area Agencies on Aging (AAAs), community centers for older adults, church groups, or the local health department. Additionally, nurses can volunteer for speakers’ bureau opportunities to spread information regarding illness prevention and health promotion (see the Evidence-Based Practice box).
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Evidence-based practice Implementation of a Motivational Intervention for Hypertension Control
Sample/Setting Twenty-two residents living in a senior urban housing site were invited to participate in this study and were encouraged to attend a meet-and-greet session to learn about People Reducing Risk And Improving Strength through Exercise, Diet and Drug Adherence (PRAISEDD). Residents were eligible to participate if they were 65 years or older, could read and write English, recall three words per the Mini-Cog, pass the Evaluation to Sign Consent, had a known history of either hypertension or hyperlipidemia and sedentary behavior (less than 30 minutes daily of a moderate level of physical activity), were taking either antihypertensive or lipid-lowering medications, and managed their own medication administration (after medications were placed in pill boxes or other reminder devices).
Methods The PRAISEDD motivational intervention, which was developed with the use of a social–ecologic model, was implemented. PRAISEDD included education about prevention of cardiovascular disease (CVD) via diet, exercise, and medication adherence, and exercise sessions were provided. Sixty-minute intervention sessions were held three times per week for 12 weeks. During the first week, four advanced practice nurses (APNs) and a pharmacist were involved in delivering education. Remaining weekly sessions included exercise, ongoing education, and motivation and were implemented by a lay exercise trainer (LET) and the PRAISEDD research nurse (PRN). The first week focused on education about CVD, motivational interventions (e.g., verbal encouragement, goal development) and ways to overcome challenges associated with adherence to CVD prevention and maintenance behaviors. At the end of the
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first week, the APNs, the LET, and the PRN assisted each individual in identifying a behavior change goal related to exercise, diet, and medication adherence. The remaining 11 weeks, or 33 sessions, included a combined aerobic exercise (simple marching and dance steps), resistance exercise (BigBand Resistance bands), and a stretching program developed by the LET using guidelines established by the National Institute of Aging. At the end of each session, participants were given help to update exercise, diet, and medication logs and to record blood pressure and weight measurements. Positive reinforcement of cardiovascular prevention behaviors was consistently offered during interactions. The PRN and the LET evaluated the environment in and around the housing facility with regard to exercise opportunities and implemented practical interventions to optimize the environment (e.g., indoor and outdoor walking paths). Evaluation of sidewalks and straight and clear walking areas were identified, and participants were encouraged to walk daily. To optimize access to foods consistent with a heart healthy diet, the PRN evaluated nearby grocery stores for healthy options and, if necessary, asked the manager to offer, for example, a wider selection of cereals that were lower in fat and sugar content.
Findings Session attendance was rigorously monitored, and, on average, 60% of the participants came to each session. Fifty percent of the participants came to more than half of sessions, and 6 individuals (33%) attended more than 90% of sessions. Three individuals (15%) attended 0 sessions. Consistently, 12 to 14 participants attended each session. Reminder calls were needed for approximately 50% of the participants for the first few weeks of the study and then attendance stabilized. The reasons for not attending sessions were illness, work-related conflicts, or family or caregiving responsibilities. Significant decreases in systolic (p = 0.02) and diastolic blood pressure (p = 0.01) and a nonsignificant trend toward improvement in cholesterol intake (p = 0.09) were seen. No changes in time spent in moderate level physical activity, sodium intake, medication adherence, or self-
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efficacy and outcome expectations across all three behaviors were observed.
Implications We were able to implement this study with a group of African American and low-income older adults and demonstrated that participation resulted in improvements in blood pressure. We identified a group champion, and exercise activities continue among the group twice a week. Once a month the nursing research team members volunteer in the facility and provide some health screening, health education, motivation interventions, and our exercise program. Future research is needed to test PRAISEDD using a randomized controlled design with a sufficient sample to detect differences over time. (From Resnick, B., Shaughnessy, M.A., Galik, E., et al. (Sep-Oct, 2009). Pilot testing of the PRAISEDD intervention among African American and low income older adults. Journal of Cardiovascular Nursing,24(5), 352-361.)
Regionally, the nurse may begin to get involved by contacting the state department on aging regarding rules and regulations for care for older adults. Another way to get involved is to attend and interact at state legislature meetings and hearings. Some states have set aside an annual nurse lobby day in the state capitol. Meetings with legislators may provide an opportunity for the nurse to express opinions related to health care issues.
At the national level, action may begin with personal education involving public policy. This education may include (1) becoming aware of current and changing social policy, (2) studying the facts and the opinions of leaders on all sides of an issue, (3) speaking to civic groups, political party groups, and senior citizen groups, (4) testifying before the legislature as an advocate for healthy aging, (5) being informed on the issues and knowing social and political hot buttons, (6) putting the best foot forward with lobbying, (7) studying issues and techniques of negotiation and compromise, and (8) actively supporting the role of the advanced practice nurse working with physicians as a primary provider of health care.
Assessment
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When assessing an individual, the nurse must look at potential health hazards to identify risk factors for illness or injury. Contributing risk factors include habits, lifestyle patterns, personal and family medical histories, and environmental conditions. An example of an environmental risk factor is the lack of access to opportunities to engage in enjoyable physical activity; other examples include the physical presence of clutter, poor lighting, and poor footwear, which put the older person at risk of falling.
Assessment for health promotion and disease prevention begins with collecting data about the person. The assessment must be developed in a comprehensive manner (see Chapter 4). Subjective data are obtained through the health history. Objective data are obtained through a complete physical examination. To obtain a complete, nursing-focused assessment, the nurse must have an understanding of functional health patterns of aging. Eleven of the basic functional health patterns of older adults that are important to assess are as follows:
1. Self-perception or self-concept pattern
2. Roles or relationships pattern
3. Health perception or health management pattern
4. Nutritional or metabolic pattern
5. Coping or stress-tolerance pattern
6. Cognitive or perceptual pattern
7. Value or belief pattern
8. Activity or exercise pattern
9. Rest or sleep pattern
10. Sexuality or reproductive pattern
11. Elimination pattern
The following discussion expands on these identified functional health patterns, which are based on Gordon’s typology of 11 functional health patterns (Gordon, 2009), which are also available in Spanish. Each pattern presented includes a description and subjective and objective assessments. Within each of these patterns,
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the nurse needs to identify the older adult’s knowledge of health promotion, ability to manage health-promoting activities, and value given to activities of health promotion.
Self-Perception or Self-Concept Pattern Description: This pattern encompasses a sense of personal identity;
body language, attitudes, and view of self in cognitive, physical, and affective realms; and expressions of sense of worth and emotional state. Perceptions of self should be explored with direct questions, asked with sensitivity. Emotional patterns may be identified during this exploration of perceptual patterns.
Subjective: Determine the patient’s feelings about his or her competencies and limitations, particularly with regard to preventive health behaviors and behavior change, withdrawal from previous activities, self-destructive actions, excessive grieving, and increased dependency on others. Assess changes in eating, sleeping, and physical activity patterns. Explore the person’s perception of his or her identity, self-worth, self- perception, body image, abilities, successes, and failures.
Objective: Identify verbal and nonverbal cues related to the above subjective data. Verbal cues elicit feelings about self (strengths and limitations), and nonverbal cues include a change in personal appearance. Using tools for assessing anxiety and depression is helpful.
Roles or Relationships Pattern Description: This pattern encompasses the achievement of expected
developmental tasks. Basic needs for communication and interactions with other people, as well as meaningful communications and satisfaction in relationships with others, are examined.
Subjective: Determine family structure, history of relationships, and social interactions with friends and acquaintances. Focus on health behavior beliefs and activities among his or her social network. Assess the perceived reasons for unsatisfactory
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relationships, and identify attempts to change patterns and outcomes.
Objective: Examine the family or friend dynamics of interdependent, dependent, and independent practices among members.
Health Perception or Health Management Pattern Description: This pattern encompasses the perceived level of health
and current management of any health problems. Determine health maintenance behaviors and the importance the older adult places on these behaviors.
Subjective: Determine the level of understanding of any treatments or therapy required for management of health deficits or activities, including the possible sources of reimbursement and concerns about costs; include assessment of performance of activities of daily living (ADLs), instrumental activities of daily living (IADLs), or both.
Objective: Observe for cues that indicate effective management of deficits, including the physical environment in which the patient resides. Assessment should include information about prior health promotion activities (e.g., mammography, vaccinations) and management during sickness and wellness. Focus specifically on barriers to engaging in these behaviors and what has prevented them from participating in the past.
Nutritional or Metabolic Pattern Description: This pattern encompasses evaluation of dietary and
other nutrition-related indicators.
Subjective: Determine the older adult’s description, patterns, and perception of food and fluid intake and adequacy for maintaining a healthy body mass index. It may not be realistic to obtain an accurate 24-hour food and fluid recall; however, the nurse could possibly obtain information on how meals are prepared, who prepares them, and approximately how much is eaten during a
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typical day. Identify any recent weight loss or gain, and identify food intolerances, fluid intake, and gastrointestinal symptoms. Consider also access to grocery stores and restaurants and opportunities for obtaining appropriate heart healthy food sources.
Objective: Observe general appearance and various body system indicators of nutritional status. Note height, weight, and fit of clothes. If possible, observe the older adult eating a meal.
Coping or Stress-Tolerance Pattern Description: This pattern encompasses the patient’s reserve and
capacity to resist challenges to self-integrity and his or her ability to manage difficult situations. The ability to successfully tolerate stress through personal coping behaviors is important to incorporate into any health promotion plan. Of equal importance is the identification of the person’s support systems.
Subjective: Assess ways to handle big and little problems that occur in everyday life. Determine the past and current amount of stress present in the older adult’s life. Discuss any recent losses and the methods used to deal with those specific situations. Identify any stress-reducing activities that are practiced and the usual results obtained.
Objective: Observe for the use of coping skills and stress-reducing techniques, and note their effectiveness. Consider evidence of health-promoting options for stress reduction (e.g., exercise).
Cognitive or Perceptual Pattern Description: This pattern encompasses self-management of pain, the
presence of communication difficulties, and deficits in sensory function. Modes include vision, hearing, taste, smell, touch, and compensatory assistive devices used when a deficit exists.
Subjective: Inquire about difficulties with sensory function and communication, and assess for any cognitive changes.
Objective: Assess usual patterns of communication, and note the
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patient’s ability to comprehend. Also note the ability to read, hear the spoken word, smell, and distinguish tactile sensations and tastes. Simple screening may be done using the Mini-Cog (Borson et al., 2003).
Value or Belief Pattern Description: This pattern encompasses elements of spiritual well-
being that the older adult perceives as important for a satisfactory daily living experience and the philosophical system that helps him or her function within society.
Subjective: Identify the older adult’s values and beliefs about health and health promotion activities. Explore also for spirituality, and note any special emphasis on how this influences health promotion behaviors (e.g., “God will take care of health promotion and disease prevention.”).
Objective: Determine what is important to the older adult’s life with regard to overall goals (e.g., long life versus quality of life) and to support coping strategies. Note any references made to spirituality or religious affiliation and practices, as well as choices and decisions that are determined by values, beliefs, and spiritual practices (see Evidence-Based Practice box).
Evidence-based practice Spirituality and the Management of Chronic Conditions Background Estimates show that older Americans will compose 20% of the U.S. population by the year 2030. The incidence rates of chronic illnesses increase with age. An expectation of self-care management exists for those with a chronic health issue. Social cognitive theory holds that a person’s beliefs coupled to environmental factors will affect their self-efficacy to perform
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self-care management. This study explored the issue of spirituality as a means for older adults to manage their chronic conditions.
Sample/Setting A total of 88 participants were enrolled from the Medicare Enrollment file for Allegheny County in Pennsylvania via a quota sampling technique.
Methods This exploratory study consisted of four separate interviews conducted with each participant over the course of a 36-month period of time to gather the qualitative data. Audiotapes of the interviews were transcribed verbatim, and thematic content analysis was employed to evaluate items that focused on how spirituality affected self-care practices related to chronic illnesses.
Findings This study identified differences in the ways older white and African Americans use spirituality in the self-care for their chronic conditions. African Americans more often than their white counterparts in the study indicated their belief in God the Healer versus God working through health care professionals, medications, or both. Results of this study also demonstrated a pattern of attribution of the participants’ self-care practices to their spirituality.
Implications The study validated the links between spirituality and self-care management of a chronic illness. Nurses caring for those with chronic health condition need to understand the importance of the mind, body, and spirit connection to overall health and well- being. (From Harvey, I.S. & Silverman, M. (2007). The role of spirituality in the self- management of chronic illness among older African and Whites. Journal of Cross Cultural Gerontology 22, 205.)
Activity or Exercise Pattern
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Description: This pattern encompasses information related to health promotion that encourages the older adult to achieve the recommended 30 minutes daily of physical activity on most days of the week.
Subjective: Screen for safety related to exercise and physical activity, using screening measures such as the Exercise Assessment and Screening for You (EASY) (EASY Screening Group, 2007; Resnick et al., 2008; Sherrington, Tiedemann, Fairhall, Close & Lord, 2011). The EASY determines whether it is safe for an individual to immediately start an exercise program and, depending on comorbid conditions, matches the individual with a useful exercise program that can be printed out from the Web, thus providing him or her with a hard copy to use. In addition, assess daily routines and activities, including patterns of exercise, leisure habits, recreation, and hobbies; and inquire about any limitations or changes in these patterns. Identify IADLs that are practiced with or without difficulty. Inquire about the older adult’s typical day. Assess for pain, fatigue, and fear of falling and fall potential, and conduct a fall history.
Objective: Obtain vital signs and conduct cardiopulmonary and musculoskeletal system assessments. Assess self-care ability by observing and asking the patient about self-care activities such as bathing, dressing, toileting, and feeding, if possible. Note the use of adaptive tools or equipment. Complete the EASY with the older individual, and provide appropriate exercise resources.
Rest or Sleep Pattern Description: This pattern encompasses the sleep and rest patterns
over a 24-hour period and their effect on function. Assess rest and sleep patterns of the older adult for usual pacing of activities with consistent energy reserves that do not require immediate rest.
Subjective: Assess usual sleep patterns, including bedtime and arousal time, quality of sleep, sleep environment, and distribution of sleep hours within a 24-hour period. Inquire about episodes of insomnia and deterrents to sleep such as pain;
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anxiety; depression; use of pharmacologic agents such as caffeine, over-the-counter agents that may cause arousal, alcohol, and prescribed medications such as some treatments for depression; lack of exercise; and inappropriate sleep hygiene. Identify the time and circumstance for regular rest periods. Record any activities associated with a rest period.
Objective: Have the patient keep a sleep diary that includes naps and rest periods. If possible, observe daily activities and note the effects of sleep disturbance on functional ability.
Sexuality or Reproductive Pattern Description: This pattern encompasses the older adult’s behavioral
expressions of sexual identity.
Subjective: Assess the patient’s satisfaction or dissatisfaction with current circumstances related to sexual function and intimacy, including perceived satisfaction or dissatisfaction with sexuality or sexual experiences.
Objective: Discuss any current sexual relationship. When none is present, elicit the meaning this has for the patient’s overall emotional and physical well-being.
Elimination Pattern Description: This pattern encompasses bowel and bladder excretory
functions.
Subjective: Assess lifelong elimination habits and excretory self-care routines. Inquire about the patient’s perception of normal bowel and bladder functions, and explore specifically for recent changes in usual bowel and bladder functions. Assess for the impact of elimination patterns and the ability to control elimination on quality of life and on participation in health promotion activities such as exercise.
Objective: Perform abdominal and rectal examinations; external genitalia and pelvic examinations may be indicated. Note daily intake of food, particularly amount of dietary fiber, and assess
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total fluid intake over a 24-hour period. A nurse’s approach to completing thorough functional health
assessments of older adults must be positive and reassuring. Permitting older adults to be active participants in this process is important to the success of gaining insight into their needs.
Planning The role of nursing in promoting health among older adults relies on organized planning. The planning may begin by exploring older adults’ personal ideas and beliefs concerning health needs. Reading current literature provided by the U.S. Department of Health and Human Services, the National Institutes of Health, the National Institute on Aging, or the CDC will help the nurse keep abreast of the latest specific health promotion recommendations. Internet addresses for these and other information centers are provided at the end of this chapter.
Being well versed on current health policy information will safeguard patient rights. The nurse is then able to inform older adults of significant policy changes as soon as they are made at the highest (federal) level. Often, the dissemination of health policy is slow, and news reaches the recipient long after the fact. When policies are retroactive or are to be enforced on a certain date, passing the information on to older adults may be crucial to their health and well-being. Moreover, it will help establish and maintain a trusting relationship. Encouraging an older adult to engage in screening activities that are not covered by Medicare, for example, may cause a financial hardship for the older individual and may decrease his or her level of trust in the nurse.
Planning involves understanding and use of the social–ecologic model, as well as behavior change and behavior change theories such as the theory of self-efficacy. The theory of self-efficacy states that the stronger the individual’s belief that he or she can perform a behavior and the stronger his or her belief in a positive benefit to performing the behavior, the more likely he or she is to engage in the given activity. Recommendations to facilitate behavior change are shown in Table 8-5.
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Table 8-5 Interventions to motivate individuals to change behavior using a social–ecologic model
Component Description Example of Interventions Intrapersonal Demographics Optimization of health status (e.g., treatment of
anemia) Comorbidities Ice, heat, medication management to decrease
pain Psychosocial factors (e.g., mood, motivation, resilience), cognitive status, pain, fatigue, fear
Interpersonal Social supports Verbal encouragement Use of verbal encouragement to strengthen self-
efficacy and outcome expectations Goal setting Goal identification (e.g., losing weight, being able
to walk the dog) Rewards Exposure to others exercising similarly Role models
Environment Physical environment (indoor and outdoor) Clear walking paths Accessible healthy food choices or restaurants
Policy Current coronary vascular disease prevention guidelines Institutional policies and procedures National laws
Use of guidelines in educational interventions to encourage adherence
Implementation Implementation may begin by adopting a proactive stance toward an action plan for health promotion of the older individual. Seeking activities, locations, and means for disseminating health promotion information to a group of older adults is an example of implementing a proactive stance. Proactive activities may have benefits as well as liabilities. The benefits include an early approach to a problem that has not been acted on previously. Annual health promotion screenings may be incorporated into programs that provide vaccinations for older adults and may include screenings for bowel cancer, diabetes, osteoporosis, and macular degeneration, as appropriate. Likewise, monthly health talks provided in senior centers, senior housing sites, or continuing care retirement communities may be a useful way to repeatedly advocate and educate about health promotion activities such as exercise, prevention of osteoporosis, or safe medication use. Working one- on-one with older individuals during outpatient office visits to promote preventive behaviors and health promotion activities is strongly supported through programs such as Pay for Performance (Hoangman et al., 2008). Medicare sponsors quit smoking programs at local levels with some states support. However, changes may
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occur with the Affordable Care Act (ACA) in place. Check locally for programs in a specific location within the United States.
Evaluation Evaluation involves determining the effectiveness of your care plan. Was the patient able to achieve the mutually established goals? The nurse should consider why these goals were or were not achieved and negotiate with the patient to establish appropriate and realistic revised goals and realistic steps to achieve them.
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Supporting empowerment of older adults Nurses can provide a bridge between the theory of health promotion and the implementation of health promotion, health protection, and preventive services. The active participation of nurses in encouraging older adults to set health promotion goals aimed at maintaining the best possible health, function, and quality of life throughout the rest of their life span is essential. Nurses can participate in collaborative interactions with other health care professionals and organizations such as the American Geriatrics Society to establish guidelines, write papers, and influence policy (see the list of websites at the end of this chapter).
Learning about community resources and local, state, and federal programs that can provide information or services to older adults and then disseminating the information to older adults in a variety of settings are legitimate nursing roles. Health promotion programs and activities may be provided to individuals, small groups, and larger groups where older adults congregate. Many retirement centers, assisted living facilities, church groups and organizations, Salvation Army centers, and senior citizen centers look for speakers on a variety of health subjects. In most cases, the managers of these facilities welcome nursing students or registered nurse volunteers to present health promotion or disease prevention programs on a regular basis. Empowering older adults requires initiative, organization, and knowledge of the major areas of health promotion relevant to this population.
Nurses should ideally use an individualized approach to health promotion when working with older individuals. This approach focuses on providing appropriate education both formally in health promotion classes and informally during health care visits. The education should provide current recommendations for health promotion activities (e.g., when to get a mammogram) and help older patients decide what health behaviors they want to engage in. This type of individualized approach has the advantage of being
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cost effective in that screening is not performed if the individual does not have any intention of acting on the results; in addition, individualized health promotion increases adherence to positive health behaviors such as smoking cessation and exercise.
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Summary This chapter discussed the practices of health promotion, health protection, and disease prevention in the older adult population. In addition to the use of a social–ecologic model, several models of interpersonal health promotion activities were presented. The first is a community change model identified by the acronym ONPRIME. The second, the Health Belief Model, is an example of a model used to determine the likelihood of a person’s participation in a health promotion program. The third model is the PRECEDE/PROCEED Model. This multidisciplinary model is aimed at communities. The Health Promotion Model presumes a collaborative effort by the participant and the health care professionals involved.
Barriers to participation in health promotion activities are complex issues involving both provider and participant. Reluctance on the part of the health care professional is compounded by the lack of coordination of preventive services. Barriers to health promotion and disease prevention programs by older adults were addressed in terms of past health care experiences, health beliefs, and factors not related to health, including a lack of transportation and financial burdens. The issue of ethnic and cultural diversity and the resulting ineffectual coordination of services were discussed. The goals identified in the Healthy People 2020 initiative in regard to health protection were presented.
Primary, secondary, tertiary, and quaternary measures of disease prevention were discussed. Primary prevention includes immunizations and counseling programs. Prevention counseling is aimed at healthful living through smoking cessation, limitation of alcohol consumption, participation in regular physical activity, weight management and adherence to heart healthy diets, bone health, and stress management. Other areas of concern include safety issues around the home and safe and appropriate medication use. Secondary prevention focuses on detection and early treatment of disease. Tertiary prevention involves eliminating or slowing the progression of symptoms, whereas quaternary prevention deals
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with limiting disabilities caused by chronic conditions. Chronic illnesses do not need to be detrimental to functional abilities.
The nurse’s role in health promotion and protection or prevention of disease may be based on a framework of functional health patterns. Data about these health patterns are best obtained when the nurse completes a comprehensive nursing assessment of each of the areas of function using positive and reassuring communication.
The best results are achieved when the nursing process is used to assess, to plan action through goal setting, and to implement a plan for health promotion, behavior change related to health care activities, or disease prevention followed by evaluation. Suggested health promotion activities that offer several levels of commitment are available to nurses who wish to become involved in social policy or political action. Involvement in a proactive movement to increased health promotion is possible at local, regional, and national levels. The use of an individualized approach and the empowerment of older adults to make their own health care decisions will help them achieve their optimal level of health, function, and quality of life.
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Key points • Health promotion, health protection, and disease prevention will
continue to be a national goal with the Healthy People 2020 initiative.
• Models of health promotion are available to guide the change process in establishing a local, regional, or national effort.
• Psychosocial factors, health beliefs, environmental factors, transportation, finance, ethnic and cultural influences, and a sense of futility may be barriers to health promotion.
• Health protection targets five areas: (1) unintentional injuries, (2) occupational health and safety, (3) environmental issues, (4) food and drug safety, and (5) oral health.
• Primary prevention focuses on immunizations and health screening activities.
• Secondary prevention focuses on detection of occult disease.
• Tertiary prevention focuses on preventing the progression of symptoms while facilitating rehabilitation.
• Quaternary prevention deals with limiting disability caused by chronic disease.
• The nurse’s role in health promotion begins with a complete health assessment using the functional health patterns framework; this should incorporate an individualized approach for each patient.
• Using the nursing process in health promotion activities provides a sound foundation for success.
• Involvement in health promotion activities may be at the local, regional, and national levels.
• Using an individualized approach and empowering older adults to determine the level of health promotion and primary, secondary, tertiary, and quaternary prevention activities will help them achieve their optimal quality of life.
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Critical thinking exercises 1. A 74-year-old woman brings her 95-year-old mother into the ambulatory clinic. The mother is deaf and motions for her daughter to talk for her. The daughter gives an account of the mother’s health condition. While the health history of the mother is being given, the nurse notices several skin lesions on the daughter’s lower arms. The daughter is overweight, seems out of breath, and is perspiring heavily although the room temperature is 76 ° F. What actions would you suggest the nurse take with regard to the daughter? If an action is taken, when is it the appropriate time to do so?
2. Several nurses have volunteered to give flu shots to older adults at a senior center. When the line to receive the injections slows down, one nurse notices a table of four older women playing cards. None of the women has approached the flu shot registration table. What actions, if any, are appropriate for the volunteer nurses in this situation? Does the fact that the nurses are volunteers change any potential course of action?
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Websites AARP. http://www.aarp.org
International Counsel on Active Aging. http://www.icaa.cc
Administration on Aging. http://www.aoa.gov
Alliance for Aging Research. http://www.agingresearch.org
American Geriatrics Society. http://www.Americangeriatrics.org/products/positionpapers/
American Society on Aging. http://www.asaging.org
BenefitsCheckUp. http://www.benefitscheckup.org
Centers for Disease Control and Prevention. http://www.cdc.gov
Exercise Assessment and Screening for You Tool. http://www.easyforyou.info
Healthy People 2010 documents online. http://www.health.gov/healthypeople/ or call (800) 367– 4725
Information on Wellness Activities. http://www.wellmedia.com
National Council on the Aging. http://www.ncoa.org
National Health Information Center. http://www.health.gov/nhic/
National Institute on Aging. http://www.nih.gov/nia/
National Institutes of Health. http://www.nih.gov
U.S. Department of Health and Human Services. http://www.os.dhhs.gov
* Previous author: Barbara Resnick, PhD, CRNP, FAAN, FAANP.
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C H A P T E R 9
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Health care delivery settings and older adults Marie H. Thomas, RN, PhD, FNP-C, CNE
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe acute care hospital use patterns in the older adult population.
2. Describe a functional model of nursing care.
3. Identify risks associated with hospitalization of older adults.
4. Identify ways to modify the physical and social environment to improve care for hospitalized older adults.
5. Identify special considerations in caring for critically ill older adults and those suffering from trauma.
6. Describe two nursing interventions for each of the three conditions that make up the geriatric triad.
7. List adaptations that can be made to facilitate learning in older adults.
8. Describe a profile of a “typical” noninstitutionalized older adult, including common diagnoses and functional limitations.
9. Distinguish the categories and types of home care organizations in existence.
10. Explain the benefits of home care.
11. Analyze the effect of the recent changes instituted by Medicare on home health agencies and home health clients.
12. Discuss the philosophy of hospice care and how it differs from traditional home health care.
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13. List five common factors associated with institutionalization.
14. Identify the differences between the medical and psychosocial models of care for institutional long-term care.
15. Summarize key aspects of resident rights as they relate to the nursing facility.
16. List assessment components included in the minimum data set of the Resident Assessment Instrument.
17. Describe common clinical management programs in the nursing facility for skin problems, incontinence, nutritional problems, infection control, and mental health.
18. Differentiate types of nursing care delivery systems found in the nursing facility.
19. Describe assisted living, special care units, and subacute care units as specialty care settings of the nursing facility.
http://evolve.elsevier.com/Meiner/gerontologic
This chapter focuses on care of the older adult in acute care, home, community health, and long-term care settings. Among subsets of these delivery settings are housing options, hospice care, and delivery systems such as functional nursing, team nursing, and primary team nursing. Long-term care settings may be categorized on a continuum, according to the care and services required by the residents served.
With the steady growth in the number of older adults in the United States, it is now estimated that most of a nurse’s career is spent working with older adults, and almost all nurses will care for older adults in the acute care setting at some time. Older adults are a diverse, heterogeneous group in terms of age, life experiences, the aging process, health habits, attitudes, and response to illnesses. Nurses need to have specialized knowledge, skills, and abilities to care for older adults during hospitalization and beyond.
The discussion of home and community nursing for older adults includes topics regarding health care needs of community-living older adults, community-based services, and the role of home
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health agencies and hospice nurses in community-based care for this population. The nursing facility is the dominant setting in which long-term care is provided for people who require regular or continuous skilled nursing care. In this chapter, long-term care will refer to the nursing facility. Each of these settings will be presented in sequence.
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Characteristics of older adults in acute care The older-than-85 group is the fastest growing segment of the U.S. population. The most common diagnosis-related groups (DRGs) in hospitalized older adults (older than 85) include those with heart failure, pneumonia, urinary tract infections, cerebrovascular disorders, digestive disorders, gastrointestinal hemorrhages, nutritional and metabolic disorders, rehabilitation, and renal failure (National Center for Health Statistics, 2013). The major causes of death in those older than 65 are diabetes mellitus; heart disease, including congestive heart failure; cancer; hypertension, stroke; chronic lower respiratory disease; accidents; pneumonia; and influenza (National Center for Health Statistics, 2013).
Chronic conditions refer to chronic illness and impairments, and an individual’s level of disability is typically categorized by the amount of assistance required in both basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Arthritis, diabetes mellitus, hypertension, and heart disease are the most prevalent chronic diseases in older adults and are the leading causes of disability. The exacerbation of a chronic illness may precipitate hospitalization, and complications may profoundly affect the progress of a hospitalized patient. Because the acute event for which an older patient is hospitalized is frequently superimposed on a chronic condition or disease, this older age group is increasingly influencing the acute care environment and the professional caregiver skills required in this setting.
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Characteristics of the acute care environment It is a challenge for caregivers to attend to the diverse needs of each individual admitted to the acute care setting. The older adult is not likely to be admitted to the hospital until a high level of acuity or complications exists. The intensity of care required for the typically emergent condition for which an older adult was admitted, compounded by the normal aging process, chronic illness, and impaired functional status, requires astute care planning and case management on the part of the health care team. The health care team’s success in providing this care is influenced by the philosophy of care, awareness of the risks of hospitalization, and safety features of the acute care environment.
Philosophy of Care Rapidly rising costs and concerns over quality in acute care have fostered a climate in which the value and efficacy of hospitalization have come under increasing scrutiny. With an increasing number of aged hospitalized patients, the technologic and mechanistic orientation toward care is being recognized as obscuring those activities aimed at improving function of the chronically, physically, and mentally disabled. Effective caregiving practices enable older persons to maintain or improve their independence and to return to their preferred setting at discharge. However, in the hospital setting health care professionals may become so involved in addressing the acute condition that they fail to appreciate the underlying problems and how these too influence the patient’s health and recovery.
The hospital is a highly technologic system that is in a good position to address both chronic and acute problems. The focus needs to be on not only the restoration of health but also the promotion and preservation of health. The value placed on technology fosters a task orientation that may detract from the holistic focus required for the care of older adults. Acute care
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centers have traditionally provided care within a medical model whose focus is on diagnosis and treatment rather than providing care within a functional model, which more broadly integrates all aspects of care. With older adults, particularly those hospitalized because of an exacerbation of a chronic illness, focusing on a functional model helps address concerns related to both their medical and functional stability. The biomedical model practiced in the hospital needs to be expanded to include this functional model, in which the main goal may not be curing the disease but managing the disease, with a focus on self-care and symptom management strategies.
Risks of Hospitalization Adverse Drug Reactions Polypharmacy (defined as an inappropriate number of medications) is a common cause of iatrogenic illness among patients over 65 years of age and is associated with multimorbidity in older adult patients (Heppner et al., 2012) Hospitalized patients are often admitted with a large number of prescribed, over-the-counter, and homeopathic drugs in their bodies; when given additional medications during their hospital stay, they have a heightened risk for an adverse drug reaction.
Conversely, adverse drug reactions frequently precipitate hospitalizations and, although often unreported, are among the most common iatrogenic events in the acute care setting. The hospital staff needs to get an accurate drug history of a patient, be aware of pharmacokinetic and pharmacodynamic changes related to aging, and have a working understanding of drug–disease, drug–drug, and drug–food interactions in older adults (De Rui, Manzato, Sarti, & Sergi, 2011). Nurses should be particularly aware of drugs that may be high risk when used in older adults and carefully monitor patients taking them for signs and symptoms of toxicity (De Rui et al., 2011).
Falls Studies indicate that up to 79% of all adverse inpatient incidents are
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related to falls, and patients age 65 or older experience the most falls; approximately 10% fall more than once during their hospital stay, usually in their hospital rooms. Risk factors for hospital falls include both intrinsic and extrinsic factors. Intrinsic factors include age-related physiologic changes and diseases, as well as medications that affect cognition and balance. Extrinsic factors include environmental hazards such as cluttered hospital rooms, wheels on beds and chairs, and beds higher than what an older adult usually has at home. The hospital is sometimes a dangerous and foreign place for inpatients because of unfamiliarity and because of changes in the patient’s medical condition (Rowe, 2013; The Joint Commission, 2013) emphasized the need to improve patient fall risk by improving the environment of patient rooms, staff abilities, and interventions (see Chapter 12).
Infection Older adults are generally more vulnerable to infections because of physiologic changes in the immune system and underlying chronic disease (see Chapter 15). The health care–associated infection (HCAI) rate for hospitalized patients overall is approximately 5%. Of these 65% occur in the older patient population (Merck Manual of Geriatrics, 2013). This may be a low estimate because older adults with infections may have an atypical presentation, making infections more difficult to diagnose. Urinary tract infections (UTIs) occur frequently, although bacteriuria in an older adult is often asymptomatic. Subclinical infection and inflammation may occur with presenting symptoms such as acute confusion, functional capacity deterioration, anorexia, or nausea rather than the classic symptoms of fever and dysuria. Increased instrumentation and manipulation and decreased host immune mechanisms contribute to the increased risk of older adult patients developing sepsis originating from the urinary tract (Hubbard & Woodhouse, 2010). Hospital-acquired pneumonia is the second most common HCAI, symptoms in older adults are often mental changes or confusion making the diagnosis more challenging (Dougdale, 2012).
Other common sites of infection in hospitalized older adults include the skin, soft tissues, wounds, the gastrointestinal tract, and
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blood. Older adults are at increased risk for colonization and infection with antibiotic-resistant strains of organisms (Merck Manual of Geriatrics, 2013) such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). Control of the spread of resistant strains of organisms continues to be a problem in institutional settings. Adhering to basic principles of infection control is critical for nurses. It is essential to comply with proper hand washing, disinfection of the environment, and appropriate precautions when caring for patients infected or colonized with resistant strains.
Hazards of Immobility Once older adults are hospitalized, immobilization through enforced bed rest or restraint often results in functional disability. Immobilized patients are vulnerable to rapid loss of muscle strength, reductions in orthostatic competence, urinary incontinence or retention, fecal impaction, atelectasis and pneumonia, acute confusion, depression, skin breakdown, and many other complications (Heppner et al., 2012). The occurrence of iatrogenic illnesses often represents a vicious cycle, referred to as the cascade effect, in which one problem increases the person’s vulnerability to another one. Gerontologic nurses must be leaders in advocating more appropriate care and treatment of hospitalized older adults to prevent or at least reduce the occurrence of iatrogenic illness.
Safety Features Older adults have a decreased ability to negotiate within and adapt to an unfamiliar environment. Multiple stimuli such as contact with many departments and personnel or multiple room changes may prompt confusion and exhaustion and result in the loss of crucial personal items necessary for maximum functioning such as hearing aids, prostheses, dentures, and eyeglasses. The environment may be modified in many ways for older adult patients (Box 9-1). Some modifications require additional resources, but some changes require minimum creativity on the part of the nursing staff.
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Box 9-1
Environmental modifications • Stabilized furnishings (e.g., removing or locking wheels)
• “Blue” fluorescent lighting
• Night-lights
• Extra lighting in bathrooms
• Consistent lighting intensity
• Light switches that glow
• Solid-color designs for floors (i.e., avoidance of patterns)
• Nonskid, nonglare floor wax
• Carpeting with uncut, low pile and padding underneath
• Contrasting color to identify boundaries between floor and wall
• Nonglossy wall surfaces
• Polarized window glass to decrease glare
• Nonglare glass over pictures; avoidance of abstract designs
• Rounded handrails for easy grasp in all areas where walking occurs; use of high-contrast colors in these areas
• Levers for doors and dressers instead of knobs
• Large-numbered, white-on-black (or black-on-white) clocks with nonglare glass
• Large-print calendars within patient’s line of vision
• Telephones with large numbers
• Cases for glasses and prostheses attached to bedside and within reach
• Amplified and hearing aid-compatible phones
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• Pocket talker
• Beds that lower to a height that enables patient to sit on the edge with both feet on the floor
• Use of no side rails or half-rails to deter climbing over rails
• Bed or chair exit alarms
• Chairs with armrests
• Portable elevated toilet seats
• Grab bars in shower and around toilet Modified from Morath, J., Fulton, J. (1998). Acute care of elders. In Burnside I (Ed): Nursing and the aged, 3rd ed. New York: McGraw-Hill; Tideiksaar, R. (1993). Environmental modifications. In Tideiksaar R (Ed): Falls in older persons: prevention and management in hospitals and nursing homes. Boulder, CO: Tactilitics.
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Nursing in the acute care setting The nursing staff in the hospital provides the lion’s share of the health care delivered there. Nurses are considered an integral part of the health care team and frequently provide leadership to this team. Those with nursing skills can be instrumental in ensuring that high-quality, cost-effective health care is provided to hospitalized older patients; they can also help equip older patients and their families with the necessary self-care skills at discharge. The quality of the nursing care provided is influenced by the philosophy of nursing, the nursing-specific competency and expertise of the nursing staff, and the various aspects of the nursing role that are implemented in acute care.
Nursing-Specific Competency and Expertise Developing nursing competency helps the nursing staff customize the care provided to patients age 65 or older. It enhances the nurse’s job performance and the quality of care delivered. The Joint Commission (2012) requires documentation that all staff members (e.g., nurses, unlicensed assistive personnel, phlebotomists, and physical therapists) have a documented competency assessment that includes the special needs and behaviors of the specific patient age groups (e.g., geriatric, pediatric, and adolescent) that are being cared for in the assigned area. The Joint Commission further requires that this be done on initial employment and then periodically reviewed.
A priority at the beginning of every hospitalization is the assessment of the older adult’s baseline functional status so that an individual care plan can be developed within the acute care environment (The Joint Commission, 2012). Systematic functional assessment in the acute care setting also provides a benchmark of a patient’s progress as he or she moves along the continuum of care, and it promotes systematic communication of the patient’s health status between health care settings (The Joint Commission, 2012). Assessment in the acute care setting includes recognition that older
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adults are in an unfamiliar environment, which is not conducive to optimal functioning at a time when reserves and homeostatic needs are compromised by acute illness. Many common assessment tools for ADLs and mental status assess areas of function that may not be easily evaluated at the time of admission or may not be significant at that time (i.e., orientation when a calendar is not present in the room and when daily routines are disrupted). The primary goal of the acute care nurse is to maximize the older patient’s independence by enhancing function. Functional strengths and weaknesses need to be identified. The care plan must provide for interventions that build on identified strengths and help the patient overcome identified weaknesses (see Chapter 4). Function integrates all aspects of the patient’s condition; any change in functional status in an older adult should be interpreted as a classic sign of illness or as a complication of their illness. By knowing an older patient’s baseline function, the nurse can assess new-onset signs or symptoms before they trigger a downward spiral of dependency and permanent impairment.
Nursing expertise is needed in the acute care setting to guide the staff in understanding the unique needs of older patients and enhancing their skill in managing common geriatric syndromes (Hartford Institute for Geriatric Nursing, 2008; St. Pierre & Twibell, 2012). The advanced practice nurse functions in the role of clinician, educator, consultant, and researcher. A growing number of acute care settings are recruiting and hiring advanced practice nurses. Nurse practitioners are also being employed to assist with the day- to-day assessment and management of patients in the acute care setting. Some studies demonstrate a significant decrease in the length of stay when patients are co-managed by a nurse practitioner and an attending physician (Moote, Krsek, Kleinpell, & Todd, 2011). The advanced practice nurse can be instrumental in developing and implementing protocols for managing common geriatric syndromes such as those defined in the geriatric triad.
The geriatric triad includes falls, changes in cognitive status, and incontinence (Chang, Tsai, Chen, & Liu, 2010). These three conditions need special attention during hospitalization. Falls may be a classic sign of illness for older adults; an older adult in the
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acute care setting is often at high risk for falls and consequent injuries. A strange environment, confusion, medications, immobility, urinary urgency, and age-related sensory changes all contribute to this increased risk. Falls resulting in injury may be minimized by gait training and strengthening exercises, appropriate nutrition, careful monitoring of medications, supervised toileting, environmental modifications, proper footwear, and control of orthostatic hypotension (Tinetti & Kumar, 2010). Bed and leg alarms to provide warnings of patient movement, thereby minimizing falls, are being used in many institutions (see Chapter 12) (see Emergency treatment box).
Emergency treatment
Falls • Reassure patient and family.
• Examine for presence of injury.
• Assess for injury and call attending physician to assess physical injury.
• Advocate for adequate assessment designed to identify covert or symptomless consequences of the fall (e.g., computed tomography, radiography).
• Explore the cause of the fall with the health care team by reviewing the patient’s history, including any history of falls and any intrinsic or extrinsic factors that may be related to the fall.
• Document the incident and its precipitating factors, along with a plan to prevent future falls.
• Implement a fall prevention program.
Critical Care and Trauma Care
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Older adults admitted to the hospital are often critically ill, and effective nursing care requires an understanding of their impaired homeostatic mechanisms, the diminished reserve capacity of their body systems, and their impaired immune response. The homeostatic mechanisms are altered with age so that the abilities to generate a fever, to respond to alterations in tissue integrity, and to sense pain may be very different from those manifested by young or middle-age adults in critical care (Merck Manual of Geriatrics, 2013). The atypical and subtle nature of disease presentation becomes even more important in the intensive care unit (ICU), where the patient is often less able to articulate discomfort and new problems may arise quickly. The nurse must be aware that the most common presenting symptom of sepsis in older patients is acute mental status change (Tucker, Clark, & Abraham, 2013). Astute observation for delirium is essential in aggressively managing its underlying cause (see Chapter 27). Delirium in this setting was referred to in the past as “ICU psychosis” and was thought to be caused by sensory overload or sensory deprivation. The causes are now recognized as multifactorial and, in this environment, are often secondary to acute illness, drugs, and the environment. Critically ill individuals are at particular risk for delirium because of impaired physical and mental defenses (Monkhouse, 2013) (Table 9-1).
Table 9-1 Changes in Cognitive Status
Two additional issues for the critical care of older adults are prevention of nutritional compromise and recognition of adverse drug reactions. Up to 65% of hospitalized older adults are
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malnourished on admission or acquire nutritional deficits while hospitalized (Monkhouse, 2013). In the critical care setting, patients are sicker and have ever-changing metabolic requirements that necessitate daily nutritional monitoring. Patients over 75 years of age admitted to the ICU after emergency surgery or for medical reasons have a mortality rate of up to 67% (Monkhouse, 2013). Clinical recognition of the pharmacokinetic and pharmacodynamic changes associated with aging is most important in the critical care setting, where more drugs are used to combat more problems (see Chapter 20). Drugs given in the critical care context may be lifesaving and life threatening at the same time (Fuchs et al., 2012).
The most common traumatic injuries (see Chapter 12) experienced by those older than age 65 result from falls, automobile accidents, and burns. Older adults suffer injuries of equivalent severity to those of younger persons; however, the consequences are more severe. It is essential to obtain a thorough history of an injury from the patient and his or her family, including the circumstances surrounding the event and the events leading up to the injury. Health care professionals in the field need to realize that older adults do not tolerate hypoperfusion long and may quickly go into cardiogenic shock and multisystem organ failure. Early hemodynamic monitoring is required. The vital signs of an older adult might be restored to normal, yet the person might still be in cardiogenic shock. As much as volume depletion is a concern, so is volume overload in patients with limited cardiac and renal reserves. Insertion of a catheter does increase the risk of infection in older adults but is often justified for its monitoring value (Legome & Shockley, 2011; Fuchs et al., 2012).
Thermoregulatory mechanisms become impaired as a person ages, and older adults with trauma are particularly vulnerable. Care should be taken to reduce heat loss with the use of warm intravenous solutions, warm blankets, and proper environmental control. The degree of long-term recovery of older adults who survive injury is variable, and aggressive rehabilitation and social support are important factors in recovery. Research supports the fact that older adults are at greater risk for complications and higher mortality even when injuries are not severe (Legome &
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Shockley, 2011). Frailty is defined as the presence of at least three of the following criteria: (1) decreased strength, (2) exhaustion, slow walking speed, low physical activity and unintentional weight loss associated with increased functional impairment, falls, prolonged hospitalizations, and death (Monkhouse, 2013). Frailty is associated with female gender, chronic disease, increased chronological age, and decreased functional status. Frailty is a measure of vulnerability and indicates those at risk for increased mortality and institutionalization. Frail individuals have a limited capacity to respond to internal and external stressors (Hubbard & Woodhouse, 2010).
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Home care and hospice Community-based service providers are challenged to develop affordable and appropriate programs to assist older adults to remain in the home while maintaining their quality of life. Community-based services for older adults include home health care, community-based alternative programs, respite care, adult day care programs, senior citizen centers, homemaker programs, home-delivered meals, and transportation, among many others (Box 9-2). In some areas, churches and neighborhoods have organized volunteer programs to help meet the needs of older adults who rarely leave home. Some of these programs rely on paid nurses and volunteers from the community.
Box 9-2
Services for older individuals Access Services • Case management
• Information and referral
• Transportation
Community-Based Services • Adult day care
• Congregate nutrition programs
• Elder abuse/protective services
• Health screening/wellness promotion services
• Housing services
• Institutional respite care
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• Legal assistance
• Multipurpose senior centers
• Psychological counseling
• Retirement planning
In-Home Services • Home-delivered meals
• Home health services
• Home hospice care
• Homemaker services
• Home maintenance and repair or chore services
• In-home respite care
• Personal emergency response systems
• Telephone monitoring and friendly visitors
To identify the needs of the older population, nurses in the community must have sharp assessment skills and knowledge of normal aging changes, chronic illnesses, and the effects of illnesses and treatments on older adults. They must also be aware of available community resources. Home health remains one way to help the older adult who has a physical or cognitive impairment stay in the home. Because of changes in reimbursement for federal programs that provide services for older adults and limited funds for state programs, home health nurses are challenged to use interventions that are both effective and cost efficient.
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Factors affecting the health care needs of noninstitutionalized older adults Functional Status Functional status is a term used to describe an individual’s ability to perform the normal, expected, or required activities for self-care. It is a determinant of well-being and a measure of independence in older adults. Functional measures are much more useful in describing the service needs of older adults living in the community than are measures of acute and chronic illness. Because of their ability to predict service needs, functional measures are used to determine eligibility for many state-funded and federally funded, community-based, long-term care programs. Physicians frequently order physical or occupational therapy as part of home health when a functional deficit exists (van Hout et al., 2010).
Functional status determines whether an older adult needs home health care or whether a home health client is recertified for home care services. The use of adaptive equipment as well as barriers to the client’s function should be noted. While assessing the client’s functional status, the home health nurse considers the client’s cognitive status, respiratory and cardiovascular status, and skin integrity. Deficits in these areas could impair the client’s ability to perform ADLs and IADLs safely. The client’s perception of self-care is also important because he or she could believe that no assistance is required when, in fact, a deficit exists (van Hout et al., 2010).
For older adults, adapting to functional limitations is crucial for maintaining independence. The outcomes of severe functional impairments are costly (e.g., institutionalization). The home health nurse must assess for functional impairments. Early detection of limitations leads to interventions that help preserve function and avoid more severe disability. Frailty, as previously defined, has become a predictor for older adults. Frail older adults are more likely to require assistance in the home care setting or require a
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supervised care setting (Monkhouse, 2013).
Cognitive Function Cognitive impairment, which often affects an individual’s functional status, is another eligibility criterion used by various community programs. Cognitive status is assessed on admission and again with every skilled nursing visit. Other disciplines are also responsible for reporting a change in cognition to the nurse or case manager in home health. A change in cognitive status frequently signals a change in another body system (see Chapter 27). The home health nurse must establish a baseline assessment and be alert to deviations. Cognitive impairments may be reversible or irreversible, and home health personnel are in a key position to detect any changes.
Cognitive impairments are associated with functional limitations. For example, individuals with deficits in memory, language, abstract thinking, and judgment have great difficulty executing ADLs or IADLs (e.g., shopping, paying bills, preparing meals, and personal care tasks), even though they may have no physical impairments or disabilities. Cognitively impaired individuals often need supervision and cueing, rather than physical assistance, to perform ADLs and IADLs.
Although cognitive impairment alone does not meet the criteria for home health care services covered by Medicare, many states provide services for individuals with Alzheimer disease and related dementias through Medicaid and Medicare waiver programs. Medicare covers skilled nursing visits when (1) the skill is necessary to maintain the client’s health, (2) the cognitive impairment interferes with the client’s ability to perform the skill, and (3) no caregiver is present or able to perform the skill. An older adult who requires daily insulin injections but is unable to draw up or administer the insulin because of a cognitive impairment is an example of someone who qualifies for home health care.
Housing Options for Older Adults
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Although older adults prefer to live independently, it is not always possible or appropriate; financial status, functional status, frailty and physical health may dictate consideration of alternative housing options that provide a more protective and supportive environment. Table 9-2 describes the most common housing options for older adults. Each option has its advantages and disadvantages. The decision about which option is most appropriate depends on such factors as the amount and type of assistance an older person requires financial resources, geographic mobility, preferences for privacy and social contact, and the types of housing available. The American Association of Retired Persons (AARP) has several publications that describe each of these options in greater detail, including issues to consider when evaluating each option (AARP, 1992).
Table 9-2 Housing Options for Older Adults
Type of Housing
Description of Housing
Accessory apartment
This is a self-contained apartment unit within a house that allows an individual to live independently without living alone. It generates additional income for older homeowners and allows older renters to live near relatives or friends and remain in a familiar community.
Assisted living facility (also called board and care home; personal care home; or sheltered care, residential care, or domiciliary care facility)
This is a rental housing arrangement that provides room, meals, utilities, and laundry and housekeeping services for a group of residents. Such facilities offer a homelike atmosphere in which residents share meals and have opportunities to interact. What distinguishes these facilities from simple boarding homes is that they provide protective oversight and regular contact with staff members. Some facilities offer additional services such as nonmedical personal care (e.g., bathing, grooming) and social and recreational activities. In many states, these facilities operate without specific regulation or licensure; therefore, the quality of service may vary greatly.
Congregate housing
Congregate housing was authorized in 1970 by the Housing and Urban Development Act. It is a group- living arrangement, usually an apartment complex, which provides tenants with private living units (including kitchen facilities), housekeeping services, and meals served in a central dining room. It is different from board and care facilities in that it provides professional staff such as social workers, nutritionists, and activity therapists who organize social services and activities.
Elder Cottage Housing Opportunity (ECHO)
This is a small, self-contained portable unit that can be placed in the backyard or at the side of a single- family dwelling.
The idea was developed in Australia (where it is called a “granny flat”) to allow older adults to live near family and friends but still retain privacy and independence. ECHO units are distinct from mobile homes in that they are barrier-free and energy-efficient units specifically designed for older or disabled persons.
Foster home care
Foster care for adults is similar in concept to foster care for children. It is a social service administered by the state that places an older person who needs some protective oversight or assistance with personal care in a family environment. Foster families receive a stipend to provide board and care, and older clients have a chance to participate in family and community activities. Adult foster care is appropriate for older adults who cannot live independently but do not want or need institutional care.
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Home sharing
Home sharing involves two or more unrelated people living together in a house or apartment. It may involve an older person and a younger person or two or more older people living together. The participants may share all living expenses, share rent only, or exchange services for rent. For the older homeowner, renting out a bedroom generates revenue that may make it possible to afford taxes and home expenses. Home sharing is viewed by many older adults as a practical alternative to moving in with adult children. Some communities provide house-matching programs, usually sponsored by local senior centers or the Area Agency on Aging.
Life care or continuing care retirement community (CCRC)
This is a facility designed to support the concept of “aging in place.” It provides a continuum of living arrangements and care—from assistance with household chores to nursing facility care—all within a single retirement community. Residents live independently in apartments or houses and contract with the community for health and social services, as needed. If a resident’s need for health and nursing care prohibits independent living, the individual can move from a residential unit to the community’s health care unit or nursing facility. In addition to providing shelter, meals, and health care, a CCRC provides a variety of services and activities (e.g., religious services, adult education classes, library, trips, and recreational and social programs). The key attribute of a CCRC is that it guarantees a lifetime commitment to care of an individual as long as the person remains in the retirement community. The major disadvantage of a CCRC is that it can be expensive; most CCRCs require a nonrefundable entrance fee and charge a monthly assessment, which may increase.
Modified from American Association of Retired Persons (AARP). (2013). Housing: Independent & Assisted Living Senior Housing 2013. <http://www.aarp.org/home- garden/housing/>.
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Community-based services Use of Community and Home-Based Services by Older Adults Assessment of functional status aids in determining the type of services an older adult needs to remain in his or her home. A low score on a functional status test does not necessarily indicate the need for institutionalization, but it means that the older adult needs assistance with specific activities (van Hout et al., 2010). The type of services needed, the availability of the services, the cost of the services, and the requirements to qualify for the services are determined by a home health agency.
Community services are categorized into formal and informal services. Home health care is a short-term, formal service that provides assessment, observation, teaching, certain technical skills, and personal care. A client may receive home health care for a limited time and for a specific diagnosis. Homemaker services are another formal service. To qualify for most homemaker services, the older person must demonstrate a financial requirement and a specified need for service. Informal services include senior citizen centers, adult day care services, nutrition services, transportation services, and telephone monitoring services. Community resources, formal and informal, must meet the client’s needs (see Cultural Awareness box).
Cultural awareness
Community-based long-term care for latino older adults The number of Latinos older than 65 is projected to increase 500% by the year 2030. In a national survey of 2299 Latinos (of any Hispanic ancestry but predominantly Mexican Americans and
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Puerto Rican Americans) age 65 or older, Wallace and Lew-Ting (1992) found that Latinos have higher rates of disability than their white counterparts and a greater need for community-based long-term care (Hanlin, Delgado-Rendón, Lerner et al, 2013).
Two major factors influence the interest and ability of Latino families to seek formal long-term care: cultural influences and structural influences. Cultural influences include the belief systems and preferences that cause certain patterns of health care use. Because long-term care often involves nontechnical assistance that can be provided by family members, Latino older adults tend to use nursing facilities less often as family members make sacrifices to help older relatives. More acculturated families provide lower levels of care and less informal support for older adults than less acculturated ones.
Structural influences include the way the health care system and other social institutions are organized and operated. They may present both incentives and barriers to the use of health services. Given the importance of income and insurance in determining long-term care use, a major gap exists in the health insurance status of Latino older adults. In the general population, one third of Latinos are uninsured compared with 13% of whites and 19% of blacks. This is largely because Latinos are concentrated in industries that do not offer insurance, such as personal services and construction and because they tend to live in states such as Texas and Florida that have stringent Medicaid eligibility criteria. As a result, serious illness in the family is considered a financial problem almost twice as often among Latinos as other whites (39% versus 19%).
Research reveals that the need for in-home health services for older Latinos is substantial. Mexican American older adults are less likely than the average Latino to use in-home health services despite similar levels of need. Nurses should not assume that Latino families are taking care of their disabled older members simply because of a cultural preference. Nurses should provide information and advice on the use of in-home health services when an older Latino client is physically disabled. From Wallace, S. & Lew-Ting, C. (1992). Getting by at home: community-based long-
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term care of Latino elders. Western Journal of Medicine 157:337-344. Adapted and reproduced with permission from the BMJ Medical group (supported by Hanlin, E., Delgado-Rendón, A., Lerner, E, Hargarten, S. Farías, R.). (2013). Fall risk and prevention needs assessment in an older adult Latino population: A model community global health partnership. Progress in Community Health Partnerships: Research, Education, and Action, 7(2).
Because of fragmentation, noninstitutional long-term care depends on the coordination of efforts between informal and formal care providers. In some instances, families function as case managers, ensuring that resources and services are provided appropriately. In other situations, case management services are provided by formal organizations such as home health care agencies or managed care agencies. These nurses must be familiar with community resources and should assist older individuals and their families in accessing these resources. Home health nurses have a particular responsibility to assess older adults who are receiving home health services and to determine how their individual needs can best be met. The home health nurse identifies appropriate community resources, initiates the referral process, develops a care plan, coordinates services, evaluates the services, and determines whether a need exists for additional services. Home health nurse visits that target frail older adults may have a significant impact on mortality and instutionalization (van Hout et al., 2010).
Profile of Community- and Home-Based Services Area Agencies on Aging The major goal of the Older Americans Act (OAA) of 1965 was to remove barriers to independent living for older individuals and to ensure the availability of appropriate services for those in need. Through Title III, the Administration on Aging (AOA) and state and community programs were designed to meet the needs of older adults, especially those at risk for loss of independence. The OAA established a national network of federal, state, and area Agencies on Aging (AAAs), which is responsible for providing a range of community services for older adults. States are divided into areas for planning and service administration. The OAA requires that
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each AAA designate community “focal points” as places where anyone in the community can receive information, services, and access to all of a community’s resources for older adults. Multipurpose senior citizen centers often serve as these focal points, but community centers, churches, hospitals, and town halls may also be designated as focal points. The types of services provided through the OAA and the AAAs include information and referral for medical and legal advice; psychological counseling; preretirement and postretirement planning; programs to prevent abuse, neglect, and exploitation; programs to enrich life through educational and social activities; health screening and wellness promotion services; and nutrition services (Bales & Ritchie, 2009; Smith, 2010).
Multipurpose Senior Centers Senior centers are community facilities that provide a broad range of services to older adults in the community. These services include (1) health screening, (2) health promotion and wellness programs, (3) social, educational, and recreational activities, (4) congregate meals, and (5) information and referral services for older individuals and their families. Senior centers are used primarily by relatively active and independent older adults because such centers do not provide nursing and custodial care services. Older adults who require these types of services would benefit from attending an adult day care program. Funding for senior centers is provided primarily through the OAA and agencies such as the United Way.
Adult Day Care Services Adult day care services provide a variety of health and social services to older adults who live alone or with their families in the community. Most people who use adult day care services are physically frail, cognitively impaired, or both and require supervision or assistance with ADLs. Adult day care programs help delay institutionalization for older adults who require some supervision but who do not need continuous care. This allows family members to maintain their lifestyles and employment and still provide home care for their older relative.
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The majority of adult day care services operate 5 days a week during typical business hours. Charges vary with each facility, from per week to per day to per half day. Adult day care services vary considerably in terms of eligibility criteria and the types of services provided. Key services may include transportation to and from the facility, assistance with personal care, nursing and therapeutic services, meals, and recreational activities.
Adult day care services are not federally regulated but may be licensed or certified by the state. Certification is required to receive federal funding such as Medicaid and OAA funding. Other funding sources include private pay, foundations, and long-term care insurance. Medicaid is a major funding source for most of these programs; however, participants usually pay part of the fee. Some facilities may accept only private pay or long-term care insurance. Other private sources of funding include religious organizations, businesses, and the United Way.
Some programs accept only clients with dementia. It is difficult to combine clients with dementia and clients who have no cognitive impairment. This situation requires extra staff and usually a larger facility with separate areas for the two different groups. The staff in these programs is trained to work with persons with dementia.
Respite Care Respite care provides short-term relief or time off for persons providing home care to ill, disabled, or frail older adults. Adult day care services are a form of respite provided outside the home. Respite care is often provided at home or in institutional settings such as specially designated hospital or nursing facility units. Respite staff includes health professionals, trained volunteers, and personal care attendants. In-home and institutional respite may be provided on a regular schedule (e.g., 4 hours a week) or for longer time intervals (e.g., 1 week, a weekend, or on an intermittent basis). Private pay and state programs that target lower income families are the two main funding sources for respite care.
Homemaker Services
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Homemaker services include such things as housecleaning, laundry, food shopping, meal preparation, and running errands. Fees vary according to the type and frequencies of services provided and are usually not covered by Medicare or Medicaid. These services are offered through home health agencies, AAAs, the Department of Health and Human Services, and private companies and organizations that provide other services to older adults. Prices vary with the type of agency offering the homemaker services. In most states, no licensing or certification is required for the individual providing the care. Background checks and letters of recommendations are often the only qualifications for the positions.
Nutrition Services Nutrition services provide older adults with inexpensive, nutritious meals at home or in group settings. Home-delivery programs such as Meals-on-Wheels deliver hot meals to the home once or twice a day, 5 days a week, and can accommodate special diets. Some Meals-on-Wheels programs sell nutritional supplements at reduced rates to older adults who cannot leave the home. Congregate meal sites provide meals in group settings such as senior centers, churches, synagogues, schools, and senior housing. The advantage of congregate meal sites is that they provide social opportunities for older adults who are otherwise socially isolated. Most nutrition programs charge a minimum fee or ask for donations. Another advantage of home-delivered meals is that the volunteer delivering the meal is able to check on the older adult daily and report any problems to the supervisor. In some instances, a Meals-on-Wheels volunteer has been the first person to discover an older adult who fell in the home and was unable to seek assistance.
Transportation Services Many communities provide transportation services for disabled older adults through public or private agencies. The transportation may be handled by volunteer drivers in cars or by a bus, taxi, train, or a public van equipped to accommodate wheelchairs. The fee for such transportation services is usually minimal and is often based on a sliding scale. In addition, many facilities that serve older adults
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(e.g., adult day care services, senior centers, and health facilities) have their own transportation services.
Telephone Monitoring and Friendly Visitors Telephone monitoring programs provide regular phone contact (usually daily) to older persons who live alone or are alone during the day. The phone calls provide social contact, as well as a check for those who are concerned about their health and safety. Friendly visitors make home visits for the purpose of companionship, assistance with correspondence, and needs assessment. Telephone monitoring staff and friendly visitors are volunteers who work through local community organizations such as churches, synagogues, senior centers, and social service agencies. Even if older adults live in areas where these formal services are not available, nurses can encourage informal telephone monitoring and visiting by family members, friends, and neighbors. Telephone services that will call individuals to remind them to take their medications are also available, usually for a monthly fee.
Personal Emergency Response Systems Personal emergency response systems (PERSs) are home monitoring systems that allow older persons to obtain immediate assistance in emergent situations, for example, after a fall or when suffering life-threatening symptoms. A PERS consists of a small device worn on the body and, when triggered, will send an alarm to a central monitoring station. The central monitoring station then contacts predesignated persons or the police, who respond to the emergency. A PERS may be purchased or leased for a monthly fee. Because these devices are relatively expensive, they are not a practical alternative for older adults in lower-income groups. They are not recommended for persons with dementia because resetting the device is very difficult, and the device may be triggered too often for nonemergencies.
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Home health care Home care consists of multiple health and social services delivered to recovering, chronically ill, or disabled individuals of all ages in their place of residence. There are three main categories of home care providers, known as home care organizations (National Association for Home Care and Hospice [NAHC], 2013). Medicare- certified agencies include hospice and freestanding and facility- based home health agencies.
Home health services are covered by Medicare, Medicaid, private insurance, managed care plans, and private pay. Persons of all ages are eligible for home health services. Criteria for services vary based on the type of insurance. The majority of home health care recipients are 65 or older. Medicare, the primary payer source for home health services, requires the home health client to (1) have a skilled care need, (2) be homebound, (3) be unable to perform the skilled care alone and have no one in the home to provide care, and (4) require only intermittent care. If a caregiver is present, he or she must be unwilling or unable to provide the care needed. Being homebound means that the home health client has a physical reason (e.g., being bedridden) or medical condition that limits his or her ability to leave home. The use of assistive devices or a wheelchair alone does not qualify an individual for the homebound status. The home health client is allowed to leave home for medical reasons, but it must be an effort to do so. In other words, if the client could get to a physician’s office to receive care on a regular basis, Medicare would deny the home health services. The client must also have a physician’s written plan of treatment for the service specifying the frequency and duration of care provided.
Medicare establishes specific criteria for coverage by the physician, home health agency, disciplines providing care, and other entities (e.g., medical supply companies) that provide goods or services to the client. The purpose of eligibility criteria is to ensure that Medicare dollars are being spent in the most cost- effective manner. Other payer sources (e.g., health maintenance organizations [HMOs] and private insurance) use Medicare criteria
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as a guideline for eligibility but have the flexibility to vary the criteria with individual circumstances (Mollica, Kassner, Walker, & Houser, 2009).
Medicaid is delivered by each state and has its own criteria for reimbursement. Other funding sources of home health include social service block grants, OAA funds, and general state revenues. The dollar amount spent on home health by sources other than Medicare and Medicaid varies with each state. The U.S. Department of Veterans Affairs, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and the Civilian Health and Medical Program of the Department of Veteran’s Affairs (CHAMPVA) have their own coverage guidelines and payment methods for home health, and each covers different home health services (CHAMPVA, 2013).
Managed care companies have various methods for approving services related to home health care. The admission assessment is usually approved first. Then, based on the diagnosis, the functional status of the home health client, and the ability of the caregiver to provide help, the company assigns further home health visits. Other companies approve a specified number of visits based on the diagnosis and information from the referring physician. The home health agency stays in close communication with the managed care company to report progress and request any changes in the original care plan.
Home Health Agency The predominant and most familiar provider of home care is the home health agency. Home health agencies have as their primary function the treatment or rehabilitation of clients through the intervention of skilled nurses or therapists. Clients admitted to a home health agency must be under a physician’s supervision, and services must be provided in accordance with a physician’s signed order. Home health agencies can provide a different combination of services. Skilled nursing and physical therapy may stand alone; that is, either the registered nurse (RN) or physical therapist may serve as the case manager. Speech therapists, occupational therapists, and
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medical social workers are not allowed to admit clients to home health care but must work with a nurse or physical therapist. In addition, many agencies offer nutritional services on a limited basis. Agencies may also provide disposable medical supplies as appropriate for the diagnosis and treatment plan for a client.
Proprietary Agencies A proprietary or for-profit, home care agency is designed to make money for its owners. Until 1982, proprietary home care agencies were not allowed to participate in Medicare. This was changed in response to a concern that not enough home care services were available to meet the demand. As a result, the Omnibus Budget Reconciliation Act (OBRA) of 1982 allowed proprietary home care agencies to become Medicare certified, but they were not allowed to make a profit on the Medicare portion of their business. Owners of a for-profit entity are stockholders in the corporation.
Facility-Based Agencies A facility-based home care agency is a department or component of an organization. It may be a part of a skilled nursing facility (SNF) or rehabilitation center, or it may be hospital based. The vast majority of agencies are hospital based; that is, they function as a department of the hospital. These agencies may or may not share clinical, financial, or management services with the hospital.
The first hospital-based home care agency was established in 1947. Its programs offered nursing care and housekeeping and chore duties. In 1958, radiology services, nutritional services, and physical therapy were offered. With the enactment of Medicare and Medicaid in 1966, nurses were able to offer more home care to the sick and the disabled.. Hospital-based home care agencies were few in number until the enactment of Medicare reform (OBRA, in 1987), when hospitals began to be paid for patients receiving Medicare benefits on the basis of DRGs. With shorter lengths of stay, hospitals established home care agencies or affiliated with existing home care agencies to provide options for patients who were going home with existing health care needs. The Affordable Care Act
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(2011) made changes to Medicare reimbursement, resulting in a 5% reduction in reimbursement for home care visits (Eck, 2010).
What determines a facility-based home care agency from the Medicare program’s point of view is whether it receives an allocation of the institution’s corporate overhead. A facility-based home care agency, according to The Joint Commission (2012), shows evidence of an organizational and functional relationship between the home care agency and the facility or public representation of the home care agency as a service of the facility.
Visiting Nurse Associations A visiting nurse association (VNA), or community nursing service, is a community-based home care agency with a governing board consisting of community representatives. Because of the commitment to provide home care services to a defined community and a not-for-profit status, VNAs are often recipients of United Way or Community Givers funds.
Benefits of Home Care In survey after survey, older Americans choose “home” as their treatment place of choice. Because of changes in technology, equipment is smaller, easier to manage, and less expensive. As a result, individuals who at one time could be treated only in the hospital can now be managed at home. Family, friends, and even patients themselves can be taught to manage enteral and parenteral feedings, central lines, pain control, antibiotic therapy, and urinary catheters with a minimum of assistance (TJC, 2011).
Among those older adults who can benefit from home care services are individuals who:
• Have chronic medical conditions with exacerbations such as congestive heart failure, chronic obstructive pulmonary disease (COPD), unstable diabetes, kidney or liver disease with subsequent transplantation, or recent strokes;
• Have chronic mental illnesses such as depression, schizophrenia, or other psychoses;
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• Need assistance with medical regimens to prevent readmission to an acute care facility;
• Need continued treatment after discharge from a hospital or nursing facility (e.g., wound care, intravenous therapy, or physical therapy); or
• Require short-term assistance at home after same-day or outpatient surgery or are terminally ill and want hospice care to die with their families and to die with dignity in the comfort of their own homes.
Home care is less expensive than hospitalization in most cases. For example, considerable savings may be achieved through the use of home care services for infusion therapy services. Although home care services are being used because of financial considerations, sound medical and humane reasons also exist for treatment to take place in a person’s home. Evidence suggests that people recover faster at home than in institutions, and hospital-acquired infections from exposure to multiple infectious processes are minimized in a person’s home (see Evidence-based practice box).
Evidence-based practice Comprehensive Evaluation of Functioning for Quality of Life
Background Hoeck et al (2012) studied patterns of health- and home-care utilization among Belgian frail older persons living at home.
Methods: A cross-sectional study was conducted based on a sample of 4777 older adult participants (≥ 65 years) in the Belgian Health Interview Survey. The prevalence of frailty was estimated according to age, gender, comorbidity, place of residence, survey year, living situation and socioeconomic status. Differing health- care utilization [contacts with a general practitioner (GP), specialist and emergency department; and hospital admission) and home-care utilization (home nursing, home help, and meals-
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on-wheels] patterns among the frail, prefrail, and robust subpopulations were examined.
Results: Overall, 9.3% of respondents (426) were classified as frail, 30.7% (1636) as prefrail, and 60.0% (2715) as robust. Frailty was associated with age, gender, comorbidity, region, survey year, and socioeconomic status. The frail and prefrail groups were more likely than the robust group to contact a GP, a specialist, or an emergency department and were more likely to be admitted to hospital, independent of age, gender, comorbidity, survey year, living situation, region, and socioeconomic status. They were also more likely to appeal to home nursing, home help, and meals-on-wheels than the robust participants.
Conclusion: After adjustment for potential confounders, including age, gender and comorbidity, frailty among Belgian older persons is associated with their socioeconomic status and is strongly associated with their health- and home-care utilization.
Implications Home care for older adults has long been a staple of continuing medical care, but it appears that additional measures must be undertaken to both identify and assist those frail older adults to sustain or improve cognitive function and functional status.. From Hoeck, S., François, G, Geerts, J., Van der Heyden, J.,Vandewoude, M., and Van Hal, G. (2012). Health-care and home-care utilization among frail elderly persons in Belgium. European Journal of Public Health, 22(5):671-677. doi: 10.1093/eurpub/ckr133.
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Continuity of care Enhancement of the continuum of care from hospital to home is a goal shared by both hospital and home care personnel. Continuity of care involves assisting older adults to remain in the home and avoid institutionalization by having available resources that are responsive to their needs (Sharma et al., 2009; van Hout, 2010). The American Academy of Family Physicians has endorsed the establishment of the Patient-Centered Medical Home (PCMH) care model. The PCMH is a model of care led by a primary care physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. A PCMH service includes preventive services; treatment of acute and chronic illness; and assistance with end-of-life issues. This care model promotes improved access and communication; care coordination and integration; and care quality and safety. The Patient Protection and Affordable Care Act (2010) endorsed a move toward the PCMH model with reimbursement incentives for PCMH care. The end result of this change is to ensure that a continuum of care exists from hospital to home (Davis, Abrams, & Stremikis, 2011). Health care providers should follow the “Plan, Do, Check, Act Cycle” (Box 9-3).
Box 9-3
Plan, do, check, act cycle Plan • Gather data on admission.
• Identify goals for discharge.
• Identify specific functional problems.
• Validate that a problem exists.
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• Structure problems by delineating components.
Do • Gather information about resources. • Select all possible options.
• Identify measurable objectives in terms of the client’s functional problems.
• Analyze each option for capacity to fulfill objectives.
• Identify advantages and disadvantages.
Check • Compare alternatives for probability of fulfilling discharge
objectives.
• Project results of alternatives.
• Explore alternatives with the client and family.
• Choose among alternatives.
Act • Develop the discharge plan.
• Implement the plan.
• Evaluate and follow up on the plan.
• Revise the plan, as indicated.
• Update the resource file.
Box 9-4 lists client characteristics that should suggest further evaluation for a home care referral. These characteristics alone do not warrant the need for home health care, but in combination with one another or with a new diagnosis that requires monitoring, they provide an excellent guideline to determine the need for services. The assessment may be done as a prehospitalization screening, at the time of admission to the hospital, after a client’s condition has changed, or as a client is being discharged. What really matters is that the client be assessed for home care needs before he or she leaves the hospital.
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Box 9-4
High-risk client indicators for Home Care Services • Unexpected readmission to the hospital within 15 to 30 days
• Frequent readmissions
• Alteration of health care problem or management
• Changes in mental status
• Noncompliant behavior before or during hospitalization
• Terminal or preterminal condition
• Seen in the hospital by physical, occupational, or speech therapist
• After amputation
• After hip or knee replacement
• New assistive devices
• Foley catheter, ileal conduit, suprapubic catheter, and/or incontinence
• Complex health management regimen
• Enteral or parenteral feedings
• Ostomies or tubes of any kind
• Draining wounds
• After wound débridement or irrigation and débridement for decubitus
• Pain management
• Intravenous antibiotics
• Peripherally inserted central catheter
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• Intravenous chemotherapy
• Multiple medications or a major medication change
• Ventilator dependence
• Low-air-loss bed or other complex medical equipment
Ideally, a client is screened for home care needs at the time of admission to a hospital to ensure adequate time to plan for continuity of care. In most instances, unless a client is already known to a home care agency, discharge planning occurs late in the hospital stay. As hospital lengths of stay become increasingly shorter, the time available to plan adequately for a client’s postdischarge care is limited. Home care agencies and hospital discharge planners or case managers need to develop a good working relationship to ensure that clients going home have a plan that picks up where the hospital plan leaves off. To ensure a smooth transition, members of all disciplines who were caring for a client in the hospital—nurses, physicians, physical therapists, social workers, and others—should provide qualitative and quantitative information about the client’s disposition at discharge. The same principles apply to the discharge process from SNFs or rehabilitation facilities.
In most cases, a social worker or case manager is responsible for notifying the home health agency of a client’s discharge. The home health agency requests information needed to ensure a smooth transition from the facility to home. In addition to demographics, necessary information includes the following:
• Identification of the primary care physician (PCP) or the PCMH who will sign the home care orders
• Orders for home health care treatments (e.g., wound care, intravenous therapy, physical therapy, occupational therapy, or speech therapy)
• A description of the client’s knowledge about the disease and the treatment
• A summary of the client’s independence with skills
• Quantitative measures of range of motion and client response to
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treatment modalities
• Known social situations that could complicate or hinder the home treatment plan
• A list of supplies and medications going home with the client
• Expectations for rehospitalization or follow-up clinic visits
• Anything that would enhance a timely and efficient response from a home care agency
Role of the Home Care Agency Admission to the home care agency begins with the referral intake. Referrals are called in to the home care agency, and the agency confirms home care benefits, schedules the admission visit consistent with the expectation of the discharge planner, physician, or client, and communicates the referral information to the nurse who will be admitting the client into service. The client must be admitted within 24 hours of discharge, according to Medicare regulations.
Nurses are assigned to clients in various ways. Some assignments are made according to geographic areas, the client’s special needs, or the nurse’s specialty.
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Implementing the plan of treatment The Nurse’s Role The nurse conducts the initial evaluation visit after a client is referred for home care. During the initial visit and throughout subsequent visits, the nurse assesses the client’s physical, functional, emotional, socioeconomic, and environmental well- being. Nurses initiate the care plan and make revisions as appropriate throughout the length of stay in home care.
Other activities requiring the specialized skill of RNs include the following:
• Health and self-care teaching
• Coordination and case management of complex care needs
• Medication administration (e.g., intramuscular and subcutaneous) and teaching about all medications
• Wound and decubitus care
• Urinary catheter care and teaching
• Ostomy care and teaching
• Postsurgical care
• Care of the terminally ill client Additional activities provided by some home care nurses are as
follows:
• Case management
• Intravenous therapy, enteral and parenteral nutrition, and chemotherapy
• Psychiatric nursing care
Characteristics of a Home Care Nurse Home health nursing is a subspecialty of community health nursing. It is community based in that the focus is the client and
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family, not an aggregate population. The American Nurses Association (ANA) has endorsed practice standards for home health nurses. As with other specialties, the standards address theory, research, ethics, and professional development. The ANA’s statement on The Scope of Home Health Nursing Practice (ANA, 1999) presents the conceptual model for home health nursing. The model depicts the holistic practice of the home health nurse. Nurses who work in home care require a diverse set of skills and abilities. Most home care agencies require a nurse to have a minimum of 2 years of hospital experience before working as a home health nurse. Working in home care requires knowledge of acute and chronic disease processes and how they affect older adults. Knowledge of gerontology, pharmacokinetics in older adults, rehabilitation nursing, and principles and presentation of disease processes in older adults are areas in which home care nurses need to be competent. The home care nurse also needs to know adult learning principles and interpersonal communication techniques, and he or she must be aware of cultural differences and how they affect health and health care.
The home care nurse coordinates care with all disciplines involved with the case and reports findings, changes, and recommendations to the primary physician. The home care nurse also works cooperatively with community resources and governmental agencies if a situation warrants. The nurse, often the sole health care provider who visits a client’s home, knows that observations made must be acted on immediately and that the instruction provided must last until the next visit. If emergency hospitalization is required, the nurse coordinates it with the family, the physician, the hospital, and emergency services.
Home care nurses need to be conscious of their own safety. Some neighborhoods are dangerous, and visits sometimes need to be made in the evening or night. The home health nurse should never go into a situation that might be physically threatening or dangerous. He or she must be self-reliant, self-assured, and comfortable in providing care in the client’s locale. Taking precautions at all times, not just in potentially dangerous neighborhoods, will ensure the nurse’s safety. In a recent position
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paper, The Joint Commission endorsed the role of the home health care nurse in managing patients in noninstitutional settings and preventing admissions and readmissions to the institutional setting (The Joint Commission, 2012).
Role of the Home Health Aide In 2010, approximately 1.8 million home health aides (HHAs) worked in Medicare-certified agencies. HHAs are the second largest group of employees in home care (Bureau of Labor Statistics, 2012). Under the direction of an RN, HHAs assist clients with intermittent personal care services (e.g., ADLs and hygiene), take vital signs, perform simple duties (e.g., nonsterile dressing changes and Foley catheter care), assist with medications that are normally self- administered, and report changes in clients’ conditions or needs. The HHA is a nonprofessional caregiver who has completed a course of study and has been certified by an appropriate agency. In addition, an HHA is required to complete at least 12 hours of in- service training each year of employment. The HHA must demonstrate competency in certain required skills and subjects taught at in-service training at least once a year (Sengupta, Ejaz, & Harris-Kojetin, 2012).
Because the HHA sees the client more often than do caregivers from other disciplines, he or she is one of the most important members of the home care team. The client feels comfortable with the aide and often shares concerns that the nurse or therapist cannot elicit. The RN supervises the HHA on a bimonthly basis (Sengupta et al., 2012).
Home health agencies also employ personal care attendants (PCAs). PCAs are generally hired for private duty cases in which only a sitter is required (as opposed to someone who provides personal or skilled care). No formal or informal training is required, but individual agencies may provide orientation and some training. Duties performed by PCAs may include, but are not limited to, the following:
• Preparing light meals
• Helping the client to the bathroom
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• Assisting with dressing and ambulation
• Light housekeeping
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Oasis Outcome and Assessment Information Set (OASIS) is an assessment tool that is integrated into an agency’s assessment form. It is used to monitor outcomes of home care. OASIS is mandated by the Centers for Medicare and Medicaid Services (CMS) for all adult clients except maternity clients. Its purpose is to improve performance through an approach called outcome-based quality improvement (CMS, 2012a). OASIS was developed to help shape the future direction of Medicare reimbursement and the future of home health.
OASIS data are reported to regulatory bodies at least every 30 days. The completion and reporting of OASIS data are part of the conditions of participation for the Medicare program (CMS, 2012a). OASIS is intended to focus on outcomes of care such as satisfaction and improved client outcomes. OASIS data are completed on admission, discharge, interruption of services, and resumption of services. Surveyors who monitor agencies use the data for on-site reviews. They compare the data on OASIS with data from the assessment of a client when visiting the client in the home.
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Hospice Dying is the final phase in the trajectory of a chronic illness. Terminal illnesses such as a number of cancers and acquired immunodeficiency syndrome (AIDS) remain incurable. However, because of pharmacologic and technologic advances in treatments, many cancers and AIDS are now considered chronic illnesses. Many chronically ill persons choose to remain in their homes during the last phase of their illness to prepare for their death in familiar surroundings, together with family and friends. Hospice provides care and services to terminally ill persons and their families that can provide a choice for the patient to die in a facility or at home.
Hospice Philosophy Hospice is a special kind of medically directed compassionate care for dying individuals and their families. It is a concept of care, not a particular place or building. The care is designed to address the physical, emotional, psychological, and spiritual needs of dying persons and to provide support services for their families during both the dying and bereavement processes. The goal of hospice is to provide comfort care, not a cure. Individuals with incurable or irreversible diseases that do not respond to treatment may choose hospice care. In addition, when a person and the family have decided to stop pursuing aggressive medical treatment, hospice is an appropriate choice.
Hospice and Palliative Care A clarification of the terms commonly used in the end-of life literature and clinical practice is necessary. In the United States, the terms hospice and palliative care are frequently used. Palliative care refers to the broader concept—it is therapy aimed at relieving or reducing the intensity of uncomfortable symptoms; it is not aimed at producing a cure. Hospice refers to a specific type of palliative care. Because of reimbursement policies such as the Medicare
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hospice benefit (discussed later in this chapter), American hospices are mandated to include specific services and are subject to the eligibility requirements that clients have a terminal diagnosis and a 6-month prognosis. Palliative and hospice care both have the goal of comfort, not cure. However, palliative care is provided in settings outside a hospice program and currently is not subject to the same regulations as are hospice programs.
In Canada, the term palliative care is pervasive, and hospice usually refers to a particular agency or program. Many of the international journals on palliative care originate from Canada, the United Kingdom, and the United States. Therefore, it is critical to understand the meaning of the terms as used in the literature about end-of-life care in the respective country of origin. In addition, the health care delivery systems and the private versus governmental insurance programs also differ among the countries. Terminally ill persons, families, and health care providers in Canada and the United Kingdom do not have the constraints of the 6-month prognosis required by the U.S. system.
A widely accepted definition of palliative care, developed by the World Health Organization (WHO), reads, in part:
Palliative care is the active total care of clients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount. The goal of palliative care is achievement of the best possible quality of life for clients and families. It affirms life and regards dying as a normal process. Palliative care neither hastens nor postpones death. It emphasizes relief of pain and other distressing symptoms, integrates the physical, psychological, and spiritual aspects of client care, and offers a support system to help the family cope during the client’s illness and in their own bereavement (WHO, 2009).
Since the 1990s, tremendous interest in palliative care and end-of- life issues has grown throughout the world. Palliative medicine is a recognized medical specialty in the United Kingdom and Canada. In the United States, numerous initiatives, federal funding, and financial support from private foundations are available for research and innovative programs regarding end-of-life issues. As
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the research-based knowledge continues to grow, interventions to achieve the outcomes of high-quality end-of-life care for all may become a reality.
Hospice Services In 2011, approximately 3600 Medicare-certified hospices in the United States served 1.65 million clients (National Hospice and Palliative Care Organization [NHPCO], 2012). Services provided by a comprehensive hospice program include physician services; nursing care; medical social work; counseling services and spiritual care; certified nursing assistant services; additional therapies, as needed (e.g., physical, occupational, and speech therapy); inpatient care related to difficulty in managing symptoms; medications; supplies; equipment; volunteers; respite services; continuous care in times of crisis; and bereavement services. These services constitute a basic level of hospice care established through the development of the NHPCO’s Standards of a Hospice Program of Care and the federally mandated operating standards for Medicare certification for hospice programs (NHPCO, 2013).
Hospice services are provided by an interdisciplinary team consisting of the client’s own physician, hospice physicians, nurses, HHAs, medical social workers, chaplains, bereavement coordinators, and volunteers. Team members use their skills and expertise to meet the needs of dying persons and their families. These needs may include teaching family and friends how to administer medications, helping dying persons maintain as much mobility and activity as possible, and listening and responding to a dying person’s needs. Help from the hospice team is available 24 hours a day. One member of the team is always on call and will make home visits as needed. However, the dying person and his or her family direct the care and are directly involved in the decision- making processes.
Hospice professionals anticipate problems and concerns, including preparing a family for the loss of a dying person. After the patient’ death, various types of bereavement services are available: individual and family counseling, bereavement volunteer visits, support groups, and grief classes. The bereaved family
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members determine their level of participation in any of the activities and services offered.
Historically, the majority of hospice programs in the United States follow the home care model. This means that the interdisciplinary team provides routine hospice care in a terminally ill person’s own home. In contrast to traditional home health care, it is not necessary for a terminally ill person to be homebound or to have a skilled nursing need. A family member or friend is usually designated as the primary family caregiver. Family members provide the 24-hour care of the dying person, and the hospice team consults and supports the family in their commitment to care for the hospice client. However, the creativity and innovation of the hospice team enables many dying individuals to remain in their homes without family caregivers.
On the basis of the needs of a dying person and his or her family, other levels of care are also available. Inpatient care is available when the client experiences acute or severe pain or symptom management problems. Inpatient respite care provides family caregivers with release time from the daily care of the client. This type of respite care is usually limited to 5 consecutive days. Continuous care is reserved for times of crisis. This service is provided in the client’s home by nurses and HHAs. It allows up to 24-hour care.
Medicare Benefit Hospice services are a fully covered Medicare benefit. Anyone covered by Medicare Part A is eligible for hospice care. The following three conditions must be met to qualify for the Medicare hospice benefit. First, a terminally ill person’s physician and the hospice medical director must certify that the client is terminally ill and has a life expectancy of 6 months or less. Second, a client must choose to receive care from a hospice instead of receiving standard Medicare benefits. Third, care must be provided by a Medicare- certified hospice program. The Medicare benefit pays for two 90- day periods of hospice care and an unlimited number of 60-day periods if the client is reassessed and recertified as terminally ill at the beginning of each period. Hospice clients may change their
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minds at any time, discontinue hospice care, and return to the cure- oriented care covered by standard Medicare benefits (NHPCO, 2012).
The Medicare hospice benefit covers pain- and symptom-control medications for a terminal illness. Durable medical equipment needed to care for a client in the home is also covered. The Medicare hospice benefit does not pay for treatment or services unrelated to the terminal illness. Attending physician charges continue to be reimbursed in part through Medicare Part B coverage. The standard Medicare benefit program continues to pay covered costs necessary to treat unrelated conditions that the hospice client may have concurrently with the terminal diagnosis (NHPCO, 2012).
HMOs are not required by law to provide hospice services. However, most HMOs do provide these end-of-life services. In addition, HMOs that receive Medicare funding are required to inform their members who are Medicare beneficiaries of Medicare- certified hospice programs located in their geographic area. If such a person chooses hospice care, he or she does not need to leave the HMO and will continue to receive HMO benefits not covered by Medicare (NHPCO, 2012). Most private insurance companies and Medicaid also provide hospice benefits.
Location of Care In the United States, hospice care is primarily provided in the home. However, other sites include hospital-based units, freestanding independent facilities, and long-term care facilities (nursing facilities). The use of these facilities is based on the needs of a dying client and his or her family and on the type of services offered in the client’s geographic area.
The hospice team recognizes that circumstances change. For example, a dying person and his or her family may initially choose to care for the dying person at home with the support of the hospice. Later, the primary caregiver may become exhausted or sick and be unable to provide that care any longer. The hospice team will assist the family in choosing an alternative to home-based
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hospice care. The transition between locations of care should be seamless with the assistance of the hospice team.
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Overview of long-term care Definition Long-term care has several meanings in the gerontologic nursing literature. The phrase is most accurately used to describe a collection of health, personal, and social services provided over a prolonged period. Of people over 65, 70% will use some form of long-term care in their lifetime (U.S. Department of Health and Human Services [DHHS], 2012). Recipients of long-term care services typically include older adults but may also include developmentally disabled persons, persons permanently impaired from traumatic injuries, and chronically ill younger persons. Services range from supportive care to very complex care. Long- term care settings may be categorized on a continuum according to the complexity of care provided and the amount of skilled care and services required by the residents served. Settings go from more structure to less structure as one moves from the institutional setting to community-based programs to the home setting. Table 9- 3 illustrates this continuum of long-term care settings.
Table 9-3 Continuum of Settings in Which Long-Term Care is Provided
Institutional Community Home Nursing facility Adult day care center Home health nursing Group home Senior center Home health rehabilitative services Board and care facility Congregate meal programs Homemaker Assisted living Hospice Home-delivered meals Continuing care retirement communities Adaptive devices to home environment Hospice Hospice
Persons living in nursing facilities are called residents. The facility is their permanent or temporary home. Some residents require nursing care until death. Other residents are admitted from an acute care hospital. They stay for a short time to recover from an acute illness, injury, or surgery and then return home. Medical, nursing, dietary, recreational, rehabilitative, social, and spiritual care is usually provided. All nursing facilities must function under the federal regulations set forth by the OBRA. Some facilities are
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also accredited by The Joint Commission.
Factors Associated with Institutionalization As life expectancy and the size of the older adult population increase, the possibility of a person entering a nursing facility at some point also increases. Personal factors associated with institutionalization include advanced age, physical disability, mental impairment, white race, living without a spouse, and the presence of chronic medical conditions such as heart disease, arthritis, hypertension, and diabetes (Luppa, Luck, Weyerer, et al., 2010). Factors contributing to the need for institutionalization may be categorized according to characteristics of the person, characteristics of the person’s support system, and the community resources available to the person (Box 9-5).
Box 9-5
Factors affecting the need for nursing Home Admission Characteristics of the Individual • Age, sex, and race
• Marital status
• Living arrangements
• Degree of mobility
• Ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)
• Urinary incontinence
• Behavior problems
• Mental status
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• Memory and cognitive impairment
• Mood disturbance
• Tendency to fall
• Clinical prognosis
• Income
• Payment eligibility
• Need for special services
Characteristics of the Support System • Family capability
• Age and health of spouse (if married)
• Presence of responsible relative (usually an adult child)
• Family structure of responsible relative
• Employment status of responsible relative
• Physician availability
• Amount of care currently received from family and others
Community Resources • Formal community resources
• Informal support systems
• Presence of long-term care institutions
• Characteristics of long-term care institutions
From Halter, J., Ouslander, J., Tinetti, M. Studenski, S. High, K. Asthana, S. Hazzard, W. (2009). Hazzard’s Geriatric Medicine and Gerontology. New York, NY: McGraw-Hill.
According to a 2010 report by the National Center for Health Statistics (U.S. DHHS, 2012), many older persons receive long-term care services in the home from relatives and friends and in small group settings with intermediate levels of care. Despite an older person’s preference to stay at home, admission to a nursing facility becomes necessary when the person’s physical and mental
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capabilities deteriorate to a point where adequate family and community resources are no longer available. The total number of men and women older than age 65 has continued to rise (National Center for Health Statistics, 2013).
Medical and Psychosocial Models of Care Nursing facilities evolved from the acute care hospital system and the medical model. Like hospitals, nursing facilities were designed around the departments and professionals rather than the consumers they served. Although the organization of nursing facilities tends to be hierarchic and bureaucratic, alternative methods of staffing are being developed and implemented (White- Chu, Graves, Godfrey et al., 2009). This emphasis is on using more licensed nursing personnel to perform primary nursing and case manager roles. Within these models, graduates with a bachelor of science in nursing will have opportunities to fill midlevel management roles and have the opportunity to effect positive changes in long-term care.
The medical model places residents in a sick role and in need of physician-directed help. Compliance with the medical regimen is emphasized. Residents are expected to comply with staff and medical decisions rather than actively participate in determining them (White-Chu et al., 2009). However, one of the changes mandated by the OBRA is an emphasis on the social and psychological health of nursing facility residents, in addition to the traditional medical concerns. Residents’ subjective evaluations of their quality of life need to be solicited and valued. Psychosocial models of care emphasize resident decision making and the exercise of personal choice. The ideal long-term care facility is a combination of both medical and social models, not exclusively one or the other (Box 9-6).
Box 9-6
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Major regulatory “level a” requirements defined by the omnibus budget reconciliation act of 1987 • Resident rights
• Admission, transfer, and discharge rights
• Resident behavior and facility practices
• Quality of life
• Resident assessment
• Quality of care
• Nursing services
• Dietary services
• Physician services
• Specialized rehabilitative services
• Dental services
• Pharmacy services
• Infection control
• Physical environment
• Administration
Sometimes, nursing facility personnel do not fully understand resident rights. Creative strategies are necessary to enhance a resident’s perception of autonomy. The baccalaureate-prepared nurse is in a wonderful position to combine his or her knowledge of medicine, nursing, psychology, and sociology into a model that truly provides individualized care to each resident in the nursing facility.
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Clinical aspects of the nursing facility Resident Rights One of the accomplishments of the report of the Committee on Nursing Home Regulation of the Institute of Medicine (IOM) was to lay the foundation for greater regulatory support of resident rights in the nursing facility (IOM, 1986). Emphasis on resident rights was directly related to a revised view that residents really did have the right to autonomy and to be active participants and decision makers in their care and life in the institutional setting.
Resident rights that are unique to the nursing facility are to be promoted in several ways. These include but are not limited to the following (NHPCO, 2012):
• Establishment and maintenance of a resident council
• Public display of posters listing resident rights
• Public display of local ombudsman program information
• Public display of annual state inspection results
• Aggressive attempts to provide opportunities for residents to exercise their right to vote during public elections
• Provision of opportunities for competent residents to self- administer medications
• An informed consent process for the use of side rails and chemical and physical restraints
• An informed consent process for the withdrawal or withholding of life-sustaining treatments
• A grievance process whereby residents and families can challenge the care that is given
All departments within the nursing facility, including social services, activities, nursing, dietary, and maintenance, must share responsibility for ensuring the enforcement of these resident rights. Ideally, this effort will be the operational philosophy for all nursing facilities.
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Regulatory enforcement focuses strongly on resident safety without always considering a resident’s individual right to be autonomous and make a conscious decision to place himself or herself at risk (e.g., for falling) to retain some degree of independence. Each situation must be evaluated individually, and the legalities may be complicated (NHPCO, 2012).
Resident Assessment Interdisciplinary functional assessment of residents is the cornerstone of clinical practice in this setting. The OBRA prescribed the method of resident assessment and care plan development in an instrument known as the Resident Assessment Instrument (RAI). The RAI consists of three parts: the minimum data set (MDS), the resident assessment protocols (RAPs), and the utilization guidelines specified by the CMS’s MDS 3.0 RAI Manual (CMS, 2012b).
The MDS is a tool that includes a comprehensive assessment of residents. Categories include resident background information; cognitive, communication and hearing, and vision patterns; physical functioning and structural problems; mood, behavior, and activity pursuit patterns; psychosocial well-being; fecal and urinary continence; health conditions; disease diagnoses; oral, nutritional, and dental status; skin condition; medication use; and special treatments and procedures. This resident profile is used to develop an individualized, comprehensive care plan for each resident.
Deadlines for completion of each section and care-planning decisions emanating from the assessment process are prescribed by regulation. Box 9-7 lists the 18 problem areas that need to be addressed in the care-planning process. The outcome of the interdisciplinary team’s clinical decision making related to the 18 problem areas as it feeds into care plan development is explicitly described in the RAP summary.
Box 9-7
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Problem areas of the resident assessment protocol summary • Delirium
• Cognitive loss and dementia
• Visual function
• Communication
• Activities of daily living (ADLs) functional and rehabilitative potential
• Urinary incontinence and indwelling catheter
• Psychosocial well-being
• Mood state
• Behavioral symptoms
• Activities
• Falls
• Nutritional status
• Feeding tubes
• Dehydration and fluid maintenance
• Oral and dental care
• Pressure ulcers
• Psychotropic drug use
• Physical restraints
The specific method used to complete the RAI varies from facility to facility. Some facilities assign one nurse to complete all documentation related to the RAI; others distribute this responsibility among all the nurses. The RAI is completed for each resident on admission, annually, when a significant change of condition occurs (as defined by the CMS MDS 3.0 RAI Manual), and quarterly, using an abbreviated one-page version of the RAI. For persons admitted for skilled care under Medicare Part A, the MDS,
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and the RAI are completed at 5 or 14 days, 30 days, 60 days, and 90 days and with any significant change.
Both licensed vocational or practical nurses and RNs may contribute to the RAI. However, only an RN can sign the document and function as the RN assessment coordinator (RAC). The RAC signs and certifies the completion of the assessment, not the accuracy of the assessment data (CMS, 2012b). Contributions to the RAI are also made by the dietary supervisor, social worker, recreational therapist, medical records clerk, and physical and occupational therapists.
The overall goal of the RAI is to provide an ongoing, comprehensive assessment of a resident, emphasizing functional ability and both a physical and a psychosocial profile. It is also a key component in the development of a national database for long- term care.
Skin Care Skin and nail care programs are important to a resident’s overall health and quality of life. Skin care programs in the nursing facility are focused on prevention and treatment of skin problems. Preventive strategies include prevention of pressure ulcers, skin tears, and dry skin or xerosis.
Other skin-related problems commonly occurring and treated in this setting include MRSA infections, circulatory ulcers, dermatitis, eczema, herpes zoster, scabies, pediculosis, bullous pemphigoid, and skin tumors. The prevention of skin tears, pressure ulcers, and circulatory ulcers is an ongoing challenge for the staff in nursing facilities. The development of pressure ulcers during a person’s stay in a nursing facility is considered an indicator of poor quality of care, although research and current knowledge of pressure ulcer etiology does not support this view as totally accurate. Aggressive and appropriate preventive measures are initiated to address each resident’s specific and unique risk factors (see Chapter 28).
Most nursing facilities have a structured skin care program that is coordinated by an RN and involves all nursing department staff plus a physical therapist, occupational therapist, and dietitian. On
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admission, a resident’s skin is thoroughly assessed. Individual risk for developing pressure ulcers is established, and preventive interventions are initiated as appropriate. These may include some type of special bed mattress, heel protectors, positioning devices, vitamin and nutritional supplements, skin lubricants, and a schedule for repositioning the resident in beds and chairs. The certified nursing assistant (CNA) plays a key role in providing effective preventive skin care by assisting the resident in routine bathing, toileting, and maintenance of schedules for turning and repositioning. The individualized care plan, developed by the interdisciplinary team, provides specific instructions concerning the preventive treatment measures for each resident.
On the basis of the physical examination as well as RAI data, a care plan is initiated. Individual states have varying regulations concerning the required frequency of the nurse’s clinical staging and routine assessment of pressure ulcers. Most facilities require at least weekly monitoring by an RN. The nurse measures and stages the ulcers and evaluates the efficacy of the treatment plan. The director of nursing may also work with the medical director or individual physicians practicing in the facility to coordinate and standardize treatments for various stages of pressure ulcers. Another alternative is to intervene in skin problems on a case-by- case basis according to the preference of the resident’s attending physician.
Facilities may have sustained relationships with companies that manufacture specialized beds for residents with stage III or IV pressure ulcers. Often the company provides a nurse consultant as a clinical resource to the facility. The nurse functioning as the skin care program coordinator might meet routinely with the consultant. The two nurses often work collaboratively, along with the dietitian and physical therapist, to treat skin problems. Consistently following a treatment plan is essential for positive outcomes.
Incontinence As functional dependence increases, the prevalence of incontinence increases. This common health problem has financial, physical, and
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psychosocial consequences, and incontinence is a common reason for placing a person in a nursing facility.
Caring for an incontinent resident is expensive; it requires more nursing time and frequent linen and clothing changes. Physical consequences of incontinence include skin breakdown, UTIs, and an increased risk of falling and consequent hip fracture. Urinary incontinence is one of the most psychologically distressing health problems faced by older adults. It may lead to depression, decreased self-esteem, and social isolation (DuBeau, Kuchel, Johnson, et al., 2010). One of the features of the OBRA was the inclusion of specific standards and recommendations for the assessment and treatment of urinary incontinence. Clinical programs in nursing facilities are directed at prevention, treatment, and management of incontinence. Prevention is aimed at reducing the risk of developing urinary incontinence among at-risk residents of nursing facilities. Preventive measures include assessment of individual patterns of elimination so that anticipatory assistance with toileting may be provided, aggressive staff response to residents’ requests for assistance in toileting, and arrangement of the physical environment to minimize the physical effort involved in getting to the bathroom.
Treatment programs are resident oriented and focus on creating changes in the function of the lower urinary tract. Treatments include surgery, pharmacologic interventions, bladder training, pelvic muscle exercises, and biofeedback procedures (DuBeau et al, 2010). It is important to identify those residents who can benefit from these therapies.
Management programs for urinary incontinence are the dominant form of intervention in the nursing facility. Some residents benefit from programs that involve behavioral approaches such as scheduled toileting, habit training, and prompted voiding. These approaches focus on changing the behavior of the caregiver and the resident to minimize the incontinence. However, residents with dementia and other cognitive impairments may not benefit from these interventions; the use of incontinence pads and protective undergarments are necessary for these individuals. External condom catheters may be helpful to men.
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Intermittent self-catheterization may be appropriate for residents who are cognitively intact and have adequate manual dexterity. Long-term, indwelling catheterization is indicated for residents who cannot empty their bladders and have not responded to other treatments. Residents who are terminally ill and those with skin breakdown may also benefit from indwelling catheterization. Indwelling catheterization is used only after other interventions have failed.
Effective management of urinary incontinence involves a well- coordinated and sustained effort between licensed nursing staff, certified nursing assistants, and activities staff. The nurse must play a key role in managing incontinence and preventing complications; management and treatment must be directed at the cause of incontinence (see Chapter 26).
Nutrition Nutritional deficiencies contribute to adverse clinical outcomes in nursing facility residents. Protein-calorie undernutrition results from two broad categories of factors: those causing inadequate intake and those causing increased nutritional requirements (Kaiser, Winning, Bauer, et al., 2010) (see Chapter 10).
The older population is the single largest demographic group at disproportionate risk of inadequate diet and malnutrition. Aging is associated with a decline in a number of physiologic functions that may impact nutritional status, including reduced lean body mass and a resultant decrease in basal metabolic rate, decreased gastric secretion of digestive juices and changes in the oral cavity, sensory function deficits, changes in fluid and electrolyte regulation, and chronic illness. Medication, hospitalization, and other social determinants also may contribute to nutritional inadequacy. The nutritional status of older people is an important determinant of quality of life, morbidity, and mortality (Brogan & Jen, 2010). Contributing factors include loss of manual dexterity, pain, dementia-related illnesses, certain medications, and chronic medical disorders. Culture, religion, and personal choice also affect how and what a person eats. A resident’s appetite is affected by
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personal comfort and unpleasant odors, sights, and sounds. Meeting a resident’s nutritional needs requires involvement of the entire health care team. The physician, dietitian, nurse, speech and language pathologist, occupational therapist, social worker, and nursing assistant all play roles in the assessment of individual needs, care planning, care plan implementation, and care plan evaluation. The resident is always included, and the resident’s family may also provide important information.
Increased nutritional requirements may be a consequence of hyperactivity in some persons with dementia-related illnesses. Infectious illnesses, periods of recovery after surgical interventions that require tissue healing, and recovery from pressure ulcers also increase nutritional requirements of nursing facility residents.
Various clinical interventions are directed at the nutritional support of residents, including programs focused on maintaining adequate caloric intake and effective identification of residents requiring supplemental nutritional support.
Enhancement of the dining experience through improved aesthetics, improved dining room service, attractive food preparation, and increased sensitivity to the social nature of mealtimes is directed toward maintenance of adequate caloric intake. Other strategies related to this goal include increasing staff assistance for residents who need help with eating and improving staff techniques for providing assistance with eating. Sensitivity to dental needs and provision of the textures of foods most easily and safely consumed by each resident are additional strategies.
In nursing facilities the most common program for prompt identification of residents requiring supplemental nutritional support consists of routine weighing. Weights are taken daily, weekly, biweekly, or monthly, depending on the severity of weight loss or gain experienced by a resident. Interdisciplinary team members, including the nurse, restorative nursing assistant (a CNA with 30 hours of formal training beyond CNA with a focus on direct restorative care and delegated formalized therapy tasks as assigned to continue an ongoing formalized therapy program), dietitian, and speech and language pathologist, may meet routinely to review weight changes and develop interventions directed at
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supplemental nutritional support. In addition to the strategies already described, changes in therapeutic diets and the use of nutritional products (e.g., Ensure), vitamin supplements, and enteral nutrition products may be considered. Laboratory tests are often ordered to help monitor a resident’s nutritional status.
Compliance with the OBRA requires aggressive monitoring of the variables of nutritional status, with attention focused on unplanned weight loss. The functional implications of reduced caloric intake are to be considered. Any unplanned weight loss of 5% or greater in 30 days or 10% or greater in 90 days is an indicator of poor quality of care. Any weight loss or weight gain must be carefully monitored. The reasons for the loss or gain and the interventions taken must be documented.
Medications One of the basic services provided in nursing facilities is administration of medications through oral, intravenous, intramuscular, subcutaneous, and enteral routes. In the nursing facility, the licensed nurse is often responsible for the administration, documentation, storage, ordering, cart stocking, and destruction of many medications. In some states, medication aides are used to administer medications. The RN is responsible for monitoring the medication’s therapeutic effects, side effects, and any allergic reactions. The RN also monitors and evaluates the skills of medication aides on an ongoing basis. Because most nursing facilities do not have an onsite pharmacy, the nursing staff is responsible for medication-related functions that would be handled by the pharmacy staff in an acute care hospital.
Monitoring for the clinical manifestations of polypharmacy, the occurrence of adverse drug reactions, and the overuse of “as required” (prn) drug orders have increasingly been emphasized since the enactment of the OBRA. The pharmacist contributes to this monitoring effort in a monthly drug review of each resident’s medical record, and the nurse has numerous structured opportunities to monitor for these medication-related problems. These opportunities include routine interactions with residents
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while administering medications and assessment at quarterly care- planning conferences, monthly reviews of psychotropic drug regimens, and completion of the long form of the MDS (Sergi, De Rui, Sarti, & Menzato, 2011). Facilities must have policies and procedures to monitor for drug interactions and side effects.
The routine use of certain drugs, including long-acting benzodiazepines, hypnotics, sedatives, anxiolytics, and antipsychotics, has been curtailed since the enactment of the OBRA. Recommended drug dosages and indications for the use of such medications are given to federal and state survey teams to assist them in the survey and inspection process of each nursing facility (CMS, 2012a).
Residents have the right to participate in decisions about care and treatment. They must be informed of any changes in their medication regimens. Nurses must document their ongoing instruction to each resident (or the resident’s legal representative) regarding the initiation of new drug therapy and changes in the dosages of medications. If a resident is cognitively intact, the opportunity to self-administer medications is to be provided (CMS, 2012a). Facilities must have and follow policies and procedures for identifying and following up on medication errors.
Rehabilitation The provision of rehabilitation programs in nursing facilities has increased over the past 15 years. Factors contributing to this growth in rehabilitation include the OBRA regulatory mandate that facilities provide services directed at achieving the highest practicable level of physical, mental, and psychosocial well-being for residents; the growth of the subacute level of care, including nursing facility participation in managed care programs; and sustained political will to control the growth of health care expenditures (Gronstedt, Frändin, Bergland et al., 2013).
Rehabilitation teams in nursing facilities consist of the physician, physical therapists, occupational therapists, speech and language pathologists, and facility interdisciplinary team members, including the nurse, social services representative, activity coordinator, and
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clinical dietitian. Ideally, the rehabilitation team is coordinated by a medical director with rehabilitation training and experience.
For facilities receiving funds from Medicare, managed care organizations, or private insurance groups, weekly rehabilitation meetings are held to review clinical cases. Residents and family members participate in these meetings to mutually set goals and review progress. Weekly meetings promote communication, effective discharge planning, and resident and family education.
Rehabilitation programs may be categorized into two groups. (1) The more intensive rehabilitation programs are reimbursed through the Medicare Part A program, managed care organizations, or private insurance groups. Some of these intensive rehabilitation programs seek credentialing by The Joint Commission and the Commission for Accreditation of Rehabilitation Facilities (CARF) to be recognized as benchmark quality programs. Intensive rehabilitation includes daily or twice-daily therapy sessions involving two or more therapy specialties. These sessions are directed toward returning a resident to a prior level of function and to residence in the community. Endurance building, strengthening, ADL training, treatment of aphasia and dysphasia, cognitive testing and retraining, new disability adaptations training (e.g., after a stroke or an amputation), and training with new adaptive equipment are therapeutic components of these programs. (2) The less intensive rehabilitation programs that exist in nursing facilities are reimbursed through the Medicare Part B program or private payments, or they are part of the basic services offered by the nursing facility. These services include restorative nursing programs involving ambulation, ADLs, self-feeding, and range of motion. Such programs are provided by specially trained certified nursing assistants or facility nursing staff. These programs are established, revised, and supervised by the physical and occupational therapists and the speech and language pathologist. Program goals are focused on the maintenance of functional gains achieved during the more intensive rehabilitation program, regaining a level of function lost because of a short-term illness, and prevention of unnecessary loss of function.
Facilities must provide the required rehabilitation services or
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obtain them from an outside source. The needs of the individual resident are based on a comprehensive assessment. The goal is to help the resident maintain or regain the highest possible level of physical, mental, and psychosocial well-being.
Infection Control The development and spread of infections are a major health and safety hazard in nursing facilities. A written program to protect residents, staff, and visitors from infection is required. Facility policies and procedures must include the use of standard precautions and transmission-based precautions, as outlined by the Centers for Disease Control and Prevention (CDC). They must also follow the Occupational Safety and Health Administration’s (OSHA’s) Bloodborne Pathogen Standard.
The OBRA requires nursing facilities to have an infection control program designed to provide a safe, sanitary, and comfortable environment; its purpose is to help prevent the development and transmission of disease. Facilities must have policies and procedures for investigating, controlling, and preventing infections. Records of incidents and corrective action taken related to infections must be maintained. The infection control program should be able to identify new infections quickly. Special attention is given to residents at high risk of infection (e.g., those who are immobilized, have invasive devices or procedures, have pressure ulcers, have been recently discharged from the hospital, have decreased mental status, or are nutritionally compromised). The program must also include measures to prevent outbreaks of communicable diseases, including tuberculosis (TB), influenza, hepatitis, scabies, and MRSA. Preventive measures involve TB testing and screening programs for residents and staff. The facility must have procedures for following up on any positive results. Programs to make annual influenza vaccinations and pneumococcal pneumonia vaccinations available as appropriate are also in place.
According to OSHA, employees at risk for exposure to bloodborne pathogens must receive free information and training on employment and annually thereafter. Employers must make the
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hepatitis B vaccine available to employees within 10 working days of being hired. Personal protective equipment such as gloves, goggles, face shields, gowns, shoe covers, and surgical caps must be made available free of charge to employees; they must also receive instructions on when and how to use this equipment.
An infection control committee consisting of staff members representing each department meets either monthly or quarterly to review data describing the prevalence and incidence rates of infection. This committee discusses any new or proposed revisions in policies and procedures. Typically, one nurse is designated as the infection control nurse and is responsible for coordinating surveillance, data-collecting activities, and ongoing educational sessions for the facility (Chami et al., 2011). The infection control nurse is the facility’s resource for information related to the infection control program. It is this person’s responsibility to obtain and use current information from the CDC, OSHA, CMS, and state department of health to ensure that the facility’s infection control program is effective and meets standards. The facility’s medical director and consulting pharmacist also are valuable resources.
Every department and every employee has a responsibility to know and follow the policies and procedures outlined in the infection control program. Policies and procedures include hand washing, standard precautions, respiratory protection, the Bloodborne Pathogen Standard, linen handling, housekeeping, hazardous waste disposal, and proper use of disinfectants, antiseptics, and germicides.
Mental Health General topics related to mental health and aging are described in Chapter 27. Among the aged and institutionalized population, mental health issues of particular concern include a variety of behavioral problems that may jeopardize the safety of the resident or other residents (e.g., wandering, kicking, or hitting). Because the residents live in a community setting, behavioral problems are not just an issue for the affected resident. The aberrant behavior of one resident has an effect on other residents.
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Residents manifesting behavioral problems commonly have dementia-related illnesses. More than 60% of nursing facility residents have some degree of cognitive deficit. These deficits frequently precipitate behaviors that are difficult to understand and ameliorate. The use of physical and chemical restraints has finally been restricted, and emphasis is now placed on using behavioral interventions and environmental modifications (see section on Special Care Units). Doors may have alarms to deter wandering, and exercise, music, massage, low-stimulation environments, lighting, and aromatherapy may be used to decrease agitation.
Most important, nurses are learning ways to determine the causes of the disturbing behaviors by assessing for pain, hunger, infection, and inappropriate environmental stimulation. Psychotropic medications are to be used only as a last resort, and the side effects are to be carefully monitored. As research continues to identify the various types of dementia, it will become more and more important to specifically diagnose the type. All dementia is not Alzheimer disease, and residents with other types of dementia may have negative and dangerous responses to psychotropic medications.
End-of-Life Care The nurse working in a nursing facility is responsible for helping the entire health care team meet the physical, spiritual, and psychosocial needs of dying residents. Ministering to the residents’ families is an important part of this care. Knowledge about a resident’s culture and religious beliefs helps the team provide more effective and compassionate care. Some facilities provide hospice training for staff. Hospice programs may also provide care to residents in the nursing facility (see Chapter 18).
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Management aspects of the nursing facility The Nursing Department The nursing department is the largest department in the nursing facility. The director of nursing is responsible for managing the entire nursing staff. This consists of RNs, licensed vocational or practical nurses, CNAs, and, occasionally, gerontologic nurse practitioners. In some facilities, nurse managers (usually RNs) assist the director of nursing in managing and carrying out functions of the nursing department. Nurse managers may be responsible for a particular shift, a nursing unit, or specific nursing department functions such as infection control, restorative nursing, total quality management (TQM), and nursing education. Some facilities use unit charge nurses. These are usually RNs, but in some areas, they are licensed vocational or practical nurses. Some facilities employ nurse practitioners to provide clinical expertise and serve as a valuable resource for the nursing staff. Nurse practitioners often work closely with the medical director and the resident’s primary care physician to manage the resident’s day-to-day care. They may write orders for medications and treatment following collaborative practice protocols.
Of the RN work force, 8% work in long-term care facilities (Bureau of Labor Statistics, 2012). Certified nursing assistants are the largest employee group in the nursing departments and the facilities as a whole; nursing assistants provide as much as 80% of direct care for long-term care residents (National Network of Career Nursing Assistants, 2012).
Working in the nursing facility presents rewards, opportunities, and challenges for nurses. Rewards include the chance to establish long-term relationships with residents and family members and an opportunity to work in a setting that has a holistic orientation toward resident care. Nurses employed in nursing facilities have many opportunities to use their professional skills as clinicians, teachers, and managers. They are part of an interdisciplinary team
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that provides a broad spectrum of health care services. The nurse frequently takes a leadership role in developing policies and procedures, assessing resident care needs, developing and implementing care plans, and evaluating outcomes. Excellent assessment and critical thinking skills are very important. A qualified, creative nurse can advance from staff nurse to charge nurse to nurse manager. Opportunities to chair committees on topics such as TQM, infection control, restorative nursing, and pharmacy are also available. Opportunities for professional growth continue to increase in this evolving, challenging area of health care. However, nurses who choose long-term care as a career must be willing to function in a highly regulated industry. Funding for innovative programs and services is often limited, and in some geographic areas, salaries are lower than in acute care settings.
Nursing Care Delivery Systems Several nursing care delivery systems are found in nursing facilities. This section discusses the pros and cons of the various delivery systems. Unfortunately, the system that is most likely to be in place is the one that is the least expensive. Federal regulations regarding staffing requirements for nursing facilities are broad and vague. They are not based on resident acuity and allow the individual facility to determine whether it can provide the care required for any given resident. Few, if any, states have required staffing ratios that are more stringent than the federal requirements.
One nursing care delivery system is functional nursing. Jobs of licensed nurses and CNAs are determined according to work tasks. For example, these may include a minimum data set (MDS) nurse, an admission nurse, a medication nurse, a treatment nurse, a restorative nursing assistant, and possibly a dining assistant. CNAs may take groupings of rooms as an assignment for a variable period. A charge nurse functions as the first-line manager. This care delivery system is widely used because it can carry out basic care somewhat efficiently while maintaining only the minimum staffing levels required by regulations. However, if verbal communication between staff members is poor and written documentation inadequate, many resident issues and care needs go unaddressed.
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Team nursing is a more integrated care delivery system than functional nursing. The licensed nurse, working with a group of residents (usually 30 to 50), provides medications and treatments to residents, functions as charge nurse or first-line supervisor to the certified nursing assistants, and maintains the required documentation for the residents. The licensed nurse may change the resident group assignments on a scheduled basis, usually weekly or monthly. CNAs may change every week or every month. The team nursing system has several advantages. Long-term continuity cannot be provided when CNAs and licensed nurses change group assignments frequently. Staff do not form attachments to residents, and residents, particularly those with memory loss, often have difficulty coping with these changes (e.g., remembering new names and faces and adjusting to the expectations of new personnel) (Duffield, Roche, Diers et al., 2010). The other major disadvantage of this system is the burden placed on one licensed nurse to safely and efficiently provide medications and treatments to 50 residents, thoroughly assess episodic health problems, and meet documentation requirements.
A third delivery system is primary team nursing, which is also called total client care. This involves the combination of a licensed nurse and a CNA working together to care for approximately 10 to 15 residents (Duffield et al., 2010). This team provides all nursing care, including admissions, assistance with ADLs, and administration of medications and treatments. The main disadvantage is that too few staff members are available to meet all of the residents’ needs, and a risk of inadequate coverage exists when some staff are on break (Duffield et al., 2010).
Regardless of the care delivery system used, the RN practicing in the nursing facility is challenged to work effectively with licensed vocational or practical nurses and CNAs, incorporating them into a professional practice model. It is essential that the RN practicing in this setting have excellent supervisory and management skills. The leadership positions in the department of nursing are held by RNs; these positions include director of nursing services and, increasingly, director of staff development. The baccalaureate level nurse is the best prepared to fill these positions and significantly
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affect the quality of care and the quality of life of many residents.
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Specialty care settings Assisted Living Programs Assisted living facilities are an increasingly attractive long-term care setting, placed between home care and the nursing facility in the continuum of long-term care (Assisted Living Provider Type Definitions, 2013). Regulations are minimal, so great diversity exists in the types of service delivery models used, the types of services offered, and the setting within which assisted living is provided.
Assisted living settings are homelike and offer an array of services, including meals, assistance with bathing and dressing, social and recreational programs, personal laundry and housekeeping services, transportation, 24-hour security, an emergency call system, health checks, medication administration, and minor medical treatments (Assisted Living Provider Type Definitions, 2013). Many services are purchased individually as needed by the resident.
The professional nurse can provide a broad and holistic array of services to residents in assisted living facilities. Many opportunities exist to incorporate both health promotion and illness care into the model. Resident education may delay admission to long-term care. The professional nurse may help coordinate the services provided by various departments, for example, activities, social services, physical and occupational therapy, and housekeeping. As the need for assisted living facilities continues to grow, so will the opportunity for professional nurses to define their contributions and enhance the services offered to frail older adults.
Special Care Units Since the 1980s, the popularity of specialized units for persons with dementia has expanded. Special care unit (SCU) is the designation given to freestanding facilities or units within nursing facilities that specialize in the care of people with Alzheimer disease and other types of dementia-related illnesses. Behavioral manifestations of
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dementia are managed in the environment without the use of chemical or physical restraints, whenever possible.
It is advisable for SCUs to have objective, measurable criteria for admission. An objective discharge policy should also be in place. These admission and discharge criteria are helpful to both nursing staff and families who are reluctant to transfer residents to another care setting when a particular resident can no longer benefit from the specialized milieu of the SCU and no longer requires a secured unit. Admission criteria also deter SCU placement for residents without dementia who have other behavioral problems.
SCUs have physical environmental features that control stimuli and maximize safety yet minimize environmental barriers to freedom of movement (e.g., door alarms and outside fencing to facilitate safe wandering). Program features emphasize nutrition (e.g., finger foods and portable foods), structured daily activities, family involvement, and special staff training in behavioral manifestations of dementia and communication with residents who have dementia. An interdisciplinary team coordinates services and care.
Employment opportunities for the nurse in the SCU are similar to those in the traditional nursing facility. The SCU is a desirable work setting if the nurse has a particular interest in the health care needs of persons with Alzheimer disease and other dementia-related illnesses that have behavioral manifestations. It is not a work setting that everyone can enjoy. Nurses who work with these special resident populations are in a position to provide valuable consultation regarding persons with Alzheimer disease to nurses practicing in other settings, including hospitals, home care, and nursing facilities.
Subacute Care Subacute care, a $1-billion business annually, has become an increasingly popular level of care (Marcantonio & Yurkofsky, 2009). The growth of subacute care has been spurred by the belief that up to 40% of clients in acute medical or rehabilitation hospital units could be treated as effectively in less costly settings. With increased
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political awareness of the rising costs of the Medicare and Medicaid programs, the prospect of significant savings provided by subacute care is an attractive one. Insurance companies are looking to less costly settings to provide patient care. It is estimated that subacute care could eventually replace almost 50% of current acute care hospital lengths of stay.
Subacute care is an industry category rather than a reimbursement or regulatory category. Professional organizations have developed guidelines for the clinical and business development of this level of care. Facilities with subacute care programs are able to obtain accreditation through The Joint Commission and CARF. These accreditations are granted to facilities with well-defined subacute care programs. Care may be reimbursed through Medicare, HMO benefits, private payment, or Medicaid.
Persons in a subacute care unit are stable and no longer acutely ill or requiring daily physician visits. They may require services such as rehabilitation, intravenous medication therapy, parenteral nutrition, complex respiratory care, and wound management.
The nursing facility has not traditionally been considered a setting in which aggressive rehabilitative services or acute care treatments such as intense rehabilitation, ventilator care, and intravenous infusion therapy are provided. Subacute care is a growing industry in which services such as these are offered to older persons, clients of managed care organizations, and clients whose private insurance company has contracted with a nursing facility to provide care. To care for such clients, the nursing staff requires a level of clinical skill beyond what is typically needed in the nursing facility. Staffing levels, particularly related to licensed nurses, are higher in response to the increased client acuity (Marcantonio & Yurkofsky, 2009). Physician involvement has also increased significantly.
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Innovations in the nursing facility Creativity in “Everyday” Nursing Facilities All that is required to put a little life and love into any nursing facility is some creative thinking, a desire to make life better for residents, and adequate funding. As in similar endeavors, obtaining the financial resources can be the most difficult aspect of this process. However, the innovative nurse accepts this challenge and looks beyond the usual sources to obtain the necessary resources to develop and support new interventions.
Nursing facilities all over the country have acquired dogs, cats, and other animals that can live in the facility and serve as loving companions to the residents. More functionally capable residents can sometimes take primary responsibility for walking and feeding these pets. Aviaries containing tiny birds provide hours of enjoyment for many residents. Music therapy, touch therapy, and aromatherapy are among other innovative activities currently being used in nursing facilities. Indoor and outdoor gardening projects are therapeutic for many residents (Box 9-8).
Box 9-8
Case study The following situation depicts how a team of home care providers, coupled with a determined client, can accomplish more than any one discipline working independently.
Situation Mrs. T is a 68-year-old Polish housewife who suffered a left-sided cerebrovascular accident on February 25. Her hospitalization consisted of a stay in an acute care facility followed by an
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extensive stay in a rehabilitation setting. She was discharged to home with a referral to home care on May 1. On admission to home care, the nurse’s assessment indicated that Mrs. T had right hemiparesis and aphasia. She had fecal and urinary incontinence and has an indwelling Foley catheter. Her blood pressure was 152/94 mm Hg; apical pulse was 74 beats per minute; respirations were 20 breaths per minute; and temperature was 98.0° F (36.6° C). These vital sign findings remained consistent throughout the initial stages of her home care program. She also complained of gastrointestinal pain. Her behavior was described as labile with periods of agitation, tearfulness, hyperventilation, and impulsiveness. Mrs. T required 24-hour supportive care with maximum assistance with activities of daily living (ADLs). She wore a right short leg brace and a sling to prevent subluxation of her right arm. A wheelchair, hospital bed, and commode were ordered by the hospital discharge planner to aid in Mrs. T’s care. She was given prescriptions for the following medications:
• Folic acid 1 mg orally (po) every day (qd)
• Docusate (Colace) 240 mg po, qd
• Bisacodyl (Dulcolax) suppository ½ to 1 rectally, every morning as needed (prn)
• Famotidine (Pepcid) 40 mg po, every hour of sleep (qhs) prn
• Enteric-coated aspirin 325 mg po, qd
• Psyllium (Metamucil) 1 tbsp po, qd, prn
• Magnesium hydroxide (Milk of Magnesia) 2 tbsp po, prn
• Amlodipine besylate (Norvasc) 5 mg po, qhs
Although Mrs. T had the support of two sons and her sister, the primary caregiver was her 70-year-old retired husband. Mr. T wanted his wife at home but had no experience or desire to assist with caregiving. This attitude made it more difficult for the home care team to develop and implement the care plan.
Because of the severe sequelae of the stroke, the following services were ordered:
• Nursing—one to three times a week to observe vital signs,
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ensure medication compliance, assess bowel and bladder function, change Foley catheter, and begin bowel training program
• Physical therapy—two or three times a week to decrease spasticity, increase range of motion, and increase endurance
• Speech pathology—two times a week to improve communication abilities
• Occupational therapy—two or three times a week to assess and reinforce ADLs
• Medical social work—two to four times a month to assist with community resources and possible placement in a nursing facility
• Home health aide (HHA) service—three or four times a week to assist with personal care
Early in the home care program, it was determined that Mrs. T’s labile behavior was interfering with her home rehabilitation program. She cried easily, became agitated, and hyperventilated when frustrated. When transferring or walking, she anticipated the next move before it was time to move, thereby increasing her risk for falls and injury. The hyperventilation interfered with therapy, so the treatment would have to stop until she became calm and ready to continue. After some discussion of this problematic behavior, the team determined that teaching Mrs. T to breathe slowly, deeply, and through pursed lips would diminish the hyperventilation.
This technique was so successful that Mrs. T was able to recognize independently when she was beginning to hyperventilate and then stop herself. A psychiatric occupational therapist provided additional assistance to Mrs. T and the team to minimize the additional labile behaviors. During this time the primary nurse assisted Mrs. T with a bowel and bladder program and was able to remove the Foley catheter successfully. Bowel control was achieved through dietary changes and consistent use of the commode. Mrs. T’s blood pressure was also under control, and her gastrointestinal upset was diminished by consistently
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eating breakfast.
The HHA worked with physical and occupational therapists to reinforce the exercises and safe transfer techniques. Because the aide was assisting with personal care, she was able to reinforce physical and occupational therapy exercises while assisting with transfers, walking, and bathing. The aide reported that Mrs. T wanted to use the bathtub and recommended that placement of the commode in the tub could allow Mrs. T to transfer safely to the commode and then into the tub. This observation and recommendation from the HHA greatly enhanced Mrs. T’s progression with self-care activities.
Although team members worked on their individual treatment plans, they also shared observations and planned combined goals with Mrs. T. Her husband, however, distanced himself from the planning and indicated that he wanted to be only minimally involved with her treatment. He did, however, reiterate his commitment to have her at home and “try to make it work.”
With the active involvement of all the team members, Mrs. T made significant progress toward independence. She progressed from using only the wheelchair to a hemiwalker and was ready to begin training with a four-prong cane. Then, on October 10, her husband died suddenly, having recently been diagnosed with pancreatic cancer. This unexpected event caused Mrs. T to become depressed and to regress. She made suicidal statements that alarmed several of the team members. The team requested the involvement of a psychiatric nurse to work with Mrs. T on the grieving process and to conduct a suicide risk assessment. Although it is usually necessary to have a psychiatrist involved when a psychiatric nurse makes visits, in this case the psychiatric nurse visited in place of the primary nurse and also provided medical and surgical nursing services. The psychiatric nurse made three visits, working with Mrs. T on the grieving process, planning for the upcoming holidays, and dealing with issues of altered body image brought on by the stroke. Mrs. T shared her concern that her grandchildren were afraid of her because of her stroke. At this point Mrs. T indicated that she was ready to continue her treatment, and she made no further allusion to
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suicide.
Because Mrs. T was now alone and the temporary assistance from her adult children was not a permanent solution, a referral was made to social work to help Mrs. T plan for her future living arrangements. A 24-hour, live-in homemaker was hired as a temporary measure until Mrs. T could decide if she wanted to move to a retirement community. In some respects, the presence of the homemaker encouraged Mrs. T to make greater accomplishments because she refused to allow the homemaker to do certain things in the kitchen and would not allow her to assist with personal care. Mrs. T also tackled stair climbing so she could get outside for walks.
At this time, Mrs. T continues with her home exercise program. She has not made a decision about moving, so her live-in homemaker is still with her. She is completely independent in dressing, bathing, meal preparation, and ambulation. The team of home care personnel has conducted several case conferences regarding Mrs. T and her progress. This progress is the result of the dedication of a diverse team of home care workers and the desire of an individual to work hard and set her sights on goals that no one thought she could attain.
Nurse Practitioners in the Nursing Facility Over the past two decades, many studies have been conducted to evaluate the impact of the nurse practitioner on older adult residents of nursing facilities. Long-term care facilities that use nurse practitioners are able to provide more timely care to acutely ill residents. The use of nurse practitioners in collaboration with physicians has been shown to reduce emergency department transfers, hospital days, and subacute days. Several HMOs are using physician–nurse practitioner teams to provide primary care to nursing facility residents (Bakerjian, 2008).
A nurse practitioner hired by a facility must have the full support of administration to have a real effect on care. He or she must be free to be an educational resource for staff without being required to participate in staff evaluations. The nurse practitioner must also
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have the full support of the facility medical director, who serves as a resource for the practitioner and sanctions his or her services and expertise.
Despite studies demonstrating the cost-effectiveness of nurse practitioners in nursing facilities, few facilities currently employ them on a full-time basis. The major employment opportunities are with groups of physicians who carry a large nursing facility practice. These nurse practitioners may go on rounds with the physician or see nursing facility residents independently on alternate months, while the physician sees residents in the intervening months. Medicare reimburses both the physician and the nurse practitioner for this method of overseeing residents. In addition to seeing residents in the nursing facility, the practitioner may handle telephone calls from nursing facilities, triage problems, diagnose problems, and prescribe treatments and medications as needed.
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The future of the nursing facility The future of the nursing facility is complicated and uncertain. Its destiny is intimately linked to public policy regarding health care reform, long-term care, and mechanisms of reimbursement. Certain aspects of this service setting are flourishing, including subacute care and SCUs for the cognitively impaired. Some industry analysts believe that the rapidly developing market of assisted living programs will radically change the face of the nursing facility over the next 10 years. It is speculated that the nursing facility will exist to provide care for severely cognitively and physically impaired residents.
Whatever happens, it is essential that the professional nurse play a dominant role in improving and transforming this practice setting. Nurses can better prepare themselves to play this role by becoming better educated in nursing, nursing administration, health care regulation, and public policy related to long-term care.
Nurses need to be leaders in helping to shape the future of how and where long-term health care is provided. Being creative in a highly regulated industry is a significant challenge. Professional nurses who conceptualize their practice as including care for the whole person, principles of health promotion and disease prevention, and creative use of the organizational and social environment to achieve health outcomes will make a valuable contribution to society. Through such efforts by nurses and other like-minded professionals committed to achieving excellence, the nursing facility will be a place where people truly can live out their days with dignity, integrity, and a sense of personal autonomy.
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Summary Although nursing is a recognized specialty, most nurses working in a variety of practice settings today are working primarily with older adults. Nurses need to provide competent, evidence-based care. The growing number of certified basic and advanced practice nurses will help in the endeavor, as will the inclusion of more content in nursing school curricula. New acute care models will improve the care of hospitalized older adults, as will the development and dissemination of protocols that guide the assessment and treatment of commonly encountered geriatric syndromes.
Attitudes affect care delivery, and a nurse’s respect and care for the special needs of older adults are essential. The diverse roles of acute care nurses working with older patients include those of practitioner, advocate, collaborator, educator, and case manager. In addition to ensuring safe and restorative health care in the hospital, the nurse must also address the learning needs, decision making, and ethical and legal issues involved in caring for older persons.
The health care needs of a growing, noninstitutionalized older adult population, coupled with rapid changes in today’s health care delivery system, demand continued exploration of alternative services and delivery mechanisms that support the care of older persons in home and community settings. This chapter explored the current health care needs of community-residing older persons, community-based services, the role of family members and friends in providing informal care, and the role of home care agencies and home health nurses in community-based care for this population.
The need for programs and services aimed at supporting older persons and their caregivers in the community setting will continue to grow. Options for care must expand, and nontraditional alternatives must be developed for use by various health care personnel. The reimbursement structure is currently challenged, and will clearly continue to be, to accommodate these developments.
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This chapter presented a variety of issues relevant to long-term care. Care of this type has evolved into the specialty care settings discussed. Clearly, the entire long-term care industry is one of the greatest challenges not only to society at large but also to all health care professionals.
Recent attempts at regulating nursing facilities for the benefit of residents’ overall health and well-being are an important yet modest step toward reform. Professional nurses must combine caring with innovative leadership to continue to make positive changes within this setting.
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Key points • Adults older than age 65 account for 47% of the country’s
inpatient days; the average length of hospital stay is 2 days longer than that of younger patients.
• The physical and social environment in which care occurs must be modified to facilitate maintenance of function and reduce the incidence of iatrogenic complications.
• Three conditions that require special attention during the hospitalization of older adults are falls, changes in cognitive status, depression, and incontinence.
• New models of acute nursing care have emerged that are demonstrating improvements in the quality of the nursing care provided to hospitalized patients.
• Increasing numbers of older adults are discharged from hospitals with significant needs related to medical care and functional impairments; therefore, home health care for older adults is becoming more common and more complex.
• Older adults, family members, and health care providers, including nurses, must learn about hospice care in order to make timely and appropriate referrals.
• Terminally ill older adults and their families are not maximizing the benefits of hospice care because of late referrals and misunderstanding of the Medicare hospice benefit.
• The Medicare hospice benefit covers (1) services and visits by all hospice staff, (2) durable medical equipment, (3) supplies needed for the plan of care, (4) medications related to the terminal diagnosis (may involve a small copayment at the discretion of the individual hospice), and (5) dietary supplements.
• Home care is often chosen as a preferred treatment site because people want to remain in their homes, home care is usually less expensive than hospitalization, and home care minimizes exposure to multiple infectious processes. In addition, technology
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has evolved to support complex treatments in the home.
• Assessment for home care should be done early in a client’s hospital stay. Hospital discharge planners and home care managers must work together to ensure the continuity of care necessary for a timely and effective discharge.
• The home care nurse assesses the physical, functional, emotional, socioeconomic, and environmental well-being of clients. The nurse works in collaboration with all other members of the home care team whose services are needed to address the home care plan of treatment.
• Hospice nurses perform comprehensive, holistic assessments that are similar to those of home health nurses. In addition, the spiritual dimension is an important component of hospice care. In the hospice, the terminally ill person and the family are the unit of care. Therefore, all assessments by members of the interdisciplinary hospice team address both as a unit.
• Residents in nursing facilities may be categorized according to their length of stay as short-term residents or long-term residents.
• Risk factors associated with institutionalization include advanced age, physical disability, mental impairment, white race, living without a spouse, frailty, depression and the presence of chronic medical conditions.
• The MDS includes a comprehensive and interdisciplinary assessment of residents.
• The RN plays a key role in all clinical programs, including programs for skin care, management of incontinence, nutrition, infection control, and the promotion of mental health.
• Nursing care delivery systems in nursing facilities include functional nursing, team nursing, and primary team nursing.
• Assisted living programs, SCUs for dementia, and subacute care units provide unique opportunities for RNs who wish to specialize in one aspect of the care provided in institutional settings.
• Recent innovations in the nursing facility involve self-governance
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programs for residents, nursing education programs, and the use of nurse practitioners.
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Critical thinking exercises 1. You have just admitted a 92-year-old woman to your nursing unit. How will you modify the hospital’s physical and social environment to accommodate the needs of this patient? Why are such modifications necessary?
2. An 88-year-old man is being treated for a cardiac disorder. He is alert and interested in his care, but he has a hearing deficit. On teaching him about his cardiac medications, you notice that he often gets confused about the dosing schedules, names, and side effects of each medication. Offer several strategies to help him remain independent and maintain accurate medication schedules and monitoring.
3. A 90-year-old woman has been living with her 68-year-old daughter for 5 years. The daughter is suffering from complications of long-term diabetes and feels that she is no longer able to care for her mother. No other family members are willing to take the woman into their home. How would you go about determining the options available to the mother?
4. Symptom management is a critical part of hospice nursing care. What is meant by the statement, “Make pain assessment the fifth vital sign”? What are some strategies you can use in assessing the pain status of older adults?
5. What is the OBRA, and what positive effects is it designed to make on the care of older adults residing in long-term care facilities?
6. A 90-year-old man has fractured his hip, and his recovery has been very slow. He has suffered occasional complications, but he is progressing. Why might long-term care be advantageous to him during his recovery?
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* Previous authors: Acute Care: Janet Dugan, MS, RN; Donna Deane, PhD, RN; Linda K. Mosel, MSN, RN, CS; and Kathleen Fletcher, RN, CS, MSN, GNP; Home Care and Hospice: Judith J. McCann, DNSc, RN; Kathryn E. Christiansen, DNSc, MA, BSN; Deborah K. Fultner, MS, RN, CS; and Barbara M. Raudonis, PhD; Long-term Care: Mary Ellen Dellefield, MS, RN; Bernie Gorek, RNC, GNP, MA; and Gayle Andresen, RN, MS, A/GNP; Revised and combined: Sue E. Meiner, EdD, APRN, BC, GNP.
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PA R T 3 Wellness Issues
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C H A P T E R 1 0
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Nutrition Kathleen M. Rourke, PhD, MSN, RD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Differentiate between the social, cultural, and emotional aspects of food as well as the physiologic aspects of nutrients in food.
2. Correlate the physiologic changes of aging with food intake patterns.
3. Differentiate between a nutritional screen and a nutritional assessment.
4. Identify the steps and core data collection elements of a nutritional assessment.
5. Describe the changes in nutritional requirements for aging persons.
6. Describe the role of therapeutic diets and nutritional support in nutritional therapies.
7. Identify major dietary guidelines and recommendations for healthy persons of all ages.
http://evolve.elsevier.com/Meiner/gerontologic
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Social and cultural aspects of food Although the core role of food is simply the provision of energy and nutrients for bodily functions, very few individuals view food from this perspective. Throughout history, different types of foods have served as poisons, potions, or panaceas for health, potency, long life, and love. Hippocrates (460–377 bc), the “Father of Medicine,” reflected his commitment to the importance of diet in a statement from the Hippocratic Oath: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice” (Tannahill, 1988). Cato the Elder (234–149 bc), a Roman statesman, ate large amounts of cabbage in the belief it had special healing properties. A later Roman scholar, Pliny the Elder (23–79 ad), ate the foot and snout of the hippopotamus to enhance sexual potency, whereas a Chinese physician of the 6th century bc prescribed certain foods for patients to stimulate the yin (female principle) and the yang (male principle) to keep a person healthy (Tannahill, 1988).
The increased interest and use of complementary and alternative medical therapies, including consumption of herbal teas, vitamin therapy, and a variety of touch therapies such as massage therapy further emphasizes the role of nutrition and the importance of integrative health care teams. It is also emphasizes the importance for the clinician and practitioner of Western medicine to maintain a thorough and up-to-date understanding of not only the concepts and mechanisms of Eastern medicine but the U.S. Food and Drug Administration (FDA) regulations that protect the health care consumer (Cohen, 2003). Some research has demonstrated the efficacy of therapies in relation to a particular physiologic problem. Certainly, the role of nutrition in controlling epigenetic modifications is becoming more clearly understood in relation to its importance in the short- and long-term impact on health and well- being and should not be disregarded (Park, Frisco, & Choi, 2012). Nurses who use evidence-based research to guide their patients on the use and consumption of complementary and alternative therapies in the treatment of any disease or condition enhance
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patient outcomes and avoid therapy interactions and side effects. The use of vitamin and mineral supplements, ergonetic aids, and herbal teas may affect drug or nutrient interactions, or both. Therefore, careful assessment of a patient’s diet and supplement intake is important in understanding the patient’s overall medical picture. A nursing referral to a registered dietitian (RD) is very helpful for patients with complex dietary and medical conditions.
In today’s fast-paced, complex society, food is often purchased prepared and prepackaged. Food and diet are manipulated to enhance athletic performance, carbohydrates are avoided to force the body into ketosis in an effort to burn fat for weight loss, and supplements are taken to replace the vitamins and minerals missing from the “fad diets” many Americans try. Water is bottled, sold, and purchased at extraordinary costs under the assumption that “it is better for me.” Comfort foods are now a designated and popular category, particularly after the terrorist attacks on September 11, 2001, when purchases of donuts and pastries increased significantly (Balon, 2002; Comforted but unfattened, 2002).
Food is much more than fuel for the body; food in our society is a social centerpiece, a source of comfort, and a symbol of celebration. Consider the monthly calendar:
• January: New Year’s Day and the Super Bowl
• February: Valentine’s Day
• March: St. Patrick’s Day, March Madness
• April: Passover and Easter
• May: Mother’s Day and Memorial Day
• June: Father’s Day and Weddings
• July: Fourth of July
• August: Summer fairs
• September: Labor Day
• October: Halloween
• November: Thanksgiving
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• December: Holidays
In addition to these holidays, birthdays, anniversaries, and other personal holidays are also part of the annual calendar. Life, death, and everything in between is celebrated with food. Culturally, food is a symbol of heritage, land, and environment, and religiously food is abstained from, eaten only on certain days, and certainly blessed by a higher power for the energy it provides to the body. Religious practices also specify prohibited foods and beverages (see Cultural Awareness boxes).
Cultural awareness
Selected Examples of Cultural Meanings in Food • Critical life force for survival
• Relief of hunger
• Peaceful coexistence
• Promotion of health and prevention of disease or illness
• Expression of caring for another
• Interpersonal closeness or distance
• Promotion of kinship and familial alliances
• Solidification of social ties
• Celebration of life events (e.g., birthday, wedding)
• Expression of gratitude or appreciation
• Recognition of achievement or accomplishment
• Business negotiations
• Information exchange
• Validation of social, cultural, or religious ceremonial functions • Means to generate income
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• Expression of affluence or social status
• Expression of being well traveled or sophisticated
Cultural awareness
Dietary Practices of Selected Religious Groups*
Prohibited Foods and Beverages Hinduism All meats
Islam Pork and pork products
Animal shortenings
Alcoholic products (including extracts such as vanilla or lemon)
Marshmallows, gelatin, and other confections made with pork
Note: Fasting is common. Fasting is mandatory in the daylight hours during the months of Ramadan.
Judaism Pork
Predatory fowl
Shellfish or scavenger fish (e.g., catfish, shrimp, escargot, lobster) (Fish with fins and scales are permitted.)
Mixing milk and meat dishes at same meal
Blood by ingestion (e.g., blood sausage, raw meat) (Blood by transfusion is acceptable.)
Notes:
1. Only meat from cloven-hoofed animals that chew cud (e.g., cattle, sheep, goat, deer) is allowed. The animals must have
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been slaughtered observing rigid rules that result in minimal pain to the animal and maximum blood drainage.
2. Foods should be kosher (meaning “proper” or “fitting”), which is accomplished in one of two methods:
a. Meat is soaked in cold water with coarse salt for a half hour and drained to deplete blood content. It is then thoroughly washed under cold, running water and drained again before cooking.
b. Meat is first prepared by quick searing or cooking over an open flame, which permits liver to be eaten because it cannot be prepared by the above method.
3. Meat and dairy products cannot be served at the same meal, nor can they be cooked or served in the same set of dishes. Milk or milk products may be consumed just before a meal but not until 6 hours after eating a meal with meat products. Fish or eggs can be eaten with dairy products or meat meals.
Mormonism (Church of Jesus Christ of Latter-Day Saints) Alcohol
Tobacco
Stimulants (including beverages containing caffeine, e.g., coffee, nonherbal teas, colas, and selected carbonated soft drinks)
Seventh-Day Adventist Church Pork
Certain seafood, including shellfish
Fermented beverages
Notes:
1. Optional vegetarianism includes (a) strict vegetarianism, (b) ovolacto-vegetarianism, or (c) no pork or pork products, shellfish, or blood.
2 Snacking between meals is discouraged.
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* These dietary practices are generalizations; not all of these religions follow these guidelines.
Nutritional interventions that do not take into account the social, cultural, and emotional aspects of food are rarely effective because few individuals “eat to live”; most of us “live to eat.” For the nurse, understanding a patient’s social, cultural, and emotional ties to food may be a great asset in working with nutrition and health issues. This is especially true with geriatric patients, who hold strong ties to their culture, need social interaction to enhance functional status, and may be emotionally labile when different foods are presented and frequently suffer from more health care issues, take one or more medications, or both, which may interact with their nutritional status. For some, food may be a private and delicate matter, which the health care practitioner must be sensitive to during conversation. Although the nurse is unlikely to influence their patients’ basic beliefs about foods and their religious significance, the nurse should attempt to fully understand their cultural and religious beliefs and make recommendations that are consistent with these beliefs. Overall, within the medical field, and compared with fields such as biochemistry, chemistry, and biology, the field of nutrition is a young science. Changes in nutrition and food policy occur frequently, confusing the consumer as well as the health care practitioner who is not solely focused on nutrition. Many new frontiers remain to be discovered. For instance, a major focus is placed in research regarding the impact of nutrient substrates on disease prevention, immune system stimulation, and response to critical illness (Petchetti, Frishman, Petrillo, & Raju, 2007; Rattan, 2007; Szekely, Breitner, & Zandi, 2007). Researchers studying this use of nutrients have coined the term nutriceuticals to imply that these nutrients and nutrient substrates have pharmaceutical effects. Likewise, growth in the field of epigenetics has demonstrated a connection between the environment, diet, and cancer, among other diseases (Verma, 2013).
Nursing professionals are encouraged to work with an RD, who is constantly updated on the latest nutritional applications for patient care. This collaborative relationship may optimize patient outcomes and enhance work efficiency for each practitioner,
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bringing a higher quality of health care to the patient while growing as practitioners. Allied health researchers and practitioners perceive dietary intake as one of the most significant, controllable tools for wellness, disease prevention, rehabilitation, and treatment or therapy for a wide range of disorders. To successfully make changes in patients’ poor dietary choices, the entire team must work together and have an appreciation for the social, cultural, and emotional significance food plays in the vast majority of the population.
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Demographics of the aging population The “graying of the American population” is considered one of the most far-reaching medical, nutritional, and economic issues in our society. Medically, this is a population that has served its country, worked hard, and now faces a health care system that views patients in terms of cost. Some of the individuals in this population are survivors of deadly bacterial diseases that plagued the world in the early 1900s. With the development of antibiotics, a major pharmaceutical industry, and sophisticated medical technology, these individuals who helped automate this country are not only living longer but are also hearty souls capable of overcoming many adversities. The other very large cohort of the aging population (individuals 65 years and older) are the “baby boomers” who are expected to number more than 89 million individuals by the year 2050 (Centers for Disease Control and Prevention [CDC], 2013). This population of baby boomers has driven and changed the landscape of the United States from expanding sales of commercial baby food in the 1940s to the construction of houses and new schools in the 1950s. Their impact on health care, public policy, and other social forces should not be understated. Finally, the U.S. population is experiencing a significant shift in diversity and ethnicity, which is also reflected in the older adult population. In 2010, 80% of the population ages 65 and older were non-Hispanic whites. However, by 2030, only 71.2% of the population over 65 years will be non-Hispanic whites. At that same time, blacks will make up 10.3% of the population, and Asians will comprise 5.4% of the population (CDC, 2013).
In the past, the aging population of individuals generally believed in the benefits of home-cooked family meals with fresh ingredients and in cultural connections. Previous generations of older adults were less comfortable with the food choices being made from today’s fast-paced world and may be less comfortable with the high-tech cooking gadgetry of the new millennium. As the baby boomers are progressing through their retirement years (65–70
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age group), this aversion to technology is much less pronounced. The food choices and cooking habits in this age group are more erratic, and many prefer the use of technology in their methods of cooking to allow time for other activities; however, this age group may need support and guidance in their food choices to more positively enhance the aging process. In addition, grocery stores and supermarket superstores provide consumers with a wide variety of precooked prepared food selections for a diverse selection of palates and health needs.
It is no secret that the aging population is growing. The 85 + age cohort, which represented 3.4 million of the total population in 1993, is the fastest growing segment and makes up 10% of the older population. By 2030, the population of older adults over 65 years of age is expected to comprise 20% of the U.S. population and account for 72 million Americans (CDC, 2013). In the 120-year period between 1870 and 1990, individuals older than age 65 grew from 1 million to 32 million. Chronic disease and degenerative diseases impact health status at later stages of life, accounting for two out of three health issues among senior Americans. These chronic diseases have repeated and direct correlates with dietary intake, exercise, stress management, and locus of control and include cardiovascular disease, cancer, stroke, osteoporosis, and diabetes. Although a diagnoses of such diseases may be common among the old-old (ages 85 or older) and closer to the period of dying and death (the ninth and tenth decades of life), chronic disease conditions are occurring in the earlier stages of life and may be directly correlated with lifestyle factors. Chronic diseases and their associated health care costs account for 66% of the U.S. health care budget (CDC, 2013). In addition, individuals who experience one or multiple chronic health care conditions also experience impairment in their ability to perform activities of daily living (ADLs) and changes in sense of self-esteem.
Given the improvements in pharmaceutical medicines and technology, life expectancy has increased, but life span has not. Today’s average life expectancy at birth is about 75.7 years, whereas the life span is still considered to be 115 years, although a record of 128 years appears to have been set in January of 2009 by a woman
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in Uzbekistan, who has provided documentation to the British Broadcasting Corporation (BBC) that she was born in July 1881 (BBC News, January 29, 2009). The old-old will continue to be the fastest-growing group, and it is predicted (by the U.S. Census Bureau) to be 8.6 million by 2030. By 2050, this group may comprise 25% of the population age 65 or older (American Association of Retired Persons and Administration on Aging [AARP-AOA], 2005).
The social and economic consequences of America growing older, coupled with lower birth and mortality rates, are vast, including a heavy demand on the health care industry. The cost of providing health care to individuals 65 years or older is presently three to five times higher than the cost for those younger, and by 2030, health care costs for older Americans are expected to increase by 25%. Not included in this increase is the rate of inflation nor higher costs for new technologies (CDC, 2013). Nutrition, exercise, and engagement in other activities such as lifelong learning and education will enhance the functional capacity of the baby boomer generation and their families, as well as reduce the incidence of depression, found to be increasingly prevalent, especially in older U.S. women (McGuire, Strine, Vachirasudiekha et al., 2008; Stadler & Teaster, 2002).
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Physiologic changes in aging that affect nutritional status Aging produces physiologic changes; however, assumptions about the aged are often generalizations without merit. A distinction should be made between the healthy aging person and the aging person with acute or chronic disease. For the healthy aging person, exercise and the resulting maintenance of muscle mass are emerging in research as one of the greatest determinants of maintaining vitality (Campbell, Johnson, McGabe, & Carnell, 2008). Loss of lean body mass, which is essentially loss of skeletal muscle, may lead to decreased strength and mobility, predisposing aging adults to falls and affecting (although minimally) metabolism and bone strength. Exercise is effective in maintaining skeletal muscle mass, and it enhances functional status and fitness levels for aging adults by 10 to 20 years (Campbell et al., 2008).
Functional impairment often leads to malnutrition. Older adults with functional impairments may have difficulty performing, or be unable to perform, ADLs related to eating. They may be unable to shop for groceries, prepare food, or eat without help. Conditions that result in shortness of breath, pain, or limited mobility affect an individual’s ability and desire to eat. In addition, some medications further alter sensory receptors, resulting in greater differences in taste or smell. Changes in flavor, taste, and odor perception generally decline with age and may become quite exaggerated with some medications. For many of the older adults, foods that were once cherished and enjoyed as part of their culture now smell very different and are simply avoided. A report published by the AARP found that almost 22% of aging adults who live at home have health-related impairments in ADLs (AARP-AOA, 2005).
Physiologic changes that are common in older adults may lead to problems with nutrition. Organ function declines with age; this may alter digestion, metabolism, absorption of nutrients, and the ability to eliminate waste products via the kidneys (Keithley, 1996). Changes in the oral cavity include tooth loss or ill-fitting dentures,
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mouth dryness, and decreased esophageal motility. Medications may exacerbate dryness in the oral cavity, whereas obesity or osteoporosis may affect gastroesophageal sphincter function. Older adults may experience more frequent gastric and intestinal problems associated with less efficient enzyme function and alterations in the intestinal mucosa. Satiety triggers are diminished in older adults, yet given the increased risk for skin breakdown and the likelihood of compromised immune, circulatory, and respiratory systems, the majority of the older adult populations has increased protein requirements (Zulkowski & Albrecht, 2003). Hydration triggers are also diminished in the older adult. Thirst regulation is often affected, making dehydration a prime risk among older adults (see Evidence-Based Practice box).
Evidence-based practice Significant Economic and Health Issues of Dehydration in Community-Dwelling Older Adults
Background The increasing costs of health care may be directly related to the number of avoidable hospitalizations. This study examined the costs of unnecessary hospitalizations caused by dehydration among older adult patients. Dehydration among community- dwelling seniors or those housed in long-term care settings is widespread. Older people are susceptible to fluid loss and electrolyte imbalance because of decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse drug reactions.
Sample or Setting Records examined were from 31,077 hospitalizations of patients older than age 65 with a primary admitting diagnosis of dehydration.
Methods
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Retrospective record audit of 1999 hospital discharge data from the Healthcare Costs and Utilization Project (HCUP): The data were extracted from the Nationwide Inpatient Sample (NIS) database that contains the discharge information from 984 hospitals in 24 states. The ICD-9 code for volume depletion with a principal admitting diagnosis of dehydration was employed to gather data for descriptive analysis and multiple regression statistics.
Findings The authors found that 60.4% of all older adult patients with dehydration admitted through emergency departments were discharged back to community settings. The most common characteristics for an older adult hospitalized patient were as follows: age 80.4 years, female, living in a community setting, and receiving Medicare benefits. The usual place of residence for a dehydrated senior citizen was community dwelling (63%), nursing home (5.6%), or “residence unable to be established from the data” (31.4%). Hospitalizations for dehydration were more geographically concentrated in the South (42.1%) and the Midwest (23.1%) than in the Northeast (20.4%) or the West (14.4%). The length of stay was 4.6 days, with an average hospital charge of $7442. The total cost burden to the U.S. health care system for dehydration among those age 65 or older was estimated at $1.14 billion by the study authors.
Implications Dehydration in older adults is a costly and mostly preventable condition. The data demonstrate that senior citizens living in the community are at high risk for dehydration. Nursing interventions should include patient and family education about the health risks related to dehydration and how to prevent this condition. From Xiao, H., Barger, J., & Campbell, E.S. (2004). Economic burden of dehydration among hospitalized elderly patients. American Journal of Health-System Pharmacy, 61, 2534.
Older adults are at risk of dehydration caused by a decreased intake of fluids, loss of sodium, and increased fluid losses.
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Physiologically, the decreased intake may be related to altered thirst; older adults may not feel thirsty even when hypovolemic and often do not compensate for fluid losses during illness. Confusion, depression, and dementia also contribute significantly to reduced food and fluid intake. Dehydration takes three main forms: Isotonic dehydration results from the loss of sodium and water, as during a gastrointestinal illness. Hypertonic dehydration results when water losses exceed sodium losses. This type of dehydration is the most common and may occur from fever or limited fluid intake. Hypotonic dehydration may occur with diuretic use when sodium loss is higher than water loss (Weinberg & Minaker, 1995).
Delayed gastric emptying, hiatal herniation, and decreased secretion of gastric juices may cause bloating and discomfort. Meal size or volume declines as a consequence, and older adults may need to eat smaller meals more frequently if they are active and require the calories. The gastrointestinal system slows with age, resulting in less efficient absorption of nutrients (Zulkowski & Albrecht, 2003). Changes in the pH of the gastrointestinal tract may lead to the malabsorption of the B vitamins. Hepatic and renal reserves are decreased, which makes it harder to metabolize medications and alcohol and to conserve water or excrete nitrogenous wastes.
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Psychosocial and socioeconomic factors related to malnutrition Poverty is a significant problem for older Americans, particularly as individuals age. The U.S. Census Bureau reports that 10.1% of adults ages 65 or older were below the poverty level; in the 75 or older subgroup, 43% fell into a substandard level (AARP-AOA, 2005). When individuals have a fixed income to cover housing, clothing, utilities, food, health care, medications, and other expenses, food may be sacrificed, especially as the percentage of income required for health care rises. It is estimated that 61% of women and 31% of men older than 65 live on annual incomes less than $10,000. The cost of medication for older adults has significantly compromised many already low-income budgets, forcing individuals to choose between food and medication (Zulkowski & Albrecht, 2003). Food may initially be limited in quality as a transition to high-fat, high-carbohydrate convenience foods occurs, followed by a limitation in quantity.
Social isolation may be a significant factor contributing to malnutrition. When older adults live alone and have no one with whom to prepare and share meals, they tend to skip meals completely or overeat. Grieving over the loss of a spouse or friends also affects diet quality and intake. It is important to keep in mind that as individuals age, their loss of friends and family members may be significant and overwhelming. The CDC reports that 12% of individuals over 65 years of age report “rarely receiving the type of social and/or emotional support that they needed” (CDC, 2013). Psychosocial factors such as isolation and depression and economic issues such as poverty or the limitations of a fixed income may affect food purchases and, ultimately, total intake. Approximately 8% to 16% of older adults do not have access to a nutritious, culturally acceptable diet, and federal programs to combat hunger and malnutrition reach only about one third of the population that they are intended to benefit. When diets were scored for dietary quality via the Health Eating Index (range of 68 out of 100), those 65 years and older were found to gradually increase their unhealthy
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diet index score, leaving significant room for improvement.
Many of the older adults who receive home-delivered meals also suffer from two or three chronic health conditions and have most likely been hospitalized within the previous year (Ponza, Ohls, & Millen, 1996). Lack of companionship during mealtime may result in home-delivered meals being left uneaten. Both older women and men report eating more when they are with others, including family and friends, than when alone (ADA position paper, 2005b). “Meals on-Wheels” programs and congregate dining arrangements may bring not only meals but also socialization opportunities to older adults who are at risk. Physiologic, psychosocial, and economic factors must be assessed by the nurse, the dietitian, or both during nutritional screening or during a comprehensive nutritional assessment.
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Nutritional screening and assessment Nutritional Screening Nutritional screening is an abbreviated assessment of nutritional risk factors that identifies patients who are in need of a more comprehensive assessment and nutritional interventions. A variety of tools have been developed to conduct nutritional screening. Perhaps the most widely used of these tools is the “Determine Your Nutritional Health” screening tool developed as part of the Nutrition Screening Initiative (NSI) (Figure 10-1).
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FIGURE 10-1 Determine Your Nutritional Health. (Reprinted with permission from the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on
the Aging, and funded in part by a grant from Ross Products Division, Abbott Laboratories Inc.)
The NSI (Dwyer, 1991), a 5-year, multifaceted national effort to promote routine nutrition screening, began in 1990 under the direction of the American Academy of Family Physicians, the American Dietetic Association (now the Academy of Nutrition and Dietetics [AND]), and the National Council on Aging. As part of the initiative, a nutritional health checklist to be used by older adults or caregivers was developed to determine risk factors associated with nutrition and health. A score of 3 or more indicates moderate to high nutritional risk and triggers the need for a more
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comprehensive nutritional assessment. The Level II Screen is a tool that health care professionals use to conduct a more in-depth assessment of nutritional status (Figure 10-2).
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FIGURE 10-2 Level II Screen. (Reprinted with permission from the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the
American Dietetic Association, and the National Council on the Aging, and funded in part by a grant from Ross Products Division, Abbott Laboratories, Inc.)
The importance of nutritional screening is emphasized in the standards and guidelines developed by the Health Care Financing Administration (HCFA) (now the Centers for Medicaid and Medicare Services [CMS]) and the Joint Commission (TJC). The Outcome and Assessment Information Set (OASIS) implemented by the CMS includes data elements relating to food intake and nutritional status (Health Care Financing Administration [HCFA], 1998). This massive project is designed to collect and measure patient care outcomes for home care patients. Nutrition-related outcomes for OASIS in home care include “improvement in eating
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and stabilization in light meal preparation.” The focus of the OASIS project is to develop outcome measures that lead to performance improvement.
The impact of nutrition on immune status and length of hospital stay is clear (Feldblum, German, Bilenko et al., 2008). Outcome management attempts to identify critical interventions that produce a positive clinical outcome at lower cost. Because nutrition is an integral intervention in many diseases, disease state management programs or clinical pathways often incorporate nutritional interventions. Malnourished, hospitalized patients have more infections and other complications, which significantly increase the costs of hospitalization and care (Feldblum et al., 2008). Charney and Marian (2005) report that the prevalence of malnutrition may range from 30% to as high as 50% among hospitalized patients. Thorough nutrition screenings and assessments are critical to reducing the prevalence of malnutrition and its complications, especially in older adults.
Standards developed by the TJC require nutritional screening of all hospitalized and home care patients who receive clinical services (JCAHO, 1998). The standards also require referral for a comprehensive assessment if the patient is found to be at moderate to severe nutritional risk.
Nutritional Assessment A nutritional assessment is a comprehensive evaluation of a patient’s nutritional status and typically includes data collection in each of the following areas: demographic and psychosocial data, medical history, dietary history, anthropometrics, medications and laboratory values, and a physical assessment. Nutritional assessment may be performed as a result of an identified risk on a nutritional screening or when the risk status is obvious without a preliminary screening. The American Society for Parenteral and Enteral Nutrition (ASPEN) published standards that identify nutritionally at-risk patients (Box 10-1) (ASPEN, 1995). ASPEN also identified the goals of a nutritional assessment as follows:
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Box 10-1
Nutritionally at-risk patients • Involuntary loss or gain of 10% or greater of usual body weight
within 6 months, or
• Loss or gain of 5% of usual body weight in 1 month
• 20% over or under ideal body weight
• Presence of chronic disease or increased metabolic requirements
• Altered diets or diet schedules
• Inadequate nutrient intake for more than 7 days Data from the American Society for Parenteral and Enteral Nutrition, Board of Directors. (1995). Standards for nutrition support: hospitalized patients. Nutrition in Clinical Practice, 10, 208.
• Establishing baseline subjective and objective nutrition parameters
• Identifying specific nutritional deficits
• Determining nutritional risk factors • Establishing nutritional needs
• Identifying medical and psychosocial factors that may influence the prescription and administration of nutritional support
• Setting goals for nutritional deficits; if applicable set goals in area of medical and psychological factors to be worked on with interdiscliplinary team
Diet History In addition to a complete history and physical assessment, patients who are found to be at nutritional risk require a more specific evaluation of their dietary intake patterns. Information that is typically part of a diet history includes number of meals and snacks
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per day; chewing or swallowing difficulties; gastrointestinal problems or symptoms that affect eating; oral health and denture use; history of diseases or surgery; activity level; use of medications; appetite; need for assistance with meals and meal preparation; and food preferences, allergies, and aversions. A diet history may also include a food recall. For accuracy and relevancy, the food recall must include specific information about the type of food ingested, the preparation method, and an accurate estimate of the amount. The patient should be asked to select days for recording that are typical of his or her intake patterns. It is generally best to select two weekdays and one weekend day to record the best information on intake patterns. Patients should be instructed about how to estimate portion sizes and should be given samples from which to estimate their intake (e.g., 3 ounces [oz] of meat is the size of a pack of cards; a serving of vegetables is usually half a cup). The use of food models or large specific and detailed pictures of food category serving sizes may be very helpful as the typical consumer is unfamiliar with standard serving portions. The purpose of the food recall is to estimate the average number of calories and amount of protein ingested daily and to detect any deleterious food intake patterns such as overuse of fried foods or lack of vegetables or fruit. Some patients may need assistance from another person, if available, to complete the food recall.
For a more detailed picture of a patient’s diet and food patterns, a 3- to 7-day food intake history is obtained. Patients are asked to keep a detailed record of everything they eat, the time at which they eat, and the amount of each type of food item that is consumed. In addition to recording eating habits, patients are also asked to record activities and feelings, which allow the health care professional to determine whether there are emotional issues or activities that may either interfere with or enhance eating pleasure. Seven-day diet histories may be very helpful in detecting many behavioral issues in patients; however, many individuals have difficulty recording their food intake for a continuous period.
The final means of assessing dietary patterns is to look at food frequency. Food frequency questionnaires allow a health care professional to assess a particular nutrient category such as calcium
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or the adequacy of an individual’s entire diet. A food frequency questionnaire is completed either by a medical assistant or by the patient during his or her wait in a health professional’s office. Food frequency questionnaires are recommended for new patients because they allow the practitioner to collect reasonable dietary data without compromising the patient’s sense of privacy about food intake and diet.
Anthropometrics Height and weight are the mainstays of anthropometric measurements. Ideally, the patient is weighed in the morning while wearing light clothing. Height is measured, if possible. For patients who are unable to stand without assistance, height may be estimated by measuring the distance from the heel to the top of the knee (knee height) with the use of a broad-bladed caliper. This measure may be used to estimate height with the following formula (Nutritional assessment of the elderly through anthropometry, 1988):
In comparing weight and height, the nurse may use instruments such as the Metropolitan Life Insurance Table of Weight for Height as a reference. Surveys of weight changes with age reveal that the young-old are more likely to be overweight, whereas the old-old tend to be underweight (Andres et al., 1985). With age, loss of lean body mass and increase of body fat may occur; therefore, body weight alone may be misleading. If an older adult remains active, some lean body mass may be maintained. However, older adults should be cautioned against extreme leanness. Andres and colleagues, (1985) report an increased mortality risk in lean older adults compared with older adults who have 10% to 15% more body weight. With this information, Andres and colleagues created a table of heights and weights (Table 10-1).
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Table 10-1 A weight table for older adults
This age-adjusted weight chart, devised by Johns Hopkins University gerontologist Dr. Reubin Andres, indicates medically sound weight ranges for people in their 50s and 60s. The ideal weight for most people is around the midpoint for each person’s age and height. Those in the lower ranges are probably heavy enough to maintain good health, as long as no sudden or unexplained weight loss has occurred. Weights in the upper ranges may also be acceptable, but if a patient finds himself or herself on the high side, he or she should talk with a physician about the possibility of losing weight. A physician makes recommendations based on where the patient tends to store fat and his or her general health.
Height Weight (Pounds [LB]) Ages 50 TO 59 Weight (LB) Ages 60 TO 69* 4 feet (′) 10 inches (″) 107–135 115–142 4′11″ 111–139 119–147 5′0″ 114–142 123–152 5′1″ 118–148 127–157 5′2″ 122–153 131–163 5′3″ 126–158 135–168 5′4″ 130–163 140–173 5′5″ 134–168 144–179 5′6″ 138–174 148–184 5′7″ 143–179 153–190 5′8″ 147–184 158–196 5′9″ 151–190 162–201 5′10″ 156–195 167–207 5′11″ 160–201 172–213 6′0″ 165–207 177–219 6′1″ 169–213 182–225 6′2″ 174–219 187–232 6′3″ 179–225 192–238 6′4″ 184–231 197–244
Reprinted with permission from Health after 50. (1999). Johns Hopkins Medical Letters, 7(1), 5. * Those older than age 69 should use the ranges for individuals in their 60s.
Measuring body surface area may help to detect those who are overweight or underweight for their heights. Other types of anthropometric measurements include triceps skinfold and midarm muscle circumference. These measurements are of limited value when measured only one time and are also of limited use in their applicability to older adults. The standards for “normal” anthropometric ranges are based on a healthy middle-aged population; however, methods of comparing anthropometric measurements over time for older adults have been published (Nutritional assessment of the elderly through anthropometry, 1988). Measurements such as triceps skinfold and midarm muscle circumference may be of value when the initial reading is used as its own standard for a given individual. Measurements over time may reveal changes in fat stores and muscle mass. Standardization in measurement of both these variables is of importance for
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ensuring accuracy. The midarm muscle circumference should be measured at the midpoint of the distance between the tip of the acromial process of the scapula and the olecranon process of the ulna. Triceps skinfold should be measured with calipers that have a known degree of accuracy. An in-depth discussion of how to perform anthropometric measurements is presented in most nutrition texts (Williams & Schlenker, 2003).
Another fast, noninvasive, and highly accurate method for assessing lean tissue and bone mass is dual-energy x-ray absorptiometry (DXA). These scanning devices allow the practitioner to evaluate not only bone density at several sites but to also evaluate body fat in a minimum amount of time (generally less than 20 minutes) with minimum radiation exposure (rem; less than 5 millirem [mrem]) (DXA, Hologic, Inc., Bedford, MA). The advantage of a DXA scan is that a patient is able to obtain a more reliable picture of his or her body composition (body fat versus lean body mass) compared with anthropometric measurement. Utilization of anthropometric measures (BMI) may overestimate or underestimate body fat and lean body mass. The disadvantage of DXA scanning is that the patient must be mobile; however, newer models that allow for portability into homes and senior centers are now on the market.
Laboratory Values No single laboratory test is diagnostic of malnutrition. Several tests that reflect protein synthesis may also reflect nutritional status. Serum albumin is the serum protein most frequently cited in reference to malnutrition; it reflects the liver’s ability to synthesize plasma protein. Albumin has a half-life of about 21 days, so it is not always reflective of current nutritional status. Albumin values may also be affected by immune status and hydration. Given these limitations, albumin levels below 3.5 grams per deciliter (g/dL) may indicate some degree of malnutrition.
Transferrin is a carrier protein for iron and has a shorter half-life of 8 to 10 days. It is a more rapid predictor of protein depletion. Levels below 200 milligrams per deciliter (mg/dL) may indicate mild-to-moderate depletion, respectively. Levels below 100 mg/dL
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may indicate severe depletion.
Prealbumin is a carrier protein for retinol-binding protein and has a half-life of 2 to 3 days. It is sensitive to sudden demands on protein synthesis and is often used in the acute care setting. Prealbumin levels that range from 15 to 5 mg/dL reflect mild to moderate protein depletion. Levels below 5 mg/dL are considered reflective of severe protein depletion.
Total lymphocyte count (TLC) is sometimes used as a nutritional marker. In severe or prolonged malnutrition, immune proteins are depleted and the TLC is decreased.
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Nutritional guidelines for all ages Healthy eating is important for all Americans, regardless of age. Nutritional guidelines are published by a number of organizations. MyPlate is a well-recognized tool for assisting Americans in eating a more nutritious and balanced diet published by the Department of Agriculture (Figure 10-3). The 2010 Dietary Guidelines for Americans place a greater focus on fruits and vegetables as part of a nutrient dense diet, as a continued and growing amount of evidence demonstrates that the typical American diet is deficient in fruit and vegetable intake (CDC, 2013; U.S. Department of Agriculture [USDA-DHHS], 1995). MyPlate emphasizes and stresses that one half of an individual’s food plate should be comprised of fruits and vegetables (Choose My Plate 2012). Consistent evidence demonstrates a strong link between low consumption of fruit and vegetables and risk factors for many chronic diseases such as cardiovascular disease, cancer, macular degeneration, and Alzheimer disease, and many studies support a negative correlation between fruit and vegetable intake and obesity, diabetes, and hypertension (CDC, 2013). Adequate intake of fruits and vegetables rich in fiber, antioxidants, beta-carotene, and other vitamins is associated with a reduction in the risk of cancer, cardiovascular disease, macular degeneration of the eye, and other diseases (Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study Group, 1994; Omenn et al., 1996). The USDA provides many online and interactive materials as part of MyPlate, and the 2010 Dietary Guidelines stress a minimum of five servings of fruits and vegetables daily and a movement to a more plant-based diet (USDA-DHHS, 2005, Box 10-2).
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FIGURE 10-3 MyPlate for Older Adults. (From Tufts University in Conjunction with Somerville Council on Aging. Accessed July 3, 2014 from
http://hnrca.tufts.edu/wp-content/uploads/81059_TuftsMyPLate.pdf)
Box 10-2
Dietary guidelines for americans, 2005, pertaining to adults and older adults • People older than 50 years: Consume vitamin B12 in its crystalline
form (i.e., fortified foods or supplements).
• Older adults, people with dark skin, and people exposed to insufficient ultraviolet band radiation (i.e., sunlight): Consume extra vitamin D from vitamin D-fortified foods, supplements, or both.
• Overweight adults and overweight children with chronic diseases and those taking medications: Consult a health care provider about weight loss strategies before starting a weight-reduction program to ensure appropriate management of other health
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conditions.
• Older adults: Participate in regular physical activity to reduce functional declines associated with aging and achieve the other benefits of physical activity identified for all adults.
• Individuals with hypertension, African Americans, and middle-aged and older adults: Aim to consume no more than 1500 milligrams (mg) of sodium per day, and meet the potassium recommendation (4700 mg/day) with food.
• Pregnant women, older adults, and those who are immunocompromised: Only eat certain deli meats and hot dogs that have been reheated to steaming hot.
Modified from the U.S. Department of Health and Human Services. (2005). Dietary guidelines for Americans. Washington, DC: U.S. Government Printing Office. In Nix, S. (2009). Williams’ basic nutrition & diet therapy (13th ed). St. Louis, MO: Mosby.
The National Health and Nutrition Examination Survey (NHANES) data obtained from older adults demonstrate that their diets are insufficient in a number of macronutrients and micronutrients. First, many of the older adults begin to consume fewer calories as they age. As caloric intake declines, so does the individual’s ability to consume an adequate amount of each micronutrient (vitamins and minerals). The NHANES reported an increased prevalence of anemia, either as iron deficiency or in combination with folate or vitamin B12 deficiencies (ADA position paper, 2005b). The ADA endorses a liberalized diet for older adults in long-term care settings and encourages all older adults to eat a diet rich in fruits and vegetables, whole grains, and dairy products (ADA, 2005a).
Physical problems such as poor appetite, infections, weight loss, pressure ulcers, and polypharmacy are common among institutionalized older adults; therefore, the nurse should carefully weigh the risks and benefits of restrictive diets for patients in long- term care settings. As a result of several pieces of legislation, the HCFA defined what is considered adequate care for residents of long-term care, which includes writing a standardized assessment tool and delineating a process for incorporating assessments into a care plan for each resident. The document may be used to develop,
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review, evaluate, and revise care plans for residents (Minimum data set reference manual, 1993). Nutrition interventions may play an important role in addressing the health care problems identified in the minimum data set (MDS) and resident assessment protocols (RAPs) established by the HCFA (Nutrition interventions based on OBRA resident assessment protocols, 1995). The triggers established in the MDS and RAPs may have a nutritional basis and should be considered as part of the assessment process.
Dietary Reference Intakes Since its introduction in 1943, the recommended dietary allowances (RDAs) have been utilized to assess the adequacy and quality of an individual’s dietary intake (Table 10-2). The RDAs would list protein, vitamins, minerals, and selected trace elements and their recommended daily intake for infants and children, women and men, ad pregnant and lactating women. However, given the explosion in scientific knowledge, particularly regarding the roles of nutrients in the body and in health, a partnership between the Food and Nutrition Board and Health Canada worked to update the RDAs, taking a new approach to display this nutritional information. The new guidelines are referred to as the dietary reference intakes (DRIs), which include the recommended dietary allowances for nutrients as well as the upper tolerable limits and risk for toxicity for each nutrient for both age categories and gender categories (Institute of Medicine, 2004).
Table 10-2 Dietary reference intakes for older adults
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Compiled by the National Policy and Resource Center on Nutrition and Aging, Florida International University, Revised March 19, 2004.
ND indicates values not determined; PUFA, polyunsaturated fatty acid. The values for this table were excerpted from the Institute of Medicine. (2002). Dietary reference intakes: Applications in dietary assessment; and Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids (macronutrients). 1 Recommended dietary allowances (RDAs) are in bold type and adequate intakes (AIs) are in ordinary type followed by an asterisk (*). 2 Values are based on height of 5′7″ and “low active” physical activity level; the median body mass index and calorie level were calculated for men and women. Caloric values based on age were calculated by subtracting 10 kilocalories per day (kcal/day) for males (from 2504 kcal) and 7 kcal/day for females (from 2188 kcal) for each year of age older than 30. For ages 51–70, values were calculated for 60 years old; for 70 +, values were calculated for 75 years old; 80-year-old male calculated to require 2004 kcal, female,
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1838 kcal. 3 The RDA for protein equilibrium in adults is a minimum of 0.8 gram per kilogram (g/kg) body weight for reference body weight. 4 The RDA for carbohydrate is the minimum adequate to maintain brain function in adults. 5 Because the percentage of energy consumed as fat may vary greatly and can still meet energy needs, an acceptable macronutrient distribution range (AMDR) is provided in the absence of AI, or RDA for adults. 6 Values for mono- and polyunsaturated fats and cholesterol not established as “they have no role in preventing chronic disease, thus not required in the diet.” 7 AMDRs for intakes of carbohydrates, proteins, and fats expressed as % of total calories.
Some of today’s older adults are at risk for malnutrition as a function of a number of factors noted earlier. The DRIs allow the practitioner to address the differential in energy requirements and nutrient requirements for men and women older than age 50. Although the modifications still do not adequately consider the diversity of the older adult population, more data are becoming available regarding the ethnic dietary differences in both the young and older populations, given the nation’s increasingly diverse population.
It is important to keep in mind that recommended guidelines are simply that—guidelines. Although the new guidelines have set tolerable upper limits and toxicity parameters for each nutrient, it is important to keep in mind the unique variations of each individual. In the older adult population, individuals are in complex situations in which they, for example, consume many types of medications, have a variety of underlying medical conditions, and perhaps take vitamins and other supplements. It is always advisable to consult a dietitian when considering special dietary needs.
Food Labeling In 1990, the Nutrition Labeling and Nutrition Act enabled the FDA to develop and enforce labeling in the food industry. The law requires the label to include the amount of protein in grams, the energy as calories, the fat-soluble vitamin content (A, D, E, and K), the water-soluble vitamin content (vitamin C, thiamine, riboflavin, niacin, B6, folate, and B12), calcium, phosphorus, magnesium, iron, zinc, iodine, and selenium. The label must also specify calories
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based on serving size and indicate the number of servings. In addition, the label specifies the percentage of the DRI that the product provides, which is typically based on 2000 kilocalories (kcal) a day.
Although the label law did much to standardize labeling of foods and provide a clearer means of comparing the nutrient content of foods, label claims such as “low-fat,” “lite,” or “free” continued to confound consumers. In September 1993, the FDA published a dictionary, which includes common labeling claims and standardized the meaning of these terms (Table 10-3).
Table 10-3 Food and drug administration–approved definitions of label claims
Terminology Definition Sugar Sugar free Less than 0.5 gram (g) per serving
No added sugar; without added sugar; no sugar added
(1) No sugars added during processing or packing, including ingredients that contain sugars (2) Processing does not increase sugar content above the amount naturally present in the ingredients (3) Compared foods normally contain added sugars
Reduced sugar At least 23% less sugar than in compared food Calories Calorie free Fewer than 5 calories per serving
Low calorie 40 calories or less per serving, if the serving is 30 g or less or 2 tablespoons (tbsp) or less; 40 calories or less per 50 g of food
Reduced or fewer calories At least 25% fewer calories than in compared food Fat Fat free Less than 0.5 g of fat per serving
Saturated fat free Less than 0.5 g of saturated fat per serving, and the level of trans-fatty acids does not exceed 1% of total fat
Low fat 3 g or less per serving and, if the serving is 30 g or less or 2 tbsp or less, per 50 g of the food
Low saturated fat 1 g or less per serving and not more than 15% of calories from saturated fatty acids
Reduced or less fat At least 25% less per serving than compared food Cholesterol Cholesterol free Less than 2 mg of cholesterol and 2 g or less of saturated fat per serving
Low cholesterol 20 mg or less and 2 g or less of saturated fat per serving and, if the serving is 30 g or less or 2 tbsp or less, per 50 g of the food
Reduced or less cholesterol At least 25% less than compared food Sodium Sodium free Less than 5 mg per serving 140 mg or less per serving and, if the serving is
30 g or less or 2 tbsp or less, per 50 g of the food Very low sodium 35 mg or less per serving and, if the serving is 30 g or less or 2 tbsp or less,
per 50 g of the food Reduced or less sodium At least 25% less per serving than compared food
Fiber High fiber 5 g or more per serving Good source of fiber 2.5 to 4.9 g per serving More or added fiber At least 2.5 g more per serving than compared food
Adapted from Food Labeling Education Information Center, Beltsville, MD; and Famighetti, R. (Ed). (1985). The world almanac book of facts. New York: Copyright World Almanac Education Group.
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Drug–nutrient interactions Medication use is common in older adults. A medication history should include prescription and over-the-counter drugs, herbal therapies, and alternative medicines. The interactions between nutrients and medicines may affect metabolism, absorption, digestion, or excretion of drugs. Table 10-4 lists the interactions between nutrients and drugs that are commonly taken by older adults. Many older patients take a variety of vitamin and herbal supplements. It is very important for the nurse to obtain an accurate assessment of all the over-the counter therapies and drugs the patient may be taking. As the patient’s drug profile changes, the nurse must continue to screen for drug–drug or drug–nutrient interactions and consult with a pharmacist or an RD, as needed.
Table 10-4 Sample of drug–nutrient interactions*
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From: Pronsky ZM, Crowe JP: (2012). Clinical: Food-Drug Interactions. In L.K. Mahan, J.L. Raymond, & S. Escott-Stump: Krause's food and the nutrition care process (13th ed.). St. Louis: Elsevier. * Not intended to be an exhaustive or all-inclusive list. Always check pharmacology references before administering medications.
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Nursing diagnoses associated with nutritional problems Nursing diagnoses are derived from an assessment of the patient during a comprehensive health history and physical examination, during a patient interview, or while carrying out nursing interventions. The nursing diagnoses subsequently become the basis for the nursing care plan and goals for nursing care. Box 10-3 lists nursing diagnoses associated with a primary nutritional problem and diagnoses that commonly have a nutritional component.
Box 10-3
Nursing diagnoses associated with nutritional problems Primary Nutritional Problem Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: More Than Body Requirements
Risk for Imbalanced Nutrition: More Than Body Requirements
Nutritional Component Risk for Aspiration
Diarrhea
Dysfunctional Family Processes
Deficient Fluid Volume
Feeding Self-Care Deficit
Impaired Swallowing
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Risk for Ineffective Gastrointestinal Perfusion Adapted from Ackley, B.J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidenced-based guide to planning care (10th ed.). St. Louis, MO: Mosby: Elsevier.
Alterations in nutrition require a care plan that specifically addresses the nutritional problem. Nursing interventions related to nutrition include instruction and counseling regarding a diet that is adequate in a specific nutrient or nutrients, calories, and fluids. Therapeutic diets have been modified to include more or less than the DRI for a specific nutrient or nutrients and are usually prescribed to manage or treat a chronic disease or illness. Examples of therapeutic diets include those which are restricted in sodium, protein, cholesterol, total calories, fat, or gluten. Therapeutic diets may also include modifications in the texture of foods such as a low-fiber or high-fiber diet, liquid diet, semiliquid diet, or clear liquid diet. Finally, therapeutic diets may include specialized nutrition such as parenteral nutrition, enteral tube feeding, or oral supplements.
Oral supplements are often prescribed for patients who are unable to ingest adequate protein or calories because of early satiety or fatigue during eating. By adding a concentrated liquid oral supplement to the meal plan, the patient may improve protein or overall caloric intake. Supplements should be timed so that they do not become a “meal substitute.” Most often, supplements are given between meals and at bedtime, but the nurse must carefully assess the impact of the supplement on overall intake. Commercial oral supplements such as Ensure, Nutren, Osmolite, and Complete Modified are available at most pharmacies and grocery stores without a prescription. In addition, supplements are available as soups, nutrient bars, and smoothies. Commercial products are convenient but are often more costly than using regular food or dry powder products such as Carnation Instant Breakfast mixed with whole milk, cream soups, puddings, regular candy bars, ice cream, and powdered fortified milk.
Dysphagia is a problem that often affects nutritional status and may occur because of a cerebrovascular accident, oral or neck cancer treatment, or a neuromuscular or neurologic disorder. Dysphagia after a stroke may be successfully treated with
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swallowing exercises and retraining. Referral to a speech therapist is indicated for patients who have dysphagia. The nurse can help the patient who is not totally dysphagic to ingest thickened liquids and solids; thin liquids are most difficult to swallow for patients with dysphagia. Thickeners may be added to liquids to achieve a consistency that patients can ingest, usually about the consistency of mashed potatoes. Patients with dysphagia must be assisted during meals, and the nurse or caregiver should carefully observe that foods are successfully swallowed instead of being trapped in the mouth. Aspiration of liquids or solids may occur and lead to aspiration pneumonia. Patients with severe dysphagia require enteral tube feeding.
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Specialized nutritional support Specialized nutrition is used when a patient is unable to ingest, digest, or absorb nutrients. Common indications for enteral tube feeding include conditions in which a patient is unable to swallow foods, for example, following a cerebrovascular accident or with myasthenia gravis, amyotrophic lateral sclerosis, and multiple sclerosis. Enteral nutrition is also used when the upper gastrointestinal tract is obstructed, as in cancer or severe esophageal stenosis. A feeding tube is placed below the area of obstruction; feeding tubes may be placed into the stomach or the intestine. The tubes are placed through the nose (nasogastric or nasointestinal), directly into the stomach (gastrostomy, percutaneous endoscopic gastrostomy [PEG], or radiology-assisted gastrostomy), or directly into the jejunum (jejunostomy or percutaneous endoscopic jejunostomy). For decompression of the stomach and simultaneous feeding into the intestine, a PEG tube is placed into the stomach, and a smaller feeding tube is threaded through the PEG and guided, with the use of endoscopy, into the small intestine. The PEG tube is used for decompression, and the intestinal tube is used for feeding.
Enteral formulas include standard (whole protein and complex carbohydrate), modified protein (peptide), and elemental (amino acid) formulas. Some enteral formulas have added soluble or insoluble fiber. Disease-specific formulas are also available for the dietary treatment of diseases, for example, reduced protein for patients receiving renal dialysis, increased lipid percentage of total calories for patients with diabetes and pulmonary disease, and increased percentage of branched-chain amino acids for patients with hepatic disease. Specialized enteral formulas are considerably more expensive than standard formulas and should be used only when clearly indicated. Short-term enteral feeding is often used after surgery, traumatic injury, and burns. Research indicates that patients receiving enteral nutrition support benefit from $4.20 for every $1 invested in nutrition support management (Journal of the American Dietetic Association [ADA], 1995). Transition to an oral diet
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occurs as soon as is feasible, generally when the client is able to consume about 50% to 75% of nutrient and fluid needs (ASPEN, 1998).
Parenteral nutrition consists of an intravenous solution that includes dextrose, amino acids, vitamins, minerals, electrolytes, trace elements, and water. A lipid emulsion is commonly added to produce a total nutrient admixture, but it may be given by separate infusion. The dextrose and lipids provide calories to support metabolic needs, while amino acids are administered to meet daily protein requirements.
Parenteral nutrition is indicated when the gastrointestinal tract cannot be used for enteral feeding or cannot absorb adequate nutrients to maintain health. Diseases and conditions typically associated with the need for parenteral nutrition include severe inflammatory bowel disease, fistula, acute pancreatitis, and massive bowel resection. Research has shown that feeding into the bowel is protective of bowel mucosa and maintains immunity (Kudsk, Minard, Croce et al., 1996); thus, critically ill older adults may receive both parenteral and enteral nutrition.
Parenteral nutrition is administered through a vascular access device such as a central venous catheter, tunneled catheter, peripherally inserted central catheter, or implanted port. Most parenteral nutrition solutions are hypertonic and must be administered into a large central vein.
Patients receive enteral and parenteral nutrition in various health care settings or at home. Nurses educate home care patients about the use and care of their access devices, administration of the enteral formula or parenteral solution, use of an enteral or intravenous pump, management of common problems associated with specialized feeding, and signs and symptoms of complications. Although specialized nutrition is prescribed to patients of all ages, a large percentage of the patients who receive enteral tube feeding and parenteral nutrition are older adults.
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Failure to thrive Failure to thrive is a label originally applied to infants who did not gain weight and grow despite the apparent absence of a physiologic, psychological, or pathologic condition. In fact, failure to thrive in infants often does have disease as its source, and failure to perform a comprehensive diagnostic workup on these infants may delay appropriate treatment. Failure to thrive in older adults is similar. It is characterized by deterioration in biologic, psychological, and social domains, weight loss and a lack of any obvious explanation. Rocchiccioli and Sanford (2009) estimate that 5% to 35% of older adults living in the community and 25% to 40% of those in nursing homes, as well as over 50% of those in Veterans Affairs (VA) hospitals and acute care institutions suffer from geriatric failure to thrive.
Sarkisian and Lachs (1996) have described commonly impaired domains associated with failure to thrive in older adults, including impaired physical functioning, malnutrition, depression, and cognitive impairment. Failure to thrive in older adults is described as the 11 D’s: (1) disease (physical), (2) dementia, (3) delirium, (4) drinking alcohol, (5) drug use, (6) dysphagia, (7) deafness or other sensory deficits, (8) depression, (9) desertion, (10) destitution, and (11) despair (Rocchiccioli and Sanford, 2009). Physiologic changes associated with aging; mental disorders such as dementia and depression; and medical, social, and economic factors have been cited as causes of failure to thrive in older adults (Marcus & Berry, 1998). Although initial treatment is directed toward correcting the malnutrition through the use of diet, oral supplements, or specialized nutrition, as necessary, a thorough diagnostic evaluation is warranted.
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Summary Food has strong cultural, spiritual, religious, and social connotations, which were recognized by physicians, statesmen, and scholars throughout history and need to be recognized and assessed by the nurse when working with a patient. Interest in homeopathic remedies and the pharmaceutical and disease prevention properties of food and nutrients are major areas of research, including the area of epigenetics. Nurses must understand the role of vitamins and mineral supplements in the overall diet of their patients to get a clear picture of their health and pharmaceutical history.
The older adult population is increasingly becoming the larger percentage of the total population, and the percentage of older adults will peak around 2030 with the aging of the baby boomer generation. General perceptions of older adults do not correlate with reality, and differentiation should be made between healthy older adults and older adults with chronic diseases.
Malnutrition is detected through nutritional screening and nutritional assessment. Anthropometrics, diet history, and laboratory studies are components of a nutritional assessment. Organizations that provide accreditation of hospitals and home care agencies and the CMS require nutritional screening of all patients receiving clinical services, and a referral for a comprehensive assessment is indicated if the patient is found to be at risk of malnutrition.
Although a number of organizations have published nutrient requirements and ideal weight tables, none of these resources is well researched for the aged. Surveys of eating patterns of older adults have found inadequate intake of fruits and vegetables as well as energy and nutrient intake. Older Americans are advised to follow the recommendations of MyPlate and are referred to MyPlate.gov. Specialized nutrition therapies such as parenteral nutrition and enteral tube feeding may provide nourishment to patients who are unable to ingest, digest, or absorb nutrients. Parenteral nutrition is a life-saving measure; in addition, research
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has shown that nutrients provided via the gastrointestinal tract also enhance recovery and improve immune response.
The nurse, along with the dietitian, plays an important role in identifying alterations in nutrition and in developing nursing interventions that restore nutritional adequacy. The nurse collaborates with the physician, the dietitian, the pharmacist, and other members of the health care team to promote the nutritional health of patients.
Home care
1. Instruct caregivers and homebound older adults to keep a nutritional log for a defined period to enable the home care nurse to compare it with MyPlate.
2. Instruct caregivers and homebound older adults on nutrients and selected food sources that supply required vitamins and minerals.
3. Be aware that geographic location, culture, and religion play a part in food patterns, preferences, and the meaning of food for homebound older adults.
4. Assess physiologic conditions and psychosocial issues that may place homebound older adults at risk for nutritional deficiencies.
5. Assess homebound older adults’ medications for any that may predispose them to nutritional deficiencies.
6. Carefully assess older adult patients’ over-the-counter drug and supplement intake to prevent herbal supplement–drug, herbal supplement–nutrient interactions.
7. Instruct caregivers and homebound older adults on assistive devices that promote independence in eating (e.g., strong plastic plates, bowls with suction cups, or padded utensils). An occupational therapist should evaluate the patient and provide
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assistive devices.
8. Instruct caregivers and homebound older adults on any treatments that provide nutritional support (e.g., enteral nutrition).
9. Ensure that appliances (such as stoves and microwave ovens) are functioning safely. Assess older adults’ functional ability to use appliances safely.
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Key points • Appropriate food intake for health maintenance was recognized
by Hippocrates (460–377 bc) and other early scholars.
• Explosion of the older population to more than 32 million people calls for the control of lifestyle factors such as adequate nutrition.
• Among middle-aged and older adults, age alone is the poorest predictor of capacities, interests, performance, and health status. Exercise with maintenance of muscle mass is a good predictor of vitality.
• Wellness, as contrasted to health, is an ongoing dynamic process in the state of becoming; it is the prime objective of health promotion and disease prevention.
• Recent literature has determined a correlation between nutrients and chronic disease.
• A balanced dietary intake, based on the MyPlate and the Healthy People 2020 guidelines, may promote nutritional health.
• Nurses have the opportunity and responsibility to assess nutritional status and should collaborate with other members of the health care team to formulate a comprehensive and coordinated nutritional care plan.
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Critical thinking exercises 1. A 68-year-old man with chronic obstructive pulmonary disease (COPD) has been referred to home health nursing services for medication instruction and respiratory assessment. During the nurse’s first visit, the following information is obtained during history taking: overweight for height by about 30 pounds, weight loss of 10 pounds over the past 2 months, complaints of shortness of breath while eating, and unable to get to the grocery store (relies on a neighbor for assistance). How would this information relate to the development of a nursing care plan?
2. An 80-year-old woman who is 5 foot, 4 inches tall, weighs 152 pounds, and is in generally good health records the following 24- hour intake:
Breakfast: 1 glass orange juice, 2 slices whole wheat toast, 1 tablespoon butter
Lunch: 1/2 cup cottage cheese, 1 bag cheese curls, 1/2 peanut butter and jelly sandwich, 1 cup tea
Dinner: 1 cup wheat flakes cereal, 1/2 cup skim milk
Snack: 1 candy bar, 1 cup ice cream
Analyze this patient’s diet.
What conclusions, if any, can be made about her dietary status based on this 24-hour recall?
3. A 72-year-old man is a Seventh Day Adventist and practices vegetarianism. He does not eat fish, but he does eat eggs. His physician has recommended that he ingest more protein. What recommendations can the nurse offer?
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Marcus EL, Berry EM. Refusal to eat in the elderly. Nutrition Reviews. 1998;56:163.
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C H A P T E R 1 1
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Sleep and Activity Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Identify three age-related changes in sleep.
2. Describe the features of insomnia.
3. Discuss four factors influencing sleep in older adults.
4. Discuss two sleep disorders.
5. List four components of a sleep history.
6. Describe three sleep hygiene measures.
7. Describe the effects of lifestyle changes on sleep and activity in older adults.
8. Define basic and instrumental activities of daily living.
9. Discuss the benefits of physical activity for older adults.
10. Identify three characteristics of meaningful activities for older adults with dementia.
http://evolve.elsevier.com/Meiner/gerontologic
Sleep and activity are two universal, dichotomous functions of all human beings. Sleep is a natural, periodically recurring, physiologic state of rest for the body and mind; sleep is a state of inactivity or repose that is required to remain active. Activity includes the things we do while awake, for example, personal care, daily tasks, exercise, and recreation. The type, amount, and intensity of the activities pursued vary widely among individuals according to personal choice, lifestyle, and health status. This chapter considers age-related changes in sleep and activity and the
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role of the nurse in assisting older individuals to adapt to those changes.
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Sleep and older adults Biologic Brain Functions Responsible for Sleep Regulation of sleep and wakefulness occurs primarily in the hypothalamus, which contains both a sleep center and a wakefulness center. The thalamus, limbic system, and reticular activating system (RAS) are controlled by the hypothalamus and also influence sleep and wakefulness. The hypothalamus consists of several masses of nuclei, interconnected with other parts of the nervous system, and is located below the thalamus, where it forms the floor and part of the lateral walls of the third ventricle. Sleep is a state of consciousness characterized by the physiologic changes of reduced blood pressure, pulse rate, and respiratory rate along with a decreased response to external stimuli.
Stages of Sleep Normal sleep is divided into rapid eye movement (REM) sleep and four stages of non-REM sleep (NREM) (Table 11-1). NREM sleep accounts for about 75% to 80% of sleep (Burke & Laramie, 2004; Hoffman, 2003). The remaining 20% to 25% of sleep is REM sleep. A night’s sleep begins with the four stages of NREM sleep, continues with a period of REM sleep, and then cycles through NREM and REM stages of sleep for the rest of the night. Sleep cycles range from 70 to 120 minutes in length, with four to six cycles occurring in a night.
Table 11-1 Normal Stages of Sleep
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Modified from Touhy, T. & Jett, K. (2012). Ebersole & Hess’ Toward healthy aging (8th ed.). St, Louis, MO: Mosby; and Beers, M.H. & Berkow, R. (2000). The Merck manual of geriatrics (3rd ed.). Whitehouse Station, NJ: Merck Research Laboratories. NREM, non–rapid eye movement; REM, rapid eye movement.
Stage 1 of NREM sleep is the lightest level of sleep. During stage 1, an individual can be easily awakened. Sleep progressively deepens during stages 2 and 3 until stage 4, the deepest level, is reached. Muscle tone, pulse, blood pressure, and respiratory rate are reduced in stage 4 (Hoffman, 2003). In REM sleep, pulse, blood pressure, and respiratory rate increase (Burke & Laramie, 2004). The REMs of this stage of sleep are associated with dreaming. When the amount of REM sleep is reduced, an individual may experience difficulty concentrating, irritability, or anxiety the next day.
Variations in the REM and NREM sleep stages occur with advancing age. REM sleep is interrupted by more frequent
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nocturnal awakenings, and the total amount of REM sleep is reduced. The amount of stage 1 sleep is increased, and stage 3 sleep and stage 4 sleep are less deep. In the very old, especially men, the amount of slow wave sleep as determined by electroencephalography (EEG) is greatly reduced (Kryger, Monjan, Bliwise, & Ancoli-Israel, 2004).
Sleep and Circadian Rhythm The sleep–wake cycle follows a circadian rhythm, which is roughly a 24-hour period. The hypothalamus controls many circadian rhythms, which include the release of certain hormones during sleep (e.g., growth hormone [GH], follicle-stimulating hormone [FSH], and luteinizing hormone [LH]). Numerous factors may gradually strengthen or weaken the sleep and wake aspects of circadian rhythm, including the perception of time, travel across time zones, light exposure, seasonal changes, living habits, stress, illness, and medication (Hoffman, 2003). The decrease in nighttime sleep and the increase in daytime napping that accompanies normal aging may result from changes in the circadian aspect of sleep regulation (Cohen-Zion & Ancoli-Israel, 2003; Lewy, 2009).
Insomnia Insomnia, or the inability to sleep, is a complex phenomenon. Reports of insomnia include difficulty falling asleep, difficulty staying asleep, frequent nocturnal awakenings, early morning awakening, and daytime somnolence. Insomnia may be transient, short term, or chronic (WebMD, n.d.). Transient insomnia lasts only a few nights and is related to situational stresses. Short-term insomnia usually lasts less than a month and is related to acute medical conditions (e.g., postoperative pain) or psychological conditions (e.g., grief). Chronic insomnia lasts more than a month and is related to age-related changes in sleep, medical or psychological conditions, or environmental factors. Insomnia may affect the older adult’s quality of life with excessive daytime sleepiness, attention and memory problems, depressed mood, nighttime falls, and possible overuse of hypnotic or over-the-
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counter (OTC) medications (Kryger et al., 2004).
Age-Related Changes in Sleep Many older adults experience changes in sleep, which are considered “normal” age-related changes (Box 11-1). However, although some older adults either do not experience these common changes or do not consider them sources of distress, other adults find these changes problematic (Beers & Berkow, 2000). The sleep changes experienced by many older adults include increased sleep latency, reduced sleep efficiency, more awakenings in the night, increased early morning awakenings, and increased daytime sleepiness (Hoffman, 2003).
Box 11-1
Age-related changes in sleep • Increased sleep latency
• Reduced sleep efficiency
• Increased nocturnal awakenings
• Increased early morning awakenings
• Increased daytime sleepiness
Sleep latency, a delay in the onset of sleep, increases with age. Over 30% of women report taking more than 30 minutes to fall asleep; for men, this number is under 15%. Older adults report that it takes longer to fall asleep at the start of the night and after being awakened during the night. Because the time spent awake in bed trying to fall asleep increases, sleep efficiency decreases. Sleep efficiency is the relative percentage of time in bed spent asleep. For young adults sleep efficiency is approximately 90%. However, this percentage drops to 75% for older adults (Hoffman, 2003).
Nocturnal awakenings contribute to an overall decrease in the
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average number of hours of sleep. The frequency of nocturnal awakenings increases with age; older adults may wake up four or more times per night. The interruptions of sleep contribute to the perception that the amount of sleep is inadequate or of poor quality. If the person has little difficulty falling back to sleep, the decrease in the number of hours of sleep may be slight. However, some older adults report increased periods of wakefulness after nocturnal awakening. The reasons for nocturnal awakening include trips to the bathroom, dyspnea, chest pain, arthritis pain, coughing, snoring, leg cramps, restless legs syndrome (RLS), and noise (Beers & Berkow, 2000). Early morning awakening and the inability to fall back to sleep may be related to changes in circadian rhythm or to any of the reasons for nocturnal awakening.
Daytime sleepiness is often reported by older adults and may be caused by frequent nocturnal awakening or other sleep disturbances. However, in some older adults, daytime sleepiness suggests underlying disease. It is associated with functional impairment and depression and contributes to the increased risk of motor vehicle accidents. When cognitive dysfunction is present, daytime sleepiness is a predictor of mortality and cardiovascular disease (Chasens, Sereika, & Burke, 2009). Daytime sleepiness may also be caused by medication side effects (e.g., antiarrhythmics, clonidine, selective serotonin reuptake inhibitors [SSRIs], and antihistamines).
Daytime napping is common in older adults and does not necessarily indicate problems with nighttime sleep. Naps, that is, voluntary and involuntary episodes of daytime sleep, occur throughout the day. Floyd (1995) found that no difference existed in the length of nighttime sleep between individuals who took naps and individuals who did not take naps, and the amount of nighttime sleep and the duration of naps were not correlated. Floyd concluded that the time spent napping supplemented the total daily amount of sleep.
Although some of the sleep changes experienced by older adults are related to aging, other sleep changes are associated with chronic disease and other health problems. When patterns of sleep are examined, an increase in light sleep is seen as deep sleep declines.
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The loss of deep sleep is associated with stages 3 and 4 of sleep (see Table 11-1). This sleep disturbance may be a normal part of aging caused by changes in the reticular formation (RF) in the brain (Friedman, 2010). When older adults describe the ways their sleep has changed as they have aged, they offer nurses valuable clues. Their descriptions indicate health problems (actual or potential), safety concerns, and possible interventions to improve sleep quality.
Factors Affecting Sleep Proper sleep is essential for a person’s sense of well-being and health. Sleep is often defined subjectively and linked to an individual’s feelings on awakening. A good night’s sleep is described as one that refreshes, restores, and leaves a person ready for the coming day’s activities. Feeling tired and less alert after a poor night’s sleep may lead to a less active and productive day. Factors that influence sleep quality in older adults include the following, alone or in combination: environment, pain, lifestyle, dietary influences, medication use, medical conditions, depression, and dementia. Nursing interventions can modify these factors and promote a good night’s sleep.
Environment The environment can positively or negatively influence a person’s quality and amount of sleep. For older adults, environments conducive to sleep include low levels of stimuli, dimmed lights, silence, and comfortable furniture (Rosto, 2001).
Home Environments The home environment supports a good night’s sleep by its very familiarity. The bed and bedding, the people, and the noises are all familiar. The routines leading up to bedtime are natural and individualized.
Hospitals and Long-Term Care Facilities The environment of a health care institution may detract from the
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quality of sleep. Not only are these environments unfamiliar, but they also typically have bright lights, noisy people and machines, limited privacy and space, and uncomfortable mattresses. Physical discomfort or pain may be caused by invasive procedures such as Foley catheterization, intravenous line placement, venipuncture, mechanical ventilation, and discomfort or pain from equipment such as oxygen masks, casts or traction devices, and monitors. The hospital patient or long-term care facility resident is often awakened to receive medications and treatments or to be assessed for changes in vital signs and condition. Nocturnal awakenings for incontinence care or for other care procedures such as repositioning and skin care interrupt the normal sequence of sleep stages (Nagel, Markie, Richards, & Taylor, 2003). Fear of the unexpected or unknown may also keep older adults awake in health care institutions. The quality of sleep in institutional settings improves as nursing interventions address (1) the scheduling of procedures and care activities to avoid unnecessary awakenings, (2) modification of environmental factors to promote a quiet, warm, relaxed sleep setting, and (3) orientation of older adults to the institutional setting.
Noise Environmental noise potentially interferes with sleep in all health care settings. The consequences of environmental noise may include (1) sleep deprivation, (2) alteration in comfort, (3) pain, and (4) stress or difficulty concentrating, which may interfere with the enjoyment of activities. Sources of noise include personnel, roommates, visitors, equipment, and routine activities on the nursing unit (Box 11-2). Interventions to reduce environmental noise include closing the doors of patient and resident rooms when possible, adjusting the volume control on telephones, rescheduling nighttime cleaning routines, and reminding staff and visitors to speak quietly. Some older adults may appreciate headphones to provide relaxing music and block background noise. Headphones will also reduce noise from late evening television watching. Noise reduction may include asking the facility’s maintenance staff to clean and lubricate the wheels on all of the unit’s utility carts. Reducing environmental noise in institutions involves cooperation
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among employees from other departments, visitors, and nurses.
Box 11-2
Sources of nighttime noise in nursing facilities • Talking and calling out by residents
• Talking by staff
• Television
• Intercoms, bells, alarms
• Equipment (e.g., linen carts, floor cleaning equipment) Modified from Schnelle, J.F., Cruise, P. A., Alessi, C. A., Ludlow, K., al-Samarrai, N., R., & Ouslander, J. G. (1998) Sleep hygiene in physically dependent nursing home residents: Behavioral and environmental intervention implications. Sleep, 21, 515-523.
Lighting Most individuals are accustomed to sleeping in darkened rooms. The lights in hallways and nurses’ stations in some health care institutions interfere with the sleep of patients and residents. The nurse should assess environmental lighting in the institutional setting for glare, brightness, and uneven levels of illumination. Selectively dimming the institution’s lights at night may promote better sleep. However, safety concerns must be considered. Nightlights in rooms, bathrooms, and hallways may be a safe compromise—promoting sleep by reducing the glare of bright lights while allowing enough light to see.
Temperature Falling asleep and staying asleep is difficult when a person is cold. Older adults may wake during the night because of a nighttime reduction in core body temperature related to reduced metabolic rate and reduced muscle activity. Being too warm will also disrupt
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sleep, but some older adults sleep better if simple measures are used to keep them warm. The ambient temperature of the bedroom should be no lower than 65 ° F (Worfolk, 1997). Several light thermal blankets and flannel sheets (both fitted and flat) make for a warmer bed. Flannel pajamas or nightgowns, bed socks, and nightcaps help sleepers stay warm. If bed socks are worn, slippers should be used when out of bed to prevent slipping on uncarpeted floors. Heating devices such as heating pads or hot water bottles should be avoided so that the fragile skin on the feet and lower legs are not exposed to thermal injuries.
Pain and Discomfort Body pain, acute or chronic, interferes with falling asleep and staying asleep. Nursing interventions to relieve pain begin with assessment of the location, intensity, onset and duration, quality, and any aggravating or alleviating factors. The effect of pain on older adults’ lifestyle, including sleep quality, should also be assessed. Both nonpharmacologic and pharmacologic measures may be used to relieve pain. When body pain interferes with sleep, analgesics are more effective for sleep promotion than sedative or hypnotic medications. However, alterations in pharmacokinetics common to older adults taking medication make careful selection of analgesics important. Drugs with long half-lives linger longer in many older adults. Small initial doses that may be titrated upward to achieve analgesia may be better tolerated than generous initial doses. Attention must be paid to common side effects such as constipation.
Even without any report of body pain, some older adults find just being in bed uncomfortable. For the older individual whose discomfort prevents sleeping in a standard bed, comfortable chairs may be a solution. Reclining chairs with soft cushions may be more comfortable for individuals with heart failure or severe chronic obstructive pulmonary disease (COPD). The rhythmic motion of a rocking chair may comfort some individuals and thus promote sleep. If being out of bed is not feasible, modifying the bed with extra pillows to support painful limbs and promote comfortable body positioning or using special mattresses (e.g., air or water
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mattresses) may be effective. Nighttime garments should be made of a soft material such as cotton and should not be restrictive so that freedom of movement is allowed. The use of lightweight blankets avoids adding weight to sensitive body areas.
Lifestyle Changes Loss of Spouse Widowhood is a common life event in the older adult population. Loss of a spouse is much more common among older women than among older men. Forty percent of women older than 65 are widows; 13% of men are widowers (Administration on Aging [AOA], 2012). Loss of a bed partner may make sleep psychologically less comforting. Older widows and widowers describe the strangeness of going to bed alone after many years of marriage. This change in bedtime routine may interfere with the onset of sleep. If the widow or widower experiences depression, the depression should be treated.
Retirement Retirement brings about changes in schedule and activities. For decades the older adult’s times for going to bed and awakening were influenced by the work schedule; retirement removes that variable. The structure of a day in retirement is not imposed by the demands of a job. The work activities that caused fatigue have ceased. It is no longer necessary to get a good night’s sleep to be restored from the day’s work and prepared for the next day’s efforts. The activities that remain are personal care activities, activities around the house, recreational activities, and any new activities adopted with the coming of retirement. These changes create the potential for alterations in sleep. Some retired older adults may follow the same schedule they observed while working. It is familiar; it feels comfortable. However, other retired older adults find their days and nights without structure. In the absence of old routines, sleep is disturbed. Unless other activities replace work activities, retired older adults may not feel fatigued at the end of the day or sleepy at bedtime. Sleep may also be disturbed by the
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uncertainties that come with retirement. Questions about family relationships, finances, and future activities may lead to sleep- disturbing stress.
Relocation Some older adults experience relocation, or a change of residence, from their house or apartment to the home of their children or siblings, a retirement community, assisted living facility, or nursing facility. Sleep is adversely affected by the transition to these unfamiliar surroundings. Deciding to move from the familiar place of residence to another residence, even if that other residence is desirable and the relocation voluntary, engenders stress during the time of decision making, during the actual move, and during the time of adjustment to the new residence. The unfamiliar environment of the new residence also contributes to disturbed sleep. As older adults become accustomed to a new residence, sleep should improve.
Having a Roommate Having a roommate (or a bed partner in the case of a spouse) may interfere with sleep. Some sleep-related problems occur in long- term care facilities when roommates do not get along with one another because of different interests or lifestyles. For example, one older adult may watch television to fall asleep, and the other may find this disruptive to sleep. The nursing staff must make every effort to review significant psychosocial interests with residents and to match roommates accordingly. Ideally, residents should be allowed to select roommates with whom they share common interests. The roommate or bed partner who snores loudly, sleepwalks, talks in sleep, or has RLS is also a cause of sleeplessness. Treatment must be directed toward the cause of the roommate’s problem; if treatment is impossible, or ineffective, separate bedrooms may be needed.
Dietary Influences Sleep is influenced by what we eat and drink. Popular caffeine- containing beverages (e.g., coffee, tea, and cola drinks) make falling
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asleep more difficult for some older adults. The effects of caffeine include restlessness, nervousness, insomnia, tremors, reduced peripheral vascular resistance, increased heart rate, and relaxation of bronchial smooth muscle.
The standard advice is to avoid caffeine-containing beverages for several hours before going to bed. This diminishes the likelihood that the stimulant effect of caffeine will interfere with falling asleep and staying asleep. Other sources of caffeine include hot chocolate, chocolate candy, some OTC pain analgesics and cold remedies, and some brands of decaffeinated tea and coffee (Cochran, 2003). Some herbal products also contain caffeine. Alternative choices for late evening beverages are fruit juices, milk, and water.
Alcohol occupies an equivocal position among beverages that influence sleep. Many adults include alcohol as part of their normal lifestyle and continue to do so in their advancing years. They enjoy a glass of wine or sherry with an evening meal or an occasional beer or mixed drink. Small amounts of alcoholic beverages may cause a slight drowsiness or a relaxation that promotes falling asleep. However, larger amounts of alcohol reduce the amount of both REM sleep and deep sleep and impair the overall quality of a night’s sleep (Burke & Laramie, 2004). The diuresis caused by alcohol-induced inhibition of antidiuretic hormone (ADH) secretion leads to nocturnal awakenings for urination. When discussing the use of alcohol with older adults, the nurse must determine how they define a “small” or “large” amount of alcohol and the circumstances of alcohol use. These details of alcohol use vary from group to group and from culture to culture.
Fluid intake in the evening and immediately before going to bed is associated with nocturia. Although nocturia may have other causes such as urinary retention related to benign prostatic hypertrophy or diuretic therapy for heart failure, many older adults reduce the kind and volume of fluid intake in the evening. However, it is important that older adults, who as a group are at risk for inadequate fluid intake and dehydration, not reduce the total amount of liquids consumed in 24 hours.
Hunger and thirst may be causes of sleeplessness. Bedtime snacks and small amounts of liquids may provide the touch of
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comfort that promotes sleep. Warm snacks containing protein are better at bedtime than cold snacks (Cochran, 2003). Milk, eggnog, creamed soup, or flavored gelatin may all be served hot to provide warmth and calories. Pudding, custard, or tapioca may be more palatable than crackers or graham crackers. For older adults with diabetes, bedtime snacks should be included in their special diets. Falling back to sleep after awakening during the night with a dry mouth is facilitated when a cup of water is available close to the bed.
Drugs Influencing Sleep Both prescription and OTC drugs may contribute to sleep and to sleep disturbance. Drugs affect sleep in three ways: (1) causing sleep by intent, (2) causing drowsiness by side effect, and (3) causing insomnia or other sleep disturbances by side effect.
Drugs Used to Promote Sleep Medications are often used to treat insomnia, although nonpharmacologic interventions for insomnia are also available. Tranquilizers and sedatives decrease activity and calm the recipient. Sleep may follow the calming effect. Hypnotics produce drowsiness and facilitate the onset and maintenance of sleep by causing central nervous system depression. Hypnotics should be used only for a short course of therapy (3 weeks or less) or for intermittent use in chronic insomnia (once every 2 or 3 nights) (Cochran, 2003). Long-term use of hypnotics may lead to tolerance of the drug and rebound insomnia (Hill-O’Neill & Shaughnessy, 2002). When selecting a medication to promote sleep, nurses should avoid barbiturates, chloral hydrate, antihistamines, and OTC preparations because of their side effects (The American Geriatrics Society 2012 Beers Criteria Update Expert Panel [AGS], 2012).
Benzodiazepines have been used to relive insomnia; they help persons both fall asleep and stay asleep. When benzodiazepines are used in older adults, the risk of side effects is increased because some benzodiazepines have long half-lives and active metabolites that prolong the sedating effect of the drug (The American Geriatrics Society 2012 Beers Criteria Update Expert Panel [AGS],
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2012). Age-related changes in the clearance of benzodiazepines increase the risk of prolonged sedation. Complications of benzodiazepine use include daytime drowsiness, increased risk of falls during the night or in the early morning, confusion, disorientation, and performing activities (e.g., driving or eating) while asleep. Benzodiazepines may also worsen sleep apnea.
Drugs with Drowsiness as a Side Effect Many medications, prescription and OTC, have drowsiness as a side effect. Although this side effect may be welcomed as a benefit beyond the intended therapeutic purpose of the medication, the use of these medications to induce sleep is problematic. Some of these medications have other side effects that negate the sleep-inducing benefit. Two types of medications will serve as examples: antihistamines and tricyclic antidepressants (TCAs) (Cohen-Zion & Ancoli-Israel, 2003). Drowsiness is one side effect of antihistamines, and other side effects include increased intraocular pressure; dry mouth; constipation; urinary retention; and, paradoxically, confusion, agitation, restlessness, and insomnia. As another example, TCAs may be slightly sedating but may also cause insomnia and nightmares.
Drugs Causing Insomnia or Sleep Disturbances Several types of medications have insomnia as a side effect or have side effects that lead to disturbed sleep or nocturnal awakening (Table 11-2). OTC medications that interfere with sleep include nasal decongestants containing amphetamine-like substances and analgesics containing caffeine. Many prescription medications have side effects that affect sleep.
Table 11-2 Examples of Medications that Disturb Sleep
Type of Sleep Disturbance
Examples of Medications
Alteration of rapid eye movement (REM) sleep
Alcohol, barbiturates, benzodiazepines
Insomnia Haloperidol, risperidone, phenytoin, sertraline, theophylline, amitriptyline Delayed onset of sleep Caffeine, amphetamines, theophylline, nasal decongestants containing stimulants Nocturnal awakening Diuretics Nightmares, vivid dreams Atenolol, nifedipine, carbidopa-levadopa, propranolol, amitriptyline
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Daytime sleepiness Antipsychotics (haloperidol, risperidone), long-acting benzodiazepines, cold remedies containing antihistamines, atenolol, diltiazem, nifedipine, ranitidine, cimetidine
Compiled from Beers, M.H. & Berkow, R. (2000–2006). The Merck manual of geriatrics (3rd ed.). Whitehouse Station, NJ: Merck Research Laboratories; and Foreman, M.D. & Wykle, M. (1995). Nursing standard-of-practice protocol: sleep disturbances in elderly patients. Geriatric Nursing, 16, 238.
Natural or Herbal Remedies Various natural or herbal remedies have been recommended as aids for securing a good night’s sleep. Unlike prescription drugs, the composition of these compounds is not readily available, and their side effects and interactions with prescription or OTC drugs have not been fully explored (Box 11-3). Some herbal remedies contain active ingredients that resemble prescription and OTC drugs, increasing the risk for drug–drug interaction (Cochran, 2003).
Box 11-3
Tips for older adults using herbal and homeopathic remedies 1. Before treating any symptom with a nonprescription product,
make sure no conditions requiring medical attention exist.
2. Discuss the use of any nonprescription product with your physician and other health care providers.
3. Be cautious about viewing herbal or homeopathic products as a substitute for prescribed medications.
4. Use single-ingredient products rather than combinations.
5. Observe for beneficial and harmful effects.
6. Report any possible side effects to your physician for evaluation.
7. Seek information from objective sources rather than relying on promotional materials and package information.
8. Check any warnings on the label or package, and check for
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information from additional sources.
9. Consider the fact that herbal and homeopathic products are not required to meet standards for safety and efficacy.
10. Be skeptical about exaggerated claims—if it sounds too good to be true, it probably is!
From Miller, C.A. (1996). Alternative healing products. Geriatric Nursing, 17(3), 145-146.
Depression Depression among older adults is a treatable condition that is frequently accompanied by insomnia. Patients awaken in the early morning and are unable to return to sleep. Patients may also report excessive daytime somnolence. Evaluation and treatment are essential if depression is suspected.
Dementia and Disturbed Sleep Older adults with Alzheimer disease or other dementias may experience disturbed sleep. Increased confusion at night, nocturnal wandering, and agitation have been reported.
The causes of the sleep disruption may be no different from causes that disturb sleep in any older adult. However, cognitive impairment complicates assessment, intervention, and evaluation. The nurse may not receive a clear response when asking about sleep or any conditions that contribute to insomnia. Instead, nurses must anticipate the needs of older adults with dementia. Interventions include reducing confusion with an explanation of what is expected of the older adult (“Now it’s time to sleep”), identification of the place for sleeping (“This is your bed”), and reassurance that going to bed is the right thing to do (“Your bed is ready for you”). Assisting older adults with dementia to perform bedtime routines redirects their behavior. Nocturnal wandering behaviors may signal a need that cannot be expressed verbally, for example, hunger, thirst, or the need to go to the bathroom. Wandering may also be an expression of pain or of a need for exercise. Once the meaning of the wandering is discerned, appropriate interventions follow naturally (Rowe, 2003). Medications such as sedatives or antipsychotics should be avoided
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because of their side effects, which may worsen confusion, interfere with safe ambulation, and alter the sleep–wake cycle.
Sleep Disorders and Conditions The two most common sleep disorders experienced by older adults are sleep apnea and periodic limb movements in sleep (PLMS). Both disorders are seen with excessive daytime sleepiness and reports of insomnia. However, PLMS is essentially a benign condition, whereas the hypoxia related to sleep apnea may lead to serious consequences.
Sleep Apnea During sleep, individuals with sleep apnea experience recurrent episodes of cessation of respiration. These apneic episodes may last from 10 seconds to 2 minutes. The number of apneic episodes may range from 10 to more than 100 per hour of sleep (Cohen-Zion & Ancoli-Israel, 2003). The incidence of sleep apnea increases with age, and it is more common in men than in women. Complications related to sleep apnea include cardiac disease, hypertension, stroke, obesity, headaches, irritability, depression and anxiety, sexual dysfunction, daytime sleepiness and difficulty with memory, thinking, and concentration. Persons with sleep apnea are also at increased risk for automobile or work-related accidents (Nabili, 2012).
The three major types of sleep apnea are central sleep apnea (CSA), obstructive sleep apnea (OSA), and complex sleep apnea. In CSA, a cessation of respiratory efforts, both diaphragmatic and intercostal, occurs. CSA is usually accompanied by daytime fatigue, nocturia and nighttime awakening, morning headaches, poor memory and concentration, and moodiness. Risk factors associated with CSA include heart failure, hypothyroidism, chronic kidney disease, neurologic diseases, and damage to the brain stem. Treatment consists of managing underlying associated risk factors, weight loss, avoidance of alcohol and sleeping pills, sleeping on the side, and using sprays to maintain open nasal passages. Continuous positive airway pressure (CPAP) treatment may be beneficial for
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those with CSA, especially those with associated heart failure (Ratini, 2012).
OSA is more common in older adults than CSA (Beers & Berkow, 2000). In OSA, air flow ceases because of complete or partial airway obstruction; respiratory efforts increase in an attempt to open the airway. Factors associated with OSA include obesity, short or thick neck, jaw deformities, large tonsils, large tongue or uvula, narrow airway, and deviated septum (Olson, Moore, Morgenthaler et al, 2003). Additionally, smoking, hypertension, and cardiac risk factors increase the likelihood of developing OSA. Older adults with OSA report daytime fatigue; waking with a headache and sore throat or dry mouth, and confusion; trouble concentrating and irritability; and sexual dysfunction. The families of older adults with OSA describe loud snoring and choking or gasping sounds during the person’s sleep. Treatment consists of weight loss, avoidance of alcohol and sleeping pills, propping oneself on the side using pillows, and using sprays to maintain open nasal passages. CPAP prevents collapse of the airway during sleep (see the Nursing Care Plan box). Other options include mandibular advancement devices that prevent the tongue from blocking the throat and surgery (somnoplasty, uvulopalatopharyngoplasty, mandibular or maxillary advancement surgery, or nasal surgery) (Goldberg, 2012).
Nursing care plan
Sleep pattern disturbance
Clinical Situation Mr. V is a 79-year-old single white man who is admitted to the nursing facility for convalescence after a tracheotomy for obstructive sleep apnea (OSA). Before hospitalization, he was living alone on the third floor of an apartment complex for older adults. He describes himself as limited in activities such as driving, traveling, and cooking because of respiratory distress. He reports daytime fatigue associated with grooming, dressing,
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feeding, and toileting. He admits to sleeping poorly, with several nighttime awakenings and general fatigue all day long, which prompts him to take a daytime nap.
Medical history includes hypertension, obesity, chronic obstructive pulmonary disease (COPD), severe peripheral vascular disease with a stage II venous stasis ulcer of the lower leg, and recent tracheotomy for OSA.
While at the nursing facility, Mr. V tells you that he plans on discharging himself home in 1 to 2 weeks. He is observed to need assistance in mobility and uses a wheelchair to wheel himself around his room. He refuses to go to the dining room but requests to have a refrigerator in his room. He eats all his meals in his room and rarely socializes with any resident or staff member. His pastimes include playing solitaire in his room and watching television. He is a retired sales representative, having worked in the business for more than 40 years.
Nursing Diagnosis Disturbed sleep pattern related to obesity and reduced activity
level
Outcomes Patient will identify personal lifestyle habits contributing to sleep
pattern disturbance.
Patient will achieve weight loss of 1 pound (lb) per week.
Patient will eat a well-balanced diet, as evidenced by food diary.
Patient will participate in one group activity a day.
Patient will walk 100 feet twice daily, increasing distance to tolerance.
Patient will report increased length of uninterrupted periods of sleep.
Interventions Teach relationship between weight and sleep pattern, and
importance of losing weight to improve sleep pattern.
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Explore with patient motivators to lose weight; reinforce as needed.
Teach about the USDA’s food guidance system, MyPlate (http://www.choosemyplate.gov/), and assist him in identifying nutritious foods.
Teach use of food diary for self-monitoring.
Offer nutritious foods as snacks.
Encourage patient to increase level of activity on the unit by increasing mobility and engaging in nonsedentary activities; review a list of available activities with patient. Offer to accompany patient on a walk on the unit to his tolerance at least twice a day to help with wound healing and weight reduction.
Introduce patient to fellow residents on the unit who share common interests.
Encourage patient to join other residents in activities to tolerance.
Explore with patient his likes or dislikes, previous hobbies, and level of activity during middle adulthood.
Schedule an activity with the patient that will be part of his daily routine.
Discourage daytime napping; instead, replace it with a stimulating activity.
Teach patient to monitor pulse, to watch for symptoms of respiratory distress when engaging in activities on the unit, and to stop if respiratory distress occurs or an increase in heart rate causes adverse symptoms.
Offer praise and positive reinforcement when he performs a nonsedentary activity and when weight loss is achieved.
Observe patient during sleep for signs of obstructive apnea such as loud snoring or periods of apnea. Observe for daytime fatigue and somnolence.
Encourage patient to assume a side-lying position for sleep.
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Discuss with patient plans for discharge, and explore alternative living arrangements, including residence on a first-floor apartment, especially if mobility is impaired.
Complex sleep apnea syndrome (CompSAS) occurs when persons treating OSA with CPAP are found to also have CSA during initial therapy. Persons present with excessive fatigue, sleepiness, and depression; these symptoms are secondary to unresponsiveness to CPAP. Risk factors include cardiovascular and cerebrovascular diseases, as well as use of opioid drugs. Prevalence may be as high as 20% and increases with age; it is predominant in men. Maintaining adherence to CPAP may improve ComSAS after 8 to 12 weeks. However, adherence is problematic because of poor initial response to therapy. Other methods that have been investigated include adding oxygen to CPAP, the addition of carbon dioxide to CPAP and the use of adaptive servo-ventilation (ASV), which automatically adjusts to a person’s respiration on a breath-by-breath basis (Wang, Wang, Feng, et al, 2013).
Periodic Limb Movement in Sleep Approximately 30% of older adults experience PLMS (Cleveland Clinic, 2012). In PLMS, repetitive kicking leg movements occur throughout the night, most often during non-REM sleep, and may occur every 5 to 90 seconds; each kick causes a brief disruption of sleep. Some older adults are unaware of their leg movements; others wake up and have difficulty falling back asleep. Older adults with PLMS report insomnia and excessive daytime sleepiness (EDS). Their bed partners report being kicked during the night. Medications such as dopamine agonists (DAs), anticonvulsants, benzodiazepines, and narcotics are accepted pharmacologic therapies for PLMS. First-line pharmacologic therapy is DAs. Additionally, patients are encourage to eliminate caffeine- containing products (e.g., tea, chocolate and coffee) from their diet; they should also discuss the use of antidepressants with their health care provider, as these medications may worsen symptoms (Cleveland Clinic, 2012). If the movements are frequent, the nurse may suggest that older adults sleep alone to allow their bed partners less disturbed nights’ sleep (Ancoli-Israel, 2004).
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Getting a Good Night’s Sleep Whether sleep is disturbed by the environment, diet, medications, lifestyle changes, or sleep disorders, the first step in developing interventions to improve the amount and quality of sleep is taking a thorough sleep history. Supplementing the sleep history are measurement tools to assess sleep quality and quantity, direct observation of the older adult during sleep, a sleep diary, and diagnostic studies such as electroencephalography (EEG) monitoring, and sleep study evaluation. After assessment, interventions to improve sleep usually begin with basic sleep hygiene measures.
Evidence-based practice The Significance of Noise and Light on Sleep and Activity
Background Sleep deprivation adversely affects health outcomes in the older adult. Environmental factors in the acute care setting may interfere with sleep quality, leading to cognitive, psychological, and general health status changes.
Sample/Setting Seven in-patients from a community hospital participated in this study to help determine the amount of time spent sleeping, as well as the level of noise and light experienced during their time of sleep.
Methods Sleep versus activity was determined by a wrist monitoring device. Light and sound were measured by meters. Time for sleep was determined to be from 10:00 pm to 6:00 am.
Findings
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Patients slept very little the first night (224 minutes), and this did not improve over the 3 days. Patients awoke frequently during the night. The light level mean was 6.14 lux but had frequent intervals of intense light. Sound levels were generally elevated at those above an urban residence.
Implications Nurses must be vigilant to promote sleep for older adult patients. One consequence of lack of sleep for older adults is delirium, which may affect length of stay and mortality. Nurses may promote sleep by reducing conversations near the patient, using low lighting for nursing tasks, treating pain, and addressing known reasons for poor sleep in certain individuals. From Missildine, K. (2008). Sleep and the sleep environment of older adults in acute care settings. Journal of Gerontological Nursing, 34(6), 15–21.
Components of the Sleep History A complete sleep history begins with the patient’s report of his or her sleep pattern and sleep-related problems (Box 11-4). The quality of sleep is usually described along a continuum of poor, fair, good, or excellent. The quantity of sleep refers to the amount of sleep in a 24-hour period, including daytime naps. Quantity may be difficult to calculate, especially for the patient with frequent nocturnal awakenings who cannot recall whether sleep occurred after the awakening. The nurse should determine when the patient retires for bed, falls asleep, and usually awakens. The number of nocturnal awakenings and length of time awake at night are important to review with the patient. If a patient retires at 9 pm, does not fall asleep until 11 pm, arises at 4 am, and takes a daytime nap from 4 to 5 pm daily, this individual has slept a total of 6 hours. Information about a person’s typical bedtime rituals or practices should also be obtained.
Box 11-4
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Sleep history components • Sleep quality
• The self-report of the older adult, described as poor, fair, good, or excellent
• Sleep quantity
• The number of hours asleep per 24 hours, including daytime naps
• Bedtime routines
• Place of sleep
• Characteristics of the bed, bedding, and bedroom environment
• Food and fluid intake in the evening and at bedtime
• Use of alcohol and caffeine-containing beverages
• Medications (prescription and nonprescription)
• Characteristics of the sleep disturbance
• Difficulty falling asleep
• Difficulty staying asleep
• Frequent nocturnal awakenings
• Early morning awakening
• Daytime sleepiness
• The older adult’s account of the reasons for the disturbed sleep
The older adult is likely to seek additional help in achieving satisfaction with sleeping habits. If the older adult is too tired or fatigued to perform normal activities, the sleep problem may be viewed as disruptive to the daily routine and may require further evaluation. The nurse should ascertain whether the older adult experiences daytime sleepiness or has a strong desire to nap.
A patient’s activities before bedtime and his or her exercise and activity pattern provide additional information about sleep habits. In general, strenuous activity should be avoided at least 2 hours
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before bedtime. The nurse should identify what the patient does to relax before bedtime, for example, reading or drinking a warm beverage. The nurse should question the patient having difficulty with sleep about the consumption of alcohol, caffeinated beverages, sedative-hypnotics, OTC medications, and other practices before bedtime.
Questions about the type of bed in which the person sleeps are also important. Does the patient sleep in the same bed every night? Is it comfortable? Is the mattress soft, or does it provide adequate support? Some individuals who are unable to sleep in a recumbent position because of medical problems may be able to sleep in a semi-recumbent position in a lounge chair or recliner. Patients who are unable to fall asleep in the supine position and who need several pillows or cushions in bed require further medical evaluation for heart failure, pulmonary disease, or musculoskeletal problems (Spieker & Motzer, 2003). Common problems that cause pain and discomfort in bed include COPD; rheumatologic problems such as osteoporosis; degenerative joint disease of the spine, hips, or neck; and rheumatoid arthritis. Nocturia occurring several times in the course of one night must be further evaluated. Older men with prostate enlargement need to urinate several times during the night. Older adults with congestive heart failure or urinary tract infections may also have nocturia.
Further Assessment of Sleep A sleep diary kept by the older adult is helpful in recalling the amount of sleep, bedtime routines, and possible symptoms of disturbed sleep over a 24-hour period. The type and quantity of activities are also noted in the diary for the same 24-hour period. To complete the sleep diary, the older adult may need the assistance of a family member or the nurse. The nurse may suggest measures to help patients enter information in the diary, for example, tape- recorded entries for patients with visual impairment or difficulty writing.
Sleep laboratories specialize in treating patients with primary sleep disorders. Patients are asked to spend the night so that a sleep study can be administered. This often includes poly-somnography,
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which provides data about the stages of sleep and ventilation, and an EEG for graphic tracing of the variations in the brain’s electric force. Physicians specially trained in sleep disorders evaluate the history and objective findings, including a review of basic sleep hygienic measures, to arrive at a diagnosis and treatment plan.
Additional information about sleep may be collected with the use of questionnaires for research purposes and clinical evaluation. Two examples of instruments are the Stanford Sleepiness Scale (SSS) and the Epworth Sleepiness Scale (ESS). The SSS measures feelings of sleepiness or tiredness at specific times. The ESS also measures sleepiness, but it measures in terms of sleep propensity, the likelihood of falling asleep at a particular time. The person completing the ESS considers certain situations and indicates the likelihood (low to high) that he or she would fall asleep in those situations (Cochran, 2003). A third instrument is the Pittsburgh Sleep Quality Index, which subjectively measures sleep quality and includes five additional questions for the bed partner. In addition to instruments that only address sleep, other instruments that have questions about sleep may be used (Cohen, 1997).
Sleep Hygiene Basic sleep hygiene includes those activities that foster normal sleep and that can be practiced by individuals on a routine basis. The goal of sleep hygiene measures is to achieve normal sleep. The various measures reinforce habits, routines, and attitudes that promote sleep and advocate changes in habits and routines that do not contribute to a good night’s sleep (Kirkwood, 2001). Sleep hygiene measures emphasize stable schedules and bedtime routines, a sleep-friendly environment, avoidance of any substances that would interfere with sleep, regular exercise (but not immediately before trying to sleep), and stress reduction.
Retiring at the same time every night and awakening at the same time every morning helps establish a routine. A patient may condition himself or herself to such a routine over time. Likewise, limiting the amount of time spent in bed to only the time spent sleeping establishes a routine for sleep. Retiring to the same location such as the bedroom, and not a couch or chair on some
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nights, also helps solidify the routine. If unable to fall asleep, the person should get up and move to another area to perform other activities until sleepy. Eliminating noise and creating a darkened environment promotes sleep. Limiting day time napping and having warm beverages and light nutritious snacks at bedtime are additional measures that promote sleep.
Avoiding caffeinated beverages, sleeping pills, and alcohol may reduce the chances of sleep-related breathing disorders (SBDs). The basic measures to help reduce episodes of sleep apnea include losing weight, sleeping on one’s side or stomach, avoiding central nervous system (CNS) depressants such as sedative–hypnotics and alcohol, and treating any obvious nasal or upper airway diseases.
Fostering Normal Sleep in Homebound Older Adults It is important for the nurse to assess risk factors (e.g., environment, pain, or equipment such as a Foley catheter) that predispose homebound older adults to sleep disturbances. Review all medications to identify those that may interfere with sleep patterns. Instruct caregivers and homebound older adults on activities that foster normal sleep, for example, avoidance of caffeinated beverages and alcohol. Assist with environmental changes that foster normal sleep, such as using a rocking chair or taking a warm bath. It must be kept in mind that worry and anxiety concerning safety and welfare may be an obstacle to sleep in older adults. A system of notification and monitoring to link older adults living alone with the outside world is important to promote their sense of security.
Other Therapies to Promote Sleep In addition to sleep hygiene measures, other nonpharmacologic interventions may be used to promote sleep. Among these measures are relaxation therapies, stimulus control therapy, and sleep restriction therapy. Relaxation therapies reduce either somatic arousal or cognitive arousal. Progressive muscle relaxation is one example of a therapy to reduce somatic arousal. Cognitive arousal is reduced by attention-focusing therapies such as guided imagery or meditation. Stimulus control therapy attempts to reestablish the
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bedroom environment as the stimulus for sleep by banning activities from the bedroom that are not related to a good night’s sleep. Examples of such activities include eating and watching television. Stimulus control therapy is helpful for individuals with sleep-onset insomnia (Cochran, 2003). Sleep restriction therapy limits the amount of time spent in bed. Individuals stay in bed only for the number of hours they estimate as their average time asleep, plus 15 minutes (Cohen-Zion & Ancoli-Israel, 2003). These measures may be combined with basic sleep hygiene to improve sleep.
The assessment of sleep for older adults should include questions about sleep habits, bedtime routines and rituals, medications, diet, and the sleep environment. Physiologic factors such as pain, sleep disorders, and other health problems that might affect sleep should be included in the assessment (Foreman & Wykle, 1995). Nursing interventions that follow assessment include educating patients about normal age-related changes in sleep; basic sleep hygiene measures; and strategies to improve sleep that are specific to the patient’s health status, lifestyle, and environment. Evaluation of the effectiveness of the intervention depends on the older adult’s report of sleep quantity and quality (Table 11-3).
Table 11-3 Nursing Standard of Practice Protocol: Sleep Disturbance in Older Adult patients
Assessment Intervention Evaluation
Sleep–Wake Patterns Maintain Normal Sleep Pattern
Objective Evidence
Inquire about usual times for retiring, falling asleep, and rising; frequency and duration of nighttime awakenings; frequency and duration of daytime naps; daytime physical and social activity. Have person provide a subjective evaluation of the quality of sleep.
Maintain usual bedtime. Schedule nighttime activities to provide uninterrupted periods of sleep of at least 2–3 hours. Balance daytime activity and rest. Discourage daytime naps. Promote social interaction.
Time required to fall asleep: should fall asleep within 30–45 minutes Time for awakening: at usual reported time Behavior, alertness, attention, ability to concentrate, reaction time Observe duration of sleep: should remain asleep for at least 4-hour intervals
Bedtime Routines/Rituals Support Bedtime Rituals/Routines
Subjective Evidence
Inquire about activities performed before bedtime (e.g., personal hygiene,
Offer a bedtime snack or
Verbalizations about the quality and quantity of sleep (e.g., statements of difficulty falling asleep, frequent awakenings;
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prayer, reading, watching TV, listening to music, snacks).
beverage. Enable bedtime reading or listening to music. Assist with aspects of personal hygiene at bedtime (e.g., a bath). Encourage prayer or meditation.
having slept well, feeling well-rested or refreshed; or an increased sense of well-being)
Medications Avoid or Minimize Drugs That Negatively Influence Sleep
Obtain information relative to all prescribed and self-selected over-the- counter medications used, especially sleep aids, diuretics, laxatives. Determine types of medications and length of time used.
Pharmacologic treatment of sleep disturbances is treatment of last resort. Discontinue or adjust dose or dosing schedule of any offending medications. Consider drug–drug potentiation. Administer medications to promote sleep; give diuretics at least 4 hours before bedtime.
Diet Effects Minimize or Avoid Foods That Negatively Influence Sleep Obtain information about consumption of caffeinated and alcoholic beverages.
Discourage use of beverages containing stimulants (e.g., coffee, tea, sodas) in afternoon and evening. Encourage use of warm milk. Provide snacks according to patient preference. Generally discourage use of alcoholic beverages. Decrease fluid intake 2–4 hours before bedtime.
Environmental Factors Create Optimal Environment for Sleep Evaluate noise, light, temperature, ventilation, bedding.
Keep noise to absolute minimum. Set room temperature according to patient preference. Provide blankets, as requested. Use nightlight, as desired. Provide soft music or white noise to mask noise of hospital activity.
Physiologic Factors Promote Physiologic Stability Evaluate breathing pattern during sleep, with attention to pauses. Observe for periodic movement or jerks during sleep. Inquire about usual position and number of pillows used during sleep. Note diagnoses of sleep disorders (e.g., sleep apnea, narcolepsy). Note diagnoses of specific health problems that adversely affect sleep (e.g., congestive heart failure).
Elevate head of bed as required. Provide extra pillows per patient preference. Administer bronchodilators, if prescribed, before bedtime. Use medical therapeutics (e.g., continuous positive airway pressure [CPAP] machine) as prescribed.
Illness Factors Promote Comfort Inquire about pain, affective disturbances (e.g., depression, anxiety, and worry), fatigue, and discomfort.
Provide analgesia, as needed, 30 minutes before bedtime. Massage back or feet to help patient relax. Use warm and cool compresses on painful areas as indicated. Assist with progressive relaxation or guided imagery. Encourage patient to urinate before going to bed. Keep path to bathroom clear, or provide bedside commode.
From Foreman, M.D. & Wykle, M. (1995). Nursing standard-of-practice protocol: Sleep disturbances in elderly patients. Geriatric Nursing, 16, 238. Bibliography for the development of protocol from Jenike, M.A. (1989). Geriatric psychiatry
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and psychopharmacology: A clinical approach. St. Louis, Mosby; Johnson, J.E. (1988). Bedtime routines: Do they influence the sleep of elderly women? Journal of Applied Gerontology, 7, 97; and National Institutes of Health. (1990). Treatment of sleep disorders of older people. Consensus Statement 8(3), 1.
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Activity and older adults Activity, as discussed in this chapter, includes routine daily activities, diversional activities, and physical exercise. Changes occur in the activities pursued by older adults as they age or experience acute or chronic illness. Other changes in activities occur in response to major lifestyle changes such as retirement, relocation, or loss of a spouse. Specialized activities to meet the needs of older adults with Alzheimer disease or a related dementia are also available. Whether cared for at home or in a long-term care facility, the older adult with dementia benefits from an activity program that includes both diversional activities and activities to promote independence in activities of daily living (ADLs). Physical exercise deserves special attention because of its health-promoting benefits for all older adults. Although the activities pursued by a particular older adult are influenced by his or her preferences, situation, and health, some general considerations for activity in older adults do exist. In some settings, nurses participate in planning activities, adapting activities to the older adult’s current situation, and evaluating the effects of activities on health.
Activities of Daily Living ADLs include the things that most adults do every day, often without special attention or effort. Until something happens to interfere with normal daily routines, little thought may be given to bathing, dressing, eating, or attending to elimination needs. However, with advancing age and changes in health and circumstances, activities that once were accomplished with ease may require modified approaches or the assistance of others. In addition to providing direct assistance with ADLs, nurses assist older adults in the modification of routines and the use of assistive devices that help maintain independence. Nurses also support and advise family members and friends who assist the older adult with ADLs.
Instrumental activities of daily living (IADLs) include activities
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such as driving, shopping, cooking, housekeeping, and using a telephone. Older adults modify their approaches to IADLs because of commonly experienced changes in aging such as reduced strength, impaired vision, or impaired hearing. Assistive devices make the tasks of cooking or housekeeping easier and safer. Driving may be restricted to familiar areas and daylight hours. Family members, friends, or paid caregivers may help with shopping and other tasks. During episodes of acute illness or recovery from hospitalization, additional help may be needed. If sufficient assistance with IADLs is available in the home, relocation to a long-term care facility is not necessary.
Basic ADLs include the everyday personal care tasks related to hygiene, nutrition, and elimination. Remaining independent in these activities is highly prized by older adults. Dependency in basic ADLs increases the risk of relocation to a long-term care facility or to the home of a family member. To remain independent in basic ADLs, older adults use assistive devices and modify their care routines. Handheld shower sprays, raised toilet seats, sturdy grab bars in bathrooms, plate guards, and built-up handles on toothbrushes and eating utensils are examples of assistive devices. Clothing with Velcro instead of buttons, ties that can be clipped on rather than tied, and shoes that can be slipped on rather than laced are examples of modifications to help with dressing. However, for some older adults the amount of assistance needed with personal care exceeds their ability to modify routines and the capacity of family members and friends to help. Home care nurses may supplement the care provided by family members and friends, or relocation to a long-term care facility may be necessary.
Physical Exercise Physical activity is important for older adults to maintain health, preserve the ability to perform ADLs, and improve general quality of life. The benefits of physical activity include prevention of heart disease and diabetes, reduction in elevated blood pressure, reduced risk of osteoporosis, promotion of appropriate weight, reduction in depressed mood, reduced cancer risk, and promotion of more restful sleep (Schoenborn, Vickerie, & Powell-Griner, 2006).
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Exercise preserves mobility and reduces the risk of falls by promoting muscle strength and joint flexibility.
Older adults exercise for a variety of reasons (Schoenborn et al, 2006). They exercise to have fun, to socialize with friends and neighbors, and to simply feel better. Exercise is used to reduce stress, to promote relaxation, and, together with a good nutritional program, to control weight. The World Health Organization (2011) recommends moderate-intensity aerobic exercise for 150 minutes a week. The activity may be divided into smaller segments of at least 10 minutes’ duration. To measure the appropriate intensity while walking, the “talk test” may be used: The person exercising should be able to carry on a conversation while walking. Breathing may be slightly labored, but a conversation should still be possible. The walker should not be out of breath. Muscle strengthening should be done at least 2 days per week. Older adults with restricted abilities because of medical conditions should perform physical activity within their limitations.
If the older adult has not been exercising every day, starting with only 5 minutes of exercise each day and gradually working up to 20 or 30 minutes a day is appropriate (Schoenborn et al, 2006). A gradual progression in an exercise program for older adults who have been sedentary is recommended. A sedentary lifestyle is not unusual for older adults. In one study, physical activity and sedentary behavior were measured in adults over the age of 60. Results indicate older adults average 10 minutes to 106 minutes per day in moderate physical activity. Activity declines with age; those over 80 averaged 5 to 60 minutes of moderate physical activity per day. Women were more active than men. Older adults spent an average of 8.5 hours per day in sedentary behavior, with those over 80 spending the most time in sedentary behavior (Evenson, Buchner, & Morland, 2012).
In addition to recommending gradual increases in the amount of exercise time for older adults who have not been exercising regularly, the nurse may pass along other safety tips. Drinking water before and after exercise is important because of fluid loss during exercise. Clothing worn for exercise should allow for easy movement and perspiration. Athletic shoes should provide both
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support and protection. Outdoor exercise should be avoided in extremely hot or extremely cold weather. Enclosed shopping malls are sheltered places for walking during the extremes of weather or when there are concerns about neighborhood safety. Exercising with a partner provides both encouragement to continue exercising and safety. Nurses should advise older adults to stop exercising and seek help if they experience chest pain or tightness, shortness of breath, dizziness or lightheadedness, or palpitations during exercise (Gunnarsson & Judge, 1997).
Activity as Affected by Lifestyle Changes Retirement, relocation, and the loss of a spouse influence older adults’ activity levels and the types of activities they pursue. Many older adults directly experience these lifestyle changes; others experience them indirectly when a spouse retires or is admitted to a long-term care facility.
Retirement Retirement represents a major lifestyle change for older adults. During most of their lives, older adults have gone to work or watched a spouse go to work each day. With retirement the daily schedule changes. The hours spent on the job and in transit to and from the job are no longer committed. For couples where only the husband has worked, the wife’s daily routine is affected by her husband being home. If the wife is still working outside the home when the husband retires, the husband finds himself at home alone. For the unmarried retired person, retirement may be a transition from a companionable work setting to a lonely, empty house. Key issues for the retired older adult are the replacement of work with meaningful activities and the replacement of work-related friends with new acquaintances.
Activities in retirement may be chosen to be meaningful and to meet socialization needs. Choices about activities are influenced by past interests. If past interests have focused only on work-related topics, retirement choices may be restricted unless the retired older adult develops new areas of interest. Finances may also impose
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practical restrictions on the types of activities chosen. Health status issues such as limited mobility, limited endurance, or sensory deficits may also restrict activity choices. However, for many older adults, retirement is a time to become involved in activities that could not be pursued while working because of time and energy constraints. Many older adults volunteer in community organizations, return to school for the joy of learning, or even start second careers. Nurses are empathetic listeners to accounts of the changes retirement brings and sources of information about different activities available.
Relocation Relocation is movement from one place of residence to another. Relocation may be from the long-time home in a cold climate to a house or apartment in a warmer part of the country. Older adults may also move from their home to the home of their children or grandchildren. Still other older adults may move to a retirement community or an assisted living or long-term care facility. Regardless of the destination, relocation is always an uprooting and a disordering of usual routines. Even when the move is from an unpleasant or unsafe situation, a risk that relocation may adversely affect well-being still exists.
Relocation disrupts usual patterns of activity. Adaptations that maintained independence in ADLs may no longer function. The walk through a familiar neighborhood for exercise may no longer be possible. The new community or long-term care facility will have different options for activities. New social networks can be established. The nurse’s role during relocation is to support efforts to become accustomed to new situations and opportunities and to monitor the effect of relocation stress on health.
Activity programming in long-term care facilities is the responsibility of activity directors. A sufficient variety of activities is provided to allow residents to have choices. Although residents are encouraged to participate in a variety of activities, they always have the right to determine the degree of their participation. The activity preferences of each resident are assessed on admission. The individualized care plan includes activities that are appropriate for
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the resident. Individual (one-on-one activities), small group, and large group activities are typically provided (Figure 11-1). Some facilities provide mechanisms for residents to participate in planning future activities and for families and friends of the residents to be part of the activity program (Box 11-5).
FIGURE 11-1 Recreational activities are important for older adults. (From Byers-Connon, S. (2004). Occupational therapy with elders: Strategies for the
COTA, ed 2. St, Louis, MO: Mosby).
Box 11-5
Examples of activities in long-term care facilities Exercise Walking programs (indoor, outdoor)
Dancing (balloon, square, line)
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T’ai Chi (or similar disciplines)
Spectator Activities Television (selected programming, including telecourses) Video movies
Live performances at the facility
Participative Activities Games
Cards, bingo, and board games
Adapted versions of bowling and volleyball
Adaptations of TV game shows (Jeopardy, Wheel of Fortune)
Yard games such as croquet, miniature golf, bocci ball, and horseshoes
Field trips to museums, sports events, restaurants, shopping malls, and parks
Picnics and barbecues
Fishing
Creative Activities Art projects (painting)
Crafts (woodworking, stitchery)
Gardening (indoor or outdoor)
Cooking or planning menus for special meals at the facility
Music (vocal or instrumental performances by residents)
Writing a newsletter for the facility
Intergenerational Activities Visits from children’s groups
Adopting (and being adopted by) a schoolroom or scout troop
Pets and Other Animals
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Domestic animals kept at the facility (dogs, cats, rabbits, songbirds, parrots, fish, sheep, goats, llamas, chickens, ducks, and geese)
Other animals brought to the facility by zoos or conservation groups (owls, hawks, chimpanzees, and nonvenomous snakes)
Loss of Spouse The loss of a spouse disrupts both joint activities and those activities where one spouse supported the other. If death is preceded by an illness, activities are altered in advance of death. During the period of grief, activities may be reduced. For example, the older adult may not feel up to participating in an exercise class. However, part of the process of grief and recovery from grief is the adoption of a new pattern of life. That new pattern includes new activities but also includes the resumption of former activities, although these may be altered by the absence of the spouse.
Nurses assist the older adult who has experienced the loss of a spouse by listening attentively and supporting the development of new activities. Some of these new activities may require learning new skills such as handling finances, cooking, doing the laundry, or maintaining the car. Other activities may involve making new friends. Information from nurses about available programs and services may help with the acquisition of new skills and the reestablishment of social connections. During the period of adjustment after the loss of a spouse, nurses also monitor the patient’s physical and mental health, remembering that stress may lead to alterations in health.
Activity Affected by Alzheimer Disease and Other Dementias Alzheimer disease and other dementias affect an estimated five million people in the United States (Alzheimer’s Association, 2013). As Alzheimer disease progresses, cognitive impairment increases, which adversely affects the ability to initiate and participate in routine daily activities. The older adult with advancing dementia also loses the ability to initiate diversional activities and to
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participate in activities that were once enjoyed. Caregivers gradually assume more responsibility for monitoring behavior, performing basic personal care tasks, and providing opportunities for physical exercise, cognitive stimulation, and entertainment.
At the heart of planning activities for an older adult with dementia is the desire to preserve the remaining physical and cognitive abilities and to promote independence. Activities should draw on assets rather than deficits and should maximize the remaining abilities (Alzheimer’s Association, 2012a). When planning activities, nurses or other caregivers must consider the extent of cognitive impairment, any concomitant physical constraints caused by aging or other diseases, and safety concerns.
Activities for older adults with dementia should be meaningful (Alzheimer’s Association, 2012a). A meaningful activity has a purpose. The purpose may be to exercise arthritic joints or simply to have fun, but the activity should not be aimless. Meaningful activities are also voluntary. No one is compelled to participate. Instead individuals are invited to participate and given encouragement and explanations of the activity. Meaningful activities foster a sense of well-being for the participants. If an older adult with dementia is stressed by the activity or indicates discomfort, that person should be allowed, or assisted, to stop or leave the activity. Activities should also be consistent with the older adult’s social status and support his or her dignity. Older adults may choose to participate in an activity that appears childish, but they must also have the option to refuse to participate. Activities should promote good feelings, not feelings of embarrassment, distress, or failure. To successfully plan and implement activities for older adults with dementia, nurses and other caregivers must be flexible, patient, and sensitive to the environment (Alzheimer’s Association, 2012b). Communication is enhanced when the nurse or other caregiver speaks to the older adult as one adult to another and assumes the older adult will understand. If the older adult does not understand, repetition or rephrasing may be necessary, but it is best to begin with the positive expectation that the older adult will understand. Scolding, addressing the older adult as a child, or issuing negative instructions (“Don’t …”) should be avoided
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(Alzheimer’s Association, 2012b).
As cognitive impairment increases, the older adult with dementia requires more supervision and assistance with personal care activities such as bathing, dressing, grooming, toileting, oral hygiene, and eating. Personal care activities are best accomplished in regular routines that involve simple, single-step instructions and visual cues. The environment should be quiet, soothing, uncluttered, and unhurried. To promote independence and preserve functional ability, nurses should encourage older adults with dementia to do the personal care tasks, or parts of tasks, that are within their abilities.
Physical exercise for the older adult with dementia is important for general physical well-being, but exercise may also reduce agitation or wandering. The rhythmic movement of a rocking chair may reduce agitation. Going for a walk may redirect the impulse to wander. Whether the benefit is from the change of setting, the removal of the older adult from a provocative stimulus, or the physical effects of walking, the end result is often an older adult who appears more comfortable. Exercise is also important for preserving muscle strength, flexibility, and ambulation. Other activities providing physical exercise include dancing, marching in place or swinging the arms to music, and gardening.
Older adults with dementia gradually lose the ability to select diversional activities, yet when diversional activities are provided, they appear to enjoy themselves and participate to the extent of their abilities. Activities for older adults with dementia range from playing simple games to dancing to watching birds at a bird feeder. Activities may include simple housekeeping tasks such as dusting or folding towels. Activities may be one-on-one activities such as taking a walk with a caregiver or group activities such as attending a church service.
Activities that tap into the older adult’s past life experiences and interests may stimulate memory. Older adults with dementia may enjoy reminiscence, in groups or individually, because long-term memory may be preserved in the early stages of dementia. Activities that involve making or growing things evoke pride in the self and in accomplishments. Even in later stages of dementia, an
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object or a song may evoke a memory. Song lyrics or the familiar motions of cooking, painting, or playing the piano may be remembered when many other things have been forgotten.
The benefits of activity for older adults include the promotion of health and the preservation of independence. Nurses help older adults adapt their activities to the situations that arise in the later years. Nurses also work with older adults to identify new activities. Whether the activities involve daily activities, physical exercise, or diversion, older adults and nurses should work together to design and select activities that improve the quality of life.
Home care
1. Assess risk factors (e.g., environment, pain, or equipment such as a Foley catheter) that would predispose homebound older adults to sleep disturbances.
2. Review all medications to identify those that may interfere with homebound older adults’ sleep patterns.
3. Instruct caregivers and homebound older adults on activities that foster normal sleep, for example, avoidance of caffeinated beverages and alcohol.
4. Assist caregivers and homebound older adults with environmental changes that foster normal sleep, for example, using a rocking chair or taking a warm bath.
5. Remember that anxiety concerning safety and welfare may be an obstacle to sleep. A system of notification and monitoring to link older adults living alone with the outside world is important to promote a sense of security.
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Summary Sleep and activity are two halves that make a whole day. Without sleep, we are not restored from the previous day’s efforts and today’s activities are slowed by fatigue. Without activities, we face going to bed without feeling the necessity of rest. Without the appropriate balance of rest and activity, we are at risk of alterations in health. Nurses, by recognizing the changes that come with age and with alterations in health status, are able to assist older adults with their sleep and activity needs.
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Key points • The sleep changes experienced by many older adults include
increased sleep latency, decreased sleep efficiency, increased awakening in the night, increased early morning awakening, and increased daytime sleepiness.
• Some of the sleep changes experienced by older adults are associated with chronic disease and other health problems.
• Factors influencing sleep quality include environmental factors, pain, lifestyle changes, diet, medication use, medical conditions, depression, and dementia.
• Sleep apnea and PLMS are two common sleep disorders that may result in excessive daytime sleepiness and reports of insomnia.
• The first step in developing interventions to improve the amount and quality of sleep is a thorough sleep history.
• The sleep history includes questions about sleep amount and quality, bedtime routines, the sleep environment, activities, diet, and medications.
• Direct observation of the older adult during sleep, reports from a roommate or bed partner, a sleep diary, measurement instruments to assess sleep quality and quantity, and diagnostic studies in a sleep laboratory may be used to supplement the sleep history.
• Sleep hygiene measures include activities that promote sleep, emphasis on stable schedules, bedtime routines, a sleep-friendly environment, avoidance of substances that interfere with sleep, exercise, and stress reduction.
• Activities pursued by a particular older adult are influenced by that individual’s preferences, lifestyle, and health.
• With advancing years and changes in health and lifestyle circumstances, performance of ADLs may require modified approaches or the assistance of others.
• Physical exercise is important for older adults to maintain health,
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preserve the ability to perform ADLs, and improve the general quality of life.
• Safe exercise requires gradual increases in the amount of exercise for older adults who have not been exercising regularly, adequate hydration before and after exercise, and suitable clothing and footwear.
• Retirement, relocation, and the loss of a spouse influence the ways older adults are active and the types of activities that they pursue.
• The goals of activities for older adults with Alzheimer disease and other dementias include preservation of physical and cognitive abilities and promotion of independence.
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Critical thinking exercises 1. A nursing facility resident tells you she has not been sleeping well and asks you to have the doctor order a sleeping pill. What questions do you ask to assess her sleep quality and quantity? Because you are aware of the drawbacks of the use of sedatives and hypnotics, what other interventions do you suggest to improve her sleep?
2. In the clinic, you meet with an older gentleman who is accompanied by his wife. She reports that he is snoring loudly every night and is always falling asleep during the day. He denies snoring but admits that he is often very sleepy during the day. What sleep disorder do you suspect? What reports and symptoms would strengthen your suspicion? What recommendations do you make to the patient?
3. You are checking blood pressures at a senior citizen health fair. After you check the blood pressure of an older woman, she asks you about starting an exercise program. She has not been exercising, but some of her friends have told her that she should start to exercise regularly. What recommendations do you give her? What precautions do you include in your recommendations?
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* Previous authors: Deanna Lynn Gray Miceli, MSN, RN, CS, Myra A. Aud, PhD(c), RN; Lynn Ferebee, MSN, RN, FNP; and Sue E. Meiner, EdD, APRN, BC, GNP.
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C H A P T E R 1 2
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Safety Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C; Deb Bagnasco Stanford, MSN, RN, CCRN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Identify the nurse’s role in the promotion of safety for older adults.
2. Name various community, state, and federal safety-related resources for older individuals.
3. Identify safety hazards in the health care setting that may lead to litigation.
4. Differentiate between intrinsic and extrinsic causes of falling in older adults.
5. Identify common treatable causes of falling in older adults.
6. Implement the nursing standard of practice for patients experiencing falls.
7. Use home safety tips to prevent burns, accidental poisoning, smoke inhalation, and foodborne illnesses among community- dwelling older adults.
8. Differentiate between hypothermia and hyperthermia and the nursing needs of each.
9. Identify disaster planning resources.
10. Differentiate among the various types of elder abuse.
11. List clinical syndromes and conditions that could impair older individuals and lead to safety hazards on the roadway.
12. Describe the pros and cons of having firearms in the homes of older adults.
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http://evolve.elsevier.com/Meiner/gerontologic
Feeling safe and secure in one’s living environment is important for all people. With aging comes a need to maintain peace of mind while engaging in daily activities. The confidence to carry out daily tasks is affected by perceived security and safety. Safety is a broad concept that refers to security and the prevention of accidents or injuries. When working with older adults, the gerontologic nurse must provide a standard of care that promotes safety and prevents foreseeable accidents or injuries while also respecting individuals’ autonomy to make decisions. This standard of care should pervade all aspects of the nurse’s health care relationships with older adults.
Healthy People 2000 and 2010 identified motor vehicle accidents, firearms, falls, and fires as the responsible factors for most of the 400 deaths from injuries per day in the United States. Violent crimes including homicide are another concern for all Americans, including older adults (United States & Healthy People 2010, 2006).
Part of the nurse’s role in ensuring safety is educating older adults so that they can make informed choices. Education allows one to weigh benefits versus risks and to choose the best option in the situation. In situations in which patients are unable to make informed choices, family members or significant others are sought as advocates for the patients. If patients are unable to make informed choices and no family members are available, the nurse must use nursing judgment and follow an acceptable standard of care to promote safety and security.
This chapter presents common problems that jeopardize patient safety and lead to accidents, injuries, and even death. These include falls, restraint use, accidental injuries, crime and victimization, elder abuse, vulnerability to temperature changes, disasters, and dangers in the home environment. Attention will be given to safety tips and interventions for injury prevention.
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Falls Overview and Magnitude of the Problem Falls are a common clinical problem affecting nearly half of older persons in the United States. Falling is a major health problem for those older than 65 (Elliott, Painter, & Hudson, 2009). In 2010, 21,649 people 65 or older died from injuries related to unintentional falls; about 2.3 million people 65 or older were treated in emergency departments for nonfatal injuries from falls, and more than 662,000 of these patients were hospitalized (Centers for Disease Control and Prevention [CDC], 2012). Falling occurs among people of all ages, but falling results in higher rates of morbidity and mortality among those older than 75 because of the higher incidence of frailty and a limited physiologic reserve among the aging population (CDC, 2012). After age 75, white men have the highest fall-related fatality rates, followed by white women, black men, and black women; non-Hispanics have a higher fatal fall rate compared with Hispanics (CDC, 2012). In terms of serious injury, falls are the leading cause of hip fractures, accounting for more than 271,000 occurrences annually (CDC, 2012). A meta-analysis of 11 studies found that severe traumatic brain injuries (TBIs) resulted in an almost 80% fatality rate (McIntyre, Mehta, Janzen, Aubut, & Teasell, 2013). Women are three times more likely to sustain a hip fracture from a fall compared with men (National Hospital Discharge Survey [NHDS], 2013). In a research study by Tideiksaar (2009), falls accounted for nursing facility placement in 40% of the population seeking institutionalization.
Falling has numerous antecedents and consequences that can be identified and managed. Most clinical research demonstrates a reduction in fall frequency as a result of intervention strategies to modify risk factors. Clinical programs targeting high-risk older adults have incorporated intervention strategies aimed at medication modification, environmental improvements, and behavioral modification. Clinical research findings demonstrate variability in the effectiveness of these interventions. Not all falls are preventable; therefore, goals for individuals who fall frequently
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are fall reduction, prevention of serious injury, and modification of significant risk factors.
It is also important to note that because falls are multifactorial, not all individuals fall as a result of the same antecedents. For instance, an older woman may lose her balance and fall when hurrying to answer the telephone and then experience a second fall the next morning when getting up from bed too quickly. In this example, two distinct causes of falling are present, and both can be modified through education and behavioral modification. Thus, because falls tend to be multifactorial in this age group, care must be taken to perform a comprehensive assessment of individuals who have fallen; this includes a detailed history and physical examination.
Patient education is the cornerstone of fall prevention and management. The gerontologic nurse must explore patient beliefs and misconceptions about falling. Older individuals may consider falling to be a normal part of the aging process. For some, it is an expectation of growing old. Individuals who hold these stereotypes must be educated about the normal aging process, which is distinct from diseases and the adverse effects of medications. It is important to tell older adults that the etiology of falling can most often be determined by a health care professional who has expertise in fall assessment and that falls can be reduced and even prevented through some simple interventions (Box 12-1). The treatable causes of falling must also be emphasized in continuing education and staff development programs in all health care settings. Once the patients’ and staff’s knowledge of falling improves, the reporting of falls in an effort to seek treatment may improve.
Box 12-1
General Fall Prevention Guidelines General Care
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• Wear low-heeled shoes with small wedge platforms.
• Wear leather- or rubber-soled shoes.
• Leave nightlights on at night.
• Keep items within reach to avoid overreaching.
• Check the tips of canes and walkers for evenness.
• Have the last step painted a different color, indoors and outdoors.
• Dangle the legs between positional changes and rise slowly.
• Avoid the use of alcohol.
• Avoid rushing.
• Avoid risky behavior such as standing on ladders unaided.
Steps and Floor Surfaces • Be careful to avoid slippery floors and frayed carpets.
• Watch for the last step when descending the stairs.
• Count the number of steps as a cue while ascending and descending the stairs.
• Install and use sturdy banisters on both sides of staircases.
• Tack down throw rugs or remove them entirely.
• Remove obstacles in the path of traffic.
• Use carpeting on landing surfaces that has color contrast.
Bathroom • Have grab bars installed in the tub and shower and near the
toilet.
• Avoid throw rugs; have carpeting installed.
• Avoid bar soaps; use liquid soap from a dispenser mounted in the shower.
Definition of Falling
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It is crucial for the gerontologic nurse to recognize that older individuals define falling in variable ways and are influenced by perceptions of aging and disease and the context of the situation. For instance, older individuals may not perceive a slip that results in a fall to the floor to be an actual “fall”; rather it may be termed a slip, trip, or accident, but not a fall. Box 12-2 illustrates some common reasons given by older adults to explain a fall. The falling event needs to be reviewed in detail to determine whether the person fell to the lowest level (i.e., the ground). Moreover, how individuals define falling is likely to influence the reporting of falls. A fall may be anything that causes a person to move unintentionally from one level plane to another. An example of this is a sudden and unexpected drop from standing upright into a seat or onto the floor. Injuries such as bruising, sprains, strains, or fractures may result from minimal height drops.
Box 12-2
Common Explanations for Falling Given by Older Adults • “I think I slipped.”
• “I don’t remember what happened.”
• “I was in a hurry.”
• “I tripped.”
• “I lost my balance.”
History taking should be detailed enough for the examiner to envision the details leading to the fall. Refer to the later section “Evaluation of Clients Who Fall” for specific questions to ask during history taking (Tideiksaar, 2009).
Meaning of Falling to Older Adults
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Falling, in a broad sense, is a concept that holds negative connotations because it is associated with a decline, drop, or descent to a lower level. As it relates specifically to patient falling, the same negative connotation appears to hold true, as evidenced by the plethora of research that presents the significant negative consequences of falling. However, to patients, falling may mean something entirely different. It may not be associated with an actual dropping to a lower level, such as the ground; falling might mean a perceived loss in status. In a research investigation of community- dwelling older adults’ statements about falls, the extent to which the fall was attributed to a person’s own limitations instead of the environment depended on self-rated health, among other variables. Thus, the meaning of falling involves several related variables and most likely is determined according to an individual perception of how serious the fall is in terms of daily living.
The health care professional may equate a fall with a decline in patient health or function or a worsening of a patient’s condition. Falling may be viewed as a marker of future decline. In fact, the concept of prodromal falling refers to a series of falls that occurs before the onset of illness or disease, as a prelude (or prodrome). Events such as infections are classic examples of medical conditions associated with falling.
Normal Age-Related Changes Contributing to Falling Numerous age-related changes predispose older adults to falling, especially when these changes affect functional ability and give rise to sensory impairment or gait and balance instability. This section highlights the salient age-related changes associated with falling, along with nursing interventions directed at modifying the impact of these changes to prevent falling. Normal age-related changes in organ function may contribute to an intrinsic risk for falling (Tideiksaar, 2009).
Vision Structural changes in eye shape and crystalline lens flexibility
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accompany the aging of the eye. It is the latter change—inflexibility of the lens—that causes presbyopia, a reduction in the eye’s accommodation for changes in depth, as when ascending or descending the stairs. If older individuals are experiencing presbyopia, instruction must be given for them to carefully watch door edges, curbs, and landing steps, which signal a change in height. Additionally, because of the tendency for the crystalline lens to become cloudy and form a cataract with advancing years, eye glare may occur and cause temporary visual disturbances. This effect is particularly evident outdoors on sunny days or indoors as bright light reflects off shiny floors. Instruction must be given to older individuals with this problem to wear wide-brimmed hats or sunglasses to shield the eyes from the glare effect and to shade indoor windows with drapes or blinds to minimize the effects of sun glare.
Hearing An age-related change affecting the inner ear is atrophy of the ossicle in the inner ear, which causes changes in sound conduction, including a loss of high-tone frequencies, called presbycusis. Other age-related changes include an amplification of background noise and a decrease in directional hearing. The vestibular system is an integral part of maintaining balance and to a large degree is dependent on intact hearing. Therefore, older individuals with hearing impairments are more susceptible to falling when feedback to the brain is altered.
Assessment of hearing difficulties begins during the initial interview. In some individuals with significant hearing loss, it becomes necessary to use alternative forms of visual cues to signal where their feet and bodies are in space so that they can maintain stability. For instance, when hearing loss cannot be corrected, one aim of the management of hearing problems is to introduce vibratory or visual cues to compensate for hearing loss. The use of bells on shoelaces causes a vibratory sense that can be felt by older adults when a foot is placed on the ground. Nursing interventions include instructing older patients to observe foot placement on the floor by literally “watching their step” and to be especially
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cognizant of environmental conditions such as floor surfaces.
Cardiovascular Factors One of the most common problems facing older adults is the loss of tissue elasticity, which affects the arteries. This lack of elasticity leads to a decrease in tissue recoil, resulting in changes in blood pressure with position changes. Older adults who lie supine and then get up quickly are likely to experience the effects of lack of tissue elasticity when the blood pressure drops and a feeling of lightheadedness develops. It is important to educate older individuals to change position slowly and to dangle the legs a few minutes when arising from a supine position. Older adults should be encouraged to wait between position changes and to hold onto the side of the bed or other furniture should an episode of lightheadedness occur. The use of a single bed rail specially manufactured for transferring aids older adults in getting in and out of bed.
Musculoskeletal Factors The bones of aging individuals, particularly the weight-bearing joints, undergo “wear and tear,” which causes loss of supportive cartilage. As a result, joints may become unstable and “give way,” leading to a fall. In many instances, osteoarthritis occurs in the weight-bearing joints, causing pain with weight bearing and further eroding joint stability. Interventions are directed at identifying such problems and correcting them through the use of antiinflammatory agents, prescribed activity and exercise, braces, joint replacement, or all of these measures. If joint pain develops and remains untreated, it may cause older adults to become sedentary or immobile. This phenomenon of disuse and muscle atrophy contributes to muscle weakness. This cycle of pain, reduced mobility, disuse, and atrophy may become a vicious one unless interrupted by regular mobility and pain control through the use of topical or systemic medication. Nursing interventions are directed at encouraging, supervising, or assisting with regular ambulation; appropriate use of ambulation aids; joint range of motion; and modalities such as ice, hot packs, and physical therapy.
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Another normal age-related musculoskeletal change is the reduction in steppage height, which may place older adults at risk for tripping, especially when door edges are not visible or carpeting is frayed. The gerontologic nurse’s role is to identify these changes and offer suggestions for improvement, depending on the cause. In some cases, an assistive device may have to be employed to aid mobility and avoid further joint damage.
Neurologic Factors One of the most universal age-related changes affecting the neurologic system is a slowing in reaction time. It takes older individuals a longer time to respond both verbally and physically to changes in position. Older adults who lose their balance are able to right themselves to an upright position, provided the musculoskeletal strength of hips, ankles, and shoulders is adequate. However, those with functional impairments and diseases, muscle weakness, or adverse effects from medications might lose their postural stability and fall. For these individuals, uneven surfaces in the environment such as steps, sidewalks, and curbs may lead to loss of footing and subsequent falls. Nursing interventions for those with impaired righting reflexes include monitoring mobility for signs of unsteadiness and offering supervision and assistance when needed. In an effort to promote autonomy, it is important to allow older patients to continue to perform their usual activities independently and safely.
When independent activity is no longer possible, older adults require a physiatric, or physical therapy, evaluation for the use of a walking aid such as a straight cane, stationary walker, or posterior walker. Nursing interventions also include the use of chair or bed alarms or call buttons worn around the neck to signal that assistance is needed. Shoes should be inspected for sturdy heels that are low and preferably wedge-type. Observation of an older adult patient’s ability to walk is crucial. For instance, is the walking path straight, or does the patient deviate from it? Does the patient trip when walking because of inappropriate shoes? For some older adults with gait disorders, rubber soles, for example, those on sneakers, worn on high-pile carpeting may actually be a hindrance
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and result in shuffling or stumbling while walking. Leather soles are preferable, as are those that are low heeled and have laces, providing extra ankle and foot support.
Fall Risk Overall, most published research on falls and falling pertains to determining fall risk. Antecedents (e.g., diseases such as stroke, delirium, dementia, or urinary incontinence) that lead to falls have been clearly defined (Box 12-3), but many individuals with these disease-related risk factors do not fall. Thus, fall risk is not determined solely on the basis of the number and kind of diseases but also on how these risk factors influence an older adult’s functional ability, specifically in the areas of mobility, transferring, and negotiating within the environment.
Box 12-3
Treatable Causes of Falling in Older Adults • Orthostatic hypotension
• Dehydration
• Profound anemia
• Cardiac arrhythmia (e.g., bradyarrhythmia, tachyarrhythmia, sick sinus syndrome)
• Overdosing with medication or alcohol
• Urinary tract infection
• Vitamin B12 deficiency
• Osteoporosis
• Hypoglycemia
• Seizures
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• Carotid hypersensitivity
• Carotid stenosis
• Delirium*
* Mental status is an important determinant of fall risk because changes in mental status such as those incurred with delirium may cause older individuals to have difficulty negotiating within the environment. Delirium causes individuals to misperceive sensory input as well as stimuli and objects in the environment.
Fall risk is best determined by observation of mobility. Fall risk may be categorized according to intrinsic (illness or disease-related) or extrinsic (environmental) risk. A risk for falling according to these categories is different from the intrinsic or extrinsic causes of falling. Risk is determined by the clinician and is a term that reflects a judgment, based on a thorough evaluation of a patient, known hazards for falling, and foreseeable events. Older patients at “risk” for falling may not experience a fall at all. Numerous extrinsic risks for falling exist, for example, lack of color contrast on curbs, poor lighting, frayed carpeting, and unsteady furniture. Intrinsic risks for falling include conditions such as orthostatic hypotension, blindness, or advanced dementia. The presence of these risk factors, however, does not mean that an older patient will actually fall—just that he or she is likely to fall given certain circumstances. In fact, some individuals who are at risk for falling, as evidenced by the presence of these risk factors, do not fall. Some of the circumstances that may lead to falling in older adults include unsteady gait or balance instability, delirium or side effects of medications causing unsteadiness, and an inability to right themselves when footing is lost or balance is unstable.
As mentioned, risk for falling is different from actual intrinsic or extrinsic causes of falling. In the latter case, a fall has actually occurred and is the result of either intrinsic disease, extrinsic causes in the environment, or a combination of the two. These falls are likely to occur among those deemed at “risk for falling.” The workup seeks to identify the underlying cause so that it can be treated, thus ultimately preventing or reducing recurrent falling. One aim of fall management is the reduction of risk factors to
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promote safety while still respecting patient autonomy. Because falling is individually determined and not always preventable or predictable, it is important to avoid classifying patients according to the clinician’s perception of their risk for falling (i.e., high risk versus low risk). As previously discussed, falling does not necessarily occur among individuals who are deemed at greatest risk. The effect of functional ability has significance as it relates to older individuals who fall. Research has shown that the individual with frailty and physical functional limitations is at greatest risk for falling (Tideiksaar, 2009).
Intrinsic Risk Intrinsic risk for falling refers to the combined effect of normal age- related changes and concurrent disease. The most salient observations for intrinsic risk relate to gait, balance, stability, and cognition. This requires the gerontologic nurse to observe and analyze older individuals’ gait and balance and determine whether impairment exists. Measurement tools have been developed to rate both gait and balance. These tools identify key components of gait such as step length and height, step symmetry, and path. Important areas of balance assessment include sitting and standing balance, turning, and the ability to sit without loss of balance. The Tinetti Gait and Tinetti Balance instruments are measurement tools that quantitatively score gait and balance. These tools have been tested through clinical research and hold acceptable validity and reliability ratings (Tinetti, 1986). Before managing gait or balance impairments with assistive aids or physical therapy, older individuals require medical workups for treatable causes of gait and balance abnormalities (Table 12-1).
Table 12-1 Treatable Causes of Gait and Balance Abnormalities
Physical Examination Finding Possible Associated Gait or Balance Impairment Peripheral neuropathy Inability to feel feet on the floor Charcot joint Foot instability, foot pain, or both Loss of proprioception Foot placement on floor altered Hemiparesis Leaning to one side; gait instability Hammer toe Foot pain during weight bearing Decreased steppage height Shuffling gait; tripping
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Extrinsic Risk Numerous environmental hazards, both indoors and outdoors, may predispose individuals to falling. Research has found that older persons continue to perform the same types of risk-taking behaviors in their later years of life as in their younger years. Modification of risky behaviors in the face of functional impairment may prevent accidental falls in and around the home. Instruction in home safety tips should be incorporated into health encounters with older individuals who suffer falls.
The modification of environmental risk factors is also critical for fall prevention. Environmental hazards are those that contribute to accidental falls. Research has found that about 30% of falls can be prevented through environmental modification (Wentz, Wentz, & Wallace, 2011). The key areas that require evaluation for safety are steps, floor surfaces, edges and curbs, lighting, and grab rails; nursing interventions are directed at environmental assessment of the indoor living space in these key areas. Whenever possible, steps that are uneven should be repaired or at least have a sturdy handrail to hold onto for support. Floor surfaces should have low- pile carpeting in good repair. Tears should be sewn to prevent shoe heels from becoming caught. Throw rugs should be eliminated because they are a tripping hazard. Curbs and cement landing surfaces should be painted with a contrasting color to outline edges. Lighting should be adequate in high-traffic and dimly lit areas. On a more global scale, a community effort to notify the local Housing Commission of areas needing improvement is an important step in the design of future homes that are safe for older adults.
Steps The most commonly cited place where falls occur in the home is the last step of a staircase. The last step is a problem area, primarily because of visual changes or functional impairment. Handrails should be present on both sides of a staircase or series of steps. The handrail typically ends at the second to last step; if a person descending the stairs is using the handrail as a guide for the landing surface, it will place the individual at the second to last step. Interventions to correct this include educating patients about
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this situation, teaching individuals to count the steps (i.e., keeping a mental tally of the number of steps ascending or descending), and reinstalling handrails that meet individuals’ needs. Another problem with regard to the staircase is unevenness of steps (Figure 12-1). Observation and correction of this phenomenon may be the first step toward fall prevention in the home.
FIGURE 12-1 Steep stairs with handrail missing on the right. (Courtesy of Deanna Gray-Miceli.)
Floor Surfaces Floors that have been waxed or polished are common slippery surfaces that are a safety risk for older adults, especially persons with visual impairments. Heels may be caught in carpeting that is frayed or torn. Throw rugs may cause tripping or sliding (if on a hardwood or tile surface). In general, it is advisable to tack down throw rugs or remove them altogether. Floor surfaces should also be clutter free, as clutter can lead to tripping and accidental falls.
Edges and Curbs Edging that lacks a contrasting color may lead to falls because surfaces tend to blend together. In the interior of the home,
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carpeting on the staircase and landing surface that are the same color may lead to falling. In the exterior of the home, concrete steps that are homogeneous in color may lead to misperceptions and subsequent falling. Uneven pavement outdoors may cause falling. Curbs that are not clearly marked with a bold contrast in color may also cause falling. Simple modifications include painting the outdoor steps a contrasting color at the landing surface and using carpet borders in a contrasting color (or adhesive tape) to distinguish changing indoor surfaces.
Lighting Dimly lit rooms cause difficulty for aging eyes and also for those with low levels of vision or impaired vision. Bright lights may lead to glare and temporary visual impairment. Lighting should ideally be evenly distributed and have consistent brightness. Diffuse overhead lighting is often preferable to one bright light source.
Grab Bars or Rails Grab bars and rails aid those with functional impairments and serve those who accidentally slip in the tub or shower. Grab bars to steady balance should be placed around the toilet, in the shower, or on the tub. Grab bars should be strategically placed to be most beneficial for the person with the impairment. Misplaced grab bars, which cause older persons to reach, may actually lead to falls. Tubs and showers should have adhesive mats and be well lit, and use of bar soaps should be avoided, as they may lead to slipping and accidental falls during showering.
Risk for Serious Injury A small percentage of older individuals who fall are at the greatest risk for serious physical injury (Box 12-4). It is vital for the gerontologic nurse to identify these individuals because they possess intrinsic risk factors that can be identified and often modified to prevent serious injury. Additionally, recognition and treatment of these individuals are part of the gerontologic nurse’s role in preventing foreseeable accidents. Serious injuries such as hip fractures, head trauma, and internal bleeding affect only a relatively
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small percentage of older individuals who fall. Although falls are the leading cause of hip fractures, only about 5% to 6% of older individuals who fall sustain them (CDC, 2012). A high mortality rate is associated with hip fractures, and the cost of their treatment places great economic strain on society for rehabilitation and other ancillary services (Liporace, Egol, Tejwani, Zuckerman, & Koval, 2005).
Box 12-
Conditions Associated with Greatest Risk for Serious Injury • Mental status changes (e.g., those related to delirium and
dementia)
• Osteoporosis
• Gait or balance instability
• Concurrent fractures (e.g., of the hip, pelvis, humerus, or ulna)
• Restraint use
In addition, the use of physical restraints may increase the risk for serious injury. Individuals who are physically restrained may injure themselves attempting to remove the restraints. Incidents of strangulation and asphyxiation have been reported secondary to restraint use. The elevation of both side rails may cause demented or delirious older adults to fall in their attempts to climb over the side rails. These individuals are at risk for serious injury because of the height of the fall; thus, the impact is greater than if the side rails had not been elevated. Physical restraint use does not prevent falls and therefore should never be employed as “safety precautions.”
Reducing the Risk of Serious Injury Behavioral modification is a broad term applied to interventions that alter behavior to achieve positive outcomes. The gerontologic nurse
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is in a pivotal position to educate older individuals, especially those at risk for serious injury from falling, about fall prevention measures. Older individuals’ knowledge base and receptivity to changing behavior are important aspects for the gerontologic nurse to assess before initiating a teaching program. Specific teaching points will vary individually, but general guidelines for fall prevention and home safety may be illustrated through a pictorial display of high-risk environmental hazards or by issuing a handout with teaching points. As they relate to those conditions most likely to result in serious injury, specific interventions can be reinforced (Table 12-2).
Table 12-2 Behavioral Interventions to Prevent Serious Injury
Condition Patient Interventions Osteoporosis Take medications prescribed for increasing bone mineral density.
Take vitamin D and calcium supplements. Eat well-balanced, nutritious meals high in calcium. Perform moderate weight-bearing exercises on a routine basis. Avoid smoking. Avoid excessive alcohol ingestion. Avoid strain on the spine (e.g., heavy lifting, bending).
Gait instability Wear footwear with nonskid soles. Use mobility aids and assistive devices, as prescribed. Make deliberate attempts to scan the environment while walking to look for possible hazards. Participate in an exercise program that includes muscle strengthening and gait training. Make environmental modifications, as needed.
Balance instability Change positions slowly and carefully. Stabilize position before moving. Use mobility aids and assistive devices, as prescribed. Assume a seated position during high-risk activities such as bathing and dressing.
Behavioral modification and instruction, for example, teaching an older patient who has orthostatic hypotension to rise slowly or an individual with dizziness who moves too quickly to slow down, may not be as easy as it seems. Behavior modification first requires older patients to recognize behaviors that are contributing to problems. Often, the causes and effects of these behaviors need to be pointed out to patients in a clear and concise manner. However, this is not a foolproof method because falls might not occur while the patients are still trying to modify their behaviors. The patient’s earlier behavior may thus be negatively reinforced, and he or she may feel justified in continuing to perform those same behaviors. Behavioral modification requires older patients to make conscious attempts, whenever a behavior is performed, to change or alter it.
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Much of what the nurse teaches must be remembered for later action; the use of notes and tape recorders as daily reminders may help.
Disease or condition modification to reduce the risk of serious injury from falls includes appropriate treatment of the actual disease. In the case of osteoporosis, agents to prevent bone demineralization and build bone mass are prescribed and used with calcium and vitamin D supplements. The nurse plays a key role in teaching patients with osteoporosis about the importance of calcium-rich foods and ways to incorporate these foods into the diet on a daily basis. Teaching about the risk factors associated with the development of osteoporosis is also important.
In cases of delirium, condition modification includes a determination of the underlying etiology; unless the cause is identified and treated, the condition will not resolve and patients will remain at increased risk of serious injury from a fall. It is imperative for the nurse to recognize that the etiology is often multifactorial, thus requiring a variety of interventions based on the identified causes. While the delirium is resolving, injury can be prevented through additional nursing interventions, including padding of side rails, increased surveillance, assistance with activities of daily living (ADLs), and measures to promote a calm and reassuring environment.
Fall Antecedents and Fall Classification Falling occurs when persons are upright and walking, termed bipedal or ambulatory, or when they are sitting or lying down, termed nonbipedal. Falls may also be considered serious or nonserious, depending on the consequences for patients. Individuals who fall but not to the lowest level (the ground) and those who catch themselves are considered to be experiencing “near falls”; those who actually fall to the ground are experiencing true falls. Falling may be classified according to the cause of the fall (intrinsic, extrinsic, or multifactorial), frequency of falling, and the timing of falling in relation to other diseases. Most falls in the older adult are multifactorial in etiology, that is, a combination of both
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intrinsic and extrinsic factors. Because so many different circumstances lead to falls in older adults, it is important to determine the type of fall according to a classification system (Box 12-5).
Box 12-5
Fall Classification • Multifactorial
• Extrinsic (environmental)
• Intrinsic (illness or disease related)
• Intentional
• Isolated
• Cluster
• Premonitory
• Prodromal
Isolated falling refers to a one-time event that was most likely purely accidental. The term accidental fall has been avoided in the literature during the last decade because most falls are not accidental but rather indicate specific disease processes or conditions.
Cluster falls may be observed among individuals with specific diseases who decompensate. The classic example is an older individual with congestive heart failure who falls with the onset of oxygen desaturation or cerebral hypoperfusion associated with overexertion. Usually, several falls occur over a short period and are markers of a decline in health.
Premonitory falls are those produced by specific medical illnesses. These types of falls have key symptoms that may be elicited on history taking; physical examination findings and diagnostic tests
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may also confirm this type of falling. Classic examples of premonitory falls are those in individuals with the new onset of stroke, seizure activity, hypoglycemia, or positional vertigo.
Prodromal falling refers to the onset of frequent falling heralding an acute medical problem; thus, falling is a prodrome to later disease onset. An infectious disease typically causes this type of fall. Falls have also been associated with a clinical syndrome called drop attack. A drop attack has been defined as sudden leg weakness without loss of consciousness. Drop attacks are diagnosed when all other medical illness and environmental conditions have been excluded and patients continue to fall.
Intentional falls refer to falls by individuals who fall on purpose, possibly with a desire to do harm. Older patients with significant depression or suicidal ideation may throw themselves down to cause bodily harm. Other types of intentional falls include when one resident pushes another resident to the ground. This is frequently observed among residents with dementia in long-term care institutions.
Thus, classifications of falls will often aid in determining the underlying causes of the falls. Box 12-6 illustrates the risk factors associated with the various types of falls. It is important to note that individuals may experience any one of these types of falls singularly or in combination. If an older resident experiences a premonitory fall on one occasion, the next fall may be from a different cause altogether. Because falls are often unpredictable and therefore not always preventable, the clinician needs to start the evaluation with the goal of identifying and managing those falls that are treatable (Arbesman, Chase, Mann, & Wasek, 2012).
Box 12-6
The Multifactorial and Interacting Causes of Falls
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Intrinsic Risk Factors • Gait and balance impairment
• Peripheral neuropathy
• Vestibular dysfunction
• Muscle weakness
• Vision impairment
• Medical illness
• Advanced age
• Impaired activities of daily living (ADLs)
• Orthostasis
• Dementia
• Drugs
Extrinsic Risk Factors • Environmental hazards
• Poor footwear
• Restraints
Precipitating Causes • Trips and slips
• Drop attack
• Syncope
• Dizziness Modified from Rubenstein, L.Z. & Josephson, K.R. (2006). Falls and their prevention in elderly people: What does the evidence show? Medical Clinics of North America, 90, 807- 824.
Fall Consequences Physical Injury The incidence of fall-related injuries spans from trivial trauma such
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as skin tears and sprains to serious injury such as hip fractures, internal bleeding, or subdural hematomas. Each year thousands of older Americans fall in their homes. Many of them are seriously injured, and some become disabled. In 2010, more than 21,650 people older than 65 died because of falls (CDC, 2012). One study showed that 30.8% of home care older adult patients had one or more falls, and 6.5% experienced falls with injury (Hnizdo, Archuleta, Taylor, & Kim, 2013). Research investigations have found that cognitive impairment, gait and balance impairment, low body mass index, and at least two chronic conditions were factors independently associated with serious injury during a fall (Tinetti, Baker, King, et al., 2008). Among older adults, most injuries caused by falling are considered minor. Perhaps because of the low incidence of serious injury, older individuals often do not perceive falling to be a problem that warrants a report or a medical evaluation (Bell, Talbot-Stein, Hennessy, 2000).
Serious injury from falling is more likely to occur among those with osteoporosis. Bones weakened by osteoporosis, particularly weight-bearing bones such as the femur, are more susceptible to breakage. Injury prevention measures to reduce the impact of falling, for example, lowering the distance an older patient might fall to the ground and even using padding over the bony prominences of the hips, are required. Undergarments such as girdles with extra padding over the high-risk bony prominences have been designed for women. Individuals with osteoporosis should also be prescribed medications to increase bone mineral density and strength over time. Exercise can aid in increasing bone mass.
Psychological Trauma Older individuals who fall may or may not experience psychological trauma after the fall. Many factors influence the development of postfall trauma, including personality, depression, anxiety, and stress-related syndromes. Overall, little research has been done to elucidate the incidence, prevalence, and occurrence of postfall psychological trauma. One significant consequence of falling may be fear of falling again or fear of being able to get up
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independently after a fall. Both these conditions have been researched more extensively than other psychological trauma associated with the postfall period. However, the fear is not limited to those who fall; it has also been reported among those who do not fall (Tideiksaar, 2009).
Fear of falling appears to occur variably in the older adult population. Some research has shown that if older persons express a fear of falling, they may avoid activities and become physically dependent. Research has also supported the hypothesis that chronic dizziness is strongly associated with a fear of falling (Tideiksaar, 2009).
The gerontologic nurse’s role is to determine whether fear of falling or other psychological trauma has occurred after the fall. The best time to elicit this information is during history taking with older individuals who fall. The nurse focuses attention on how confident the older adults are in performing activities that might predispose them to falling. One exception to consider, however, is an older individual who falls when nonambulatory, as in the case of a fall from bed. In this case, confidence may be unaffected during mobility. Issues related to a fear of falling are presented in Box 12-7.
Box 12-7
Fear of Falling (FOF) Issues 1. FOF is higher among women than men.
2. FOF increases as aging progresses.
3. FOF is more prevalent in community-dwelling older adults.
4. FOF is more prevalent in older adults living alone.
5. FOF is decreased when social support is consistent.
6. FOF is a modifiable risk factor for falling.
7. FOF is lowered with the consistent use of ambulatory devices
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(cane, walker) when balance impairment is present. 8. FOF is reduced when home modifications (e.g., rails, grab bars)
are made in appropriate (polypharmacy, balance deficit, history of falls, visual impairment, increased age, and certain chronic diseases) residences.
Modified data from Elliott, S., Painter, J., & Hudson, S. (2009). Living alone and fall risk factors in community-dwelling middle age and older adults. J Community Health, 34, 301-310; Scheffer, A.C., Schuurmans, M.J., van Dijk, N., et al. (2008). Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and Ageing, 37, 19-24.
Defining and Measuring Fear of Falling An older adult’s fear of falling may be assessed in several ways. A simple method is to simply ask the older individual an open-ended question such as, “How do you define fear of falling, and what does it mean to you?” Responses will provide insight into the patient’s perception about falling and give direction for intervention.
While interviewing an individual who falls, the nurse may also assess his or her fear of falling by simply asking the respondent to quantify fear using a visual analog scale that measures (on a 100- millimeter [mm] line) perception of how fearful the patient is during ambulation.
Fear of falling has been operationally defined by some researchers as low perceived self-efficacy at avoiding falls during nonhazardous ADLs. The Tinetti Falls Efficacy Tool lists a series of questions, on a Likert scale, related to how confident the person is during activities such as walking, reaching into cabinets, or hurrying to answer the telephone. This tool is based on Bandura’s self-efficacy theory and is reported as a measure of fear of falling self-efficacy or confidence (Tinetti, 1986).
Jung (2006) studied the psychological impact of the fear of falling and found that an exercise regimen decreased a person’s fear of falling and that a previous fall increased an individual’s fear of falling.
Evaluation of Patients Who Fall
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History Most often the underlying cause of falling will be identified during the health history. Because a tendency to underreport symptoms exists, the gerontologic nurse must be sure to ask about key symptoms that could be related to a treatable cause or causes of falling. At the onset of the interview, an older individual should be informed that falling is not a result of normal aging and therefore information about the fall onset, location, activity associated with the fall, and other details is essential to the evaluation. It is important to elicit the patient’s own words about the circumstances surrounding the fall. Inquiries should be made about fall frequency and what usually happens immediately before a fall. The acronym SPLATT helps in further evaluation (Tideiksaar, 2009):
• Symptoms at the time of the fall
• Previous fall
• Location of the fall
• Activity at the time of the fall
• Time of the fall
• Trauma, postfall
A fall history depends on fall recall and intact memory. If the patient who falls suffers from dementia or delirium, it is advisable to seek additional information from witnesses or significant others. Often, a fall diary may be useful in retrieving detailed information about the fall that the individual may have forgotten. Key symptoms to inquire about are related to diseases that are known to cause falls. Every older adult needs to be asked about a series of key symptoms that will help to further identify the underlying cause of the fall. If these symptoms occurred at the time of the fall or precipitated the fall, it is likely that a treatable cause does exist (Table 12-3).
Table 12-3 Key Symptoms to Elicit During History Taking from Patients Who Have Fallen
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Symptom Associated Medical Condition Sudden onset of visual or hearing loss Stroke Sudden leg weakness (unilateral) Stroke Lower extremity weakness (bilateral) Arthritis Dizziness Vertigo, labrynthitis Light-headedness with standing Orthostatic hypotension Tremors or confusion Hypoglycemia, hypoxia Loss of consciousness Syncope Involuntary loss of urinary or bowel function immediately after the fall Seizure Difficulty breathing or shortness of breath Arrhythmia Palpitations Arrhythmia
Physical Examination The physical examination of an individual who falls includes a focused examination based on the patient’s presenting complaints in addition to the sensory, cardiovascular, musculoskeletal, and neurologic systems. Many treatable causes of falling may be identified on physical examination. Sensory input originates from visual, auditory, tactile, cardiovascular, and motor response systems. Sensory inputs from vision and hearing, proprioception of the distal lower extremities, and the peripheral sensory system all provide stimuli for the brain to process with regard to the maintenance of balance. The cardiovascular system is also critical because blood pressure regulation aids in homeostasis. Changes in apical heart rate such as bradycardia, tachyarrhythmias, or irregular rhythms may alter cerebral perfusion and thus affect balance. In particular, a drop in blood pressure when a patient goes from supine to standing may lead to falling because of cerebral hypoperfusion as blood pools in the lower extremities.
Assessment of the motor response system includes muscle strength testing, and particular attention should be paid to hip and knee extension and ankle dorsiflexion. Several research investigations have found that poor ankle dorsiflexion affects the ability to right oneself during the phases of a fall (Tideiksaar, 2009). Manual muscle strength testing identifies weakness in particular muscle groups, which can then be targeted for exercise. Gait analysis includes evaluation of footwear, base of support, limb stability, and clearance. The neurologic examination focuses on position sense and vibratory sense and includes the Romberg test and cranial nerve assessment. Refer to an assessment textbook for details regarding the examination of older adults.
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Physical examination should identify any findings that might explain a patient’s symptoms. For instance, if a patient complains of dizziness while getting up in the morning, the nurse should check orthostatic blood pressures. Other causes of dizziness for older adults include carotid artery hypersensitivity, cervical arthritis, carotid stenosis, and positional vertigo, all of which may cause dizziness with head movement and may often be reproduced during a physical examination.
Special Testing A few tests will aid the nurse in further evaluating gait and balance. One helpful test for static balance is the sternal nudge. This is a test of the righting reflex and is done with two persons and the patient. One examiner stands in front of the patient and one behind; the examiner in front pushes on the patient’s sternum to displace the patient. If the patient begins to fall, the test is considered positive. A test result is deemed “negative” when the patient is able to maintain standing balance despite the nudge. Tests of dynamic balance include observance of the patient walking and changing position. Additional tests of balance include administration of the Tinetti assessment tool for balance (Figure 12-2). The “timed up and go (TUG) test” is a measure of the patient’s ability to arise from a seated position, walking, and sitting down. The test is timed, and results are correlated with the prognosis of risk for falling. Results of less than 20 seconds have a good prognosis compared with more than 30 seconds (Kristensen, Foss, & Kehlet, 2009).
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FIGURE 12-2 Tinetti Balance and Gait Evaluation (From Fortinsky, R., Iannuzzi-Sucich, M., Baker, D., Gottschalk, M., King, M., Brown, C., & Tinetti, M.
(2004). Fall-risk assessment and management in clinical practice: Views from healthcare providers. Journal of the American Geriatrics Society, 52(9), 1522-1526.
doi:10.1111/j.1532-5415.2004.52416.x.)
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Nursing management of falls The management of falls is challenging to the nurse, especially when older individuals experience multiple or recurrent falls. In these cases, it is helpful to identify a pattern, if any, to the falling. Similarities in antecedents that lead to falling or specific symptoms might help identify the underlying cause. The goals of management are to identify the underlying cause, to reduce the incidence of recurrent falling, and to prevent serious injury.
Several aids for monitoring and preventing falls are available. The fall diary helps to monitor fall occurrences, injuries, and patterns. Community-dwelling older patients may use a fall diary to jot down all the important information that led to the fall, occurred during the fall, or followed the fall. This information is extremely useful in determining antecedents and consequences of falling. Fall diaries are inexpensive or may be created by the nurse simply by using a pen, paper, and ruler (Box 12-8).
Box 12-8
Designing a Fall Diary 1. Gather several sheets of 8½ × 11 inch paper.
2. Across the longest margin write or type the headings “Date,” “Time of Fall,” “Activity at the Time of Fall,” “Symptoms,” and “Injury.”
3. Instruct patients to write, in the space underneath each heading, the information pertaining to each fall soon after the fall occurs.
4. At the bottom of the fall diary include an “Emergency Contact Number” for patients to call in case a fall results in serious injury.
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5. Instruct patients who have experienced a fall to keep a record of the fall events and to bring it to the health care provider’s office at the next scheduled appointment.
For institutionalized older individuals at risk for serious injury from bed or chair falls, the use of bed or chair alarms help alert the nurse when movement is initiated. A sensor is attached to a patient and to the chair or bed via a long thin wire. When the patient attempts to get up, the wire falls off the sensor and signals an alarm. These alarms are noninvasive and do not restrict voluntary movement in any way. The alarm is fairly loud and may startle an older adult, so it is important to alert the patient and family about the noise to be expected when the alarm is triggered. In the corridors of hospitals and nursing facilities, video surveillance cameras help staff view ambulatory patients around the corner or in distant areas. These cameras are prohibited, however, in private areas such as patient rooms because of privacy laws. Other safety aids include safety belts in wheelchairs and the “lap buddy,” which is a soft foam cushion that fits on the patient’s lap and wraps underneath the armrests of a wheelchair. However, if a patient is unable to remove these devices voluntarily, they are considered restraining devices. If the use of these aids fits the criteria for “restraint” for a particular patient, then the clinical guidelines for restraint use must be instituted. Health care providers must ensure that the use of these aids is the least restrictive alternative available for the patient and that the aids do not replace observation or inhibit purposeful activity.
Injury epidemiology is the study of the interaction of effects of injury on the host, the environment, and the agent. The process of aging, along with the effects of disease, results in changes that affect the host. One aim of injury prevention is to alter factors that impinge on the host by maximizing patient health and functional status, reducing unnecessary medications, and altering risk-taking behaviors. These combined efforts will reduce the risk of unintentional injuries. Alterations in environment through the elimination of environmental hazards will reduce accidental injuries that occur in older patients’ homes. Improved technology through research seeks to alter the transfer of energy and thus
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modify those agent-related factors contributing to injuries in older adults. One such example is the alteration in the transfer of energy by use of supersoft mats and floor surfaces designed to absorb the impact of a falling body and redistribute its mass. Thus, when an older patient falls on a special floor surface, the rate of injury is likely to be lower than on a conventional surface.
For all older patients at risk for falls and those at risk for serious injury from a fall, it is advisable to discuss with them the possibility that falling will result in serious injury and how to reduce the potential for such injury. Patients should be given the choice of reducing mobility to prevent serious injury or continuing ambulation, knowing that the risk of serious injury is present. Patient autonomy should be promoted and respected; it is the patient’s choice. In instances in which patients are demented or unable to make informed choices, discussion with the families or guardians is required. In any event, the goal of the gerontologic nurse is to promote safety.
Fall and injury prevention modalities have received much attention in recent years. Evidence suggests that certain activities that improve flexibility and balance will prevent injury (Agostini, Han, & Tinetti, 2004). It is advisable to follow the recommendations presented in Box 12-9 and the Nursing Care Plan in an effort to reduce falling. The Emergency Treatment box gives recommendations for treating a patient who has fallen.
Box 12-9
Fall and Injury Prevention Strategies Physical Modifications • Cushion the landing surface.
• Use specialized tile that absorbs the impact of falls.
• Pad the floor.
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• Cushion bony prominences.
• Use padding around high-risk bony prominences.
• Gain weight (if appropriate).
• Lower the distance to the floor surface.
• Use low-rise beds.
• Use futon beds or a mattress on the floor.
• Sit during dressing and shaving, whenever possible.
• Sit in a shower chair instead of standing in a tub.
• Avoid high heels; use wedge heels or flat shoes.
Behavioral Modifications • Slow the pace of activities.
• Avoid risk-taking behaviors such as climbing on ladders, if feeling unsteady.
• Rise slowly and dangle the legs before changing position.
• Pay attention to the environment, terrain, and uneven or slippery surfaces.
Environmental Safety • Have the curbs and edges painted in different colors.
• Have intravenous tubing removed in the hospital setting.
• Have urinary catheter and drainage bag removed.
• Have grab bars or rails installed.
• Use the “Lifeline” for fall detection.
• Set a predetermined schedule for “checking in” with neighbors or friends.
Nursing Care Plan
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Risk for Injury: Fall Clinical Situation Ms. B is an 82-year-old woman admitted to the hospital from home with acute congestive heart failure secondary to aortic stenosis and new-onset pneumonia. Her medical history includes osteoporosis and a hip fracture 3 years ago. She is short of breath with minimum exertion despite a recent diuresis and the loss of 10 pounds. Ms. B is receiving intravenous diuretics and antibiotics. Vital signs include a temperature of 98 ° F, a pulse of 100 beats per minute at rest, respirations of 26 breaths per minute at rest, and a blood pressure of 90/60 mm Hg; her pulse oximetry while receiving 2 liters (L) of oxygen is 90%. She insists on walking by herself to the bathroom to “stay independent.” As a result of the diuretic, the patient has to rush to the bathroom to prevent urinary incontinence. On examination, the patient complains of dizziness when first getting up.
Nursing Diagnosis Risk for injury: risk for falls related to altered mobility, urinary
urgency, and treatment modalities secondary to osteoporosis and respiratory compromise.
Outcome Patient will maintain autonomy and independence while
avoiding falls during the hospital stay.
Interventions Observe patient during basic activities of daily living (ADLs),
instructing her regarding ways to conserve energy while still encouraging independence.
Check blood pressure and pulse, supine and standing, to determine whether orthostatic hypotension exists.
Keep immediate environment free of obstacles.
Instruct patient to dangle legs before standing up from a supine position.
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Place call light within reach to encourage patient to call for assistance.
Provide temporary use of bedside commode to limit exertional activities while still encouraging independence; instruct in the use of safe transfer procedures.
Monitor electrolyte, blood urea nitrogen, and serum creatinine levels for evidence of drug-induced dehydration.
Weigh patient daily to monitor fluid status.
Monitor intake and output.
Provide nonskid slippers.
Eliminate intravenous tubing and use Heplock so that tripping over clear tubing is avoided.
Don’t forget to include checking for outdoor hazards: decks, sand, and uneven surfaces.
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Safety and the home environment Environmental hazards in the homes of older adults are common. These hazards are found in all living areas and entrances to homes of community-living older adults. Hazards have been observed less frequently in housing that is age-restricted to older adults (Gill, Williams, Robison, & Tinetti, 1999) or has been remodeled or designed with older adults in mind. Hazards especially injurious are those associated with temperature-regulating equipment and household chemicals. The equipment includes sources of fire, heat, and ventilation, and the chemicals include household cleaners, herbicides, and pesticides (Wentz et al., 2011).
Emergency Treatment
Mr. J is an 84-year-old man who was found lying on the floor in his bedroom in a residential care facility. He says, “I just fell down, but I feel okay.” Closer examination reveals a large hematoma over the right temporal area and swelling of the right ankle and lower extremity. Mr. J’s distal dorsalis pedis pulse on the right is obscured by the edema. A right lower extremity fracture is suspected. To stabilize the patient, the nurse carries out the following interventions:
1. Immobilization of the suspected fractured extremity with a splint or board and flexible bandage
2. Application of ice to the right lower extremity and right temporal area
3. Checking of the apical pulse immediately to ascertain whether an arrhythmia occurred, resulting in the fall; monitor vital signs, especially blood pressure and apical pulse
4. A neurologic assessment and inquiry about a postfall headache
5. Checking of the environment for any spills or hazards that
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could have led to the fall
6. Taking of health history for symptoms of medical conditions that could have led to the fall, for example, syncope, seizures, or vertigo
7. Contacting emergency transportation to move the patient to the local emergency department for radiography and evaluation
Burn Injuries in the Home Burns Residential fires are directly related to the increase in deaths of older adults as the result of burns to the body. Although hot food or beverages often cause scald burns, they do not account for the large percentage of deaths from burns. Home maintenance is associated with older adults living in older homes with limited resources for needed repairs and thus risk for fire (Tanner, 2003). The major cause of scald burns is the temperature of the hot water coming from the faucets (Harper & Dickson, 1995). Wentz and associates (2011) stated that scalds resulting from bathing or showering were caused by hot water tank temperatures in excess of 140 ° F (60 ° C). Scalds can be prevented by turning down the thermostat on the household water heater to 120 ° F. At temperatures of 140 ° F, only 3 seconds of exposure is needed to produce third-degree burns on sensitive skin (Wentz et al., 2011).
The nurse should instruct older adults to use a meat thermometer and a container with a padded or safety handle to check the hot water temperature in the kitchen and bathroom. Water should be allowed to run until steam is noted, and the container is then filled. After the thermometer registers a stable temperature, the hot water tank controls are adjusted accordingly. The temperature should not be above 120 ° F.
Cigarette Smoking Home fires occur more frequently at night, and deaths are attributed to smoke injury more often than burns. Smoking materials are often the source of home fires (Touhy & Jett, 2012).
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Smoking in the home has been associated with the dangers of secondhand smoke for many years (Jones & McEwen, 2012). Smoking in bed or in a chair has also resulted in the deaths of numerous older adults from unintentional home fires. The environmental hazards of cigarette smoking include the careless disposal of cigarette butts and cigarettes dropped onto cloth surfaces (e.g., stuffed furniture, curtains, carpets, and clothing). Multiple injuries and deaths have been attributed to older persons falling asleep while smoking (Markowitz, 2013; Wentz et al., 2011).
The nurse should obtain information from the National Safety Council about smoking in the home, prepare an instructional plan to offer to older adults who smoke, and review the materials with them on a quarterly basis to refresh the safety steps associated with smoking at home. These include the following instructions: (1) Never smoke in bed; (2) do not smoke in a chair when a possibility of falling asleep exists; (3) do not smoke after taking any mind- altering medications (e.g., sleeping pills, tranquilizers, or narcotic pain medicine); and (4) place all smoking debris in a container away from all combustible items (e.g., curtains, furniture, clothing, and trash). Have fire extinguishers available for use. Several types of fire extinguishers are available, but the best type for home use is a multipurpose “ABC” type extinguisher. ABC extinguishers generally use ammonium phosphate as the active chemical and are capable of putting out most common fires (National Agricultural Safety Database [NASD], 2013).
Fireplace Hazards The risk of starting a residential fire exists when a wood or gas fireplace is used. Wood fireplaces need to be cleaned of ash and soot buildup regularly when used during winter and in geographic areas where cold weather persists for many months. When ash and other wood debris accumulate over time, the flue may become blocked, causing the smoke or flames to enter the living area instead of exiting through the chimney or vent. All chimneys, vents, and flues need to be checked annually for patency. The ash and wood debris must be removed to prevent blocking the exit of fire and smoke. If proper cleaning is not done regularly, the resulting
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inhalation of smoke may lead to substantial airway damage and pulmonary complications (Wentz et al., 2011).
In the past 20 years, natural gas fireplaces have replaced many wood-burning fireplaces. Although the danger of ash and wood debris is eliminated, the draft element of the fireplace must be checked regularly to ensure a patent opening for the gas fumes to escape. In many municipalities, a regulation on the use of gas fireplaces includes installation of safety valves and permanent vents to prevent the introduction of natural gas into the home (Lee- Chiong, 1999; Tearle, 1998).
The nurse should discuss fireplace safety and maintenance with older adults who acknowledge using fireplaces and suggest having the flues checked for blockages on a routine basis. Setting at least an annual date in early autumn will establish a routine.
Kitchen Hazards Kitchen fires are frequently the result of a “dry fire” from an unattended stove with water boiling in a pan or kettle. Older adults in homes or congregate residences frequently put water on a stove to heat for instant soup, coffee, or tea. Forgetfulness concerning the boiling water is the major reason for dry fires in the homes of older adults (CDC, 2012; Wentz et al., 2011).
The nurse should instruct older adults living alone about the possibility of dry fires. Patients with mild dementia need to be evaluated for their ability to cook safely because of their forgetfulness. Instruct older adults to remember three basic rules:
1. Be on the lookout for potential hazards.
2. Accidents can be prevented by doing things the right way (no shortcuts).
3. Use protective equipment when needed (e.g. pot holders, oven mitts, etc.).
Space Heaters A space heater may be overturned by accident, causing a fire that may not be noticed until it is fully engulfing the home. All space
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heaters should have a safety mechanism that will turn the unit off as soon as it changes position (e.g., falls forward or backward). This safety device can shut off the heater and prevent the ignition of a fire in carpeting, curtains, or upholstery (CDC, 2012; Wentz et al., 2011).
The nurse should recommend that older adults have home inspections; programs are often available through local fire departments. When space heaters are used, an emergency shutoff must be operable. The equipment housing and the electrical cords must be intact. The cords must be appropriate for the electrical outlets being used (i.e., a three-prong plug cannot be placed in a two-prong adapter, which negates a grounded outlet).
Fire Safety Tips Local fire districts across the country are encouraging families to keep fire extinguishers, smoke detectors, and carbon monoxide detectors in their homes. Home fire drills are recommended for all families, but especially for households with older adults. Box 12-10 lists safety tips to protect the home from the hazards of fire. Identification of exits and a plan for meeting outside the building are necessities for independent older persons or couples living alone in a private residence (Wentz et al., 2011). The nurse should instruct older adults and families with older adult members regarding prevention measures (USFA, 2008).
Box 12-10
Safety Tips to Protect the Home from Fire • Maintain smoke alarms.
• Develop and practice a fire escape plan.
• Have home fire sprinklers installed.
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• Never smoke in bed.
• Put your cigarette or cigar out at the first sign of feeling drowsy while watching television or reading.
• Use deep ashtrays, and put out your cigarettes completely.
• Do not walk away from lit cigarettes and other smoking materials.
• Never leave cooking unattended.
• Always wear short or tight-fitting sleeves when you cook. Keep towels, pot holders, and curtains away from flames.
• Never use the range or oven to heat your home.
• Double-check the kitchen before you go to bed or leave the house.
• Keep fire in the fireplace by making sure you have a screen large enough to catch flying sparks and rolling logs.
• Space heaters need space. Keep flammable materials at least 3 feet away from heaters.
• When buying a space heater, look for a control feature that automatically shuts off the power if the heater falls over.
Adapted from United States Fire Administration. (2008). Fire safety facts for people 50- plus. Emmitsburg, MD: USFA.
Common fire hazards in the home are flammable liquids (e.g., gasoline, acetone, and paint thinner), combustible liquids (e.g., lighter fluid, turpentine, and kerosene), overloaded or worn electrical circuits, rubbish and trash stored near a heat source, Christmas trees and lighting used that are frayed or have poor insulation, and natural gas leaks (Touhy & Jett, 2012).
Other Injuries in the Home Knife Injuries The use of knives, particularly in the kitchen, provides the potential for injury. The nurse should instruct older adults in six basic rules (NASD, 2002):
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1. When using knives, always cut away from the body and on a proper cutting surface.
2. Keep the blades sharp and clean.
3. Keep the knife grips clean.
4. Never leave knives lying in water because this may injure an unsuspecting person washing dishes.
5. When wiping blades, always point the cutting edge away from the hand.
6. If a knife should fall, do not try to catch it; pick it up after it has fallen.
Carbon Monoxide Poisoning Carbon monoxide toxicity from use of heating oil or natural gas may occur during the winter months. Furnaces that do not have flues checked for patency may be one of the causes of this silent killer (Iqbal, Clower, Hernandez, et al., 2012). The condition of furnace venting should be checked annually just before the furnace is turned on for the home heating season (Wentz et al., 2011).
Power interruptions during cold weather increase the risk of unintentional carbon monoxide poisoning. Often, power outages occur during severe winter storms. This may create a need for alternative heating methods. Methods associated with carbon monoxide exposure are gasoline generators, propane or kerosene heaters, and charcoal grills (Houck & Hampson, 1997; Wrenn & Conners, 1997; Yoon, Macdonald, & Parrish, 1998). Warnings regarding the use of alternative heating methods during power outages should become part of all home safety instructions.
The nurse should include a recommendation for installation of a carbon monoxide detector in all home safety programs. Box 12-11 lists ways to prevent carbon monoxide in the home.
Box 12-11
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Carbon Monoxide Poisoning: Prevention Guidelines • Do have your heating system, water heater and any other gas,
oil, or coal burning appliances serviced by a qualified technician every year.
• Do install a battery-operated carbon monoxide (CO) detector in your home, and check or replace the battery when you change the time on your clocks each spring and fall. If the detector sounds, leave your home immediately and call 9-1-1.
• Do seek prompt medical attention if you suspect CO poisoning and are feeling dizzy, light-headed, or nauseous.
• Do not use a generator, charcoal grill, camp stove, or other gasoline or charcoal-burning device inside your home, basement, or garage or near a window when outside.
• Do not run a car or truck inside a garage attached to your house, even if you leave the door open.
• Do not burn anything in a stove or fireplace that is not vented.
• Do not heat your house with a gas oven. From Centers for Disease Control and Prevention. (2005). Carbon monoxide poisoning: prevention guidelines. Atlanta, GA: Department of Health and Human Services.
Chemical Injuries Inadvertent skin exposure or ingestion of household chemicals, herbicides, or pesticides has been linked to deaths or injuries requiring long-term medical care (Lee, Chen, & Wu, 1999). Reading labels and properly storing chemicals used in and around the home are essential for the protection of health and safety. Many chemicals available for household and yard or garden use require mixing before administration. Proper ventilation during mixing and storage is mandatory for most chemicals approved for home use.
Misinterpretation of the label or visual difficulties in older persons may lead to improper mixing and storage. All home safety programs should include information related to the correct reading
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of labels and storage of herbicides and pesticides (Wentz et al., 2011). When labels are written in small print, older adults with visual deficits should be instructed to ask for a large print version of the label. These can usually be obtained from the manufacturer (Lanson, 1997).
To prevent accidental poisoning, all hazardous household cleaning substances should be kept in a locked cabinet. This cabinet should be made difficult to be accessed by an older adult with cognitive impairment. Some household cleaning agents (e.g., disinfectants and oven or drain cleaners) are caustic or corrosive to human skin or mucous membranes and may cause critical injuries or death if swallowed. These agents are labeled with cautions and require gloves and eye protection during use. Immediate action is required if an agent is ingested or comes into contact with the eyes or mucous membranes. Where poison centers are available, one should be contacted immediately and given the name and contents of the product that caused the injury. The emergency system (activated by dialing 9-1-1 in most areas) should be contacted for any accidental poisoning when antidotes are not immediately available in the home (Wentz et al., 2011).
Cooling Fans Ceiling, floor, and table fan injuries occur over the summer months when air conditioning is unavailable, not used, or ineffective. Floor and table fans need to have screening surrounding the entire mechanism of the fan blade. The electric cords should be placed in no-traffic or low-traffic areas and checked monthly during use for any defect or fraying of the wires. During seasonal use of fans, cleaning should be done with floor and table fans unplugged and ceiling fans completely turned off (Potts, 1999). To avoid falls while climbing ladders to clean ceiling fans, older adults should use extension poles with dusting attachments made for fan blades (Wentz et al., 2011). If the older homeowner is unsteady on a ladder, he or she should seek assistance with the ladder use or ask someone else to help with the project.
Foodborne Illnesses
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Food handling, preparation, and consumption behaviors associated with foodborne diseases are common in the homes of older adults. Fruits and vegetables are available all year in most parts of the United States because of the long-distance trucking industry. These foods are shipped from unknown locations, where pesticides and other sprays may have been used. Therefore, washing fruits, vegetables, and hands before beginning food preparation is a must to prevent foodborne illnesses. Ground meat and ground poultry are more perishable than most foods. In the danger zone between 40 ° F and 140 ° F, bacteria multiply rapidly. Because bacteria cannot be seen, smelled, or tasted, ground meats should be kept cold to keep them safe. Safe handling and safe storage are a must when preparing ground meat and poultry (NASD, 2002).
Evidence-Based Practice Health Risks with Food Preparation and Handling
Background Assessing safety in food preparation and handling is an important measure in preventing foodborne illnesses.
Sample/Setting A sample of 19,356 completed questionnaires (2461 in Colorado, 3335 in Florida, 2212 in Indiana, 1572 in Missouri, 3149 in New Jersey, 2477 in New York, 2110 in South Dakota, and 2040 in Tennessee) on food safety practices, including food handling, preparation, and consumption behaviors, were collected over a 12-month period.
Methods The 1995 Behavioral Risk Factor Surveillance Systems (BRFSS) Questionnaire was administered by the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and several state health departments.
Findings
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Questionnaire analysis revealed that 50.2% reported eating undercooked eggs, 23.8% ate home-canned vegetables, 19.7% ate pink (undercooked) hamburgers, 8% ate raw oysters, and 1.4% drank raw (unpasteurized) milk. The prevalence of not washing the hands with soap after handling raw meat or chicken and not washing a cutting board with soap or bleach after using it for cutting raw meat or chicken was 18.6%.
Implications Health care professionals should develop and present teaching programs to the public that discuss the dangers inherent in questionable food preparation and handling practices to prevent foodborne illnesses.
Yang, et al. (1998). Multistate surveillance for food handling, preparation, and consumption behaviors associated with food- borne diseases: 1995 and 1996 BRFSS food-safety questions. Morbidity and Mortality Weekly Report and Surveillance Summary, 47(4), 33.
Cleaning all surfaces before and after food preparation is essential for preventing the spread of bacteria and fungus that are common on raw foods. Common household bleach diluted with tap water may be sprayed and wiped off preparation surfaces after cleaning with soap and water. Cleaning procedures should be done after each different type of food is prepared (CDC, 2010).
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Seasonal safety issues Older adults are at particular risk for environmental temperature- induced illnesses. Predisposing medical conditions and side effects from a variety of medications may render older persons vulnerable to heat- or cold-related symptoms ranging from weakness, dizziness, and fatigue to exhaustion, coma, and death.
The nurse should prepare seasonal information materials that deal with the dangers of hyperthermia or hypothermia for all older adults living independently. Additionally, the nurse should identify those patients at risk for illnesses associated with temperature extremes and promote ways of initiating a neighborhood watch program for dangerous climatic changes.
Health care facilities, including acute, subacute, and long-term care, need to have oversight of environmental conditions for safe patient care and living. In some areas of the United States, climatic changes may develop rapidly and unexpectedly, especially as seasons change from cold to hot or the reverse. Nurses acting as patient advocates should work with physicians and management of the health care facility to maintain environmental temperature and humidity levels that are conducive to patient well-being.
Hypothermia and Hyperthermia in Older Adults With aging, thermoregulatory mechanisms undergo physiologic changes, placing the older individual at risk for inability to manage extreme temperatures. The hypothalamus is responsible for regulating the body temperature. Although no significant age- related changes occur in this organ, the hypothalamus depends on the sensory functions to transmit sensory information. These sensory functions undergo changes with aging, and older persons may be unable to effectively manage changes in temperature.
Hypothermia
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Hypothermia is defined as a core body temperature of less than 95 ° F (35 ° C). The two categories of hypothermia are primary and secondary hypothermia. Primary, or exposure, hypothermia follows exposure to low temperature or immersion accidents with intact thermoregulation. Secondary hypothermia is most commonly seen in patients with chronic illnesses, alcohol or substance abuse, and extreme age (Edelstein, 2007).
Hypothermia in the United States has approximately a 21% mortality rate. This rate increases with severe hypothermia to about 40%. It is estimated that about 700 people die of hypothermia each year in the United States (Edelstein, 2007).
At rest, an individual produces 40 to 60 kilocalories (kcal) of heat per square meter of body surface area. Heat production increases with movement. Shivering increases the rate of heat production by two to five times.
The body loses heat through a variety of mechanisms. Under dry conditions, heat is lost via radiation (55% to 65%). However, evaporation is the dominant mechanism of heat loss with medical alterations in the body, especially when the person is receiving drugs that hinder perspiration. Conduction and convection account for about 15% of heat loss, and respiration accounts for the remainder (Edelstein, 2007). Changes in the environment drastically affect the way heat is lost. The hypothalamus controls the mechanism of thermoregulation, and alterations in the central nervous system (CNS) may impair this mechanism.
Risk Factors Primary hypothermia is caused by environmental exposure; no underlying medical conditions contribute to this process. Secondary hypothermia is associated with an underlying medical condition that prevents the body from conducting normal thermoregulation. The causes and risk factors include the following:
• Accidental immersion in cold water
• Exposure to cold temperature
• Drastic changes in the environmental temperature
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• Alcohol and substance abuse
• Excessive heat loss or impaired production
• Burns, psoriasis, or other desquamating skin conditions that contribute to heat loss
• Surgery and trauma, especially cardiac surgery
• Nutritional deficiency
• Sepsis
• Spinal cord injury with poikilothermy
• Stroke
• Anoxia
• Uremia
• Hypoglycemia
• Adrenal insufficiency and hypothyroidism
• Drugs (benzodiazepines, opiates, alcohol, barbiturates, clonidine, and lithium)
Clinical Manifestations In its early stages, hypothermia, like other conditions in older adults, presents in a nonspecific manner. Findings include fatigue, apathy, confusion, lethargy, shivering, numbness, slurred speech, impaired coordination, and possible coma. As the core temperature drops below 95 ° F (35 ° C), the individual’s clinical picture starts to appear more like a disorder. For this reason, nurses need to become familiar with clinical manifestations of hypothermia in older adults. Early signs of hypothermia include confusion, impaired gait, fatigue, lethargy, and combativeness. As the core temperature drops, the signs and symptoms worsen. When an older adult’s temperature drops below 93 ° F (34 ° C), cardiac arrhythmias occur, particularly bradyarrhythmias, flattening of the T or P waves, and atrial fibrillation. Death is usually the result of lethal arrhythmias or respiratory arrest (Kare & Shneiderman, 2001). Peripheral vasoconstriction occurring with hypothermia may also lead to increases in kidney perfusion and a subsequent increase in urine
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output referred to as cold diuresis.
Diagnostic Findings The most objective finding for the diagnosis of hypothermia is a measured core temperature of less than 95 ° F (35 ° C). In addition to physical findings, individuals may manifest changes in their acid–base balance. Initially the individual hyperventilates, which leads to respiratory alkalosis. As the hypothermia progresses, the metabolic rate drops, and metabolic and respiratory acidosis ensues. As a result of these stresses on the body, glucose and white blood cell levels become elevated. Coagulopathy may be seen as a result of prolonged hypothermia. Thyroid-stimulating hormone and corticotropin should also be assessed. Toxicology screening is performed to rule out the presence of opiates or illicit substances as the causative factor. Chest radiography is necessary to rule out patchy infiltrates or signs of pneumonia. Computed tomography (CT) of the head is done to rule out concomitant conditions.
Management The therapeutic management of hypothermia depends on the core temperature. If hypothermia is mild, passive external rewarming with insulated coverings and moving the older adult to a warm environment are indicated. Active external rewarming is useful in mild to moderate hypothermia without cardiac symptoms. This rewarming includes warming blankets, covering of the head, heating lamps, and warm water immersion. Moderate to severe hypothermia requires active core rewarming techniques such as warm intravenous fluids, warm humidified oxygen, and warm gastric and bladder irrigation. Peritoneal dialysis and pleural lavage are reserved for cases with cardiac instability (Kare & Shneiderman, 2001). In older patients with co-morbid conditions, the mortality rate after moderate to severe hypothermia may be greater than in the general population (by 50% or more), depending on the severity at presentation and the underlying disease (Edelstein, 2007).
Hyperthermia Hyperthermia is defined as a disorder affecting the
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thermoregulatory mechanism in which patients have a core body temperature greater than 105 ° F (40.6 ° C). Hyperthermia causes severe CNS dysfunction and hot, dry skin. The most severe and life- threatening heat illness in older persons is heat stroke. This condition is most often seen in debilitated individuals and usually presents differently from the exertional heat stroke seen in the young.
To balance the core temperature, the body should have the ability to produce and dissipate heat. Core heat develops as a result of cellular metabolism. When the environmental temperature exceeds the core temperature, the body’s thermoregulatory mechanism activates heat loss via dissipation. Dissipation occurs via the skin, which is one of the most important elements in body heat regulation (CDC, 2013).
In response to elevated core temperature, the hypothalamus activates efferent fibers of the autonomic nervous system to stimulate vasodilation of the skin vessels, which leads to perspiration. This form of heat dissipation is achieved via the convection and evaporation mechanisms. Heat in the body can only be generated by activity occurring in the muscular system. For body temperature to increase, the rate of heat production has to exceed the rate of heat loss. Consequently, hyperthermia occurs when excessive metabolic production of heat, excessive ambient heat, or the inability to dissipate heat overwhelms the thermoregulatory mechanism.
Risk Factors Risk factors leading to hyperthermia are either physiologic or environmental but usually work in combination. Older individuals are unable to increase their cardiac output for heat dissipation. This condition, together with poorly ventilated homes lacking air conditioning during heat waves, increases the probability for heat stroke. Combining environmental conditions with a sedentary lifestyle, disabilities, poor hydration, and prescription medications that impair the ability to tolerate heat (e.g., diuretics, antihypertensives, neuroleptics, and anticholinergics) may also hasten the development of heat stroke (Kare & Shneiderman, 2001).
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Additional factors that cause or predispose older adults to hyperthermia are as follows:
• Disorders leading to excessive heat production
• Malignant hyperthermia associated with anesthesia
• Thyrotoxicosis (hormonal hyperthermia)
• Salicylic acid intoxication
• Delirium tremens
• Extensive use of occlusive clothing
• Dehydration
• Cerebrovascular accident (CVA)
• Alcohol abuse (ethanol [EtOH])
• Heat syncope and heat exhaustion
Clinical Manifestations Anhidrosis (lack of perspiration) is the most common manifestation in hyperthermia other than a core temperature greater than 105 ° F (40.6 ° C). Most of the clinical manifestations occur as a result of altered CNS function and range from confusion to coma. Additional neurologic signs of hyperthermia include hallucinations, combativeness, bizarre behaviors, and syncope. Extensive evaluation is required to rule out possible psychiatric alterations contributing to this phenomenon.
Management It is important to monitor core temperature and perform complete neurologic and physical assessments in older persons with hyperthermia. The main objective is to bring the temperature down immediately. Interventions used to decrease body temperature include the following:
• Spraying or sponge bathing the individual with cool water (approximately 90 ° F [32 ° C])
• Placing a fan near the patient to circulate cool air
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• Decreasing the room temperature
• Placing ice packs on the groin and axillae together with cooling blankets
The nurse should use protective cream on the older adult to prevent skin burns from the cooling blanket and provide a lightweight gown and bed coverings for the individual. Bed rest should be maintained to decrease muscle activity and subsequent heat production. Antipyretic medications may be administered, as ordered, to facilitate patient comfort. It is also essential to administer oral and intravenous fluids to maintain adequate hydration.
More invasive medical techniques used in the treatment of hyperthermia include peritoneal and gastric lavage with ice water. Precautions need to be taken before conducting these interventions. The airway needs to be protected, and no surgery should be scheduled. Benzodiazepines may be used to manage shivering (Kare & Shneiderman, 2001). By understanding the risk factors for the development of thermoregulatory disorders, the nurse is better equipped to develop strategies to prevent these alterations in older persons.
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Disasters Natural and human-generated disasters have become more publicized over the past decade. Floods, tornadoes, earthquakes, hurricanes, and other severe weather phenomena have frequently been brought to the attention of the public. Hurricane Katrina in 2005 was the largest natural disaster to hit the Gulf Coast of the United States. Human-made disasters such as the September 11, 2001, terrorist attacks on the United States and the bombing at the Murrah Federal Building in Oklahoma City have caused concern and initiated the development of better preparedness plans to protect the safety and health of citizens, especially older or more frail adults.
The American Association of Retired Persons (AARP, 2013) determined that more than 60% of those who suffered medical problems or died during Hurricane Katrina were frail older adults. To provide guidelines for responding to disasters involving older adults, AARP’s Public Policy Institute reports, We Can Do Better; Lessons Learned for Protecting Older People in Disasters and Recommendations for Best Practices in the Management of Elderly Disaster Victims, were produced. Nurses should be knowledgeable about these materials to help prevent similar outcomes in the future.
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Storage of medications and health care supplies in the home The majority of older adults takes medications on a regular basis. The storage of medications at home may become a safety and drug- effectiveness issue. Some storage areas in the home are not safe for keeping medications. The windowsill in the bathroom or kitchen is frequently used to shelve medication bottles. Most drugs degrade when left in direct sunlight, with or without excessive heat. Heat changes the chemical makeup of specific compounds in the medication, and moisture is considered an undesirable element for solid-based drugs such as medications in tablet form.
The nurse should review the home conditions and instruct patients to identify those places that are undesirable areas for medication storage (e.g., kitchens, bathrooms, laundry rooms, basements, and windowsills) (Skidmore-Roth, 2013). Patients should be instructed to appropriately dispose of all outdated prescriptions when new ones are written. The most common method of disposal for outdated or unused medications is to flush them down the toilet. Instructions to older adults for throwing away old medications must explicitly direct them to dispose of them in the toilet and not in trash or garbage containers.
If health care has been delivered in the home setting, dressings and other medical supplies may remain after the treatment ends. Patients should be instructed on how to dispose of used wound dressings and needles or syringes according to local health department regulations. Dressings and bandages touched by infectious disease drainage require special disposal instructions by home care nurses. The nurse should provide and collect biohazard containers for contaminated dressings and sharp objects (e.g., needles and syringes) when home care is being provided. The nurse should also prepare instructional material related to safety and the use of sharp objects that may be left with patients after home care is discontinued. These sharp objects must not be disposed of among regular paper trash in home trash collection. Arrangements for
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disposal should be made through the local health department or hospital.
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Living alone Fear of crime reduces the subjective well-being of older adults while also curtailing neighborhood mobility (Bazargan, 1994). The fear of crime in the home differs somewhat from fear of crime outside the home. In one study, a gender variable was identified: women were significantly more fearful of crime outside the home and much less fearful of crime inside the home. Among factors that affected the perception of personal fear was previous victimization, media exposure, trust of neighbors, and length of residence in the neighborhood (Bazargan, 1994).
Community action groups have developed neighborhood strategies to protect older adults living alone. Among those strategies are the following (Chu, 1998):
• Daily telephone calls to specific persons on a call list
• Raising and lowering window shades or curtains at specific times of the day and evening, which will be monitored by a specific person
• Mail carrier alerts when mail is not picked up daily from mailboxes of enrolled older persons
Tanner (2003) developed an evidence-based home safety assessment tool. This tool includes fall risks, injury risks, fire risks, and a crime risk assessment.
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Automobile Safety Maintaining independence after retirement includes the ability to travel to shopping centers and health care providers’ offices, to visit family and friends, and to participate in recreational activities. A decline in an older adult’s ability to drive safely may result in the loss of driving privileges. This decline may be a result of presbyopia, decreased dark adaptation, decreased depth perception, susceptibility to glare, and the general slowing of reflexes and cognitive processing (Touhy & Jett, 2012).
Because driving is a complex skill that involves rapid cognitive and psychomotor coordination and because many older adults have age-related changes, have illnesses, or are taking medications that slow their responses to road conditions, automobile safety eventually becomes an issue. In drivers who had suffered a stroke, vision and attention essential for safe driving are often impaired. The severity of these deficits could influence driving behaviors (Fisk, Owsley, & Mennemeier, 2002).
Operating a motor vehicle often requires quick reflexes and reaction time, especially in hazardous road conditions. As response time diminishes with advancing age, health care professionals and their patients must address driving safety issues. Driving evaluations are essential for older adults with suspected dementia. Valcour, Masaki, and Blanchette (2002) identified that driving rates dropped as performances on cognitive tests declined, yet a significant percentage of older adults continued to drive with poor results on these tests.
Carr, LaBarge, Dunnigan and associates (1998) established a traffic sign identification test that differentiates drivers with mild or moderate senile dementia of the Alzheimer’s type from cognitively normal older adults. This test was devised to protect the driving rights of older adults while identifying those persons at risk for automobile accidents because of dementia.
Alzheimer disease causes impaired visual–spatial ability and misperception of the environment. Because of damage to neurons
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and a lack of neurotransmitter substances, thinking and reflexes are slowed, impulse control and judgment are impaired, short-term memory loss occurs, and attention span is reduced. When dementia affects language function, road signs and signals may be misinterpreted or ignored. Persons suspected of having early (mild) dementia should have a driving evaluation that can determine their continued ability for safe driving (Carr et al., 1998).
Guerrier, Manivannan, and Nair (1999) found that older drivers have difficulty at intersections, especially when making left turns. Their work indicates that a deficit in information-processing abilities of older persons was responsible for accidents at intersections. The three deficits identified were in visual field dependence, visual search skills, and working memory of decision making to complete a left turn maneuver. Box 12-12 lists common reasons for pedestrian accidents.
Box 12-12
Most Commonly Cited Reasons for Pedestrian Accidents • Vehicles turning left are more dangerous than vehicles turning
right. Pedestrians step off the curb before being sighted by vehicles turning left.
• Pedestrians are most vulnerable when first stepping off the curb because less time is available for the driver or pedestrian to react or respond.
• Vehicles leaving an intersection are more dangerous because they are picking up speed.
• Pedestrians or vehicles may initially be hidden from each other’s view by visual screens.
• Immediate action by pedestrians often occurs as the signal turns green or changes to “Walk,” often while a vehicle is still in the
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intersection. • “Walk” or a green signal does not give sufficient time to allow
older persons to cross safely. From Automobile Association of America. (1993). Pedestrian safety for the older (65 +) adult. Motorist 14, May-June 1993.
When Finelli and Lee (1996) studied the effects of stroke and automobile accidents among older adults, visual field defect, impaired consciousness, and loss of motor control were major contributing factors to accidents. Data analysis revealed that few strokes were caused by accidents, and accidents caused by stroke were not common. When stroke survivors were questioned about driving practices, 50% reported they did not receive advice about driving, and 87% reported they did not receive any type of driving evaluation. These individuals were driving 6 or 7 days a week or 100 to 200 miles a week (Fisk, Owsley, & Pulley, 1997).
Older adults with mild to moderate Parkinson disease have been found to have diminished driving performance (Heikkila, Turkka, Korpelainen et al., 1998). When medical treatment is effective, driving performance may improve during remission of symptoms.
Other disorders that can adversely affect driving ability are as follows (Heikkila et al., 1998):
• Vertigo
• Seizure disorders
• Stroke sequelae
• Macular degeneration or retinal hemorrhage
• Unstable cardiac arrhythmias
Nursing assessment and instruction of older patients must include inquiry about driving as a separate and independent component of a functional assessment (Gallo, Rebok, & Lesikar, 1999). When a functional assessment strongly indicates that a driving safety issue exists, discussion regarding cessation of driving may become necessary. Because an older adult’s lack of driving may place a burden on other members of the family, this discussion is best done in the presence of significant others viewed as
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trustworthy by the patient. States laws and policies differ as to mandatory reporting of high-risk individuals and to licensing provisions. The nurse must be aware of the significance that driving has for older adults. If driving is an important quality-of-life issue for an older person and he or she wants to continue to drive, the nurse should provide the following guidelines for safe travel (Touhy & Jett, 2012):
• Preplan the route of travel.
• Bring someone else to assist in navigation.
• Maintain space between oneself and the vehicle in front.
• Avoid night driving.
• Continue to wear appropriate hearing aids and glasses while driving.
• Avoid driving in poor weather conditions (e.g., ice, snow, rain, or fog).
• Keep the automobile’s maintenance records up to date.
• Avoid driving if medications warn against using mechanical devices while under the influence of the drug.
The issues of quality of life, personal autonomy, and safety dictate that older adults need to be supported in their desire to continue to drive automobiles. As the number of drivers older than the age of 70 continues to grow, new ways of evaluating driving safety while supporting personal autonomy are needed (Touhy & Jett, 2012).
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Abuse and neglect With the estimated number of older adults suffering mistreatment by neglect or actual physical abuse reaching two million by the year 2020, the nurse needs to assess patients for risk factors to identify those who are most vulnerable (Bird, Harrington, Barillo et al., 1998). When signs of injury are evident, the nurse should screen for risk factors of substance abuse, familial violence, dependency needs, or stresses in the spouses, roommates, or guardians of older persons. A suggested scale for determining levels of abuse and neglect was studied by Bird and associates (1998). The four-level scale placed patients in one of the following categories:
• Low risk for abuse
• Self-neglect
• Neglect
• Abuse
A scale to rate the potential for abuse or neglect helps nursing personnel become aware of the incidence and prevalence of this tragedy. Once aware, they can initiate action to remove a patient from an abusive environment.
Older persons with physical or mental frailties are more vulnerable to abuse and neglect than are independent older adults. When they need assistance to perform basic ADLs such as bathing, dressing, toileting, walking around the immediate living area, and eating meals, stress may overtake the caregivers (Cromwell, 1999). For older spouses or adult children with heavy financial and family responsibilities, the stress and strain of caregiving tasks is often the cause for the initial abuse or neglect (Butler, 1999; Jones, Holstege, & Holstege, 1997). Some abusive family members report the reasons that led to abuse as lack of any relief from irritable feelings or constant illnesses and fatigue. Often, they lacked knowledge about caregiving skills and community resources available to provide caregiver relief before they become abusive or neglectful (Cromwell, 1999).
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Elder abuse or neglect reached such magnitude that the U.S. Congress passed the Family Violence Prevention and Services Act of 1992. The act mandated a national study, which reported that 551,000 older persons living in the community were abused or neglected in 1996 (National Center on Elder Abuse, 1998). The identified cases were broken down into six areas of abuse or neglect:
• Neglect: failure or refusal of a caregiver or other responsible person to provide for an older adult’s basic physical, emotional, or social needs (e.g., nutrition, hygiene, clothing, shelter, and access to health care) or failure to protect them from harm (e.g., failure to prevent exposure to unsafe activities and environments)
• Psychological or emotional abuse: occurs when an older adult experiences trauma after exposure to threatening acts or coercive tactics (e.g., humiliation or embarrassment, controlling behavior, social isolation, disregarding needs, or destroying property)
• Financial abuse or exploitation: unauthorized or improper use of the resources of an older adult for monetary or personal benefit, profit, or gain (e.g., forgery, misuse or theft of money or possessions, use of coercion or deception to surrender finances or property, improper use of guardianship or power of attorney)
• Physical abuse: occurs when an older adult is injured, assaulted, or threatened with a weapon or inappropriately restrained (e.g., scratched, bitten, slapped, pushed, hit, burned, or threatened with a knife, gun, or other object to harm)
• Sexual abuse: sexual contact against an older adult’s will (e.g., intentional touching directly or through clothing of the genitalia, anus, groin, breast, mouth, inner thigh, or buttocks)
• Abandonment: the willful desertion of an older person by a caregiver or other responsible person (National Research Council, 2003; National Vital Statistics Report, 2010; Teaster, Dougar, & Mendiondo, 2006)
In nearly 90% of abuse and neglect cases, a family member was identified as the perpetrator. The spouse or adult child of the
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abused or neglected older person was identified as being responsible for more than 65% of the poor care. To a lesser degree, abuse or neglect is experienced at the hands of caregivers that may or may not be family members (National Vital Statistics Report, 2010).
Each state has an adult protective service (APS) agency. When geriatric assessment teams work with APS agencies, the chances of identifying the perpetrator and taking corrective action are greatly increased (Dyer, Gleason, Murphy et al., 1999; Dyer, Pickens, Burnett, 2007). The CDC’s information on elder abuse (maltreatment) is available on www.cdc.gov/ncipc.
A newly developing nursing specialty is forensic nursing. Nurses in this specialty care for the injuries and emotional distress of the victims while collecting and preserving evidence of the crimes for the legal system. Forensic nursing represents the response of nurses to the rapidly changing health care environment and to the global challenges of caring for victims and perpetrators of intentional and unintentional injuries (American Nurses Association [ANA], 2009). Through continued support, these nurses aid the healing process and provide information to prevent further victimization.
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Firearms A firearm in the home may offer both benefits and risks. “Having a gun in the home might affect the risk of homicide, suicide, or unintentional firearm injury,” according to Cummings and Koepsell (1998). Community training programs for the care and safe use of legal firearms have addressed gun safety issues for several decades. However, firearms are associated with high rates of suicide among older men and women (Adamek & Kaplan, 1996; American Association of Suicidology, 2010)). When mortality records of three age groups of white and black men age 65 or older were examined, firearms accounted for 80% of all suicides (Adamek & Kaplan, 1996).
Contrary to myths about methods of suicide among women, firearms have become the most common suicide method among women age 65 or older. A study found that the risk of suicide by firearms varied significantly across culturally diverse groups of older women (Adamek & Kaplan, 1996). Suicide rates among older adults continue to be the highest of any age group. The age group with the highest rate of successful suicide attempt with firearms is persons age 80 or older. In one retrospective study, a large percentage of suicide victims had seen a health care provider within 6 months of their death (Purcell, Thrush, & Blanchette, 1999). Suicide is often associated with alcohol or drug dependence. In fact, in addition to advancing age in men, alcohol and drug dependence are among the greatest risk factors (see Chapter 27).
Other dangers of firearms in the homes of older adults include the potential for accidental injury during weapon cleaning and handling. Another concern is the risk of a criminal entering a home and taking the weapon away from an older person, which often has fatal consequences.
Home Care
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1. Assess the home environment for the presence of hazards and risk factors that predispose homebound older adults to falls.
2. Carefully assess the physical status of homebound older adults for risk factors that predispose them to falls (i.e., examine feet, gait, vision, posture, muscle control, and memory).
3. Instruct caregivers and homebound older adults on tools and techniques to maximize independent functioning.
4. Assist caregivers and homebound older adults in planning a safe environment for the older adults based on the identified risks and hazards.
5. Emphasize the value of physical therapy in assessing the home setting; determine what environmental adaptations should be made to make it safer and easier for homebound older adults.
6. Teach older adults the effects of prescribed medications, focusing on the potential risks associated with falling. Instructions to decrease the effects of orthostatic hypotension, for example, rising slowly and waiting 1 to 2 minutes before standing, are important in preventing falls.
7. For frail older adults, ascertain that emergency phone numbers are located in accessible locations throughout the home; identify emergency call buttons or boxes and alarms.
8. Assess community-dwelling older adults’ homes for hazards associated with fire and heat, chemicals, food handling, storage of medications and health care supplies, and firearms, and instruct or make recommendations to promote a safe, hazard- free environment.
9. Assess the temperature of the home environment during seasons of extremely high or low temperatures. Refer homebound older adults to area energy-assistance programs, if indicated, or to other community agencies that provide heating and cooling assistance.
10. Be alert to signs of abuse and neglect of homebound older adults by caregivers. If abuse or neglect is suspected, follow the reporting laws of the given state.
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Summary The concept of safety encompasses many aspects of an older person’s internal and external environments. The challenge for the nurse caring for older patients is to conduct individualized safety assessments, to identify age-related risk factors that affect safety, and to develop interventions aimed at the prevention of harm and injury.
Fall-related injuries are common among older adults. It is essential to identify some of the more common risk factors before planning nursing interventions or preventive measures. Risk factors include environmental issues and existing health conditions.
Nurses must also consider non–fall-related injuries such as burns, poisoning with carbon monoxide or pesticides, seasonal safety issues with hyperthermia and hypothermia, disasters, motor vehicle accidents, crimes and abuse, and suicide. Gerontologic nurses are on the cutting edge for developing nursing interventions and seeking research opportunities that highlight safety issues among independent older adults. Patient assessment and education concerning safety matters must be incorporated into every discharge plan and, in the case of primary care, into each clinic or office visit. The most challenging step to promoting safety in the homes of older adults is the prevention of injuries and illnesses from environmental hazards.
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Key points • Safety and freedom from harm are essential to an older adult’s
sense of well-being.
• A direct correlation exists between an older person’s sense of autonomy and his or her sense of personal safety.
• Risk factors contributing to falls in older adults include sensory impairment, cognitive impairment, unsafe living environments (e.g., poor lighting, staircases and walkways in poor repair or without hand rails, lack of grab bars in bathrooms, unsecured or worn rugs, and unstable furniture), and a history of falls.
• Thorough and accurate assessment of the risk factors related to falls is essential.
• Methods for preventing falls in older adults may include exercise programs, alarms, and safer environmental conditions.
• As a leading cause of injury in older adults, burns may occur from scalds associated with bathing, cooking, fireplace hazards, use of space heaters, and careless smoking in the home. Chemical burns or injuries may occur when household chemicals, including pesticides and herbicides, are mixed or stored.
• Carbon monoxide poisoning is preventable through maintenance and repair of heating sources in the home and detection with properly placed carbon monoxide detectors.
• Fan injuries may occur when proper guards are not in place over the fan blade housing on floor and table fan models or during the cleaning of overhead fans. Maintenance is essential to the safe use of fans and all other electrical equipment in the home.
• Foodborne illnesses may be prevented through careful cleaning of all foods before cooking and cleaning of the food preparation area before, during, and after meal preparation.
• With aging, thermoregulatory mechanisms undergo physiologic changes, placing the older individual at risk for inability to manage extreme temperatures.
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• Hypothermia is defined as a core body temperature of less than 95 ° F (35 ° C).
• Primary hypothermia is caused by environmental exposure; no underlying medical conditions contribute to this process.
• Secondary hypothermia is associated with an underlying medical condition that prevents the body from conducting normal thermoregulation.
• Hyperthermia is defined as a disorder affecting the thermoregulatory mechanism in which the core body temperature is greater than 105 ° F (40.6 ° C).
• Anhidrosis (lack of perspiration) is the most common manifestation in hyperthermia other than a core temperature greater than 105 ° F (40.6 ° C).
• Neighborhood safety programs for older adults, especially homebound persons or those living alone, should become a component of all neighborhood watch organizations.
• Operating a motor vehicle is often a basic factor in an older adult’s independence. However, with this independence comes increased risk for accidents, mainly as a result of decreased visual acuity and peripheral vision.
• Many older adults are victims of abuse, usually from a relative. Risk factors include poor health, physical or mental dependency, advanced age, and alcohol abuse.
• The maintenance of firearms in the homes of older adults may present special problems. The safety of the equipment, need for its use, ability to manage firearms, and safety of others in the home must be considered.
• Suicide is a leading cause of death in older adults. It is often associated with poor physical or psychological health, alcohol or drug abuse, a history of suicide attempts, and social isolation.
• Nurses must be aware of the risk factors associated with safety hazards and injury in older adults, and they must implement the necessary methods to prevent injuries.
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Critical thinking exercises 1. A 77-year-old woman is hospitalized for management of her diabetes. She has a history of functional urinary incontinence and poor vision from the diabetes. The nursing staff observes her climbing over the side rails on numerous occasions at night en route to the bathroom. She is quite agitated during this time. The nursing assistant requests that you obtain an order for a body restraint at night to prevent her from falling out of bed. Should this patient be restrained to prevent injury? Would you request the order for a body restraint? Why, or why not? What other information is relevant to this case? What nursing interventions could be tried before considering a restraint?
2. A 75-year-old woman, hospitalized on a medical–surgical unit, shares a room with another older adult. You see her sitting on the edge of her bed with her feet dangling about 2 feet from the floor. She has two intravenous lines and a Foley catheter. The Foley catheter is hanging on the floor beneath her feet as she sits on the edge of her bed. Her bed is next to a window, which is usually left open. In the middle of the night, she climbs over the side rails to get out of bed and walks barefoot to the bathroom, which is about 30 feet away. She tells you she hangs onto her intravenous pole to steady her balance and drags her Foley catheter bag alongside. What environmental hazards can you identify, and what environmental modifications could you make to improve her safety?
3. You are a home care nurse visiting a 71-year-old man in his small second-story apartment, following his discharge from the hospital after having two toes amputated because of frostbite injuries. During your initial visit you note that he lives in a two-room, dimly lit, musty-smelling apartment. Stacks of newspapers and old mail are scattered in both rooms. The temperature is noted to be 68 ° F on the wall thermostat. Cold drafts can be felt around the large window in the bedroom. List the safety hazards in this apartment and identify nursing interventions that will improve the patient’s living conditions.
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* Original authors: Catherine E. O’Connor, DNSc, RN, CS and Deanna Gray Miceli, MSN, RN, CS; and Revised: Sue E. Meiner, EdD, APRN, BC, GNP.
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C H A P T E R 1 3
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Sexuality and Aging Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Identify the myths surrounding sexual practice in older adults.
2. Explore the possible reasons for a nurse’s hesitancy in assisting older adults with fulfilling their need for sexuality and intimacy.
3. Describe the normal changes of aging in male and female urogenital systems.
4. Describe pathologic problems of the aging male and female urogenital systems.
5. Explain the influence of dementia on older adults’ sexual desires and practices.
6. Discuss the environmental barriers to older adults’ sexual practices and the ways to deal with these barriers.
7. Conduct an assessment interview related to an older adult’s sexuality and intimacy.
8. State two nursing diagnoses applicable to older adults’ sexual practices.
9. Plan nursing interventions for assisting older adults in fulfilling their need for sexuality and intimacy.
http://evolve.elsevier.com/Meiner/gerontologic
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Older adult needs for sexualality and intimacy Until 2007, no comprehensive, nationally representative, population-based data were available to inform health care providers’ understanding of the sexual norms and problems of older adults. Lindau and colleagues (2007) designed the National Social Life, Health, and Aging Project (NSHAP) to provide data on the sexual behaviors and problems of older adults. Aside from the NSHAP study, literature pertaining to the sexuality of older adults remains limited.
Sexuality is an important aspect of health, general well-being, and quality of life. Human sexuality includes intimate activity as well as sexual knowledge, beliefs, attitudes, and values. Not only does sexual activity provide pleasure for older adults, it may also help maintain a healthy self-esteem, an aspect of life often diminished after retirement. Sexual activity can help each partner express love, affection, and loyalty. It can also enhance personal growth, creativity, and communication. Older persons, especially older women, who feel desirable and attractive often feel younger as well (Locklainn & Kenny, 2013; Messinger-Rapport, Sandhu, & Hujer, 2003).
Older adults regard sexual activity as an important part of life. Although the need to express sexuality continues among older adults, they face several barriers to sexual expression, including problems arising from low desire, aging, disease, and medications; societal beliefs; and changes in social circumstances (Lindau et al., 2007). Nurses are in a pivotal position to assess normal aging- related changes, along with those caused by disabling medical conditions and medications, and to intervene at an early point to enhance sexuality in older adults.
This chapter explores both normal and pathologic aspects of sexuality and intimacy for older adults. The obstacles in assessing and managing sexuality in the various care settings in which older adults reside are discussed. Finally, this chapter proposes the
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application of the nursing process to older adults’ need for sexuality and intimacy.
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The importance of intimacy among older adults Despite the fact that the literature supports the existence of sexual interest and practice in older adults, health care professionals carry out few interventions to facilitate older adults’ expression of sexuality. One reason for this is that society continually equates sexuality with sexual intercourse. However, according to the World Health Organization, sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. Although sexuality may include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biologic, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors. If sexuality among older adults is viewed as a need for intimacy, society and health care professionals may be more comfortable in helping older adults meet those needs.
The absence of male partners for older women propagates the stereotype that older adults should not participate in sexual relationships. The life span of men in the United States is shorter than that of women. The Administration on Aging (2012) reports women reaching age 65 have an additional 20.4 years life expectancy and men an additional 17.8 years. This often leaves older women without sexual partners. The loss of a partner does not necessarily mean that the woman does not have continuing sexual needs. It is imperative health care professionals value the need of older adults for sexuality and intimacy. Research has shown older men and women are not embarrassed about discussing sexual matters with nurses and other providers, although men do prefer to speak with their physician while women have no preference (Farrell & Belza, 2012).
At times, such interventions might include increasing
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socialization for older women to assist them with finding new partners. Older adults may be reluctant to begin dating, feeling unfamiliar with dating practices. How to date and make new relationships may be challenging (Butler & Lewis, 2000). Alternatively, masturbation is a method through which both men and women may feel sexually fulfilled in the absence of partners. Lindau and colleagues (2007) found that the prevalence of masturbation was lower at older ages but higher among older men than among older women. Assisting older adults with masturbation may appear beyond a nurse’s ability; however, excellent references are available in commercial bookstores to help older adults use this method to feel sexually fulfilled.
The literature has established that in addition to older adults’ ongoing need to express their sexuality through traditional sexual methods, the human need to touch and to be touched must also be fulfilled. A person’s need for intimacy and closeness to another does not end at any age (Kaiser, 2000a, b). Little information is available about the role of touch as a substitute or addition to the sexual practices of older adults. It is known that touch is an overt expression of closeness, intimacy, and sexuality and is an integral part of sexuality.
The importance of touch is often undervalued by society. In fact, touch is often thought of as the invasion of a person’s space, and caregivers should not assume that a person likes and wants to be touched (Rheaume & Mitty, 2008). Non–task-related “affective” touching such as simply stroking a person’s check or holding the hand may be viewed as assaultive, erotic, comforting, or presumptuous, depending on a person’s culture, personal comfort level, and relationship with the one touching (Rheaume & Mitty, 2008). For legal as well as privacy reasons, many people have shied away from touching. To older adults experiencing touch deprivation, the social rules that govern touch may be devastating. It is important to remember that touching each other is a way in which older adults may fulfill their sexual needs. Touch may be both a welcome addition to traditional sexual methods and an alternative means of sexual expression when intercourse is not desired or possible.
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When older adults are not able to participate in sexual relationships with others, the nurse’s use of touch is fundamental in preventing touch deprivation. Therapeutic touch is an alternative nursing intervention developed by Kreiger and Kunz (Krieger, 1975). Based on Martha Rogers’ Science of Unitary Human Beings, therapeutic touch has been widely used to diminish anxiety, accelerate healing, and decrease pain. The use of therapeutic touch in fulfilling the need for intimacy in older adults (Ventegodt, Morad, & Merrick, 2004) is an exciting yet understudied area of nursing.
Sexuality, intimacy, and sexual expression were not formally or informally taught during the developmental years of today’s cohort of older adults. In fact, sexuality was hidden behind closed doors for most of these older adults’ lives. Therefore, the sexuality assessment of an older adult may be the first opportunity he or she has to openly discuss sexuality. Embarrassment, shyness, and apprehension in this area are common. In addition, the patient may view the normal changes of aging as embarrassing or indicative of illness and may be reluctant to discuss these matters with a nurse. Some are misinformed about sexuality and may refuse to discuss sexual issues about which they harbor feelings of guilt and shame (Butler & Lewis, 2000; National Council on Aging, 1998). Understanding older adults’ attitudes and myths about aging will help the nurse assess and intervene to sensitively promote the expressions of sexuality and intimacy.
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Nursing’s reluctance to manage the sexuality of older adults The thought of older, and often disabled, people engaging in sexual intercourse is unpleasant to society. Nurses often share society’s ageist beliefs about the asexuality of older adults, which may lead to nurses discouraging sexual activity (Messinger-Rapport et al., 2003).
In long-term care settings, including assisted living facilities, a resident’s attempt at sexual expression is often viewed as a “problem” behavior (Rheaume & Mitty, 2008). However, residents of long-term care facilities do still have their sexual identity, so their need to express themselves sexually and intimately should be encouraged, not extinguished. Educational programs for facility staff may help dispel myths related to aging and sexuality, thus encouraging environmental change designed to enhance resident expression of sexuality and intimacy (Benbow & Beeston, 2012; Katz, 2013).
Older adults face many barriers to sexual expression. The NSHAP found that low desire (43%), lack of vaginal lubrication (39%), and anorgasmia (39%) were the greatest barriers among women. Among men, erectile difficulty (37%) was the most prevalent barrier (Lindau et al., 2007).
Acute care nurses are in a key position to address newly developed or potential sexual dysfunctions before discharge to a community setting or long-term care environment. However, because of discomfort, myths, and lack of training in the area of sexuality, these problems are often ignored. The end result is that older adults are discharged home or to another setting with a newly developed or chronic sexual dysfunction.
In the community setting, nurses have access to the patient’s entire family unit in his or her natural surroundings. The information needed to make a sexual assessment is therefore readily accessible. However, nurses may feel intimidated or uncomfortable questioning older adults about their sexual desires,
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needs, and practices. Consequently, the information needed for proper diagnosis and intervention is not obtained. The end result is that sexually interested older adults in both the long-term care and community settings are in a situation in which they may have multiple disabilities, no support, and no appropriate way in which to express their sexual feelings (Wallace, 2007).
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Normal changes of the aging sexual response If nurses are to assist older adults in fulfilling their need for sexuality and intimacy most effectively, it is critical that they understand the normal changes of the aging urogenital system. Knowledge about these normal changes enables the nurse to work more confidently with the patient to compensate for these changes, to assist the patient in understanding these changes, and to become aware of possible pathologic problems within the aging urogenital system.
To assess sexual function in older adults, health care providers need to understand the sexual response cycle, which is a psychophysiologic cascade of events leading to orgasm (Wise & Crone, 2006). The cycle includes the excitement phase, plateau phase, orgasmic phase, and resolution phase. Sexual dysfunctions include sexual desire disorders, sexual arousal disorders, erectile dysfunction, premature ejaculation, orgasm disorders, and sexual pain disorders.
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Physiologic changes The orgasm response changes with aging. Dysfunctions include anorgasmia, premature ejaculation, and retarded ejaculation. In addition, a longer period of stimulation is typically required for both men and women to reach orgasm. The refractory period after orgasm is also longer for both men and women.
In older adults, the reduced availability of sex hormones in both genders results in less rapid and less extreme vascular responses to sexual arousal (Wise & Crone, 2006). Although some older adults view this gradual slowing as a decline in function, others do not consider it an impairment because it merely results in them taking more time to achieve orgasm (Butler & Lewis, 2000).
Common physiologic changes associated with aging men are an erection that is less firm and of shorter duration, less preejaculatory fluid, and semen that is less forceful at ejaculation (Butler & Lewis, 2000; Messinger-Rapport et al., 2003). The refractory period between ejaculations is long. Andropause (male menopause) has several physical, sexual, and emotional symptoms. Disagreement exists about which term should be used to accurately describe the phenomenon. Most endocrinologists now use the term ADAM, an acronym for androgen decline in the aging male (Blackwell, 2006). A decline in the concentration of testosterone is believed to be the cause of ADAM (Blackwell, 2006). Serum sex hormone-binding globulin (SHBG) concentrations gradually increase as a function of age, making less free testosterone. Testosterone levels diminish with age from a reduction in both testosterone production and metabolic clearance. These hormonal changes lead to a loss of libido, decreased muscle mass and strength, alterations in memory, diminished energy and well-being, an increase in sleep disturbance, and possibly osteoporosis secondary to a decrease in bone mass. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli (Kaiser, 2000a; Messinger-Rapport et al., 2003). Despite these physiologic changes, aging men may still experience orgasmic pleasure (Messinger-Rapport et al., 2003).
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An instrument such as the ADAM Questionnaire, created by Morley (2000), is a helpful screening tool that should prompt further workup, including determination of the testosterone level. Other laboratory studies should include a complete blood cell (CBC) count, complete metabolic panel, and a prostate-specific antigen (PSA) test (Blackwell, 2006).
Erectile dysfunction is the inability to develop and maintain an erection long enough for sexual intercourse (Araujo, Mohr, & McKinlay, 2004). Causes of erectile dysfunction include structural abnormalities of the penis, the adverse effects of drugs, psychological disorders, and vascular, neurologic, and endocrine disorders. It is most common to have more than one cause of erectile dysfunction (Wise & Crone, 2006).
Women usually do not have difficulty maintaining sexual function in older age unless a medical condition intervenes. The infrequency of sexual activity for older women is usually from their lack of desire, according to the NSHAP study. Most sexual changes occur with menopause, including atrophic vaginitis, decreased lubrication, thinning of the vaginal wall leading to irritation or pain and bleeding during intercourse (Butler & Lewis, 2000; Messinger- Rapport et al., 2003). Urinary incontinence from detrusor insufficiency or stress may cause embarrassment during intercourse (Messinger-Rapport et al., 2003). The age-related shortening and narrowing of the vagina may further compromise pleasurable intercourse (Butler & Lewis, 2000). Women may also have increased facial hair from decreased estrogen levels, causing them to feel less attractive (Butler & Lewis, 2000).
Women experience a decline in both ovarian hormones and adrenal androgens in the years preceding menopause. This may cause a diminished sense of well-being, loss of energy, loss of bone mass, and decrease or loss of libido (Kaiser, 2000b). Some of the causes of decreased libido include low bioavailable testosterone, elevated prolactin, and, indirectly, decreased estrogen. Incontinence may also decrease libido and inhibit arousal (Kaiser, 2000b). Dyspareunia, painful intercourse or pain with attempted intercourse, is a condition often experienced by older women, resulting in a decreased desire to participate in sexual activity. About one third of
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sexually active women older than the age of 65 experience dyspareunia. Causes of dyspareunia include inadequate vaginal lubrication, irritation and dryness of the external genitalia, urethritis, improper entry of the penis, anorectal disease, altered anatomy of the female genital tract, vulvovaginitis, local trauma (e.g., episiotomy scars), and even arthritis (Kaiser, 2000b). Vaginismus, involuntary painful contraction (spasm) of the lower vaginal muscles, is also often experienced by older women, again decreasing their desire to participate in sexual activity. Causes may be related to dyspareunia, vaginal infections, or vaginal mucosal irritation. It may be triggered by fear of losing control or of being hurt during intercourse (Kaiser, 2000b).
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Pathologic conditions affecting older adults’ sexual responses Illness, Surgery, and Medication Sexual function is a process that depends on the neurologic, endocrine, and vascular systems. It is also influenced by several psychosocial factors, including family and religious beliefs, the sexual partner, and the individual’s self-esteem (Wise & Crone, 2006). Several medical disorders common to older adults can affect sexual function (Box 13-1).
Box 13–1
Conditions that affect sexual function Cardiac Conditions Congestive heart failure
Myocardial infarction Angina
Arrhythmias
Hypertension
Endocrine Conditions Diabetes mellitus
Hypothyroidism
Genitourinary Conditions Prostatitis
Cystitis and urethritis
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Chronic renal failure
Incontinence
Immune Conditions Human immunodeficiency virus (HIV) infection and acquired
immunodeficiency syndrome (AIDS)
Cancer
Musculoskeletal Conditions Arthritis
Chronic pain
Neurologic Conditions Parkinson disease
Dementia
Stroke
Depression
Respiratory Conditions Chronic emphysema
Bronchitis
Sleep apnea
Surgery Hysterectomy
Mastectomy
Prostatectomy Modified from Messinger-Rapport, B., Sandhu, S., & Hujer, M. (2003). Sex and sexuality: Is it over after 60? Clinical Geriatrics, 11(10), 45; Butler, R. & Lewis, M. Sexuality. In Beers, M. & Berkow R. (Eds.). (2006). The Merck manual of geriatrics. Rahway, NJ: Merck; Wise, T. & Crone, C. (2006). Sexual function in the geriatric patient. Clinical Geriatrics, 14(12), 17-26; Rheaume, C. & Mitty, E. (2008). Sexuality and intimacy in older adults. Geriatric Nursing 29(5), 342-349; and Srinivasan, S. & Weinberg, A. (2006). Pharmacologic treatment of sexual inappropriateness in long-term care residents with dementia. Annals of Long Term Care, 14(10), 20-28.
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Surgeries may also affect an older adult’s sexual responses. Some of these surgeries include coronary artery bypass surgery, hysterectomy, mastectomy, prostatectomy, orchiectomy, and removal of the anus and the rectum. In addition, many drugs adversely affect sexuality (Table 13-1).
Table 13–1 Drugs affecting sexuality
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Data from Messinger-Rapport, B., Sandhu, S., & Hujer, M. (2003). Sex and sexuality: Is it over after 60? Clinical Geriatrics, 11(10), 45; Nusbaum, M., Hamilton, C., & Lenahan, P. (2003). Chronic illness and sexual functioning. American Family Physician, 67, 347; and Butler, R. & Lewis, M. (2000). Sexuality. In Beers, M. & Berkow, R. (Eds.). The Merck manual of geriatrics. Rahway, NJ: Merck.
Human Immunodeficiency Virus Older adults continue to be a considerable proportion of the population infected by human immunodeficiency virus (HIV) (Lovejoy, Heckman, Sikkema et al., 2008). In 2011, those over 55 were the highest percentage of persons diagnosed with HIV (Stewart & Graham, 2013). Statistics indicate a diagnosis of HIV infection is more likely to be followed by acquired immunodeficiency syndrome (AIDS) in less than 12 months in older adults compared with younger persons. The estimated
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number of new diagnoses of HIV and AIDS has also increased among adults older than 65 years of age, from 696 in 2004 to 803 in 2007, and has almost doubled from what it was 5 years ago (Centers for Disease Control and Prevention [CDC], 2009).
Results from a 2007 study led by Travis Lovejoy along with Ohio University psychologist Timothy Heckman, revealed that one third of HIV-infected older adults who were sexually active have unprotected sex. Older adults may be at risk for HIV infections if they engage in unprotected sex (Lovejoy et al., 2008). Despite the fact that older adults do engage in behavior that puts them at risk for HIV infection, they are less likely than younger persons to adopt safer sexual practices because they do not perceive themselves as being at risk. Some of the reasons older adults do not practice safer sexual behaviors are as follows:
• They see sexually transmitted disease (STD) as something that happens to somebody else because they were settled in marriages when the safe sex battles of the 1980s were raging.
• Older women do not fear pregnancy because they are postmenopausal, so having the man wear a condom is not a concern.
• Older women outnumber older men, which allow men many partners to choose from; therefore women try to please their male partners by agreeing to unprotected sex.
• Older adults grew up when men made most of the decisions in a relationship; thus, if a man does not want to use a condom, then it is not used.
Age-related changes also increase the risk of HIV infection. For example, age-related thinning of the vaginal mucosa and the subsequent vaginal tissue disruption, as well as age-related reductions in immune function, place older adults at increased risk for HIV infection. Older adults who do contract HIV are more likely to be diagnosed late in disease and experience progression more quickly; death from AIDS comes sooner after diagnosis than in their younger counterparts (Resnick, 2003).
The study by Lovejoy and associates (2008) also revealed that
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sexual activity was more prevalent among HIV-positive older adults who were not cognitively impaired, were younger, and considered themselves to be in good health. According to their study, most of those having sex were male, took sildenafil (Viagra), and were in a relationship.
Malignancies Breast cancer, one of the leading cancers affecting older women, has clear implications for self-esteem and sexual functioning. Dysphoria from the disease, fears of death, and disfigurement may diminish sexual desire before treatment begins (Wise & Crone, 2006). The presence of medical illnesses as well as myths about sexuality and the benefit of treatment to older adults often prevents clinicians from aggressively treating older women with breast cancer.
Prostate cancer is the most common cancer in men and the second leading cause of death from cancer in men in the United States. The risk of developing prostate cancer increases with age. Radical prostatectomy, a curative treatment, involves a massive disturbance of hormone-producing glands, surrounding nerves, and urinary structures. This often results in temporary urinary incontinence and impotence, both affecting a male’s sexuality. The introduction of nerve-sparing techniques has greatly decreased sexual dysfunction; however, men may need to wait 2 to 3 years for maximum function to return. Phosphodiesterase inhibitors and prosthetic devices may be used to modify post–radiation treatment dysfunctions that occur in 50% of those receiving treatment (Wise & Crone, 2006).
Colon cancer may result in the need for an ostomy, the presence of which may result in fear of fecal spillage and odor inhibiting sexual pleasure. Women with ostomies may develop dyspareunia secondary to fistula formation (Wise & Crone, 2006).
Dementia Dementia in older adults may lead to various sexual disturbances. Factors associated with dementia that may affect sexual functioning
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include failure to recognize a partner, misidentification of a partner, delusions, hallucinations, personality changes, and disinhibition (Lesser, Hughes, & Kumar, 2005). One behavior common among patients with dementia is hypersexuality, also referred to as sexually inappropriate behavior and sexual disinhibition (Srinivasan & Weinberg, 2006; Wallace & Safer, 2009). Older adults with dementia may masturbate in public, strip themselves of clothing, expose themselves, or make overt gestures to other patients or staff. These behaviors are disturbing to others and often difficult to address. Although no apparent explanation may exist for such behavior, family and staff should consider the possibility that these behaviors are triggered by unmet intimacy needs; however, they may also indicate pain, hyperthermia, or the need to be freed from a restrained situation (Messinger-Rapport et al., 2003; Wallace & Safer, 2009).
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Environmental and psychosocial barriers to sexual practice One of the most difficult problems encountered when intervening to assist older adults with meeting their needs for sexuality and intimacy is overcoming environmental barriers. In the community setting, older couples may be hindered by a lack of assistive equipment needed to safely fulfill their sexual desires. In long-term and acute care settings as well as in assisted living settings, lack of privacy often prevents older residents from pursuing sexual relationships. Interventions used to overcome these environmental barriers are discussed later in this chapter.
Fear of becoming the topic of conversation among staff members as well as their peers may make older adults hesitant to seek advice from staff or pursue opportunities for sexual fulfillment. The issue of privacy of information becomes a reality for older adults desiring sexual relations (Rheaume & Mitty, 2008).
Sexual dysfunction may signal other psychosocial disorders such as depression, delirium, and dementia. Sexuality may also be affected by anxiety concerning partner availability and lifestyle issues. Substance abuse, including smoking, alcohol, and street drugs, is often associated with sexual dysfunction. Many older individuals may be self-medicating with alcohol and drugs as a way of managing depression or anxiety symptoms, coping with loneliness or loss, or dealing with pain, which can impact sexual function (John Hopkins Special Report on Depression and Anxiety in Older Adults, 2009; Lesser et al., 2005).
Patients with dementia should be given special attention to ensure their safety when they decide to engage in sexual relationships. Health care professionals working with cognitively impaired older adults need to determine whether the individual is actually consenting to a sexual activity. If the person is unable to consent to participation in a sexual activity and has a surrogate decision maker, that person should be involved with judgments regarding the benefits or potential harm associated with that
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person’s sexual expression (Rheaume & Mitty, 2008).
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Alternative sexual practice among older adults Society’s lack of understanding of sexuality of older adults and homosexuality is the double burden carried by aging homosexuals. As they age, compared with their heterosexual counterparts, lesbian, gay, bisexual, and transgender (LGBT) individuals feel socially isolated, fear discrimination from health care providers, live alone, and do not have children to assist in their care (Anderson, 2008). According to the 2006 MetLife study of LGBT seniors, they are twice as likely to live alone, half as likely to have a life partner or significant other, half as likely to have close relatives to call on for help, and four times less likely to have children to help them (MetLife, 2006). Gay and lesbian persons who have “come out” to others often need to hide their sexual orientation when they need health care services. The attitudes and practices of aging networks with regard to gay and lesbian older adults have gone unchallenged, which has resulted in a senior health care system that is even more homophobic than other health care systems (MetLife, 2006). Despite prevailing stereotypes, it is important for nurses to recognize that same-sex companionship is an acceptable expression of sexuality for both men and women.
Although change in providing health care to gays and lesbians has been slow, some progress has been made. In Broward County, Florida, for example, Edith Lederberg assisted in the opening of the Noble A. McArtor Adult Day Care Center in late 2002. The Center is the first in the country to specialize in caring for gay and lesbian seniors.
Nurses need to be sure that their own personal beliefs about alternative sexual practices do not prevent older homosexual patients from fulfilling their sexual desires. Examination of their own feelings toward this alternative sexual practice may allow nurses to recognize what the homosexual lifestyle means to patients. This allows nurses to enter into a therapeutic relationship with these older adults without the interference of personal
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feelings. Homosexual patients’ partners should be encouraged to participate in the sexual assessment and planning when appropriate. Nurses should also remember that no information about the sexual orientation of patients should be shared with a patient’s family unless permission has been given. See Box 13-2 for questions that can be added to an assessment.
Box 13-2
Questions on sexuality • Are you currently sexually active? If so, with one or more than
one partner?
• Male or female partner?
• Are your sexual desires being met?
• Do you have any questions or concerns about your sexual function? About your partner’s sexual function?
• What kind of information would you like?
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Nursing management Assessment
Sexual health may have a direct impact on the well-being of individuals with chronic illnesses (Nusbaum, Hamilton, & Lenahan, 2003). Therefore, it is essential to obtain a sexual history (Table 13-2); however, one of the greatest obstacles in assessing the sexuality of older adults occurs at the beginning of the assessment. Getting started with the sexual history becomes easier with experience. One challenge nurses face is to help older adults develop and sustain the intimate relationship they desire. This involves active assessment, including actively reviewing health concerns and conditions that affect sexual functioning (Szwabo, 2003). Although discomfort in this area is understandable, increased proficiency comes with experience. According to the NSHAP (Lindau et al., 2007), a total of 38% of men and 22% of women reported having discussed sex with a physician since the age of 50 years. Healthy sexuality depends on good communication between the health professional and the patient. Nurses are in a pivotal position to begin this communication. The PLISSIT model has been used to assess and manage the sexuality of adults since 1976 (Annon, 1976). PLISSIT is an acronym for Permission, Limited Information, Specific Suggestions, and Intensive Therapy (Rheaume & Mitty, 2008). The model offers suggestions for initiating and maintaining a discussion of sexuality with older adults. It was first used with young adults but has also been successful in use with older adults. Nusbaum and Hamilton developed the Proactive Sexual Health History in 2002. A simple sexual history performed by nurses may include questions such as those found in Box 13-2.
Table 13-2 Evaluating sexual risk in older adults
Normalizing the discussion • I discuss sexual activity with all of my patients because it is an important part of their medical care.
Broaching the topic • Tell me about your sex life.
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• When you say you have had sex, what exactly do you mean? • Do you have sex with men, women, or both?
Asking about partners • Tell me about the number of sex partners within the past 3 months. • Where do you meet your partners? • Have you ever gone online to meet partners for sex? • How well do you know your sexual partners? • What do you know about the human immunodeficiency virus (HIV) status of your partners? • How does your partner’s HIV status affect your sexual behavior? • Have you noticed symptoms in your partner that are causing you concern?
Asking about sexual activity • What sexual activities do your sexual partners engage in? • Do you have oral sex? Vaginal sex? Anal sex? • Do you select partners on the basis of HIV status? • Do you ever get drunk or high before you have sex?
Asking about prevention methods
• What do you do to protect yourself during sex? • Do you use condoms when having sex? How often? With what types of sex? • What has been your experience with using condoms? • What factors or situations get in the way of using condoms?
Adapted from Centers for Disease Control and Prevention (CDC); Health Resources and Services Administration; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. (2003). Incorporating HIV prevention into the medical care of persons living with HIV. Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recommendations Report,52(RR-12), 1-24.<www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm> Accessed 03/15/2013.
Some nurses are more comfortable than others in completing a sexual assessment; however, being able to do the following will help develop the necessary skills (Association of Reproductive Health Professionals [ARHP], 2002):
• Be a sympathetic listener.
• Reassure the patient who has sexual concerns that strategies for addressing those concerns do exist.
• Make an appropriate referral, if needed.
A detailed sexual history should be completed by the primary care practitioner (nurse practitioner or physician). The goal of the assessment, regardless of the model used, is to gather information that allows patients to express sexuality safely and feel uninhibited by normal or pathologic problems.
It is common for nurses and nursing students to feel uncomfortable and embarrassed when assessing the sexual desires and functions of older patients. Nonetheless, a sexual assessment should be performed as a routine part of the nursing assessment. Knowledge, skill, and a sense of comfort are necessary for the nurse to assess the sexuality of older adults. According to ARHP (2008),
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nurses may take a number of steps to create a nonthreatening environment conducive to communication. They should provide a quiet, private meeting place and avoid interruptions during the discussion. Nurses should sit at eye level with the patient and ask questions in a manner that is not threatening. Nurses need to avoid using terms that may suggest they are making assumptions about sexual behavior or orientation. For example, when asking about an older adult’s sexual orientation, they should avoid using the term husband or wife and instead use the term partner. They also need to avoid medical terminology and the use of slang words (Nusbaum & Hamilton, 2002).
Other components of the sexual history taking include reviewing medications and medical conditions that may contribute to a sexual dysfunction, as discussed earlier. In addition, the nurse should review the older adult’s early experiences, if he or she is willing to share. A physical assessment of the breasts and genital tissue is an essential part of the assessment of sexuality. Laboratory tests may be useful in determining reductions in hormone levels that may contribute to decreased libido or erectile dysfunction. Box 13-3 lists laboratory tests relevant to a sexual assessment of older adults.
Box 13–3
Laboratory tests to guide sexual assessment • Total serum testosterone
• Dihydrotestosterone
• Estradiol
• Mean gonadotropin-releasing hormone
• Serum luteinizing hormone
• Serum prolactin
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• Prostate-specific antigen
• Complete blood cell count
• Complete metabolic panel
• Thyroid-stimulating hormone
The nurse should also obtain information on sexual preferences. This should be followed by an assessment of the environments in which patients live. The nurse should determine where patients plan to participate in sexual activity. In acute and long-term care settings, the environment should be assessed for privacy and safety. This enables older adults to proceed with sexual activity safely and comfortably. In the community setting, the environment should be assessed for safety and the availability of adaptive equipment such as side rails, trapezes, and specialized beds, which may be needed to allow older adults to practice sexual activity safely within the home.
The nursing staff should be cognizant of indications of sexual interest in older adults. Overt gestures of sexuality in public areas or hints of sexual interest during conversations with patients should not be ignored or punished; they should be viewed as an indication of sexual interest between two older adults.
Evidence-based practice Discussion of Sexual Concerns with Providers Sample/Setting A nationally representative probability sample of community- dwelling persons 57 to 85 years of age was taken from households across the United States.
Methods Respondents were interviewed regarding their sexual concerns, interests, and experience and whether they had discussed sex after age 50 with their physicians.
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Findings Thirty-eight percent of men and 22% of women reported having discussed sex with a physician.
Implications Health care professionals’ knowledge about sexuality at older ages should improve patient education and counseling as well as the ability to clinically identify a highly prevalent spectrum of health-related and potentially treatable sexual problems. From Lindau, S., Schumm, P., Laumann, E., et al. (2007). A study of sexuality and health among older adults in the United States. New England Journal of Medicine, 357(8), 762-774.
Among older adults, an added risk factor is possible cognitive impairment, which may hinder patients’ decision-making abilities. Before a sexual relationship commences, it may be appropriate for the nurse to meet with both patients individually and together to discuss their intentions and expectations regarding the sexual relationship. In so doing, the patients’ fears and apprehensions may be expressed and their questions answered. In addition, such a discussion may reveal whether one patient is being coerced into the relationship or is not mentally competent to decide to enter into such a relationship.
A cognitive assessment such as a Mini-Mental State Examination (MMSE) should be performed as part of the assessment of older adults. The information gained from this assessment is useful if the nurse suspects that patients are cognitively impaired and unable to make decisions to participate in sexual relationships. If the cognitive assessment does not provide sufficiently clear information regarding patients’ decision-making abilities, a more thorough assessment by a psychology team may be necessary to prevent anyone from taking advantage of these patients.
Diagnosis After the assessment of older adults’ sexuality, the nurse is prepared to make a nursing diagnosis. Several nursing diagnoses are appropriate for older adults experiencing actual or potential
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sexual problems. The first, “ineffective sexuality patterns,” is defined as the expression of concern regarding one’s own sexuality (Gulanick & Myers, 2006). The expected outcome would be that the patient or couple verbalizes satisfaction with the way they express physical intimacy. Both members of the couple exhibit behaviors that are acceptable to the partner (Gulanick & Myers, 2006). This diagnosis is appropriate when the older adult has experienced a life change that causes a new impediment to sexual functioning. Related factors for this diagnosis in older adults are knowledge or skill deficits about alternative responses to health-related transitions, altered body function or structure, illness or medical treatment, lack of privacy, lack of a significant other, conflicts with sexual orientation or variant preferences, fear of acquiring sexually transmitted diseases (STDs), or impaired relationship with the significant other (see Nursing Care Plan on Ineffective Sexuality Patterns).
Nursing care plan
Ineffective Sexuality Patterns
Clinical Situation Mr. B, a 76-year-old retired brick layer, comes to the clinic complaining of headaches that have been increasing in severity over the past several months. His initial assessment shows severe hypertension. During the nursing assessment, it is revealed that Mr. B is a widower and lives alone. However, he has a female friend who visits him often, and they have sexual intercourse every 1 to 2 weeks. To date, he has not experienced any problems with his sexual performance. He was prescribed a beta-blocker to control his hypertension.
Nursing Diagnosis Ineffective Sexuality Pattern, related to potential side effects from antihypertensive medication
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Outcome The patient will not experience a disruption in his sexual patterns.
Interventions Instruct the patient on the normal aging changes of the male and
female sexual systems.
Instruct the patient that impotence is not a normal aging change and may be a side effect of his antihypertensive medication.
Instruct the patient to notify his physician or advanced practice nurse if impotence or any other sexual problem is noticed.
Suggest that the patient’s partner meet with the nurse and patient to discuss his current medical condition, normal changes of aging, and the precautions outlined by the Centers for Disease Control and Prevention (CDC).
Another diagnosis that may be appropriate for older adults experiencing a sexual problem is “sexual dysfunction.” The expected outcome would be for the patient to adapt sexual techniques and engage in sexual activity with assistive devices as needed (Gulanick & Myers, 2006). This diagnosis is appropriate if an older patient is exhibiting unacceptable sexual activity such as exposure. This diagnosis might also be applicable if an aging woman is experiencing dyspareunia or decreased or absent sexual desire (see Nursing Care Plan on Sexual Dysfunction).
Nursing care plan
Sexual Dysfunction
Clinical Situation Mr. J is a 74-year-old retired boxer who has resided at a nursing facility for 3 years. He has Parkinson disease and uses a walker. He is generally happy and pleasant. Mrs. H is an alert 75-year-
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old widow, who was admitted to the facility 1 month ago after a stroke left her wheelchair bound and unable to perform her activities of daily living (ADLs) independently. She was upset when she arrived at the nursing facility and had some difficulty adjusting to her new home.
Over the past 2 weeks, a close relationship has developed between these two residents. Mrs. H has been happier than she was on admission, and both residents appear to have a new sense of energy and enthusiasm for life. Recently, the nursing staff has noticed that they display sexual expression and signs of intimacy to each other in public areas.
Nursing diagnosis Sexual Dysfunction, related to lack of privacy
Outcome Patients will be free to pursue their sexual relationship in private.
Interventions Perform a sexual assessment of both patients.
Provide a climate in which both can openly discuss the situation and respond with trust and confidence.
Pay close attention to verbal and nonverbal cues while listening. Provide reassurance, as needed.
Meet with both patients individually to assess each one’s desire regarding sexual activity and each one’s degree of competence.
Assess the level of comfort in discussing the topic and issues, alone or with each other present; provide opportunity for both.
Provide teaching on normal changes of the aging sexual system (see Box 13-1 and the Patient/Family Teaching boxes).
Compensate for any physical disabilities assessed.
Implement precautions against the spread of sexually transmitted diseases (STDs).
Find a safe, private location for the couple to pursue their sexual
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interests.
Other potential appropriate nursing diagnoses include knowledge deficit, risk for ineffective coping or ineffective coping; situational low self-esteem and risk for situational low self-esteem; chronic low self-esteem and risk for chronic low self-esteem; or disturbed body image, social isolation, anxiety, and fear (Gulanick & Myers, 2006; Swearingen, 2007).
Planning and Expected Outcomes The nurse should develop an individualized care plan that includes the information elicited during history taking, physical assessment, and discussion about specific sexual relationships. This plan should (1) compensate for the physical disabilities of older adults, (2) prevent the spread of infection, (3) provide for the emotional well- being of older adults, (4) satisfy the needs of family members when possible, and (5) ensure patient safety. Expected outcomes of the care plan should result from specific, time-limited goals aimed at restoring or promoting the patient’s sexual satisfaction.
Expected outcomes include but are not limited to the following:
1. The patient attains a satisfactory level of sexual activity as evidenced by resumption of sexual activity at a level acceptable to the patient.
2. The patient verbalizes his or her sexual concerns and discusses them with his or her significant other.
3. The patient explores alternative sexual activities and practices to attain sexual satisfaction.
4. The patient verbalizes his or her feelings about sexual performance.
Intervention Older adults should be provided information, education, and direction to assist them in creating and sustaining intimate relationships. Education starts with discussing changes associated
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with aging. Teaching and reassurance by the nurse that some changes are a normal part of aging helps patients understand their bodies and feel comfortable learning how to compensate for these changes (see Patient/Family Teaching boxes). Teaching regarding coital positioning for couples with physically disabling conditions is often a necessary intervention (Figure 13–1).
FIGURE 13–1 Coital positioning for older couples.
Patient/family teaching
Normal Changes of the Aging Female Sexual System Instruct female patients that with aging, the following occur:
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• Vaginal secretions diminish; the use of an artificial water-based lubricant helps decrease discomfort.
• The vagina becomes shorter and does not expand to accommodate the penis. Some discomfort may be experienced, so the use of alternative positions for intercourse (see Figure 13- 1) may help decrease discomfort.
• Orgasmic contractions are fewer and may be accompanied by painful uterine contractions. However, these generally do not indicate pathologic problems.
• Vaginal irritation and clitoral pain are common and do not signify illness.
• The breasts lose tone, and the areolar area does not enlarge as much.
• Infrequent rectal sphincter contractions, which do not interfere with orgasm, and postcoital need to void may be experienced.
Patient/family teaching
Normal Changes of the Aging Male Sexual System Instruct male patients that with aging, the following occur:
• The penis may take longer to become firm and may not be as firm as at a younger age; therefore, a longer period of foreplay should be planned.
• Ejaculation may take longer to achieve, may be less expulsive, and may be shorter in duration. The patient should conserve strength and not work hard at the beginning of intercourse, which could result in tiring before climax.
• The erection diminishes more quickly after climax, so if condoms are being used, the patient should plan to withdraw immediately after climax.
• It takes longer to achieve a second orgasm, so the patient should
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plan to resume foreplay or use this time to touch or talk.
• Rectal sphincter contractions may be experienced, but these do not interfere with orgasm.
When sexual intercourse is not the preferred method of intimacy or is not possible for an older couple, the couple may be taught alternative methods of intimacy in the form of touch. The physical and psychosocial changes of aging affect the ability of older adults to be intimate with one another. Touch is a means of expressing intimacy and closeness that may fulfill older patients’ sexual needs and desires. Touch is best fulfilled by finding a comfortable environment in which an older adult couple can expose parts of their bodies to each other as they feel comfortable. A shower or bath may be enjoyable. The couple should be taught to move their fingertips slowly or lightly over each other’s skin while enjoying the closeness of the other person. Massage therapy, books, and videos may provide older adults with a way of touching that results in the fulfillment of sexual desires. Soft music may make the environment more conducive for older couples.
Proper precautions need to be implemented to prevent the spread of disease from one patient to another. Older adults are rarely the focus of existing HIV prevention and care services. Low- risk behaviors such as practicing monogamous relationships, reduction in number of partners, and consistent use of condoms (male and female types) should be encouraged (Resnick, 2003). According to the National Association on HIV over Fifty (2009) and AIDS Action (2001), several actions need to be taken to prevent the spread of HIV among older adults (Box 13-4).
Box 13–4
Actions to prevent spread of human immunodeficiency virus among older adults
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• Implement specific education programs for older adults on the transmission and prevention of human immunodeficiency virus (HIV) infection.
• Hold workshops and training sessions devoted to basic information on HIV and acquired immunodeficiency syndrome (AIDS), including safe sexual practices, all in relationship to aging.
• Fund and support more research pertaining to older adults’ sexual behaviors.
• Educate health care professionals on high-risk behaviors for HIV infection, symptoms of HIV infection, misdiagnoses, testing technologies, treatments, support groups, case management, and the importance of being actively involved in the health and well-being of their older patients.
• Increase media and social marketing campaigns, which may help raise awareness of HIV and AIDS among older people and reinforce the need for educational programs while promoting respect and validation for older adults as a group.
From National Association on HIV over Fifty. (2009). Educational tip sheet: HIV/AIDS and older adults. <http://www.hivoverfifty.org/tip.html> Accessed 05/25/2009; and AIDS Action. (2001). Older Americans and HIV/AIDS. <http://www.aidsaction.org>Accessed 04/28/2004.
If an older adult is concerned about his or her family’s feelings regarding a sexual relationship, further counseling should be provided and should include the family, when possible. At this time, family members may bring forth their concerns regarding the relationship, and the older adult may answer them with a nurse present. It is important for the older adult’s family to understand and accept his or her decisions about any relationships. However, if no agreement that is amenable to both the older adult and family can be reached, the older adult’s needs must be the nurse’s primary consideration.
As discussed previously, cognitively impaired patients often display inappropriate sexual behavior such as exposure or advances toward other patients and staff. It is important for the nurse to manage these difficult behaviors while maintaining the
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dignity of these older adults. Ignoring the behavior or punishing the older adult does not curtail the behavior. A thorough assessment of mental status and sexuality is necessary to isolate the cause of the behavior. Inappropriate behavior is best managed by determining the root cause of the behavior (e.g., pain, discomfort, or hyperthermia) and redirecting cognitively impaired older adults’ sexual interest toward socially acceptable behaviors, which may be accomplished by provision of a quiet place for masturbation and viewing sexually explicit materials (magazines or videos). The U.S. Food and Drug Administration has not approved any medications for the treatment of sexually inappropriate behaviors (Kettl, 2008; Wallace & Safer, 2009).
Policies that incorporate the sexual needs of older adults in care plans are becoming more prevalent (Messinger-Rapport et al., 2003). Acute and long-term care facilities should make proper arrangements for privacy during older adults’ sexual experiences. The physical facilities within each setting vary. The ideal situation is to set up a room with a pleasant environment, which can be used for a variety of activities but may also be reserved by older adults for private visits with a spouse or partner. In most settings, this may not be possible; thus, patients’ rooms may be used if the nursing staff gains permission from patients’ roommates and plans alternate activities for them.
In any setting, patient safety should be maintained. The call lights should be easily accessible. Side rails on the bed should be used, if necessary, and the room should be situated such that the nursing staff is aware when it is in use. Although the patients’ privacy is important, they should not be left alone in any situation in which they may injure themselves.
In the community setting, adaptive equipment such as hospital beds, side rails, or trapezes may be needed to allow patients to function safely. On the basis of the information gathered from assessments, the nurse may assist patients in ordering the necessary devices. The nurse may also need to demonstrate the transfer process to ensure that patients are able to transfer, as well as to function, independently or with the help of the partner. See Box 13- 5 for strategies that may enhance sexual function in older patients.
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Box 13–5
Strategies to enhance sexual function in older adults Dietary Strategies Avoid alcohol or tobacco.
Consult with a registered dietitian about well-balanced meals.
Medication Strategies Take pain medications before sexual activity, if needed.
Discuss with a primary care provider (medical doctor or nurse practitioner) discontinuing medications that may impair sexual function.
Environmental Adaptations Plan for sexual activity when most rested.
Consider conjugal visits or home visits.
Acquire a pet; pets provide sensory stimulation.
Older adults with dementia should be offered objects to touch, fondle, and hold, for example, dolls or stuffed animals.
Psychological Strategies Communicate desires to partner.
Discuss fears and concerns with a primary care provider.
Consider routine visits to hairdresser to promote self-esteem and well-being.
Join a support group.
Use relaxation techniques.
Physical Strategies
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Improve exercise tolerance by participating in a supervised exercise program.
Use touching, kissing, and hugging.
Use pillows under painful joints.
Take a warm shower before activity.
Get regular checkups. Modified from Nusbaum, M., Hamilton, C., & Lenahan. P. (2003). Chronic illness and sexual functioning. American Family Physician, 67, 347; Mosley, R. & Jett, K. (2007). Advance practice nursing and sexual functioning in late life. Geriatric Nursing, 28(1):41- 42; Arena, J. & Wallace, M. (2008). Sexuality issues in aging. Nursing standard of practice protocol: Sexuality in older adults. <http://www.consultgerirn.org/topics/sexualiity_issues_in_aging/want_to_know_more> Accessed 05/04/2009; and Rheaume, C. & Mitty, E. (2008). Sexuality and intimacy in older adults. Geriatric Nursing, 29(5), 342-349.
Staff education about the sexuality and intimacy of older adults should include recognition of cues, desires, and interest in sexual activity and intimacy. Staff should recognize that older adults may use and have access to pornographic material, especially through the Internet. Education of nursing staff also needs to address eliminating stereotypes such as “the dirty old man” (Rheaume & Mitty, 2008). Open discussion of attitudes and sexual issues among staff may help increase comfort in dealing with older patients’ sexual issues. Case studies and other learning tools such as trivia games may be effective means of education. Education should also be available to the family. The training should begin by discussing and dispelling the myths surrounding older adults’ sexual desires and activity. The training should include normal changes associated with older men and women and how to compensate for specific physical disabilities. A more positive attitude toward the sexual expression of older adults may develop with increased knowledge and may allow such expression to become a natural part of the aging process.
Training should conclude with discussion groups to allow staff and family to discuss their own feelings about sexuality and its role in the life of older adults. Role-playing may be an effective technique to gain understanding of the effect of the staff and family’s personal values on older adults.
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The use of medications such as sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil hydrochloride (Levitra) has increased public awareness of the prevalence of erectile dysfuncton among men in the United States. These medications, classified as erectile enhancers, have been thought to be overprescribed and misused among men who are seeking erectile enhancement to increase sexual potency. It has also been suggested that these drugs contributed to the transmission of HIV and other sexual diseases among older adults (Huffstetler, 2006). These medications may be effective in treating erectile dysfunction in older men when appropriately prescribed and therefore may enhance the quality of life in older adults.
Evaluation Evaluation of older adults with sexual health–related concerns is based on patient achievement of the established expected outcomes. Older adults may attain a satisfying level of sexual activity that is compatible with functional capacity with the help of sound, sensitive nursing interventions. When total sexual functioning cannot be restored, alternative sexual practices should be explored. The use of touch and massage may be an alternative to sexual intercourse and may help older adults achieve sexual satisfaction. Although many stereotypes hinder the ability of professionals to promote sexuality among older adults, older adults can, and should be allowed to, achieve satisfactory sexual outcomes with the full assistance of the staff. It is important to continue to assess and intervene until the goals have been met. Documentation of the sexual diagnosis within the care plan is an essential method of communicating the interventions and progress toward meeting the expected outcomes. Interventions that have been attempted, including the procurement of artificial aids and teaching, should be documented.
Home care
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1. Assess sexual patterns in homebound older adults who have chronic conditions.
2. Provide information regarding sexual positions or sexual function to accommodate environmental barriers (e.g., a Foley catheter) to both homebound older adults and their significant others.
3. Foster a supportive environment for homebound older adults and their partners to discuss sex-related fears, concerns, and feelings.
4. Explain pathologic conditions that may affect older adults’ sexual responses, for example, types of medications and chronic illnesses.
5. Teach safer sex practices to homebound older adults and their partners.
6. Teach alternative methods of intimacy to both homebound older adults and their significant others on the basis of identified sexual dysfunctions or alterations.
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Summary The need and desire to function sexually continues throughout a person’s life span. It is the nurse’s role to disregard the myths of society toward the sexual practices of homosexual, heterosexual, and bisexual older adults and to assist older adults in reaching their sexual potential. Many normal and pathologic changes are common in older men and women. However, most of these changes may be compensated for so that older adults can continue to function sexually.
With a thorough nursing assessment and management of the normal and pathologic changes of the aging sexual system, older adults are free to pursue sexuality as desired. The end result may be that older adults are able to pursue the highest quality of life attainable.
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Key points • Sexual desire and interest persist throughout the life span of
people into older adulthood.
• Nurses are often influenced by myths surrounding the sexual practices of older adults, and many lack the knowledge and training on how to assist older adults in fulfilling their sexual desires.
• Older adults may experience normal, age-related changes in their sexual systems, which may hinder their sexual response.
• Pathologic problems with the aging sexual response are often related to illnesses and medication.
• Older adults with dementia may display inappropriate sexual behavior and may not be competent to participate in sexual relationships.
• Environmental barriers in the home, as well as in acute and long- term care settings, may prevent older adults from fulfilling their sexual desires.
• It is imperative that all older adults receive a sexual assessment so that normal and pathologic changes can be identified.
• Normal changes of aging may be compensated for by teaching older adults about these changes.
• Interventions used to assist older adults in adapting to age- related changes include manipulation of the environment and procurement of assistive equipment and devices needed to continue to function sexually.
• Touch is an alternative to sexual intercourse and provides the intimacy needed by some older adults.
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Critical thinking exercises 1. A 73-year-old female patient confides that she is embarrassed because her 75-year-old male friend wants to know why he is having difficulty getting an erection. She confesses she is very uncomfortable and does not know how to help her friend. What suggestions can you offer in dealing with this sensitive but important matter?
2. A married couple resides in the long-term care facility where you are employed. The husband is ambulatory, but his wife needs a great deal of assistance with her daily care. One afternoon as you enter their room with medication, you find the couple in bed together, and it is obvious they are attempting to have sex. How should you respond? Discuss your feelings about this situation.
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PA R T 4 Common Psychophysiologic Stressors
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C H A P T E R 1 4
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Pain Jacqueline Kayler DeBrew, PhD, MSN, RN; Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C
Learning objectives
On completion of this chapter, the reader will be able to: 1. Define the concept of pain, including types and sources.
2. Describe the consequences of unrelieved pain in older adults.
3. Discuss the goals of pain management in older adults.
4. Identify barriers that affect the assessment of pain or its management in older adult patients.
5. Describe the effect of pain on the quality of life of older adult patients.
6. Identify factors that may affect older adults’ pain experiences.
7. Use a pain assessment tool to rate patients’ pain intensity.
8. Describe the use of pharmacologic and nonpharmacologic therapies for older adults with pain.
http://evolve.elsevier.com/Meiner/gerontologic
Pain has long been recognized as a symptom of something else in the body. Pain has often been referred to as the fifth vital sign. When all of the body systems are working together well, pain should not be felt. These are facts, whereas pain, as an expectation of aging, is a myth. Many misconceptions about pain and age exist; predominant among the ones held by health care professionals is the myth that pain is a normal aspect of growing old (Natan, Ataneli, Admenko, & Har Noy, 2013). Pain is under-recognized, highly prevalent, and undertreated in older adults, especially in those with impaired cognition. The incidence rate of pain more than doubles after age
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60. Many health care practitioners have only encountered older adults in an emergency room or in hospitals, where they are in need of unusually intense medical or nursing treatment; this is not a good way to understand that the conditions of these patients are not representative of normal aging. However, older adults are at high risk for pain-inducing situations during their life span. Degenerative changes, musculoskeletal changes, and pathologic and comorbid conditions from disease or injury lead to pain in older adults (Herr, Bursch, Ersek et al., 2010).
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Understanding pain Definition Understanding pain and how to efficaciously treat it calls for a look at how pain is defined. Multiple definitions of pain exist; most include the mind–body relationship. According to some, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (International Association for the Study of Pain, 2010). McCaffery (2000) further stated that pain is “whatever the experiencing person says it is, existing whenever he or she says it does.” The definition by Aronoff (2002) is more specific: “a subjective, personal, unpleasant experience involving sensations and perceptions that may or may not relate to bodily or tissue damage.” Pain is also defined as an unpleasant sensory and emotional experience (Merskey & Bogduk, 1994). The literature on pain is in agreement that pain is (1) a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions (Leo & Huether, 2010; Sternbach, 1978) and (2) usually associated with injury or a pathophysiologic process that causes an uncomfortable experience. These authors clearly noted that pain is individual and may be very different for different persons with the same disease or injury.
Pain Classification Pain may be classified as acute or chronic. Acute pain is defined by rapid onset and relatively short duration and a sign of a new health problem requiring diagnosis and analgesia. Treatment usually involves treating the underlying disease or injury and short-term use of analgesics. In contrast, chronic or persistent pain continues after healing or is not amenable to a cure. This pain usually has no autonomic signs and is associated with longstanding functional and psychological impairment. The older adult is most likely to suffer from chronic, or persistent pain, rather than acute pain (Jansen, 2008). The American Geriatrics Society (AGS, 2002) advocates the use of the term persistent pain rather than chronic pain, which may be
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associated with negative images and stereotypes.
The AGS Panel on Persistent Pain identified four categories of pain that encompass most syndromes (Box 14-1) (AGS, 2002):
Box 14-1
Pathophysiologic classification of chronic pain Nociceptive Pain Arthropathies (e.g., rheumatoid arthritis, osteoarthritis, gout,
posttraumatic arthropathies, mechanical neck and back syndromes)
Myalgia (e.g., myofascial pain syndromes)
Skin and mucosal ulcerations
Nonarticular inflammatory disorders (e.g., polymyalgia rheumatica)
Ischemic disorders
Visceral pain (pain of internal organs and viscera)
Neuropathic Pain Postherpetic neuralgia
Trigeminal neuralgia
Painful diabetic polyneuropathy
Poststroke pain (central pain)
Postamputation pain
Myelopathic or radiculopathic pain (e.g., spinal stenosis, arachnoiditis, root sleeve fibrosis)
Atypical facial pain
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Complex regional pain syndromes (CRPS): type I: reflex sympathetic dystrophy (RSD)
Complex regional pain syndrome: type 2: causalgia
Mixed or Undetermined Pathophysiology Chronic recurrent headaches (e.g., tension headaches, migraine
headaches, mixed headaches)
Vasculopathic pain syndromes (e.g., painful vasculitis)
Psychological-Pain Syndromes Somatization disorders
Hysterical reactions From American Geriatrics Society Panel on Chronic Pain in Older Persons. (1998). Clinical practice guidelines. Journal of the American Geriatrics Society, 46, 635.
1. Nociceptive pain may be visceral or somatic and is usually a result of stimulation of pain receptors. It may arise from tissue inflammation, mechanical deformation, ongoing injury, or destruction of tissue. This type of pain usually responds well to common analgesic medication and nonpharmacologic strategies.
2. Neuropathic pain results from a pathophysiologic process involving the peripheral or central nervous system. These types of pain do not respond as predictably to analgesic therapy as do nociceptive types of pain. They do, however, respond to unconventional analgesic drugs such as tricyclic antidepressants (TCAs), anticonvulsants, or antiarrhythmic drugs.
3. Mixed or unspecified pain has mixed or unknown mechanisms. Treatment is unpredictable and may require more trials of different or combined approaches.
4. Other types of pain may be caused by rare conditions such as conversion reaction or psychological disorders. Persons with these disorders may benefit from specific psychiatric treatments, but traditional medical interventions for analgesia are not indicated. Age-associated changes in pain perception have been observed in some older persons with unusual manifestations of common illnesses. An AGS panel concluded that age-related changes in pain
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perception are probably not clinically significant (AGS, 2002).
Scope of the Problem of Pain Even though pain is not part of normal, healthy aging, pain is a common problem among older adults, and persistent physical pain is widespread in the older population (AGS, 2002). It is estimated that 25% to 50% of community-dwelling older adults experience significant pain problems (Park & Hughes, 2012; Reid, Bennett, Chen, Eldadah et al., 2011). Pain is even greater in older adults in nursing homes, where it has been shown that 70% to 80% of residents have substantial pain that is undertreated (AGS, 2002; Robinson, 2010; Shoefield, 2010).
Stereotyping older persons as having less pain because of their age contributes to less frequent pain assessment and consequently less appropriate and effective treatment for the pain. Older adults commonly report less pain because they do not want to be complainers, fear having to undergo more tests and medical treatments, and fear losing their independence (AGS, 2009). In addition, older adults have been told that they will have pain sometime in their later years. Thus, they become resigned to the experience of pain. The fear that pain will be seen as a reason for having to give up independent living is associated with a reluctance to express pain freely to nonfamily members. Older adults may be ambivalent about the benefit of any action for their pain. Some of these responses by older persons may be attributed to health care practitioners saying, “What do you expect at your age?” which supports the belief that nothing can be done to control or stop the pain.
Compounding this problem is the fact that older patients have been systematically excluded from clinical trials of analgesic drugs despite the fact that they are more likely to experience the side effects of analgesic medications. Research groups do not want comorbid conditions confounding the findings of a single medication or treatment.
Consequences of Unrelieved Pain
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Consequences of persistent pain are numerous. Depression, anxiety, decreased socialization, sleep disturbance, decreased or impaired ambulation, prolonged recovery periods, increased use of health care resources, premature death, and increased health care use and costs have all been documented with the presence of pain in older patients (AGS, 2009). Unrelieved pain has been shown to result in decreased ambulation, impaired posture, sleep disturbance, anxiety, and impaired appetite in nursing home residents (Leo & Huether, 2010). Pain may make getting to the bathroom so difficult that it leads to incontinence. Constipation may also be related to unrelieved pain when the person changes diet plans, decreases activity, and has difficulty getting to a toilet before the urge passes (Jansen, 2008). Untreated pain may result in the older person being unable to participate in self-care activities or health promotion activities (Bishop & Morrison, 2007). Pain may go untreated if the older adult has dementia or some form of cognitive impairment (Herr, Bjororo, & Decker, 2006).
The assessment and management of pain in older adults pose unique challenges to health care professionals. The nurse caring for older adults in pain must understand the special needs of this diverse population. Although older adults are at risk for chronic disease and the often painful conditions that accompany those ailments, their pain is often under recognized. Therefore, accurate and ongoing assessment is essential for effective pain management in older adults. Goals for pain management in older adults include the following:
• Relief from pain
• Control of chronic disease conditions causing pain
• Maintenance of mobility and functional status
• Promotion of self-care and maximum independence
• Improved quality of life
These goals can be achieved through education of patients, families, and health care professionals and through good nursing care.
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Epidemiology of Pain The causes of pain are both chronic and acute; however, older adults are more likely than younger persons to suffer from pain caused by chronic diseases and issues. Chronic diseases that cause pain that are especially prevalent in this age group are arthritis, polymyalgia rheumatica, temporal arteritis, peripheral vascular disease, diabetic neuropathy, postherpetic neuralgia, and cancer. The resulting effects of injuries that occurred in the patient’s younger years may lead to chronic pain in later life. The effects of acute injuries sustained at work may persist for decades. Spinal disease or degenerative disk disease may lead to a life focused on finding and maintaining pain relief just to be able to perform basic activities of daily living (ADLs). The older adult experiencing acute pain, which can still occur, must also deal with the chronic illness management while attempting to control the acute pain (Campbell, Andrews, Scipio et al., 2009).
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Pathophysiology of pain in older adults Pain has multiple components that affect one’s physical and psychosocial functioning. Although older adults develop more chronic diseases as they age, pain does not need to be an expectation of normal aging. An understanding of pain physiology and pain theories is essential to effective pain management in older adults.
The three major components of the nervous system that cause the sensation and perception of pain are (1) the afferent pathways (reception), (2) the central nervous system (CNS) (perception), and (3) the efferent pathways (reaction). The afferent pathways have nociceptors and are found on the skin. Pacinian corpuscles that mediate sensation, including pain, pressure, and itching, are the nerve endings that are distributed in the skin. Stimulation of these nerve endings by vibrations from massage or sound waves may reduce the perception of pain in conditions such as chronic rheumatoid arthritis. The free nerve endings of nociceptors are sensitive to mechanical, thermal, electrical, or chemical stimuli and are responsible for transmitting sensory pain information. This stimulation flows through peripheral sensory nerves (afferent pathways) to the spinal cord. A painful stimulus (e.g., a pinprick) sends an impulse to a nociceptor (a receptor for painful stimuli) along a peripheral nerve fiber, which enters the gray matter of the spinal cord. Nociceptors terminate in the spinal cord (McCaffery & Pasero, 1999). Here, the nociceptor stimulation flows to the brain through a series of relay neurons.
When the pain stimulus or signal reaches the CNS, it is evaluated and interpreted in the limbic system, reticular formation, thalamus, hypothalamus, medulla, and cerebral cortex. The brain’s interpretation is based on both physical and psychological factors. Modulation of the pain stimulus may occur in the gray matter, the dorsal horn of the cord. Here, transmission occurs from the nociceptor to the spinothalamic tract neuron. Substance P, a
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neurotransmitter, facilitates transmission of the stimulus from the afferent (peripheral) neuron across the synapse to the spinothalamic tract neuron. Uninhibited by medications or other modalities, the pain impulse travels to the cerebral cortex of the brain, where the brain interprets the quality of pain, processing past experiences with pain, knowledge of pain, and cultural associations related to pain perception. The interpretation is relayed back through the peripheral nervous system (efferent) pathways that are made up of fibers connecting the reticular formation, midbrain, and substantia gelatinosa. Pain modulation takes place in the efferent neural pathways and may involve chemical factors of neuropeptides, which may increase the sensitivity of the afferent pain receptors to noxious stimuli. These pathways result in the sensation and perception of pain (McCance & Huether, 2010.)
Atypical Acute Pain in Older Adults Older adults often experience an atypical presentation of pain, making it difficult for the nurse to assess and manage it effectively. The reasons for the atypical presentation are not fully understood, but are most likely due to normal age-related changes in the body. Examples include myocardial infarction (MI) and appendicitis. Typical silent myocardial infarction occurs more commonly in older adults, and the acute pain of appendicitis experienced by young adults is often not experienced by older adults (McCaffery & Pasero, 1999). It is accepted, although not understood, that pain perception differs in older adults, when compared with younger people; however, the complexity of pain assessment and management in the older adult is also a contributor (McCleane, 2008).
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Barriers to effective pain management in older adults Many barriers impede the assessment and management of pain in older adults. Some of these barriers are related to nursing care, some related to efforts on the part of the prescriber, and some related to the older adult and his or her beliefs about pain and aging. Although reports on age-associated changes in pain perception are controversial, many health care professionals, as well as older patients and their family members, believe that pain is a natural occurrence of aging and chronic disease. This belief may lead to underreporting of pain and may prevent accurate pain assessment and appropriate use of pain relief measures. This lack of interventions for pain relief has many negative outcomes, including decreased function and exacerbation of the cause of the pain.
Accurate assessment and pain management is also inhibited when older patients underreport their pain. Older patients may underreport pain because they believe that stoicism and refusal to “give in” to the pain are appropriate behaviors or attitudes. Pain assessment may also be hindered by older patients who do not report pain because they “don’t want to bother anyone” or they believe their report of pain will not be believed.
Older adults with cancer may fear the meaning of pain and its implications of worsening disease and possible death. Patients experiencing cancer-related pain may believe that this is a natural outcome of cancer and cannot be relieved. These patients and their family members needlessly suffer from the patients’ experiences of pain.
Inadequate access to diagnostic services is another barrier to appropriate pain assessment for older residents of nursing facilities and frail older adults in the community. Often, it is difficult to schedule appointments and arrange transportation so that a family member or health care professional can accompany the patient to a diagnostic testing facility. Furthermore, many older adults do not have children who live near them and have lost their social
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networks (Robinson, 2010).
The nurse’s lack of knowledge regarding adequate pain assessment is viewed as a barrier as well. Nurses should be knowledgeable of assessment techniques, how to adapt these techniques, as well as standardized tools to utilize when assessing an older adult’s pain. When using any pain assessment tool, the nurse must evaluate each patient’s ability to give accurate responses with that tool. The use of a second tool may help confirm the value obtained with the first tool. The Hartford Institute for Geriatric Nursing (2012) has found that commonly used pain assessment tools, such as the Faces Pain Scale – revised (FPS-R Scale), are valid and reliable for use with older adults, even those with mild to moderate cognitive impairments. The AGS (2009) found that the most accurate and reliable indicator of pain intensity and experience is the patient’s self-report.
However, the compromised ability of people with moderate to severe dementia to clearly or consistently report on their internal states provides both challenges and opportunities to nurses who want to improve care and comfort. The Serial Trial Care Protocol (STCP), developed to assess and treat physical pain and affective discomfort in people with dementia who are no longer able to clearly and consistently verbalize needs, addresses critical steps in the breakdown and disconnection between nurses’ understanding of the person’s need and the provision of care for that unmet need (Figure 14-1). The STCP is an innovative approach that has concrete specifications but allows discretion in individualizing assessments of and interventions for the situation.
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FIGURE 14-1 Serial trial intervention to assess and treat physical pain and affective discomfort in people with dementia unable to
clearly and consistently verbalize needs. (Courtesy of Christina Kovach, Milwaukee, WI.)
The STCP is based on the assumption that behaviors associated with dementia (e.g., fidgeting, exiting, pacing, decreased appetite, and combative behavior) signal an unmet need. When the sources of these behaviors are not easily identified, the nurse begins the STCP protocol by doing a physical assessment. If the physical assessment reveals a problem, the nurse institutes an intervention to target the problem. If the physical assessment is negative or the intervention provided is ineffective in returning behaviors to baseline, the nurse assesses for common psychosocial and environmental needs. Intervention trials are pharmacologic or nonpharmacologic treatments provided when specific domains of assessment or intervention have failed to uncover the source of the problem or failed to ameliorate behaviors. The STCP is a systematic process for using intervention trials that proceeds from nonpharmacologic comfort interventions, to a trial of analgesics, and then perhaps to a trial of psychotropics (Kovach, Logan,
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Noonan et al., 2006).
Patient/family teaching
Controlling Pain Through a Team Approach The best way to control pain is through a team approach involving the patient, the family, and the nurse and physician. In addition to a patient telling the others the extent of his or her pain, he or she should be asked the following:
• Where is your pain located?
• When did the pain start?
• Describe the pain. Is it sharp? Dull? Throbbing? Burning?
• Does the pain come and go, or is it constant?
• What makes the pain worse?
• What makes the pain better?
• What medications are you taking for the pain?
• Are you using any other methods such as relaxation, a heating pad, or a cold pack to relieve your pain? Do they seem to help?
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Pain assessment Pain assessment begins when the nurse accepts the person’s report of pain and takes that report seriously. Assessment is essential in differentiating acute life-threatening pain from longstanding chronic pain (Herr, 2002). Otherwise, disease progression and acute injury may go unrecognized and be attributed to preexisting disease or illness. Table 14-1 identifies components of the clinical assessment of pain in older adults.
Table 14-1 Assessment of Pain in Older Adults
History Physical Examination Assessment of Other Variables Medical History Routine Examination Pertinent Laboratory Data and Tests Acute illnesses Depression Scales Chronic illnesses Beck Depression Inventory Previous surgeries Zung Self-Rating Scale Timed events leading to present pain complaint Geriatric Depression Scale
Musculoskeletal Examination Cognitive Assessment Neuromuscular: Mini-Mental State Examination Weakness Short Portable Mental Status Questionnaire Hyperalgesia Philadelphia Geriatric Center MSQ Numbness
Pain History Signs of Trauma
Functional Assessment
Intensity Character Frequency Pattern Location Precipitating factors Relieving factors Alleviating factors
Bruises Inflammation Tenderness Guarding Swelling
Katz Activities of Daily Living Lawton Instrumental Activities of Daily Living Stanford Health Assessment Questionnaire Barthel Index SPICES
History of Trauma Functional Performance Psychosocial Assessment Recent falls Range of motion Finances Other injuries Up-and-Go Test Social networks
Tinetti Gait and Balance Test Dysfunctional relationships
Medication History Pain Assessment Scales Prescription Visual analog scale Over-the-counter Word descriptor scale Herbal or natural Numeric scale Side effects Faces scale
Pain Medications Quality of Life Measures Drugs that worked Dartmouth COOP Project Drugs that did not work Profile of Mood States
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Prescription or over-the-counter Pain/Quality of Life Scale Natural remedies Side effects
Previous Pain Experiences
From American Geriatrics Society Panel on Chronic Pain in Older Persons. (1998). Clinical practice guidelines. Journal of the American Geriatrics Society, 46, 635.
Pain assessment should include a thorough history and a physical examination. These assessments are especially important for older persons because effective pain management often depends on the appropriate treatment of underlying disease or illness. When the underlying disease is unknown, multidisciplinary consultation is indicated (AGS, 2002; Linton & Lach, 2007).
Some of the following are general principles on pain assessment from the AGS Panel on Persistent Pain in Older Persons (2002):
• No biologic markers for the presence of pain exist.
• The patient’s report is the most accurate and reliable evidence of pain and its intensity.
• Patients with mild to moderate cognitive impairment may be assessed through the use of simple questions and screening tools.
• Older patients may be reluctant to report pain despite substantial impairments.
• Older persons expect pain with aging.
• Older adults may use words such as discomfort, aching, and hurting, rather than pain.
• They may see pain as a metaphor for serious disease or death.
• Pain may represent “God’s will” or atonement for “bad” deeds.
• Assess patients for evidence of chronic pain.
• Recognize pain that significantly affects functional ability or quality of life as a significant problem.
• For patients with cognitive or language impairments, observe nonverbal pain behaviors, recent functional changes, and vocalizations (e.g., groans and cries).
• For patients with cognitive or language impairments, seek
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caregiver reports and input.
• Seek specialist consultation for patients with debilitating psychiatric problems, substance abuse problems, or intractable pain.
• Monitor patients with chronic pain by recording pain intensity, medication use, response, and associated activities in a pain log or diary.
• Reassess all patients with chronic pain regularly for improvement, deterioration, positive or negative effects of medications, and complications of treatment. Use the same pain instruments at each patient visit.
Pain Assessment and Culture Pain is an individual experience. Patients’ pain intensity and pain distress are related to factors such as culture, past pain experiences, individual attributes, and pain threshold. Nurses need to take an individual approach with each patient, incorporating his or her cultural beliefs and practices when assessing and managing pain.
Pain Assessment Tools Pain assessment tools assist health care professionals in objectively and accurately measuring a patient’s report of pain and any relief or change in that pain. Pain assessment tools include numeric pain rating scales, such as a 0-to-10 scale, where 0 means no pain and 10 means the worst pain; visual analog scales; descriptive pain intensity scales, using descriptions such as “no pain,” “a little pain,” “a lot of pain,” and “too much pain”; pain diaries; and pain logs. Examples of pain assessment tools are illustrated in Figure 14-2.
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FIGURE 14-2 Daily pain diary. (From McCaffery, M. & Pasero, C. [1999]. Pain: Clinical manual (2nd ed.). St. Louis, MO: Mosby.)
A patient’s report of pain should also be evaluated for its intensity and the amount of distress it causes. Pain intensity is a measure of the amount of pain that the patient is experiencing and is measured by a numeric pain rating scale, such as the 0-to-10 scale. The numeric pain rating scale translates the patient’s report of pain into a number that provides the health care professional with an objective description of the patient’s pain. This measure of pain can then be used to gauge relief, given the assumption that the number is lower after treatment of the pain. These measures should be recorded in the patient’s pain log or chart.
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The use of standardized tools when assessing pain in the older adult provides a consistent approach to managing pain, especially the cognitively impaired older adult. Using pain assessment tools assists the nurse in planning the appropriate intervention for the severity and type of pain the older adult has and promotes care and comfort more promptly (Jett, 2012).
When it is used in the posttreatment period, a pain scale that relies on the level of activity rather than a subjective rating of pain alone can provide more specific data that are helpful in assessing the level of pain and the effectiveness of pain interventions (Table 14-2). Using other terms in addition to the word pain has been shown to more accurately reflect how many older persons view their discomfort or pain.
Table 14-2 Functional Pain Scale
Score Description of Pain by Patient Function 0 No pain 1 Tolerable (and does not prevent any activities) 2 Tolerable (but does prevent some activities) 3 Intolerable (but can use telephone, watch TV, or read) 4 Intolerable (cannot use telephone, watch TV, or read) 5 Intolerable (and unable to verbally communicate because of pain)
From Gloth FM, Scheve AA, Stober CV, Chow S, Prosser J: The Functional Pain Scale (FPS): Reliability, validity, and responsiveness in a senior population. (2001). Journal of the American Medical Directors Association, 2(3), 110–114.
History The nurse should carefully question and thoroughly assess a patient’s report of pain. This is especially important in older adults because of their tendency to have multiple sources of pain from multiple chronic problems occur simultaneously. Acute pain is often attributed to chronic illness, but it should be evaluated with the knowledge that older adults often demonstrate an altered presentation of common acute illnesses, including “silent” myocardial infarctions and “painless” intraabdominal emergencies. In addition, chronic pain is characterized by variable intensity and character and thus is often overlooked.
Linton and Lach (2007) suggested that questions should address
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the onset (acute or chronic), location (localized, referred, subcutaneous, or visceral), duration (constant or intermittent), intensity (have the older adult rate the pain on a standardized scale), characteristics (stabbing, shooting, sore, grinding, gnawing, achy, lightening, burning, etc.), aggravating and alleviating factors, and self-treatment (use of heat, cold, immobilization, elevation, or medication) or other prescribed treatments that either helped or did not help. A variety of physical assessment books recommend using the mnemonic “P, Q, R, S, T, U” to assist in remembering how to ask questions regarding pain. The root word for the mnemonic may differ from text to text, but the meaning is similar: P for the pattern of pain; Q, quality of the pain; R, what relieves the pain; S, what stimulates the pain; T, the timing, duration, and frequency; and U, what do you do that has worked and what have you not tried that was suggested or tried that did not work.
Physical Examination Pain assessment for older adults includes a comprehensive physical examination of the musculoskeletal and nervous systems. This is an important aspect of pain assessment in this population because many older adults experience painful traumatic and degenerative musculoskeletal problems. A thorough neurologic assessment includes an evaluation for autonomic, sensory, or motor deficits; these may indicate neuropathic conditions or nerve injuries (review Chapter 4).
Evaluation for Functional Impairment Impaired functional status is a major problem for older adults. An evaluation of an older adult’s level of function is important so that mobility and independence can be maximized. Evaluation of functional status includes the assessment of ADLs, ambulation, psychosocial well-being, and overall quality of life. Standardized tools are available to assess functional status and have been proven effective with older adults. These include tools such as the Katz Activities of Daily Living Scale, and Fancapes’ SPICES tool (review Chapter 4). Functional activities may be restricted by the presence and intensity of pain. A functional evaluation includes an
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assessment of factors that contribute to or help alleviate pain. Functional status can be significantly improved through aggressive pain management. It is important to assess for new or different causes of pain; it should not be assumed that increased pain represents an exacerbation of a previous diagnosis. It is also imperative that the nurse assess the older person for the cause of a complaint of pain and not simply attribute it to age. Aging does not cause pain: disease and injury do.
Evaluation of Quality of Life Pain is not an isolated phenomenon; it is an experience that influences all dimensions of an individual’s quality of life. Pain assessment should include an evaluation of the impact of pain on a patient’s quality of life. Practitioners can make a quick assessment of their patient’s quality of life by asking “How is life for you?” “Are you doing and enjoying what you want to do and enjoy?” and “Has there been a recent change in your life activities?” Such questions may be as effective and accurate as more scientific tools that are not practical for use in daily practice.
Evaluation for Depression Pain assessment of older adults also includes an evaluation for depression. A high incidence of depression is associated with chronic pain. Persistent depression affects a person’s ability to cope with the pain, so it must be treated. Anxiety may also affect the management of chronic pain, especially if the outcome of the chronic problem is uncertain. Yesavages’ Geriatric Depression Scale is a valid and reliable tool that can be used to screen for depression in an older adult. The reader is also referred to Chapter 4 for additional tools for effective assessment.
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Nursing care of older adults with pain Pharmacologic Treatment As the administrators of medications, nurses play a major role in ensuring that older adults have their pain treated in a safe, effective, and efficient way. Nurses must be knowledgeable about the physiologic changes of aging that may alter drug absorption, metabolism, and excretion in the older adult. Changes that require ongoing assessment of a patient’s response to a medication, with subsequent adjustments in dose and dosing intervals or prescribed drug, are as follows:
• Changes in physiologic factors such as decreased gastric acid production and gastrointestinal motility
• Changes in body composition such as decreased total body water, lean body mass, and serum protein and increased body fat
• Changes in organ function such as decreased hepatic blood flow and reduced glomerular filtration rate
These changes, especially those in liver and renal function, may increase the risk of accumulation of lipid-soluble drugs such as fentanyl and may slightly delay the onset of action and increase the risk for accumulating agents used to control pain (AGS, 2009). Age- related changes in absorption, distribution, metabolism, and elimination demand that prescribers be conservative, especially as recommendations for age-adjusted doses are rarely available for most analgesics (AGS, 2009).
Analgesic drugs may be classified into two categories: (1) nonopioid analgesics, and (2) opioid analgesics. Additionally, a number of adjuvant drugs are useful in the management of pain in the older adult.
When considering pharmacologic interventions for cancer pain, a three-step approach has been recommended by the World Health Organization (WHO, 1990). This widely accepted practice model helps guide nurses’ decisions when determining how to medicate an older adult in pain, after a pain assessment has been completed
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(Figure 14-3). If pain occurs, drugs should be orally administered promptly in the following order: nonopioids, followed, as necessary, by mild opioids (codeine), and finally strong opioids such as morphine, until the patient is free of pain (see Figure 14-3). Adjuvant drugs should be added when the person is anxious or needs more relief. Guidelines state that pain medications should be given around the clock in anticipation of the patient’s pain, rather than waiting for the patient to ask for it. The WHO has found that this three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80% to 90% effective (WHO, 1990; http://www.who.int/cancer/palliative/painladder/en/).
FIGURE 14-3 Incorporation of analgesics in the treatment of older adults experiencing cancer pain.
Nonopioid Analgesics
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Analgesics are used as a first-line approach to pain management. Acetaminophen (Tylenol), ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve) are examples of nonopioid analgesics. These drugs block pain by inhibiting pain reception at the local level. As with all medications, their use by older adults must be continuously monitored. Acetaminophen seems to be well tolerated by older adults and does not affect platelet function. It is the drug of choice for relieving mild to moderate musculoskeletal pain (AGS, 2009). The maximum dosage of all consumed acetaminophen is between 4000 milligrams (mg) in 24 hours; however, this must be reduced in people who consume alcohol on a regular basis. Acetaminophen has few side effects and is probably the safest nonopioid for most people. Acetaminophen is as effective as aspirin in its analgesic and antipyretic properties but less effective than aspirin in its antiinflammatory properties. Although acetaminophen has not been associated with renal or gastric problems, it may result in hepatic toxicity in patients with a history of alcohol abuse or after the ingestion of persistently high doses. Older adults should be cautioned to be aware of “hidden” acetaminophen in over-the- counter products such as cold remedies or sleep aids.
Nonsteroidal antiinflammatory drugs (NSAIDs) are especially effective for treating mild to moderate arthritic pain and other inflammatory disorders. NSAIDs have been associated with a variety of adverse side effects in older adults, including stomach ulcers, renal insufficiency, and a tendency to bleed. The most common complaint associated with NSAIDs is indigestion. Indigestion may be reduced with antacid use or food consumption timed to coincide with analgesic intake. However, the health care professional must remember that gastrointestinal irritation may occur without symptoms. Severe ulceration may result in perforation and extensive bleeding. An older adult’s response to the medication must be evaluated closely. NSAIDs should be avoided in high doses, for long periods, in patients with abnormal renal function, and in patients with a history of ulcer disease or bleeding (AGS, 2009).
Opioid Analgesics
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Opioids are usually prescribed for patients with mild to moderate pain that is poorly tolerated or cannot be adequately managed with a nonopioid analgesic. Clinical experience suggests that older adults are particularly sensitive to the effects of opioid analgesics because they experience a higher peak and longer duration of pain relief (AGS, 2009).
Because older adults may be more sensitive to opioids, clinicians should follow the advice to “Start low, and go slow” and monitor patients until the drug is titrated for adequate pain relief. Problems with opioids usually involve those with long half-lives such as methadone (Dolophine) or levorphanol (Levo-Dromoran). The half- life of an opioid is defined as the time it takes for the drug to decrease to half its initial plasma concentration. Plasma levels of drugs that have long half-lives rise slowly over several days after the initiation of a dosing schedule. Thus, the risk of delayed toxicity is much greater with these drugs than with drugs having shorter half-lives. Codeine, hydromorphone, and morphine, in appropriate doses, can be used safely in older adults with pain (see Nursing Care Plan).
Nursing care plan
Prostate cancer with bone metastases
Clinical Situation Mr. K is a 77-year-old retired telephone company executive who has been admitted to the local hospital-based home care program. Mr. K had always been in good health until diagnosed with prostate cancer 2 years ago. He and his wife have enjoyed an active social life. Her four adult children live in cities throughout the United States. The couple does not have any church affiliation. Mr. and Mrs. K have been married for 10 years and live in a mobile home park in the desert. They also own a condominium in the city but do not have any resources for support in that neighborhood. Three years ago, they acquired a
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puppy named Max. Up until the last 2½ months, Mr. K had taken morning and evening walks with Max throughout the neighborhood and local park.
In the last 2 months, Mr. K has complained about a great deal of pain in his legs and back. He has lost 35 pounds in the past month. He tires easily and is unable to walk outside his home or for distances longer than 25 feet without resting. Mr. K’s first wife had died 20 years ago from breast cancer. Mr. K relates how she suffered intensely from the effects of chemotherapy and severe pain. He had refused all treatment for his cancer until 6 months ago, when he started receiving hormone therapy. He has refused to take the long-acting opioid prescribed by his physician because he does not want “to get hooked.” Mr. K rates his pain as a 9 on a scale of 0 to 10, with 0 meaning no pain and 10 meaning the worst pain. Mrs. K is having difficulty caring for him and dealing with his impending death.
Nursing diagnoses Chronic Pain, related to inadequate knowledge of pain
management; Risk for Constipation related to analgesic use; Impaired Physical Mobility, related to pain
Outcomes The patient will report decreased pain (between 0 and 3) at rest
and with activity, as evidenced by self-report.
The patient will continue his usual bowel elimination pattern: a soft, formed stool every day.
The patient will maintain ADLs and other physical activities as he is able.
Interventions Discuss general pain content information with the patient and his
wife.
Elicit the patient’s description of his pain, including the quality of the pain, its location, and its precipitating and relieving factors.
Identify the intensity of the patient’s pain by using a pain
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assessment tool.
Identify the distress the patient experiences in relation to his pain.
Evaluate the patient’s current use of pharmacologic and nonpharmacologic pain relief methods.
Discuss the patient’s fear of addiction and the need to maintain control of his life and remain alert and functional.
Implement the use of a self-care pain management log, including the use of a pain rating scale.
Instruct the patient and his wife about around-the-clock scheduling for analgesics.
Discuss the current pain management regimen and plans for further treatment with the patient’s physician.
Identify the patient’s current fecal elimination pattern.
Explain the physician’s prescription for a stool softener.
Discuss the use of a mild laxative if bowel movement has not occurred after 2 days.
Encourage a fluid intake of at least eight glasses of water each day.
Modify the patient’s diet to increase his intake of high-fiber foods.
Discuss the effect of analgesics on fecal elimination with the patient.
Reinforce the fact that although constipation is an expected side effect of opioids, it can be prevented.
Instruct the patient to take analgesic medications on a regular basis.
Identify activities that are important to the patient and that he would like to maintain.
Encourage him to take short walks with his dog and sit in the dining room for his meals.
Encourage use of a self-care log.
Instruct the patient about energy conservation and about the need
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to space activities with periods of rest.
Evaluate the environment to determine the need for equipment for ambulation or other activities.
Moderate-to-severe pain may be relieved with opioids such as hydrocodone, oxycodone, hydromorphone, oxymorphone, or immediate-release morphine.
Side Effects Common side effects of opioids include nausea, vomiting, constipation, and urinary retention, especially in individuals with prostatic hypertrophy. Older adults are more sensitive to sedation and respiratory depression, probably as a result of altered distribution and excretion of medications. This is especially true in opioid-naïve patients, that is, those who have not had earlier exposure to opioids. Fentanyl patches should never be given to patients who are opioid-naïve because of the high risk for severe adverse reactions. If oral opioids are not successful and higher doses have been tried without success, a smaller dose of fentanyl may be tried with upward titrations until the correct level is found. Most nurses will never be involved in this titration determination but may be involved in the assessment of the pain response after an increase is made by the provider.
Constipation as a side effect of opioid use is of particular concern in older patients because many of them have preexisting bowel conditions. It is good practice to start a patient on a bowel program when initiating opioid treatment (see Patient/Family Teaching box). Careful assessment of bowel habits, including the use of stool softeners and laxatives and the dietary intake of high-fiber foods, is essential when a patient is using opioids. The health care professional must emphasize to the patient and his or her family the importance of being proactive, that is, preventing the occurrence of constipation rather than waiting for it to occur. To deal with the side effect of constipation, the Oncology Nursing Society recommends the following (Woolery et al., 2008):
• Increase fluid intake.
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• Modify diet; add high-fiber foods (see Nutritional Considerations box).
• Maintain or increase activity levels.
• Adapt a daily evacuation schedule that takes into account when gastrocolic reflexes are most active.
• Take medications such as stool softeners, expanders, or natural laxative mixtures, avoiding pharmaceutical laxatives when possible.
Patient/family teaching
What can you do for constipation? Opioid analgesics cause constipation in most people. The following suggestions help prevent constipation from becoming a problem and causing discomfort:
• Eat foods high in fiber, for example, uncooked fruits and vegetables and whole grain breads and cereals.
• Add 1 or 2 tablespoons of unprocessed bran to foods.
• Drink plenty of liquids—8 to 10 glasses per day.
• Eat foods that have helped relieve constipation in the past.
• Plan your bowel movement for the same time each day, if possible.
• Try to use the toilet or bedside commode for fecal elimination.
• Have a hot drink about 30 minutes before the planned time for a bowel movement.
• Consult with a physician about using a bulk laxative such as psyllium (Metamucil) or any other laxative or stool softener.
Modified from American Cancer Society and National Cancer Institute. (1992). Questions and answers about pain control: A guide for people with cancer and their families, Atlanta, GA: The Society.
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Nutritional considerations
High-Fiber Foods to Relieve Constipation • Oatmeal, bran, whole wheat, rye
• Apples, pears, strawberries, peaches, plums, citrus
• Beans, dry beans
• Peas, cabbage, root vegetables, fresh tomatoes, green beans, carrots
Although nausea and vomiting caused by opioid use usually disappear after a few days of taking the medication, it is critical that clinicians take a preventive approach in treating these side effects. As with all medications, antiemetics must be evaluated for their effectiveness in controlling nausea and vomiting in older adults as well as for side effects such as sedation. The nurse should advise patients and family members that sedation may occur as a result of the antiemetic. If nausea persists beyond a few days of starting the opioid, a new opioid should be tried (AGS, 2002) (Table 14-3).
Table 14-3 Equianalgesic Chart: Nonopioids and Opioids for Mild to Moderate Pain
From McCaffery, M. & Pasero, C. (1999). Pain: Clinical manual (2nd ed.). St. Louis, MO: Mosby.
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Sedation and impaired cognitive performance should be anticipated when starting opioids (AGS, 2009). The sedation usually decreases in 1 to 3 days. In case it does not, the patient needs to be informed orally and in writing that the health care provider should be notified. Sedation may also be related to sleep deprivation resulting from unrelieved pain. A fact that must be stressed is that sedation may occur without adequate pain relief. This type of rest does not result in the expected rejuvenation offered by sleep. Nurses should monitor for respiratory depression (< 8 breaths per minute or oxygen saturation of < 90% [AGS, 2009]), especially during rapid, high-dose escalations. Table 14-4 identifies analgesics that should be avoided in older adults.
Table 14-4 Drugs to Avoid in Pain Management of Older Adults
Drug Precautions Potential Solutions Meperidine (Demerol)
Extremely low oral potency; metabolite normeperidine; may accumulate and cause confusion, agitation, and seizure activity, especially among patients with renal impairment.
Choose a drug with higher oral potency; no advantages to either oral or parenteral meperidine exist over other opioid drugs.
Pentazocine (Talwin)
Mixed opioid agonist or antagonist activity often leads to central nervous system excitement, confusion, and agitation.
Avoid all use in frail older adults.
Levorphanol (Levo- Dromoran)
The optimal analgesic dose varies widely among patients. Doses should be titrated to treat pain or for prevention. Use with caution in patients with hypersensitivity reactions to morphine, hydrocodone, hydromorphone, oxycodone, or oxymorphone.
For use in relief of moderate-to- severe pain.
Modified from Ferrell, B.R. & Ferrell, B.A. (1995). Pain in the elderly. In McGuire, D.B., Yarbro, C.H., & Ferrell, B.R. (Eds.). Cancer pain management. Boston, MA: Jones & Bartlett.
Adjuvant Medications Adjuvant medications, defined as medications without intrinsic analgesic properties, are helpful in treating certain types of chronic pain. Adjuvant medications include anticonvulsants, antidepressants, and some sedatives. The treatment of underlying depression or mood disorders may enhance other pain management strategies.
Anticonvulsants, drugs usually used to treat seizures, are often helpful in controlling painful conditions such as postherpetic neuralgia, diabetic neuropathy, and phantom limb pain. An anticonvulsant that is useful in the treatment of older adult patients and that has few side effects is gabapentin (Neurontin) Medications
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in this category include zonisamide (Zonegran), tiagabine (Gabitril), pregabalin (Lyrica), and milnacipran (Savella). Anticonvulsants may cause blood dyscrasias; therefore, laboratory data must be obtained on a regular basis. For older adults, some sedatives or tranquilizers may cause side effects such as increased confusion and constipation. Thus, the use of these medications in older adults must be continuously monitored. TCAs have been found to be useful in treating neuropathic pain but do not seem to be effective in the case of musculoskeletal pain; higher doses are needed for therapy superimposed on cancer pain. Desipramine hydrochloride seems to be better tolerated by older adults, with fewer anticholinergic side effects compared with certain other medications such as amitriptyline. However, TCAs may cause constipation, blurred vision, dry mouth, urinary retention, and sedation; they should be avoided by those with glaucoma and benign prostatic hypertrophy. TCAs have been known to cause arrhythmias, cognitive changes, orthostatic hypotension, and falls. Selective serotonin reuptake inhibitors (SSRIs) seem to have relatively low side-effect profiles. Newer combination drugs of selective norepinephrine reuptake inhibitors (SNRIs) and SSRIs are helping to achieve better results in additional pain relief and antidepressant effects. These drugs appear to block pain transmission pathways (AGS, 2009).
Adjuvant medications alter or modulate the perception of pain. They may be used alone or with other pain medications (Touhy & Jett, 2012). It is important that the nurse notify patients and their family members when these adjuvant medications are being used to treat the patient’s pain. Clinical experience has shown that a patient may discontinue the analgesic when an adjuvant medication is added. The patient may also take an adjuvant medication such as an antidepressant without realizing that it is being used in conjunction with the analgesic to treat pain. As with all analgesics, the nurse must continue to assess the patient’s reports of pain and the effectiveness and side effects of the adjuvant medication.
The combined use of pharmacologic and nonpharmacologic pain management therapies works well in older adults. Individually, most of the nondrug therapies work well only with mild pain. With
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moderate pain, drug therapy must complement the other therapies. Clinical experience suggests that many of these techniques are effective in individual cases. As with all treatment modalities, the individual response must be evaluated.
Complementary and Alternative Medicine Complementary and alternative medicine (CAM), as well as integrative medicine, is gaining new ground in healthcare. These terms, however, may be confusing and are often used interchangeably, even though they have different meanings. The National Center for Complementary and Alternative Medicine (NCCAM) suggests using the term to describe products and practices that are used in addition to mainstream medical practices (http://nccam.nih.gov/health/whatiscam). These practices fall into two subgroups: (1) natural products and (2) mind and body practices. Natural products include herbals and botanicals, as well as vitamins and minerals. Capsicum is commonly used for pain control, particularly because it can be used as a cream and applied directly to painful areas (http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/herbsvitaminsandminerals/capsicum Mind and body practices include such things as acupuncture, massage therapy, meditation, movement therapies, relaxation techniques, spinal manipulation, T’ai Chi, healing touch, and yoga. Nurses should be aware of these alternative therapies and assess their use and effectiveness in their patients.
Heat and Cold Heat is useful in decreasing pain and discomfort. It increases blood flow to the skin and superficial tissues, increases oxygen and nutrient delivery, and decreases joint stiffness by increasing the elasticity of muscles. (AHCPR, 1994). Heat is delivered by hot water bottles, heating pads, compresses, tub baths, soaks, and heat lamps. Patients and caregivers need to be cautious of thermal burns when using these items. Temperature and length of use is important to determine prior to use.
Cold reduces inflammation, edema, and pain, especially after an acute injury such as a fall. It may reduce muscle spasms not
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relieved by heat therapy (AHCPR, 1994).
Visualization or Imagery This is a state of pleasure and peace achieved by creating a vivid picture in one’s mind. This picture might be the setting sun, a serene forest, or rolling waves of water. It might be recalled from the past or a new experience imagined. It transports the patient to another place and uses all five senses (Hoffart & Keene, 1998).
Progressive Relaxation This can include an alternate contraction and relaxation of the various muscle groups. It is usually done lying down in a quiet, often darkened room. It can be accomplished with soft music in the background. Relaxation tapes can be found in many bookstores.
Distraction Distraction can be almost anything that takes one’s mind off of pain. They can include radio, television, videos, music, memories, pet therapy, projects such as games or puzzles. This is usually used with mild pain, but it can be used in conjunction with pain medication.
Exercise Exercise and physical therapy prevent stiffness, maintain function, relieve muscle spasms, and increase the sense of well-being. Medical consultation should be obtained for patients before instituting physical therapy. Many patients need pretreatment analgesic medication shortly before starting the regimen.
Peripheral Nerve Stimulation Peripheral nerve stimulation (transcutaneous electrical nerve stimulation [TENS]) is a technique for the management of chronic pain, in which electrical leads are placed subcutaneously into the area of a person’s pain. It may be used to treat a variety of painful conditions such as neuralgia, migraines, and orthopedic pain. Kouroukli, Dionissios, Panareto, and coworkers (2009) found that
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peripheral nerve stimulation was effective in relieving the pain of two older adults who suffered from postherpetic neuralgia for a range of 2 to 10 years.
Music Therapy Music therapy may be incorporated into many other therapies presented here. Furthermore, it is one therapy that has been used extensively in clinical practice with older adults (Clair, 2008). The music used should be the kind appreciated by the patient and at a volume that the patient can control.
Hypnosis Hypnosis includes some of the other cognitive modalities such as deep concentration, imagery, and breathing exercises. Self-hypnosis and imagery begin with developing a relaxed state, closing the eyes, focusing on the pain, and visualizing its color, shape, and size. Then the pain is projected out into space. It is made bigger, then smaller, and then allowed to be any size. Its color is changed and then put back as it was. Finally, the eyes are reopened.
Education Education is a cognitive therapy that involves teaching a patient about pain and the role of cognition in pain perception. The patient learns to track the pain and record episodes of pain and distress. The nurse helps the patient interpret the thoughts that accompany pain. Relaxation is incorporated to divert attention from the pain of the body. The goal is to help a patient develop some mastery over his or her pain.
Planning Pain Relief The primary consideration in selecting pain relief methods is individualized planning. Patients vary greatly in their medication requirements, choices of nonpharmacologic interventions, and prior pain experiences. Patients should be involved in choosing pain management methods and should share responsibility for implementing pain relief measures. Active involvement of patients
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and family caregivers is essential to the successful implementation of pain management regimens. This applies to both pharmacologic and nonpharmacologic pain relief measures.
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Summary Pain continues to be under-recognized and undertreated in older adults despite dramatic increases in the knowledge of pain and pain management. Pain in patients in nursing facilities is a large problem. Older adults suffer many painful chronic illnesses such as arthritis and cancer. When conducting patient assessments, the practicing nurse must look for pain in older adult patients and be alert for chronic diseases that may cause pain. Many excellent pharmacologic treatments for pain and many routes of administration are available today; thus, it is possible to individualize care for each patient. Though pharmacology is the main therapy for most chronic illnesses, many alternative and complementary therapies are available that will benefit the nurse’s older adult patients. For further information, see Box 14-2, which provides a list of helpful websites.
Box 14-2
Websites American Academy of Hospice and Palliative Medicine
www.aahpm.org
American Academy of Pain Medicine
www.painmed.org
American Geriatrics Society
www.americangeriatrics.org
American Pain Society
www.ampainsoc.org
International Association for Hospice and Palliative Care
www.hospicecare.com
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National Hospice and Palliative Care Organization
www.nho.org
Pain.com
www.pain.com
SeniorHealthCare.org
www.seniorhealthcare.org
Worldwide Congress on Pain
www.pain.com
World Health Organization
www.ConsultGeriRN.org
Evidence-based practice Pain management programs for older adults can be as unique as pain perception
Background Many older individuals who live with chronic pain falsely believe it to be a part of the normal aging process. Aiding a senior citizen in formulating an individualized pain management plan is one method to shatter this pervasive myth through the empowerment of the patient. The intent of this study was to test a pain management intervention that integrated goal setting in a population of older adults (age 65 or older) living independently in residential settings.
Sample/Setting A nonrandom sample of 17 men and women with rheumatic disease was recruited from three independent-living settings within one community.
Method
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Study participants completed pretests and posttests of five different instruments: (1) Chronic Pain Experience Instrument, (2) Pain Management Outcomes Expectations Instruction, (3) Barriers to Arthritis Pain Management, (4) Pain Management Inventory, and (5) General Information Form. Goal attainment setting (GAS) was employed for goal setting.
Findings Two methods of pain control were used more often after the interview and goal setting with patients: (1) exercise techniques and (2) heated pool, tub, or shower. Overall 76% of the study participants met goals at their expected level of pain management or above. Participants identified distraction and exercise as significantly helpful in controlling their pain. Related variables to pain control that revealed significant change were the experience of living with persistent pain and the expected outcomes of pain management.
Implications Functioning as a part of a support system for those experiencing chronic pain is an important role for nurses. The use of individual goal setting in pain management programs allows for the potential of differing levels of response to an intervention and ultimately leads to treatment plans that are unique to the level of care needed by each person. From Davis, G.C. & White, TL. (2008). A goal attainment pain management program for older adults with arthritis. Pain Management in Nursing, 9(4), 171.
Home care
1. The nurse caring for homebound older adults should know the effects pain has on functional status and quality of life.
2. The home care nurse should evaluate a patient’s pain at each home visit.
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3. The nurse should assess factors that may influence effective pain control in homebound older adults (e.g., motor, cognitive, and functional impairments).
4. When using a pain assessment tool, a home care nurse must evaluate a homebound older adult’s ability to use the tool.
5. Caregivers are an important source of information to the nurse when he or she assesses homebound older adults with pain.
6. The nurse should instruct homebound older adults and their caregivers on adjunctive therapies that can be used with analgesics to enhance pain management.
7. The nurse should assess and identify barriers for homebound older adults and caregivers related to pain and its management.
8. The nurse should encourage around-the-clock pain management to provide optimal pain control.
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key Points • Pain often remains under-recognized and undertreated in older
adults, mainly because of limited gerontologic pain research. Therefore, nurses must have a special understanding and conduct an accurate and ongoing assessment of the needs of this population with regard to pain.
• Goals for pain management in older adults include control of chronic disease conditions that cause pain, maintenance of mobility and functional status, promotion of maximum independence, and improvement of quality of life.
• Barriers to effective pain management in older adults include the misconception that intolerance to pain is age related, underreporting of pain, lack of access to diagnostic services, cognitive and functional impairment, the inability to communicate pain effectively through pain behavior scales, fear of addiction, and inadequacies in pain education.
• Accurate and ongoing assessment, as well as a thorough understanding of pain physiology, is essential for effective pain management in older adults.
• The nurse’s clinical assessment of older adults’ pain includes a number of important components: medical history; pain history; history of trauma, medications, and previous pain experiences; physical examination, examination for signs of trauma; musculoskeletal system examination; assessment of range of motion; and assessment of functional impairments. A variety of tools and scales are available for these assessments.
• The quality-of-life assessment is a vital part of pain assessment in older adults. This assessment may include sleeping, ADL function, pain, social relationships, and a number of other areas. Different areas will have different values based on an individual’s preferences.
• Pharmacologic pain management includes the use of analgesics, opioid analgesics, and adjuvant medications. Nonpharmacologic
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therapies include methods using cold, or heat; relaxation or distraction; imagery; TENS; and hypnosis. For the pain management to be effective, the nurse must continually assess a patient’s response to pain when employing any of these methods.
• A standard assessment scale that differentiates between pain intensity and pain distress in older adult patients is a useful tool for nurses when planning successful pain interventions. Consistent use of this tool, coupled with accurate record keeping, helps promote effective pain management.
• Family members often play an integral role in the pain management of older adults. Family members may provide insight into older adult patients’ pain experiences by offering the nurse information that the patients may not be willing or able to share accurately.
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Critical thinking exercises 1. A 91-year-old woman with a small bowel obstruction is admitted to the hospital from a long-term care facility. She also has a history of dementia and is incoherent. Discuss how you would revise your assessment and evaluation techniques in managing her pain.
2. What criteria should you use to determine whether an older adult patient requires an adjustment in dose or dosing interval or a change in the drug prescribed for pain management?
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References Agency for Health Care Policy and Research (AHCPR). (1994).
Management of cancer pain. Clinical Practice Guidelines No. 9. US Dept. of Health & Human Services. Rockville, MD. US Public Health Service.
American Geriatrics Society (AGS). The management of persistent pain in older persons. Journal of the American Geriatrics Society. 2002;50(S224):S205.
American Geriatrics Society. Pharmacological Management of Persistent Pain in Older Persons: Americans Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Adults. Journal of the American Geriatrics Society. 2009;57(1331).
Aronoff G. Drawing the line between pain management and addiction. Psychopharmacol Update. 2002;12(9):1.
Bishop T, Morrison R. Geriatric palliative care- part 1: pain and symptom management. Clinical Geriatrics. 2007;15(1):25–32.
Campbell LC, Andrews N, Scipio C, Flores B, Feliu MH, et al. Pain coping in Latino populations. The Journal of Pain. 2009;10(10):1012–1019 Oct.
Clair AA. Therapeutic uses of music with older adults. 2nd ed. Baltimore, Md: Health Professional Press; 2008.
Davis GC, White TL. A goal attainment pain management program for older adults with arthritis. Pain Management Nursing. 2008;9(4):171.
Ferrel BR, Ferrel BA. Pain in the elderly. In: McGuire DB, Yarbo CH, Ferrel BR, eds. Cancer pain management. Boston, MA: Jones & Bartlett; 1995.
Gloth 3rd FM, Scheve AA, Stober CV, Chow S, Prosser J. The functional pain scale: reliability, validity & responsiveness in an elderly population. Journal of the American Medical
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Directors Association. 2001;2(3):110–114 May-June.
Hartford Institute for Geriatric Nursing. Pain assessment for older adults. Retrieved from: 2012. www.consultgerirn.org/uploads/File/trythis/try_this_7.pdf Accessed on April 20, 2014.
Herr K. Chronic pain: challenges and assessment strategies. Journal of Gerontological Nursing. 2002;2:20.
Herr K, Bjororo K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state of the science review. Journal of Pain and Symptom Management. 2006;31:170.
Herr K, Bursch H, Ersek M, et al. use of pain behavioral assessment tools in the nursing home: Expert consensus recommendations for practice. Journal of Gerontological Nursing. 2010;36:18.
Hoffart MB, Keene EP. The benefits of visualization. American Journal of Nursing. 1998;98(12):44.
International Association for the Study of Pain. Position Statement: IASP Pain Terminology. 2010.
Jansen MP. Pain in older adults. In: Jansen MP, ed. Managing pain in the older adult. 2008 New York.
Jett K. Pain and comfort. In: Touhy Jett, Ebersole Hess, eds. Toward Healthy Aging: Human needs & nursing response. 8th ed. St. Louis: Mosby/Elsevier; 2012.
Kouroukli I, Dionissios N, Panareto V, Zompolas V, Papastergiou D, Sanidas G, et al. Peripheral subcutaneous stimulation for the treatment of intractable postherpetic neuralgia: two case reports and literature review. Pain practice: the official journal of World Institute of Pain. 2009;9(3):225–229.
Kovach CR, Logan BR, Noonan PE, et al. Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia. American Journal of Alzheimer's Disease and Other Dementias. 2006;21:147.
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Leo J, Huether SE. Pain, temperature regulation, sleep, and sensory function. In: McCance K, Huether S, eds. Pathophysiology. ed 3. St Louis: Mosby; 2010.
Linton AD, Lach HW. Matteson & McConnell’s gerontological nursing: concepts and practice. St Louis: WB Saunders; 2007.
McCaffery M. Pain: nursing management of the patient with pain. ed 3 Philadelphia: Lippincott; 2000.
McCaffery M, Pasero C. Pain: clinical manual. ed 2 St Louis: Mosby; 1999.
McCance KL, Huether SE. Pathophysiology: the biologic basis for disease in adults and children. ed 6 St Louis: Mosby; 2010.
McCleane G. Pain perception in the elderly patient. Clinics in Geriatric Medicine. 2008;24(2):203–211.
Merskey H, Bogduk N, eds. Classification of chronic pain. (p. p xi (ed 2). Seattle: IASP Press; 1994.
Natan B, Ataneli M, Admenko A, Har Noy R. Nurse assessment of residents’ pain in a long term care facility. International Nursing Review. 2013;60(2):251–257.
Park J, Hughes K. Nonpharmacological approaches to the management of chronic pain in community dwelling older adults: a review of empirical evidence. Journal of the American Geriatrics Society. 2012;60(3):555–568.
Reid MC, Bennett DA, Chen WG, Eldadah BA, et al. Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them. Pain Medicine. 2011;12(9):1336–1357 Sep.
Robinson P. Pharmacological management of pain in older persons. The Consultant Pharmacist. 2010;25(suppl a):11.
Shoefield P. “It’s your age”: The assessment and management of pain in older adults. Continuing Education in Anaesthesia, Critical Care & Pain. 2010;10:93.
Sternbach RA. Clinical aspects of pain. In: Sternbach RA, ed. The psychology of pain. New York: Raven Press; 1978:p. 223.
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Touhy TA, Jett K. Ebersole & Hess’ Toward healthy aging: human needs & nursing response. 8th ed. St. Louis: Mosby/Elsevier; 2012.
Woolery M, Bisanz A, Lyons H, Gaido L, Yenulevich M, et al. Putting evidence into practice: evidenced-based interventions for the prevention and management of constipation in patients with cancer. Clinical Journal of Oncology Nursing. 2008;12(2):317–337.
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* Original authors: Betty R. Ferrell, PhD, RN, FAAN; Lynne M. Rivera, MSN, RN; and Ann Schmidt Luggen, PhD, RN, CNAA; Revised: Margaret Louis, PhD, RN, BC, and Sue E. Meiner, EdD, APRN, BC, GNP.
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C H A P T E R 1 5
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Infection Jennifer J. Yeager, PhD, RN
http://evolve.elsevier.com/Meiner/gerontologic
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Learning objectives On completion of this chapter, the reader will be able to:
1. Describe alterations in the immune system related to aging.
2. Describe nutritional factors that influence immune status.
3. Describe psychosocial factors that influence immune status.
4. Describe the effect of lifestyle factors on immune status.
5. Describe the effect of medications and drugs on immune status.
6. Identify strategies to prevent nosocomial infections, community- acquired infections, or both.
7. Incorporate nutritional, psychosocial, and lifestyle factors into a nursing care plan.
The importance of investigating infections in older adults cannot be overstated. Infection is one of the 10 most common causes of death in patients older than age 65 (Kane, Ouslander, Abrass, & Resnick, 2009). Infections in older adults are often masked in their presentation, which may lead to delayed treatment. The immune system enables the body to defend itself against disease-causing microorganisms and other foreign bodies; it is vital to human survival. However, this system exhibits a diminished ability to provide such protection with aging (Newson, 2007). Considering the immune system’s fundamental importance to maintaining health, a clear understanding of age-related changes is crucial.
The immune system has two primary functions: (1) to discriminate between that which is self and that which is nonself and (2) to remove from the body that which is recognized as nonself. This system comprises antibodies, cells, chemicals, and proteins, as well as lymphoid tissue, bone marrow, and the spleen (Porth, 2004). Furthermore, this system interacts with the neurologic and endocrine systems in a highly complex manner to modulate the human immune response. Immunologic function may be mediated by psychological and behavioral factors. Awareness of the impact of mood, activity level, stress, and nutrition on the
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capacity of this system to provide optimal protection is increasing.
This chapter examines age-related changes in the immune system, and the influence of other factors such as psychosocial and nutritional status on the immune status of older adults. Cancer, autoimmune diseases, human immunodeficiency virus (HIV), and significant nosocomial pathogens are also discussed.
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The chain of infection For an infection to occur, a reservoir of an infectious disease, a portal of entry, and a susceptible host must be present. The source of an infectious disease is the reservoir or substance from which the infectious agent was acquired. The source may be a person’s own microbial flora (endogenous) or something in the environment (exogenous) such as water, air, food, soil, or another person. Infectious diseases passed from other animal species to humans are called zoonoses, for example, cat-scratch fever and rabies. Infections acquired in the hospital are called nosocomial infections, and those acquired outside the health care facility are called community- acquired infections. The source of transmission may be feces, blood, and body fluids. Infections may be transmitted from person to person through shared inanimate objects (fomites) contaminated by infected body fluids. Examples of infections transmitted through this mechanism include Clostridium difficile infection from a commode or other contaminated surface and HIV infection from the use of shared needles by intravenous drug users.
The portal of entry is the way a pathogen enters the body and gains access to tissues, where it may multiply and cause disease. The portal of entry may be penetration of the skin, direct contact, ingestion, or inhalation. Any disruption or penetration in the integrity of the skin and mucous membranes is a potential portal of entry. The break may be accidental (e.g., an abrasion or burn), the result of a medical procedure (e.g., surgery or catheterization), or the result of direct inoculation from animal or arthropod bite (e.g., Lyme disease or malaria). In direct contact, pathogens are transmitted directly from infected tissues or secretions to exposed intact mucous membranes. Sexually transmitted diseases (STDs) such as gonorrhea and chlamydia are examples of direct contact transmission. The oral cavity and gastrointestinal tract are the most efficient portals of entry. Pathogens are ingested and successfully compete with normal bacterial flora to cause infection. Cholera, food poisoning, and hepatitis A are examples of diseases that occur through ingestion. Pathogens must be able to survive the low pH
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and the enzymes of the gastric acid secretions to establish infection. People with reduced gastric acidity (because of disease or medications) are more susceptible to this mode of infection.
A number of pathogens may invade the body through the respiratory tract and cause diseases such as influenza, the common cold, and bacterial pneumonia. The portal of entry does not limit the site of infection. Ingested pathogens may penetrate the mucosa, disseminate through the circulatory system, and cause disease in other organs (Porth, 2004). Hepatitis A and vancomycin-resistant enterococci (VRE) are examples of ingested pathogens causing infection in the liver and the bloodstream, respectively. Genetic, constitutional, and other nonspecific factors in the host determine whether a pathogen will succeed in causing infection and clinical disease.
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Age-related changes in the immune system Some researchers believe that much of the illness seen in older adults may be the direct consequence of changes in “both cell- mediated and antibody-mediated immune response” (Townsend, 2008). Alterations in immune status may be responsible for infections, cancer, and autoimmune processes, all of which may be life threatening (Porth, 2004). Scientists have tried to determine whether the diminished immunocompetence noted with age is a result of decreased numbers of immune cells or merely decreased functioning of the cells. However, because immunocompetence is affected by numerous other factors, it has been difficult to isolate changes that are related to age alone. Atrophy of the thymus, which occurs naturally with aging, affects T-lymphocyte function. Diminished cellular (T cell–mediated) and humoral (B-lymphocyte) immunity have both been associated with aging. Box 15-1 summarizes age-related changes in the immune system (Townsend, 2008).
Box 15-1
Age-related changes in the immune system Lymphocytes No change in total number of lymphocytes
No change in number of B cells
No change or increase in T helper cells
Decrease in suppressor T cells
Decreased T cell responsiveness
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Decreased CD4 and CD8 cells
Polymorphonuclear Leukocytes Reduced migration ability
Antibody Decrease of T cell–dependent antibody responsiveness
Decreased primary response to new antigens
Maintenance of secondary response to antigens
Increased globulins associated with secondary response and autoimmunity
Increased incidence of antibodies to self-antigens
Lymphoid Tissue Involution of thymus
Atrophy of thymic cortex
Atrophy or hypertrophy of some lymph nodes
Mechanical Barriers Changes in skin and mucous membranes, resulting in reduced
effectiveness of physical barriers
Cell-mediated immunity is the ability of the host to differentiate between self and nonself. Diminished cell-mediated immunity in older adults is generally associated with diminished T-cell response (Goldman & Ausiello, 2004). With aging, B cells demonstrate reduced antibody response (Frasca & Blomberg, 2011).
As age increases, so does the production of autoantibodies. This predisposes older adults to an increase in autoimmune diseases. The mechanism underlying this issue is felt to be alteration in both T-cell and B-cell function (Agrawal, Sridharan, Prakash, & Agrawal, 2012). The skin is the largest immunologically active system of the body, and the body’s first line of defense. Normal microbial flora on the skin (e.g., Propionibacterium acnes and Staphylococcus aureus) prevent pathogenic bacteria from flourishing (“Immune system”
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2013). With aging, the skin becomes more fragile and prone to breakdown or abrasion, thus disrupting the defensive mechanisms and providing a portal of entry for bacteria.
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Factors affecting immunocompetence Nutritional Factors Nutritional and dietary status is of critical importance to immune function. This is especially true in the older adult population. Older adults are at high risk for nutritional deficits; at least one third of individuals older than age 65 have nutritional deficiencies (review Chapter 10). Risks associated with the development of a nosocomial infection include poor nutrition, unintentional weight loss, low serum albumin levels, decreased fluid intake, poor oral hygiene, and altered mental status. Factors contributing to this tendency toward inadequate nutrition include altered taste, social isolation, physical inability to prepare food, altered absorption, and poverty. Older adults should consult with their health care providers and have a thorough assessment of their dietary intake done prior to beginning nutritional supplementation. When adequate amounts of vitamins and minerals are consumed in the diet, supplementation is unnecessary and may lead to toxicity.
Protein-Energy (Caloric) Malnutrition Significant deprivation of protein and energy (caloric) nutrients has been shown to result in altered immune function (Nowson, 2007). Along with other age-related changes in the immune system, this deprivation results in increased susceptibility to infectious disease. Restoring nutritional balance, especially protein balance, can improve older adults’ immune status (Nowson, 2007).
Iron and Trace Element Deficiency The effects of iron deficiency on immunocompetence and susceptibility to infection have not yet been fully determined. Low levels of iron also decrease the number of circulating T cells. Iron deficiency contributes to decreased functioning of neutrophils, macrophages, and B and T cells. In addition, iron deficiency contributes to a delayed responsiveness to antigens.
Zinc is thought to be associated with immune function. A
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prolonged zinc deficiency leads to impaired cell-mediated immunity, wound healing, and protein synthesis. Patients with decreased zinc levels experience an increase in the number of infections and an increase in the needed healing time (Nowson, 2007).
Psychosocial Factors Awareness is growing of the potential impact of psychosocial factors on immune status. These factors include chronic and acute stress, depression, bereavement, and social relationships. Recognition that such factors influence immune status is relatively recent, and our understanding of the nature of these relationships is constantly changing. Therefore, the clinical relevance of these changes remains a source of investigation and controversy.
Older adults experience many psychosocial changes which potentially impact immune status and must be taken into consideration. Older adults work through bereavement as they lose family and friends. Additionally, they experience a shrinking sphere of social relationships and exhibit a high incidence of depression.
Depression Depression has also been associated with decreased immune function. This is significant because approximately 6% of community-dwelling older adults are diagnosed with depression (Akincigil et al., 2011) (review Chapter 29). Furthermore, adults older than 65 years represent nearly 14% of the population (United States Census Bureau, 2014) but make up nearly 15% of all suicides (Span, 2013). Some evidence suggests that the negative impact of depression on the immune system increases with age. Thus, older adults who are depressed may be at risk for greater immune deficiencies than younger individuals with depression.
Medications A variety of medications may affect the immune system; these
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include immunosuppressants and immunoenhancers. Many drugs given for therapeutic purposes have an immunosuppressant effect. Some of these drugs include corticosteroids, cyclosporine, and chemotherapeutics for cancer. Corticosteroids such as prednisone, are given for a variety of reasons, including treatment of autoimmune processes (e.g., rheumatoid arthritis). Individuals receiving corticosteroids, those taking cyclosporine following transplantation to reduce the risk of organ rejection, or individuals taking anticancer drugs have an altered immune response and are at higher risk for infection.
Herbs Some individuals take herbs to bolster their immune system (e.g. Echinacea, garlic, ginger, St. John’s wort). However, herbal products are not thoroughly tested and have significant variability based on growing conditions and methods of harvest. Additionally, some herbs are harmful and may negatively affect the immune system (e.g., Bupleurum, glucosamine, red yeast rice, and cascara sagrada) or interact with prescription medications. Patients should be advised to discuss all herbal supplementation with their health care provider.
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Common problems and conditions The immune deficits seen so often in older adults make this population more vulnerable to both infection and cancer. As people age, the likelihood of autoimmune antibodies being found in serum increases, which suggests an increased likelihood of autoimmune processes. However, whether such autoimmune processes are actually age related is still being debated (Kane et al, 2009).
Individuals with diminished immune function are susceptible to numerous infections. Some of the more common infections in older adults include influenza, pneumonia, tuberculosis, urinary tract infections (especially in women), and shingles (herpes zoster). Medical management of infections consists primarily of determining the source of the infection and prescribing the appropriate antibiotic or antiviral medication. See Box 15-2 for examples of autoimmune diseases.
Box 15-2
Examples of autoimmune diseases Systemic Diseases Rheumatoid arthritis
Scleroderma
Systemic lupus erythematosus (SLE)
Vascular Diseases Autoimmune hemolytic anemia
Idiopathic thrombocytopenic purpura
Diseases of Other Organs Goodpasture syndrome
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Insulin-dependent diabetes mellitus
Myasthenia gravis
Ulcerative colitis Modified from McCance, K., Huether, S., Brashers, V., & Rote, N. (2010). Pathophysiology: The biologic basis for disease in adults and children (6th ed.). St. Louis, MO: Mosby.
Influenza and Pneumonia Pneumonia and influenza are ranked as the seventh leading cause of death in older adults (Administration on Aging [AOA], 2012). More deaths from influenza occur in the 65 or older age group than in any other age group (Eliopoulos, 2005). The predominant portal of entry is inhalation of small droplets transmitted through sneezing, coughing, or talking. Closed populations such as those in long-term care facilities provide an ideal setting for the spread of influenza. The social environment in these institutions also facilitates transmission of influenza through group activities, communal dining rooms, and rehabilitation activities.
The most effective measure to control influenza is the vaccination of persons at high risk. Influenza vaccination is a Medicare-covered benefit for older adults, yet only approximately 68% of the population 65 years or older is vaccinated. Every adult over the age of 65 should receive the influenza vaccination annually, unless they have had a serious reaction to a previous vaccination or are allergic to eggs (Wallace, 2008). Other strategies to control the nosocomial spread of influenza include the early identification and grouping of infected patients, careful hand washing, and the use of barrier precautions when handling bodily substances, especially respiratory secretions.
About 50% of pneumonia cases result from viral infection. Community-acquired pneumonia results from bacterial infection, most often from Streptococcus pneumoniae, and pneumococcal pneumonia results from Streptococcus pneumoniae. Early recognition and treatment of bacterial pneumonia leads to recovery, although antibiotic resistance is becoming a problem. The pneumococcal vaccine is recommended for everyone over the age of 65; in 2008, 67% of older adults were vaccinated (“Pneumonia Fact Sheet,”
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n.d.).
The major host factor associated with community-acquired pneumonia is advanced age (Wachtel & Fretwell, 2007). Smoking, excessive alcohol intake, chronic lung disease, recent history of viral upper respiratory tract infection, and neurologic disease (which may contribute to microaspiration of secretions from the oropharynx) are other contributing factors. Changes in lung function that come with aging enable inhaled microorganisms to survive and multiply. Social environments such as congregate housing, communal dining rooms, churches, crowded shopping centers, adult day care centers, or nursing facilities place older adults at risk for exposure and infection. However, social isolation is not recommended because of its negative psychological consequences. Older adults should be encouraged to select activities that reduce the risk of infection during the colder months.
Infection control measures should be in place to reduce the risk of illness. Hand washing, monitoring fluids and nutritional intake, and proper disposal of bodily secretions help to manage the spread of infection when it does occur (Eliopoulos, 2005). Older adults and their families should be instructed to seek early medical attention for subtle changes that may signal the onset of infection. For example, pneumonia may be signaled by confusion or tachypnea, with no other findings. Many older adults present with atypical or diminished signs and symptoms. Nursing care of older patients must be attentive to ensure early detection of subtle changes (Eliopoulos, 2005).
Cancer Neoplasms occur with greater frequency in older adults. Common types include lung cancer, breast cancer, and prostate cancer. However, the potential for numerous other forms of cancer should not be overlooked. (See Chapter 17 for more information.)
The presence of cancer reveals the presence of decreased immune response. Cancer cells are normally detected by the immune system and eliminated after being recognized as abnormal cells. It is only when the immune system fails to carry out this function that cancer
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occurs. However, the cancer and treatment for cancer may induce additional immune deficits.
For example, cancer is often accompanied by a decrease in appetite, which increases the possibility of malnutrition. Furthermore, anticancer drugs often deplete immune cells, causing further debilitation of the immune system. Because many of these drugs have their greatest effect on rapidly dividing cells, the rapidly dividing immune system cells are attacked concurrently with the cancer cells. Each patient’s response to treatment is individual; decisions about treatment need to be personalized. The prognosis for cancer is highly variable, depending on the time of diagnosis, the patient’s general health, and the type of cancer.
Autoimmunity Older adults may have autoimmune diseases such as rheumatoid arthritis; however, these cannot be considered solely age associated. Older adults with autoimmune diseases are more likely to take immunosuppressant drugs as treatment, and they still risk the immune deficits that accompany aging. Therefore, these older adults carry higher risks for infection compared with older adults without autoimmune disease. Criteria for identifying autoimmune disease include (1) evidence of autoimmune reaction, (2) determination that immunologic findings are not secondary to another condition, and (3) lack of other identified causes for the disorder.
Systemic Lupus Erythematosus Systemic lupus erythematosus (SLE) may affect many parts of the body, including the joints, skin, kidneys, heart, lungs, blood vessels, and brain. The most common symptoms are extreme fatigue, painful or swollen joints, unexplained fever, skin rashes, and kidney problems. The antinuclear antibody (ANA) test is one of the more specific tests for SLE. No cure for SLE exists at this time. The management objective is to control the severity of symptoms and prevent a flare. The warning signs of a flare are increased fatigue, pain, rash, fever, stomach discomfort, headache, and dizziness.
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Patients must monitor their health and learn to recognize symptoms of disease activity. Avoiding the sun, exercising, complying with medications, limiting stress, and having regular health care visits are important.
Rheumatoid Arthritis Rheumatoid arthritis (RA) is characterized by inflammatory polyarthritis of unknown cause. Symptoms include morning stiffness lasting for hours, tenderness, pain on motion, limited range of motion, and joint deformity in the small joints of the hands and feet. Extraarticular signs are pulmonary (e.g., pleuritis and pneumonitis), cardiac (e.g., pericarditis and myocarditis), renal (e.g., amyloidosis), and ocular (e.g., scleritis); rheumatoid (subcutaneous) nodules also develop. The course of RA is highly variable; most people develop progressive functional limitation and physical disability. Patients with RA have a higher mortality rate compared with the general population. In addition to physical therapy, first-line medications for RA are nonsteroidal anti- inflammatory drugs (NSAIDs). These medications reduce inflammation, pain, and swelling. During arthritis flare-ups or when NSAIDs are ineffective, patients may be treated with short bursts of corticosteroids. Because of their side effects, corticosteroids should not be used for long periods in high doses. Patients with RA also need medications to slow joint destruction. These second-line medications are known as disease-modifying antirheumatic drugs (DMARDs) and may take months to demonstrate an effect.
Autoimmune Hepatitis Autoimmune hepatitis has an unknown etiology and is characterized by progressive destruction of the liver parenchyma, leading to hepatic fibrosis and cirrhosis (Czaja, 2008). Although it was once thought to be rare in older adults, autoimmune hepatitis is now thought to be underrecognized in this population. A liver biopsy is essential for confirming the diagnosis and assessing for disease activity and the presence of cirrhosis (Czaja, 2008).
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Human immunodefiency virus infection in older adults HIV infection is an underrecognized problem among the older adult population; 31% of persons living with HIV and 17% of newly diagnosed cases are in those over the age of 50 (“Older Adults and HIV/AIDS,” n.d.). Many erroneously believe that the incidence of acquired immunodeficiency syndrome (AIDS) in older adults can be attributed to blood transfusions. However, the spread of HIV and AIDS is a multigenerational crisis. The low clinical suspicion of HIV infection and delayed recognition of AIDS-defining infections contributes to the poor prognosis of HIV infection in older adults. In older adults, only a short interval exists from HIV infection to the development of AIDS and death. The aging immune system is not able to eliminate the HIV residing in macrophages, lymphoid tissue, or the brain. Because the immune system’s regenerative capacity is diminished and not all replacement cells are fully functional, the disease progresses more rapidly (Eliopoulos, 2005). The proportion of AIDS cases among older adults attributed to heterosexual transmission and intravenous drug use has continued to rise since 1988. Only a small proportion of older adults participating in risky sexual behavior reported the use of condoms.
These findings hold major implications for nursing practice. In assessing older adults, nurses must complete a sexual history. Nurses need to discuss HIV and risk behaviors for acquiring HIV. Older adults should be taught the proper use of condoms and how and when to get tested for HIV.
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Significant nosocomial pathogens Clostridium difficile C. difficile is a nosocomial pathogen. The presence of C. difficile alone does not indicate infection. Disease occurs when this organism is present and the normal flora of the bowel are disturbed. C. difficile produces toxins, which cause hemorrhaging and cellular damage, resulting in fluid accumulation in the intestines. The hallmark diarrhea is caused by a motility-altering factor that stimulates muscle contractions.
C. difficile is transmitted person to person, primarily from the hands of health care worker. It has also been transmitted indirectly through contaminated equipment such as rectal probes and electronic thermometers. Consistent hand washing between contacts with patients and the use of gloves when handling body substances such as feces are imperative. Patients with C. difficile should be placed in private rooms with their own bathrooms or commodes.
Vancomycin-Resistant Enterococcus VRE was first identified in the United States in 1989 (Wachtel & Fretwell, 2007). Multiple factors predispose a person to infection with VRE, but colonization precedes most infections (Wachtel & Fretwell, 2007). Vancomycin use has increased dramatically in the past 20 years as a result of many factors, including increases in the incidence of methicillin-resistant Staphylococcus aureus (MRSA). Risk factors for VRE acquisition include an age of more than 65 years, antimicrobial therapy, chronic kidney disease, serious illness, and prolonged hospitalization (Wachtel & Fretwell, 2007).
VRE is transmitted from person to person via the hands of health care workers. VRE is also transmitted by contaminated medical devices, including electronic thermometers, fluidized beds, and environmental surfaces (Wachtel & Fretwell, 2007). To control transmission of VRE, health care workers must perform a
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meticulous 15-second hand washing with an antimicrobial soap. Dedicated equipment (e.g., stethoscopes) is required for infected patients. Colonized and infected patients should be isolated in private rooms or grouped with other infected patients in the acute care setting. Barrier precautions, gloves, and gowns should be implemented for patient care. Antibiotics are not used in persons with colonization but no symptoms; symptomatic patients should be treated with antibiotics indicated through culture and sensitivity.
Methicillin-Resistant Staphylococcus aureus In the early 1940s, when penicillin first became available, S. aureus was highly susceptible to antibiotic treatment. By the early 1950s, 80% of nosocomial S. aureus was resistant to penicillin. Methicillin became available in the 1960s, and by the mid-1970s MRSA became a significant problem.
The antibiotic of choice to treat MRSA infection is vancomycin. However, exposure to vancomycin is a risk factor for the acquisition of VRE (Wachtel & Fretwell, 2007). Other drugs used to treat MRSA include Bactrim, clindamycin, and Zyvox.
MRSA is transmitted from patient to patient via the hands of health care workers; transmission often occurs when patients are transferred from institution to institution, especially nursing homes (Wachtel & Fretwell, 2007). MRSA may also be transmitted via contaminated equipment, especially in burn units. Risk factors for acquiring MRSA are insulin-dependent diabetes mellitus, chronic hemodialysis, illicit intravenous drug use, prolonged hospitalization, prolonged antibiotic therapy, stays in intensive care or burn units, and rooming next to a patient colonized or infected with MRSA. Control of MRSA focuses on health care worker hand washing to reduce transmission. Health care workers should wear gloves for all contact with patients who are either colonized or infected. MRSA-positive patients should be placed in private rooms.
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Nursing management Assessment
With such a spectrum of possible infections, clinical assessment varies widely. However, health care workers must keep in mind some crucial aspects to assessing older adults for the presence of infection (Box 15-3). Older adults with decreased immune function may not exhibit classic symptoms of infection. Diminished inflammatory response may lead to false-negative results for skin tests used in the diagnosis of disease, for example, the purified protein derivative (PPD) skin test for tuberculosis (Eliopoulos, 2005). Similarly, redness, swelling, or inflammation may be reduced with infections. These reduced responses are even more likely to occur in people who have diseases or drug treatments that further suppress the immune system, for example, patients with cancer or those taking immunosuppressants.
Box 15-3
Assessment of individuals at high risk for infection Subjective Take history:
• Previous infections • Predisposing illnesses
• Medications
• Vaccinations
• Living environment
• Lifestyle factors (e.g., smoking, activity level, and chemical
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exposures)
• Social support system
Objective Assess for signs and symptoms of infection:
• Fever: high grade or low grade
• Inflammation: pronounced or slight
• Pain: slight or severe
• Malaise, fatigue
• Turbidity, odor, and amount of body fluids
• Complete blood cell (CBC) count with differential
Another classic example of a reduced response to infection is the absence of fever. With an infection, local or systemic fever is provoked by the immune response. In younger adults, an elevated temperature is an indicator of infection. However, in older adults with decreased immune function, temperature increase may be limited, or no increase may occur at all (Newson, 2007). Symptoms of pain may also be reduced or absent. Thus, infection in these older adults may progress to the life-threatening stage before it is detected.
Because of this reduced immune response, mild symptoms such as a low-grade fever must be taken seriously. Close observation is needed to detect subtle symptoms. Changes in the behavior of patients (e.g., increased malaise or fatigue, especially combined with other symptoms) may indicate the onset of infection. Fever and inflammation may be reduced, whereas the white blood cell (WBC) count may still reflect an increased value (Wachtel & Fretwell, 2007). However, if immunosuppression is present from drug treatment for diseases such as cancer or AIDS, elevations in WBC counts may not be seen, even with severe infection.
In addition to observed data, subjective and historical data are valuable when evaluating older adults with infection. A history of previous episodes of infection, including the timing, nature, and severity of the infection, is important. Infections in older adults
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often recur. Information regarding exposure to others with infections may also be helpful. Older adults are more susceptible to infection, especially if they are living in environments conducive to the spread of pathogens. Such environments include nursing facilities, hospitals, and crowded environments, where strict hygiene standards are difficult to maintain. Immunization records also provide important information that needs to be kept on file.
It is also important to determine other disease processes for which patients may currently be receiving treatment. Persons with cancer may be experiencing assaults on their immune systems from the disease and from treatment. Older adults with autoimmune diseases may be receiving antiinflammatory and immunosuppressant drugs. Individuals with HIV infection experience an extreme assault on their immune system. All of these make older adults more prone to a variety of infections.
A thorough record of medications is necessary to detect the potential for drug-related immunosuppression. This record should include both prescription and over-the-counter drugs, herbs, and other dietary supplements. Patients receiving drugs with immunosuppressant qualities are more prone to infections. In addition, information on the use of alcohol, tobacco, and other drugs, as well as exposure to toxic substances, should be obtained.
Knowledge about a patient’s lifestyle may provide invaluable information in developing a care plan. Information should include a thorough nutritional history as well as activity and exercise habits. An understanding of an individual’s social support system should be acquired, and indicators of life stressors should be elicited. A classic life stressor is bereavement, especially the loss of a spouse. However, the loss of friends and other family members should not be overlooked. Even the loss of a home or relocation to another place may result in a sense of bereavement.
Diagnosis Several nursing diagnoses may be applicable to older patients who either have infections or are at high risk for developing infections (Box 15-4). The risk factors determined during the assessment
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indicate potential nursing diagnoses. For example, many older adults are either inadequately or inappropriately nourished. Thus, a diagnosis of “Imbalanced Nutrition: Less Than Body Requirements” is likely. People with cancer may be malnourished because of lack of appetite or side effects resulting from medications. Poor nutrition may also be attributed to self-care deficit in preparing and eating food; older adults sometimes have difficulty preparing their own meals. These difficulties may be related to a variety of problems such as visual deficits, arthritis, or depression. Regardless of the cause, if these self-care deficits result in poor nutrition, the older adults are then at higher risk for infection.
Box 15-4
Nanda nursing diagnoses appropriate for older adults with autoimmune diseases Risk for Infection
Imbalanced Nutrition: Less Than Body Requirements
Feeding Self-Care Deficit
Deficient Knowledge, related to immunizations, nutrition, protection from infection
Social Isolation
The diagnosis “Risk for Infection” is applicable to those at risk for developing an infection and those with existing infections. The presence of an infection indicates the immune system is already challenged. This increases the likelihood of a secondary infection. For instance, it is not unusual for an individual with viral influenza to later develop a secondary bacterial infection of pneumococcal pneumonia.
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A diagnosis of “Knowledge Deficit” is also a possibility. Knowledge deficits may be in the areas of (1) immunizations, (2) nutrition, or (3) protection against infection from oneself or others. Patients may be unaware of their nutritional needs or the relationship between nutritional and immune status. If they have this knowledge, older adults may be more likely to consume appropriate foods. Similarly, older adults may be unaware of available vaccinations or the benefit such vaccinations may hold for them. Older individuals need information on ways to reduce their risk for developing infections.
Finally, “Social Isolation” may be a relevant diagnosis associated with the individual at risk for infection because social support has also been associated with immune status.
Planning and Expected Outcomes In planning care for older patients, the health care team and patients must set goals together. Goals must be congruent with realistic expectations and with patients’ desired outcomes. For individuals at increased risk for infection, goals include (1) avoiding primary or secondary infection and (2) maintaining or improving immune status. A careful assessment of patient knowledge in areas related to infection prevention, maintenance of immune status, and health practices determines the goals for patient teaching.
In setting nutritional goals, nurses might find a consultation with a registered dietitian appropriate. They must consider patients’ dietary preferences and financial ability to buy food (if not in an institutional setting). An outcome might be that a patient consumes a well-balanced, high-calorie diet on a daily basis. Patients with cancer may have even more extreme nutritional needs. An outcome for these individuals might be that they stabilize body weight and then gradually increase it at a rate of 1 pound every 3 weeks. Another outcome may be that a patient performs self-care activities with minimum energy expenditure and risk of injury. For patients with activity deficits, an appropriate goal might be to participate in 15 minutes of moderate exercise 3 times a week. The exact target
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goal for exercise should be established in consultation with the primary care provider and possibly achieved through physical therapy.
Intervention Nursing management of older adults with alterations in immunity focuses on the prevention of infections. Interventions addressing this goal are targeted at (1) preventing exposure to infections and (2) enhancing the immune system to enable patients to better resist infections. Totally preventing exposure to pathogens is impossible, especially because one source of pathogens is the body’s own natural flora. However, exposure can be minimized for individuals with diminished immune capacity. During times of epidemics such as during the influenza season, the patient should try to avoid places with crowds of people. In an institutional or home setting, visitors should be screened for respiratory infections. If contact is unavoidable, infected visitors may be given a mask to wear to minimize potential contamination of the patients. Any catheters, intravenous fluids, or similar therapeutic devices should be carefully assessed for pathogen growth. Teaching patients to drink at least 2000 milliliters (mL) of fluid a day, unless contraindicated, will aid in preventing urinary tract infection and constipation. In addition, teaching stress management techniques to promote immune system function may be indicated. Finally, hygiene standards should be rigorously maintained, especially for patients experiencing treatment-induced immune suppression, as is seen with some anticancer drugs. In addition to normal bathing, careful attention should be paid to oral and perineal care. Both patients and caregivers should be alert for changes in the color, consistency, and odor of body fluids to detect the onset of infections.
Nutritional Interventions Other measures may be taken to strengthen the immune system to better enable patients to resist infection. As previously mentioned, optimal nutritional status is important. Although all nutritional needs for healthy older adults may be met through normal dietary
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intake, many older adults have dietary deficiencies. In patients with cancer, the nutritional deficits may be extreme. After assessment, efforts should be made to resolve detected deficiencies. In institutional settings, dietary supplements and frequent meals may be supplied. Food may be prepared specifically to suit the patients’ tastes and needs. For older adults in the community, it is helpful to have services such as Meals on Wheels, assistance with food preparation, or the ability to visit a senior center nutrition site. Liquid food supplements or over-the-counter vitamins are other alternatives. However, these may be beyond the financial resources of some patients.
The inability to feed oneself is another barrier to proper nutrition. Individuals feeding patients, either in the home or institutional setting, must ensure that the patients receive a balanced, nutritional diet. Family members or nonprofessional care providers may need special instruction on how best to accomplish this with patients.
Psychosocial Interventions A variety of modalities based on the relationships between psychosocial factors and immunity are available, and their use may enhance immunocompetence. These include (1) relaxation and visualization, (2) social support, and (3) exercise.
Exercise programs should be tailored to suit individual abilities. For patients with physical debility, exercise programs should be tailored to meet their specific needs and interests. Possible exercises include walking, dancing or dancelike movements, water exercises, or swimming. It is important to develop exercise programs that are moderately difficult rather than strenuous for older individuals.
As the relationships between immune status and psychosocial variables are explored, new treatment modalities are developed. Modalities currently being explored include biofeedback, therapeutic touch, and hypnosis.
Evidence-based practice
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Infection Sample/Setting The sample consisted of 39 patients at a Veterans Affairs (VA) hospital who were prescribed antibiotics for suspected infection. The ages of participants ranged from age 47 to 72 years. On average, participants took six other medications for comorbid conditions.
Method In this feasibility study, patients were randomly assigned to receive either placebo or brand name probiotics in conjunction with the prescribed antibiotic. Patients took the study medication while in the hospital and at home. A diary characterizing bowel movements was kept by each study participant.
Findings Patients tolerated probiotics without major side effects. Those taking the placebo were more likely to have diarrhea. One patient from the placebo group had Clostridium difficile–positive toxin. This study was too small to make generalizations or determine statistical significance but did show that probiotics could be tolerated in an older population taking multiple medications for a larger study.
Implications Antibiotic-associated diarrhea may be a detrimental side effect of antibiotic therapy, prolonging hospitalization or causing the need for further medication to treat the diarrhea. Probiotics are an over-the-counter treatment that is sometimes recommended to patients; however, substantial evidence is not available to support their use, especially in an older patient population taking multiple medications. Nurses should be aware that many over- the-counter treatments do not have evidence-based support; as such, nurses should strive to be knowledgeable about the treatments with the best supporting evidence for their patients. From Safdar, N., Barigala, R., Said, A., & McKinley. L. (2008). Feasibility and tolerability of probiotics for prevention of antibiotic-associated diarrhoea in hospitalized US
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military veterans. Journal of Clinical Pharmacological Therapy, 33, 663-668.
Evaluation Monitoring the success of interventions is based on patients’ responses in meeting their goals and outcomes. One standard for evaluation is whether a patient contracts an infection, either through contact with others or by his or her own flora. Improving or at least maintaining immune status may be more difficult for some patients because the understanding of both the immune system and the concomitant changes that occur with aging is incomplete. Furthermore, many individuals are enduring severe assaults on their immune systems. Persons with cancer receive anticancer drugs that may literally destroy the immune response. In persons with AIDS, the immune system is directly targeted by viral attack. Interventions such as diet, exercise, and psychosocial enhancement are rarely sufficient in overcoming such odds, although unexplained recoveries have been known to occur. For the majority of situations, it may be unreasonable to expect a return to normal status for immunocompromised individuals. However, any improvement in immune status, or even maintenance, may allow older patients to live better lives (see the Nursing Care Plan boxes).
Nursing care plan
Pneumococcal Pneumonia Clinical Situation Mrs. C is an 80-year-old woman admitted to the hospital for treatment of pneumococcal pneumonia, which she developed while she had influenza. She lives alone in a low-rent housing development in a large city, having moved there 2 years ago after the death of her husband. Without his income, she was unable to afford the rent on her previous home. Her nearest family member, a niece, lives 75 miles away and rarely visits. Her
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former neighbors, who live across town, are unable to visit because of the distance and because of their own debilities. Mrs. C is 20% underweight for her height and is anemic. Her white blood cell (WBC) count is high. Her blood values are as follows: red blood cell count, 3.7/milliliter (mL); hematocrit, 34%; hemoglobin, 10.8; WBC count, 18,200/mL; and serum albumin, 2.6 grams per deciliter (g/dL).
Nursing diagnoses Risk for Infection, related to compromised immune status Imbalanced Nutrition: Less Than Body Requirements, related to
low income, transportation difficulties
Social Isolation, related to loss of friends and limited contact with family
Deficient Knowledge, related to influenza and pneumococcal vaccination because of new experience
Outcomes The patient will not experience additional infections as evidenced
by (1) WBC count returning to normal limits, (2) afebrile state, and (3) other vital signs being within normal limits.
The patient will verbalize knowledge of infection prevention strategies.
The patient will have adequate nutrition as demonstrated by (1) weight gain of half pound per week, (2) an increased hemoglobin level, and (3) an increased serum protein level.
The patient will consume a well-balanced, sufficient-calorie diet, as evidenced by (1) calorie counts showing an intake of at least 1800 calories per day and (2) consumption of food from all food groups, including protein sources, breads, fruits and vegetables, and dairy products.
The patient will acquire social contacts desirable to her, as evidenced by (1) spending time each week with others and (2) voicing satisfaction with social contacts.
The patient will identify the advantages of the influenza and
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pneumococcal vaccines.
Interventions Screen all visitors with infection who may come into direct
contact with the patient. Provide family and visitors with information on transmission of
infection.
Teach the patient that she is at risk for additional infections because of her depressed immune status and should limit her exposure to additional pathogens. Observe for slight increases in temperature every 4 hours or more often, as needed.
Be aware that the patient may develop subtle or undetected signs and symptoms of infection and that slight changes in temperature may be highly significant.
Observe for increased respiratory difficulty.
Auscultate the patient’s lungs at every shift.
Have the patient report any sore throat.
Monitor dietary intake using calorie counts.
Teach what constitutes a well-balanced diet that is high in protein.
Ensure adequate intake of vitamins and trace minerals through diet or through supplements.
Encourage the patient to eat foods that include vitamins and minerals, as well as trace minerals such as zinc and magnesium.
Provide vitamin and mineral supplements in addition to the high- protein diet, if needed.
Arrange for Meals on Wheels on discharge, or facilitate attendance at a nutrition site to provide better nutrition after discharge.
Contact churches or other organizations to include the patient in their social gatherings to help her reestablish a social support system.
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Assess the patient’s level of stress to determine whether an easily accessible, low-exertion relaxation program is indicated. (A relaxation program may provide an easily accessible, low- exertion intervention with an immune benefit.)
Plan a program of graduated exercise designed to fit the patient’s tolerance.
Contact social services or a local senior citizen center to identify center activities and transportation.
Contact area organizations or churches for information about activities.
Provide information to the patient and develop a plan of action with her.
Provide information for the patient regarding the influenza vaccine: (1) influenza could be a serious, life-threatening condition in older people; (2) yearly immunization (in early fall) is important to protect her from getting influenza; (3) the signs and symptoms of influenza are weakness, coughing, headaches, a sudden increase in temperature, aches, chills, and occasional vomiting; and (4) pneumonia is a common complication of influenza.
Refer the patient to her primary care provider for specific advice regarding recuperation time before taking the vaccine.
Provide information for the patient on the pneumococcal vaccine —primarily that she should be immunized once in her lifetime.
Inform her that the vaccine should not be administered soon after having pneumonia.
Refer the patient to her primary care provider for the specific timing of administration after her illness.
Nursing care plan
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Effects of Chemotherapy Clinical Situation Ms. M is a 68-year-old woman who is receiving chemotherapy after a modified radical mastectomy for breast cancer. Although she was previously well nourished, chemotherapy has diminished her appetite and stomatitis has made eating painful. In addition, the chemotherapy has decreased her white blood cell (WBC) count to 2000. Ms. M lives with her husband in their home. She receives her chemotherapy on an outpatient basis but is visited daily by a home health nurse to maintain her Hickman catheter.
Nursing Diagnoses Risk for Infection, related to suppressed immune system
Imbalanced Nutrition: Less Than Body Requirements, related to inability to eat secondary to side effects of chemotherapy
Outcomes The patient will not develop an infection, as evidenced by (1) no
temperature elevation, (2) no elevation in WBC count, (3) no sore throat or mouth, and (4) no redness or irritation around wounds, intravenous tubes, or catheters.
The patient will have adequate intake of proteins, vitamins, and minerals, as evidenced by (1) calorie counts of at least 2000 calories per day and (2) maintenance of body weight.
Interventions Teach the patient to minimize exposure to pathogens and to
screen visitors with contagious infections.
Explain the need to maintain careful hygiene (e.g., daily shower and proper oral, foot, and perineal care).
Use sterile technique when working with Hickman catheter.
Monitor the patient’s mouth and throat for signs of infection such as white patches or redness; teach the patient to report the same to the nurse.
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Auscultate the lungs at each visit.
Teach the patient to monitor body fluids for alterations in color, odor, or consistency.
Encourage fluid intake of at least 2000 milliliters per day unless otherwise indicated.
Teach the patient to eat small, frequent meals, rich in protein, vitamins, and minerals.
Teach the patient about food sources high in calories, protein, vitamins, and minerals.
Have the patient take food supplements to increase intake, if needed.
Teach the importance of eating nutrient-dense foods (e.g., those with high nutritional content in small volumes).
Acquire an oral anesthetic to treat stomatitis.
Teach the patient how to prepare bland foods of moderate temperature.
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Summary This chapter explored age-related changes in the immune system. The influences of other factors such as psychosocial influences and nutrition on the immune status of older adults were also discussed. Discussions on cancer, autoimmune diseases, HIV, and significant nosocomial pathogens in older adults were also presented.
A key role of the nurse in caring for older adults in all settings is to recognize the potential for infection in this population and develop care plans to prevent infection and promote its early detection. Because of the increased risk of morbidity and mortality associated with infection in this age group, immunizations and interventions specific to various body systems should be implemented for those identified as susceptible to infection.
Home care
1. Assess nutritional and dietary status to ensure proper immune functioning in homebound older adults.
2. Instruct older adults and caregivers about the need to receive a balanced nutritional diet and the role of vitamin supplements in promoting proper immune functioning.
3. An altered emotional state may lead to decreased immune functioning in homebound older adults.
4. Vaccinations are imperative for homebound older adults (e.g., annual influenza vaccine and pneumococcal vaccine [Pneumovax]).
5. Assess and report any signs of impaired immunity (e.g., fever and changes in white blood cell [WBC] count).
6. Bedridden or immunocompromised older adults are at high risk for infections. Instruct older adults and caregivers about ways to protect the older adults from infection from themselves
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and others.
7. Tailor an exercise program for homebound or bedridden older adults to enhance their immune system and to prevent infection.
8. Assess how homebound older adults manage personal hygiene, and teach them the importance of hand washing.
9. Practice appropriate cleaning and maintenance of humidifiers, catheters, respiratory equipment, and other devices used in home care-related treatment.
10. Develop a plan for alternative care in case a caregiver develops an infection.
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Key points • With aging, the immune response diminishes.
• The diminished immune response reduces the normal responses to infection such as fever, which makes infection in older adults more difficult to detect.
• Nutrition, especially in regard to protein, energy, vitamins, and trace minerals, has a substantial effect on immune status.
• Activity has a substantial effect on immune status. Even moderate amounts of daily exercise may enhance immune status.
• Interventions dealing with infection and decreased immune response must address nutrition, exercise, mood, stress, and physical protection.
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Critical thinking exercises 1. Your neighbor is a 72-year-old woman whose husband died last year. Since his death, she has become sedentary and withdrawn. Feeling concerned about her, you decide to stop by to see her. She explains that she has been ill off and on for the past few weeks and does not understand why she keeps getting sick. She says she is losing faith in her doctor. Recognizing that her depression and sedentary lifestyle may have altered her immune response, how might you intervene to help her?
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2012. Retrieved from http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/index.aspx
Agrawal A, Sridharan A, Prakash S, Agrawal H. Dendritic cells and aging. Retrieved from Expert Review of Clinical Immunology. 2012. ;8(1):73–80. http://www.medscape.com/viewarticle/755539.
Akincigil A, Olfson M, Walkup JT, Siegel MJ, Kalay E, Amin S, Crystal S. Diagnosis and treatment of depression in older community-dwelling adults: 1992–2005. Journal of the American Geriatrics Society. 2011. ;59:1042–1051. http://dx.doi.org/10.1111/j.1532-5415.2011.03447.x.
Czaja A. Clinical features, differential diagnosis and treatment of autoimmune hepatitis in the elderly. Drugs and Aging. 2008;25(3):139–219.
Goldman L, Ausiello D. Cecil textbook of medicine. ed 22 Philadelphia: W.B. Saunders; 2004.
Eliopoulos C. Immunity. In: Eliopoulos C, ed. Gerontological nursing. Philadelphia: Lippincott; 2005.
Frasca D, Blomberg BB. Aging affects human B cell responses. Journal of Clinical Immunology. 2011. ;31:430–435. http://dx.doi.org/10.1007/s10875-010-9501-7.
Immune system, skin microbiome “complement” one another, Finds Penn medicine study. (2013). Retrieved from http://www.uphs.upenn.edu/news/News_Releases/2013/08/grice/
Kane R, Ouslander J, Abrass I, Resnick B. Essentials of clinical geriatrics. 6th ed. New York: McGraw-Hill; 2009.
McCance K, Huether S, Brashers V, Rote N. Pathophysiology: the biologic basis for disease in adults and children. ed 6 Philadelphia: Elsevier/Mosby; 2010.
Newson P. Presentation of illness in the elderly patient. Nurs
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Residential Care. 2007;9(5):218–221.
Nowson C. Nutritional challenges for the elderly. Nutrition and Dietetics. 2007;64(Suppl 4):S150–S155.
Older adults and HIV/AIDS. (n.d.). Retrieved January 22, 2014, from http://www.aoa.gov/AoARoot/AoA_Programs/HPW/HIV_AIDS/
Pneumonia fact sheet. (n.d.). Retrieved January 22, 2014, from http://www.lung.org/lung-disease/influenza/in-depth- resources/pneumonia-fact-sheet.html
Porth CM. Pathophysiology: concepts of altered health state. ed 7 Philadelphia: Lippincott Williams & Wilkins; 2004.
Safdar N, Barigala R, Said A, McKinley L. Feasibility and tolerability of probiotics for prevention of antibiotic- associated diarrhoea in hospitalized US military veterans. Journal of Clinical Pharmacy and Therapeutics. 2008;33:663– 668.
Span P. Suicide rates are high among the elderly. Retrieved on January 24, 2014 from The New York Times. 2013, August 7. http://newoldage.blogs.nytimes.com/2013/08/07/high- suicide-rates-among-the-elderly/? _php=true&_type=blogs&_r=0.
Townsend MC. In: Essentials of psychiatric mental health nursing. (ed 4). Philadelphia: FA Davis; 2008:581–609.
United States Census Bureau. State & county quickfacts. 2014. Retrieved on January 24, 2014 from http://quickfacts.census.gov/qfd/states/00000.html.
Wachtel T, Fretwell M. Practical guide to the care of the geriatric patient. 3rd ed. Philadelphia: Mosby/Elsevier; 2007.
Wallace M. Essentials of gerontological nursing. New York: Springer Publishing Company; 2008.
* Previous authors: Martha Hains Bramlett, PhD, RN, Teresa M. Garrison, BSN, MSN; Sue E. Meiner, EdD, APRN, BC, GNP; and Dianne Thames, RN, DNS.
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C H A P T E R 1 6
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Chronic Illness and Rehabilitation Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C
Learning objectives
On completion of this chapter, the reader will be able to: 1. Define chronic illness and its relationship to rehabilitation.
2. Identify potential goals for an older adult with chronic illness.
3. Plan interventions that support an older adult’s adaptation to a chronic illness or disability.
4. Describe the nurse’s role in assisting older adults in managing chronic conditions.
5. Identify opportunities for change in the health care system to improve care for older adults with chronic illness and disability.
http://evolve.elsevier.com/Meiner/gerontologic
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Chronicity Chronic disease affects the physical, psychological, and social aspects of the lives of individuals and families. A person’s lifestyle, interactions, and relationships with others may change. Many older adults with chronic illness become homebound, and this decreased outside contact leads to social isolation. Individuals with chronic illness may perceive themselves as a burden, and families often experience caregiver stress. The individual is often stigmatized or acquires a label such as “that cancer patient” or “that person with chronic pain.” The disease becomes the patient’s identity.
It is important to differentiate between the terms chronic disease and chronic illness. Often these terms are used interchangeably by both health care providers and the general public. Disease refers to a condition viewed from a pathophysiologic model such as an alteration in structure and function; it is a physical dysfunction of the body. Illness is what the individuals (and their families) are experiencing, that is, how the disease is perceived, lived with, and responded to by individuals and families (Larsen, 2013a). As health care providers, we can often modify the disease process or assist the patient in achieving optimal health; however, it is often the illness experience that we can most influence.
Just as the terms chronic disease and illness are complex, defining them is as well. An early national group, the Commission on Chronic Illness (1957), defined chronic illness as:
All impairments or deviations from normal that have one or more of the following characteristics: (a) are permanent, (b) leave residual disability, (c) are caused by nonreversible pathological alteration, (d) require special training of the client for rehabilitation, and (e) may be expected to require a long period of supervision, observation, or care.
The Centers for Disease Control and Prevention (CDC, 2013a) defined chronic disease as follows:
Noncommunicable illnesses that are prolonged in duration, do not resolve spontaneously, and are rarely cured completely.
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Both the early definition from the Commission on Chronic Illness and the CDC definition emphasize the physicality of chronic disease, in other words, the pathology. Neither definition addresses the total experience of the individual and the family. The following definition better defines the illness experience and how the nurse can intervene:
Chronic illness is the irreversible presence, accumulation, or latency of disease states or impairments that involve the total human environment for supportive care and self-care, maintenance of function, and prevention of further disability. (Curtin & Lubkin, 1995)
More than 133 million adults in the United States have one or more chronic conditions, which is 1 of every 2 adults (CDC, 2013a). Chronic conditions continue to be the primary causes of death in individuals 65 or older. Note the number of chronic conditions in Table 16-1. As one might expect, the costs of treating individuals with chronic conditions account for more than 75% of our nation’s medical care costs each year (CDC, 2013a).
Table 16-1 Percentage of deaths from leading causes among persons ages 65 and over: united states, 2005
Cause of Death Number Percent All causes 2,468,435 100 Heart disease 597,689 24 Cancer 574,743 23 Cerebrovascular disease (stroke) 129,476 5 Chronic lower respiratory disease 138,080 6 Alzheimer disease 83,494 3 Diabetes 69,071 3 Influenza and pneumonia 50,097 2
From Centers for Disease Control and Prevention (CDC). (2010). Deaths and Mortality. Retrieved from http://www.cdc.gov/nchs/fastats/deaths.htm. Accessed on April 22, 2014.
The continuing increase in the prevalence of chronic conditions is caused by many factors. Primary among them are lifesaving and life-extending technologies not previously available, an expanding population of older adults, and as a result, increasing life expectancy. Individuals who would have succumbed to an acute illness in the past now recover, age, and live with a chronic
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condition. The young adult with a spinal cord injury, who years ago would not have survived, may now have a normal life span because of lifesaving technology and preventive health care. Think about the very-low-birth-weight infants of today who would not have survived in earlier years: they are now flourishing and growing into adulthood or they survive with chronic health problems. The individual diagnosed with cancer, heart disease, or other condition can now expect to live into “old age,” as formerly acute conditions have now become chronic in nature.
Even though the prevalence of chronic conditions has increased, most health care services remain oriented to acute illness. The current U.S. health care system was largely developed in the two decades after World War II. It was designed to provide acute, episodic, and curative care and was never intended to address the needs of those with chronic conditions. Overall, the health care system does a reputable job of caring for those with acute illness or injury. However, it is a health care system that does not know how to care for the older adult with chronic obstructive pulmonary disease (COPD), Parkinson disease, longstanding heart disease, or cancer. The health care system applies the “acute care model” to those individuals with chronic conditions, and as a result, a mismatch exists between the needs of older adults and what the system can provide. This conflict results in fragmented care, inadequate or inappropriate care from the system, and dissatisfaction on the part of the patient.
Prevalence of Chronic Illness Although chronic disease and disability may occur at any age, the bulk of these conditions occurs in adults 65 years or older. Julie Gerberding, former director of the CDC, stated that “the aging of the U.S. population is one of the major public health challenges we face in the twenty-first century” (CDC & Merck Company, 2007). By 2030, older Americans will number nearly 70 million, representing 20% of the total population as compared with 13.2% predicted for 2010 (Administration on Aging [AOA], 2013). With aging, the chances of having a chronic condition increase. The State of Aging and Health in America (CDC & Merck Company, 2007) reported that
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80% of older Americans have at least one chronic health condition. Similarly, Medicare data document that 83% of all its beneficiaries have at least one chronic condition (Anderson, 2005). Comorbidities are particularly common: approximately 50% of older adults have at least two or more chronic conditions (CDC & Merck Company, 2007). With this increasing number of individuals with a chronic condition, the health care system has to do a better job of caring for them. Nursing care, in particular, needs to focus on increasing functional ability, preventing complications, promoting the highest quality of life, and, when the end stage of life occurs, providing comfort and dignity in dying. A key role for the nurse caring for an older adult with a chronic condition is to help the patient achieve optimal physical and psychosocial health.
The most frequently occurring conditions in older adults include hypertension, diagnosed arthritis, heart disease, cancer, diabetes, and sinusitis (AOA, 2008). Regarding hypertension, National Hospital Discharge Survey data state that 65% of men and 80% of women 75 years or older either had high blood pressure or were taking antihypertensive medications in 2003 to 2006 (National Center for Health Statistics, 2008).
Individuals with chronic conditions typically have repeated hospitalizations to treat exacerbations of their illness. For both men and women ages 65 to 74, the most common reasons for hospitalization are heart disease, cancer, pneumonia, and stroke (Table 16-2). As men and women reach 75 or older, these diseases continue to predominate (Table 16-3). Hospitalizations resulting from injuries, particularly in women (e.g., hip fractures), increase significantly, as does heart disease in this age category. Given these statistics, it is easy to see that older women have significantly more hospitalizations compared with men of the same age.
Table 16-2 Discharges in nonfederal short-stay hospitals, by gender, age, and selected first-listed diagnosis (Ages 65–74), 2006
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From Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey. (2008). Health, United States. Atlanta, GA: The Agency.
Table 16-3 Hospital discharges and by diagnosis (Ages 75–84), 2006
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From Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey. (2008). Health, United States. Atlanta, GA: The Agency.
The Illness Experience The diagnosis of a chronic disease and subsequent management of that disease bring unique experiences and meanings of the process to both the patient and family (Larsen, 2013b). Just as each individual and his or her disease process are unique, so, too, are the meanings and experiences of that disease to the individual and his or her family. However, the educational background of most health care professionals is one that fits with the medical model and does not consider the different illness perceptions and illness behaviors of individuals. We have been taught that patients have diseases and the degree of their pathology dictates their treatment. Health care has even developed algorithms that tell us how and what care to provide. Nonetheless, having a chronic illness is not a black and white, quantifiable concept. Many shades of gray exist. Kleinmann, a longtime author on illness behavior and its meaning, became concerned that researchers have “reduced sickness to something divorced from meaning in order to avoid the heard and still unanswered technical questions concerning how to actually go about measuring meaning and objectivizing and quantifying its effect on health status and illness behavior” (Kleinmann, 1985).
Health within Illness Health care providers typically view an older person who is ill within a disease framework. This framework is an acute care framework that “fixes and cures.” However, we know that chronic conditions are not cured and probably cannot be “fixed.”
In caring for older adults with chronic illness, health care professionals need a paradigm shift in attitude. After learning and mastering the requirements imposed by the condition, older adults often view themselves as “well.” The disease is only one component of their life and is not their identity. The physical traits of chronic illness should not determine an older adult’s state of wellness. Many older adults are now more involved in their health care than
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ever before and accept responsibility for their wellness. They seek education about health promotion and the management of their illness. The nurse is in a position to support older adults by working with them to identify areas that may hinder progress along the wellness continuum and by teaching self-care management in these areas. (Review Appendix 16A for resources).
Cultural Competency Concepts of health and illness are deeply rooted in culture, race, and ethnicity and influence an individual’s (and family’s) illness perceptions and health and illness behavior (Larsen & Hardin, 2013). Ethnic minorities do not necessarily subscribe to the values or tenets associated with this country’s medical system. Additionally, each culture is not homogeneous, and variations and subcultures exist within each.
According to the 2000 U.S. Census, approximately 30% of the population is racially and ethnically diverse. Projections are that by 2100, this percentage will increase to 40%, and non-Hispanic whites will make up only 60% of the U.S. population (CDC, 2013b). With the increase in the numbers of ethnically and culturally diverse older adults, health care providers need to be better attuned to their needs.
A number of nursing frameworks can assist health care providers in providing culturally competent care. The website of the Transcultural Nursing Society (www.tcns.org) provides information about six different theories and models. The models include those by Margaret Andrews and Joyceen Boyle, Josepha Campinha-Bacote, Joyce Giger and Ruth Davidhizar, Madeline Leininger, Larry Purnell, and Rachel Spector (Upadhyaya & Kautz, 2009).
Quality of Life and Health-Related Quality of Life Advancements in health care have increased interest in the quality of life (QOL) of persons with chronic illnesses. Multiple definitions
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of quality of life exist, but most include physical, psychological, and social components; disease and treatment-related symptoms; and spirituality. However, no consensus on the definition exists. The following definition, although somewhat older, fits well with regard to older adults. QOL is “an individual’s perceptions of well- being that stem from satisfaction or dissatisfaction with dimensions of life that are important to the individual” (Ferrans & Powers, 1985). This definition is particularly applicable to chronic illness. The complexity of health and function in chronic illness, particularly if one believes that health can be present within illness, suggests that neither “good” health nor functional abilities are necessary for quality of life. QOL is determined by the individual, not the health care provider.
Adding to the complexity of the issue, most researchers draw a distinction between QOL and health-related quality of life (HRQOL). Most have suggested that HRQOL is a subset of QOL. Brown, Renwick, and Nagler (1996) believed that HRQOL should be used in a narrow sense within the medical–nursing environment by those who are interested in the outcomes and quality of changes resulting from medical and nursing interventions. Patrick and Erickson (1993) conceptualized HRQOL in terms of opportunity, health perceptions, functional status, impairment, and death and duration of life.
How QOL and HRQOL intersect is salient to the patient with chronic illness and those providing care. For example, a person who has adjusted to a wheelchair for mobility might perceive his HRQOL and his QOL as excellent, whereas the health care provider may not rate the person’s HRQOL high because a wheelchair may not be that person’s optimal state of function and wellness. The subjective and objective components of both of these concepts are important.
Adherence in Chronic Illness In the past, compliance has been the term used for all patient behaviors consistent with health care recommendations (Holroyd & Creer, 1986). However, the term adherence has now replaced
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compliance because adherence is the term used on the global stage of health care delivery (Berg, Evangelista, Carruthers, & Dunbar- Jacob, 2013). A number of factors influence nonadherence. These factors include (1) individual characteristics, (2) psychological factors, (3) social support, (4) prior health behaviors, (5) somatic factors, (6) regimen characteristics, (7) economic and sociocultural factors, and (8) patient–provider interactions (Berg et al., 2013).
Although adherence, formerly compliance, has been researched for a number of years, the results of that research have not effected significant changes in patient behavior. Health care providers are perhaps better able to identify the factors that influence patient behaviors toward adherence or nonadherence, but the interventions that produce positive behaviors remain elusive.
The World Health Organization (WHO) suggests adopting the use of the five A’s in an effort to assist patients with the self- management aspects of their chronic disease, of which treatment adherence is just one part (WHO, 2003). The five A’s include assess, advise, agree, assist, and arrange. Although these key aspects seem straightforward and easy to follow for health care providers, data suggest that adherence to treatment regimens is only 50% in individuals with chronic illness (Khanna, Pace, Mhabaleshwarkar et al., 2012; WHO, 2003). Data in studies that examine age and adherence behaviors are mixed. Park and Skurnik (2004) suggested that a variety of factors may interfere with the ability of the older adult to adhere to a treatment plan. However, in general, developmental issues such as age have not been well addressed in the adherence literature (Khanna et al., 2012).
Berg and associates (2013) suggested that although the five A’s is a good framework for health care providers to use, it is also important to (1) advise the patient of the importance of the treatment plan, (2) establish agreement with the treatment plan, and (3) arrange adequate follow-up.
Overall strategies to enhance adherence include educational, behavioral, and organizational approaches. The nurse must first assess the older adult’s belief in the mutually established goals. Does the older adult have self-motivation to work toward these goals, or were these goals not mutually established but generated
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by the health care provider? The assessment should include identification of strengths such as self-motivation.
Evidence-based practice The Importance of Exercise and Quality of Life for Older Adults
Sample/Setting The 139 participants that completed the study resided in one of the six participating nursing homes in the Hong Kong area. Inclusion criteria were as follows: ability to walk independently, ability to speak Cantonese, age older than 65 years old, intact cognitive function, and Chinese ethnicity.
Method The intervention group (n = 66) consisted of the study participants who lived in two of the six nursing homes. They were led in a 1-hour Tai Chi program three times a week for 26 weeks. The same instructor led all classes at both nursing homes. Baseline characteristics were measured with the Satisfaction with Nursing Home Instrument, the Physical Activity Questionnaire, Single Limb Stance Timed Test, and the Modified Sit and Reach Test. The SF-12 Health Survey Standard version 1 was used to measure the mental and physical components of health-related quality of life (HRQOL). The three end points for this testing were baseline, at 13 weeks, and at 26 weeks.
Findings The Tai Chi program improved overall HRQOL for these nursing home residents. This was evidenced by a change in mean score from 49.88 to 56.80 in the mental-component score of the HRQOL. The physical component of the HRQOL did not change significantly. No injuries were sustained during the course of the study, and attendance was high for each program session.
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Implications As one ages and experiences health-related changes, the goal is to have a good quality of life. Tai Chi is thought to be a safe form of exercise for older adults, who may have many physical limitations. Meditation while performing the exercises can promote mental well-being. Tai Chi may be one method of exercise that can be easily implemented in any environment and have many benefits for older participants. From Lee, L., Lee, D., & Woo J. (2009). Tai Chi and health related quality of life in nursing home residents. Journal of Nursing Scholarship, 41(1), 35-43.
The cost of today’s health care requires that nurses be aware of specific needs of older adults when structuring their therapeutic regimens. Regimens should emphasize activities that build endurance and self-reliance and that facilitate self-care and quality of life. Older adults must believe that a therapeutic regimen aids in the recovery or maintenance of their functional level.
Psychosocial Needs of Older Adults with Chronic Illness Understanding the relationship between the older adult’s social, psychological, and physiologic needs is important for health care providers. Each older adult and their family are unique, and the presence of one or more chronic illnesses further illuminates their uniqueness. The end result of understanding the patient’s unique situation assists the health care provider in establishing interventions that support psychosocial adaptation.
Adaptation Adaptation infers that an event or something unusual or different that has occurred is perceived as a threat or stressor to the individual and merits a reaction, a change, or a behavior by an individual (Stanton & Revenson, 2011). Other authors have seen adaptation as good quality of life, well-being, vitality, positive affect, life satisfaction, and global self-esteem (Sharpe & Curran, 2006). Adaptation is a complex, multidimensional holistic concept.
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Consensus exists regarding the centrality of an individual’s appraisal of their adjustment: It is their adjustment and their perception, not the health care professional’s (Hoyt & Stanton, 2012).
Just as frameworks or models are helpful in caring for those with acute, episodic disease, they may be helpful in caring for those with chronic illness as well. Three frameworks for practice are discussed here, although more are described in the literature.
Chronic Illness and Quality of Life Around 1975, nursing pioneers were working with dying patients and determining through research what kind of “care” those patients wanted. Their work provided a rudimentary framework that addressed the issues and concerns of patients with chronic illness. The framework was simple but was an early attempt to examine the psychosocial needs of patients versus their physical needs. Basic to patient care was an understanding of the key physical and psychosocial problems:
• The prevention of medical crises and their management if they occur
• Controlling symptoms
• Carrying out the medical regimen
• Prevention of, or living with, social isolation
• Adjustment to change in the disease
• Attempts to normalize interactions and lifestyle
• Funding
• Confronting attendant psychological, marital, and familial problems (Strauss, Corbin, Fagerhaugh et al., 1984)
Trajectory Framework Corbin and Strauss (1992) developed the trajectory framework to assist nurses in (1) gaining insight into the chronic illness experience of the patient, (2) integrating existing literature about
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chronicity into their practice, and (3) providing direction for building nursing models that guide practice, teaching, research, and policy making. A trajectory is defined as the course of an illness over time, plus the actions that patients, families, and health care providers use to manage that course (Corbin, 1998). The illness trajectory is set in motion by the pathology of the patient, but the actions taken by the health care providers, patient, and family may modify the course. Even if two older adults have the same chronic condition, the illness trajectory of each individual is different and takes into account the uniqueness of the individual (Jablonski, 2004).
Nine phases—pretrajectory, trajectory, stable, unstable, acute, crisis, comeback, downward, and dying—are described in the trajectory model, and although the trajectory could be conceived as a continuum, it is not linear. Patients may move through a phase, regress to a former phase, or plateau for an extended period.
Shifting Perspectives Model of Chronic Illness This model from Thorne and Paterson (1998) resulted from an analysis of 292 qualitative studies on chronic physical illness that were published between 1980 and 1996. Of these, 158 studies became part of a metastudy in which patient roles in chronic illness were described. The model depicts chronic illness as an ongoing, continually shifting process in which individuals experience a complex dialectic between the world and themselves (Paterson, 2001). The model considers both the “illness” and the “wellness” of the individual. The illness-in-the foreground perspective focuses on the sickness, loss, and burden of the chronic illness. With wellness- in-the-foreground, the self is the source of identify and not the disease. Neither the illness perspective nor the wellness perspective is right or wrong but merely reflects the individual’s unique needs, health status, and focus at the time (Paterson, 2001).
Older Adults and Chronic Illness As we look at chronic illness and the older adult, a number of phenomena that may be experienced by individuals and families
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need to be considered. Several are mentioned in the following text; however, this list does not include all of the factors.
Powerlessness An older adult’s self-concept may be affected if he or she feels unable to control an illness or disability or feels that self-care patterns have contributed to the present disorder. Feelings of powerlessness may be a result of normal aging changes, an altered body image, or numerous losses. Older people grieve the loss of function or the loss of their former self. How they grieve depends on the individuals, and the significance of the loss also influences the grieving process. The result of powerlessness is a loss of hope. In addition, older adults who feel powerless may lose their independence to family members or health care professionals who take over and make decisions for them. This cycle of powerlessness, loss of control, and dependence may be perpetuated by well- meaning caregivers.
Stigma Stigma is defined as “a mark of shame or discredit or an identifying mark or characteristic” (Merriam Webster, 2013), and it may be a significant factor in many chronic illnesses and disabilities. Individuals with chronic illness present deviations from what many people expect in social exchanges (Stuenkel & Wong, 2013). American values of youth, attractiveness, and personal accomplishment provide daily examples of how those with chronic illness are different. A disease characteristic or having a disease with an unknown etiology may contribute to the stigma. Thus, the individual may be stigmatized by society.
However, older adults with the chronic illnesses may inflict the stigma on themselves. They may feel ashamed of their disability, disease, physical condition, and other factors. As a result, they become reclusive and socially isolated from others.
Social Isolation Social isolation may occur as an illness or disability becomes more
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severe or debilitating. This isolation may be initiated by the individual or by society. From the individual’s perspective, it may become too difficult to functionally participate in activities, too complex to keep up with a medical regimen when away from home, or too difficult to manage physical symptoms such as pain or fatigue. Thus, the individual initiates the isolation and withdraws or limits social contact. This may be a difficult decision for individuals and their families, or it may be a relief to stay within the “safe” confines of their homes where they may have more control.
Conversely, others may withdraw from the individual and family experiencing chronic illness. Friends may tire of hearing about the physical limitations of their friend or acquaintance. The long-term time frame or the individual with recurring cancer over a number of years, for example, may cause others to withdraw. Stigma might also be involved, and others may pull away from individuals with “unpleasant” diagnoses such as HIV and AIDS. Regardless of how or why social isolation occurs, the result is that basic needs for intimacy may be unmet (Biordi & Nicholson, 2013).
Meaning of Life in Adaptation Adaptation to chronic illness or disability is affected by the meaning an older adult attaches to life. According to Frankl (1962), a person’s search for meaning in life is the primary source of motivation. An older adult with a disability or illness faces a variety of losses, including loss of his or her former self, changes in body image, loss of control over a disease process, and possibly loss of work and changes in residence. The older adult may experience other losses associated with age-related changes such as deaths of significant others, retirement, and declining health status.
Nursing Interventions to Assist Psychosocial Adaptation The ability of older adults to cope with the issues and problems encountered in the course of living with and managing a chronic illness determines the nurse’s role and the type of interventions needed. A collaborative relationship may be most effective in facilitating psychosocial adjustment (Strauss & Corbin, 1988). This
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type of relationship allows older adults to participate in their care planning and retain control and dignity. Independence is a major concern, especially for older persons in the American culture, where it is highly valued. Teaching older adult patients the trajectory model may actually help them cope with acute exacerbations (Strauss & Corbin, 1988).
Adaptation is an individual process and depends on the circumstances of the disability. Developmental changes, life transitions, and meaning placed on the disability or illness influence this ongoing process. Interventions may include supporting existing relationships or referring older adults who have lost significant relationships to a senior center where they can establish new relationships. The nurse may also explore interventions that meet spiritual needs. The nurse may refer and encourage older adults to participate in formal or informal learning opportunities available in the community.
The group process is one way to assist patients in their psychosocial adaptation. Self-help groups provide a support system in which older adults redefine themselves, focus on issues, adjust to new roles, or learn about their disease processes and how others manage (Touhy & Jett, 2011). The group may encourage greater self-understanding and responsibility and provide older adults the opportunity to reshape how to live with life’s imperfections and with love and compassion for the self and others (Holkup, 1998).
Changes in positions within the family affect family duties and responsibilities. Successful coping requires a positive attitude toward new roles and the ability to obtain a feeling of independence and security. Traditional roles are often masked in the hospital, and patients may think that everything will be fine on returning home. However, the transition from hospital to home is often difficult for patients and their families. They discover how much has changed and begin to face their losses. Roles may need to be renegotiated, and those that are no longer applicable must be acknowledged and mourned (Hibbard, Neufeld, & Harrison, 1996).
The nurse should guide, educate, and support older adults and their families in developing positive coping strategies. Understanding the illness and what to expect is directly related to
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the ability to cope. In providing support to older adults and their families, the nurse assists them in identifying their feelings. A reduction in the distress that accompanies chronic illness or disability may be achieved with nursing interventions that encourage an active problem-solving and coping orientation and that interrupt avoidant, passive coping patterns (Aikens, Fischer, Namey, & Rudnick, 1997). Direct questions such as “How are you dealing with this illness? What helps you deal with this change in your family? What interferes with your ability to deal with this illness?” will provide an indication of a patient’s coping strategies and their effectiveness (Twibell, 1998). The nurse should also observe older adults and family members for signs of stress that may result from ineffective coping.
One of the most difficult tasks in adaptation is balancing hope and realism. A patient and his or her family may need to express frustration and anger with the course of the illness and rehabilitation. By setting mutually agreed on goals, divided into small increments, the nurse and the older adult may succeed in achieving them. Sharing goals with family members may elicit their support or assist them in accepting the need to avoid active involvement (Twibell, 1998). Personal coping also involves problem solving. The nurse serves as a resource for older adults and their families in solving care management problems.
A supportive social network also has been found to have a significant impact on stress (Tremethick, 1997). The roles of the home, neighborhood, friends, and family need to be considered in assessing the adequacy of social support. Referrals for day care, home health nursing, temporary long-term care, or respite care may be needed.
Another obstacle is understanding and coping with role reversals. The nurse should guide older adults in finding tasks and responsibilities within their new roles and assist in conflict resolution as old roles are redefined. Chronic illness requires long- term adaptation on the part of older adults and their families. Ongoing support by health care professionals is crucial for them to find enough strength to continue coping.
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Physiologic Needs of Chronically Ill Older Adults A thorough nursing health history includes a comprehensive review of body systems as well as a medication and treatment review (see Chapter 4). The medication review should include both prescription drugs and over-the-counter medications (see Chapter 20). An older adult may have more than one physician prescribing drugs and additionally may be using nonprescription remedies.
Pain A major issue with chronic disorders is the management of pain. In evaluating pain, the nurse should note its characteristics, location, and intensity (on a scale of 1 to 10). The nurse should make an assessment of causes of possible discomfort other than the chronic illness. In addition to pharmacologic therapy, the nurse may teach the patient relaxation techniques, deep breathing exercises, guided imagery, and visualization. These techniques may relieve muscular and emotional tension, enhance the sense of control, and possibly improve coping abilities (see Chapter 14 for a more detailed discussion of pain management and treatment strategies).
Fatigue Older adults living with a chronic disorder often experience fatigue. Fatigue may be unpredictable, making it difficult to manage or alleviate. The nurse should help older adults identify causes and patterns of fatigue. Older persons may need to be taught how to conserve energy to enjoy meaningful activities. Emphasizing the benefits of periodic rest, a slower pace of activity, and more time to complete tasks may help older patients cope and feel in control. The nurse should encourage older adults to choose where to expend energy and should respect the priorities established.
Immobility and Activity Intolerance Activity may be the most important factor in maintaining or recovering health and wellness in the older adult (Easton, 1999). Physical activity and psychosocial interaction are important in
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maintaining chronically ill older adults on the continuum of wellness. Inactivity may result from functional loss, and as activity levels decline, even more function may be lost. Problems as a result of inactivity are compounded when patients, families, and health care professionals display reduced expectations of activity. One possible nursing goal may be to prevent complications of prolonged inactivity during an acute exacerbation of illness.
Sexual Activity Aging, in and of itself, causes changes to the reproductive system in both men and women. Chronic disease may further affect the sexual activity and functioning of the older adult. These changes in a patient’s sexual life may cause psychological distress. Effects of the condition, medications, treatments, fatigue, changes in body image, and the feeling that one is no longer attractive may present difficult emotional barriers. Open communication between partners, including frank discussions of needs and feelings, may result in helpful adjustments in sexual practices and a deeper commitment to the relationship. Counseling partners or individual patients may smooth over these transitions. In addition to a medication review, a sexual history provides the nurse with insight into a patient’s needs. The nurse should create an open, accepting atmosphere to facilitate a discussion of sexuality and should provide information in a nonjudgmental manner. Only when concerns are identified and discussed can problem solving occur (see Chapter 13).
Effect of Chronic Illness on Family and Caregivers More and more families are faced with providing care for older family members with chronic illness because of the rapidly aging population and the present ability to manage chronic illness. Family caregivers constitute the overwhelming majority of unpaid caregivers and provide the equivalent of billions of dollars of care annually (Shirey & Summer, 2000). Studies have enhanced our awareness of family caregiver stress and the difficulty of balancing
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caregiving with activities such as personal time or social activities (Figure 16-1). The primary family caregiver often receives little help from siblings or children and considers institutionalization only when he or she is physically or emotionally exhausted.
FIGURE 16-1 A daughter–caregiver assisting her mother down the hallway of her home. (Courtesy of Rod Schmall, West Linn, OR.)
Situational factors related to caring for adults with chronic illnesses contribute to caregiver stress. As noted previously, chronic illnesses are present for a long period and have an uncertain course. Periods of improvement, stability, and exacerbations in the
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trajectory of the illness cause uncertainty. Anticipation of these phases may also produce stress. Some chronic conditions develop slowly, and planning for crisis periods is possible. Advance notice of impending stress may allow the caregiver to activate coping strategies and reduce the stress experienced. However, anticipation may also be related to fear of the worst possible outcome.
The characteristics of a chronic illness may contribute to caregivers’ stress. Caregivers report stress when, for example, the patient does not recognize family members or does not remember previous relationships because of cognitive changes. Behavioral problems resulting from illness also contribute to stress. The patient’s functional ability and the type and amount of care needed affect caregiver stress. Ongoing care or the perception that ongoing care is needed may be physically and psychologically draining. When a caregiver is faced with a spouse’s illness, the marital relationship may be affected. The quality of the past and present relationship contributes to how a spousal caregiver copes. In questioning a spousal caregiver, the nurse should determine if unresolved marital problems exist because these problems may affect the caregiver’s reactions to the caregiving experience. Interventions that focus on resolution of issues in relationships and identification of negative coping skills may improve relationships and decrease the possibility of depression in spousal caregivers.
Role strain is a problematic feature inherent in balancing the role as primary caregiver with other roles within the family network. Most caregivers feel a strong sense of responsibility to caregiving, and although most have a family system in place, it is rarely used as a source of support. Maintaining a healthy sense of self and successfully coping with role strain requires a balance of caregiving and caring for one’s self. Personal activities may include work outside the home. Many caregivers experience work conflicts that result in changes in work schedules or performance.
Caregivers may feel powerless when they seem to have no control over events and perceive the stressors in their life as irreversible. Fewer than 15% of all “helper days of care” for people needing help with activities of daily living (ADLs) are provided by paid caregivers or sources outside the family. Factors that influence
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coping with caregiver stress and powerlessness are personal characteristics (e.g., age, gender, marital status, health, and social roles) and include knowledge of the illness, knowledge of available resources, personal perceptions, and coping strategies. Female caregivers experience a greater sense of burden and stress than male caregivers. The caregiving burden and feelings of being overwhelmed are related to a subsequent decline in mental and physical health (Hibbard et al., 1996). Assumption of a role previously assigned to an older adult with chronic illness may significantly affect stress levels.
Nursing Implications of Caregiver Stress Effective nursing care of a patient with chronic illness requires providing care not only to the identified patient but also to the caregiver. The caregiver’s personal characteristics, social and emotional support, financial resources, and perception of the caregiving situation should be assessed in relation to feelings of powerlessness. Personal coping strategies, including the ability to solve problems in managing care, need to be explored by the nurse. Questions such as “Many family member caregivers have trouble with [such and such]. Have you found that to be true for you?” may help the nurse determine stressors and problem-solving abilities in a nonthreatening manner.
Support may be obtained from other resources such as community social service agencies, local church members, visiting nurse organizations, and other family members. Support groups for caregivers are also becoming more prevalent. Group participation decreases the sense of isolation and may help a caregiver cope with new situations. The nurse should provide information about the illness and reassurance that feelings of frustration or helplessness are not unusual reactions. Referral to a social worker may be necessary to provide detailed information regarding Medicare coverage and Medicaid eligibility, as well as other means of obtaining assistance in the health care system. Stress may be reduced by the use of adult day care or home health nursing. Temporary placement in a nursing facility provides the caregiver much-needed respite.
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Caring for older adults with chronic conditions requires long- term adaptation on the part of family members. To continue in a caregiving role, a family member caregiver needs ongoing support by all involved health care professionals (see Chapter 6).
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Rehabilitation Rehabilitation refers to services and programs designed to assist individuals who have experienced a trauma or illness that results in an impairment that creates a loss of function that may be physical, psychological, social, or vocational (Remsburg & Carson, 2006). Rehabilitation is a philosophy of care that promotes an optimal quality of life in those with chronic illness.
Gerontologic rehabilitation nursing is a specialty practice that focuses on restoring and maintaining optimal function while considering holistically the unique effects of aging on the person (Clark, Kortebein, & Siebens, 2012). Interestingly, the specialty did not arise from gerontologic nursing but from rehabilitation nursing as a subspecialty. It was seen as a need because of the large number of older adults with more disease-related conditions rather than injury or trauma conditions. Clearly, these older patients needed a different approach to their care. The main goal of the gerontologic rehabilitation nurse is to assist the older adult in achieving their personal optimal level of health and well-being by providing holistic care in a therapeutic environment (Easton, 1999). What is unique about the role is that these nurses consider the special needs, roles, social relationships, and potential comorbidities that occur in the aging process.
Centenarians, the so-called elite-old, are the fastest growing segment of our population, followed by the age group that is 85 years or older, the oldest-old (Touhy, 2011a). Strokes occur more commonly after age 65, and the incidence of stroke doubles with every decade after age 55 (Reddy & Reddy, 1997). Hip fractures peak in the eighth decade of life and are expected to double by the year 2040 (Ethans & MacKnight, 1998). Older drivers are involved in more crashes per mile driven compared with middle-aged drivers (Foley & Mitchell, 1997). These data suggest an increasing need for rehabilitation with a gerontologic focus. Rehabilitation planning should begin at the time an older adult is first seen or hospitalized.
The growth of the older population has specific implications for
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disability, and it affects the nurses who provide preventive, restorative, and rehabilitation services to this population. Age- related physiologic changes may slow recovery and increase residual debilitation from an acute illness or injury. Age-related changes also increase the likelihood of physical limitations from a chronic illness. Studies agree that older adults are more likely to be functionally impaired in ADLs and mobility.
Care Environments Rehabilitation services are offered in a variety of settings. Therapy on acute medical–surgical units may assist a patient in maintaining strength when confined to bed. However, the acute medical environment offers little opportunity to apply skills learned in therapy and often emphasizes inactivity. Rehabilitation services lasting 1 to 3 hours a day are available in intermediate rehabilitation facilities and skilled care facilities (Figure 16-2). This environment is suitable for an older adult who has the goal of returning home, who is unable to tolerate more therapy, or who only requires one therapy discipline. Intensive rehabilitation (3 hours of therapy or more) is available in the rehabilitation units of acute care hospitals, freestanding rehabilitation hospitals, and some geriatric assessment or rehabilitation units. Outpatient rehabilitation therapy services may be available to older adults in their homes.
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FIGURE 16-2 A patient receiving therapy in a rehabilitation setting. (Courtesy of Loy Ledbetter, St. Louis, MO.)
Reimbursement Issues Medicare becomes available to older adults at age 65 regardless of whether they continue to work. Part A, or basic coverage (inpatient hospital coverage), is without cost to those who qualify. Part B (more comprehensive coverage) is available for a monthly premium with deductibles. A variety of private insurance plans are available to cover the “Medigap,” or the 20% of service cost not reimbursed under Medicare guidelines. Medicare is a fee-for-service delivery system. Medicare also contracts with health maintenance
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organizations (HMOs). HMOs provide the full range of Medicare benefits and may offer additional benefits at little or no additional charge.
Medicaid is a state-specific medical care source of funding for people with low incomes. It varies from state to state, but generally the costs of inpatient, outpatient, home health, and nursing facility rehabilitation services are partially reimbursed. Increasing fiscal constraints in local, state, and federal agencies will affect rehabilitation reimbursement and may further decrease resources available to older adults.
Public Policy and Legislation Nurses have the power to influence public policy and legislation by advocating for the needs of older adults with disabilities and supporting and conducting relevant nursing research. The process of national public policy making started in 1951 when the first White House Conference on Aging was held. This conference made the problems of older adults visible and since then has been held each decade. The Older Americans Act of 1965 (last amended in 2006) introduced the concept of a focal point of services for older adults. Also in 1965, Medicare and Medicaid were established and have been revised in subsequent years. In 1982, the Tax Equity and Fiscal Responsibility Act introduced prospective reimbursement for hospitals under Medicare diagnosis-related groups.
The Americans with Disabilities Act (ADA) of 1990 outlawed discrimination on the basis of disability in employment, in programs and services provided by state and local governments, and in the provision of goods and services provided by private companies and commercial facilities (ADA, 2013). However, the ADA did not eliminate the discrimination inherent in the current system of risk-based health insurance. The Affordable Care Act of 2012 will change the issues of quality, access, and cost significantly over the next several years. This legislation and its accompanied parts provide a set of health benefits available and affordable to most citizens of the United States (Merlis, Dentzer, Haislmaier, & Turnbull, 2010).
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The National Council on Disability (NCD), founded in 1978, champions the disability movement. The NCD strives to ensure full participation, equal opportunity, independent living, and economic self-sufficiency for all Americans with disabilities. Currently, 54 million Americans (of all ages) are listed as disabled (www.ncd.gov).
Enhancement of Fitness and Function The goal in caring for older adults with disabilities is to maintain or improve function. Maintaining mobility, even when hospitalized, may prevent or decrease the effects of deconditioning. Referral of the older adult to physical therapy assists the nurse in developing and implementing an exercise plan. Many activities that older adults enjoy, for example, walking, swimming, cycling, rowing, and dancing, may be incorporated into exercise and endurance training. In teaching older adults that deconditioning can be reversed, the nurse should stress that activity and exercise not only increase muscle strength and endurance but also help reduce diastolic blood pressure, body fat, and the risk of coronary artery disease. Other benefits include increased bone mineral density, improved joint flexibility, and improved mental health.
Many of the nation’s chronic health problems could be reduced by increases in physical activity. Finding ways to increase fitness levels, in all ages, is a national public health priority.
Older adults often think that they are too old begin and sustain a program of exercise. However, even a small amount of time (at least 30 minutes several times a week) may improve health. The National Institute on Aging produced their first guidelines for older adults and exercise, titled Exercise: A Guide from the National Institute on Aging in 1998 (NIA, 1998). The updated guide, Exercise and Physical Activity: Your Everyday Guide from the National Institute on Aging, was published in 2009 (NIA, 2009). The guide lists four types of exercises important in older adults. These include endurance training; which are exercises to increase breathing and heart rate; strength training, which builds muscles and increases muscle strength; balance exercises, which improve standing and gait; and
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flexibility exercises, which keep the body limber (Touhy, 2011b).
Functional Assessment Regular, comprehensive assessment of older adults is a central principle of gerontologic care. Function is a useful measure in the diagnosis of illness and self-care deficits. Functional assessment may help older adults, their families, and health care providers identify problem areas and plan appropriate interventions that assist in treatment or provision of support measures.
Similarly, in rehabilitation, progress is noted through assessments. In rehabilitation, assessment tools measure the functional status of patients. These tools provide baseline data, progress data, and outcomes of therapy. A commonly used tool is the Functional Independence Measure (FIM). This tool measures abilities in six areas: (1) self-care, (2) sphincter control, (3) transfers, (4) locomotion, (5) communication, and (6) social cognition. The 18 items are all measured on an ordinal scale from 1 (dependent) to 7 (independent) (Mauk, 2013). In a rehabilitation setting, functional assessment is incorporated into the initial nursing assessment and provides information about a patient’s level of functioning before any planned rehabilitation program begins. Establishing a patient’s baseline level of functioning helps the nurse identify the patient’s strengths and rehabilitation potential.
Keys for Completing a Functional Assessment To successfully complete a functional assessment:
• The nurse should be aware of a patient’s mental status before assessment. For example, some people with cognitive impairment deny any and all problems, whereas people with depression may just respond, “I don’t know.”
• The assessment approach should be adapted to the degree of potential or actual disability. Healthy older adults may not need to be to be assessed in all areas. Older adults with complex problems need specific assessments of their abilities and
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disabilities.
• Self-reported data and observation may be used along with data from a functional assessment tool. Some older adults may deny any functional difficulty or may minimize the amount of assistance needed. The nurse should ask the older adult what they can do rather than what they cannot do.
• The nurse should screen for safety factors that limit older adults in their self-care or in their ability to remain in their home independently: (1) confusion, (2) safety awareness, (3) toileting, (4) continence, (5) depression or poor motivation, (6) falls, and (7) transfer ability. The most important physical task for an older adult is the ability to transfer in and out of a bed or chair. A person who cannot transfer from bed to chair or chair to toilet cannot be left alone for long periods.
• A geriatric assessment must consider older adults’ values and beliefs. An older patient’s cultural and spiritual beliefs, feelings regarding health practices, and beliefs about quality-of-life issues should be incorporated into the care plan.
Health Promotion Health promotion is a multidimensional concept that focuses on maintaining or improving the health of individuals, families, and communities (Huckstadt, 2013). Research over the years has demonstrated that pursuing a healthy lifestyle and making lifestyle changes prevents disease; however, health care providers and patients continue to have difficulty implementing needed changes in lifestyle. If health promotion activities enhance function, what motivates older adults to pursue health promotion? Skinner (1951) stated that all activity is motivated behavior. Motives are desires, intentions, and goal sets, whereas incentives are praise, rewards, and punishments. Although chronic disease and disability cannot be eliminated, health promotion within rehabilitation allows older adults to achieve a maximum level of functioning and increase longevity. Health promotion in chronic illness involves behavioral change for positive lifestyle activities, accepting one’s condition and making the necessary adjustments, decreasing the risk of secondary
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disabilities, and preventing further disease, all while striving for optimal health.
Determining reasons why an older adult participates in rehabilitation may provide the nurse with insight to further promote health in the patient. Some authors have promoted self- efficacy as a major determinant of behavior (Resnick, 2002). Other studies have found that fitness, health, independence, and socialization are important incentives to older adults (Lavie & Milani, 1997; McWilliam, Stewart, Brown et al., 1996) (Figure 16-3). Motivational assessment tools may be used in rehabilitation programs to facilitate planning of interventions that enhance participation and compliance.
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FIGURE 16-3 Older adults in exercise class, practicing health promotion. (Courtesy of Ursula Ruhl, St. Louis, MO.)
As Calloway stated, “nurses have been leaders in health promotion since the time of Florence Nightingale, whose pioneering work with the use of statistics demonstrated the positive effect of improved sanitation on the health of injured soldiers” (Calloway, 2006).
Management of Disabling Disorders It is important for the nurse to understand the normal physiologic effects of aging and their effect on rehabilitation. For example, a cardiac rehabilitation program should focus on exercise training,
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education, secondary prevention, and vocational counseling. Modifications in exercise training may be needed for older adults with other physical impairments.
Peripheral vascular disease frequently limits activities of endurance. A graded reconditioning program to increase endurance is most successful. If amputation is required, rehabilitation goals and candidacy for prosthetics should be determined by premorbid function, the condition of the residual limb, and the goals of the amputee.
An older adult who is incapacitated by chronic obstructive pulmonary disease (COPD) can improve the quality of life and ease functional tasks through pulmonary rehabilitation. Success depends on the patient’s motivation because improvement may occur in symptom management but not in pulmonary function testing.
Acute presentation of neurologic disorders in older patients is confounded by comorbid conditions. About 75% of all strokes occur in persons older than 65 (CDC, 2013c). With pharmacologic reduction of blood pressure, an older adult with a stroke is at greater risk for compromised cerebral perfusion. Functionally, an older adult who survives a brain injury needs more personal assistance and is more likely to require institutional care for some time. Only 30% of stroke survivors older than age 75 return home compared with 73% of those younger than 65 (Reddy & Reddy, 1997).
Life Issues For those with lifelong conditions, complications and continued deterioration of function may go unrecognized as a result of inadequate transition from pediatric to adult health services. People with disabilities treated by rehabilitation are usually not “sick” but have a narrower margin of health. Many persons with disabilities state that they must constantly educate health professionals about the idiosyncrasies of their condition and their unique needs when treatment is prescribed.
A wide range of responses to disability exists. An individual who has had arthritis for many years may attach little significance to the
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condition. An individual faced with a long rehabilitation after a stroke may respond with shock, fear, and disbelief. The human spirit is remarkably resilient, adjusting to seemingly unbearable circumstances. In time, most people (in their own ways) come to accept the reality of their condition.
A person with a chronic illness or disability finds that taking health or ability for granted is no longer possible. Symptoms may spoil plans for the day, week, or month. Side effects from medication may present a variety of problems from dry mouth to ataxia. A short trip to the store may be impossible if the day is windy or the sidewalks are wet or icy. As discussed previously, fatigue is a constant companion for many older adults with chronic disabilities.
Older adults must also reorganize their lives to enhance their functional ability and rehabilitation. The nurse may assist older adults with organization. For example, calendars, schedules, and lists may assist with organizing self-care activities. Home blood glucose and blood pressure monitoring, weight measurement, self- assessments of physical condition based on the specific illness, and records of findings are examples. Organizing medications and treatments might include establishing a schedule for medications or treatments such as catheterization, toileting, or home dialysis. Organizing for working with health care professionals might include establishing a means to make and keep appointments, preparing for a visit, and obtaining the information needed to improve self-care.
The nurse should help older adult patients maximize financial resources by interpreting insurance coverage and making referrals to community agencies. Most assistive devices, handrails, canes, walkers, and hearing aids are paid for out-of-pocket. The nurse should encourage patients to shop around, ask questions, try the equipment, and inquire about service and cost of repairs. Used equipment may be purchased at medical supply stores or privately from individuals. Nurses need to influence legislators regarding the insurance industry’s coverage of monitoring equipment, adaptive equipment, and supplies needed to maintain health. The NCD periodically reviews Medicare and Medicaid benefits packages to
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ensure inclusion of assistive technologies that accurately reflect contemporary health and medical practices. The NCD also recommends that the insurance term medical necessity be clarified to include the concept of maintaining and improving the functional capacity of individuals.
Nursing Strategies In addition to helping older adults with rehabilitation, the nurse may assist the patient in setting and achieving goals that facilitate reintegration to former environments. As with all patients, old or young, the patient should be in agreement regarding all goals. The goals cannot be imposed by the health care providers. Potential goals for older adults in rehabilitation include the following:
• Improving range of motion
• Improving endurance and tolerance for activity
• Restoring functional ability to an acceptable level
• Improving ambulation (if appropriate)
• Maintaining safety
An important tenet of rehabilitation is setting goals; however, the goals must be the patient’s goals, not the health care provider’s goals of care. Often, health care providers make assumptions as to what is most important for patients (often what is most important for themselves) as opposed to listening to the patient and identifying his or her priorities. Drawing up a contract with a patient may clarify expectations. The strategy of providing homelike routines is consistent with teaching patients how to live with their illnesses and disabilities. Incorporating a patient’s normal routine into teaching content can provide a sense of security that facilitates learning. Showing interest by listening to older adult patients and involving them in all decision making increases their confidence in their ability to achieve care outcomes.
Case study
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Mrs. W is a 75-year-old woman admitted to a skilled nursing facility for rehabilitation after a cerebrovascular accident (CVA) resulting in right hemiparesis. She has a history of hypertension. In addition to the hemiparesis, she displays fatigue and emotional lability. She receives physical and occupational therapy twice a day. Her goal is to return home to be with her husband. The priorities in her care are to (1) prevent complications and permanent disabilities, (2) help her achieve independence in activities of daily living (ADLs), (3) support the coping process and integration of changes into her self-concept, and (4) provide information about the CVA, prognosis, and treatment.
The nursing staff assists Mrs. W in turning and repositioning until she masters bed mobility in physical therapy. Mrs. W becomes tearful and frustrated with her attempts at self-care. She is upset with the length of time and effort needed to complete tasks. The nurse supports Mrs. W by anticipating the time required for the self-care and getting her started. The nurse provides assistance only as necessary, maintaining a supportive but firm attitude. The nurse praises Mrs. W’s efforts, and slowly Mrs. W gains a sense of self-worth that encourages her continued endeavors. She loudly expresses her feelings about her body. She refers to the affected side as “it.” The nurse acknowledges Mrs. W’s feeling about the betrayal of her body but retains a matter-of- fact attitude that Mrs. W can still use the unaffected side and learn to control the affected side. The staff uses words such as weak, affected, right, and left to treat that side as a part of her body. Small gains in function are celebrated. Mrs. W is also referred to social services for additional support.
After 60 days Mrs. W is independent in ambulation with a quad cane and independent in self-care. She is able to assist in meal preparation in the sitting position. She is discharged home with her husband. Follow-up home care includes an assessment of the home environment by the occupational therapist and additional physical therapy in the home. Homemaker assistance is not necessary because of family support.
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Summary Our health care system is based on acute and episodic care and does not fit with long-term chronic disease and disability. The aging of the population and increasing prevalence of chronic disease will continue to challenge the health care system. Currently, 75 cents of every dollar spent on direct medical costs is associated with chronic disease. A major shortcoming in the health care system is the manner in which it pays for health care. The current system offers little incentive for providers and payers to make investments up front (e.g., in health promotion and in disease prevention) to avert medical problems later.
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Key points • Health care providers need to understand the unique illness
experience of each older adult and his or her chronic condition.
• It is important to recognize that health may exist within illness.
• Regular, comprehensive assessment, both physical and psychosocial, is a central principle of the care of older adults.
• Assessing what is meaningful to older adults helps the nurse plan interventions to support psychosocial adjustment to a chronic condition or illness.
• Rehabilitation of older adults focuses on improving functional ability.
• Health promotion incentives that are important to older adults are fitness, health, independence, and socialization.
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Critical thinking exercise 1. An 83 year old woman, independent and in relatively good health, has had a nagging cough for the past several months. She is concerned that the cough may indicate a serious illness. She is reluctant to seek help because she does not want to prolong her life if it means a loss of quality. Make a judgment about where she fits within the illness trajectory, and explain how a nurse can be of assistance.
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Appendix 16A Resources AARP
601 E Street NW
Washington, DC 20049
(888) 687-2277
http://www.aarp.org
ADA Information Line
(800) 514-0301 (voice)
(800) 514-0383 TTY
http://www.ada.gov
Administration on Aging
One Massachusetts Avenue, NW
Washington, DC 20001
202-619-0724
www.aoa.gov
Alzheimer’s Association National Office
225 N. Michigan Avenue, Fl. 17
Chicago, IL 60601
(800) 272-3900 (24/7 help line)
www.alz.org
American Academy of Physical Medicine and Rehabilitation
330 N. Wabash Avenue, Suite 2500
Chicago, IL 60611-7617
847-737-6000
www.aapmr.org
American Parkinson Disease Association
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135 Parkinson Avenue
Staten Island, NY 10305
(800) 223-2732
www.apdaparkinson.org
Arthritis Foundation
PO Box 7669
Atlanta, GA 30357-0669
800-283-7800
www.arthritis.org
National Council on Disability
1331 F Street NW, Suite 850
Washington, DC 20004
(202) 272-2004
(202) 272-2074 TTY
www.ncd.gov
National Institute on Aging
Building 31, Room 5C27
31 Center Drive, MSC 2292
Bethesda, MD 20892
(800) 222-2225
(800) 222-4225 TTY
www.nia.nih.gov
National Stroke Association
9707 E. Easter Lane
Centennial CO 80112
800-STROKES
800-787-6537
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www.stroke.org
* Original author: Teresa M. Garrison, MSN, BSN; Revised by Pamala D. Larsen, PhD, CRRN, FNGNA.
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C H A P T E R 1 7
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Cancer Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe the physiologic and environmental factors that contribute to the increased risk of cancer in older adults.
2. Identify the malignancies most commonly found in older adults.
3. Discuss the nurse’s role in cancer prevention and early detection.
4. Design therapeutic nursing plans of care by applying principles of cancer treatment to older adults.
5. Develop strategies to manage symptoms experienced by older adults receiving cancer treatment.
6. Discuss unique dimensions of psychosocial problems encountered by older adults with cancer.
7. Analyze ethical concerns related to the care of older adults with cancer.
8. Identify appropriate resources for older adults with cancer.
http://evolve.elsevier.com/Meiner/gerontologic
Cancer risk increases with aging, as do multiple comorbidities affecting cancer treatment and care. Adults over the age of 65 account for 60% of all new cancer diagnosis. Older adults account for 70% of all cancer deaths; death from cancer has declined for all cancer types since 2005. The most common cancers in older adults are: (1) lung cancer, (2) prostate and breast cancers, and (3) colon and rectal cancers (Gambert, 2009).
In the United States, the population of those 65 years or older has
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grown to 41.4 million people, accounting for 13.3% of the total population. In the last decade, the proportion of older adults in the population has increased to18%. By the year 2040, the number of persons older than age 65 is expected to surpass 79 million. The oldest-old population (those ages 85 or older) has grown to 5.7 million and is expected to reach 14 million by 2040 (Administration on Aging [AOA], 2012). As the number of older adults increases, so does the prevalence of cancer; the number of new cancer diagnoses is expected to increase by 42% by the year 2050 (Meniscus Educational Institute, 2010).
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Incidence Cancer incidence refers to the number of new cases in a given period, usually a year, in the general population. The leading types of cancer in men are lung, prostate, and colorectal cancers. The leading types of cancer in women are lung, breast, and colorectal cancers. Mortality is the rate of deaths per number of incidences. Many persons survive cancer; some cancers have relatively high incidence rates and relatively low death rates.
The National Cancer Institute (2009b) estimates that approximately 11.1 million Americans alive today have a history of cancer. This has increased from 7.4 million Americans in 2003. Of the survivors, some may be completely cured, whereas others still have some evidence of disease. Cancer deaths have declined over the past decade: an average of 1.6% per year (Thompson, 2013). The improvement in survival reflects progress in diagnosing certain cancers at an earlier stage and improvements in treatment. However, nearly a third of adults over 65 years have comorbidities affecting survival, including diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular and cerebrovascular diseases (Thompson, 2013).
Lung cancer remains the leading cause of cancer-related death for both men and women, accounting for 28% of cancer deaths in 2012. While lung cancer-related deaths for Caucasian men have leveled, lung cancer-related deaths continue to rise for women across all racial and ethnic groups. Kentucky has the highest incidence of lung cancer in the United States, and the highest prevalence of cigarette smoking; Utah has the lowest incidence of lung cancer in the country and the lowest prevalence of cigarette smoking (“Lung Cancer Fact Sheet,” n.d.).
The likelihood of developing any type of invasive cancer during one’s lifetime is approximately 44% for men and 38% for women (“Lifetime Risk,” 2013). The 5-year survival rate for all cancers is 64%; the 20-year survival rate for all cancers is 15% (American Cancer Society [ACS], 2012). Cancer survival varies by stage of disease and race; the survival rate is lower in African Americans
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compared with that in Caucasians (National Cancer Institute, 2009).
Racial and Ethnic Patterns Like the rest of the population in the United States, the aging population is becoming more diverse. In addition to Caucasians of European descent, four other main racial and ethnic groups are present in the American population: (1) African Americans, (2) Hispanic Americans, (3) Asian/Pacific Islanders, and (4) Native Americans. Cancer affects Americans of all racial and ethnic groups; however, the incidence of cancer does demonstrate patterns according to racial and ethnic origins. African Americans have higher overall incidence rates than Caucasians, whereas Hispanic Americans and Native Americans have lower incidence rates overall (Tables 17-1 and 17-2).
Table 17-1 Cancer incidence rates (number of new cases each year)
Group Males Females African American 601 395.9 Non-Hispanic White 548.6 436.2 Asian/Pacific Islander 326.1 282.6 Hispanic/Latino 426.8 330.8 American Indian/ Alaskan Native 441.1 372
Per 100,000, age adjusted to the 2000 U.S. standard population. From American Cancer Society. (2014). Cancer Incidence and Death Rates by Site, Race, and Ethnicity, U.S., 2006-20010. Retrieved May 1, 2014, from http://www.cancer.org/acs/groups/content/@research/documents/document/acspc- 041785.pdf.
Table 17-2 Cancer death rates (number of deaths each year)
Group Males Females African American 276.6 171.2 Non-Hispanic White 217.3 153.6 Asian/Pacific Islander 132.4 92.1 Hispanic/Latino 152.1 101.2 American Indian/Alaskan Native 191 139
From American Cancer Society. (2014). Cancer Incidence and Death Rates by Site, Race, and Ethnicity, U.S., 2006-2010. Retrieved May 1, 2014, from http://www.cancer.org/acs/groups/content/@research/documents/document/acspc- 041785.pdf. Per 100,000, age adjusted to the 2000 U.S. standard population.
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Racial and ethnic group age cohorts demonstrate different patterns of cancer incidence. Older Japanese immigrant women demonstrate a lower incidence of breast cancer compared with second- and third-generation Japanese women born in America. Age is an important factor, especially when environmental influences are evaluated in cases in which persons of the same race and ethnicity had different exposures as children; any examination of patterns of cancer among racial or ethnic groups should include age and environmental considerations.
Because the incidence of cancer has demonstrated patterns by race and ethnicity, both these factors are important in determining which groups are at risk. When incidence is examined by race, several cautions are in order. First, race and ethnicity are both prone to misclassification. The U.S. Census Bureau has defined race and ethnicity (Box 17-1), but no accepted scientific definition for race exists. Persons with mixed-race parents lack a single classification. Second, as demonstrated by Freeman (1989) in his landmark investigation of genetics and cancer, no known genetic basis exists to explain the major racial differences in cancer incidence. Third, race and ethnicity may be viewed as rough indicators for certain lifestyle and environmental factors. Race and ethnicity are highly correlated with socioeconomic status. Persons living in poverty tend to lack education, employment, adequate housing, good nutrition, preventive health practices, and access to health care. Within any one race or cultural group, economic status is the major determinant for cancer risk and outcome. Economic status as a risk factor for cancer is demonstrated globally. For most cancers, notable geographic variations in incidence rates exist and reflect socioeconomic differences, particularly differences between developing and developed countries (Hansen, 1998). Freeman (1989) concluded that correcting poverty among groups of people, regardless of their race or ethnic origin, would lead to decreased cancer incidence and increased survival rates.
Box 17-1
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U.S. Census bureau definitions of race and ethnicity
Race/Ethnicity Definition African American
Asian/Pacific Islander
Persons having their origins in any of the black racial groups of Africa. Persons having their origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This group is very diverse, including individuals from at least 24 ethnic populations who speak more than 30 major languages or dialects.
Native American
Persons who are American Indians and Alaskan Natives, having their origins in the original peoples of North America, and who maintain cultural identification through tribal affiliations or community recognition. American Indians and Alaskan Natives represent more than 500 tribes, each with unique cultural, genetic, and sociodemographic characteristics.
Caucasian (white)
Persons having their origins in any of the original peoples of Europe, North Africa, or the Middle East. Caucasians are the largest racial group in America.
Hispanic Persons having their origins in Mexico, Puerto Rico, Cuba, Central or South America, or another Spanish culture, regardless of race. By this definition, Hispanics are present in most racial groups.
From U.S. Census Bureau. (2000). Profile of general demographic characteristics. Washington, D.C.: U.S. Department of Commerce.
The leading cancers among Caucasian men are prostate, lung, colorectal, and urinary bladder cancers; melanoma; and non– Hodgkin lymphoma. Caucasian men have a higher urinary bladder cancer incidence rate compared with men of any other racial or ethnic group; the rate is almost two times higher than that of Hispanic men, who have the second highest rate along with African American men. The incidence rate for breast cancer among Caucasian women is higher than that for women of any other racial or ethnic group. African American men have a higher overall cancer incidence rate than any other racial or ethnic group in America (619.7 per 100,000 versus 543.1 for Caucasian men). In contrast, Caucasian women have the highest cancer incidence rate among all ethnic groups (424 per 100,000) (Tables 17-3 and 17-4). In the United States, African American men and women have shorter cancer survival times and higher cancer death rates compared with other races and ethnicities.
Table 17-3 Cancer incidence rates of african american and caucasion males
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Per 100,000, age adjusted to the 2000 U.S. standard population. From American Cancer Society. (2014). Cancer Facts & Figures for African Americans, 2009-2010. Retrieved May 1, 2014, from http://www.cancer.org/acs/groups/content/@nho/documents/document/cffaa20092010pdf.pdf
Table 17-4 Cancer incidence rates of african american and caucasion females
Per 100,000, age adjusted to the 2000 U.S. standard population. From American Cancer Society. (2014). Cancer Facts & Figures for African Americans, 2009-2010. Retrieved May 1, 2014, from http://www.cancer.org/acs/groups/content/@nho/documents/document/cffaa20092010pdf.pdf
Cancer incidence rates vary considerably among the subgroups of Asian/Pacific Islanders. Although Asian/Pacific Islanders have lower rates overall compared with other groups, they do have higher death and incidence rates for certain cancers, especially for liver and stomach cancers in both sexes. In men, the top three cancers among Chinese, Filipinos, Hawaiians, and Japanese are prostate, lung, and colorectal cancers; among Koreans, lung, stomach, and colorectal cancers; and among Vietnamese, lung, liver, and prostate cancers. Stomach cancer rates among Korean men and liver cancer rates among Vietnamese men are higher than
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those among men of any other racial or ethnic group. The top three cancers among Asian/Pacific Islander women are breast, lung, and colorectal cancers, with the following exceptions: stomach cancer is the leading cancer in Japanese and Korean women, and the cervix in Vietnamese women. The incidence rate of cervical cancer for Vietnamese women is more than 21⁄2 times higher than that for any other racial or ethnic group. Asian Americans have the highest overall incidence of liver, bile duct, and stomach cancers for both men and women (ACS, 2008).
Information on cancer incidence among Native Americans is based on data from 54% of the U.S. Indian/Native American populations in 624 counties. Alaskan Natives have the highest cancer incidence rates among any racial group for kidney and pelvic cancers. Alaskan Natives have a relatively high incidence of cancers of the esophagus, stomach, liver, gallbladder, and pancreas. According to the National Cancer Institute: Surveillance, Epidemiology, and End-Results program (1975-2006), American Indians who live in New Mexico and Arizona have excessive incidence rates for stomach, cervix, uterine, liver, and gallbladder cancer. American Indians have the highest gallbladder cancer incidence rate of any racial group, including blacks, Caucasians, or Hispanics (National Cancer Institute, 2009c).
The leading cancers in Hispanic men and women are the same as those in Caucasians—lung, prostate, breast, and colorectal cancers. Other cancers commonly diagnosed among Hispanics include cancers of the urinary bladder and stomach in men and cervical cancer in women (ACS, 2008). (See the Cultural Awareness box.)
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Aging and its relationship to cancer Age is consistently considered the most important determinant of cancer risk. However, what is it about the aging process that predisposes a person to cancer?
Biologic aging is a process that occurs naturally in adult life and results in changes in both structure and function. Although it occurs at a variable pace, the aging process creates a pattern of changes that predictably unfolds over a course of time—a biologically programmed life span. According to the Cellular Clock Theory of Aging, each species has a uniquely programmed life span. For humans, that life span is around 100 years, which is to say that it is biologically improbable that a human will live much beyond 100 years. Life expectancy is the number of years an individual may be expected to live, based on averages within a population group born during a particular period and traced through time or cohort. Life expectancy is influenced primarily by external, environmental factors (Genome Error Theory). For example, a cohort of persons living their childhood in conditions of famine and malnutrition might have a life expectancy different from a cohort that did not experience childhood malnutrition. Both biologically programmed life span and environmentally influenced life expectancy are important concepts when the relationship between aging and cancer is considered.
The relationship between aging and cancer begins at the cellular level, where two types of cells should be considered: replicating cells and postreplicating cells. Cells show a limited replicating potential; that is, cells divide only a limited number of times before entering a phase in which they can no longer reproduce. At that point, cells survive in a senescent postreplicating state; they continue to metabolize and synthesize nutrients necessary for survival except that deoxyribonucleic acid (DNA) synthesis ceases and replication does not occur. Human cells are estimated to undergo approximately 50 population replications before entering the senescent postreplicating phase. Although the cell-replicating capacity generally decreases with age, several age-related processes
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involve accelerated replication, or hyperproliferation. Prostatic hypertrophy, atherosclerosis, and cancer are examples of disease states among older adults thought to be influenced by accelerated cellular replication.
The aging cell has a tendency toward aberration or abnormalcy as it replicates. Aberrant cell growth is related to failure of growth control mechanisms, which leads to less cell regulation during replication. Cancer occurs more commonly in replicating than in nonreplicating cell groups, which suggests that changes in internal cellular control mechanisms give rise to cancer.
External or environmental factors are believed to contribute to decreased regulation of cell growth by causing cell damage and then promoting the replication of damaged cells (Cohen, 1994).
The process of cancer growth is believed to occur in three stages: initiation, promotion, and progression (Figure 17-1). Initiation results from intense or prolonged exposure to an external agent that causes mutation of genetic material. The mutations are nonlethal, but they are passed on to future cell generations during replication. An initiated cell will continue to produce the mutations with each cell replication; however, the mutations alone are not enough to lead to cancer. Cancerous cell growth begins when an initiated cell encounters a promoting agent; thus, the second stage of cancer development is called promotion. Promoting agents are external or environmental agents. A number of substances may be considered promoters of cancer in humans; they may come from a variety of sources, including air, water, or soil, and they may be naturally occurring or chemically produced. Promoting agents share the common property of inducing replication of an initiated mutant cell, thus transforming the initiated cell into a cancer cell. The promoting agent cannot cause cellular transformation unless the cell has been initiated, regardless of the intensity of exposure to the promoting agent. Promotion is dose dependent in its effect, and although promotion may transform a cell immediately after initiation, promotion is thought to be most successful when it involves repeated exposure to an initiated cell. Prevailing thought is that initiation is irreversible, whereas promotion is reversible. This belief has been demonstrated clinically in tobacco smokers: once the
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exposure to the promoter (tobacco) is withdrawn, the incidence of cancer is reduced.
FIGURE 17-1 Stages of cancer growth.
Progression is the third stage of cancer growth. This stage may be subdivided into transformation, clonal progression, and metastasis. Transformation involves conversion of initiated cells to cancer cells. Clonal progression involves further growth of the small cluster of transformed cancer cells. The transformed cells contain mutated genetic material. As the transformed cells replicate, the progeny cells show more and more genetic abnormalities. Unless detected and treated, the cluster of cancer cells will continue to replicate in a somewhat unregulated fashion, ultimately metastasizing. Metastasis involves a change in location of the cancer cells from one organ or part of the body to another that is not directly connected.
Within normal human DNA material are genes that code cell growth–regulating substances. Oncogenes are genes that produce abnormal codes for growth-regulating substances. Oncogenes are believed to play a role in the development of cancers because, once activated, oncogenes interfere with normal physiologic regulation of cell growth. Oncogene activation is believed to result in excessive production of cell growth–regulating substances. Because oncogenes can cause improper regulation of cell growth, they are capable of causing cancerous transformation in normal cells. The mechanism controlling oncogene activation is unclear; however, activation appears to be tightly controlled. The immune system is believed to play an important role in controlling oncogenes.
In 2003, researchers identified the sequence of the genome in the human body as part of the Human Genome Project. Each cell in the human body contains about 20,500 genes. Genes are the blueprints that direct growth and development. They are arranged in pairs and are made of genetic material called DNA. The totality of one’s
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genes is known as a genome. Genomics is the study of what genes do and their interaction with each other.
A growing area of cancer research, cancer genome research, studies the differences in genes found in tumors to understand which ones are important in the development and proliferation of a tumor. Researchers collect thousands of samples from different types of tumors to find a tumor’s genetic “fingerprint.” Different genes are involved in different tumor types, and understanding what genes are important to the development of cancer has led to improvements in detecting, diagnosing, and treating cancer.
Studying or “mapping” the cancer genome helps researchers understand the mutated genes that lead to cancer. By identifying mutated genes that cause cancer to develop or spread, researchers hope to develop drugs that target those specific genes to stop the cancer’s growth. Also, identifying the genes responsible for cancer helps researchers and doctors develop tests to detect cancer earlier. The identification of many mutated genes in breast cancer, colon cancer, melanoma, and other cancers has led to the development of tests that can determine which treatment will be the most effective, as well as to the development of several new treatments that target mutated genes. For example, trastuzumab (Herceptin) is a drug used to treat breast cancers with a specific genetic mutation that causes tumors to have too much of a protein called HER2.
One of the biggest efforts underway to map the cancer genome is The Cancer Genome Atlas (TCGA) project. This project was started by the National Cancer Institute and the National Human Genome Research Institute. As part of TCGA, researchers are collecting tissue samples from patients treated at cancer centers across the United States. By studying these tissue samples and comparing them with tissue samples from people who do not have cancer, researchers will map the genomes of glioblastoma, lung cancer, and ovarian cancer. Depending on the results of this research, TCGA may map the genomes of other types of cancer.
Although some results of cancer genome mapping may not be ready for use in cancer treatment today, discoveries from this research may lead to better tests for diagnosing cancer, as well as more effective treatments (American Society of Clinical
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Oncology, 2007).
Several mechanisms have been proposed to explain the way in which the aging process directly influences the cancerous transformation of cells (Box 17-2):
Box 17-2
Stages of cancer growth and influence of aging on cancer development
Stage of Cancer Growth
Influence of Aging on Cancer Development
Initiation Longer time for exposure to agents that may cause cell mutations Aged cells more vulnerable to damage
Promotion Longer time for exposure to dose-dependent cancer-promoting agents Aged cells less able to repair damage
Progression Longer time for transformed cells to grow into cancer clusters Aged immune system resulting in decreased surveillance Increased oncogene activation, resulting in greater misregulation of cell growth Continued cluster growth for a time sufficient for development of clinical signs and symptoms
• Aging increases the duration of exposure to substances that may act as promoting agents. The effects of promoters are dose dependent; a significant dose may accumulate in older adults over decades. Also, cellular transformations and progression of cancer cells occur over time. Cancer cells grow at various rates, and in some cases, significant time is needed for the small cluster of cancer cells to grow large enough to cause signs and symptoms.
• Aging cells demonstrate a tendency toward abnormal growth. Aged cells are more vulnerable to damage; thus, aging likely increases the susceptibility of cells to substances that cause genetic mutations.
• Once an aged cell is damaged by a carcinogen, it is more difficult to repair it.
• Oncogene activation might be increased in older persons, resulting in decreased regulation of cell growth and the
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development of cancer cells.
• Decreased immune surveillance, or immunosenescence, may contribute to increased development of cancers and their progression, although the evidence on the role of the immune system in the development of cancer is inconclusive (Crawford & Cohen, 1987; Pfeifer, 1997a).
Aging and Cancer Prevention The risk of cancer, either increased or decreased, frequently reflects changes in the habits of a particular birth cohort. Because most cancers are the result of a lifelong exposure, the risk of developing malignant disease after age 65 is probably already determined by the time one reaches that age. Frequently, cancer risk is similar for a given birth cohort within specific environmental boundaries. Although it appears difficult to undo or reverse the cellular damage sustained in younger years, prolonged exposure to promoting agents is, nonetheless, needed for the initiated cells to be transformed. If exposure to promoters can be avoided or reduced and antipromoters can be used, cancerous transformation may not take place or may be delayed.
Interference with the promotion stage of cancer would seem to offer the best prospects for cancer prevention. Only recently has research included the search for interventions that halt the promotion phase. It is currently believed that fresh fruits and vegetables may contain antipromoters. It is possible to decrease behaviors earlier in life that promote a predisposition to certain types of cancer; for example, limiting the number of severe sunburns in youth and reducing exposure by applying sunscreen may both be ways to interfere with the promotion stage of cancer. Secondary to this, various vitamins and minerals contained in foods are being examined for their effects on the promotion phase. Older adults should be encouraged to consume the recommended daily requirements of fruits and vegetables because dietary habits may be beneficial in slowing, or halting, the cancer process. In addition, evaluation of environmental risk factors may lead to specifically targeted education and screening programs among selected high-
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risk cohorts.
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Common malignancies in older adults Lung Cancer Lung cancer is the most common type of cancer and the leading cause of cancer death in both men and women. It occurs most often in older adults; 81% of persons with lung cancer are over the age of 60. Lung cancer accounts for 14% of all cancer diagnoses and 32% of all cancer deaths. The incidence of lung cancer has increased steadily in both men and women for several decades, although the increase for women is higher than for men. It dropped for men (22% decrease) but increased for women (106%) (American Lung Association, n.d.).
Risk Factors Smoking (e.g., cigarettes, pipes, or cigars) is, by far, the most important risk factor in the development of lung cancer, both for active smokers and nonsmokers exposed to secondhand smoke. Tobacco smoke is considered a cancer promoter demonstrating a dose–response relationship; that is, the risk of lung cancer increases with the quantity of cigarettes smoked. The greatest lifetime cumulative exposure to cigarette smoking occurs between ages 70 and 80. It has been known for some time that the risk of lung cancer decreases over time for ex-smokers; the risk of lung cancer is increased for both current and former smokers compared with nonsmokers (Ebbert, Yang, Vachon, et al., 2003).
Other risk factors include exposure to certain industrial substances such as asbestos, chromium, nickel, arsenic, soot, tar, or radon. Radiation exposure from occupational, medical, and environmental sources is also a risk factor. Air pollution contains several substances that, with repeated exposure, may increase the risk of lung cancer. The risk for developing lung cancer is increased for those with a family history of the disease and persons infected with the human immunodeficiency virus (HIV). Most lung diseases are chronic and diminish the quality of life for those persons living with the disease (American Lung Association, 2004).
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Signs and Symptoms Over a quarter of individuals diagnosed with lung cancer have no presenting symptoms. When symptoms do occur, they may be vague and attributed to other problems, especially in older adults who have underlying lung or other chronic illnesses. Others present with symptoms they develop when the tumor becomes large and the cancer metastasizes to other organs. The classic clinical presentation of lung cancer is a persistent cough, sputum streaked with blood, chest pain, fatigue and weight loss, recurring respiratory infections, shortness of breath, and hoarseness. This constellation of symptoms is also associated with cigarette smoking, and its significance as an indicator of cancer may be overlooked (Chang, 2011).
Early Detection Lung cancer may grow for years before exhibiting clinical symptoms. Because symptoms often do not appear until the disease is advanced, early detection is difficult. When used in combination, chest radiographic studies and cytologic examination of sputum cells help detect small tumors. Both tests are expensive, requiring special facilities and personnel. The Mayo Lung Project, conducted between 1972 and 1982, examined the benefits of screening for lung cancer and determined that although screening programs achieved earlier diagnoses and longer survival times, no significant reduction in mortality was demonstrated (Woolner, Fontana, & Cortese, 1984). Early detection appears to lengthen the interval between diagnosis and death without increasing total life span. Currently, the ACS does not recommend routine screening for lung cancer in asymptomatic persons. In a retrospective review of lung cancer among male veterans, older men were found to have more localized disease at diagnosis than younger men. This finding was attributed to earlier diagnosis in the older group, who likely had lung cancer detected serendipitously by chest radiology used to monitor other chronic conditions such as cardiopulmonary disorders, which were prevalent among the group.
Treatment
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Options for treatment include surgery, radiation therapy, and chemotherapy, depending on the type and stage of disease. Lung cancer is classified into two basic types: (1) small cell lung cancer (SCLC) and (2) non–small cell lung cancer (NSCLC). NSCLCs are further divided into three types: (1) adenocarcinoma, (2) squamous cell carcinoma, and (3) large cell carcinoma. These various types of lung cancers have different growth patterns and respond differently to therapy.
SCLC represents about 20% of all lung cancers and is strongly associated with cigarette smoking. Because of SCLC’s aggressive growth rate and tendency to metastasize early and widely, patients with SCLC have a poor prognosis. Chemotherapy combined with thoracic radiation is treatment of choice. With surgery alone, SCLC tends to relapse, but with combination chemotherapy and radiation therapy, more persons with SCLC experience longer periods of remission. Five-year survival rate for SCLC is 5% to 10% (National Cancer Institute, 2013b).
NSCLC is common and is diagnosed in 80% of lung cancer cases. As with SCLC, a strong association exists between NSCLC and smoking. However, adenocarcinoma may occur in nonsmokers. Adenocarcinoma accounts for 30% to 40% of NSCLC cases. It most often develops in the outer parts of the lungs; it is slow growing and may be detected before metastasizing. Squamous cell carcinoma occurs in 30% of cases. It typically begins in the cells lining the airway and develops in the middle of the lungs near the bronchus. Large cell carcinomas develop in any part of the lung; 10% to 15% of NSCLC are of this type. Large cell carcinoma grows fast and spreads quickly. NSCLC does not respond well to chemotherapy. Results are improved with surgical resection, if possible, followed by chemotherapy. In patients who are not surgical candidates, radiation therapy may be combined with chemotherapy. Five-year survival rates vary according to cancer stage: stage 1A, 49% and stage IV, 1% (ACS, 2013c).
Breast Cancer Breast cancer is the most common neoplasm in women, increasing
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in incidence with advancing age; 79% of new cases and 88% of deaths from breast cancer occur in women over age 50. The incidence of breast cancer decreases after age 80, although this may be attributed to a decrease in cancer screening, as opposed to an actual decrease in cancer development. Women face a 12% risk of developing breast cancer during their lifetime (1 in 8) (ACS, 2013a).
Breast cancer is the leading cause of cancer-related death in women ages 55 to 74. Late-stage diagnosis is a serious concern for older adults. The primary presenting symptom is a lump in the breast; however, approximately 10% of women show symptoms of metastasis as the first indication of disease. The lungs, liver, bones, and adrenal glands are predominant metastatic sites for breast cancer. Specific symptoms are related to the metastatic site and extent of disease (American Geriatric Society [AGS], 2000).
Although all women are at risk for developing breast cancer, the older a women is, the greater are her chances of developing breast cancer. Breast cancer is more common in Caucasian women than in other racial or ethnic groups. According to the most recent data, death rates are continuing to decline in Caucasian women; African American women of all ages have the highest mortality rates from breast cancer. Asians/Pacific Islanders have the lowest incidence of breast cancer in the United States (ACS, 2013a).
Risk Factors The risk of breast cancer increases with age. Dominant risk factors appear to be related to duration and intensity of exposure to hormonal influences, especially estrogen, and include early menarche (before age 12), late menopause (after age 55), lengthy exposure to postmenopausal estrogen, recent use of oral contraceptives, and never having given birth or having first given live birth at a late age (after age 35). Additional risk factors for the development of breast cancer include female gender, a personal or family history of breast cancer (5% to 10% of breast cancers have a genetic predisposition), history of benign breast disease or dense breast tissue, excessive alcohol use, and smoking. Obesity and weight gain after menopause, as well as a sedentary lifestyle, have also been shown to increase the risk of developing breast cancer.
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Women exposed to diethylstilbesterol (1940s through 1960s) have a 30% higher risk for developing breast cancer. Workers exposed to ethylene oxide also face a higher risk. New research is looking at the risks associated with the circadian rhythm disruption experienced by shift workers; research is looking at the effect of light exposure during night shift and its effect on melatonin production and estrogen levels. At this time, however, no conclusive evidence exists to support a link between shift work and breast cancer development (ACS, 2013a).
Cultural awareness
Cultural Considerations in Cancer Patterns of cancer distribution among U.S. population groups vary according to racial and ethnic backgrounds. These patterns challenge nurses and other health care providers to discover explanations for the large differences in cancer incidence, mortality, and survival among the federally defined minority groups when compared with the Caucasian population.
African Americans have the highest overall rates of cancer incidence and cancer mortality of any U.S. population group. In 2005, the death rate for all cancers combined continued to be 33% higher in African American men and 16% higher in African American women than in Caucasian men and women. The overall 5-year relative survival rate among African Americans has improved from approximately 27% during 1960 to 1963 to 58% during 1996 to 2004. However, African Americans continue to be less likely than Caucasions to survive 5 years at each stage of diagnosis for most cancer sites. The overall 5-year relative survival rate for cancer in African Americans is 11% below that of Caucasions: 53% versus 64%. Of the 25 primary cancer sites for which survival data are available, all but three cancer sites (i.e., ovary, brain, and multiple myeloma) are associated with lower survival rates for African Americans (American Cancer Society,
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2008).
Previously widely accepted reasons for this disparity centered around differences in survival status based on socioeconomic status and the overrepresentation of an ethnic group in the lower categories of socioeconomic status. Experts believed that socioeconomic status affected access to health services; nutritional status; immune status and function; educational level; employment; cancer prevention attitudes, awareness, and practices; and acceptance of cancer as a real and potential threat. All of these affect survival and, ultimately, mortality. However, a recent study (Albain, Unger, Crowley et al, 2009) was the first to find that the disparities remain even when African American patients receive identical medical treatment and other socioeconomic factors are controlled. Because patients of all races had the same doctors and received the same state-of-the-art treatments, it was a level playing field for everyone. These findings cast doubt on a widely accepted theory that African Americans’ lower survival rates for certain cancers are solely attributable to such factors as poverty and poor access to quality health care.
Higher Incidence Rates According to Location of Cancer
African Americans Hispanics Asian/Pacific Islanders (Varies by Group) Prostate
Prostate
Prostate
Breast Breast
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Breast
Lungs and bronchus
Colon and rectum
Lungs and bronchus
Colon and rectum
Lung and bronchus
Colon and rectum
Native Americans(Highly Variable Among the Greater Than 500 Tribes) Lung (Oklahoma Indians)
Gallbladder (Southwest Indians)
Liver (Alaskan Natives)
Cultural awareness
Cultural Considerations in Breast Cancer Screening Mammography screening for early detection of breast cancer has been shown to be an effective method for reducing mortality in older women.
Recent data indicate the rates of screening mammography range from 46% to 52%. Screening is lowest for Hispanics (46%) and Asians (48%). Additionally, those without insurance have less frequent mammography than those with insurance (17% versus 55%); and those with less than 12 years of education have less frequent mammography than those with more than 12 years of education (38% versus 53%). Finally, persons born in the U.S. are more likely to have screening mammography than those in the country for less than 10 years (52% versus 27%) (ACS, 2013a).
Barriers to early detection of breast cancer have been identified
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as the following: inaccurate knowledge of breast cancer and early screening, low awareness of the necessity for early detection, lack of health insurance to cover screening mammography, and lack of reimbursement to health care providers for clinical breast examinations and health teaching for early detection.
The researchers identified the following strategies to reduce barriers to early detection of breast cancer:
• Educate health care providers about the necessity of early breast cancer detection and their role in recommending it to patients.
• Conduct research to identify culturally appropriate messages and intervention strategies for each of the at-risk groups to influence their early detection behaviors.
• Use the media to increase knowledge and promote positive early detection practices among older women from culturally diverse backgrounds.
A major advance in understanding breast cancer is that the disease has a genetic basis. Approximately 5% to 10% of breast cancers are hereditary. The genes involved in most inherited breast cancers are BRCA1 and BRCA2. These are tumor-suppressor genes that also serve to protect and preserve DNA. Mutation of these genes has been linked to hereditary breast and ovarian cancer. A woman’s risk of developing breast cancer, ovarian cancer, or both is greatly increased if she inherits a deleterious BRCA1 or BRCA2 mutation. Men with these mutations also have an increased risk of breast cancer. By the age of 70, women with BRCA1 have a 44% to 78% chance of developing breast cancer; those with BRCA2 have a 31% to 56% chance of developing breast cancer by age 70 (ACS, 2013a; Cummings & Olopade, 1998).
Genetic tests are available to check for BRCA1 and BRCA2 mutations. Federal and state laws help ensure the privacy of a person’s genetic information and provide protection against discrimination in health insurance and employment practices. Currently, many research studies are being conducted to discover newer and better ways of detecting, treating, and preventing cancer in carriers of BRCA1 and BRCA2 mutations (ACS, 2008).
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Signs and Symptoms When a biopsy is performed, the majority of breast lumps are found to be benign. Benign breast lumps are soft, mobile masses with regular borders. Malignant lumps are hard and fixed, with irregular borders, and are sometimes described as “frozen peas.” Nipple retraction or elevation may be caused by tumor fixation involving underlying tissues. Skin dimpling may also be present, usually because of invasion of the tumor into the ligaments and fixation on the chest wall. Localized erythema and warmth may be present and are related to inflammation. Characteristically, edema appears as “orange peel” skin. Pain is not usually a presenting symptom unless the disease is locally advanced.
Early Detection Breast self-examination (BSE) should be performed monthly by all women older than age 20. Roughly 40% of all breast lumps are detected by women or their partners. Premenopausal women should perform the examination at each menstrual cycle. Postmenopausal women should select a consistent date such as the first day of the month to perform BSE. Nurses caring for older women should provide ongoing educational opportunities for women to learn about BSE and consistent reinforcement to encourage performance. Older women, while having the highest incidence of breast cancer, have been shown to have the least knowledge about the importance of breast examination. The percentage of those women claiming lack of knowledge is highest among minorities. Public and professional education is available from several cancer organizations, including the ACS and the National Cancer Institute.
Mammography can detect breast tumors before they manifest physical signs. A tumor must be about 10 millimeter (mm) in size to be palpable. A 10-mm tumor contains about 109, or one billion cells. Mammography screening can detect 107 cells. Mammography screening is more accurate for older women because breast tissue is less dense than that in younger women, making tumors easier to visualize. The ACS recommends mammography screening every year for women after age 40, along with a clinical breast
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examination, as long as they are healthy (ACS, 2013a). Although Medicare pays for mammography screening every year, the use of mammography by women older than age 70 remains low, particularly among minority populations.
Treatment Breast cancer treatment should be multidisciplinary. Surgery— either breast-conserving surgery or mastectomy—is indicated for removal of the primary tumor. Because breast cancer metastasizes early in the course of the disease, axillary lymph nodes are removed and evaluated for the presence of cancer; another alternative is sentinel node biopsy. Follow-up chemotherapy may include antineoplastic agents (usually several in combination) and hormonal therapy.
Radiation therapy is indicated following breast-conserving surgery or following mastectomy for large (> 5 cm) tumors or when cancer has spread to the lymph nodes. Postoperative breast irradiation is tolerated well by older women; therefore, age is not a contraindication (Wyckoff, 1994). In general, older women treated for breast cancer do not experience greater complications or treatment toxicities compared with younger women (Masetti, 1996). Although mastectomy is not the treatment of choice, if performed, breast reconstruction is an option, depending on personal preference and the extent of the disease. As with everyone, older women should be given information and support to help make treatment decisions. Breast cancer should be treated promptly, but it is not an emergency. Nurses should provide a supportive atmosphere and encourage family members to participate in treatment decisions.
Survival The 5-year survival rate for localized breast cancer, when caught early, is 98%; for regional breast cancer, the 5-year survival rate is 84%. The survival rate drops to 24% when the cancer has spread to other organs. It is important for women to realize everyone with breast cancer is different and that survival rates are not a predictor of treatment success. Risk factors, cancer stage, and treatment
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choice all play into the success of any given therapy.
Prostate Cancer One in six men will develop prostate cancer during their lifetime. The average age at diagnosis is 67. Although prostate cancer is a serious disease, most men do not die from it. The five-year survival rate for all stages of prostate cancer is 99%; the 10-year survival rate is 98%; and, the 15-year survival rate is 93%. Prostate cancer is usually adenocarcinoma that develops slowly in the gland cells of the prostate (ACS, 2013d).
Risk Factors Prostate cancer is a disease of aging. Six out of 10 cases of prostate cancer occur in persons over the age of 65. African American men develop prostate cancer more often than Asian American and Hispanic males. Other risk factors include a family history of prostate cancer and occupational exposure to carcinogens. Equivocal evidence points to diets high in fat and red meat and a history of prostatitis and sexually transmitted diseases (STDs) (ACS, 2013d).
Signs and Symptoms Prostate cancer is asymptomatic in its early stages. Signs and symptoms of cancer are related to the increased growth of the prostate that surrounds the urethra; they include weak or interrupted urine flow, difficulty, or inability to begin urine flow, difficulty stopping urine flow, and urinary frequency, especially at night. Many of these symptoms are similar to those of infection or benign prostatic hypertrophy. As the cancer progresses, additional signs and symptoms include hematuria, pain in the hips, spine, and ribs (from bony metastases), impotence, weakness or numbness in the lower extremities, and bowel and bladder incontinence (ACS, 2013d).
Early Detection Annual digital rectal examination (DRE) and prostate-specific
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antigen (PSA) testing are the two primary screening tests for prostate cancer in the United States. However, neither screening method is 100% accurate. In addition, screening has not lowered the risk of death from prostate cancer; some prostate cancers grow so slowly that they will never cause a problem, but if they are diagnosed, the patient may undergo surgery or radiation therapy. The ACS (2013d) recommends that men begin discussing the risks and benefits of screening for prostate cancer with their doctor at age 50 (age 45 for African American men and those with family history) to make an informed decision.
Treatment Multiple methods of treatment may be used, either alone or in combination, to manage prostate cancer: active surveillance, surgery, radiation, hormone therapy, chemotherapy, and vaccine therapy. Choice of treatment is determined by the age of the patient, comorbidities, stage and grade of the tumor, the likelihood of a cure, and the patient’s inclination (ACS, 2013d).
Active surveillance involves closely following serial PSA, DRE, and ultrasonography (e.g., every 3 to 6 months). Should signs and symptoms change, treatment options may be re-addressed. The primary surgery for prostate cancer is radical prostatectomy, which involves removal of the prostate and surrounding tissue. Following surgery, men may develop incontinence and impotence. When the cancer has not spread beyond the prostate, radiation therapy may be effective. It may also be used in conjunction with hormone therapy, following surgery, or with advanced cancer to relieve symptoms (ACS, 2013d).
Hormone therapy is an adjunct to radiation therapy or may be used alone in patients who are not candidates for surgery or radiation. It may also be used in cases where cancer has returned or to shrink tumors so that radiation therapy is more effective. The objective of hormone therapy is to reduce circulating androgens in the body or to prevent androgens from reaching the prostate. The objective can be accomplished by using several methods: orchiectomy, luteinizing hormone (LH)–releasing hormone analogs, LH-releasing hormone antagonists, antiandrogens, and androgen-
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suppressing drugs. All forms of hormone therapy have similar side effects: reduced libido, impotence, shrinking of the sex organs, hot flashes, breast tenderness, osteoporosis, anemia, decreased alertness, decreased muscle mass and weight gain, elevated cholesterol, fatigue, and depression (ACS, 2013d).
Chemotherapy is not the first-line therapy for prostate cancer, although it may be used in cases of metastasis. Chemotherapy targets the rapidly dividing cancer cells. However, other cells in the body divide rapidly as well (e.g., bone marrow, mucous membranes, hair follicles), leading to side effects: hair loss, oral lesions, anorexia, nausea and vomiting, diarrhea, immunosuppression, easy bruising or bleeding, and fatigue (ACS, 2013d).
Vaccine therapy is an individualized treatment designed for advanced-stage prostate cancer. White blood cells (WBCs) from the patient are exposed to prostatic acid phosphatase (PAP) from the cancer cells; the exposed cells are then put back into the patient intravenously in an attempt to stimulate the patient’s immune system to attack the cancer cells (ACS, 2013d). This treatment is still in its infancy, and the cost is prohibitive ($93,000 per dose, with three doses required); additionally, it has not been shown to cure prostate cancer but only to prolong life by a few months (Wagstaff, 2010). Insurance may cover vaccine therapy for prostate cancer if stringent criteria are met (Aetna, 2013).
Colorectal Cancer Colorectal cancer is the third most common cancer, accounting for 8.6% of all cancer diagnosis. An individual’s lifetime risk for developing colorectal cancer is 4.8%. Death rates are declining (8.8% of all cancer-related deaths) because of a decrease in the number of cases. Early screening with polyp removal, early diagnosis and treatment leading to cure, and improvements in treatment are the reasons for the declining rates. Five-year survival is nearly 65%. The median age at diagnosis for colorectal cancer is 69; the median age at death is 74 (ACS, 2013b).
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Risk Factors A personal or family history of colorectal cancer, polyps, or inflammatory bowel disease has been associated with increased colorectal cancer risk, as have type 2 diabetes and African American or Ashkenazi background. Lifestyle choices linked to the development of colorectal cancer include eating a diet high in red meat and processed meats and eating meats that are fried, broiled, or grilled. Obesity and a sedentary lifestyle have also been associated with colorectal cancer, as have smoking and excessive alcohol intake (ACS, 2013b).
Signs and Symptoms In the early stages, colorectal cancer may not manifest any symptoms. As the disease advances, presenting signs and symptoms are related to the location of the cancer within the colon. Cancer of the right colon may cause pain, cramping, and appendicitis-like symptoms. Cancers of the transverse colon may cause bloody stools, changes in bowel habits, and obstruction. Cancer on the left side of the colon tends to be constricting, progressively restricting the lumen of the bowel. Because bright red bleeding occurs, left-sided cancers tend to be diagnosed earlier. Rectal cancer presents as a change in bowel habits and an increased frequency of evacuation and bright red bleeding.
Early Detection According to the ACS guidelines for the early detection of colorectal cancer, starting at age 50, both men and women should have yearly fecal occult blood tests; flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years, or double-contrast barium enema every 5 years, or computed tomography (CT) colography every 5 years. Fecal occult blood testing, although inexpensive and low risk, may miss polyps and some cancers and may produce false-positive test results; however, it has been proven effective in clinical trials (ACS, 2004a). Screening is appropriate for individual older adults at high risk, but care should be taken to ensure proper testing.
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Treatment The four treatments for colorectal cancer are surgery, radiation therapy, chemotherapy, and targeted therapies. Cancer stage guides treatment, although surgery is the treatment of choice for colorectal cancer. The extent of surgery is determined by the location of the cancer and the involvement of lymph nodes. Surgical procedures include removal of the cancer and segments of the major arterial and venous blood suppliers to the affected area. Permanent colostomy is seldom needed for colon cancer. For localized cancers, surgery is frequently curative.
Radiation therapy may take place prior to surgery to shrink the size of tumor or after surgery to reduce the chance of recurrence. Radiation has also been used in situations where patients are not surgical candidates and for palliative pain relief.
Chemotherapy prior to surgery may help shrink the tumor; chemotherapy after surgery is beneficial for patients with cancer that has spread to the lymph nodes or cancer that has penetrated the bowel wall. Surgery in combination with radiation therapy is the usual treatment for early stages of rectal cancer (ACS, 2004b). Chemotherapy may be used for advanced disease. When given via an artery leading directly to the tumor, referred to as regional chemotherapy, fewer side effects may occur (ACS, 2013b).
Targeted therapies attack cancer cells directly. Unlike standard chemotherapy which targets all rapidly dividing cells, targeted therapy interferes with specific molecules (e.g., protein enzymes, growth factor receptors) required for the cancer cells to replicate. Targeted therapies may be used alone or in combination with chemotherapy (National Cancer Institute, 2012); they are used for treating advanced colorectal cancer. Side effects include fatigue, diarrhea, headaches, and alterations in blood pressure (ACS, 2013b).
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Screening and early detection: issues for older adults Primary prevention of cancer is desirable and is affected by changes in lifestyle. Older adults are likely to have had a lifetime of exposure to risk factors, and although changing lifestyles is advantageous for them, the changes may not reverse the effects of exposure. Furthermore, changing habits that have developed over a lifetime is difficult, despite demonstrable benefits. Given the difficulty of cancer prevention, detection of cancer at an early stage may greatly improve survival rates. Screening asymptomatic persons at risk is feasible in many common malignancies, including breast, cervical, and colorectal cancers.
When considering a cancer-screening program, the health care provider should answer two fundamental questions:
1. Is the screening test sensitive? A sensitive test will correctly identify all screened individuals who have the disease (those with true-positive results).
2. Is the screening test specific? A specific test identifies all individuals who do not have the disease (those with true-negative results).
Current efforts at advancing the science and technology of screening have resulted in greater accuracy of many screening tests. The accuracy of screening may be increased by the recognition of highly sensitive tumor-specific circulating markers (e.g., PSA for the detection of prostate cancer); the development of imaging techniques capable of finding smaller lesions (e.g., refinements in radiographic techniques for mammography); and the identification of early molecular changes in cancer specimens (e.g., at the cellular level using Papanicolaou [Pap] tests for cervical cancer). Given the limited effectiveness of primary prevention for older adults, screening asymptomatic persons at risk for cancer may be the most promising way to reduce the number of cancer deaths in older adults.
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Yet another question to consider with a screening program is the prevalence of the disease in the population. The more prevalent the disease, the more beneficial a screening program will be. Because cancer is more common in older adults, screening is generally beneficial. The incidence of cancer increases with age; thus, the positive predictive value of screening tests (i.e., the proportion of persons screened who actually have the disease) is likely to increase. In addition, screening older adults who have comorbid conditions at the time of cancer diagnosis may result in elective treatment at an early stage of disease, thus reducing the possibility of serious treatment-related morbidity and deaths.
Recommendations on planning major screening programs for older adults should be made with caution. Screening guidelines vary greatly among different national organizations. Differences among recommendations are caused by the lack of cancer screening trials that include older adults. Because more than 56% of all cancers are diagnosed in those older than 65 and 70% of all cancer deaths occur in this age group, the lack of evidence-based criteria for screening older adults makes choosing screening protocols difficult. A decision-making process that takes into account each older adult’s personal preference and health should be used rather than relying only on age guidelines for cancer screening and detection methods. Screening should not be conducted in the absence of intent or ability to follow up on the findings with more complete evaluation and treatment. Screening is costly and useless if no follow-up occurs. Other factors that influence the decision to screen an older adult include comorbidity, functional ability, and life expectancy.
Considerable uncertainty exists concerning the use of cancer screening tests in older adults, as illustrated by the different age cutoffs recommended by various guideline panels. A framework to guide individualized cancer screening decisions in older patients may be more useful to the practicing nurse than age guidelines. Like many medical decisions, cancer screening decisions require weighing quantitative information such as risk of cancer death and likelihood of beneficial and adverse screening outcomes, as well as qualitative factors such as individual patients’ values and
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preferences.
Potential benefits of screening are presented as the number needed to screen to prevent one cancer-specific death, based on the estimated life expectancy during which a patient will be screened. Estimates reveal substantial variability in the likelihood of benefit for patients of similar ages with varying life expectancies. In fact, patients with life expectancies of less than 5 years are unlikely to derive any survival benefit from cancer screening. The likelihood of potential harm from screening according to patient factors and test characteristics must also be considered. Some of the greatest harms of screening occur by detecting cancers that would never have become clinically significant. This becomes more likely as life expectancy decreases (Reeve, Potosky, Smith, et al., 2009).
Finally, because many cancer screening decisions in older adults cannot be made solely on the basis of quantitative estimates of benefits and harms, considering the estimated outcomes according to the patient’s own values and preferences is the final step in making informed screening decisions. As more and more cancers occur in older people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters into the treatment of their patients.
The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted. Several biologic and clinical correlates of aging were identified. Strong evidence suggests that a CGA may detect many problems missed by a regular assessment in both general geriatric patients and older patients with cancer. Strong evidence also exists that a CGA improves function and reduces hospitalization in older adults. A CGA, with or without screening and with follow-up, should be used in older patients with cancer to detect unaddressed problems, improve functional status, and possibly improve the chances of survival (Extermann, Aapro, Bernabei, et al., 2005).
Although CGA is a multidimensional tool designed to detect health problems, a barrier to its use in busy health care settings is the length of time required to complete the entire instrument.
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Overcash, Beckstead, Extermann, & Cobb (2005) conducted a study to determine what items contained in the instrument could be compiled to construct an abbreviated CGA (aCGA). A retrospective chart review of more than 500 patients with cancer was performed at a large southeastern cancer center. Statistical analyses revealed 15 valid and reliable items that form the aCGA. They concluded that an aCGA may be helpful in screening those seniors who would benefit from the full-length CGA.
Walter and Covinsky (2001) developed a framework for cancer screening in older adults with the following recommendations:
• Individualize the decision by conducting a comprehensive geriatric assessment that includes an evaluation of comorbid conditions, polypharmacy, and the presence of dementia or depression.
• Estimate life expectancy. Reducing the risk of dying of a detectable cancer should be the main benefit of cancer screening. Although an exact determination of longevity is impossible, decisions can be made on the basis of understanding the distribution of life expectancies at various ages. The goal of any cancer screening program is to detect those cancers early enough for successful treatment. Therefore, a patient with more than 5 years’ life expectancy will benefit from a cancer-screening program. Although determining life expectancy for a particular individual is difficult, some attempt should be made to correlate life expectancy with the potential for future development of a specific cancer. The decision to screen should consider the treatment implications, but the decisions concerning specific treatment and how aggressively to treat are separate, and take place after the type and stage of cancer are diagnosed.
• Assess the risk of cancer screening. Certain clinically unimportant cancers increase as people age; therefore, older patients are frequently diagnosed with these types of cancer.
• Older people have more cognitive and physical conditions that increase their fear of cancer screening. Ascertain patient preferences. Consider each older person’s approach to health and discuss the risks and benefits of cancer screening tests.
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• Consult various cancer screening guidelines. The U.S. Preventive Services Task Force (USPSTF) guidelines are the most widely used and respected; however, these guidelines are very conservative and differ significantly from those of specialty organizations such as the ACS and the AGS. A listing of all USPSTF guidelines is provided at http://www.ahrq.gov/clinic/uspstfix.htm.
Ideally, effective cancer screening programs should lead to an overall reduction of cancer-related deaths and higher detection rates and prolonged survival times when cancer is diagnosed at an early stage. However, controversy has recently surrounded much of the research that cites the benefits of screening. Several notes of caution should be considered when the results of screening programs are reviewed (Yates, 1992):
• Screening programs may sometimes appear to prolong survival only because of early detection of a cancer, without any actual extension of life as a result of early treatment. This is known as lead-time bias; a cancer that has a natural history of 5 years may appear to gain a 2-year survival advantage because of diagnosis at year 1 of tumor growth instead of year 3.
• Screening favors the early detection of the more slowly growing and less malignant neoplasms, which leads to the appearance of improved survival rates; however, screening actually only increases the detection of the least aggressive cancers. This is known as length bias. Length bias appears to improve survival rates but actually dilutes the real effect of screening programs.
• Of particular importance when older adults are screened is that screening allows the diagnosis of cancers that would not have become clinically relevant during the person’s lifetime. This is known as overdetection bias.
These controversies underscore the notion that recommendations for screening require individual consideration. In addition to the controversies surrounding screening research, other factors may impede screening efforts for older adults. Older adults are often seen for episodic events in the context of chronic illnesses managed by medical specialists. Preventive services may not be appropriate
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at the time of an acute episode or may not be available within a specialty practice; therefore, screening procedures may not be offered. If they are offered, older adults may choose not to participate because they lack information about cancer screening, including the rationale, recommended frequency, and specific procedures. Aging and minority status have been linked to reduced knowledge of and access to cancer screening through mammography, rectal examination, fecal occult blood testing, Pap testing, and proctoscopy (Beydoun & Beydoun, 2008; Casey, Call, & Klinger, 2000; Yates, 1992) (see the two Evidence-Based Practice boxes). In addition to lack of knowledge, older adults may fear the diagnosis of cancer and the associated treatments, or they may be unable or unwilling to pay for health care services.
Evidence-based practice Lack of Knowledge about Colorectal Cancer Is Associated with Less Screening
Abstract Purpose Identify the influence of medical mistrust, fears, attitudes, and sociodemographic characteristics on unwillingness to participate in colorectal cancer (CRC) screening.
Design Cross-sectional, disproportionally allocated, stratified, random- digit-dial telephone questionnaire of noninstitutionalized households.
Setting New York City, New York; Baltimore, Maryland; San Juan, Puerto Rico.
Subjects
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Ethnically diverse sample of 454 adults ≥ 50 years of age.
Measures Health status, cancer screening effectiveness, psychosocial factors (e.g., perceptions of pain, fear, trust), and CRC screening intentions using the Cancer Screening Questionnaire, which addresses a range of issues related to willingness of minorities to participate in cancer screening.
Analysis Multivariate logistic regression was used to model the probability of reporting unwillingness to participate in CRC screening.
Results Fear of embarrassment during screening (odds ratio [OR] = 10.72; 95% confidence interval [CI], 2.15-53.39), fear of getting AIDS (OR = 8.75; 95% CI, 2.48-30.86), fear that exam might be painful (OR = 3.43; 95% CI, 1.03-11.35), and older age (OR = 1.10; 95% CI, 1.04-1.17) were positively associated with unwillingness to participate in CRC screening. Fear of developing cancer (OR = .12; 95% CI, .03-.57) and medical mistrust (OR = .19; 95% CI, .06-.60) were negatively associated with unwillingness to screen.
Conclusions Findings suggest that CRC health initiatives should focus on increasing knowledge, addressing fears and mistrust, and normalizing CRC screening as a beneficial preventive practice, and should increase focus on older adults. From Bynum, S.A., Davis, J.L., Green, B.L., and Katz, R.V.; Unwillingness to participate in colorectal cancer screening: examining fears, attitudes, and medical mistrust in an ethnically diverse sample of adults 50 years and older. American Journal of Health Promotion, 2012 May; 26 (5): 295-230.
Evidence-based practice
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Breast Cancer Symptoms and Quality of Life in Survivors Sample/Setting Completed surveys (n = 17) were returned from a convenience sample of breast cancer survivors who were younger than 50 years of age and premenopausal at the time of their diagnosis. The mean age of participants was 45.3 years, and the mean time since diagnosis was 22 months. All had received chemotherapy, and 10 had received both chemotherapy and radiation therapy.
Method The researchers sought to determine whether a group of symptoms as described in the literature did coexist in the breast cancer survivor population. The symptoms in question were fatigue, weight gain, psychological distress, and altered sexuality. The survey included demographic data as well as other reliable and valid tools to determine the presence and severity of these symptoms and their effect on quality of life.
Findings All four symptoms were present for 6 of the 17 study participants. Three symptoms were present in seven participants. Two symptoms were present in two participants. The symptoms of fatigue and altered sexuality always occurred together. Psychological distress occurred as a third symptom in 13 of the participants. The symptom that had the greatest negative effect on quality of life was fatigue. Even 2 years after finishing treatment, these women still experienced symptoms that negatively affected their quality of life.
Implications This study was too small to generalize the findings. Despite that, nurses should be aware that breast cancer survivors are at risk for experiencing these symptoms and that the symptoms could affect survivors’ quality of life. These symptoms may still be present many years after the treatment has been concluded. Discussing methods to address these symptoms in breast cancer survivors
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may increase their quality of life. From Wilmoth, M., Coleman, E., & Wahab, H. (2009). Initial validation of the symptom cluster of fatigue, weight gain, psychological distress and altered sexuality. South Online Journal of Nursing Research 9(3). <www.snrs.org>. Accessed 05/09/2009.
Nurses working with older adults should examine the role of cancer screening and the potential benefits for the population assigned to their care. The decision to screen or not to screen should be an active one, made after thoughtful consideration within the context of a multidisciplinary health care team. Screening guidelines, individual circumstances, potential complications of aggressive evaluation workups, and associated costs are all factors to consider in deciding to screen older adults.
As a group, older persons generally require more individualized health teaching about cancer risk and detection. Older persons may lack an awareness of the risks of cancer associated with advanced age and may not know the warning signs of cancer. They may be reluctant to report physical complaints that could be indicative of cancer. In addition, many older persons are concerned about, and even fear, the diagnosis of cancer and its effect on their overall well- being and functional status. The nurse should teach older adults the following early warning signs of cancer:
• Change in bowel or bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening or lump in the breast or elsewhere
• Indigestion or difficulty swallowing
• Obvious change in a wart or mole
• Nagging cough or hoarseness
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Major treatment modalities The four classic forms of cancer treatment are (1) surgery, (2) radiation therapy, (3) chemotherapy, and (4) biologic therapy. Each form of treatment may be used alone or in combination. Treatment selection is determined by the type and stage of the cancer, the unique biophysiologic characteristics of the cancer cells, and an older patient’s overall health status at the time of diagnosis. Treatment goals also help determine the type of therapy. Cancer therapies may be directed at a cure, or elimination of the disease; control, or minimization of the disease; or palliation, or relief of the symptoms.
Adjuvant therapies to the standard therapies have been developed that include angiogenesis inhibition, gene therapy, hyperthermia, laser therapy, and photodynamic therapy. Senger (1983) noted that cancerous tumors secrete chemicals, which he called vascular permeability factors (VPFs); these are now referred to as vascular endothelial growth factors (VEGFs). These substances promote the growth of new blood vessels to supply the tumor’s ever-expanding need for oxygen and nutrients. In theory, blocking the secretion of these blood vessel–producing chemicals will decrease the tumor’s ability to grow or survive or both.
Gene therapy involves the injection of altering substances into the cancer cells, usually in the form of viruses that make the cancer cells incapable of reproducing (Roth & Cristiano, 1997). Cancer cells are nondifferentiated; they serve no physiologic purpose other than reproduction. This reproduction takes place at an accelerated pace. Adding material to the cells makes replacement cells difficult to replicate. In breaking the cell replacement cycle, the tumor is rendered nonviable.
When cells in the body are heated (hyperthermia) past a specific point, usually considered to be 113° F, they are destroyed. The use of heat as an adjunct is not a new idea, but a great deal of advancement has occurred in the control and use of heat at specific sites and on the entire body.
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Laser light can focus a narrow beam on specific tissues at exact locations and depths. At this time, lasers are used primarily on lesions of the skin and on endothelial lesions in the linings of cavities that are accessible via endoscope. Both allow for direct visualization of the process. In photodynamic therapy (PDT), photosensitizing agents, which are chemicals that are readily absorbed by the tumor cells, are introduced into the bloodstream and absorbed by tissues, including the tumor cells. When exposed to the light from the laser, the drugs are activated within the tumor leading to cell death (ACS, 2013e).
Cancer is predominately a disease of older adults; however, research indicates older adults are subject to treatment bias based on age. Health care providers often fail to recommend older adults for cancer screening; older adults are subject to treatment delays and referrals, and are not offered surgical excision of tumors (Campbell, 2011). Chronologic age is not a major variable in determining a patient’s ability to tolerate or respond to therapy. Functional status has been reported to be a more important pretreatment variable, influencing both the decision to treat and the type of treatment (Shepherd, 1994). In addition, the number of comorbid conditions is a significant predictor of the outcome of an older adult receiving cancer treatment (Yancik, 1997). As with screening decisions, treatment decisions should consider the individual. Age is but one of many factors that should be considered.
Age-related treatment bias may also occur because of the older adults or their families. Patients or family members may believe a person may be too old to tolerate treatment; thus, they choose suboptimal therapies in lieu of more aggressive and curative treatments. Cancer care has changed dramatically over the years; however, many older adults remember friends or relatives who were treated with now-outdated therapies that had devastating side effects. One older woman, for instance, refused to have follow-up radiation therapy and decided to have a mastectomy when lumpectomy was an option. She remembered her mother’s complications related to older methods of cobalt radiation therapy, a delivery method for external beam radiation therapy that has now
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been greatly improved, and declared, “No one is going to fry me like they did my poor mother.” Patients and families need accurate information. Because cancer is so prevalent in older adults, many have some information about cancer, but it is often misinformation. The nurse should be sure that patients and families have accurate information and a clear understanding of the treatment options being offered.
Surgery Surgery, the oldest method of treating cancer, is indicated for most solid tumors. Initially, with the use of sophisticated biopsy and exploratory techniques, surgery is used to diagnose the disease, by determining tumor type, and to stage the disease, by determining its extent. The primary treatment goal of surgery is to remove the tumor when localized, thus preventing regional or distant metastasis. Surgery may also be indicated for palliative care in cases where the size or location of the tumor may create such problems as compression of surrounding tissues and organs, leading to pain, necrosis, or organ failure; large primary or metastatic tumors can be reduced with surgery. Surgery may be indicated for the placement of treatment-related devices such as implanted access devices, shunts, or drains. In addition, surgery may be indicated for rehabilitation or restorative purposes such as breast reconstruction after a mastectomy. Surgery is not a treatment of choice for disseminated disease such as metastases of multiple small tumors in diffuse locations (e.g., when breast cancer metastasizes in the lungs) or for disease that is disseminated from the onset, for example, leukemia.
In the past, surgical treatment of cancer involved extensive radical procedures. Such procedures were necessary to treat large, often neglected cancers. Poor understanding of patterns of metastatic spread and little knowledge of the benefits of adjuvant therapy contributed to the focus on radical operations. Greater insight into the pathophysiology of cancer and the development of additional therapies has led to more sophisticated surgical techniques. Early detection of smaller tumors has also contributed to the decline in the number of radical procedures. Less radical
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procedures result in fewer complications and improved quality of life. Research has demonstrated that in older adults with cancer, complication rates are no higher than age-matched cohorts without cancer (Audisio & Bozzett, 2004).
The curability of cancer in older adults is largely predicted by an individual’s ability to tolerate major surgery. Because older adults are at risk for more complications, careful preoperative assessment is critical. In-depth evaluation of the status of the respiratory, cardiovascular, hepatic, immunologic, renal, nutritional, and central nervous systems is mandatory. The severity of underlying cancer and comorbid conditions is an important factor to consider in the decision regarding surgical therapy (Pfeifer, 1997b). In addition, a patient’s rehabilitation potential should be evaluated, particularly if the intended surgery will significantly alter normal physiologic function. Some surgical procedures may produce physiologic alterations that are beyond an older adult’s adaptive capabilities. Arthritic changes and diminished visual acuity are two common problems in older adults that may make the management of surgical complications and postoperative care difficult (e.g., following colostomy creation). In general, older patients have a higher surgical risk compared with younger patients; however, through careful preoperative assessment to identify risks, older patients may be offered appropriate supportive therapies that minimize complications. Although age alone is not a determinant of surgical risk, data indicate that older adults are less likely to receive surgical therapy compared with younger persons (Farrow, Hunt, & Samet, 1996).
Postoperative priorities should include preventing respiratory complications and promoting cardiac and renal function. Because of the overall reduced compensatory reserves in these systems, older adults are susceptible to a number of serious complications, including congestive heart failure, electrolyte imbalances, hypoxia, dehydration, and venous thromboembolism. The use of invasive lines and catheters may tax an aging immune system and predispose older patients to sepsis. The overall stress of surgery, including anesthesia and other centrally acting medications, may predispose older adults to the development of delirium. Bowel
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complications may include paralytic ileus and constipation. Decreased mobility and inadequate nutrition are risk factors for pressure ulcers. Careful, complete, and ongoing assessment of all body systems provides the foundation for the nurse to accurately diagnose, plan, implement, and evaluate nursing care during the postoperative period.
Radiation Therapy Like all cancer therapies, radiation therapy is used for several different purposes. Radiation therapy may be curative for the treatment of several cancers, including skin, prostate, colorectal, lung, cervical, and Hodgkin cancers. Radiation therapy may also be indicated as an adjuvant therapy to prevent recurrence of breast cancer after lumpectomy. In some cases, radiation therapy may be used to control cancers, adding months or years to an individual’s life. Radiation therapy and chemotherapy may also be used before surgery to shrink the tumor. Often, recurrent breast and lung cancers can be controlled with radiation therapy in combination with chemotherapy, surgery, or both. Radiation therapy may also be used for palliative care. It relieves pain and prevents pathologic fractures associated with bone metastasis from breast, lung, and prostate tumors. Palliative radiation therapy is given for the relief of central nervous system symptoms caused by brain metastasis or spinal cord compression. In some cases, palliative radiation therapy may be given before a problem manifests itself, as in the treatment of vertebral lesions when spinal cord compression is imminent. According to the National Cancer Institute (2009b), approximately half of all cancer patients receive radiation therapy in the course of their treatments today.
Not all cancers are sensitive to the effects of radiation therapy, but for other cancers, radiation therapy may provide significant advantages over surgical procedures. Radiation encompasses wider areas around the tumor and removes tumors from regions where surgery cannot effectively excise the tumor. The use of radiation may also result in less disability and disfigurement than some extensive surgeries. Radiation also allows simultaneous treatment to multiple metastatic sites (Davis & Lindley, 2004).
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Therapeutic doses of radiation therapy are calculated to destroy or to delay the growth of malignant cells without destroying normal tissue. Radiation effects at the cellular level may be either direct or indirect. Direct effects occur when key molecules within the cell—the DNA or ribonucleic acid (RNA)—are damaged. Indirect effects occur when charged particles (free radicals) are created by radiation therapy, which cause damage to cellular DNA.
The administration of radiation therapy may involve external or internal techniques. External beam therapy, which is radiation from a source at a distance from the body, is administered primarily by linear accelerators and mostly in an outpatient setting. Internal therapy, known as brachytherapy, involves radiation from a source placed within the body or a body cavity. Brachytherapy uses various commercially available instruments or applicators that are inserted into target areas for a predetermined period. Rotation of either the target site or the radiation beam makes it possible to deliver a high dose to the tumor, while only part of the dose reaches the surrounding noncancerous tissue.
The response of older adults to radiation therapy has not been well evaluated. Several initial reports suggest that no difference in response exists between older persons and any other age group (Host & Lunde, 1986; Nobler & Venetl, 1985). The Joint Center for Radiation Therapy reported that younger persons (those younger than age 35) treated for breast cancer had higher local recurrence rates compared with older persons, which implies that radiation therapy may be more effective in older women. Overall, however, both research and clinical data suggest that the response of cancers to radiation therapy in older adults is similar to that in younger ones; therefore, decisions to treat using radiation therapy should be based on individual factors (Greenberg & Trotti, 1992).
The associated side effects of radiation therapy are no worse in older adults than in younger ones (Larson, Lindsay, Dodd, et al., 1993). However, older persons have greater difficulty compensating for temporary dysfunction in a single organ or in multiple organ systems. The challenge in treating older adults with radiation therapy is to provide appropriate supportive care to enable the patient to complete treatment without any significant alteration in
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functional status. Age cannot be used as a predictor for how patients will respond to radiation therapy treatment.
Chemotherapy Because not all cancers can be cured with surgery or radiation therapy, systemic treatment with chemotherapy may be necessary. Chemotherapy is the use of drugs to destroy cancer cells. Classic chemotherapy kills cancer cells either by damaging DNA, interfering with DNA synthesis, or inhibiting cell division. In contrast to surgery and radiation therapy, which are local therapies, chemotherapy is systemic. Although single-agent chemotherapy may be successful in the treatment of certain types of cancer, most tumors show only a partial response to this type of therapy. In most cancers, specifically breast, colorectal, gastric, ovarian, and lung cancers and lymphoma, combination chemotherapy is necessary to provide a better chance of long-term, disease-free survival. Broader coverage against cells and cell lines within heterogeneous tumors is provided with combination chemotherapy (Davis & Lindley, 2004).
The objectives of chemotherapy include cure, control, and palliation. In general, the survival of older persons who receive chemotherapy is significantly longer than that of untreated older persons, even though dose adjustments may be needed to control toxicity. Table 17-5 lists commonly prescribed chemotherapeutic agents by drug classification and mechanism of action.
Table 17-5 Major chemotherapeutic agents
Drug Classification
Major Mechanism of Action Drugs
Alkylating agents
Alkylating agents are highly reactive compounds that act against already formed nucleic acids by cross-linking strands, thereby preventing ribonucleic acid (RNA) transcription and deoxyribonucleic acid (DNA) replication. These agents are considered cell cycle nonspecific.
Altretamine Busulfan Carboplatin Carmustine Chlorambucil Cisplatin Cyclophosphamide Dacarbazine Ifosfamide Lomustine Mechlorethamine Melphalan Procarbazine Streptozocin
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Thiotepa Uracil mustard
Antimetabolites Antimetabolites are analogs of normal metabolites and act by interfering with synthesis of chromosomal nucleic acid. Some agents block an enzyme necessary for synthesis of essential factors, whereas others are incorporated into RNA or DNA, thus preventing cellular replication. Pyrimidine analogs, purine analogs, and folic acid antagonists are three major subgroups of antimetabolites, which are considered cell cycle specific.
5-Azacytidine 2- Chlorodeoxyadenosine (cladribine) Cytarabine Edatrexate Floxuridine Fludarabine Fluorouracil Mercaptopurine Methotrexate Mitoguazone Pentostatin Thioguanine Trimetrexate
Antitumor antibiotics
Antibiotic agents are natural products of various strains of soil fungi. These agents bind to DNA, preventing RNA and DNA synthesis, and are active in all phases of the cell cycle.
Bleomycin Dactinomycin Daunorubicin Doxorubicin Epirubicin Idarubicin Mitomycin Mitoxantrone PALA Plicamycin
Plant alkaloids Also called vinca alkaloids, these agents are derived from the periwinkle plant. As a group, the agents are similar in action, binding to proteins within cells and thereby inhibiting mitosis. Because they specifically act during cell division, they are cell cycle specific.
Docetaxel (Taxotere) Etoposide Paclitaxel (Taxol) Teniposide Vinblastine Vincristine Vindesine
Miscellaneous agents
A number of agents have unique mechanisms of action in various phases of the cell cycle.
Amsacrine Asparaginase CPT-11 Mitotane Piroxantrone Suramin Topotecan
Pharmacokinetics Pharmacokinetics refers to the activity of drugs in the body, including absorption, distribution, metabolism, and excretion. For oral chemotherapeutic agents, age-related changes in the digestive tract appear to have little effect on the absorptive capacity of the intestine. The exception may be with leucovorin, which, when given in the high doses required by some treatment protocols, may not reach desired blood levels in some older patients (Baker & Grochow, 1997). Age-related changes in body composition— decreased total body water and increased body fat—may affect drug distribution; however, no consequences for chemotherapeutic agents have been demonstrated (Vestal, 1997). The liver is the main site of metabolism for many chemotherapeutic agents. Liver size
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decreases by 20% to 40% between ages 20 and 80, which may result in reduced hepatic drug clearance in older adults, although for most older persons drug metabolism in the liver appears to be unaffected by age (Baker & Grochow, 1997; Vestal, 1997). Any impairment in drug metabolism is likely related to underlying liver damage, including exposure to environmental toxins or alcohol. Chemotherapeutic agents primarily metabolized by the liver include anthracyclines, mitoxantrone, mitomycin C, and the vinca alkaloids. Biliary excretion of drugs such as anthracyclines, mitomycin C, and the vinca alkaloids seems to be unaffected by age (Balducci, Mowrey, & Parker, 1992; Egorin, 1993). Only the age- related decline in kidney function has been demonstrated to have clinical consequences for drug dosing. Toxic drug levels have been demonstrated for agents that are primarily excreted by the kidney —methotrexate, bleomycin, carboplatin, and cisplatin (Baker & Grochow, 1997). The dosage of these drugs may need to be adjusted to account for age-related changes in the kidneys.
Pharmacodynamics Pharmacodynamics refers to the interactions between the chemotherapeutic agents and their cellular targets, including the processes that modulate the activity of the agents. All agents act at the cellular level; however, their mechanisms of action vary, as do their respective administration guidelines and side effect profiles. Nurses caring for patients receiving chemotherapeutic agents should understand the specific actions and side effects of individual agents.
Aging may make cells prone to drug resistance. Synthesis of abnormal proteins in aging cells may interfere with several pharmacodynamic steps, including the availability of membrane receptors for drugs, drug metabolism, and drug-affected enzyme inhibition. In addition, aging cells may acquire some ability to repair damaged DNA, which results in increased drug resistance and offers at least a partial explanation for the clinical observation that cancers in older adults are less susceptible to chemotherapy (Balducci et al., 1992; Kimmick, 1997).
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Biologic Therapy Biologic therapy is the use of agents (living organisms, substances derived from living organisms, or synthetic substances) to stimulate the body’s immune system to attack cancer cells. The primary mode of action is modification of the host’s biologic response to the tumor, thus achieving a therapeutic response (National Cancer Institute, 2013a).
Biologic therapy includes nonspecific immunomodulating agents and biologic response modifiers (BRMs). Biologic response modifiers include cytokines (interferons [IFNs], interleukins [ILs], and hematopoietic growth factors), monoclonal antibodies, and vaccine therapy (National Cancer Institute, 2013a).
Nonspecific immunomodulating agents are drugs that stimulate the patient’s own immune system to fight both cancer and infection. The ability to fight infection is an important aspect of cancer therapy (National Cancer Institute, 2013a).
Biologic response modifiers alter the body’s interaction with cancer by stimulating the body’s natural defense mechanisms, directing the body’s immune system toward the cancerous cells and bolstering the patient’s weakened immune system. IFNs improve immune response to cancer cells by stimulating natural killer cells, T cells, and macrophages. They may also slow cancer cell growth. ILs stimulate immune function through proliferation of lymphocytes; although ILs are naturally occurring cytokines in the body, they may also be produced in the laboratory. Hematopoietic growth factors stimulate the patient’s own bone marrow to produce more WBCs, red blood cells (RBCs), and platelets. When given to a patient receiving chemotherapy, they help fight infection, enabling the use of higher doses of chemotherapy or continuation of treatment that might otherwise be stopped because of low WBC or RBC counts. Monoclonal antibodies are agents designed to destroy cancer cells; they do not harm healthy cells. They target specific antigens expressed by the cancer cells. They may destroy cancer cells directly, stimulate anticancer immune response, or interfere with tumor growth. Vaccine therapy for cancer is given after cancer has developed. Vaccines contain antigens that trigger an increased
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immune response (stimulation of B cells or killer T cells) directed toward the tumor. Many cancer vaccines are still being tested in clinical trials (National Cancer Institute, 2013a).
All biologic therapies carry a similar side-effect profile: fever, chills, nausea, vomiting, anorexia, and fatigue. Swelling or rash at the site of injection may occur, as well as bone pain and alterations in blood pressure. Other side effects include altered blood chemistries and organ damage (National Cancer Institute, 2013a).
Chemoprotective agents have also been developed to protect specific organs from the damage associated with chemotherapy. Dexrazoxane (Zinecard) prevents damage to the heart, amifostine (Ethyol) protects the kidneys, and mesna (Mesnex) helps ensure that the bladder and bladder lining are protected from chemotherapeutic toxicity.
Endocrine Therapy Certain types of cancer that arise from hormone-sensitive tissues such as the breast, prostate, and endometrium may be treated with the use of endocrine therapy. This type of therapy inhibits tumor growth by blocking the hormone receptor, thereby eliminating endogenous hormones that supply the tumor and aid in its growth. For breast cancer, antiestrogens such as tamoxifen, toremifene, and fulvestrant or aromatase inhibitors such as anastrozole, letrozole, or exemestane are used.
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Common physiologic complications Cancer treatments are aimed at destroying cancer cells. Because most treatment pharmacodynamics includes the prevention of cell division, actively dividing cell types are particularly vulnerable and may exhibit side effects. Actively dividing cell types that are most likely to exhibit side effects include those in hematopoietic tissue, the gastrointestinal tract, and hair follicles. Chemotherapy side effects are specific to the type of agent, dosage, and duration of use (see Nursing Care Plan). Radiation-related side effects depend on the location of the radiation field, intensity of the dose, and duration of the therapy. In most cases, side effects are reversible.
Nursing care plan
Myelosuppressive Toxicities of Chemotherapy Clinical Situation Mr. K is a 69-year-old man recently diagnosed with small cell cancer of the lung. He lives with his wife in a modest home. Mr. K had no functional limitations before his diagnosis of cancer. His oncologist prescribes a chemotherapy regimen of cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), and etoposide (VePesid). As with many chemotherapy regimens, a primary side effect is myelosuppression, resulting in decreased red blood cells, white blood cells, and platelets. Because the therapy is given in the ambulatory care clinic, Mr. K and his wife will need to provide self-care for monitoring and managing the myelosuppressive effects of the agents.
Nursing diagnoses Risk for Infection, related to bone marrow depression
(granulocytopenia) secondary to chemotherapy
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Risk for Injury, bleeding caused by bone marrow depression (thrombocytopenia) secondary to chemotherapy
Ineffective Peripheral Tissue Perfusion
Outcomes The patient will remain free of infection.
The patient will remain free of injury and bleeding incidents.
The patient will not experience hypoxia, activity intolerance, or malaise.
Interventions Monitor complete blood cell count and differential (absolute
neutrophil count should remain above 500 cells/mm3).
Instruct the patient and family to:
• Maintain patient defenses:
• Perform frequent oral hygiene using soft-bristle toothbrush and low-alcohol mouthwash.
• Lubricate dry areas using skin emollients and artificial tears.
• Maintain adequate hydration (3000 milliliters per day [mL/day] is recommended).
• Minimize exposure to potential pathogens:
• Restrict visitors with colds or infections.
• Avoid large crowds.
• Perform routine bathing and perineal hygiene.
• Assess for presence of infection:
• Report temperature > 100° F.
Monitor complete blood cell count and differential; platelet count should remain above 50,000 cells/mm3.
Instruct the patient and family to:
• Avoid trauma:
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• Use a soft bristle toothbrush and low-alcohol mouthwash, and avoid flossing and use of toothpicks.
• Avoid tightly fitting or constrictive clothing.
• Use a nail file or emery board; avoid clipping or pulling hang nails.
• Use an electric razor for shaving.
• Prevent constipation; use stool softeners and maintain adequate fluid intake.
• Assess for the presence of bruising or bleeding:
• Report minor bleeding such as petechiae, ecchymosis, epistaxis, and occult blood in stool, urine, or emesis.
Monitor complete blood cell count and differential:
• Hematocrit should remain above 25%.
Instruct the patient and family to:
• Increase rest and sleep periods.
• Alternate rest and activity periods.
• Incorporate foods into the diet that are high in iron, such as eggs, lean meat, green leafy vegetables, carrots, and raisins.
• Modify roles and responsibilities, as needed.
Bone Marrow Suppression The most common universal toxicity related to cancer treatment, particularly with chemotherapeutic agents, is myelotoxicity, or suppression of the bone marrow. Myelosuppression may result in anemia, neutropenia, and thrombocytopenia. Older adults with cancer have diminished hematopoietic reserves, which may lead to increased susceptibility to chemotherapy-induced bone marrow suppression. However, older patients have been able to tolerate moderate chemotherapy treatment programs without excessive complications when dosages are adjusted according to the level of renal function. Aggressive chemotherapy such as that used for treating leukemia or in preparation for bone marrow
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transplantation may lead to prolonged and severe myelosuppression in older adults (Baker & Grochow, 1997).
Several causes for greater myelosuppression in older patients have been suggested: (1) The dosage may not be appropriately adjusted to renal function; (2) hematopoietic insufficiency may already exist because of chronic disease or malnutrition; and (3) chemotherapeutic agents may interact with other prescribed medications that also have myelosuppressive side effects (e.g., phenytoin) (Baker & Grochow, 1997). An increased risk for myelosuppression is not cause for withholding therapy from older adults. Interventions should be identified that eliminate or reduce the risk. The use of hematopoietic growth factors may greatly enhance an older patient’s ability to tolerate the myelosuppressive effects of chemotherapy.
Treatment-related anemia is associated with increased fatigue. Fatigue is a complex concept and has been related to other causes besides anemia. However, anemia remains a major contributor to the feelings of tiredness, weakness, and exhaustion that are part of the fatigue syndrome. Erythropoietin or blood transfusions may be administered to increase the RBC count. Sleep and rest are recommended. Patients experiencing fatigue should plan periods of rest during the day but not to the extent that the rest interferes with regular sleep patterns. Activities should be rearranged to allow for periods of rest. Older patients may have less tolerance at baseline; thus, they may tire more easily during treatments. Because the sleep cycle changes with age and older persons spend more time in light sleep, from which they can be easily aroused, the sleeping environment should be as quiet and comfortable as possible. Pain medications should be adjusted to provide the maximum period of uninterrupted, pain-free sleep.
Thrombocytopenia predisposes patients to easy bleeding. The risk of spontaneous hemorrhage is considered to be greater when the platelet count is less than 20,000 cells per cubic millimeter (cells/mm3). The most common cause of thrombocytopenia in older patients with cancer is decreased platelet production caused by chemotherapy or radiation therapy. In addition, platelet activity may be disrupted by other drugs, including nonsteroidal
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antiinflammatory drugs (NSAIDs), penicillin and cephalosporin antibiotics, phenothiazines, and antidepressants. Platelet counts should be monitored carefully, and patients should be instructed to use precautions during periods of thrombocytopenia. Precautions should be aimed at preventing injury, particularly to the skin and mucous membranes. Patients should be instructed to use electric razors, soft-bristled toothbrushes, and emery boards for personal hygiene. Enemas, rectal thermometers, and suppositories may traumatize rectal mucosa and should be avoided. In addition to the potential for injury and bleeding, interruptions of skin and mucous membranes predispose the patient to infections. Platelet transfusions may be used during periods of thrombocytopenia to prevent bleeding and hemorrhage.
Infection Older persons receiving cancer treatment are at increased risk for infection. Infection is the major cause of complications and death in those diagnosed with cancer; 1 in 10 patients undergoing cancer therapy develops an infection. Infectious processes, secondary to neutropenia, have been implicated in 2% to 21% of deaths in adults with cancer (National Institute for Health and Care Excellence [NICE], 2012).
Several mechanisms have been proposed that explain the introduction of an infectious process in persons with cancer: Surgery interrupts the normal protective barrier of the skin; chemotherapy and radiation therapy cause sloughing and interruption of the integrity of the mucous membranes; intravenous delivery systems and treatment-related catheters introduce bacteria; and changes in normal flora predispose patients to serious opportunistic and nosocomial infections. More than 80% of infections developing in persons with cancer arise from endogenous flora, nearly half of which are acquired during hospitalization (Ellerhorst-Ryan, 1993). Chemotherapy and radiation therapy may reduce the number of circulating neutrophils. Persons whose neutrophil count is 0.5 × 109 per liter or lower are considered to be neutropenic and at increased risk for infection. When the neutrophil count is less than 500 cells/mm3, the
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risk for infection is severe (NICE, 2012).
Nursing care focuses on prevention. Patients and their families should be knowledgeable about self-care measures for the prevention and early detection of infection. Prevention includes good personal hygiene, avoiding crowds, and postponing visits with persons who may have upper respiratory infections. The ability to monitor body temperature using a thermometer is important. Age-related vision changes may make reading a conventional glass thermometer difficult for many older adults. The nurse should evaluate each individual’s ability to use a thermometer and experiment with using various digital devices if visual impairment is a problem. The use of hematopoietic growth factors has reduced the risk of infection for many patients. When infection is suspected, it should be considered a potentially life- threatening emergency.
Nausea and Vomiting Nausea is a subjectively experienced stomach distress that may be described as a heaviness, pressure, or sinking feeling in the epigastric or sternal region. It is often associated with such physical signs as pallor, sweating, and chills. Most often patients are referring to nausea when they describe “feeling sick.” Vomiting is the ejection of stomach contents through the mouth. Nausea and vomiting are two separate and distinct events, and although they frequently occur together, it is important for the nurse to distinguish between the two when taking a patient history and planning care.
Chemotherapy-induced nausea and vomiting (CINV) are among its most distressing side effects. Not all chemotherapeutic agents cause nausea and vomiting, and those that have high emetic potential do not cause equal distress in all persons. Considerable variation exists among patients and types of agents. Antiemetic management has changed with the development of better pharmacologic agents. Before the development of these agents, an estimated 10% of patients refused chemotherapy because of actual or feared nausea and vomiting (Rhodes, Watson, & Johnson, 1985).
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Because many older adults likely have friends or family members who were treated with older therapies, nurses should reassure patients that management of this side effect has changed for the better.
A number of age-related physiologic changes might be expected to influence the propensity for nausea and vomiting, for example, increased taste threshold and decreased gastrointestinal absorption, secretion, and motility; the extent of these influences is unknown. Only a few studies have examined cancer treatment-related nausea and vomiting in older adults. Older adults were found to report less nausea and vomiting within 24 hours of receiving chemotherapy treatments; however, delayed nausea and vomiting are more common and more severe in older persons and are less well managed by pharmacologic interventions (Baker & Grochow, 1997; Balducci et al., 1992; McMillan, 1989).
Nausea may lead to decreased nutritional intake, whereas vomiting may lead to severe metabolic complications, including dehydration. Older adults are less tolerant of dehydration compared with younger persons and may manifest acute confusion in response. Dehydration may create a metabolic crisis necessitating resuscitation with intravenous fluid administration. In addition, chemotherapeutic agents excreted by the kidney may build to toxic levels, which could lead to increased side effects and renal failure, particularly when agents with known nephrotoxic side effects are used. Electrolyte imbalances may aggravate cardiac problems and precipitate drug toxicity if a patient is taking medication to manage a cardiac condition. Episodes of severe vomiting may require the dosage of drugs to be reduced or treatment to be postponed. Current pharmacologic management of CINV includes 5- hydroxytryptamine (5-HT3) receptor antagonists, neurokinin 1 (NK1) receptor antagonists, corticosteroids, benzomide analogs, phenothiazine derivatives, butyrophenones, and benzodiazepines (Navari, 2007).
Nursing care should begin with an in-depth emetic history and a preventive plan. Characteristics that have been linked with CINV include susceptibility to motion sickness, history of severe nausea during pregnancy, and poor emetic control during prior treatments.
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Nurses should evaluate the degree and duration of episodes of nausea and vomiting and monitor for signs of dehydration. Long- term nutritional compromise may result from poorly controlled nausea, and consultation with a dietitian may be helpful (see Nutritional Considerations box).
Nutritional considerations
Nutritional Consequences of Cancer Treatment The nutritional consequences of cancer treatment may be devastating, resulting in an older adult’s inability to tolerate treatment and compromising his or her quality of life. Specific consequences are related to the type of treatment. Nurses should be aware of possible nutritional consequences and complete a nutritional assessment early in the course of therapy. Early assessment provides a baseline for persons at high risk. Patients should be weighed at regular intervals. Individuals at the highest risk for nutritional compromise are those experiencing weight losses of 1% to 2% in 1 week, 5% in 1 month, 7.5% in 3 months, and more than 10% in 6 months.
Treatment Possible Nutritional Consequences Chemotherapy Individual drugs and drug combinations produce taste alterations, notably a decreased
tolerance for protein-rich foods. Drugs that cause oral mucositis and esophagitis (inflammation of the oral cavity) may lead to difficulty chewing and swallowing, resulting in decreased caloric intake and weight loss. Chemotherapy-induced nausea and vomiting may result in dehydration, decreased caloric intake, and weight loss. Drugs that cause diarrhea may lead to dehydration, electrolyte imbalance, and bleeding.
Radiation therapy of the head and neck
This may cause taste alterations, xerostomia (dry mouth), oral mucositis, and esophagitis, leading to difficulty swallowing and a decreased appetite.
Radiation therapy of the esophagus
This may cause dysphagia, sore throat, esophagitis, indigestion, and nausea, leading to difficulty swallowing and a decreased appetite.
Radiation therapy of the lung
This may lead to shortness of breath, anorexia, and nausea with generalized malaise and a decreased appetite.
Radiation therapy of the abdomen
This may cause nausea, vomiting, cramping, gas, and diarrhea, resulting in a decreased appetite.
Surgical resection of oropharynx
This surgery may cause postoperative difficulty in chewing and swallowing, changes in taste perception, and loss of appetite, leading to a dependence on tube feedings.
Esophagectomy, esophagogastrectomy, or esophageal reconstruction
This may cause gastric stasis, steatorrhea, and diarrhea, leading to a decreased appetite.
Gastrectomy (partial or complete)
These procedures may result in dumping syndrome with symptoms of cramps, fullness, and diarrhea; malabsorption of fats, iron, vitamin B12, and calcium; and early satiety secondary to decreased size of reservoir, with decreased intake of adequate nutrients and calories.
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Intestinal resection This may lead to malabsorption of nutrients, including fat, iron, vitamin B12, fluids, and electrolytes, resulting in weight loss and malnutrition.
Pancreatectomy This may result in exocrine insufficiency and malabsorption or endocrine insufficiency, leading to diabetes mellitus.
Chemotherapy-Induced Oral Mucositis Chemotherapy-induced oral mucositis is caused by the destruction of rapidly proliferating mucosal cells in the oral cavity, which results in inflammation, ulceration, pain, and bleeding. Several chemotherapeutic agents are known to cause severe chemotherapy- induced oral mucositis. Evidence suggests that older adults are at increased risk for severe chemotherapy-induced oral mucositis. The severity of chemotherapy-induced oral mucositis in older adults may be caused by delayed and incomplete repair of mucosal injury (Baker & Grochow, 1997; Balducci et al., 1992). Radiation therapy that includes mucosal tissue in the radiation field may lead to dose- related oral mucositis, which generally clears when therapy is complete.
Dental and oral care needs should be evaluated by a dentist before treatment begins, and treatment should be delayed until any dental problems are resolved. A patient should understand the importance of good oral hygiene and avoid products with alcohol, which dry the mucous membranes and increase the risk of cracking, bleeding, and infection. Most commercially available mouthwashes contain alcohol. Safer mint-flavored normal saline or hydrogen peroxide products are available at specialty pharmacies. Viscous lidocaine, topical morphine solution, and oral solution with doxepin may be used for areas of painful inflammation. Nurses should routinely assess the patient’s mouth, lips, and tongue for early signs of inflammation. Severe oral mucositis may result in decreased oral intake, which, in turn, may lead to dehydration and cause a metabolic crisis that may necessitate resuscitation with intravenous fluid administration. Also, severe oral mucositis may result in a decreased appetite, which may lead to nutritional compromise and hence decreased ability to tolerate treatment. In general, older persons become less tolerant of dehydration and nutritional depletion with age.
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Anorexia Many patients receiving cancer treatments complain of a general loss of appetite. Contributing factors include chemotherapeutic agents; radiation therapy, especially to the head and neck area; pain medications; and chemotherapy-induced oral mucositis. Decreased appetite leads to decreased caloric intake and weight loss. Severe weight loss has been linked to poor outcomes; patients with significant weight loss have more complications and decreased survival rates. Persons older than 80 years of age are more vulnerable to increased toxicity from radiation therapy when they are unable to maintain their weight (Zachariah, Casey, & Balducci, 1995). Anorexia may also contribute to decreased immune function, increasing the risk of infectious complications.
Dietary consultation and frequent weight monitoring are necessary to maintain optimal weight. For persons receiving chemotherapy, an increase of 4.4 calories per kilogram of body weight and 2 grams of protein per kilogram of body weight should be incorporated into an overall nutritional plan. The nurse should remember that food choices and eating patterns have strong cultural influences, and planning nutritional diets with patients and their families is critical to successful outcomes.
Diarrhea Diarrhea results from the destruction of the actively dividing epithelial cells of the gastrointestinal tract. When these cells are destroyed, atrophy of the intestinal mucosa occurs, resulting in shortening or denuding of the intestinal villi. When the villi and microvilli become flattened, the absorptive surface area is reduced and intestinal contents move rapidly through the gut, resulting in frequent liquid stools. Absorption of nutrients is decreased, and patients are at risk for dehydration and malnutrition. Circulatory collapse may occur, especially in older adults with cardiovascular disease. Diarrhea may aggravate perirectal problems such as hemorrhoids and may cause pain, bleeding, and infection.
Assessment of diarrhea includes the number of stools per day, their consistency, and their color. Older patients may be reluctant to
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discuss diarrhea, ignoring their symptoms until dehydration becomes a problem. To control diarrhea, patients should be instructed to eat small frequent meals and avoid coffee, tea, alcohol, and sweets. They should be advised to eat low-fiber foods and avoid fried, greasy, or spicy foods as well as milk and milk products. Patients should also be instructed to increase the potassium in their diet and drink plenty of room-temperature clear liquids. Chemotherapy is usually administered unless diarrhea is severe resulting in dehydration.
Alopecia Alopecia is a common complication of chemotherapy. Hair loss may range from thinning of scalp hair to total body hair loss, including eyelashes, eyebrows, and pubic hair. The degree of alopecia depends on both the chemical agent and the dose. Chemotherapy-induced hair loss occurs rapidly and becomes apparent over a 2- to 3-week period after initiation of treatment. Chemotherapy-induced hair loss is temporary in most cases, and hair begins to grow back slowly after treatment has been completed. Radiation-induced hair loss occurs when the scalp is in the radiation field. Hair loss is permanent if the radiation dose causes irreversible destruction of the hair follicles; otherwise, hair loss is temporary. To date, no type of hair care product or practice has been shown to satisfactorily prevent or reduce hair loss.
Although the physiologic consequences of alopecia are minimal, the emotional distress may be enormous. Hair greatly contributes to body image and sexuality. Wigs and hair pieces should be purchased before total hair loss occurs. Often, patients are too embarrassed to shop for hair replacements when they are bald. Once the hair is gone, it may be difficult to match color, texture, or style. The nurse should not assume that hair loss is only an issue for women; men may be equally devastated by hair loss. For instance, an older, completely bald man was mortified when he lost his big bushy eyebrows, but the local university theater created a pair of high-quality eyebrows for him as a means for temporary relief.
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Older adults’ experience of cancer Cancer in older adults has been viewed as aging in the context of cancer; cancer is the prominent issue. However, cancer for older persons may be more aptly framed as “cancer in the context of aging,” and aging is the predominant issue. Why do we focus on aging as the context?
Traditionally, cancer has been viewed from the perspective of younger persons. Attention has been placed on treatments that return persons to precancerous functioning and on statistics that highlight survival rates in the years after diagnosis. Successful treatment in this context means that the cancer goes away and stays away for a long time. Although a younger person’s cancer experience includes looking beyond the cancer to a disease-free return to a normal lifestyle, an older person has a different experience; older adults with cancer are close to the end of life. For a younger person, cancer may be viewed in the context of a life yet to be lived, whereas for an older person, cancer may be viewed in the context of a life mostly lived (Kagan, 1997).
A substantial body of research reveals that older adults are less likely to be offered clinical trials compared with younger adults. Older adults should be made aware that most clinical trials allow participation of older patients and do not have age limits. Older patients should ask their health care providers about available clinical trials and should use websites such as www.cancer.org and www.cancer.gov to search for clinical trials. They may also want to seek a second opinion at a major cancer center to explore clinical trials and other treatment options (Muss, n.d.).
Quality of Life Historically, length of survival has been the most important consideration in measuring the outcome of cancer treatment. Recently, efforts have been made to address not only length of life but the circumstances of life—quality as well as quantity. For an older adult experiencing cancer in the context of a life mostly lived,
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quality is a very—if not the most—important consideration.
Determining quality of life goes beyond evaluating the severity of symptoms (such as nausea, pain, or fatigue) to considering the degree of functional status reflected in the person’s ability to perform daily tasks of living. Quality of life is a multidimensional concept that includes not only functional status and the severity of symptoms but also the patient’s ideas about psychological development, sociocultural issues, ethical issues, economic issues, and spirituality.
Figure 17-2 depicts the multidimensional nature of quality of life. Attitudes in three categories—physical well-being, psychological well-being, and interpersonal well-being—have been demonstrated to be the primary determinants of overall quality of life for older adults (Padilla, Ferrell, Grant & Rhiner, 1990). Also, in older adults, quality-of-life factors are shown to be rated differently by men and women; for men, vitality and personal resources are most important, whereas for women, psychosocial well-being is most important (Dibble, Padilla, Dodd & Miaskowski, 1998).
FIGURE 17-2 Quality of life as a multidimensional concept.
Quality-of-life evaluation is relevant to both curative and palliative care. In curative care, information obtained from a quality-of-life assessment helps guide the selection of therapeutic strategies that result in a more normal life. Older adults may need
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special quality-of-life consideration when choosing a treatment. A moderate treatment that provides relatively symptom-free disease control may be a better quality-of-life choice for an older adult than a rigorous treatment that statistically offers a prolonged disease-free period. In palliative care, quality-of-life assessment provides insight into areas that may require intervention, such as family counseling, financial planning, and management of depression.
Some measure of a person’s quality of life has been included in most studies evaluating treatment modalities or chemotherapeutic agents. Historically, these studies focused on measures of functional status, primarily assessing the ability of patients to perform various activities of daily living (ADLs) using the Palliative Performance Scale (PPSv2) found at http://palliative.info/resource_material/PPSv2.pdf.
The nurse plays a central role in supporting an older patient’s quality of life. Nurses manage disease-related symptoms and treatment-related side effects. Few studies have focused on the older adult’s perception of health status while receiving cancer treatment. However, Steele and associates (2005) found that even patients with terminal illness can have a good quality of life when proper resources such as hospice care are initiated (see Evidence- Based Practice box).
Evidence-based practice Quality of Life Issues and Hospice Patients
Sample/Setting The study was conducted over a 3-year period and included 129 terminally ill patients enrolled in a home-based hospice program of care in the southeastern United States.
Methods The purposes of this study were (1) to describe the quality of life of terminally ill patients in a home-based hospice program and
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(2) to examine the relationship between quality-of-life data and symptom distress, patient ability to function, social support, affairs in order, and religious comfort or support as recorded in patient charts. Quality of life was measured by the Missoula- Vitas Quality of Life Index (MVQOLI), an instrument designed specifically for use with terminally ill patients. The MVQOLI was administered to patients within 20 days of their admission to hospice. A retrospective chart review was conducted to determine levels of symptom distress, patient ability to function, social support, affairs in order, and religious comfort or support.
Findings This study revealed positive scores on the five dimensions of the MVQOLI quality-of-life scale, which indicated that patients rated their quality of life as good to very good within 20 days of admission to hospice. Data obtained from the chart review also indicated that patients did not experience a great deal of symptom distress (pain, nausea, shortness of breath, and restlessness). Significant correlations existed between age and quality of life; interventions count and pain levels; and marital status, well-being, interpersonal relationships, and transcendence. Shortness of breath and well-being were significantly correlated with quality of life. No significant correlations existed between gender, race, or closeness to death and the five dimensions of the MVQOLI and chart review assessments.
Implications Studies are needed to examine the quality-of-life issues that face terminally ill patients enrolled in hospice care. With increasing population, as more and more older adults face terminal illness, nurses will need to identify care issues that help with this end-of- life experience. From Steele, L.L., Mills, B., Hardin, S.R., & Hussey, L.C. (2005). The quality of life of hospice patients: Patient and provider perceptions. American Journal of Hospice and Palliative Medicine, 22(2), 95-110.
Depression
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Few studies have focused on the experience of cancer in older adults from a holistic perspective. Most insight about older adults’ cancer experiences comes from psychological studies exploring depression among older adults. The association between serious illnesses such as cancer and psychological depression or depressive symptoms has been well documented. Incidences of many illnesses, including cancer, are known to increase with age. The risk of depression does not diminish with age; therefore, older adults represent a group at increased risk.
The mental health of persons with serious medical diagnoses, including arthritis, diabetes, cancer, renal disease, and non– melanoma-related dermatologic disorders, has been compared with that of physically healthy outpatients under treatment for depression (Cassileth & Chou, 1992). Both groups were compared with the psychological status of the general public. Findings suggest that the psychological status of seriously ill persons approximated that of the public at large, did not differ substantially by diagnosis, and was superior to that of physically healthy patients with psychiatric problems. The researchers concluded that the assumption that cancer or any other chronic illness leads to mental illness had no grounds (Ganz, Schag, & Heinrich, 1985; Roberts, 1992; Vinokur, 1989).
A note of caution about depressive symptoms in older adults with cancer is warranted here: Depressive symptoms may result from side effects of medications used to control cancer. Depressive symptoms are especially associated with hormone therapy and cortisone medications, two medication groups frequently prescribed for cancer treatment. In addition, older adults may have underlying diseases that are controlled by medications. Depressive symptoms are associated with many drugs used to manage chronic illness. In addition, depressive symptoms are known to increase with an increased number of medications taken.
Nurses should assess the older adult’s risk for depression. Older adults with cancer should be educated about the psychological implications of having cancer. An understanding of how the experience of cancer may affect such things as feelings of well- being, interpersonal relationships, and self-fulfillment is needed as
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much as an understanding of the schedule for taking medications. Older patients and their family members should be encouraged to discuss the effects of cancer on family functioning. Individual evaluation of depressive symptoms is needed if an older person is suspected of experiencing depression. Nurses should refer older patients for further psychiatric evaluation when symptoms last longer than a week, worsen rather than improve, or interfere with the ability to carry out daily routines or cooperate with treatment plans. Management of cancer-related depression should be individualized and may include supportive interventions, cognitive intervention, psychotherapy, and psychopharmacology.
Grief and Loss Grief is a natural and expected human reaction to loss. An older adult who is being treated for cancer may experience multiple losses, including loss of energy, loss of a body part, loss of functional ability, loss of self-esteem, and loss of control. The losses associated with cancer may overlap other losses frequently experienced by older adults, including the loss of a spouse, friends, or family; changes in living arrangements; and physical losses of vision, hearing, or mobility.
Although grief is a universal human reaction, the subject and the intensity of grief are determined by the meaning that an individual places on the loss. Grieving is a human imperative, but how people grieve varies. No one way to grieve and no one timetable for grief exist. People do not “get over” grief. They get through, reconcile with, and learn to live with the loss, but they never get over it; in some cases, a loss may be mourned forever (Bourne, 1996).
The health care literature often reports that denial is among the initial responses to loss, including losses associated with a diagnosis of cancer. Denial is believed to protect people by providing them with the time needed to assimilate the effect of the diagnosis. Unfortunately, health care providers, including nurses, often haphazardly label a person or family as being “in a state of denial.” Labels reflect a judgment or conclusion, and conclusions should be supported by evidence. Most persons need some time to
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allow the diagnosis of cancer to reach conscious awareness. The information about the diagnosis is allowed into the awareness in increments that are tolerable to the person while the person is coming to terms with the effect of the diagnosis on his or her life. It may be more reasonable to consider that a patient is “titrating” information rather than being in a state of denial. To complicate matters, family members titrate information at different paces as they realize the impact of the diagnosis on their lives. The diagnosis of cancer often leads to a confusing and conflicting experience for the family unit.
Nurses should support older patients and families by patiently repeating information when asked, validating what the family has heard, and determining what the information means to them as individuals and as a family unit. The ongoing process of assessing a patient’s and family’s understanding of the information should spur nursing interventions that are often blocked when nurses judge too quickly. Although patients and families should be allowed to come to their own level of understanding of the diagnosis, the nurse should not support unrealistic ideas about the seriousness of the illness or the benefits of treatment. Interventions may be necessary when a patient and family are so threatened by the diagnosis that they are incapable of participating in decision making about the treatment choices. Nurses should validate the patient’s feelings of grief and loss. Grief cannot be prevented, and nurses should give the individual permission to grieve in reaction to loss. Some older adults may have unresolved grief or complications associated with grieving. This may occur more often in older adults because they are more likely to experience multiple major losses within a short period of time; the death of spouses and friends; losses such as loss independence, health, and decreased physical abilities, which occur as a part of the natural aging process; and the anticipation of losing someone or something special to them. In addition, some older adults need more time to adjust to change (Curtis, 2007).
Health care providers need to be alert to these signs not only to assist older adults who are grieving but also to recognize abnormal signs and symptoms so that appropriate care can be given to
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minimize emotional and physical complications. The following interventions adapted from Curtis (2007) may help an older adult who is grieving:
• Giving the person time. Older adults may need more time to become aware of feelings and express them. Sometimes, they also need more time to complete activities. Providing extra time shows that you are concerned and respectful of their needs.
• Pointing out signs of sadness or changes in behavior. This may help the person become aware of feelings and may help the person feel more comfortable talking with you about feelings.
• Spending time with the person. An older adult who is often alone may benefit from your company. Feelings of loneliness may last for a long time when an older adult has lost something or someone special, especially a spouse.
• Talking about the loss. Ask the person to talk about his or her loss. Older people, especially those who have experienced several losses over a short period, are often helped by sharing memories related to the losses.
• Watching for signs of prolonged grieving or depression and implementing preventive therapies.
• Older adults often have more than one loss to deal with at a time. Talking about each separate loss may help identify the person’s feelings. Separating losses from one another may also help the person feel less overwhelmed and more able to cope with emotional distress.
Social Isolation Social isolation, the sense of being cut off from people and things of importance, is an experience commonly described by older adults with cancer. Social isolation may be voluntary (i.e., a person seeks disengagement from social interaction) or involuntary (i.e., imposed by others or by circumstances). Choosing to be alone may provide important time for personal reflection, psychological rebuilding, and renewal. Involuntary social isolation, however, may have negative consequences on psychological health. Risk factors for
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social isolation include physical disability or illness, frailties associated with advanced age, psychological or neurologic disorders, and environmental constraints (e.g., physical surroundings, including diminished personal or material resources that are necessary to access or modify environmental factors) (Tilden & Weinert, 1987).
Voluntary social isolation may result when an older adult with cancer no longer feels comfortable in social settings because of his or her situation, including changes in body image, energy levels, or interests. Older persons with cancer may withdraw because they perceive that others are uncomfortable in their presence and because they believe, rightly or wrongly, that others are avoiding them because of the cancer diagnosis.
Involuntary social isolation may result from physical changes that prevent a person from continuing with social activities. Treatment-related side effects may interfere with the ability to drive or use public transportation, sit comfortably at a social gathering, or eat in restaurants.
Older adults experiencing cancer are particularly vulnerable to social isolation. Overall, declining physical health may limit the number or types of social activities available. The availability of social contacts may decline as family members and friends die or relocate. The recent loss of a spouse or partner may lead to social isolation, and the person may withdraw because of feelings of awkwardness or loneliness. Many older adults feel unsafe going places alone. Social isolation is not reflective of being restricted to a single place such as a home. Many older adults live a lifetime in a neighborhood only to find that the neighbors have moved, the area has changed and become less safe, and the social network that existed in the neighborhood or town has disappeared slowly over time. Older adults may perceive themselves as disconnected from the unfamiliar people in the neighborhood.
Family members may not live in geographic proximity, decreasing the ability to visit or seek assistance. It may be necessary to relocate an older adult during cancer treatment. When an older adult is relocated to live with family or in a residential care facility, he or she needs assistance with developing and maintaining social
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contacts.
Older adults may substitute interaction with health care personnel for meaningful social interaction. A clinic or home care visit may be an older adult’s only social contact for a long time. Nurses should evaluate the older adult’s need for social interaction; assess the person’s level of social activity before the cancer diagnosis, and determine whether it was satisfactory; ask what has changed in regard to social activities since the cancer diagnosis; determine what, if anything, has changed in regard to social activities as the person has gotten older; and work with the patient and family to identify strategies for maintaining social activities and contacts. Nurses should explore the importance of various activities described by the older patient. Many older adults value religious activities such as church attendance or prayer groups. In addition to meeting social needs, religious activities help meet spiritual needs.
Resources and Support An important component to nursing care of older adults is awareness of resources and referrals to appropriate agencies or support groups. Both cancer patients and their families have found support groups sponsored by local church groups, hospitals, home health agencies, and hospices to be helpful. Nurses should have up- to-date listings for the groups in their areas.
• Association for the Advancement of Retired People (AARP) and Grief and Loss, a national organization founded in 1973 to promote quality of life for older people, provide resources. The website on grief and loss includes community resources offering support to people grieving the death of a loved one. The website also has information on coping with the loss of a loved one and making plans such as funeral arrangements and financial decisions after a person’s death: http://www.aarp.org/families/grief_loss.
• The Hospice Association of America (HAA) seeks to heighten the public visibility of hospice services. HAA offers a number of helpful, practical publications for people who are considering
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hospice, including consumer guides, fact sheets, historical perspectives, and other background information. The website offers information from the legislative, regulatory, research, legal, and public relations departments, including “Hospice Facts and Statistics”: http://www.nahc.org/haa.
• The U.S. National Hospice and Palliative Care Organization (NHPCO) offers information on local hospice and palliative care programs across America. NHPCO is committed to improving end-of-life care and expanding access to hospice care with the goal of improving quality of life for dying people and their loved ones: www.nhpco.org.
• American Society of Clinical Oncology (ASCO) Resources: http://www.asco.org
• ASCO Answers Fact Sheets: This series of fact sheets provides a brief overview about a specific type of cancer, including a description of the cancer, how it is treated, terms to know, and questions to ask the doctor.
• Cancer Advances: Summaries of research advances in clinical oncology from the Journal of Clinical Oncology, ASCO’s Annual Meetings, and ASCO’s “Meet the Experts” events.
• What to Know: ASCO’s Guidelines: Patient-friendly guides based on ASCO’s Clinical Practice Guidelines for physicians.
• Research and Meetings: Find information on ASCO’s Clinical Cancer Advances report, ASCO’s Annual Meetings and Symposia, and virtual lectures. http://www.cancer.net
• ASCO Cancer Education Slides: Prepared cancer slide presentations, adapted from select Cancer.Net Guides to Cancer, are available for free download for oncologists, oncology nurses, and other members of the health care team.
• Ask the ASCO Expert Series: Read the transcripts from Cancer.Net “Ask the ASCO Expert” events, held from 2002-2006, in which patients, families, and the public asked ASCO experts questions about cancer and related topics, either through online chats or through month-long question-and-answer forums.
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Web resources are also being used by older persons. Those related to cancer include the following:
• National Cancer Institute: http://www.cancer.gov
• American Cancer Society: http://www.cancer.org
• National Breast Cancer Foundation: http://www.nationalbreastcancer.org
• Prostate Cancer Foundation: http://www.prostatefoundation.org
• American Lung Association: http://www.lungusa.org
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Summary The incidence of most cancers increases with advancing age. However, until recently, little attention was given to the special needs of older adults. The Oncology Nursing Society has outlined the knowledge required for nurses to provide holistic care for older adults with cancer, including the physiology of aging, geriatric assessment, symptom management, hospice and palliative care, survivorship issues, psychosocial issues, and the future of nursing care of persons with cancer (McEvoy & Cope, 2012).
Cancer prevention and screening programs for older adults require special attention to ethical issues. Findings may be misleading unless there is attention to specific issues of length bias, lead time bias, and overdetection bias. Decisions to screen older adults should be made on an individual basis.
Older adults are more vulnerable to the development of cancer. Because the aging cell has been exposed to a lifetime of potentially carcinogenic substances, it is more susceptible to damage and is less able to repair damage. In general, older adults are capable of tolerating cancer treatment when careful attention is paid to dosage adjustments and comorbid factors. The experience of cancer for the older adult is unique. Cancer in the older adult is cancer in the context of a life mostly lived.
Home care
1. Instruct homebound older adults and their caregivers to be aware of and report symptoms associated with the warning signs of cancer.
2. Educate older adults about cancer screening and self- examination.
3. Breast cancer is a disease of older women; thus, breast
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screening is a lifelong process. Instruct homebound older women on the American Cancer Society’s breast self- examination (BSE) guidelines.
4. Assess nonspecific symptoms such as indigestion, loss of appetite, and weight loss in both older men and older women. These warning signs are seen in cancer of the stomach, colon, and rectum.
5. Instruct caregivers and homebound older adults with cancer about general comfort measures to promote rest and sleep, with the goal of increasing pain tolerance.
6. Assess for side effects of cancer treatment therapies (e.g., radiation therapy, chemotherapy) and report to a physician, as needed, for treatment recommendations.
7. Instruct caregivers and homebound older adults on measures to reduce the side effects of cancer treatment therapies.
8. Refer patients to hospice during the last 6 months of terminal illness.
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Key points • Three leading causes of cancer deaths in women between ages 55
and 74 are lung, breast, and colorectal cancers; in men between these same ages, the leading causes of cancer deaths are lung, colorectal, and prostate cancers.
• Aging cells show a tendency toward aberration as they replicate, probably because of the failure of growth control mechanisms. Altered growth control mechanisms make the aging cell more vulnerable to damage, leading to the development of cancer.
• Clinical manifestations of cancer in older adults may be mistakenly attributed to normal, age-related changes. Older adults should be made aware of the warning signs of cancer and report symptoms associated with them to a health care provider.
• Nurses caring for older adults have a major responsibility to recommend strategies aimed at the prevention and early detection of cancer in this age group.
• Major treatment modalities for cancer include surgery, radiation therapy, chemotherapy, and biological therapy. Therapy with any of these modalities may be used alone or in combination; therapy may be curative or palliative.
• Functional status of an older adult is the most important consideration in selecting a treatment goal and modality. Age alone is not a good predictor of treatment tolerance or response.
• Older adults generally have fewer reserves, and greater attention should be given to the status of major organs, including the kidneys, liver, heart, lungs, and gastrointestinal system. Maintenance of fluid, electrolyte balance, and caloric intake is critical to treatment outcomes for older adults.
• Older adults are especially vulnerable to the nephrologic and hematologic toxicity of some chemotherapeutic agents.
• Psychosocial care of older adults with cancer includes addressing issues related to quality of life, depression, loss and grief, and
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social isolation.
• The cancer experience for each older adult is unique. Cancer in an older adult is in the context of a life mostly lived.
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Critical thinking exercises 1. You are asked to make a 30-minute presentation at a senior center on the benefits and risks of cancer screening in older adults. Prepare a topical outline for the presentation.
2. The director of oncology services asks you to develop a procedure for functional assessment of older adults with cancer. Develop the procedure and include any functional assessment parameters and instruments to be used.
3. The family cancer support group has asked you to facilitate a discussion on family considerations when an older family member has cancer. Prepare a list of the points that you would discuss with the group.
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* Previous authors: Linda L. Steel, PhD, APRN, ANP-BC, James R. Steele, MSN, APRN, NP-C, Joyce A. Guillory, PhD, RN, and Janet S. Fulton, BSN, MSN, PhD.
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C H A P T E R 1 8
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Loss and End-of-Life Issues Cindy R. Morgan, RN, MSN, CHC, CHPN; Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C
Learning objectives
On completion of this chapter, the reader will be able to: 1. Distinguish among loss, bereavement, grief, and mourning.
2. Discuss factors that may affect the length of time of bereavement.
3. Identify physical, psychological, social, and spiritual aspects of normal grief responses.
4. Describe four ways that complicated grief reactions may manifest themselves.
5. Discuss the tasks of mourning.
6. Describe nursing care activities for assisting bereaved older adults.
7. Discuss physical, psychological, social, and spiritual aspects of dying for older adults.
8. Explain age-related changes that affect older adults who are dying.
9. Describe nursing strategies for assisting dying older adults and their families.
10. Discuss the philosophy of palliative care.
http://evolve.elsevier.com/Meiner/gerontologic
Loss is a natural part of life and aging. The longer people live, the more losses they experience. Transitions involving loss that are commonly associated with aging are moving from employment into retirement, from a lifelong home to a smaller home or senior
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apartment, from being very active to being less so, from health to chronic illness, from marriage to widowhood, and from extensive social networks to smaller circles of family and friends. These transitions are considered losses in American society and are often viewed negatively. Successful aging requires learning to deal with these losses and adapting to the changes over time. Only recently has research shown that life transitions and crises such as the death of a loved one could act as catalysts for learning new skills and experiencing personal growth.
The purposes of this chapter are twofold: (1) to provide basic knowledge regarding loss, grief, mourning, and ways that nurses can assist the bereaved with mourning and (2) to discuss the experience of dying among older adults so that nurses can assist the grieving, the dying, and their families during these difficult times. The chapter discusses the nature of life transitions, especially those focused on death and dying; the meaning that these changes may have for older persons and their families; and typical ways in which people respond to such changes. A holistic approach incorporating physiologic, psychosocial, and spiritual aspects is applied, with discussion of the nursing care of older persons and their families throughout this process.
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Definitions The terms loss, bereavement, grief, and mourning are often used interchangeably, but these words convey different meanings (Doka, 2013). Loss is a broad term that connotes losing or being deprived of something such as one’s health, home, or a relationship. Bereavement is the state or situation of having experienced a death- related loss. Grief is one’s psychological (cognitive or affective), physical, behavioral, social, and spiritual reactions to loss. Mourning is often used to refer to the ritualistic behaviors in which people engage during bereavement. More recently, mourning is the term used for processes related to learning how to live with one’s loss and grief.
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Losses A loss may involve a person, thing, relationship, or situation (Corless, 2010). Gradual and abrupt life transitions such as retirement, change of residence, ill health, loss of pets, and the inability to drive are losses that evoke varying responses of grief. Most of the literature and research on losses among older persons focuses on the death of spouses; less attention is paid to the loss of parents, siblings, adult children, and friends. For all types of transitions—from moving to a new home to the death of a loved one—people’s responses depend on their perception of the events and the meaning of the loss within the context of their lives and their physical, psychosocial, and spiritual life patterns.
Many older adults experience multiple losses with little time for grieving between the losses. The emotional crises imposed by these multiple losses can lead to disorientation, mental confusion, and withdrawal. Individual coping styles, the existence of support systems, the ability to maintain some sense of control, and the griever’s health status and spiritual beliefs all influence a person’s responses to multiple losses (Garrett, 1987).
Bereavement Bereavement includes grief and mourning, both the inner emotional response and the outward response of the survivor (Corless, 2010). The time that one spends in the period of bereavement is affected by many factors. The death of one’s spouse or life partner is usually the most significant loss that an older person may experience. It involves the loss of a companion who often is one’s best friend, sexual partner, and partner in decision making and household management, as well as a contributing source to one’s definition of self or identity. Because many older couples frequently divide the tasks of daily living, surviving spouses must take on new responsibilities while coping with the loss of their loved ones. Perceived social support after the death of a spouse has been shown to be a factor affecting the adjustment of many surviving spouses
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(Balk, 2013). Other factors that may affect bereavement outcomes include ambivalent or dependent relationships, mental illness, low self-esteem, and multiple prior bereavements.
Although bereavement after the death of a spouse is a highly stressful process, the summary of studies of widowed persons by Lund (1989) concluded that many older surviving spouses are resilient. Although 72% of those studied reported that the spouse’s death was the most stressful event they had ever experienced, they also reported high coping abilities. The overall effects of grief on the physical and mental health of many older adults were not as severe as expected, and both positive and negative feelings were experienced simultaneously. Loneliness and problems associated with tasks of daily living were two of the most common difficulties reported. Although bereaved older adults adjusted in many different ways to the deaths of their spouses, in general, the most difficult period was the first several months, with the process improving gradually but unsteadily over time.
The review by Lund (1989) also showed that older men and older women are more similar than dissimilar in their bereavement experiences and adjustment. Age, income, education, and anticipation or forewarning of death did not seem to have much effect on future adjustment processes. Religion-related variables also did not contribute much to adjustment. Social support was moderately helpful in the adjustment process, as were internal types of coping resources such as independence, self-efficacy, self- esteem, and competency in performing tasks of daily living.
Older adults’ normal grief responses to the loss of a spouse were summarized by Lund (1989). The following conclusions, drawn from his work, speak specifically to the bereavement experiences of older persons:
• Bereavement adjustments are multidimensional in that nearly every aspect of a person’s life may be affected by the loss.
• Bereavement is a highly stressful process, but many older surviving spouses are resilient.
• The overall effect of bereavement on the physical and mental health of many older spouses is not as devastating as expected.
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• Older bereaved spouses commonly experience both positive and negative feelings simultaneously.
• Loneliness and problems associated with the tasks of daily living are two of the most common and difficult adjustments for older bereaved spouses.
• Spousal bereavement in later life might best be described as a process that is most difficult in the first several months but that improves gradually, if unsteadily, over time. The improvement may continue for many years, but it may never end for some.
• A great deal of diversity exists in how older bereaved adults adjust to the death of a spouse.
As indicated in the study by Lund, the time and intensity of feelings during bereavement are based on many individual factors.
Grief Grief is the individualized and personalized emotional response that an individual makes to a real, perceived, or anticipated loss (Kissane, McKenzie, McKenzie et al., 2003). Normal grief reactions may be characterized by time: early, middle, and last phases. In the early phase, shock, disbelief, and denial are common. This phase commonly ends as people begin to accept the reality of the loss after the funeral. The middle phase is a time of intense emotional pain and separation and may be accompanied by physical symptoms and labile emotions. Lastly, reintegration and relief occur as the pain gradually subsides and a degree of physical and mental balance returns (DeSpelder & Strickland, 2010).
Human beings respond wholly to loss and manifest grief physically, psychologically, socially, and spiritually (see Patient/Family Teaching box). These are all different aspects of the whole.
Patient/family teaching
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Common Symptoms of Normal Grief Responses Grief responses have physical, psychological, social, and spiritual aspects. The duration and intensity of symptoms are highly variable. Most of the more intense symptoms subside in 6 to 12 months; however, mourning may continue for several years.
Physical symptoms commonly include crying, loss of appetite, decreased energy and fatigue, and sleep difficulties. Psychological responses commonly include feelings of sadness, guilt, anxiety, anger, depression, helplessness, and loneliness. Social changes following the loss of a loved one depend on the role of the deceased. In widowhood, a loss of social support, an adjustment to living alone, and sometimes an inability to manage tasks of daily living are frequently experienced unless new skills are learned. Spiritual responses often lead the bereaved to search for meaning in life and to reexamine his or her faith and belief system.
Physical Symptoms Physical symptoms are commonly associated with acute grief responses. Tearfulness, crying, loss of appetite, feelings of hollowness in the stomach, decreased energy, fatigue, lethargy, and sleep difficulties are common symptoms of grief. Other physical sensations may include tension, weight loss or gain, sighing, feeling of something being stuck in the throat, tightness in the chest or throat, heart palpitations, restlessness, shortness of breath, and dry mouth (Corr & Corr, 2013).
Psychological Responses Studies of grief responses have consistently identified common psychological responses. Feelings of sadness are the emotions most often mentioned (Worden, 2009). Other common feelings include guilt, anxiety, anger, depression, apathy, helplessness, and loneliness. Guilt and regret regarding one’s relationship with the person who has died may be especially troublesome (Landman, 1993). Shock and disbelief may immediately follow the death. The bereaved person may also display diminished self-concern, a
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preoccupation with the deceased, and a yearning for his or her presence. Some older persons become confused and unable to concentrate after the death of someone significant to them. Grief spasms, periods of acute grief, may come when least expected (Rando, 1988). How the grief response manifests itself is individually determined by sociocultural factors in addition to the quality of the relationship between the deceased and the mourner. For some older persons, the grief experience may include feelings of relief and emancipation, especially after prolonged suffering or a difficult relationship.
Social Responses The social changes that follow the loss of a loved one depend on the type of relationship and the definition of social roles within the relationship. Widowhood is the loss that generally has the greatest effect on social role change, but any loss of a person within one’s household is especially difficult. In addition to deep psychological pain, the bereaved person must often learn new skills and roles to manage tasks of daily living. All these social changes occur at a time when withdrawal, a lack of interest in activities, and a lack of energy make decision making and action very difficult. Socialization and interaction patterns also change. If an older couple often socialized together with other couples, widowhood may bring dramatic changes in the type and style of interaction. For others who have strong social support and established patterns of independent interaction outside the lost relationship, the adjustment process toward creating new social roles and interactions may occur more quickly.
Spiritual Aspects Lastly, the death of a loved one inevitably causes bereaved people to ponder the existential issues of life and to examine the meaning of not only the lost loved one’s life but also their own. Spiritual issues may surface as the person searches for meaning. Anger at God, sometimes followed by a crisis of faith and meaning, may accompany bereavement. It may be important for the bereaved to view the death of their loved one as a transition to a life with God
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in the spirit. Meaning in life is highly individualized, but the importance of finding meaning in life is more universal. What a person finds meaningful is not as important as the ability to look back on life and see that it has been meaningful and to understand that life can continue to be meaningful even in its last stages.
Religion and spirituality can provide a stabilizing influence during grief. One’s religious institution may provide the sense of belonging to a group of people who support one another in times of need. Some may experience a deep inner sense of peace that they are being cared for by a higher power. For others, however, the grief experience may precipitate a crisis in their beliefs and values. Gender, social class, ethnicity, and culture may influence one’s spiritual response to grief (D’Avanzo, 2008; Doka & Davidson, 1998) (see Cultural Awareness box).
Cultural awareness
Loss and End-of-Life Issues In some cultures, people believe that particular omens may warn of approaching death (e.g., some Native American and Mexican American groups believe the appearance of an owl and messages in dreams foreshadow death). Research indicates that the desire to be told of one’s impending death varies according to culture: 71% of whites, 60% of blacks, 49% of Japanese Americans, and 37% of Mexican Americans want health care providers to tell them if they are dying. Each of these groups indicated that the physician is the most appropriate person to communicate the information and that a family member is the second most appropriate.
Although death is a universal human experience, culture- specific considerations exist with regard to attitudes toward the loss of a loved one, including age (e.g., child versus older adult) and cause of death. In many Asian American cultures, the loss of an older adult (perceived as having accumulated years of
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wisdom and knowledge) may be mourned more than the loss of an infant or child (viewed as having made a lesser contribution to society because of fewer years of life experience). For many whites, the reverse may be true; relatively greater sorrow may be expressed over the loss of a younger person (perceived as having been cheated out of achieving his or her fullest potential) than is expressed over the loss of an older individual (perceived as having lived a full and productive life). It should be noted that regardless of age, human life is valued by all cultures and that loss of life is mourned by those who knew and loved the deceased.
Among the Tohono O’odham (Papago Indians of Arizona) the concept of “good” and “bad” death is prevalent. A good death comes at the end of a full life when a person is prepared, whereas a bad death occurs unexpectedly and violently (e.g., accidents, homicides, and suicides) and leaves the victim without a chance to settle affairs or “say good-bye.” Some cultural and religious groups consider suicide taboo and may impose sanctions even after death (e.g., burial in church cemeteries may be denied).
Both culture and religion influence postmortem rituals. Muslims have specific rituals for washing, dressing, and positioning the body, whereas some Jewish groups discourage cosmetic restoration or attempts to hasten or retard decomposition by artificial means. Among some Asian American groups, it is customary for family and friends of the same gender to wash and prepare the body for burial or cremation. As part of their lifelong preparation for death, Amish women sew white burial garments for themselves and their family members. Deceased members of the Church of Jesus Christ of Latter Day Saints (Mormons) are dressed in white temple clothing before being viewed by family and friends. Some Native Americans believe that the spirit of the deceased person will contaminate them and refuse to touch the body after death. The traditional Navajo is dressed in fine apparel, adorned with expensive jewelry and money, and wrapped in new blankets. Some Navajo believe that the structure in which the person died must be burned.
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Often interrelated with religious beliefs and practices, culture influences funeral and burial or cremation practices, as well as what is expected of bereaved family members (e.g., who grieves, for how long, and culturally appropriate behaviors during mourning). Among Chinese Americans, five degrees of kinship (wu-fu) are recognized, and these determine the degree of mourning that is expected according to the closeness and importance of the deceased to the mourner.
Lastly, the nurse should be aware that culture may influence the choice of a final resting place for the deceased person. For example, the bodies of older Jewish patients may be flown to Jerusalem for burial, Christians may prefer to be buried in ground blessed by a priest or minister, and those who are cremated may have expressed various preferences for the disposition of the ashes. Traditional Chinese Americans may follow a system of double burial: The coffin is initially buried for 7 years, and then the remains are exhumed and stored in an urn.
In summary, the nurse should remember that each aspect of grief is integrated within the whole person. Interventions directed at one of these areas will affect the other areas; thus, an approach that separates the mind, body, and spirit is not advocated. One’s responses to loss and death are characterized by (1) changes over time, (2) one’s natural reaction to all kinds of losses, not just death, and (3) one’s unique perception of the loss (Rando, 1988).
Types of Grief Anticipatory grief and the responses described thus far are generally considered “normal” or uncomplicated grief reactions. When grief progresses in an unhealthy way and does not move toward resolution, it is called complicated mourning or abnormal grief. The nursing diagnosis for complicated mourning or abnormal grief is Dysfunctional Grieving and shares many of the defining characteristics of normal grief. Dysfunctional grieving occurs for an extended length of time and is severe in its intensity. Nurses need to be familiar with dysfunctional grieving and should refer patients to advanced practice nurses or other health professionals skilled in
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working with complicated grieving.
Anticipatory grief is defined as grieving that occurs before the actual loss. It includes the processes of mourning, coping, and planning, which are initiated when the impending loss of a loved one becomes apparent (Rando, 1986). These may be healthy responses to an impending death, but they also may have a negative impact on the relationship with the dying person when one’s energies are predominantly focused on the future. Anticipatory grief may account for some persons’ apparent lack of overt grief reactions after the death of a loved one who experienced a long terminal illness. Anticipatory grief increases as death becomes imminent and ends when the death occurs. Anticipatory grief helps reduce early shock, confusion, and depression. Survivors who resolve grief before the death of a loved one may be criticized by others or experience self-reproach for lack of a grief reaction to the actual death. These responses may lead to further problems of adjustment.
Disenfranchised grief is grief that is not or cannot be openly acknowledged (Doka, 1989). This complicates the grieving process both because it cannot be expressed and because social support is not available. Doka (1997, 2002) described four major situations that cause disenfranchised grief: (1) when a relationship is not recognized by others (e.g., in the case of cohabitation or same-sex partners), (2) when a loss is not acknowledged (e.g., death of a pet), (3) when the griever is excluded (e.g., very old adults, those with cognitive deficits), and (4) when the circumstances of the death are disenfranchising (e.g., deaths caused by drunk driving or suicide).
Complicated grief reactions may manifest as one of four types: (1) chronic, (2) delayed, (3) exaggerated, or (4) masked. Chronic grief reactions are prolonged and never reach a satisfactory conclusion. Because bereaved individuals are aware of their continuing grief, this reaction is fairly easy to recognize. A therapist can assess which tasks of grieving are not being resolved and why. The goal of intervention is to resolve these tasks (Worden, 2009). Delayed or postponed grief reactions occur when the griever’s response at the time of the loss is either absent or not sufficient to deal with the loss. At some future time, the person may experience an intense
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grief reaction triggered by a subsequent, smaller loss or by any other event that triggers sadness. Feelings of hostility or ambivalence are usually present in this kind of reaction. Exaggerated grief reactions occur when normal feelings of anxiety, depression, or hopelessness grow to unmanageable proportions. People with exaggerated grief may feel an overwhelming sense of being unable to live without the deceased person. They may lose the sense that the acute grief is transient, and they may continue in this intense despair for a long time (Worden, 2009). Masked grief reactions occur when bereaved persons experience feelings related to the loss but cannot express or recognize the source of these feelings. This reaction may occur as a self-protective mechanism because some people may not be able to bear the stress of mourning. Repression of grief responses usually manifests as either a physical symptom, often similar to one that the deceased experienced, or as some type of maladaptive behavior (Worden, 2009).
In summary, Rando (1988) outlined factors that influence how people experience and express their grief. Categories of psychological factors include the characteristics and meaning of the lost relationship, the personal characteristics of the bereaved, and the specific circumstances surrounding the death (Table 18-1). Social factors include the griever’s support system, sociocultural and religious background, education and economic status, and funerary rituals. An individual’s physical state also influences the grief response. Important physical factors are the use of drugs and sedatives, nutritional state, adequacy of rest and sleep, exercise, and general physical health. Nurses need to be aware of how all these factors affect dying persons and their families so that they may provide the best care possible.
Table 18-1 Psychological factors influencing grief responses
Characteristics and Meaning of Lost Relationship
Personal Characteristics of Bereaved
Specific Circumstances of Death
Nature and meaning of loss Qualities of lost relationship
Coping behaviors, personality, and mental health
Immediate circumstances of death
Timeliness of death Role and function filled by deceased Level of maturity and
intelligence Perception of preventability
Characteristics of deceased Past experiences with loss and death
Sudden versus expected death
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Amount of unfinished business between bereaved and loved one
Social, cultural, ethnic, and religious background
Length of illness before death Anticipatory grief and involvement
Perception of deceased’s fulfillment in life Gender role conditioning Number, type, and quality of secondary losses that accompany the death
Presence of concurrent stress or crises in life
Modified from Rando, T.A. (Ed.) (1986). Loss and anticipatory grief. Lexington, MA: Lexington Books. Used with permission of Therese A. Rando, PhD.
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Mourning Mourning was defined at the beginning of this chapter in two ways: (1) ritualistic activities such as wearing dark clothes during bereavement or lighting candles for the dead and (2) processes related to learning how to live with one’s loss and grief. Each way is prescribed by social and cultural norms that indicate acceptable coping behaviors in a person’s society (Corless, 2010). The emphasis in this section will be on the processes of learning to live with loss of a loved one and will include the traditional stage or phase perspectives of adjustment, tasks of mourning, and two meaning- making approaches. The complexity of the mourning process does not lend itself to a single theory.
Stage or Phase Perspectives Most of the stage or phase theories of mourning have some aspect of the following concepts: avoidance, assimilation, and accommodation (Buglass, 2012). Avoidance is often felt when one is first confronted by the death of a loved one. The news is hard to believe; however, when the reality is viewed as a fact, strong emotions emerge. Deep emotional pain and even anger toward those seen as responsible for the death, for example, doctors, the deceased person, or God, is common. Gradually the reality of the new situation without the loved one is assimilated. This may be a time of despair when the void left by the deceased is felt deeply. Eventually, the physical, behavioral, psychological (cognitive or affective), social, and spiritual reactions to the loss decrease, and the bereaved move into the accommodation stage or phase. This is a time when the bereaved begin to accept the loss, move on in their lives, and yet remain attached to their loved ones in a healthy way.
An example of a stage or phase approach to mourning is the early study of survivors of the 1942 Coconut Grove fire in Boston by Lindemann (1944), in which he identified physical and psychological symptoms associated with acute grief. The ages of the mourners were not known.
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Although common elements in mourning seem to exist, the stage or phase models have been criticized. Much variation exists in how people respond to loss on the basis of factors such as the relationship the survivor had with the deceased and ways of coping with loss. Many older adults do not go through the first stage of mourning. They may have expected the death or may be beyond shock and disbelief after having experienced multiple losses in their lifetime. They may also undergo several of the stages at the same time. Regardless of whether shock or anticipation occurs, the task of accepting the reality of the loss is relevant for all.
Tasks of Mourning The tasks of mourning defined by Worden (2009) are more active and useful descriptions of mourning among older persons. He described the following four tasks of mourning: (1) accepting the reality of the loss, (2) experiencing or working through the pain of grief, (3) adjusting to an environment in which the deceased is missing, and (4) emotionally relocating the deceased and moving on with life. The first task, accepting the reality of the loss, involves coming to the realization that the person is dead, that he or she will not return, and that reunion, at least in life as we know it, is impossible. The second task, experiencing the pain of grief, is necessary to prevent the pain from manifesting itself in some other symptom or problematic behavior. Sociocultural customs that discourage open expression of grief often contribute to unresolved grief. The third task, adjusting to an environment in which the deceased is missing, involves developing new skills and assuming the roles for which the deceased was responsible. The last task, withdrawal of emotional energy and reinvestment in another relationship, entails withdrawing emotional attachment to the lost person and loving another living person in a similar way. For many, this last task is the most difficult.
It is critical that older persons who have lost loved ones acknowledge that pain is associated with grief and loss and that they must adjust to an environment where the loved one is absent. The expression of pain depends partly on culture and partly on the quality of the relationship with the lost loved one. Guilt may
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accompany the pain of grief.
Adjustment to one’s environment after the loss of a loved one involves learning new roles such as those previously assumed by the deceased and new ways of interacting with others in one’s social environment. This adjustment may be especially difficult if the loved one lost is the spouse and the social network consists primarily of other couples.
The final task, emotionally relocating the deceased and moving on with life, gives the bereaved person permission to invest emotionally in others without being disloyal to the lost loved one. Although Worden (2009) pointed out that in one sense mourning is never over, he also stated that in losses that involve a great deal of emotional attachment, the process takes at least 1 year before the wrenching pain subsides. Some older spouses have reported that they feel as though they will never “get over” their loss but that they have learned to live with it (Lund, 1989).
In contrast to detaching or “letting go” of the deceased, Klass, Silverman, and Nickman (2006) viewed the bond between survivors and the deceased as dynamic rather than static. On the basis of their research, they suggested that bereaved persons maintain a continuing bond with the deceased. This approach is different from advocating that the mourner totally disengage or sever bonds with the deceased.
Meaning Making Burbank (1992) found that the major source of meaning in life among older persons came from relationships with family members. When loved ones die, meaning derived from these relationships changes. Personal beliefs and attitudes, including cultural and religious ones, influence how the meanings of the losses are perceived. Some of the more common perceptions attached to illness and death are punishment by a supreme being, suffering that must be overcome or endured, a normal part of the life experience, and an opportunity for personal growth and transcendence. The meaning of a loss to a bereaved person has a significant effect on his or her responses to that loss. For this reason,
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it is important that caregivers explore the perceptions of the bereaved to understand and assist them as they mourn their loss.
Neimeyer (2000) proposed that reconstructing the meaning in a person’s life after the death of a loved one is an important process of mourning. The bereaved are encouraged to find or create new meaning in their lives and in the deaths of the deceased. This is a cognitive process that is affected by one’s social context as well as one’s individual resources.
The multiple definitions of meaning, however, require further clarification. Holland, Currier, and Neimeyer (2006) found that the terms, “sense making” and “benefit finding,” were central to finding meaning. Their research indicated that better outcomes came from making sense of the death and the resulting life of the survivor than from finding benefits from the death such as reordering life priorities and becoming more empathetic.
Building on the work by Holland et al., (2006), researchers further operationalized “meaning” and “grief” to include identity change and purpose in life because they found that an important facet of meaning is the significance that some aspect of one’s life experience “matters” (Hibberd, 2013).
The dual process model of coping with bereavement is another way to make meaning after the death of a loved one. In this model, Stroebe and Schut (2001) suggested that the bereaved waver between loss-oriented and restoration-oriented approaches to everyday life experiences. Regardless of whether persons are in loss-oriented or restoration-oriented states, they vacillate between positive and negative meaning (re)constructions until, over time, they become more focused on positive meaning reconstruction. For instance, persons might vacillate between positive reappraisal of the situation and negative rumination about the death, but they gradually spend more time making meaning from positive reappraisals of their situation.
Nursing Care The goal of nursing care for older persons who are grieving and mourning is not to “make them feel better” quickly, although
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nurses are often tempted to try to do so. Nurses should assist and support bereaved persons through the grieving process, recognizing that pain is a normal and healthy response to loss and allowing bereaved persons to accomplish the tasks of mourning in their own ways.
Assessment Initial assessment of bereavement risk may be accomplished by using the Bereavement Risk Assessment Tool (BRAT) developed by the Victoria Hospice Society (2013) (Figure 18-1). While a patient is moving through the phases of grief, progress can be measured using the 10-Mile Mourning Bridge (Huber & Gibson, 1990) (Figure 18-2). This tool, useful for both clinical assessment and research purposes, draws on the work by Worden (2009) and is conceptualized as a journey across a 10-mile bridge. On the bridge, the 0 represents the time before grief. The 10 reflects Worden’s last stage, in which patients recover the emotional energy consumed by grieving and reinvest it in their own lives. It is not suggested that people ever “get over” the death of a loved one but rather that grief could cease to be the primary focus of life. Patients may use the 10- Mile Mourning Bridge as a self-assessment tool with daily or weekly frequency, as determined by the patient. Because each person’s grief experience is unique, the miles on the bridge are only defined at each end. The use of this instrument may also facilitate patient–nurse discussions about grief and progress (Huber & Bryant, 1996).
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FIGURE 18-1 The Bereavement Risk Assessment Tool (From Victoria Hospice Society. (2008). Bereavement risk assessment tool (BRAT). <http://www.victoriahospice.org/health-professionals/clinical-tools> Accessed
11/08/2013.)
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FIGURE 18-2 The 10-Mile Mourning Bridge. (From Huber, R. & Gibson J. (1990). New evidence for anticipatory grief. The Hospice Journal, 6(1), 49.)
Grief Counseling Grief counseling is used to facilitate successful progression through the grief process, whereas grief therapy is intended for those who are experiencing complicated mourning. Nurses, other health care professionals, and specially trained volunteers may provide grief counseling, whereas therapy should be conducted under the guidance of a skilled therapist (Worden, 2009). The following section discusses grief counseling.
Worden (2009) suggested four ways that grief counselors may assist grieving persons in the tasks of mourning. The aim is to (1) increase the reality of the loss, (2) help the counseled person deal with both expressed and latent effects, (3) assist the counseled person in dealing with various impediments to readjustment after the loss, and (4) encourage the counseled person to make a healthy emotional withdrawal from the deceased and to feel comfortable reinvesting that emotion in another relationship. Worden’s grief counseling principles are as follows:
• Help the survivor actualize the loss. Nurses are often the first to initiate this process, especially after the death of a patient in a health care institution. Nurses are usually the professionals present to offer details and descriptions of the death or
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explanations of puzzling situations that family members may not understand. Having information about the death and the events preceding and following the death is important in helping to actualize the loss. Survivors may need to be encouraged to talk about the loss, to tell the story of events surrounding the death, and to relate memories of the deceased. This process takes time. Worden (2009) found that many survivors took up to 3 months before they began to accept the reality that their spouses were dead and not going to return.
• Help the survivor identify and express his or her feelings. Because they are unpleasant, some feelings accompanying bereavement may not be expressed or recognized by the bereaved person. Nurses need to assess a bereaved person’s feelings and ask specific questions that encourage expression. Feelings that often go unexpressed include anger, guilt, anxiety, and helplessness (Worden, 2009). Guilt and regret may be recognized and expressed through storytelling, writing in a journal, or writing a letter to the deceased. A ritual such as burying or burning the letter may assist the mourner in resolution. Sometimes, unpleasant emotions are displaced. For example, anger may be directed toward the deceased, toward God, or toward the physician or nurse who helped the family care for the loved one. Such anger may be difficult to understand, but it is helpful for the targets of the anger to detach themselves and not respond defensively. Sociocultural and gender differences influence expression of emotions and need to be taken into account. Older persons may also express their emotions differently from how younger ones do, especially after dealing with multiple losses; for example, crying may be a less common indicator of sadness among older persons.
• Assist the survivor in living without the deceased. The nurse needs to assess the survivor’s daily living situation and identify any existing or potential problems. The roles played by the deceased must now be assumed by the survivor (or someone else) to accomplish tasks of daily living. Knowledge of community resources and teaching of practical skills are necessary to meet this need. In general, survivors should be advised to postpone
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making major decisions that involve life changes such as selling property or moving. Calling on the survivor’s social support system is also useful.
• Facilitate the survivor’s emotional withdrawal from the deceased. The nurse needs to be especially sensitive to when the bereaved should emotionally withdraw from the deceased, while maintaining the bond to the deceased, and begin developing new relationships. This is especially difficult if the relationship lost was that of a spouse. Research has shown that older persons who lose a confidante are less likely than younger persons to replace the confidante. Perhaps they are unwilling to emotionally invest in another intimate relationship when the risk of repeated loss is very high. Other types of relationships such as close friendships may be encouraged to help meet an older person’s needs for intimacy.
• Give the survivor time to grieve. It used to be believed that after the first anniversary of the death, grief should be resolved. This has been shown to be inaccurate; many factors influence the time for adjustment, as discussed previously. Two points in time seem to be especially critical: 3 months after the death and 1 year after the death (Worden, 2009). Older persons who have experienced multiple losses may need more time. For some, the losses may never be resolved. A person may simply learn to live with the feelings of grief.
• Interpret “normal” behavior for the survivor. It is important that nurses, with a clear understanding of the range of normal grief responses, communicate acceptance and reassurance of the normalcy of a grieving person’s responses. Grieving individuals should be reassured that they are not going crazy, that their physical and psychological responses are normal in the face of significant loss, that grief spasms may occur, and that they will feel better in time.
• Allow for individual survivor differences. Just as nurses must be sensitive to individual differences in styles of grieving, family and friends need to accept differences among themselves in their grief responses. Nurses may need to explain the wide range of responses and assist mourners with allowing one another to
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grieve in their own ways.
• Provide continuing support for the survivor. Although nurses’ interactions with bereaved persons may be brief or intermittent, referrals may be made for outside support. This support may include community resources and support groups. Nurses should also encourage the bereaved to mobilize their own support system of family and friends.
• Examine the survivor’s defenses and coping styles. Certain coping behaviors are healthy, whereas others are not. An older person has had a lifetime of experience coping with stressful situations and usually has well-established patterns of coping. Under normal circumstances, these defenses and coping mechanisms can often be used successfully; however, they may not be effective in dealing with monumental or accumulated losses. Unhealthy coping mechanisms may lead to destructive behaviors such as alcoholism. Nurses could help the bereaved identify their coping mechanisms, evaluate their effectiveness, and either encourage their continued use or explore other ways of coping more positively.
• Identify pathologic conditions for the survivor and make appropriate referrals. Assistance through grief counseling and professional guidance may not be sufficient if additional problems arise that require more intensive help. Nurses need to be particularly alert to serious depressive illness and should make referrals accordingly. Losing a spouse and living alone puts older persons at risk for depression. Older white men have the highest suicide rate of any group, which may suggest that depression is a significant problem for this age group. Discussing with older men the meaning in their lives may give the nurse clues to problems in this area.
Nurses in all settings are in a position to assist the bereaved at various stages of grief. Nurses are the most effective, however, when they examine their own losses, grief expectations, and patterns of coping with loss. Personal experiences with loss inevitably influence the effectiveness of the help that nurses can give to others who are mourning. A nurse who has successfully worked through a loss—big or small—and has reflected on the
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experience has valuable insight into the grieving process. However, a nurse who is himself of herself grieving may be unable to invest emotional energy in the care of a patient who is experiencing acute grief.
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Approaching death: older persons’ perspectives The following section addresses the nature of dying among older persons, including stages of dying, attitudes toward death, and physical, psychological, social, and spiritual responses. Nursing strategies for older persons who are dying, palliative and hospice care, environmental considerations, and family and caregiver perspectives are other areas that are important in the optimal care of dying older adults.
In her classic work on death and dying, Kübler-Ross (1969) identified five stages that are widely used in practice with dying patients. This model purports that dying individuals progress through the stages of denial, anger, bargaining, depression, and, finally, acceptance of death. All people may not move through these stages in a sequential and orderly fashion, and some even move back and forth between stages; however, this stage theory has become popular in interpreting the behavior and feelings of dying persons, sometimes to their detriment. Retsinas (1988) critiqued these five stages and argued for a different model of death for older adults that takes into account the following factors: (1) that very old persons see themselves as confronting impending death, (2) that they may be accustomed to the sick role and their gradual decrease of vitality, (3) that roles have already been redefined, and (4) that death may truly be timely for older persons.
Psychological Aspects Kastenbaum (1978) pointed to assumptions such as older persons being ready for timely deaths as evidence of our society’s ageist attitudes. Although the literature demonstrates that older persons hold a wide variety of attitudes toward death, fear of their own death is relatively rare. Instead, major concerns among older persons about dying are fears of a long debilitating illness, fears of being a burden, fear of pain and suffering, concerns about quality of life, and fear of dying suddenly and not being found (Lloyd-
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Williams, Kennedy, Sixsmith, & Sixsmith, 2007). Cultural variations may also play a part in older peoples’ attitudes toward death (Beshai, 2008; Field, 2000; Madnawat & Kachhawa, 2007; Upadhyaya & Kautz, 2009). A person who has had positive experiences of coping and is relatively well adjusted usually approaches the stress of being close to death with adaptation and acceptance. Although personal fear of death seemed generally uncommon, Field (2000) found that even among those who accepted their nearness to death some were not ready to die. They wished to continue living as long as possible. A “good death” for this population would be one with friends and family present (Gott, Seymour, Bellamy et al., 2004), minimal physical or mental dependency, a minimal amount of being a burden to others, being able to stay in their own homes, and having their emotional, spiritual, and financial needs met (Lloyd-Williams, Kennedy, Sixsmith & Sixsmith, 2007; Payne, Langley-Evans, & Hillierk, 1996; Steinhauser, Christakis, Clipp et al., 2000). Individual assessments of feelings about death need to be conducted, however, because older adults have widely varied experiences and attitudes.
Once people have identified themselves as nearing the end of their lives, they commonly engage in a process called life review (Butler, 1963), in which they try to make sense of life as a whole. Erikson (1963) identified the last task of life as a psychosocial crisis of integrity versus despair. In this theory, older persons nearing death are expected to review their lives and draw some conclusions about the positive and negative aspects. If they can generally say their lives have been meaningful and worth living, a sense of ego integrity emerges. If, however, their lives are evaluated negatively, they may experience a sense of regret or meaninglessness and despair. Acceptance of death is influenced by positive memories that may help the person reach the happy conclusion that their life has been good (Young & Cullen, 1996).
Psychological issues associated with dying were found to cause the most concern to patients, families, and health care professionals (Reynolds, Henderson, Schuman, & Hanson, 2002; Wong et al., 2004). The most common unmet emotional needs of dying residents in nursing homes included sadness and depression (44%), anxiety
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or agitation (33%), and loneliness (21%) (Reynolds et al., 2002).
Spiritual Aspects Religious beliefs and spiritual experiences play an important part when older persons are trying to make sense of their lives. Faith in a supreme power may give life a transcendent meaning and help people view their lives within the context of a greater purpose or meaning. Sometimes, dying or a threat of loss may trigger a crisis of faith, in which people question their previous beliefs in an effort to make sense of the present experience. Moadel et al., (1999) studied ethnically diverse patients with cancer and found that up to 51% expressed unmet spiritual or existential needs. In a study by Reynolds et al., (2002), 30% of dying nursing home residents needed more care in the area of spiritual and emotional needs.
Three spiritual needs of dying persons have been identified by Doka (1993): (1) the need to search for the meaning of life, (2) the need to die appropriately, and (3) the need to find hope that extends beyond the grave. These three needs reflect Erikson’s developmental task for the last stage of life, as well as other research findings regarding older persons’ fears of dying. Religious or spiritual beliefs and experiences may be instrumental in helping older persons cope with these fears. Assessing patients’ desires for religious and spiritual assistance is particularly important when they are dying. Among the many reasons for spiritual care at this time are preparing for death and the afterlife, dealing with anger over dying, seeking forgiveness for past wrongs, searching for peace, and meeting the needs of a family coping with loss (Hall, 1997). The National Consensus Project for Quality Palliative Care (NCPQPC, 2009) included assessing and treating spiritual needs in its list of nursing competencies for quality end-of-life care; however, spiritual care is not consistently provided. The Spiritual Needs Inventory (Hermann, 2006) has been validated for use in assessing the spiritual needs of patients near the end of life.
Social Aspects Once the term dying is applied to an individual, role changes are
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often initiated or reinforced by family and friends. The adoption of the sick role may be accompanied by an acceptance of one’s fate. However, some dying individuals may adopt a fighting stance, determined to do all they can to outwit or forestall death. Some move ahead with resolve to define themselves as “still living,” refusing to accept the label of dying and thus living each day as fully as possible. The stance people take toward dying is affected by sociocultural, psychological, and life history factors. Some of these attitudes toward dying are positive and promote growth; others are negative and difficult to endure, not only for dying persons but also for those around them. For example, it is troublesome when family members want to resolve issues while the patient denies that he or she is dying and refuses to discuss matters that need resolution.
Because death and dying have been regarded as taboo topics in American society, most people are uncomfortable, at least initially, when talking about death with someone who is dying. This is partly because of having to confront one’s own mortality when facing the death of others. It is fairly easy to live an illusion of stability and immortality when around young, healthy persons. However, when a loved one is dying, thoughts turn to one’s own mortality and what life will be like without this person. Because these thoughts are uncomfortable for most, one way of relieving this discomfort is to avoid the dying person. Social isolation often results as friends and sometimes family seemingly abandon the dying person. A special concern for older persons results from society’s attitude that they are ready to die and therefore may have less need to interact with others. It is often seen as normal and natural for them to disengage and die quietly. This attitude also fosters social isolation. Thus, social isolation, loneliness, and role changes are typical concomitants of dying for older persons. Nurses and physicians may also avoid openness in communicating with older dying patients. Costello (2001) found that nurses provided individualized physical care to dying patients, but little evidence of spiritual and emotional care was included in this practice.
Physical Aspects An obvious and sometimes puzzling issue for those working with
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older persons is deciding when to consider a person to be dying. Is a diagnosis of terminal illness necessary? Are there certain physical signs that must be present? In a certain sense, all human beings are in the process of dying. Nonetheless, the probable length of time remaining before death occurs or the certainty of a fatal illness generally determines whether one is deemed to be dying. Life expectancy also enters into people’s attitudes about when dying occurs. Generally, the expectation of impending death of a frail 100- year-old is greater compared with that of an energetic 75-year-old. The most commonly used definition of “terminal illness” is life expectancy of 6 months or less, which is the length of time determined by Medicare for receipt of hospice benefits. Because no clear definition of dying exists for older persons not diagnosed with a terminal illness, this must be explored individually.
Death for older persons usually results from complications from one or more chronic illnesses rather than from a sudden, unexpected incident or illness. The three leading causes of death, accounting for 61% of deaths among adults older than age 65, are heart disease, malignant neoplasms, and cerebrovascular diseases (Centers for Disease Control and Prevention [CDC] & The Merck Foundation, 2013). These are expected to remain the major causes of mortality in the older adult population through the year 2020. Other major causes of death among older adults include chronic obstructive pulmonary disease (COPD), pneumonia and influenza, diabetes mellitus, injury from accidents, renal diseases, septicemia, and complications from Alzheimer disease.
General Health Care Needs Regardless of needs that arise from specific diseases and functional problems, dying individuals have general health care needs that must be addressed. General nursing interventions to meet these needs include (1) stabilizing and supporting vital functions and facilitating integrated functioning, (2) determining functional deviation and adjusting treatment, (3) relieving distressing symptoms and suffering, (4) assisting patient and family interaction, and (5) supporting a patient and his or her family in coping with the realities of death. Common physical problems and
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symptoms encountered by terminally ill patients include pain, dyspnea, constipation, delirium, altered urinary elimination patterns, altered skin integrity, loss of appetite, dry mouth, nausea and vomiting, restlessness and sleeplessness, difficulty swallowing, and nutritional problems (Derby, O’Mahoney, & Tickoo, 2010). Family coping and stress, safety needs, and self-care deficits are other important problems (Weitzner, Moody, & McMillan, 2003). Age-related changes and comorbid conditions combined with these general health care needs of dying older persons and their families make the provision of high-quality nursing care especially challenging. Skillful assessments and creative nursing strategies aimed at addressing multiple physical, psychosocial, and spiritual needs are necessary.
Effect of Age-Related Changes Nursing care aimed at meeting the physical needs of older persons who are dying is no different from the meticulous care needed by any other patient with a debilitating condition. Age-related changes and the effects of long-term chronic illnesses predispose older persons to greater risk of problems in hygiene and skin care, nutrition, elimination, mobility and transfers, rest and sleep, pain management, respiration, and cognitive and behavioral functioning. Only the areas that pose special problems for older persons are discussed in this section.
Age-related changes in the integumentary and vascular systems, coupled with alterations in nutrition, elimination, and mobility, quickly lead to skin breakdown. Loss of the subcutaneous fat layer and a decrease in sebaceous gland activity cause the skin to become thin and dry, which makes it more susceptible to the hazards of immobility. Pressure ulcers are a problem for older, debilitated patients and are often quick to form and slow to heal. Sometimes, even the best skin care and positioning cannot prevent the formation of pressure ulcers at the end of life (Hughes, Bakos, O’Mara, & Kovner, 2005).
Rigidity of the chest wall, decreased ciliary activity, and decreased coughing and gagging reflexes all predispose older
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persons to respiratory problems, especially pneumonia. Aspiration pneumonia is a common problem in older patients who are unable to feed themselves and who have difficulty maintaining the upright position. The decreased effectiveness of the immune system and the often nonspecific presentation of symptoms related to pneumonia may make the diagnosis and treatment of pneumonia in older adults more complicated. Shortness of breath and altered respiratory patterns in sleep such as Cheyne-Stokes respirations or sleep apnea are more prevalent among older persons and may become problematic if these patients are seriously ill or dying.
Digestive changes associated with age include decreased amounts of saliva and digestive fluids and enzymes, decreased peristaltic activity, and decreased absorption through the intestinal wall. These changes predispose an older person who is dying to additional problems with maintaining adequate nutritional status and bowel function. They are exacerbated by immobility and often contribute to constipation, fecal impaction, and sometimes diarrhea. Although health care professionals often downplay the seriousness of constipation, this problem may cause much discomfort to the dying person and contribute to other life-threatening complications.
Changes in vision and hearing that commonly accompany advancing age reduce the stimulation that older persons receive from the environment. This is complicated by the usual practice of removing eyeglasses and hearing aids from patients who are ill and well-meaning attempts to provide a quiet, darkened, and peaceful environment. Sensory deprivation may lead to mental confusion among healthy individuals and is of even greater importance among older adults who are dying.
Environmental changes and unfamiliar people and settings also contribute to cognitive impairment among older persons. Because hospitalization or a move to a nursing facility is often a part of the dying experience for older persons, the acute confusion that may result from such a move may be permanent. Institutionalization, even if temporary, may be a rite of passage for an older person and serve as an external indicator that his or her illness is progressing and death is becoming more imminent.
Although it is believed that the experience of superficial pain for
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older persons is unchanged, many older adults seem to experience less visceral pain such as organ pain associated with terminal illnesses such as cancer (Gibson & Helme, 2001). Compared with younger adults, however, older people report more complaints of chronic pain and show reduced tolerance to experimentally induced pain. This may be attributed to differences in pain modulatory mechanisms associated with age (Cole, Farrell, Gibson, & Egan, 2010). All reports of pain and discomfort need to be heeded and validated by the nurse. Nonpharmacologic interventions for pain relief, for example, therapeutic touch, massage, acupressure, relaxation, and visualization, need to be used, whenever possible.
Age-related changes in pharmacokinetics and pharmacodynamics lead to atypical drug responses. Because drugs are so widely used as an essential part of medical treatment, their effectiveness, side effects, and reactions need to be closely monitored. Physiologic changes associated with dying, for example, circulatory changes, increase the difficulty in managing drug regimens. Sleep patterns are also disturbed by physiologic changes, pain, and changes in environment. Medication is the most common answer to dying persons’ complaints of inability to sleep. Although medication may be appropriate in some instances, it needs to be prescribed with caution and monitored carefully. For a dying older person, sleep medications may cause new problems such as incontinence or delirium. Nonpharmacologic therapies should be used first before use of medications. Psychological causes of sleeplessness should also be explored. For example, if older persons fear dying alone in their sleep or if they have unfinished business to resolve with their families, sleep medication is not the best answer. Instead, a careful assessment of the cause of sleeplessness must be followed by appropriate treatment aimed at that cause.
Nursing Care Excellent nursing care of dying older persons begins with examination of a nurse’s own feelings about death and values regarding older people. In the youth-oriented American culture, old age is not typically highly esteemed or valued. An overworked hospital nurse usually has to prioritize; younger patients with
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greater probability for survival receive more attention compared with older dying patients who bear the physician orders, “Do not resuscitate (DNR); comfort measures only.” Death often comes quietly, and the nurse may not be present to care for a dying person’s physical and emotional needs. Delivering high-quality nursing care to older adults may be one of the most challenging and most rewarding of all nursing experiences. It requires knowledge of the complexities of gerontologic and end-of-life nursing combined with the knowledge, skill, and compassion necessary to deliver holistic care to both dying patients and their families. Updated clinical practice guidelines for quality palliative care have been and are available at the following website: http://www.nationalconsensusproject.org/guideline.pdf (NCPQPC, 2009).
Assessment As with any other nursing care, nurses must make careful and ongoing assessments of physical, psychosocial, and spiritual needs. Assessment tools for physical needs, described in Chapter 4, are also relevant for ill and dying older adults. Special attention, however, needs to be given to potential problem areas such as skin integrity, respiratory status, nutrition, elimination, sensory abilities, cognitive functioning, comfort, and rest. The International Association for Hospice and Palliative Care has compiled a list of assessment tools for many areas of palliative care and pain (see http://www.hospicecare.com). Assessment tools such as the Palliative Performance Scale (Anderson, Downing, & Hill, 1996) are useful for identifying and tracking care needs of patients receiving palliative care.
The psychosocial needs of the dying person, family, and caregivers must also be carefully assessed. This may be a difficult area to approach, especially when time is limited or a patient’s or family’s feelings about the process of dying are unknown. Spiritual and psychosocial needs are often discussed together because they are interrelated and affect each other. Areas for careful assessment of spiritual needs include searching for meaning in life, dying appropriately, and finding hope that extends beyond the grave
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(Doka, 1993).
Meaning in life often emerges as a theme among those who are grieving as well as among those who are dying or nearing the end of their lives. In a study of community-living older adults by Burbank (1992), leading a meaningful life was found to be associated with both physical health and a lack of depressive symptoms. A series of questions that are useful in assessing the degree of meaning in life is given in Figure 18-3.
FIGURE 18-3 Fulfillment of Meaning Scale. (From Burbank, P.M. (1992). Assessing the meaning of life among older clients: An exploratory study.
Journal of Gerontological Nursing, 18(9), 19-28.)
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The hierarchy of a dying person’s needs, based on Maslow’s hierarchy of needs framework, may assist nurses in identifying a dying older person’s specific needs at each level (Touhy & Jett, 2012) (Figure 18-4). Careful assessment of the level of a dying person’s needs may indicate individualized strategies for meeting those needs.
FIGURE 18-4 Hierarchy of a dying person’s needs. (Modified from Touhy, T.A. & Jett, K.F. (2012). Ebersole & Hess’ Toward healthy aging: Human
needs and nursing response (8th ed.). St. Louis, MO: Mosby.)
Strategies Little difference exists between nursing strategies for younger persons who are ill and those for dying older persons. The same actual interventions may be applied, but older adults require more frequent assessment, application, and evaluation of the
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effectiveness of nursing strategies. For instance, a debilitated, immobile younger person may require repositioning less often than an older person who is debilitated and immobile. Older persons may suffer from more severe xerostomia (dry mouth) compared with younger persons with the same condition. The nurse needs to ensure that care is not delivered less often because of personal biases and ageist devaluation of older persons. Pacing of care is especially important; that is, the nurse needs to exhibit patience and give the older person enough time so as to encourage as much independent functioning as possible.
Particularly difficult problems for older adults who are dying include pain, dyspnea, constipation, urinary incontinence, restlessness, hallucinations and delusions, and nutritional problems. Palliative care measures for these are discussed individually in this section because they often differ from strategies used with chronically ill older adults who are not close to death.
Pain is prevalent among individuals who are dying and may have a powerful, negative effect on a patient’s quality of life. The pain experience is complex and its management often difficult. A stepped-care approach is recommended, with the use of aspirin or acetaminophen for mild pain, a moderate opiate such as codeine or oxycodone for more constant pain, and a strong opiate such as morphine for severe pain (World Health Organization [WHO], 2013a) (Figure 18-5). Pain medication should be given around the clock to promote stable blood pressure levels. Nursing responsibilities include careful pain assessment, education of patients and family caregivers regarding pain medication, and close communication with the prescriber for changes in medication as needed. Attention needs to be given to a patient’s emotional state because psychosocial factors and emotional pain may accentuate physical pain (Wiech & Tracey, 2009).
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FIGURE 18-5 Incorporation of analgesics in the treatment of older adults.
Pain is a common complaint of older adults. The Joint Commission on Accreditation of Healthcare Organizations made pain management a condition of accreditation. Now hospitals are required to regularly assess and manage pain in patients with acute illnesses and those with chronic conditions. Pain is now considered the “fifth vital sign,” pulse, blood pressure, temperature, and respiration rate being the first four (Haugh, 2013). As the number of individuals older than 65 years continues to rise, frailty and chronic diseases with associated pain will likely increase. Therefore, primary care physicians will face a significant challenge in pain management in older adults. Older adults are more likely to have arthritis, bone and joint disorders, cancer, and other chronic disorders that cause pain. Between 25% and 50% of community- dwelling older adults have significant pain problems (NCPQPC, 2009). Nursing home–dwelling older adults have an even higher
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prevalence of pain, which is estimated to be between 45% and 80% (Ferrell, Ferrell, & Osterweil, 1990).
Older adults are often either untreated or undertreated for pain. The consequences of undertreatment for pain may have a negative impact on the health and quality of life of older adults, resulting in depression, anxiety, social isolation, cognitive impairment, immobility, and sleep disturbances (Cavalieri, 2002).
Dyspnea, or shortness of breath, is another common symptom feared by both patients and caregivers. Common causes include hypoxemia, poor handling of secretions, anxiety, bronchospasm, and pain. Elevation of the head of the bed, limitation of activity, a cool room with low humidity (but not completely dry), supplemental oxygen, and bronchodilators or analgesics may be sufficient to improve dyspnea. Morphine, which is often the most effective medication for decreasing dyspnea, also decreases anxiety. Constipation and a depressed respiratory rate are complications of morphine administration.
Constipation is common among older adults who require opioids for pain and whose diets and activities are restricted. Adding fiber to a patient’s diet or giving bulk-forming laxatives may not be practical if the person is unable to maintain sufficient fluid intake and diet. Stool softeners and oral cathartics may be more effective, but suppositories, enemas, and manual disimpaction may also be necessary. Careful assessment and individualized management of constipation are essential.
A focused history, physical assessment, bladder log, and urinalysis are important for determining the cause of urinary incontinence (UI). The management of UI is based on its cause. Intermittent catheterization or an indwelling catheter may be indicated; however, the risk of infection is always a consideration with catheter placement. For the dying patient with decreased mobility and problems with skin integrity, the benefits may outweigh the risks.
Restlessness in a dying patient may have several causes, including constipation, urinary retention, hypoxia, medication, increased pain, or unresolved psychosocial issues. Alcohol
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withdrawal has been identified as an underrated cause of agitation and terminal restlessness (Irwin, Murray, Bilinski et al., 2005). If the cause can be identified and treatment of the cause is effective, restlessness can be resolved. If restlessness continues and is upsetting to the family, palliative sedation may be necessary. The nurse should keep in mind that the goal of palliative care is to maintain a level of consciousness that allows for meaningful interactions for as long as possible (March, 1998).
Dying older adults who are cognitively impaired frequently experience hallucinations and delusions. Attempts to confront and reorient the delusional person are usually unsuccessful and may cause additional agitation. A better strategy is to ignore delusional statements and divert the conversation to more neutral topics (Craun, Watkins, & Hefty, 1997). The technique of validation, based on empathic understanding of the emotion and messages behind the confusion, is effective in communicating with those experiencing delusions and hallucinations (Feil, 1993; Feil & Altman, 2004). For instance, if a person, when alone, believes that he or she is talking to his or her mother, asking the patient if he or she is feeling lonely or afraid may help the patient express underlying emotions and ease some anxiety.
Oral nutrition and hydration should be maintained as long as a patient is able to swallow safely. Dehydration and anorexia are often of greater concern to family members than to dying patients, who may not be experiencing any resulting discomfort. In many cases, intravenous fluids and feedings are not appropriate (see Nutritional Considerations box). Palliative care physicians and nurses are aware that medically assisted nutrition and hydration rarely benefit patients at the end of life (van der Riet, Good, Higgins, & Sneesby, 2008). Adequate hydration may, in fact, increase respiratory secretions. Nasogastric tube feedings, total parenteral nutrition, and intravenous hydration increase infections and may decrease survival time (Storey, 1994; Taylor, 1995). Additional fluids may also contribute to edema caused by impaired circulation in older adults. The only documented side effect of dehydration is dry mouth, which may be relieved by administration of saliva substitutes, ice chips, and glycerin swabs
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and by promotion of good mouth care (Taylor, 1995). As long as adequate mouth care is provided, it is believed that patients at the end of life do not suffer from dehydration (van der Riet et al., 2008); however, more research is needed in this area (Dalai, Del Fabbro, & Bruera, 2009). Individual assessment and thoughtful decision making that includes the patient and family with regard to hydration and nutrition are important.
Nutritional considerations
Loss of appetite frequently accompanies the dying process. Families usually consider providing food as part of basic human caring and something they can do to prolong the patient’s life. For the dying person, however, eating may be an unpleasant and unwanted experience. Artificial feeding with nasogastric or gastrostomy tubes or intravenous nutrition frequently leads to further complications and earlier death. Because eating and food are often closely tied to many fond memories of loved ones, this is a difficult area and potential source of conflict between patients and their caregivers. Patients and families need to know that anorexia is a normal part of dying, and they need to have open discussion on the meaning of food and nutrition. Perhaps other meaningful and symbolic ways of providing sustenance may be achieved without artificial feeding.
Good communication skills are essential in dealing with dying persons and their families, although a lack of effective communication by nurses and physicians about terminal diagnoses and information about death and dying have been reported (Costello, 2001). Effective communication skills such as maintaining eye contact, using touch sensitively, and clarifying statements through reflection (i.e., restating the message as it is understood and asking for verification of its meaning) are important. Nurses’ awareness of their own limitations and strengths is critical because of the level of involvement that may result from interactions with persons confronting death. Once a nurse becomes committed to
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working with a patient and family throughout the dying process, it is important to follow through on this commitment as much as possible.
Another important role of the nurse is to educate and support families and caregivers. Caregivers experience a multitude of problems, including decreased energy levels, health problems, deep grief, and fears about life without their loved one. Nurses need to be sensitive to caregiver needs and provide education, psychological support, and referrals for additional services.
The role of a social support system is very important during the bereavement process. As a result, it is important that the nurse assess social support networks and help mobilize support for patients and caregivers, if necessary. In addition, group therapy interventions such as forgiveness therapy for older terminally ill patients with cancer have been found to be very effective in improving quality of life (Hansen, 2009).
As caregivers, nurses are not immune to intense feelings of grief after the death of a person that they have cared for. These feelings may occur whenever close relationships develop between nurses and patients, especially in long-term care and hospice settings. A dying person may have certain characteristics that invoke memories of previous unresolved losses that the nurse has experienced. Such grief needs to be recognized, accepted, and evaluated, just as any other experience of loss and grief needs to be assessed. The first step is for the nurse to recognize unresolved grief. The next step may be to express his or her thoughts and feelings to a coworker, friend, or family member. If additional help is needed, sources such as employee assistance programs, clergy, or other counselors may be contacted.
Environment and Care Services Most deaths of older adults in the United States take place in institutional settings, either hospitals (37.2%) or long-term care facilities (28.3%). Only 22.8% of older adults die at home, and less than 1% dies in hospice care (CDC, 2011). This reflects a significant change from the turn of the last century, when approximately 75%
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to 80% of Americans died at home (DeSpelder & Strickland, 2010). Often, an older person who is dying is moved back and forth, as his or her condition changes, between acute care (hospitalization) and any number of different long-term care settings.
The hospital setting is particularly problematic for older persons who are dying because the primary goal in this setting is the restoration of health. Since the implementation of diagnosis-related groups, economic constraints on hospitals force patients to be discharged if they are not receiving active treatment (treatment that cannot be provided in the home or another setting) (Csordas & Kleinman, 1990). Too often, life-support technology is applied, and death becomes even more impersonal.
Nursing facilities and long-term care institutions have different goals and different reimbursement systems than hospitals. The primary goal of a skilled nursing facility is to help patients regain their highest functional level possible. This may be done by using an interdisciplinary approach of nursing and rehab to help patients recover from surgery or a chronic illness (Upadhyaya & Kautz, 2009). Nursing facility settings can foster healthy dying through their primary goal of caring; however, the reality of the situation is that care is deficient in many nursing facilities. Thus, compassionate care of the dying is often not ensured in either the hospital or the nursing facility setting.
Hospice care was founded on the philosophy of compassionate, humane care of the dying and their families. Although a hospice may be an actual place where dying people go, in the United States, the term hospice usually refers to a caring ideology that can be implemented wherever the patient may be dying—at home, the hospital, or a nursing facility. A basic goal of hospice care is palliative care plus support services, that is, helping the dying live as fully as possible with the highest quality of life on a day-to-day basis. During the dying process and the bereavement period, physical, emotional, social, and spiritual care is provided by an interdisciplinary team consisting of the patients themselves, their families, health care professionals, and volunteers (Egan City & Labyak, 2010).
The term palliative care refers to “an approach that improves the
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quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual” (WHO, 2013b). In the long-term end-of- life care of older adults, offering palliative care before hospice care yields many benefits. It differs from hospice care in that curative treatment can be obtained through palliative care but not through hospice care (Wittenberg-Lyles & Sanchez-Reilly, 2008). This approach has been successful in guiding the care of dying patients and their families provided by interdisciplinary health care teams.
For many older adults, home is the preferred place to die. Home care may or may not include hospice care or palliative care. Many older persons die at home, cared for only by their family or sometimes visiting nurses or home health aides. In these situations, the goals of caregivers are often similar to hospice goals; however, the dying person and family do not have the benefit of an interdisciplinary team and an organized approach to follow-up care.
Legislative Initiatives Legislative initiatives with regard to death and dying include the Patient Self-Determination Act, which became law in 1991; it requires all health care facilities receiving Medicare and Medicaid reimbursement to recognize advance directives. These instructions for care (living wills and durable powers of attorney) guide families and health care providers should the patient be incapable of decision making. Despite an increased interest in death and dying, the findings of a large study funded by the Robert Wood Johnson Foundation’s Program on the Care of Critically Ill Hospitalized Adults showed that the majority of seriously ill patients in the study had not completed advance directives, and professional– patient communications about advance directives were not as effective in aiding decision making as was hoped (Lo, 1995; SUPPORT Principal Investigators, 1995; Teno et al., 1997). Confusion about consequences of life-prolonging treatments versus no treatment may undermine the older person’s ability to make
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informed choices about advance directives (Winter, Parker, & Schneider, 2007). (See Evidence-Based Practice box.)
Evidence-based practice Benefits of Preneed Advance Directives
Sample/Setting In an effort to determine the number of patients with formal advance directives and how these influenced decisions for treatment at the end of life, researchers reviewed the charts of patients who had died in a small city hospital. A total of 160 patients 65 years or older were included in the study. Most were white, and the study had equal numbers of men and women.
Method Charts were reviewed by accessing the online medical record.
Findings As the patient’s level of education increased, the presence of a formal health care power of attorney (HCPOA) and the presence of a living will were documented. The overall numbers of formal advance directives remained low: HCPOA, 20.6%; living will, 26.9%. When necessary, the health care team did document patient’s wishes for end-of-life care and code status, as well as who could make decisions for the patient. No relationship was found between the presence of formal advance directives and a stay in the intensive care unit, initiation of lifesaving treatments, or having do-not-resuscitate (DNR) status.
Implications Older persons should be encouraged to complete formal advance directives and discuss their wishes with family members while able so that they can control the medical care they may receive at the end of life. They should be connected with a social worker or case manager when they have no resources for completing the
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advance directive. Many hospitals now require patients to address these issues at the time of admission. When no formal document is present, having a patient identify a temporary HCPOA allows someone of their own choosing to make medical decisions in the event they become unable. Code status is also important to discuss at the time of admission to ensure that the patient’s wishes for end-of-life care are followed. From Dobbins, E. (2007). End-of-life decisions: Influence of advance directives on patient care. Journal of Gerontological Nursing 33(10), 50-56.
Home care
1. Homebound older adults who have lost a spouse or significant other may manifest grief through physical symptoms.
2. Homebound older adults may develop crises of faith and express anger at God. It is important for the home care nurse to avoid being judgmental and to allow an older adult to verbalize anger and grief.
3. Refer to an advanced practice nurse or other health professional skilled in working with complicated grieving if a homebound older adult experiences dysfunctional grieving.
4. Loss of a spouse or significant other, coupled with living alone, puts homebound older adults at risk for depression.
5. Assess a terminally ill homebound older adult’s feelings toward his or her own death.
6. Instruct family members and caregivers on the stages of dying and the physiologic changes that accompany them.
7. Use hospice care to help dying homebound older adults live as fully as possible on a day-to-day basis.
8. If hospice care is not available, a home care nurse may assist a homebound older adult in dying.
Nurses caring for very ill older adults need to understand the
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legal status of advance directives, living wills, and DNR orders. As natural extensions of a patient’s right to self-determination, these preferences should be adhered to by the nurse (Basanta, 2002). Other topics relevant to dying and death in the health care system include ethical decisions, euthanasia and assisted suicide, and suicide; however, these topics are so complex that they preclude a brief discussion in this chapter.
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Summary This chapter covered two major topics: (1) loss, grieving, and mourning and (2) the process of dying. Characteristics of dying or grieving older persons were presented, with a focus on the differences between the experiences of older and younger adults. Last, ways of assessing the needs of those who are mourning or dying were described, along with strategies for the nurse that help meet the identified needs. Examination of the nurse’s own value system and prior experience with loss were emphasized. Health care system approaches to care of the dying have been described.
It is hoped that care and support for dying or grieving older persons will improve with increased knowledge and positive attitudes. This improvement should benefit both older adults and nurses, who have much knowledge and wisdom to gain from those who have the most experience in life.
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Key points • Grief is the acute reaction to one’s perception of loss, mourning is
the longer process of resolving acute grief reactions, and bereavement is the state of having experienced a significant loss.
• Grief involves many changes over time, is a natural response to all kinds of losses (not just death), and is based on one’s unique perception of a loss.
• Worden (2009) views the grief process as active, involving the following four tasks of mourning: (1) accepting the reality of the loss, (2) working through the pain of grief, (3) adjusting to an environment in which the deceased is missing, and (4) emotionally relocating the deceased and moving on with life.
• Human beings respond as whole people, and their grief manifests itself in physical symptoms, psychological responses, changes in socialization patterns, and spiritual issues concerning life’s meaning.
• Complicated grief reactions may manifest as one of four types of reactions: (1) chronic, (2) delayed, (3) exaggerated, or (4) masked.
• Nursing care activities that assist in the grieving process include helping the survivor express feelings, providing time to grieve, explaining “normal” grieving behaviors, examining defenses and coping styles, identifying pathologic conditions, and making appropriate referrals.
• Sociocultural and religious background, physical and functional status, social isolation and loneliness, and the meaningfulness of everyday life are all important factors in determining a person’s approach to impending death.
• Age-related changes predispose older persons to greater potential problems in areas such as hygiene and skin care, nutrition, elimination, mobility, transfers, rest, sleep, pain, respiratory management, and cognitive and behavioral functioning.
• Nursing strategies for assisting dying older persons include
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delivering excellent physical care, using good communication skills, conducting a life review, and educating and supporting family caregivers.
• Hospice programs help dying persons live as fully as possible on a day-to-day basis by providing symptom control, addressing the psychological needs of patients, supporting family caregivers, dealing with environmental problems, and assisting patients with spiritual concerns.
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Critical thinking exercises 1. A 70-year-old woman is admitted to the hospital unit with COPD. She lives alone in a retirement community. Her children live 1 hour away. Her best friend of 40 years recently died, and her husband of 35 years died 1 year ago. How would you assess and assist this patient in coping with multiple losses?
2. An 85-year-old man is dying of terminal lung cancer. He comes from a close-knit family. As the hospice nurse, how do you prepare and help this family work through the anticipatory grief process?
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* Original authors: Patricia M. Burbank, DNSc, RN, MS, BS; and Jean R. Miller, PhD, MN, BS, MA; Revised by Sabrina Friedman, PhD, EdD, MSN, RN, FNP.
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PA R T 5 Diagnostic Studies and Pharmacologic Management
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C H A P T E R 1 9
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Laboratory and Diagnostic Tests Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Identify key laboratory values that increase or decrease with aging.
2. Describe the effect of aging on the erythrocyte sedimentation rate.
3. Name two medications that can interfere with potassium excretion and affect serum potassium levels.
4. Explain the relationship between serum sodium levels and pseudohyponatremia.
5. Explain the difference between serum creatinine concentrations in younger adults and older adults.
6. Explain the relationship between bacteria in urine and urinary tract infections in older adults.
7. Relate the significance of troponin levels in diagnosing cardiac emergencies.
8. Explain the relationship of the brain natriuretic peptide to congestive heart failure.
9. Discuss the role of laboratory tests in determining thyroid function in older adults.
10. Describe the nurse’s role in interpreting laboratory values in older adults.
http://evolve.elsevier.com/Meiner/gerontologic
Diagnostic testing in older adults takes on a different meaning than testing in younger adults. The nurse must realize that
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laboratory values are classified into three general groups with regard to aging: (1) those that change with aging; (2) those that do not change with aging; and (3) those for which it is unclear whether aging, disease, or both change the values (Sarkozi, 2002).
The gerontologic nurse must consider the effect of laboratory and diagnostic testing on an older adult’s overall health and well-being. For example, with aging, subcutaneous tissue is decreased, and the fragility of veins is increased. Consequently, a frail older adult is more likely to have increased bruising and discomfort after a venous blood drawing. It is also important for the nurse to know what tests have been ordered to be able to provide an explanation to an anxious older adult; the patient’s anxiety may range from concerns about the cost of tests to a concern for privacy to cultural concerns. For example, the Chinese and Vietnamese believe that drawn blood is irreplaceable and thus may become upset with repeated blood testing (Burnside, 1988).
This chapter provides the gerontologic nurse with a basic understanding of the purpose of commonly ordered laboratory and diagnostic tests, the importance of selected hematologic and blood and urine chemistry components in the body’s overall function, and the relative reference ranges for younger and older adults. These reference ranges may vary from institution to institution as well as in the literature (Table 19-1). Because of the scant research conducted on older adults, geriatricians and gerontologists may disagree as to whether changes are related to aging or disease (Beers & Berkow, 2000). When interpreting laboratory values and deciding the best course of treatment, the older adult should be viewed holistically; signs, symptoms, and test results should all be taken into account.
Table 19-1 Hematology test
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Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby.
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Components of hematologic testing Blood is composed of cells (erythrocytes and leukocytes), specialized cell fragments (platelets), and a fluid matrix called plasma. The cells and cell fragments are suspended in the plasma, which is the largest component of the body’s extracellular fluid (Thibodeau & Patton, 2003).
Red Blood Cells Red blood cells (RBCs), or erythrocytes, are nonnucleated biconcave disks that carry molecules of hemoglobin. Hemoglobin allows the transport and exchange of oxygen and carbon dioxide. The average life span of an erythrocyte is 120 days. Although aging does not affect the life span of an erythrocyte, replenishment after bleeding may be delayed because of a decrease in hematopoietic tissue occupying marrow of the long bones (McCance & Huether, 2008).
RBCs are necessary for maintaining oxygen and carbon dioxide transport. A reduction in the number of circulating RBCs, a decrease in the quality or quantity of hemoglobin, a decrease in the volume of packed cells (hematocrit), or a combination of all of these factors is classified as anemia. Anemia may be attributed to (1) impaired erythrocyte production, (2) blood loss, (3) increased erythrocyte destruction, (4) dietary deficiency, (5) genetic disorders, or (6) a combination of the causes (McCance & Huether, 2008). Anemia is a clinical sign, not a disease process itself. Signs of anemia may go unnoticed if the anemia is mild, or the patient may experience overt symptoms such as fatigue, shortness of breath, and paresthesia (McCance & Huether, 2008). In addition, clinicians may miss signs of anemia, even in markedly anemic older patients (Ham, Sloane, & Warshaw, 2001). The combination of vague symptomatology and vague clinical presentation may lead the health care provider to attribute an older adult’s complaints to “old age” and fail to investigate adequately.
Other conditions involving erythrocytes are related to increased cell numbers and abnormality in the cells themselves.
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Overproduction of RBCs is known as polycythemia. This may occur secondarily as a result of hypoxia caused by chronic pulmonary disease or heart failure. In sickle cell anemia, the RBCs become abnormal in shape and surface composition as a result of a genetic defect in the hemoglobin.
Hemoglobin Hemoglobin is an important iron-containing protein that is carried on RBCs and makes up about one third of the weight of the RBC. Hemoglobin is necessary for the transport of oxygen; a reduction in hemoglobin may result in a decrease in oxygen content and an increase in fatigue. Rarely, genetic mutations occur producing abnormal hemoglobin which may result in sickle cell disease and thalassemia.
Hematocrit The hematocrit is the percentage of total blood volume that represents erythrocytes. This is determined in the laboratory by centrifuging a sample of blood, causing the heavier red cells to sink to the bottom of the tube while the less dense plasma rises to the top. The percentage of cells to liquid is calculated, giving the hematocrit reading. An increase in the hematocrit may signal volume depletion (Beers & Berkow, 2000). A decrease in hematocrit may be a result of disease or dietary deficiencies (Pagana & Pagana, 2010).
Reported effects of aging on hemoglobin and hematocrit vary in the literature. Hemoglobin has been reported as remaining unchanged (Berghe, Wilson, & Ershler, 2004) or changing slightly, possibly from extrinsic factors rather than as a result of normal aging (Chatta & Lipschitz, 1999). Hematocrit and hemoglobin values decline slightly after the age of 90 (Sarkozi, 2002).
White Blood Cells White blood cells (WBCs), or leukocytes, are another type of cell present in blood. Their major function is defense against foreign
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substances. WBCs function mainly in the interstitial fluid. Leukocytes consist of neutrophils, lymphocytes, monocytes, eosinophils, and basophils. A decrease in leukocytes in older adults may be related to drugs or severe infection (Pagana & Pagana, 2010). Drugs that may cause a decrease in leukocytes include antibiotics, anticonvulsants, antihistamines, antimetabolites, cytotoxic agents, analgesics, phenothiazines, and diuretics (Pagana & Pagana, 2010). An increase in leukocytes is generally seen in the presence of infections. However, a WBC count may be only moderately elevated in older adults when an infection such as pneumonia is present. Other typical symptoms of infection such as fever, pain, and lymphadenopathy may be minimal or absent in older adults with infections (Mouton, 2001). Consequently, the nurse must be alert for other signs and symptoms of infection such as the sudden onset of confusion or lethargy. Pharmacologic agents have also been associated with an increase in leukocytes. These drugs include allopurinol, aspirin, heparin, steroids, and triamterene (Pagana & Pagana, 2010).
Neutrophils, eosinophils, and basophils are produced in the bone marrow and possess similar structures of segmented nuclei and many membrane-bound granules. Their primary function is phagocytosis (i.e., ingestion and destruction of invading microorganisms and cellular debris). In addition, the basophil’s cytoplasmic granules contain powerful chemicals such as heparin, histamine, bradykinin, leukotrienes, and prostaglandins, which contribute to activation of the inflammatory response (McCance & Huether, 2008). The monocyte, the largest of the leukocytes, is produced in bone marrow and differs in appearance from neutrophils, eosinophils, and basophils. The monocyte has a single nucleus and is capable of destroying large bacterial organisms and virally infected cells by phagocytosis (Thibodeau & Patton, 2003).
Lymphocytes, the smallest of the leukocytes, are classified into two types: B and T. Lymphocytes have large nuclei and relatively little cytoplasm. Originating in bone marrow and the thymus, lymphocytes are housed in the lymph nodes, spleen, and tonsils. Lymphocytes do not act as phagocytes but rather produce antibodies and other specific defenses against antigens (Thibodeau
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& Patton, 2003).
Aging does not appear to affect the function of neutrophils, although the effect on bone marrow to release and store these cells is reduced. Lymphocytes of older adults have shown impaired function in vitro and are suspected to be the cause of a reduction in antibody response in later life (Rothstein, 1999). It is suspected there is a decline in monocyte function, given the increased susceptibility to infections and increased incidence of malignancies in older adults. The remaining leukocytes, eosinophils, and basophils, have not been shown to be affected by aging.
Leukocytes are necessary for the body’s resistance and response to infections, cancers, and other foreign substances. The nursing implications with regard to infections and malignancies include recognizing subtle and sometimes altered responses to infections and diseases in older adults. Educating older adults about the importance of participating in cancer screening programs and maintaining the immunization status throughout life is essential.
Folic Acid Folic acid is one of the eight B vitamins that make up the B-complex group. Folic acid is a water-soluble vitamin that functions as a coenzyme, which means it is inactive unless linked to an enzyme. Folic acid is necessary for the normal functioning of RBCs and WBCs. A decrease in folic acid may indicate macrocytic anemia, megaloblastic anemia, and liver and renal disease. Alcohol and various other drugs are known to interfere with the absorption of folate. Some drugs have also been shown to decrease folic acid levels. These include anticonvulsants, antimalarials, and methotrexate (Pagana & Pagana, 2010). However, the effect of aging on folate is still debatable because of differences in defining the lower limits of “normal” and the different methods used to determine folate levels (Gilleece & Dexter, 2002).
Because of the relationship of nutrition and alcohol consumption to folic acid levels, it is important for the gerontologic nurse to assess nutritional intake, including alcohol consumption habits. Elevated levels of folic acid may be seen in people with pernicious
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anemia, who do not have an adequate amount of vitamin B12 to metabolize folic acid. Therefore, the folic acid levels should be tested in conjunction with assessment of vitamin B12 levels (Pagana & Pagana, 2010).
Vitamin B12 Vitamin B12, or cobalamin, is a water-soluble vitamin that is part of the B-complex group of vitamins. Vitamin B12 deficiency is present in nearly a quarter of older adults. Common causes of deficiency include malabsorption secondary to gastric bypass, pancreatic disease, ileal resection or inflammation, and prolonged use of certain medications such as proton pump inhibitors, colchicine, cholestyramine, histamine 2 (H2) blockers, or metformin. Strict vegetarian or vegan diets may also lead to vitamin B12 deficiency (Bryan, 2010; Orton, 2012). Malabsorption of vitamin B12 may be caused by the effect of antibodies on gastric parietal cells and a decrease in intrinsic factor, the underlying cause of pernicious anemia. The prevalence of pernicious anemia increases significantly with aging (Chatta & Lipschitz, 1999).
Vitamin B12 is important for normal erythrocyte maturation (McCance & Huether, 2008) and acts as a coenzyme with folic acid. The synthesis of nucleic acids, and therefore the structure of deoxyribonucleic acid (DNA), depends on adequate vitamin B12 intake (Grodner, Long, & DeYoung, 2004). Vitamin B12 deficiency may lead to demyelination of the dorsal and lateral spinal columns, which, in turn, may lead to paresthesias of the feet and disequilibrium and loss of vibratory sensation in the fingers (Bryan, 2010; Gaspard, 2002). Low vitamin B12 levels may also lead to fatigue, weakness, and memory loss (Orton, 2012).
Total Iron Binding Capacity Total iron binding capacity (TIBC) measures the amount of iron and the amount of available transferrin in the serum (McCance & Huether, 2008). Transferrin is a protein in the plasma that collects
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iron and transports it to the bone marrow for incorporation into hemoglobin. Increased TIBC and transferrin levels may indicate iron deficiency anemia; decreased levels may indicate anemia caused by chronic disease.
Iron Iron is found in the hemoglobin of the RBCs. When iron-containing foods are ingested, iron is absorbed by the small intestine and transported to the plasma (Pagana & Pagana, 2010). Iron is necessary for controlling protein synthesis in the mitochondria and for generating energy in the cells (Freedman & Sutin, 2002). Serum iron levels show progressive decreases in both genders with advancing age, although the ability to absorb iron appears to remain intact (Hall & Wiley, 1999). Iron deficiency anemia is the most common form of anemia seen in older adults. However, in spite of the decreases in serum iron levels seen with aging, anemia in older adults is not a normal consequence of aging. The gerontologic nurse should assess older adults for poor dietary intake of iron-containing foods and occult or chronic blood loss (Ahluwalia, Sun, Krause, Mastro & Handte, 2004).
Uric Acid Uric acid is a product of purine catabolism and is excreted by the kidneys. Age-related changes in uric acid levels are significantly different between the genders. Because estrogen is thought to promote the excretion of uric acid, elevated levels are rarely seen in women before the onset of menopause (McCance & Huether, 2008).
Problems with uric acid may be a result of faulty excretion (e.g., kidney disease), overproduction of uric acid, or the presence of other substances that compete for excretion sites (e.g., ketoacids) (Pagana & Pagana, 2010). Elevated uric acid levels are seen in patients with gout. Gout, a common condition in older adults, involves a disturbance in the body’s control of uric acid production or excretion. Excess uric acid accumulates in the body’s fluids, especially blood and synovial fluids, forming crystals in high concentrations. These crystals deposit in the connective tissue of the
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body, causing painful, inflamed joints. Thiazide diuretics, caffeine, low-dose aspirin, and antiparkinsonian drugs are also a common cause of increased uric acid levels in older adults (Pagana & Pagana, 2010).
Prothrombin Time Prothrombin is a plasma protein that is converted to thrombin in the first step of the clotting cascade. Clotting is necessary to prevent the loss of vital body fluids that occurs when blood vessels rupture (Thibodeau & Patton, 2003). In addition to measuring prothrombin time (PT), health care professionals also measure the activity of fibrinogen and coagulation factors V, VII, and X. The results of the PT laboratory test reveal how effectively the vitamin K–dependent coagulation factors of the extrinsic and common pathways of the coagulation cascade are performing (McCance & Huether, 2008). An increased PT is seen in liver disease, vitamin K deficiency, bile duct obstruction, and salicylate intoxication. Some medications, including, allopurinol, cephalothins, cholestyramine, clofibrate, and certain antibiotics, may also cause an increase in a patient’s PT (Pagana & Pagana, 2010). Pagana and Pagana (2010) also reported that digitalis and diphenhydramine may cause decreased PT levels.
Older adults are often prescribed the drug warfarin (Coumadin) after open-heart surgery and in cases of chronic atrial fibrillation. Warfarin interferes with the production of vitamin K–dependent coagulation factors, thereby decreasing the chance of thrombus formation. Warfarin may interact with many medications, especially those often taken by older adults (Pagana & Pagana, 2010). Gerontologic nurses should help patients understand the importance of keeping their appointments for PT checks and consulting their health providers before taking any over-the- counter (OTC) medications or supplements. The adequacy of warfarin therapy can be assessed by monitoring a patient’s PT level. The PT value is traditionally reported in seconds and includes a value called the international normalized ratio (INR). INR is a mathematic “correction” of the results of the one-stage PT and was created to standardize results caused by variation in laboratory reagents. The INR should be between 2.0 and 3.0 for most
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thrombosis and embolus conditions and between 3.0 and 4.0 for patients with a history of recurrent thromboembolism or mechanical heart valves (O’Neill, 2002) (see Nutritional Considerations box).
Nutritional Considerations
Vitamin K is used in emergency situations to counteract the increased coagulation times that sometimes occur when patients are receiving warfarin (Coumadin). The nurse should be aware that foods high in vitamin K may affect clotting times and counteract the prescribed therapy. Food such as turnip greens, broccoli, cabbage, spinach, and liver, which are high in vitamin K, should be eaten in moderate amounts while receiving anticoagulant therapy.
From Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach. St. Louis, MO: Mosby.
Partial Thromboplastin Time Partial thromboplastin time (PTT) refers to the measurement of the common pathway of clot formation. Heparin may inactivate prothrombin, so the PTT is a good indicator of the adequacy of anticoagulation therapy. The effect of heparin on the body is faster than that of warfarin, but the effects are shorter. Nursing considerations include monitoring for bleeding and correct administration of the heparin dosage.
D-dimer Test d-dimer is a fragment produced during the degradation of a clot. The d-dimer test may be ordered when a person has symptoms of thrombus, embolus, or disseminated intravascular coagulation. Results are interpreted when combined with clinical information
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and other laboratory data. Age, vascular disease, and kidney or hepatic disease may affect test results.
Erythrocyte Sedimentation Rate The erythrocyte sedimentation rate (ESR) test measures the time that RBCs take to settle in normal saline over 1 hour. The measured values are reported in millimeters (mm). The test does not relate to one specific condition or disorder but does indicate the presence of inflammation, so it is useful in monitoring the course of inflammatory activity in autoimmune diseases, infections, and cancers. Kane, Ouslander, and Abrass (1999) report mild elevations may be associated with advancing age. Because of the nonspecific nature of ESR values, it is important to interpret the results in older adults in conjunction with subjective and objective findings on physical examination (Calkins, 1999).
Cross-Reactive Protein Cross-reactive protein (CRP) is a marker present in the acute phase of an inflammatory response (Gambino, 1997). CRP is useful in assessing patients with tissue injuries, autoimmune diseases, or infections. Smith, Lipworth, Cree, Spiers & Winter (1995) concluded that a persistently high CRP or rising CRP level suggests the failure of antibiotic treatment or the development of a complicated bacterial infectious process.
Platelets Platelets are small, irregular bodies, also known as thrombocytes, which are essential for clotting. They are formed in bone marrow and stored in the spleen. When an injury occurs to a blood vessel, platelets are released and become “sticky,” forming a plug at the site and triggering the clotting cascade (Thibodeau & Patton, 2003).
Decreases in platelet counts (to less than 100,000 per cubic millimeter [mm3]) require investigation. In a condition known as myelodysplastic syndrome (MDS), pancytopenia is noted in more than half the patients diagnosed. Pancytopenia is considered to be
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present when the levels of RBCs, WBCs, and platelets are all below normal. More than 50% of the cases found are in adults older than age 70. Treatment usually consists of transfusions with RBCs or platelets, although in most of the older adults, death results from other disorders rather than MDS. This condition has been known to progress to acute leukemia (Gilleece & Dexter, 2002). At platelet levels below 20,000/mm3, the nurse should observe for spontaneous bleeding. If the patient’s levels are 40,000/mm3 or below, prolonged bleeding may occur after certain procedures (Pagana & Pagana, 2010).
In assessing patients for potential or hidden blood losses, nurses have traditionally questioned patients about the color and consistency of their stools. The gerontologic nurse, however, must recognize that older adults who take iron supplements have changes in bowel habits and stool color, which may not necessarily indicate the presence of occult blood. When preparing older adults for fecal occult blood testing, it is important to instruct them to stop iron supplements 3 days before testing.
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Components of blood chemistry testing Blood chemistry testing involves electrolytes, glucose, and various other blood components. Although many of these tests are done in groups, others may be ordered individually to determine the presence or absence of a particular disorder. Current terminology labels these chemical analyses into groups with names such as “basic metabolic profile” and “complete metabolic profile,” but these names may vary from institution to institution. Nurses should learn the terminology specific to their workplace and be able to identify the individual tests contained in each package.
Electrolytes Electrolytes are inorganic substances that include acids, bases, and salts. In solutions, electrolytes break up to form positively or negatively charged particles known as ions. Positively charged ions are known as cations; negatively charged ions are called anions. Compounds that are formed from acids and bases are known as salts. Blood testing may include measurement of the amount of an electrolyte in the circulating blood. Although many types of electrolytes may be tested, only the most common are discussed here.
Older adults may have serious problems with electrolyte imbalances. Dehydration is the most common form of electrolyte disorder that occurs in older adults, and it is usually attributed to excess loss of water or altered fluid intake. Excess water loss may be caused by infections such as pneumonia and cystitis or environmental conditions. Altered fluid intake may result from age- related decrease in thirst sensation in older adults or a result of decreased functional ability that limits the intake of fluids (Davis & Minaker, 1999), as when being bedridden, chemically or physically restrained, or limited by sensory changes.
Sodium
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The test for sodium (Na +) measures the amount of sodium in circulating blood, but it is actually an index of body water deficit or excess. Sodium regulation is important for the maintenance of blood pressure, transmission of nerve impulses, and regulation of body fluid levels in and out of the cells. This movement of sodium affects blood volume, which is tied to the thirst mechanism and total body fluids (Grodner et al., 2004). Although sodium is also present in intracellular fluid, the majority resides in extracellular fluid, which makes it the major cation of extracellular fluid. Serum sodium levels describe the balance between ingested sodium and that excreted by the kidneys (Pagana & Pagana, 2010). In older adults, kidney changes such as a decrease in the glomerular filtration rate (GFR) and in the number of nephrons do not lead to disability or disease (Beck & Hazzard, 1999). However, these changes might mean that an older adult has difficulty in maintaining homeostasis in the presence of crises such as sodium depletion or overload (Table 19-2). Because of the intrinsic loss in function, kidneys have a decreased renin–angiotensin–aldosterone response and may not respond appropriately; thus, further sodium losses may occur (Beck & Hazzard, 1999). A normal sodium level is necessary for maintaining the extracellular fluid balance (osmolarity).
Table 19-2 Blood chemistry
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Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby.
The occurrence of hyponatremia (a low sodium level) increases with age. The majority of cases are related to the kidneys’ inability to excrete free water because of decreased basal levels of renin and aldosterone. Vague symptoms such as malaise, confusion, headache, and nausea may also progress to coma and seizures (Davis & Minaker, 1999). It is important, however, to determine whether an older adult has low sodium level but normal osmolarity; this is known as pseudohyponatremia. In these cases, the osmolarity remains normal or high as a result of excess amounts of other osmolites in blood, for example, glucose, triglycerides, or plasma proteins. By determining the underlying cause and providing appropriate treatment, the health care provider can take steps to ensure return of the sodium level to normal (Davis & Minaker, 1999).
It is essential that gerontologic nurses understand the goal of treatment for patients with fluid and sodium disorders. In patients with fluid deficiencies, the nurse can help identify reasons for a given condition, for example, restrictions in mobility, visual disturbances, urinary incontinence, and swallowing disorders. Hypernatremia (a high sodium level) may be caused by infusion of high-sodium solute fluids, excessive water loss, and excessive diarrhea and decreased oral intake. Hypernatremia is often seen in hospitalized older adults; some cases are present on admission, whereas some are the consequence of hospitalization. Symptoms are similar to those of hyponatremia, and the most common neurologic signs are those of obtundation, lethargy, and coma. The pathophysiology behind the neurologic signs is thought to be neuronal cell dehydration and brain shrinkage (Beck & Hazzard, 1999). Laxative abuse, usually unreported but often present in older adults, may also lead to hypernatremia (Davis & Minaker, 1999).
Potassium Potassium (K +) is present in both the intracellular and extracellular fluid. The majority of potassium is found within the cell, and minute amounts in the extracellular fluid. This extracellular amount
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is measured by serum testing. Potassium levels are widely thought to be affected by aging, but conclusive studies have not confirmed this theory (Beck & Hazzard, 1999). Potassium imbalances in older adults may be caused by the same changes in the renal system as those affecting sodium. Salt substitutes, used by many older adults with hypertension or heart failure (HF), are high in potassium and should be used with caution. Many medications such as potassium- sparing diuretics, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) used in conjunction with potassium supplements, may cause hyperkalemia in older adults. In addition, nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen interfere with potassium excretion (Beck & Hazzard, 1999). Hypokalemia may be caused by gastrointestinal loss and the use of diuretics. Hypokalemia may predispose older adults to tachyarrhythmias and potentiate digitalis toxicity (Beck & Hazzard, 1999). Because OTC medication use has increased, it is important for the gerontologic nurse to carefully assess an older adult’s prescription and OTC medication history (see Emergency Treatment box).
Emergency treatment
Abnormal Laboratory Values: Potassium
Hypokalemia • If asymptomatic, may repeat test before treatment.
• Monitor for possible cardiac arrhythmias (e.g., sinus bradycardia, atrioventricular block, paroxysmal atrial tachycardia).
• Observe for signs of digitalis toxicity.
• Maximum oral replacement is 40 to 80 milliequivalents per day (mEq/day) if renal function is normal.
• The preferred rate for intravenous replacement is 20 mEq/hr; 40 mEq/100 mL is commonly used with an infusion pump.
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• Repeat test after replacement therapy.
From McCance, K.L. & Huether, S.E. (2008). Pathophysiology: The biologic basis for disease in adults and children (5th ed.). St. Louis, MO: Mosby.
Potassium, like sodium, maintains cell osmolarity, muscle function, and the transmission of nerve impulses, and it regulates acid–base balance (Grodner et al., 2004). Cardiac muscle is particularly sensitive to serum concentrations of potassium. Hyperkalemia may cause muscle twitching, arrhythmias, and gastrointestinal symptoms (Grodner et al., 2004). Hypokalemia may occur because of excessive loss of potassium through the gastrointestinal tract, usually by vomiting. Symptoms include muscle weakness, confusion, and absence of bowel sounds. When replacing potassium in older adults, the nurse must take care to prevent hyperkalemia.
Chloride Chloride (Cl–) is mostly present in the fluid outside the cell; it is the major anion in the extracellular fluid. Chloride is closely tied to sodium; losses and excesses in sodium affect chloride levels (Pagana & Pagana, 2010). Chloride levels have not been shown to change with aging (see Table 19-2).
Calcium The serum calcium (Ca++) level measures only the amount of calcium in blood, which is about 1% of the body’s total calcium. Approximately 99% of the body’s calcium is found in bones and teeth (Grodner et al., 2004). No age-related increases or decreases occur in the calcium level, even though changes occur in calcium metabolism with aging. The loss of calcium from bone maintains the normal level of calcium in blood, but the resulting bone loss secondary to calcium leaching may lead to osteoporosis (Baylink, Jennings, & Mohan, 1999). Calcium is important in blood clotting, conduction of nerve impulses, enzyme activity, and especially muscle contraction and relaxation (Grodner et al., 2004). Calcium levels measure free calcium as well as calcium that is protein bound
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with albumin. Therefore, any change in albumin level also affects calcium (Pagana & Pagana, 2010).
Calcium metabolism is one of the factors that determines phosphorus levels; an inverse relationship is present. A decrease in calcium may cause an increase in phosphorus, and vice versa. Parathyroid hormone (PTH) also affects phosphorus levels by affecting the resorption of phosphorus in the kidneys (Pagana & Pagana, 2010). PTH acts on plasma membrane receptors of the nephrons of the kidneys to increase the resorption of calcium and to decrease the resorption of phosphorus (McCance & Huether, 2008).
Phosphorus Phosphorus (phosphate) is a mineral found mostly in bone, in combination with calcium (Grodner et al., 2004). Phosphorus is generally well absorbed from the small intestine in the presence of vitamin D. Long-term use of antacids, which bind to phosphorus, may interfere with absorption (Ott, 1999). Additionally, the kidneys excrete excess phosphorus from blood; in the setting of kidney disease, hyperphosphatemia may develop. Phosphorus plays an important role in the maintenance of homeostasis (as a component in deoxyribonucleic acid [DNA] and ribonucleic acid [RNA]); the metabolism of fats, carbohydrates, and proteins; and the transfer of energy stored as adenosine triphosphate (ATP) (Grodner et al., 2004). In older adults, phosphorus levels are slightly decreased in comparison with younger adults (see Table 19-2).
Magnesium Magnesium plays a significant role in the enzymatic processes needed for energy production. The most important sites of function are muscles and nerves. Approximately two thirds of the body’s magnesium is contained in bones (Grodner et al., 2004). Magnesium levels have been reported to decrease by 15% between the third and eighth decades as renal function declines (Cavalieri, Chopra, & Bryman, 1992) (see Table 19-2).
Glucose
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Glucose is used for energy by the cells (Grodner et al., 2004). Blood glucose tests are evaluated on the basis of the time blood was drawn and the duration of fasting. New criteria for the diagnosis of diabetes mellitus were released by the National Institute of Diabetes and Digestive and Kidney Diseases in 2011. See Table 19-3 for changes in the criteria for the diagnosis and classification of diabetes.
Table 19-3 Diagnosing and classification of diabetes
Taken from American Diabetes Association. (2013). Standards of medical care in diabetes —013. Diabetes Care, 36(Suppl 1), S11-S66.
HbA1c, Glycohemoglobin; mg/dL, milligrams per deciliter.
In addition to patient symptoms, three other methods of diagnosing diabetes are as follows:
1. Fasting blood glucose. Blood is drawn after fasting for 8 hours. This test is used to detect prediabetes and diabetes.
2. Oral glucose tolerance test. A person fasts for at least 8 hours and 2 hours after the person drinks a liquid containing 75 grams of glucose dissolved in water, blood sugar is tested. This test is typically used to diagnose gestational diabetes, after confirmation with repeat testing.
3. Glycohemoglobin (hemoglobin A1c HbA1c). This is a blood test that checks the amount of glucose bound to hemoglobin. Test is used to diagnose diabetes and monitor therapy. It provides an average of blood glucose levels over the previous 2 to 3 months.
Two other blood glucose tests are used to monitor diabetes therapy, but not for diagnosis:
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1. Two-hour post-prandial. This test measures blood glucose exactly 2 hours after starting to eat. This test helps determine whether a person with diabetes has achieved adequate control of blood sugar.
2. Random blood sugar. This test measures blood glucose without fasting. Wide variance in blood glucose levels may indicate a problem.
Hypoglycemia may cause central nervous system (CNS) changes such as confusion, which is related to brain cell starvation. Diagnosing and treating hypoglycemia in older adults may be difficult because determining whether a low glucose level is a result of altered glucose metabolism related to aging or the result of type 2 diabetes affects the choice of treatment. Hyperglycemia causes symptoms that include extreme thirst, drowsiness, and frequent urination. Older adults with type 2 diabetes may develop a condition referred to as hyperosmolar hyperglycemic state (HHS). HHS occurs most often in patients with conditions leading to volume depletion. Infection is the most common cause, but many other conditions may cause volume depletion.
Amylase Amylase is an important enzyme in the catabolism of carbohydrates in the intestine. It is produced by the acinar units of the pancreas (Pagana & Pagana, 2010). Amylase levels are primarily tested while trying to rule out pancreatitis or other pancreatic diseases. Elevated levels may be because of damage to or disease of the pancreas or interference in the flow of amylase from the pancreas. Elevated amylase levels also may be seen in nonpancreatic disorders such as perforated ulcer and perforated or necrotic bowel or secondary to medications. Decreased amylase levels may be found with chronic pancreatitis, pancreatic insufficiency, or cystic fibrosis (Pagana & Pagana, 2010) (see Table 19-2).
In acute pancreatitis an obstruction causes pancreatic enzymes, including amylase, to “back up” into the pancreas, causing self- digestion of the pancreas. Because amylase plays an important part in the digestion of starches, a decrease may affect digestion. Amylase is needed to convert disaccharides to monosaccharides,
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and diarrhea may occur when this conversion does not happen. Amylase is also present in saliva, where it initiates carbohydrate digestion in the mouth and stomach (Thibodeau & Patton, 2003).
Total Protein Total protein testing measures the amount of albumin and globulin in the plasma. This test is performed to identify nutritional problems and kidney or liver disease (WebMD, 2011).
Albumin and Prealbumin Serum albumin levels are is used to monitor nutritional status, and liver and kidney disease (Grodner et al., 2004). Albumin levels decrease with age. Low albumin levels (< 3.5 grams per deciliter [g/dL]) have been associated with increased mortality in hospitalized patients (Iwata, Kuzuya, Kitagawa, & Iguchi, 2006). Additionally, when albumin is insufficient to sustain sufficient colloid osmotic pressure to counterbalance hydrostatic pressure, edema develops (typically with an albumin level < 2.5 g/dL). Low albumin levels are also associated with certain medications, including corticosteroids, insulin, and thyroid hormone. Research is conflicting concerning the relationship between serum albumin levels and pressure ulcer or wound healing, with some research indicating little connection (Lizaka, Sanada, Matsui et al., 2011) and other research indicating a relationship between albumin and wound healing in diabetics (Amir, Liu & Chang, 2012). Finally, low levels of albumin are found in patients with burns, HF, acute infection, and thyrotoxicosis. High albumin levels are associated with blood loss and dehydration.
Prealbumin is also used to assess nutritional status. It is the measurement of protein status over the short term and is a more accurate measurement of malnutrition because of its short half-life of 2 days (Grodner et al., 2004). Plasma prealbumin level may be useful in evaluating an older adult’s response to nutritional supplements (Manning & Shenkin, 1995).
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Blood Urea Nitrogen Measurement of urea in blood is known as the blood urea nitrogen (BUN) test. Urea is a major waste product of protein catabolism and a result of ammonia conversion in the liver. Urea is excreted from the body by the kidneys. BUN levels are indicative of both liver and kidney function. Values for older men are slightly higher than the adult normal levels of 7 to 22 milligrams per deciliter (mg/dL). In older women, BUN levels are also increased but less than in older men (Pagana & Pagana, 2010) (see Table 19-2).
Creatinine Creatinine is another end-product of protein metabolism. A rise in a patient’s BUN and creatinine levels is indicative of kidney disease (Grodner et al., 2004). The physiologic decline in the GFR in older adults is not generally accompanied by a rise in the creatinine level (Sands & Vega, 1999) because a parallel decrease occurs in mean muscle mass and actual creatinine production with aging (Kane et al., 1999). An 80-year-old person and a 30-year-old person who have the same creatinine concentrations do not have comparable GFRs. In this example, the older adult has approximately 40% to 50% less GFR compared with the younger adult (Beck & Hazzard, 1999). Therefore, the creatinine level in an older adult should not be considered an independent indicator of renal function, as it would be in a younger individual. It should, instead, be used to calculate the creatinine clearance for a more realistic indication of renal function in older adults.
Creatinine Clearance Creatinine clearance is the measure of the GFR, estimated from serum creatinine (SCr) and urine creatinine levels. A 24-hour urine test is required along with a serum level within the same 24-hour period. To allow for changes with aging that are not reflected in the creatinine level, many primary care providers use the Cockcroft and Gault formula to estimate creatinine clearance:
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(For women, multiply the final result by 0.85.)
An alternative method of calculating creatinine clearance is the Modification of Diet in Renal Disease (MDRD) formula:
Neither method of calculating GFR is without variation; however, the MDRD is currently the method of choice. The gerontologic nurse should recognize the importance of creatinine clearance as a reflection of an older adult’s overall health status. The older adult’s response to medications, especially newly prescribed drugs, should be monitored because impaired renal function may precipitate side effects that may be overlooked. The normal reference range is 0.7 to 1.5 mg/dL but may be lower in older adults with low muscle mass (Cook, 1999).
Triglycerides Triglycerides are the principal lipids found in circulating blood bound to a protein; they form high-density and low-density lipoproteins (HDLs and LDLs). Triglycerides are produced in the liver from glycerol and fatty acids found in blood. When the triglyceride level in blood reaches its peak, the excess is deposited in the fatty tissue for release at a later time for energy between meals (Pagana & Pagana, 2010). The American Heart Association (AHA) recommends an optimal triglyceride level of 100 mg/dL or lower.
Total Cholesterol Cholesterol is a steroid compound that helps stabilize the membranes of the body’s cells (Thibodeau & Patton, 2003). It is also
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the major lipid associated with cardiovascular disease. The liver metabolizes cholesterol and binds it to LDLs and HDLs for transport in the bloodstream (Pagana & Pagana, 2010). Total cholesterol levels are a combination of LDL and HDL levels in the bloodstream. The National Cholesterol Education Program recommends total cholesterol levels be kept at less than 200 mg/dL. However, it is important to evaluate cholesterol in relationship to HDL, LDL and triglyceride levels, not in isolation.
High-Density Lipoprotein HDL, referred to as “good cholesterol,” carries greater amounts of protein and lesser amounts of lipids, hence the term high density. HDL’s role is to take cholesterol to the liver for degradation. A high HDL level (> 60 mg/dL) is considered healthy; it is protective against heart disease.
Low-Density Lipoprotein The remaining cholesterol in the bloodstream is bound to LDL (Pagana & Pagana, 2010), known as “bad cholesterol.” The LDL level is calculated from the total cholesterol level, HDL level, and fasting triglycerides with the use of the following equation (Lindsey, Graham, Johnston, Kiroff & Freshley, 2004):
Patients with established heart disease and another risk factor such as smoking are recommended to have the LDL cholesterol level at less than 70 mg/dL. Those at high risk but without established disease are recommended to have the LDL level at less than 100 mg/dL. Patients considered at moderate risk for heart disease should maintain the LDL level at less than 130 mg/dL; and those at low risk for heart disease should have the LDL level at less than 160 mg/dL.
Brain Natriuretic Peptide
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The brain natriuretic peptide (BNP) is a neurohormone secreted from the cardiac ventricles in response to ventricular stretching and pressure overloading (Prahash & Lynch, 2004). This test helps diagnose and treat patients with HF. Studies have shown that an elevated BNP level is highly sensitive and specific for the diagnosis of heart failure (Maisel, 2003; Morrison, Harrison, Krishnaswamy, Kazanegra, Clopton & Maisel, 2002). Plasma levels of BNP are significantly elevated in patients with heart failure and left ventricular dysfunction; however, the values cannot be used to differentiate between systolic and diastolic heart failure (Prahash & Lynch, 2004).
Alkaline Phosphatase Alkaline phosphatase (ALP) is an enzyme found in many tissues, although it has its highest concentrations in the liver and bone. Testing for ALP is used to identify liver and bone disorders (Pagana & Pagana, 2010). Testing of the alkaline phosphatase level in older adults is often used in the biochemical assessment of Paget disease (Lyles, 1999) and other bone diseases (see Table 19-2).
Acid Phosphatase Acid phosphatase (ACP) is an enzyme found in the kidneys, serum, semen, and prostate gland. It is elevated in serum in prostate cancer and in trauma. ACP levels are used to diagnose prostate cancer and to estimate the extent of the disease. The incidence of prostate cancer increases substantially after age 50, and it is the second most common malignancy in men in the United States (Letran, Brower, & Hazzard, 1999). In addition to assisting with diagnosis, the ACP level is also helpful in determining whether treatment for prostate cancer has been effective (Pagana & Pagana, 2010).
Aspartate Aminotransferase Aspartate transaminase (AST; also referred to as serum glutamic oxaloacetic transaminase [SGOT]) measures the enzyme of the same name, which is found in muscles and in the liver and kidneys. It is
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primarily used to diagnose liver disease. A threefold to fivefold increase in SGOT may be indicative of hepatotoxicity from drugs such as isoniazid, rifampin, ethambutol, and pyrazinamide (Rajagopalan & Yoshikawa, 1999).
Creatine Kinase Creatine kinase (CK) is present in cardiac and skeletal muscles and in the brain and lungs. CK-BB is primarily found in the lungs and brain, whereas CK-MB is associated with cardiac muscle cells. CK- MM is normally found in circulating blood, and the level rises with damage to skeletal muscle. CK levels rise and peak at specific intervals during myocardial infarction, and these levels may be used to determine the amount of myocardial damage (Siomko, 2000); however, this test has largely been replaced by troponin. CK may also be ordered when a person has experienced physical trauma such as crushing injuries or extensive burns or to diagnose rhabdomyolysis.
Lactate Dehydrogenase Lactate dehydrogenase (LDH) is an enzyme found in the muscles, brain, liver, kidneys, and RBCs. As with CK, LDH may be isolated into five isoenzymes (CK only has three). These isoenzymes help clarify the site of release of the LDH and assist the nurse in assessing and monitoring specific complications related to the site of injury. Currently, the main use of the test is for monitoring progressive conditions such as kidney disease, liver disease, and some cancers.
Troponin The troponin test measures the levels of certain proteins in the blood that are released when cardiac muscle has been damaged. Troponins (troponin I or troponin T) are the preferred tests for a suspected heart attack because they are more specific for detecting heart injury compared with other tests. These indices appear 2 to 8 hours after a decrease in the oxygenation of cardiac muscle caused
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by occlusion of the cardiac vessels. Levels may remain elevated up to 2 weeks after a myocardial infarction (Siomko, 2000). This test may also be ordered when a patient has worsening angina or acute coronary syndrome without ST elevation.
Thyroid Function Tests Testing of thyroid function includes the assessment of two hormones secreted by the thyroid gland: thyroxine (T4) and triiodothyronine (T3). Thyroid function tests are a means of screening for hypothyroidism or hyperthyroidism and for monitoring the effectiveness of thyroid-suppression or hormone replacement therapy. T4 and T3 are generally elevated in hyperthyroidism and decreased in hypothyroidism. Thyroid- stimulating hormone (TSH), a hormone secreted by the pituitary gland, is also usually tested when thyroid function is investigated; TSH is elevated in hypothyroidism and decreased in hyperthyroidism (Table 19-4). Higher-than-normal TSH levels are most often caused by an underactive thyroid gland (hypothyroidism), which may result from autoimmune disease, treatment for hyperthyroidism, radiation therapy or thyroid surgery, or certain medications (e.g., lithium). Lower-than-normal levels may be caused by an overactive thyroid gland (hyperthyroidism), which may result from Graves disease, toxic nodular goiter, thyroiditis, or certain medications (e.g., glucocorticoids and opioid) (Hassani & Hershman, 1999).
Table 19-4 Thyroid testing
Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby.
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Prostate-Specific Antigen The prostate-specific antigen (PSA) test measures the amount of PSA, a protein produced in the prostate and found in blood. High levels of PSA may indicate the presence of prostate cancer. However, other conditions such as an enlarged or inflamed prostate may also cause an increase in PSA levels. Before any prostate screening is initiated, the gerontologic nurse needs to ensure that the patient has an understanding of the risks and benefits associated with the results: Would treatment of the prostate cancer improve or worsen the person’s quality of life? Would he want treatment if cancer exists? The U.S. Preventive Services Task Force (USPST) has recently released a study showing that the risk of prostate examinations far outweigh the benefits in men aged over 75 and in those with less than 10 years’ life expectancy.
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Components of urine chemistry testing Urine chemistry testing includes testing for the presence of protein, glucose, bacteria, blood, ketones, and leukocytes. It also involves studying the sample for properties of specific gravity and pH. Urine is a waste product formed by the kidneys and consists of 95% water. The composition of urine may inform the health care professional of the status of many body systems. When blood passes through the kidneys, water, nitrogen compounds, toxins, and electrolytes are filtered, reabsorbed, and secreted. The amounts retained or excreted affect the body’s homeostasis.
Protein Protein in urine (proteinuria) is considered an abnormal finding and indicates damage to the kidneys’ glomeruli (Table 19-5). Its presence warrants investigation to rule out urinary tract infection (UTI) or kidney disease.
Table 19-5 Urine chemistry
Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test
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reference (10th ed.). St. Louis, MO: Elsevier Mosby.
Glucose Normally, glucose is not present in urine. When the blood sugar levels exceed 180 mg/dL, the kidneys release some of the excess glucose from blood into urine. Glucose may also be found in urine when the kidneys are damaged or diseased.
Bacteria and Leukocytes Although occasional trace amounts of bacteria (bacteriuria) may normally appear in urine, significant amounts, defined as greater than 105 colony-forming units (CFU) per milliliter of urine, indicate infection. The gerontologic nurse should assess older adults for symptoms of urinary incontinence, flank pain, fever, voiding frequency, burning, and suprapubic or low back pain. However, common symptoms may be absent in most of the older adults, and symptoms such as confusion, new onset of incontinence, lethargy, nocturia, and anorexia may be the first indication of underlying UTI (Duffield, 1997; Riehmann, 1998). Women are more prone to lower UTI compared with men because of the shorter urethra and its proximity to the anus. Significant numbers of older adults are asymptomatic, even when bacteria are found in urine. Pus in urine (pyuria) is more indicative of symptomatic UTI, and a level greater than 10 leukocytes/mm3 of urine on microscopic examination is definitive.
Ketones The presence of ketones, the result of fatty acid breakdown, in urine is another abnormal finding. When overaccumulation of ketones occurs in blood, the excess is excreted in urine. Causes of ketones in urine include diabetic ketoacidosis, a low-carbohydrate diet, starvation or fasting, and severe vomiting (Pagana & Pagana, 2010).
pH The pH of the urine sample indicates the acid or base value of
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urine, which reflects the body’s homeostatic state. The normal range for urine pH is 4.6 to 8.0. Drugs that increase urine pH include acetazolamide, potassium citrate, and sodium bicarbonate; drugs that may decrease urine pH include ammonium chloride, thiazide diuretics, and methenamine. Renal calculi are acid or base in origin, depending on the underlying substances that form the stones: acidic urine is associated with xanthine, cystine, uric acid, and calcium oxalate stones; alkaline urine is associated with calcium carbonate, calcium phosphate, and magnesium phosphate stones. Prevention and treatment of calculi are aimed at changing the urine to the reverse pH of the stone’s composition (Pagana & Pagana, 2010).
Blood The presence of blood in urine (hematuria) is always an abnormal finding. The cause may be renal obstruction from calculi, trauma to the kidneys, inflammation, infection, or malignancy. Blood may be grossly apparent or occult, giving urine a cloudy or pink hue on visual inspection.
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Components of arterial blood gas testing Arterial blood gas (ABG) testing involves drawing a sample of blood from an artery, usually from the radial or brachial artery. Components of ABG testing are pH, oxygen, and carbon dioxide content, oxygen saturation, and bicarbonate level (Table 19-6). It is important that the primary care provider and laboratory personnel be aware of the conditions of an older adult’s oxygenation when blood was drawn (e.g., the type of air being breathed [room air or other], the amount of oxygen support, and the type of oxygen delivery device). Pulse oximetry is a reliable alternative to ABG testing when the percentage of oxygen saturation in blood needs to be determined. The use of pulse oximetry is less painful and less expensive, and results are immediately available (Pagana & Pagana, 2010).
Table 19-6 Arterial blood gases
Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby. HCO3
–, Bicarbonate; mEq/L, milliequivalents per liter; mm Hg, millimeters of mercury; PaCO2, partial pressure of arterial carbon dioxide; PaO2, partial pressure of arterial oxygen.
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Evidence-based practice Research May Support Some Myths in Home Remedies Sample/Setting Subjects included 153 volunteer women with a mean age of 78.5 years. Subjects were randomly assigned to drink 300 milliliters (mL) of cranberry juice or a similar-tasting placebo substance per day. Sixty-five women were residents in a nursing facility in midwestern United States and had urinary incontinence for at least 2 weeks, according to nursing facility administrators.
Methods Baseline urine samples and six clean-voided samples were collected at 1-month intervals and quantitatively tested for bacteriuria and white blood cells (WBCs).
Findings Subjects consuming the cranberry juice had odds of having bacteriuria, defined as ≥ 105 mL, with pyuria that were only 42% of the odds of the control group. The odds of continuing to have bacteriuria–pyuria were 27% of the odds in the control group if it was assumed that they had had bacteriuria–pyuria the month before.
Implications The study findings suggested that the ingestion of cranberry juice by older women decreases the frequency of bacteriuria.
Adapted from Avorn, J., Monane, M., Gurwitz, J. H.,Glynn, R. J. Choodnovskiy, I., & Lipsitz, L. A. (1994). Reduction of bacteriuria and pyuria after ingestion of cranberry juice. Journal of the American Medical Association, 271(10), 751.
Evidence-based practice
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Clinical Signs versus Subjective Assumptions of Urinary Tract Infection Are More Effective Sample/Setting This study took place in nursing homes in midwestern United States. Residents could participate if they could provide a clean- catch urine specimen that was not contaminated. It was also necessary that residents had not taken antibiotics for the past 14 days. A total of 97 urine samples were included in the final analysis.
Methods Two experienced nursing assistants performed a smell test on the wet incontinence pads of selected nursing home residents to determine whether urine had a strong, foul, or fruity odor thought to be indicative of urinary tract infection (UTI). The residents also provided clean-catch urine specimens that were sent to a laboratory to determine whether any organism grew in culture (bacteriuria) and whether certain number of white blood cells were present (pyuria). Sensitivity, the number of true- positive results, and specificity were determined, but the number of true-negative results was the ultimate indicator sought in this study. Adequate sensitivity was determined to be 95% with a specificity set at 85% by the researchers.
Findings None of the specimens was noted to have a foul or fruity smell. Only 28 specimens were considered by the nursing assistants to have a strong smell.
About half of those specimens (15) were found to be positive for bacteriuria. About a quarter of the specimens with no smell (17 of 69) were found to test positive for UTI.
When bacteriuria only was present in urine, urine odor sensitivity was 46.9% and specificity was 80%. Urine with both pyuria and bacteriuria present had an odor sensitivity of 44.4% and a specificity of 74.7%. Ultimately, the smell of the urine was not a good indicator of the presence of UTI.
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Implications Although the smell of urine is not a good indicator of UTI, a strong or foul odor is worth investigating. It may indicate other problems such as dehydration, diabetes, or infrequently changed incontinence pads. Once the problem is identified, interventions can be implemented. The researchers suggest increasing fluids in dehydration, identifying and treating diabetes, changing pads more frequently, and requiring perineal care after each toileting episode.
Nurses should always look for clinical signs to determine whether UTI may be present and obtain a urine specimen for verification. Smell as a reliable indicator is not evidence based.
Adapted from Midthun, S., Paur, R., & Lindseth, G. (2004). Urinary tract infections: Does the smell really tell? Journal of Gerontological Nursing, 30(6), 4-9.
Oxygen Oxygen (i.e., partial pressure of oxygen in arterial blood [PaO2]) levels have been shown to decline significantly with age (Cavalieri et al., 1992). Age-related changes such as a decrease in chest wall recoil, decrease in alveolar surface area, and less effective oxygen- to-carbon dioxide (CO2) exchange all contribute to this change in the oxygen level. In the absence of disease, respiratory function remains adequate in older adults. However, changes in PaO2 should be considered in the context of a patient’s age. The PaO2 decreases approximately 25% between the ages of 30 and 80 years (Cavalieri et al., 1992). The following formula for arterial oxygen saturation may be used in calculating age-appropriate PaO2 levels (Cavalieri et al., 1992):
pH of the Blood pH measures the hydrogen ion (H−) concentration in the
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bloodstream. A pH of less than 7.0 is called acid pH and a pH greater than 7.0 is called basic pH (alkaline). pH is influenced by vomiting, diarrhea, lung function, endocrine function, and kidney function (see Table 19-6).
Carbon Dioxide Carbon dioxide (CO2) in blood exists in the form of bicarbonate (HCO3−); therefore, the CO2 blood test really is a measure of blood bicarbonate level. The carbon dioxide test is used to monitor conditions that affect blood bicarbonate levels, including kidney diseases, lung diseases, and metabolic conditions. The normal adult range for carbon dioxide is 35 to 45 mm Hg.
Oxygen Saturation Oxygen saturation (O2 sat %) measures how much of the hemoglobin in the RBCs is carrying oxygen. The normal adult value for oxygen saturation is greater than 95%. Levels below 90% are low. Conditions affecting lung function (e.g., pneumonia, chronic obstructive pulmonary disease [COPD]) alter oxygen saturation.
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Blood level monitoring Three other blood tests performed in older adults receiving drug therapy are digoxin, theophylline, and phenytoin levels. Digoxin (Lanoxin) is a drug used to control the ventricular response in chronic atrial fibrillation (Goroll, May, & Mulley, 2000). The normal therapeutic range is 0.8 to 2.0 nanograms per milliliter (ng/mL), and toxic level is more than 2.0 ng/mL (Devkota, 2014). However, in older adults, toxic effects may occur at the upper levels and sometimes even the lower levels of the normal range. The nurse should be aware of a patient’s own level of “normal,” in which the heart rate is controlled but signs and symptoms of toxicity (e.g., confusion, diarrhea) are absent.
Phenytoin (Dilantin) has normal level ranges between 10 and 20 micrograms per milliliter (mcg/mL), and toxic effects occur at levels of 30 mcg/mL or greater. In older adults, signs of toxicity may sometimes appear at values slightly above 20 mcg/mL; signs may include confusion and lethargy. Phenytoin and digoxin levels should be evaluated at least 4 hours after a dose is given.
Theophylline is a drug often given to patients with pulmonary disease to dilate bronchioles, making breathing easier. The side effects of theophylline may prohibit its use in some older adults (Connolly & Tallis, 2002). Side effects include nausea, restlessness, increased respirations, and diuresis (Beers & Berkow, 2000). More serious side effects include ventricular arrhythmias and seizures. This level should be determined 4 hours after a dose of the drug is given. As with the previous drugs, the therapeutic range of theophylline may be narrow for some older adults. The normal range for a therapeutic level is 10 to 20 mcg/mL, and toxic effects are seen at levels greater than 20 mcg/mL.
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Summary Aging today is vastly different from aging in previous generations. Health care researchers and scientists have traditionally used young or middle-aged men for studies, generalizing findings and results to both genders and a variety of age groups. However, researchers are now beginning to realize that older adults have different “normals” compared with younger adults, as well as complex health histories that may affect their overall physical responses to stressors and disease. Consequently, older adults are now being included in research studies aimed at determining the effects of interventions based on age.
In providing age-specific and age-appropriate health care, providers must recognize that individuals do not respond in the same way to similar experiences. Although many laboratory values are being rewritten to compensate for age-related changes in older adults, many questions remain unanswered. An older adult must be considered within the total context of a person with unique responses to diseases. Laboratory tests and their results should be considered an adjunct to the detection and treatment of illness, not in isolation from the presenting clinical picture.
The gerontologic nurse plays an important role in promoting the well-being of older adults by reviewing and reporting laboratory values. Awareness of the changes in laboratory and diagnostic test values as a result of age helps enhance the management of older adults’ health problems. The gerontologic nurse may need to serve as an advocate for older adults when repeated symptoms and concerns occur that are not addressed by the primary care provider but are instead attributed to the complaints of “old age.” As always, appropriate assessments must be carried out, supplemented by laboratory testing, before establishing nursing interventions.
Home care
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1. The home care nurse must know the purpose of the tests ordered and must explain the reasoning for the tests to both caregivers and homebound older adults.
2. The nurse should assess the homebound older adults’ cultural values and beliefs regarding diagnostic testing.
3. The home care nurse must realize that laboratory values in homebound older adults may be altered because of aging or medication regimens.
4. The home care nurse must be able to differentiate normal versus abnormal laboratory results for homebound older adults, and the nurse must know when to notify a physician.
5. The nurse should instruct caregivers and homebound older adults about what is required before laboratory testing (e.g., nothing by mouth from midnight the night before until the procedure).
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Key points • The ESR rises approximately 10 to 20 mm in older adults; this is
considered a normal age-related change.
• Potassium-sparing diuretics and NSAIDs may interfere with potassium excretion.
• Older adults may have hyponatremia in the presence of normal osmolarity, indicating the presence of other osmolarities in excess in blood.
• Renal and hepatic system functioning may be reflected in the BUN level.
• Hypokalemia may potentiate digitalis toxicity in older adults.
• Comparable serum creatinine levels in younger adults and older adults are not indicators of comparable kidney function.
• Urine testing for glucose in older adults is considered unreliable in view of age-related changes in renal function.
• Thyroid disease may be present in older adults without the overt symptoms typically seen in younger adults with thyroid disorders.
• Older adults may be asymptomatic in the presence of bacteriuria.
• Pyuria is more indicative of symptomatic UTI than is the presence of bacteria in the urine of older adults.
• The “normal” oxygen saturation in older adults may be 95% or greater in arterial blood.
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Critical thinking exercises 1. When evaluating the laboratory data for a 73-year-old man, you note that his ESR and serum creatinine level are slightly elevated and his serum magnesium level is decreased. What conclusion, if any, can be drawn from these findings? Should the data be reported to the physician?
2. You are making home visits to an 82-year-old woman who is recovering from a fractured femur. During your last three visits, she consistently complained of being cold, even though it is summer and her house is very warm. In addition, she has had frequent complaints of constipation, has not felt like eating, and has been tired. She has a bottle of hand lotion next to her chair for her dry skin. What is your assessment, and is any action warranted on your part?
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* Previous authors: Tamara R. Tripp, AD, BSN, MSN, and Susan A. Moore, PhD, RN.
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C H A P T E R 2 0
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Pharmacologic Management Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe the characteristics of medication use in older adults.
2. List medications that are best avoided in older adults.
3. Identify potential risk factors for adverse drug reactions.
4. Describe the pharmacokinetic and pharmacodynamic changes associated with aging and the implications for drug therapy and abuse.
5. Recognize significant drug–drug, drug–food, and drug–disease interactions, giving specific examples for each.
6. State the impact that drugs may have on an older adult’s quality of life.
7. Describe issues related to the optimum use of psychotropics, cardiovascular agents, and antimicrobials.
8. Anticipate the effects of increased availability of nonprescription and herbal remedies on patient self-management.
9. Identify risk factors for nonadherence and suggest strategies to improve adherence.
10. List the key components of assessing older adults for addictions and related disorders.
11. Identify the key multidisciplinary and nursing interventions for older adults who abuse substances.
12. Identify the signs and symptoms of alcohol, prescription and nonprescription drug, and tobacco abuse and withdrawal in older adults, and describe the corresponding nursing interventions.
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Overview of medication use and problems Demographics of Medication Use Drugs have an important role in the management of conditions and the maintenance of well-being in older adults. At least 94% of community-dwelling adults aged 65 to 74 take medications. Of these, 81% regularly take prescription medications, 46% take over- the-counter (OTC) medications, and 52% take dietary supplements. The prevalence of drug use increases in those 75 years or older (Qato, Alexander, Conti et al., 2008).
Drugs may be vital contributors to health and well-being, but all drugs carry risks. For older adults, these risks may be dangerous and even life threatening. To ensure optimal health outcomes, it is important to understand how aging and conditions associated with aging affect drug processes and actions. This chapter explains the relationship between drugs and aging and provides implementation guidelines to promote safe and effective drug therapy. Emphasis is placed on the role of the nurse in ensuring optimal outcomes for the older adult.
Changes in Drug Response with Aging Aging alters the dynamic processes drugs undergo to produce therapeutic effects. These alterations involve pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body). Pharmacokinetics and pharmacodynamics, and nursing implications for care of the older adult are described in the following section.
Pharmacokinetic Changes: What the Body Does to the Drug When a drug is taken, it begins a journey of four phases: (1) absorption, (2) distribution, (3) metabolism, and (4) excretion. What
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the body does to the drug during the four phases of this journey is known as pharmacokinetics. The normal physiologic changes that occur with aging alter pharmacokinetics. This section explores pharmacokinetic changes that occur with aging. A summary of important age-related physiologic alterations that affect pharmacokinetics is presented in Table 20-1.
Table 20-1 Age-related changes in pharmacokinetics
From Hammerlein, A., Derendorf, H., & Lowenthal, D.T. (1998). Pharmacokinetic and pharmacodynamic changes in the elderly: Clinical implications, Clin Pharmacokinet 35(1):49.
Absorption refers to the movement of a drug from the site of administration to the systemic circulation. Primary alterations in absorption occur with drugs taken orally or via feeding tubes. Drugs administered orally first need to enter the stomach and intestines. With aging, the risk for decreased secretion of gastric acid, slowed gastric emptying, and decreased gastrointestinal motility, and decreased blood flow to the gastrointestinal tract exists (Kaufman, 2013). Although these effects may slow the absorption of oral drugs, they do not substantially affect the amount of drug absorption that occurs; therefore, age-related changes in the absorption of most drugs are usually insignificant (Kaufman, 2013); however, the first dose of a new drug may take longer to take effect
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(Hutchison & O’Brien, 2007). Topical drugs also face barriers to absorption. Reduction in subcutaneous fat associated with integumentary changes of aging alters topical medication absorption. These changes may result in impaired absorption of some medications administered as lotions, creams, ointments, and patches (Flammiger & Maibach, 2006).
Distribution refers to movement of the drug from systemic circulation to the site of action. Distribution is affected by relative amounts of total body water, fat content, and protein binding. Total body water decreases with aging; decreased total body water results in higher concentrations of water-soluble drugs (Kaufman, 2013; Lilley, Harrington, & Synder, 2007). Water-soluble drugs tend to stay in the circulation longer, leading to higher drug concentration levels. To decrease the risk of toxicity, smaller doses of water-soluble medications such as digoxin, lithium, atenolol, and aminoglycosides may be needed for older adults (Beers, Porter, Jones et al., 2006; Kaufman, 2013). Older adults have decreased lean body mass and increased percentage of fat compared with young adults. The increase in fat composition offers increased storage capability for fat-soluble drugs (Hutchison & O’Brien, 2007). As a result, fat-soluble drugs such as benzodiazepines and certain anesthetics (e.g., halothane and thiopental) may have extended half- lives (Hutchison & O’Brien, 2007; Kaufman, 2013; Lilley et al., 2007). A final area of concern regarding distribution involves drugs that are highly protein bound. Drugs of this type, for example, warfarin, phenytoin, furosemide, and naproxen, tend to bind primarily to albumin, a protein in the plasma, and only become active when unbound. With age, particularly for malnourished or frail adults, albumin levels may drop as much as 15% to 25% (Kaufman, 2013), resulting in increased free drug available for action. Decreased protein available for binding may result in toxicity and difficulty maintaining stable drug levels (Beers et al., 2006; Hutchison & O’Brien, 2007; Kaufman, 2013; Lilley et al., 2007).
Metabolism refers to the biotransformation of drugs into metabolites that are more easily excreted. Less commonly, metabolism will convert inactive drugs, known as prodrugs, to an active form. Metabolism is accomplished through either phase I
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reactions (oxidation, reduction, demethylation, or hydrolysis via the cytochrome P [CYP] 450 enzyme system) or phase II reactions (glucuronidation, acetylation, conjugation, or sulfation). Recent research has demonstrated that aging does not appear to affect phase II processes. Furthermore, although some isoenzymes (e.g., CYP2C19, which has a role in metabolizing diazepam, naproxen, omeprazole, and propranolol) are reduced with aging, others remain unchanged, are variable, or affect only those older adults who are malnourished or frail (Hutchinson & O’Brien, 2007). Additionally, with aging, a decrease in hepatic blood flow occurs (Hutchison & O’Brien, 2007). This is particularly relevant in relation to first-pass metabolism. First-pass metabolism is a process in which drugs absorbed from the stomach or intestines first enter the portal circulation of the liver and a portion are metabolized (inactivated) before reaching the systemic circulation. A decrease in hepatic blood flow may result in a decrease in the amount of a drug inactivated before entering the systemic circulation, resulting in a greater amount of active drug and thus increasing the risk that standard doses of drugs may result in toxic effects (Hutchison & O’Brien, 2007; Kaufman, 2013; Lilley et al., 2007). The implications of these alterations are that the metabolism of some drugs may be slowed, leading to a prolonged drug half-life and an increased risk of drug accumulation and toxic effects; however, this cannot be generalized to all older adults. Individualization of drug regimens and close monitoring for signs and symptoms of toxic effects and complications is necessary while dosing is adjusted.
Excretion, the elimination of drugs from the body, occurs primarily via the kidneys. When renal function is decreased, half- life increases and drugs may accumulate to toxic levels. This has important implications for older adults as renal function typically decreases with aging, especially for those who have conditions such as hypertension or heart disease (Shi, Mörike, & Klotz, 2008). Renal function varies from patient to patient, so it is important to evaluate renal function on an individual basis. A serum creatinine level is commonly used as a screening test for renal function; however, serum creatinine is affected by nutritional status, protein intake, and muscle mass (Hutchison & O’Brien, 2007; Shi et al., 2008). Therefore, in older adults, the best indicator of renal function is the
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glomerular filtration rate (GFR). Two methods of calculating GFR are deemed acceptable for use in older adults: (1) the Modification of Diet in Renal Disease 6 (MDRD6) formula and (2) the Cockcroft and Gault formula (CG). The MDRD6 slightly overestimates GFR and includes albumin in its calculation; the CG slightly underestimates GFR and is easier to calculate (Chauvelier, Pequignot, Amzal et al., 2012). The prescriber may then use information gleaned from the GFR to adjust drug dosing on the basis of renal function.
Nursing management associated with altered pharmacokinetics rests primarily on careful patient monitoring to assess the adequacy of drug level to achieve the desired effect and identify adverse drug reactions and events creating problems for the patient. Each drug manifests toxicity in different ways, so it is essential the nurse become familiar with signs and symptoms of toxicity for each drug that a patient takes so that toxicity can be detected in the early stages. It is also important for the nurse to understand therapeutic drug monitoring. For some drugs (e.g., digoxin), a serum drug level is measured; other drugs (e.g., warfarin) are monitored through diagnostic tests evaluating drug effects (e.g., international normalized ratio [INR]). If evidence of toxicity exists, the nurse will need to assess the patient and notify the provider promptly. The nurse should anticipate adjustment in the drug dosage.
Pharmacodynamic Changes: What the Drug Does to the Body Physiologic changes associated with aging may also alter how the older adult’s body responds to drugs. Pharmacodynamics, that is, what the drug does to the body, is the term used to explain the body’s response to a drug. Age-related changes affect all substances involved in pharmacodynamics: enzymes, receptors on cell surfaces, carrier molecules and protein transporters in cell membranes (Kaufman, 2013; Shi et al., 2008). As a result, drug sensitivity may be either increased (e.g., increased anticholinergic effects of tricyclic antidepressants) or decreased (e.g., decreased response to beta-blockers [BBs]). In both respects, the altered
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sensitivity is unrelated to the drug level. Furthermore, the bodily processes that maintain homeostasis (autonomic control and reflex activity) become less responsive; consequently, the older adult may be less able to tolerate certain drugs. As with nursing actions related to pharmacokinetics, it is imperative that the nurse assess individual responses to drugs so they can be adjusted to optimize patient outcomes.
Inappropriate Drugs for Older Patients As a result of age-related changes in pharmacokinetics and pharmacodynamics, some drugs and drug classes are less likely to be tolerated by older adults. To identify problematic medications, expert panels developed a number of screening tools and lists detailing inappropriate drugs for older adults. The most well- known of these is the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults originally formulated in 1991 (Beers, Ouslander, Rollinger et al., 1991) and subsequently revised (Stuck, Beers, Steiner et al., 1994; Beers, 1997). The most recent update was made by the American Geriatrics Society (AGS) Beers Criteria Update Expert Panel in 2012 (AGS, 2012). The National Committee for Quality Assurance recently proposed that the Healthcare Effectiveness Data and Information Set (HEDIS): Potentially Harmful Drug–Disease Interactions in the Elderly (DDE) be updated to keep in line with the 2012 revised Beers Criteria.
The Beers list is quite extensive. Readers are asked to review this list directly from the source (http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf It is not included in this text.
The Beers list has been widely disseminated in the literature since its initial development; however, the use of potentially inappropriate medication in older adults remains a significant problem. In a systematic review conducted by Opondo, Eslami, Visscher and coworkers (2012) revealed that 20% of older adults in the community setting continue to be prescribed potentially inappropriate medications (PIMs) despite recent attention to the problem. The most widely prescribed PIMs were propoxyphene, doxazosin, diphenhydramine, and amitriptyline. A separate study
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determined that 48% of older adults admitted to the hospital were taking PIMs (e.g., benzodiazepines, aspirin, and opiates); additionally, they determined that 27% of admissions were related to PIMs (Dalleur, Spinewine, Henrard et al., 2012).
Although the Beers Criteria provide important information regarding PIMs, it is important to recognize that medications considered appropriate and frequently prescribed for older adults may also carry serious drug-related risks. For example, a retrospective review of more than 175,000 emergency department visits for adverse drug events (ADEs) by older adults revealed that a third of the visits were in response to problems caused by insulin, warfarin, and digoxin (Budnitz, Shehab, Kegler, & Richards, 2007). Of these, only digoxin is included in the Beers Criteria, where it is categorized as moderate risk. Thus, it is important to remember that all drugs are potentially harmful and must be weighed in terms of benefit versus risk.
Medications and Quality of Life In addition to weighing drugs in terms of benefit versus risk, it is also important to weigh them in terms of desired versus undesired outcomes. It is natural to assume that a drug is appropriate if it achieves the desired outcome. For example, if an antihypertensive drug such as atenolol adequately maintains blood pressure within normal parameters or if a prokinetic drug such as metoclopramide promotes adequate gastric emptying to decrease gastroesophageal reflux, they would generally be perceived as appropriate drugs. However, if atenolol caused erectile dysfunction or if metoclopramide caused tardive dyskinesias, the patient’s quality of life may be lessened to a greater extent compared with the extent of the benefit provided by the drug.
Medications may have various detrimental effects on cognition, emotion, ambulation, continence, and other essential functions. These negative effects on an older patient’s quality of life must be carefully considered as part of pharmacologic therapy. Some patients may prefer to endure a condition rather than suffer an adverse effect of the treatment for it. Generally, alternative drugs or
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interventions may be used. If one uses the earlier example, an angiotensin-converting enzyme inhibitor (ACEI) will be less likely to cause erectile dysfunction compared with the BB, and the patient’s gastroesophageal reflux may be managed with drugs that decrease acidity. For this reason, if a patient refuses a medication, rather than simply charting a medication as refused, the nurse should elicit the patient’s perspective so that a more appropriate intervention can be implemented. When other options are not advisable, it is generally important to honor the patient’s wishes. Patient-centered therapeutic management considers the patient’s beliefs and goals’ regarding quality of life to be tantamount to those of the provider and is necessary to ensure optimal outcomes.
Pharmacologic Contributors to Risk A number of factors may increase the risk of poor outcomes for older adults who require pharmacologic therapy. Among the most important risk factors are drug interactions, polypharmacy, and substance abuse.
Drug Interactions Drugs may interact with other drugs and with food. Some drugs may even interact with disease processes. It is important for the nurse to be aware of potential interactions so that harmful patient outcomes can be avoided.
Drug–drug interactions occur in a variety of ways. Perhaps the most common interaction is the result of altered metabolism via the CYP450 hepatic enzyme system. Some drugs have the ability to induce or inhibit the activity of various CYP isozymes, which results in increasing or decreasing biotransformation of drugs. If the biotransformation is accelerated, the affected drug will be inactivated prematurely; however, if the biotransformation is decelerated, the drug may accumulate to toxic levels. Drugs may also interact indirectly through opposing or antagonistic actions. For example, in the patient who has both asthma and hypertension, a BB given to control hypertension may oppose the actions of a beta-agonist given to dilate bronchi. Some drug–drug interactions
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occur in other ways. For example, some laxatives may cause rapid transit of an orally administered drug through the gastrointestinal system so that it is not adequately absorbed. Drugs may also interact chemically. This is more readily seen in intravenous (IV) solutions in which incompatible drugs may crystallize when mixed; however, it may also occur when certain oral drugs are taken together. Table 20-2 lists examples of significant drug–drug interactions.
Table 20-2 Common drug–drug interactions in older adults
Drug–Drug Combination Potential Effect Warfarin and aspirin Increased risk of bleeding Warfarin and chloral hydrate Increased risk of toxicity Digitalis and quinidine Increased risk of toxicity Cimetidine and propranolol Decreased clearance, increased bradycardia Thiazides and longer-acting antidiabetics Increased risk of hypoglycemia Levodopa and clonidine Decreased antiparkinsonian effect Diuretics and NSAIDs Renal impairment Lithium and diuretics Increased risk of toxicity Lovastatin (Mevacor) and gemfibrozil (Lopid) Toxic liver effect Prednisone and barbiturates Decreased steroid effect St. John’s wort and pseudoephedrine Increased blood pressure Ginkgo with aspirin Increased bleeding risk
NSAIDs, Nonsteroidal antiinflammatory drugs.
Drug–food interactions are less common than drug–drug interactions but still increase risk. Drug metabolism or effects may be altered when combined with certain foods. For example, potentially dangerous interactions may occur when certain drugs are taken with grapefruit juice because a chemical found in grapefruit juice inhibits metabolism by 3A4 isoenzymes of the CYP450 enzyme system. The 3A4 isoenzymes are responsible for first-pass metabolism of a large number of drugs; therefore, as a result of inhibited metabolism, drugs normally metabolized by 3A4 isoenzymes, for example, calcium channel blockers (CCBs), may accumulate to high or even toxic levels. See Table 20-3 for examples (Kiani & Imam, 2007).
Table 20-3 Common drug–food interactions in older adults
Food Drug Potential Effect Caffeine Theophylline Increased potential for toxicity
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Fatty food Griseofulvin Increased absorption of drug Blue cheese Penicillin Antagonistic action Fiber Digoxin Absorption of drug into fiber,
reducing drug action Vitamin K foods: cabbage, greens, egg yolk, fish, rice
Warfarin Decreased effect of drug, inhibiting anticoagulation
Food Many antibiotics Reduced absorption rate of drug Mineral oil Fat-soluble vitamins Fat-soluble vitamins dissolve in oil;
deficiency possible Tyramine foods: aged cheese, wines, pickled herring, chocolate
Monoamine oxidase inhibitors (MAOIs) (phenelzine [Nardil], tranylcypromine [Parnate]), St. John’s wort
May precipitate hypertensive crisis
Vitamin B6 supplements Levodopa-carbidopa Reverses antiparkinsonian effect Grapefruit juice Cisapride, calcium channel blockers, quinidine Altered metabolism and
elimination can increase concentration of drug
Citrus juice Calcium channel blockers Gastric reflux exacerbated
Drug–disease interactions may exacerbate patients’ conditions or hinder healing. These drugs are generally contraindicated in patients with coexisting underlying disease. For example, 13% of African American men and 20% of African American women are carriers of a gene that may cause a deficiency in the enzyme glucose-6-phosphate dehydrogenase (G6DP). If a patient with this deficiency takes certain drugs such as sulfonamides or aspirin, erythrocyte hemolysis may occur (Lilley et al., 2007). Table 20-4 lists examples of drug–disease interactions.
Table 20-4 Common drug–disease interactions in older adults
Disease Drug Potential Effect Atrophic gastritis Aspirin, NSAIDs GI hemorrhage Sinus or atrioventricular node disease
Digitalis, verapamil Bradycardia
Venous insufficiency Calcium channel blockers or beta-blockers Edema, intermittent claudication Cataracts Corticosteroids Accelerated cataract formation Unstable bladder Diuretics Incontinence Prostatic hypertrophy Anticholinergics Urinary retention Parkinson disease Metoclopramide, neuroleptics Parkinson syndrome Renal impairment NSAIDs, contrast material, aminoglycosides Acute renal failure Chronic obstructive pulmonary disease
Beta-blockers, opiates Bronchoconstriction, respiratory depression
Hypokalemia Digitalis Cardiac toxicity Osteopenia Corticosteroids Fracture risk Orthostatic hypotension Diuretics, psychotropics, antihypertensives Increased fall risk Depression Central-acting antihypertensives, alcohol, antianxiety
drugs, corticosteroids Exacerbation of depression
GI, Gastrointestinal; NSAIDs, nonsteroidal antiinflammation drugs.
Education is an essential component of any risk prevention program. Nurses should provide patients with information regarding the risk of potentially dangerous interactions among all
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of the drugs they are taking: prescription, OTC, and complementary and alternative medications. It may be helpful to provide the patient with a list of acceptable OTC drugs for common problems such as mild pain or constipation. A “safe OTC medication list” may be a useful tool for health care providers to review with patients before completing the office visit (Table 20-5).
Table 20-5 A list of safe over-the-counter medications
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Note: These are general suggestions and should be discussed with your doctor. He or she may want to change this list or may add suggestions to fit your individual needs. Always read the label on nonprescription (over-the-counter) medicines before purchasing, and have a pharmacist assist you if you are not sure what choice to make. NSAIDs, Nonsteroidal antiinflammatory drugs.
Polypharmacy Polypharmacy is “giving medications without a clear indication, giving two similar medications for the same indication, giving medications that are contraindicated, and/or giving medications where the dosage is either too high or too low” (Alexander- Magalee, 2013) (see Evidence-Based Practice box). Older adults are vulnerable to polypharmacy because many have one or more chronic conditions requiring multiple medications. To complicate matters, patients may see more than one provider and may have
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prescriptions filled at more than one pharmacy (Emmons, 2008). Additional contributors to polypharmacy include the use of OTC and alternative medicines or supplements in the treatment of conditions (Qato et al., 2008). As a result, the patient may end up taking duplicate drugs, similar drugs from the same drug class, and drugs that are contraindicated when taken together.
Evidence-based practice Frequent Review of Prescribed Medications Is Essential When Polypharmacy Is Present
Background Although it is acknowledged that polypharmacy is a major source of drug-related problems for many American older adults, literature examining the issue for its total impact on the health care expenditures of the health care system is lacking.
Sample/Setting The sample consisted of 1161 patient records representing 13.2% of the U.S. population; records were part of the Medical Expenditure Panel Survey (MEPS).
Methods This retrospective cohort study examined the MEPS database for a relationship between potentially inappropriate medication (PIM) use among U.S. citizens older than age 65 and health care expenditures.
Findings The three medications most frequently prescribed within this cohort were propoxyphene, digoxin, and amitriptyline. The average individual health care expenditures were $9,292 in 2001.
Implications A review of health care providers’ prescriptions given to older
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adult patients may be warranted to improve patient safety and avoid prescribing PIMs. From Fu, A. Z., Jiang, J. Z., Reeves, J. H., Fincham, J. E., Liu, G. G., & Perri, M. (2007). Potentially inappropriate medication use and health care expenditure in the U.S. community-dwelling elderly. Medical Care 45(5), 472-476.
Although only advanced practice nurses can prescribe medications, other nurses play a vital role in decreasing the number of medications taken by older adults. Whenever an older patient is seen with a new symptom, the nurse should consider whether the new problem could be caused by a medication the patient is taking (Korc, 2008). If the problem is significant, the prescriber may prefer to discontinue the drug causing the problem rather than prescribe another drug to treat the problem. The nurse may also employ nonpharmacologic interventions, whenever possible. For example, methods such as relaxation therapy, sleep restriction, and chronotherapy have been shown to be effective nonpharmacologic interventions for management of insomnia in older adults (Joshi, 2008). Lifestyle changes such as weight loss, dietary modifications, and an exercise plan may reduce the need for additional medications to control hypertension (Moser, Franklin, & Handler, 2007).
Medication Errors: Human and Economic Burdens The Institute of Medicine (IOM, 2007) estimates that 1.5 million ADEs and 7000 deaths occur in the United States each year secondary to medication errors. Older adults are disproportionately affected; more than half of the medication errors occur in long-term care facilities and more than 500,000 occur among ambulatory Medicare patients (IOM, 2007). Beyond the personal costs, the yearly cumulative cost to society—money that could conceivably be used to improve health care of older patients were it not spent on errors—is estimated at $887 million for adults age 65 or older (Jenkins & Vaida, 2007).
The definition of medication error adopted by many authoritative organizations, including the National Coordinating Council for Medication Error Reporting and Prevention, the U.S. Food and Drug Administration (FDA), Centers for Medicare and Medicaid
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Services (CMS), and the U.S. Pharmacopeia, is as follows:
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use (Cousins & Heath, 2008.)
Because this definition is both comprehensive and complex, examination of its component parts may help best understand it.
The first part of the definition—“A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm …”—speaks to the outcome of a medication error. The injuries resulting from patient harm are commonly referred to as adverse drug events (ADEs).
The second part of the definition—“… while the medication is in the control of the healthcare professional, patient, or consumer”— addresses the person who manages the medication storage, dosage, schedule, and disposal. Of particular concern to older adults are findings of a 20-year study in which researchers identified a marked increase in fatal medication errors among those who take their medications at home (Spiesel, 2008). This has increased, in part, because of a trend toward shorter hospital stays. As a result, patients are taking medications at home that were previously closely monitored in a hospital setting. Additionally, development of new drugs has resulted in an increase in drugs prescribed, and this has resulted in an increase in the number of prescriptions for medications (Spiesel, 2008) as well as an increase in OTC medications. When patients take OTC medications, they may not be aware of allergies, contraindications, or interactions with prescribed medications. Further, many patients may keep medications long after they have expired rather than disposing of them (Wendling, 2006).
The final part of the definition—“Such events may be related to
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professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”— details the various means by which a medication error may occur. Nurses are involved in processes related to order communication and medication administration, education, monitoring, and use. Errors in order communication commonly occur when verbal orders are poorly communicated or misunderstood (Wakefield, Ward, Groath et al., 2008) or when illegibly written orders are misinterpreted (Cohen, 2006). Errors in administration involve what has often been referred to as the six rights of drug administration: (1) the right drug, (2) in the right dose, (3) at the right time, (4) via the right route, (5) to the right patient, (6) with the right documentation (Lehne, 2013). Medication errors related to education may occur when education is insufficient or unclear. The nurse’s role in medication monitoring involves assessing the patient’s response for both therapeutic and adverse effects (Lehne, 2013); therefore, errors attributable to monitoring may include a failure to assess for inadequate therapeutic effect or, more likely, a failure to identify when a new problem is attributable to an adverse effect of a drug. Finally, errors related to medication use occur when drugs are not used as indicated; for example, medication misuse occurs when a prescribed opioid (narcotic) analgesic is given for sedation to aid sleep rather than for pain.
Interventions to decrease medication errors are receiving increased importance after the IOM’s report on preventing medication errors (IOM, 2007). Strategies to reduce errors include use of bar coded medication labels, error tracking, and public education. Additionally, the FDA reviews drugs for look-alike or sound-alike names prior to marketing and has mandated standardized labeling for both prescription and OTC drugs (FDA, 2013).
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Commonly used medications Psychotropics Psychotropic medications, which include antipsychotics, antidepressants, sedative–hypnotics, and anxiolytics, are often prescribed for older adults. Psychotropics are likely to be prescribed for behavioral and psychological symptoms of dementia (BPSD) in the nursing home, where it is not uncommon for some residents to have a psychiatric diagnosis along with dementia. Some general problems with psychotropic prescribing reported in older adults include (1) overprescribing of anxiolytics and hypnotics, often at doses that are too high and for extended periods; (2) underprescribing of antidepressants and maintenance of subtherapeutic doses that may cause side effects without providing maximum therapeutic benefit; and (3) both underprescribing and overprescribing of antipsychotics, which potentially denies benefit to some and causes side effects without therapeutic benefit in others. Of particular concern is the practice of using certain psychotropic drugs as chemical restraints for persons with BPSD (Hughes, 2008).
Anxiolytics and Hypnotics Insomnia and anxiety are problems that plague older adults. Many drugs used to treat these problems have the potential for bothersome and potentially dangerous adverse effects when used in older adults. Because insomnia and anxiety often occur secondary to medication side effects or secondary to medical conditions such as dementia, thyroid abnormalities, or depression, proper diagnosis and treatment of underlying causes of insomnia or anxiety may decrease the inappropriate use of these medications. Nonpharmacologic interventions are often effective but tend to be underused (Adis International, 2007; Moon, 2009); therefore, a trial of nonpharmacologic treatment is preferred before initiation of pharmacologic therapy in older adults.
Barbiturates have been prescribed for both insomnia and anxiety
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in the past, but their use has declined. These drugs are not recommended for older adults because of their narrow margin of safety and the risks of significant drug interactions and dependence.
Benzodiazepines, which are often prescribed for insomnia and anxiety, also carry concerns for older adults. Benzodiazepines with long half-lives, for example, diazepam, should be avoided because of increased risk for toxicity; in addition, all benzodiazepines, including shorter-acting ones such as lorazepam, may cause excessive sedation, impaired memory, decreased psychomotor performance, and balance disturbances and may lead to drug dependence (Calleo & Stanley, 2008). If a benzodiazepine is required, it is best to give the smallest dose possible and monitor closely for side effects. Because benzodiazepines should not be used for extended periods, it is important to assess for continued need of these medications, and discontinued them in a timely manner.
First-generation antihistamines such as diphenhydramine (Benadryl) have been used for indications other than allergy, for example, treatment of insomnia and anxiety. Antihistamines are potentially inappropriate medications for use in older adults because these patients are more sensitive than younger patients to the anticholinergic adverse effects such as dry mouth, urinary retention, sedation, and even delirium (Nichols, Alper, & Milkin, 2007).
Optimal treatment rests with alternative pharmaceuticals. For anxiety, non–central nervous system (CNS) depressants such as buspirone are effective agents. They take approximately 4 weeks to demonstrate a clinical response, so a benzodiazepine may be required for short-term management if the anxiety is severe (Lehne, 2013). These medications avoid many of the adverse effects and dependence potential of the benzodiazepines. Similarly, when sleep-hygiene and other nonpharmacologic interventions for insomnia fail, short-term treatment with benzodiazepine receptor agonists (BZRAs), pyrazolopyrimidines, and melatonin receptor agonists are appropriate, short-term, alternatives for older adults (The American Geriatrics Society 2012 Beers Criteria Update Expert Panel, 2012; Lehne, 2013). BZRAs such as zolpidem have
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demonstrated decreased residual sedation and a decreased risk of falls compared with benzodiazepines, as have pyrazolopyrimidines such as zaleplon. The melatonin receptor agonist ramelteon, which is nonsedating, carries the least risk of falls; however, it may not be effective in some patients (Lehne, 2013; Sherman, 2007).
Antidepressants Most antidepressants are effective for managing depression in older adults; however, some are better tolerated than others. Older tricyclic antidepressants (TCAs) have been used to treat depression as well as insomnia and neuropathic pain; however, significant side effects occur even in low doses and well before therapeutic levels are reached. As a treatment for insomnia, the TCAs are generally too sedating and may cause daytime somnolence. Additionally, TCAs possess anticholinergic side effects that may create problems for many older adults.
Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of first choice for older adults because these agents are better tolerated; however, they are not without risks. They may cause dose-related gastrointestinal disturbances, including gastrointestinal bleeding, and CNS arousal effects. Fortunately, most of the side effects of the SSRIs last only a few days.
Selection of an antidepressant is often based on side effect profiles, which differ among available agents (Table 20-6). For instance, mirtazapine has more potential for sedation compared with some of the SSRI antidepressants. It may also reduce anxiety and increase appetite; therefore, if the patient suffers from depressive symptoms of anxiety, insomnia, and lack of appetite, then mirtazapine may be an appropriate choice to help the patient sleep while also increasing appetite and reducing anxiety. A patient exhibiting depressive symptoms such as increased sleepiness, decreased affect, and decreased socialization may benefit from a more stimulating antidepressant such as sertraline or venlafaxine. Thus, the side effect profile of an antidepressant may be used to identify the most appropriate drug for a patient’s depressive symptom pattern.
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Table 20-6 Antidepressants: comparative profiles
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Data from Drug facts and comparisons (59th ed.). (2005). St. Louis, MO: Facts & Comparisons. +++, Strong; ++, moderate; +, weak; 0, none.
Antipsychotics Antipsychotics should be prescribed only when valid and clear documentation of need exists because many side effects occur with the use of these agents. Appropriate indications for antipsychotic prescription include schizophrenia, paranoid states, and psychosis.
Antipsychotics may cause excessive sedation, which may impair
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function for days in sensitive older adults, and they may cause extrapyramidal side effects such as tremors, akinesia, akathisia, and rigidity. All the antipsychotics have been reported to cause tardive dyskinesia (TD) with long-term use. Nursing assessment for the abnormal involuntary movements associated with antipsychotic use is essential in caring for older adults receiving antipsychotic drugs.
Atypical antipsychotic medications offer a lower risk of extrapyramidal side effects and perhaps a better overall side-effect profile; however, they are not without problems. With atypical antipsychotic drugs, associated risks of weight gain, diabetes mellitus, hyperlipidemia, myocarditis, and cardiac problems exist (Üçok & Gaebel, 2008).
Antipsychotics do not have FDA approval for management of BPSD; however, they are often prescribed for this reason (Howland, 2008). As many as 40% of nursing home residents with dementia are prescribed antipsychotics, even though research shows limited effectiveness in reducing BPSD (Cornege-Blokland, Kleijer, Hertogh, & van Marum, 2012). Because antipsychotics have been shown to be associated with early death in older adults with dementia, the FDA requires black box warnings of the risks associated with prescribing these drugs to older adults with dementia for both atypical and conventional antipsychotics (FDA, 2008) and launched an initiative to reduce the use of antipsychotic drugs in the nursing home by 15% (Mitka, 2012). Although this is not a contraindication to their use (Kuehn, 2008), the FDA stresses that prescribers discuss the mortality risk with patients and their families and caregivers when prescribing antipsychotics for this purpose (Table 20-7).
Table 20-7 Antipsychotic agents
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Data from Drug facts and comparisons (59th ed.). (2005). St. Louis, MO: Facts & Comparisons. +++, Strong; ++, moderate; +, weak; 0, none.
Cardiovascular Medications Heart disease remains the number one cause of death among older adults; stroke is the third leading killer. Nearly a third of persons over age 65 have hypertension. In the United States, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) is the foremost provider of
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evidence-based clinical guidelines to guide the management of hypertension. The drugs recommended for the management of hypertension are also used in the management of a number of other cardiovascular conditions.
At the time of this writing, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) has been published to offer guidance for the management of hypertension. (The JNC 8 report is awaiting clearance by U.S. Department of Health and Human Services [HHS] at the time of writing.) In general, the JNC 7 recommends the same methods to treat older adults as well as younger adults. Lifestyle modification is advised as a primary method for preventing and treating hypertension. In older adults, particularly, weight loss, reduced sodium intake, and exercise have added benefits in preventing or reducing hypertension (JNC 7, 2003).
If a pharmacologic agent is needed to treat hypertension, the JNC 7 recommends a thiazide diuretic as first-line therapy for most patients on the basis of outcome data from clinical trials (JNC 7, 2003). The addition of a second drug is often determined by the drug’s inherent benefits and risks. Those most commonly used for older adults are BBs, ACEIs, or angiotensin receptor blockers (ARBs), and CCBs.
BBs have demonstrated improved mortality rates for patients with a history of cardiovascular disease. They decrease angina symptoms, cardiac workload, and oxygen demand through reduction of heart rate, cardiac output, and atrioventricular conduction. This provides a cardioprotective effect for patients with a history of ischemia or myocardial infarction.
CCBs have a beneficial effect in decreasing cardiac workload through decreasing peripheral resistance. For this reason, they are an alternative for patients with severe reactive airway disease or with a high degree of heart blockage where a BB might be contraindicated.
ACEIs and ARBs also have demonstrated value in decreasing the chance of cardiac mortality in patients with heart failure. They also
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confer renal protection, which is particularly beneficial for patients with diabetes.
Because older adults are likely to have more comorbidities (e.g., diabetes, reduced kidney function, and heart disease), the JNC 7 recommends selecting hypertensive treatment based on comorbid conditions or compelling indications (JNC 7, 2003) (Table 20-8). For example, a 70-year-old patient with hypertension and diabetes would benefit from thiazide-type diuretics and an ACEI or ARB, but if the patient had hypertension with ischemic heart disease, the optimal management may be with a thiazide diuretic with a BB.
Table 20-8 Compelling diagnoses for prescribing specific antihypertensive drug classes
From Fiori, M.C.; Jaen, C.R.; Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update, clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services.
ACEI, Angiotensin-converting enzyme inhibitor; ALDOANT, aldosterone antagonist; ARB, angiotensin II receptor blocker; BB, beta-blocker; CCB, calcium channel blocker.
The main concerns with the use of antihypertensive medications in older adults are an increased risk of orthostatic hypotension and dehydration, especially with volume-depleting agents and vasodilators. The older adult might have reduced kidney function and a decreased ability to maintain fluid and electrolyte balance. In
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addition, some older adults may have decreased appetite and sense of thirst resulting in decreased oral intake of food and fluids and increased risk of dehydration. Subsequently, it is not surprising that dehydration is common among older people and is a frequent reason for admission to the hospital. Assessing for the adverse effects of antihypertensive therapy is essential in maintaining the health of older adults and reducing complications and hospitalizations.
In addition to drugs used in the management of hypertension and related disorders, many older adults are prescribed digoxin. Digoxin is sometimes used to treat heart failure because it increases the force of cardiac contraction, thereby increasing cardiac output; however, research has shown that it does not necessarily reduce morbidity and mortality (Ahmed, Rich, Fleg et al., 2006). For this reason, its use in management of heart failure has become controversial, and it is no longer considered first-line therapy. However, digoxin remains a beneficial agent for the management of atrial tachyarrhythmias because it slows heart rate, allowing for adequate ventricular filling.
Antimicrobials Infections in older adults may result in devastating health events because of decreased physiologic reserves. Urinary tract infections (UTIs) and respiratory infections (especially pneumonia and exacerbations of chronic lung diseases) are common and often lead to hospital admissions. A frail older person with UTI may experience significant mental status changes, weakness, and sepsis and may require extended hospitalization and weeks of rehabilitation to return to baseline functional status.
Pharmacologic treatment of infections has the potential to achieve cures, but problems related to their use persist. Because many older adults have reduced renal function, dosage adjustments may be needed for certain antibiotics such as fluoroquinolones. Antibiotic resistance, an increasing problem, may hinder finding the right treatment mix for complicated infections. Common antibiotic side effects such as diarrhea may create significant and even dangerous
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shifts in fluids and electrolytes in the older adult. Nausea may result in decreased intake, further contributing to this problem.
Nonprescription Agents Older adults are the largest consumers of nonprescription drugs (Francis, Barnett, & Denham, 2005). They often use these drugs believing if they are available over the counter, they are safe; however, many of the prescription drugs that have been reclassified to nonprescription status (e.g., nonsteroidal antiinflammatory drugs [NSAIDs] and sedating antihistamines) have a potential for significant harm in older populations.
Older adults might not volunteer information about the use of OTC medications (Francis et al., 2005). As a result, opportunities for drug-related education and checks for interactions with prescribed medications or effects that may worsen the patient’s current health status are missed. This need for education is complicated by the realization that many older adults have decreased visual acuity, cataracts, macular degeneration, and other visual problems that limit the ability to read finely printed labels and instructions (Pawaskar & Sansgiry, 2006). Further, a recent nationwide study (Qato et al., 2008) found that 46% of patients taking prescription drugs also take nonprescription medications, thus increasing the potential for drug–drug interactions.
The first challenge for nurses regarding nonprescription drugs is to remain informed about all medications patients are currently taking. It is necessary to verify that no contraindications or significant interactions with prescribed medications exist. It is also important to caution patients against certain products that may interact negatively with other medications or with their particular medical condition(s).
Dietary Supplements Dietary supplements are an overarching category of drugs that include vitamins, minerals, herbal remedies, and alternative medicines. The use of dietary supplements is an established
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practice among many older adults. According to a recent study, almost half (49%) of older adults living in the United States take some sort of dietary supplement on a regular basis (Qato et al., 2008). The same study identified that more than half (52%) of older adults who take prescription medications also take supplements, and this increases the potential for drug–drug interactions. The most common dietary supplements identified in this study were vitamins or minerals and system-specific remedies such as omega-3 fatty acids, garlic, and coenzyme Q-10 for cardiovascular problems; glucosamine–chondroitin for joint problems; and saw palmetto for prostate problems. Additional frequently used supplements identified in a separate 6-year retrospective review of supplement use in older adults include ginkgo biloba, black cohosh, borage, evening primrose, flaxseed oil, dehydroepiandrosterone (DHEA), grapeseed extract, hawthorn, and St. John’s wort (Wold, Lopez, Yau et al., 2005). A particularly troubling finding was the identification of supplement–medication interactions with 10 of the supplements and the potential of 142 interactions over the 6-year period.
A number of additional concerns exist with regard to the use of dietary supplements. They are not regulated for safety and efficacy by the FDA in the same manner as prescription drugs, which undergo a rigorous drug approval process. As a result, predictability of product quality and potency is lacking. Many herbs are available in their natural unprocessed state, further complicating predictability. Beyond these concerns, the use and safety of these products in older adults, especially in older adults with comorbidities, have not been adequately studied.
As with any drug, dietary supplements have inherent adverse effects, particularly when taken in large doses. Although many may be beneficial, or at least not harmful, they may also interact with certain diseases and normal physiologic processes, which may lead to delayed improvement.
Unfortunately, information regarding dietary supplements is often nebulous and misleading. To address the need for scientific research and authoritative information the National Center for Complementary and Alternative Medicine (NCCAM) was established under the umbrella of the National Institutes of Health
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(NIH). NCCAM provides information to health care professionals as well as to the lay public on its website at http://nccam.nih.gov.
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Medication adherence Medication regimens are carefully planned so that optimal dosing and scheduling will prevent drug interactions and other complications while promoting optimal well-being. Many patients, however, may omit medications at times or may alter drug dosages or schedules. This failure to stick to the agreed on medication regimen is called nonadherence. Although nonadherence occurs in all age groups, it is likely to create more problems in older adults, who tend to have chronic and often multiple illnesses requiring medication.
The most common reasons for nonadherence in older adults include the cost of medications (Briesacher, Gurwitz, & Soumerai, 2007), side effects or fear of side effects (Ferdinand, 2009), complex scheduling (Bibbens-Domingo & DiMatteo, 2006), age-related changes such as visual or cognitive impairment (Kairuz, Bye, Birdsall et al., 2008; Stoehr, Lu, Lavery et al., 2008; Windham, Griswold, Fried et al., 2005), and a belief that the medications are either ineffective or unnecessary (Chia, Schlenk, & Dunbar-Jacob, 2006; Proulx, Leduc, Vandelac et al., 2007). Other contributors to nonadherence include cultural factors (Chia et al., 2006; Wen-Wen, Wallhagen, & Froelicher, 2007), and health literacy issues (Davis, Wolk, Bas et al., 2006; Maniaci, Heckman, & Dawson, 2008). By understanding the reasons for nonadherence, the nurse is better equipped to identify adherence risks and take specific risk-targeted action to decrease this common problem.
In approximately one third of older adults, prescription-related costs contribute to nonadherence (Briesacher et al., 2007). Medications may be expensive, and many older adults are on fixed incomes requiring tight budgets. Even those with insurance to deflect the cost may not be able to afford the required deductible. Although resources exist to provide pharmacy assistance to low- income patients, many are unaware of these programs or do not know how to access assistance (Federman & Safran, 2008). To cope with high drug costs, some patients decrease or skip doses to make a prescription quantity last longer. Others resort to decreasing
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money spent on food or other needs so that they can afford medications. For many, however, the costs are so high that prescriptions for necessary medicines are left unfilled (Madden, Graves, Zhang et al., 2008).
Side effects and the fear that side effects may occur are other common reasons for nonadherence. If the side effects are perceived as significant or if they interfere with daily activities, patients may be tempted to avoid these effects by omitting the medication that causes them. The impact of side effects is especially relevant if drug benefits are not obvious. Indeed, the patient’s perception of medication effectiveness and necessity of the medication plays an important role in adherence. Many of the medications prescribed for chronic illnesses serve to keep the conditions from progressing but do not cure the illness. Patients who do not feel better may perceive that the medication is ineffective. If a medication is given to cure an illness such as an infection, the patient may stop the medication prematurely once the symptoms resolve because of the erroneous belief that it is no longer needed.
Age-related changes that contribute to nonadherence may be functional (physical) or cognitive (mental). Vision changes that occur with aging may affect the ability of the patient to read labels on medication containers or to distinguish one medication from another. Stiffness of joints coupled with decreased hand strength or tremors may make it difficult to open medication bottles. Swallowing difficulties are exacerbated by large tablets. For some older adults, mental status changes that affect the ability to think clearly and make reasoned judgments contribute to unintentional nonadherence. Similarly, memory impairment and forgetfulness increase the likelihood that medications will not be taken as prescribed.
For older adults with complex or multiple chronic illnesses requiring several medications, drug schedules may be complex. For example, some medications should be taken on an empty stomach, whereas others should be taken with food. Some medications should not be taken together because drug–drug interactions may occur. Still others require scheduling to coordinate with certain times of the day (e.g., at bedtime). Keeping up with complicated
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schedules, particularly when they conflict with everyday activities, may increase the probability of nonadherence.
Assessing for Risk Factors Because the effects of nonadherence can be devastating, it is important for the nurse to be proactive in preventing nonadherence. Prevention begins with an assessment of risk factors. A simple checklist may be used to help identify areas of primary concern.
• Are the prescribed medications costly, or does the cost of medications present a substantial burden to the patient?
• Do the prescribed drugs have the potential for significant side effects, or does the patient experience troublesome side effects?
• Are medication schedules cumbersome, or do they interfere with the patient’s daily activities or sleep?
• Does the patient have any conditions that would make opening bottles, manipulating individual tablets, or swallowing medications difficult?
• Does the patient have difficulty reading and comprehending instructions?
• Does the patient believe that any of the prescribed drugs are ineffective or unnecessary?
• Does the patient have any cultural beliefs that would cause him or her to look down on reliance on drugs or regard certain medications as inappropriate?
Each item checked indicates a potential contributor to nonadherence. For those items, the nurse needs to work further with the patient to correct any misunderstandings, to establish necessary support services or networks, and to advocate for patient- centered adjustments in the medication regimens.
Strategies for Improving Adherence Many patients do not share information regarding nonadherence,
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so it is a mistake to assume that the patient takes medication as prescribed or recommended. In clinic settings, the nurse should have the patient bring in all prescription and OTC medications and any dietary supplements at the initial visit and at least every 6 months thereafter (Korc, 2008; Pham & Dickman, 2007). Nurses working in hospitals should adopt this policy for every admission or emergency department visit (“Get a better med history,” 2009). When reviewing medications, the nurse should ask the patient how each drug is taken and compare this information with the prescription label or to the medications listed in the patient’s record to see whether nonadherence is a concern.
Patient teaching is an essential intervention for addressing the problem of medication nonadherence; however, studies show that teaching alone is rarely sufficient to evoke change (Ruppar, Conn, & Russell, 2008). To adequately address issues of medication nonadherence, nurses need to understand the factors that contribute to a patient’s failure to take medications as directed and to develop risk-specific assessments and interventions that are individualized to the patient. Interventions should also consider resources available in the region where services are provided. For example, if the patient has difficulty paying for medications, the nurse may provide the patient with a resource list of pharmacies offering low-cost generic discounts. If generic drugs are not available for a proprietary drug that is ordered, the nurse may need to check for patient assistant programs for the drug in question.
The nurse should encourage all patients to have prescriptions filled at the same pharmacy each time because this provides an extra way to discover problems. The nurse should also tailor the medication regimen to the patient’s home schedule to cause the least disruption in daily life and give the patient a sense of control over the medications. The regimen should be simplified as much as possible; multiple daily doses should be avoided, where appropriate and feasible.
Reviewing the Medication List for Problems Nurses confronted with a complex medication regimen for an older
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patient should determine the answers to the following questions:
• Is a documented and appropriate indication for each medication present?
• Is a medication dosage appropriate for the patient’s age, weight, and renal or liver function?
• Does the patient have a documented drug allergy to a medication?
• Are doses of medication being scheduled appropriately?
• Is the duration of treatment appropriate?
• Is a chosen medication the best one for the patient?
• Are two or more similar drugs prescribed (i.e., therapeutic duplication)?
• Is the patient experiencing an adverse drug reaction?
• Is a potential drug–drug interaction present?
• Does a medical indication exist for the use of a medication when none is currently prescribed?
• Is the patient using OTC medications inappropriately?
• What herbal or alternative therapies is the patient using? Is the patient’s health care provider aware of these?
• Is the patient adherent?
Home care
1. During each home visit, assess both prescription and nonprescription medications being taken by the homebound older adult.
2. Document and notify the primary health care provider of the homebound older adult’s medication regimen and of multiple physician sources for medications.
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3. Teach the side effects and interactions of all over-the-counter medications to homebound older adults and their caregivers.
4. Collaborate with social workers to identify community resources for financial assistance with pharmaceutical needs.
5. Use laboratory parameters to monitor overuse and underuse of medications, as well as interactive states of medications.
6. Monitor the urinary output status of patients because changes in renal excretion may require a decrease or increase in drug dosage.
7. Teach the homebound older adult to set up a daily or weekly schedule for medications using a method or tool that fosters safe, independent administration.
8. Reduce the chance of medication errors by labeling or color coding medication bottles.
9. Keep an accurate record of the homebound older adult’s weight.
10. Teach drug safety in the home environment by instructing patients to do the following:
• Keep drugs in original, labeled containers.
• Dispose of outdated medications in a sink or toilet only; never dispose of them in the trash within reach of children.
• Never “share” drugs with friends or family members.
• Always finish a prescribed medication; do not save it for a future illness.
• Read labels carefully and follow all instructions.
11. Instruct older adults who have difficulty opening childproof containers to ask their health care providers for non–child- proof containers when writing prescriptions.
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Substance abuse Many older adults enjoy leisure activities as a result of decreased work schedules and retirement. However, some are unable to enjoy leisure activities because of the emotional, physical, social, and economic effects of growing older. Use of illicit drugs such as cocaine, opiates, and marijuana, previously thought to be a problem among young adults, has become more prevalent in older adults as baby boomers, with a history of being more tolerant of such practices, reach retirement age. Among older persons, abused substances include alcohol, prescription and nonprescription drugs, and tobacco. Marijuana and cocaine are included in the category of nonprescription drugs.
The well-documented prevalence of addictions and related disorders in older adults and the aging of the baby-boomer generation indicate that substance abuse and its treatment will soon be one of the most pressing public health concerns. In a national epidemiologic study, among those aged 65 years or older, 2.36% of men and 0.38% of women met the criteria for alcohol abuse. It is estimated that up to 11% of older women misuse prescription drugs and that the numbers of users of nonprescription drugs among older adults will increase to 2.7 million by 2020 (Trevisan, 2008).
Frequently, the symptoms are subtle or atypical, or they mimic symptoms of other age-related illnesses and remain undiagnosed. A patients’ presenting symptoms may be erratic changes in affect, mood, or behavior; malnutrition; bladder and bowel incontinence; gait disturbances; and recurring falls, burns, and head trauma (Morris, 2001; Videbeck, 2004). Many older adults began to abuse alcohol late in life because of bereavement, retirement, loneliness, or physical and emotional illnesses. Denial is more intense in older adults because of cognitive and memory problems and shame. Prescription drug abuse in older adults is two or three times higher than in the general population. The most frequently abused prescription medications are opioids, benzodiazepines, and stimulants, which may result in ataxia, falls and accidents, and cognitive impairments such as attention and memory problems
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(Fontaine, 2003).
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Definitions and common usage Nurses must understand definitions associated with addictions and related disorders to correctly assess it and plan appropriate interventions for older adults. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association (APA, 2013) is used by physicians as an aid in diagnosing patients. The DSM-5 combines substance abuse and dependence into a single category: addictions and related disorders. The DSM-5 requires two criteria be met for diagnosis.
Difficulty in Identification of Abuse The physiologic, psychological, and sociologic changes associated with aging make the identification and treatment of addictions and related disorders in older adult patients difficult. Age-related psychological and sociologic changes and symptoms may be subtle or atypical and may mimic symptoms of addictions and related disorders (Mohundro & Ramsey, 2003; Videbeck, 2004). Often, clinicians and family members are hesitant to ask whether the older adult is having problems with use or misuse of prescription medications. Traditionally accepted ways of detecting problems with substances (e.g., time lost from work, legal problems, or decreased participation in important social activities) are not helpful in older adults because they generally have fewer activities and obligations (Trevisan, 2008).
Physiologic Changes Patients with early-onset alcohol dependence appear to have a more severe course of illness. They make up about two thirds of the dependent drinkers among older adults, are predominantly male, and have more alcohol-related medical problems and psychiatric comorbidities. Patients with later onset alcohol dependence tend to have a milder clinical picture and fewer medical problems because of the shorter exposure to alcohol. They are more affluent, include
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more women, and are likely to begin their alcohol use after a stressful event such as loss of a spouse, job, or home (Trevisan, 2008).
Nurses should be aware of age-related physiologic changes of absorption, distribution, plasma protein binding, hepatic metabolism, and elimination or clearance of a drug. The assessment of these changes in relation to substance use is essential in planning interventions to prevent or halt substance abuse and misuse in the older adult population.
Psychological Changes Psychological changes in older adults result primarily from the numerous losses this age group experiences in a relatively short period. Roughly 6% of persons over the age of 65 drink heavily. Heavy drinking is often in response to bereavement, retirement, loneliness, relationship stress, and physical illness (Figure 20-1).
FIGURE 20-1 Loneliness and hopelessness may be
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manifestations of alcohol abuse. (Courtesy of Ursula Ruhl, St. Louis, MO.)
Nurses should be aware of the misconception that select prescribed or OTC substances may help the patient deal with unmet psychological needs. For example, an older adult may become anxious if sleep has decreased to less than 8 hours and may seek sedatives. In addition, some older adults tend to use certain substances to mask negative feelings about themselves; they may eventually attribute some of their positive personality characteristics to substances. Examples of such substances include alcohol and benzodiazepines (e.g., diazepam). Patients who are prescribed benzodiazepines by a physician for a limited period may become dependent on the medication. An older adult who is dependent may find another physician to prescribe the medication when the original physician discontinues it.
The nurse must also assess older adults for suicidal ideation. Patients should be asked whether they have had thoughts of harming themselves and whether they have a plan to carry out these thoughts. Advancing age and substance abuse are among the greatest risk factors for suicide. Suicide rates tend to increase with age in white men, and it should be noted that suicide is the 13th leading cause of death in older adults.
Sociologic Changes Sociologic changes such as decreases in finances, transportation, and social support tend to place older adults at risk for addictions and related disorders. As a result of decreased finances and transportation, many older adults fill prescriptions through mail- order pharmacies. Mail-order pharmacies tend to increase the potential for drug abuse and misuse as a result of prescription errors, late arrivals, and large quantities of drugs. Social conditions such as low income, difficulty shopping, and lack of socialization tend to affect the nutrition of older adults. The nurse should educate older adults about the dual effects of poor nutritional status and drug metabolism.
Sociologic changes are based on the cultural values and attitudes about substance abuse behaviors that are passed from one
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generation to another. A lower incidence of addictions and related disorders is seen in cultures whose religious and moral values prohibit or limit their use. Older adults are targeted by advertisements for prescription and nonprescription drugs because they experience minor aches, pains, and major health problems. Addictions and related disorders are symptomatic of the larger social problems among minority groups (e.g., poverty, substandard housing, inadequate health care, and lack of power). The lack of culturally competent care is an additional barrier to care for the older adult with addictions and related disorders.
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Assessment The following section is a general overview of the key concepts in assessing and planning nursing interventions for addictions and related disorders in the older adult population. Nurses should be aware of the specific assessment and nursing intervention strategies for abuse of alcohol, prescription and nonprescription medications, illicit drugs, and nicotine. Addictions and related disorders in older adults are challenging in that they require expertise in gerontology, geriatrics, psychiatric mental health, and the specific presentation and management of disorders in this population.
Substance Abuse History The DSM-5 criteria for addictions and related disorders are developed for the general population, not specifically for the older adult population. Therefore, it is essential for the nurse to assess patients’ medical and psychological histories. After history taking is completed, the nurse should identify whether the key medical and psychological manifestations of addictions and related disorders are present (Boxes 20-1 and 20-2).
Box 20-1
Medical manifestations of substance abuse in older adults Peripheral neuropathy
Diminished proprioception
Alcoholic liver disease (hepatitis or cirrhosis)
Alcoholic pancreatitis
Gastrointestinal bleeding
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Esophageal varices
Peptic ulcer or gastritis
Malignancies
Cardiomyopathy
Protein-calorie malnutrition
Hypovitaminosis (particularly B vitamins)
Anemia
Osteopenia
Susceptibility to infections
Electrolyte disturbances
Hypercortisolemia
Delirium tremens (occurs after recent cessation of or reduction in alcohol intake; is marked by signs of delirium with autonomic hyperactivity—tachycardia, sweating, hallucinations, delusions, agitation, tremor, fever, and seizures)
Seizures
Hypertension
Acquired immunodeficiency syndrome (AIDS)
Peripheral muscle weakness
Falls
Orthostatic hypotension From Solomon, K., Manepalli, J., Ireland, G. A., Mahon, G. M. (1993). Alcoholism and prescription drug abuse in the elderly: St. Louis University Grand Rounds. Journal of the American Geriatric Society, 41, 57-69.
Box 20-2
Psychological manifestations of
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substance abuse in older adults Manic (expansively elevated) mood or behavior
Depressed mood
Social withdrawal
Vegetative symptoms of depression
Apathy or poor motivation
Suicidal ideation, plans, or behavior
Violent threats or behavior
Paranoid or nonparanoid delusions
Auditory, visual, olfactory, or gustatory hallucinations
Anxiety
Panic attacks
Phobias
Poor personal hygiene
Poor skills in activities of daily living (ADLs)
Personality change
Irritability
Sleep disturbances
Memory loss (immediate, recent, or remote)
Delirium (intoxication or withdrawal)
Flashbacks
Marital, social, or legal difficulties
Noncompliance with medical care
Hallucinations
Alcoholic dementia (Wernicke-Korsakoff syndrome) From Solomon, K., Manepalli, J., Ireland, G. A., Mahon, G. M. (1993). Alcoholism and prescription drug abuse in the elderly: St. Louis University Grand Rounds. Journal of the American Geriatric Society, 41, 57-69.
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Screening Tools A number of screening tools are available to assess alcohol use. The two most commonly used tools are the CAGE (Cutdown, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) (Mayfield, McLeod, & Hall, 1974) and the Michigan Alcoholism Screening Test (MAST) (Figure 20-2) (Selzer, 1971). The Brief Michigan Alcoholism Screening Test (BMAST) is a modified form of the MAST (Figure 20-3) (Pokorny, Miller, & Kaplan, 1972). Frederick Blow developed the MAST—Geriatric Version (MAST-G) (Morton, Jones, & Manganaro, 1996). Results indicate that the MAST-G is an instrument that is more reliable and valid in the older adult population compared with the MAST (Knight & Mjelde- Mossey, 1995). Even though further research is required to validate the use of these tools for the assessment of substance abuse besides alcohol abuse, positive clinical results have been demonstrated with the use of these tools, substituting the words substance or prescription medication for drink.
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FIGURE 20-2 MAST. (Modified and reprinted with permission from Selzer, M.L. (1971). The Michigan Alcoholism Screening Test: The quest for a new
diagnostic instrument. American Journal of Psychiatry, 127, 1653. Reprinted with permission from the American Journal of Psychiatry. Copyright 1994, American
Psychiatric Association.)
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FIGURE 20-3 The Brief Michigan Alcoholism Screening Test (BMAST). (Modified from Pokorny, A.D., Miller, B.A., & Kaplan, H.B. (1972). The
brief MAST: A shortened version of the Michigan Alcoholism Screening Test. American Journal of Psychiatry, 129,:342-345. Reprinted with permission from the
American Journal of Psychiatry. Copyright 1994, American Psychiatric Association.)
Patients undergoing detoxification from alcohol abuse should be assessed with the use of the Clinical Institute Withdrawal Assessment tool on an ongoing basis. The tool measures the severity of alcohol withdrawal on the basis of 10 common signs and symptoms: (1) nausea and vomiting; (2) tremor; (3) paroxysmal sweats; (4) anxiety; (5) agitation; (6–8) tactile, auditory, and visual disturbances; (9) headache; and (10) orientation. The maximum score is 67, and patients who score higher than 20 should be admitted to a hospital (Fontaine, 2003).
Nursing Caveats In assessing older adults for addictions and related disorders, the nurse must be aware of his or her own perceptions and attitudes regarding addictions and related disorders in the older adult population. Many health care providers overlook the possibility that the presenting symptoms in an older adult may be related to addictions and related disorders. It is important to have a healthy collaborative relationship with patients, showing respect for their
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values and choices.
Inherent changes in tissue and organ function are highly variable and individual. Hence the response to medication is just as variable and as unpredictable in this population. The guiding principles are to “start low and go slow” when prescribing medications; change or add only one medication at a time; review each medication to see whether the patient is still taking it; and determine the dose, frequency, and time (see Evidence-Based Practice box).
Evidence-based practice Substance Abuse among Older Adults
Background There is a lack of recorded information on the topic of substance abuse among American senior citizens. Older substance abusers are identified when the patient presents with secondary medical issues or as a direct result of substance abuse. Concern is growing among health care providers that as the baby boomer cohort with its great size and high rates of substance abuse issues enters the latter segment of life, an already strained substance abuse treatment system will be overwhelmed. The purpose of this study was to examine the prevalence, distribution, and correlating drug use among middle-aged and older adult persons in the United States and to compare it against reported alcohol use in these same age groups.
Sample/Setting The sample was made up of those age 50 or older (6717 ages 50– 64 and 4236 age 65 or older) drawn from the 2005–2006 public use files of the annual National Survey on Drug Use and Health conducted by the Office of Applied Studies, Substance Abuse and Mental Health Service Administration.
Methods Data collection methods included a combination of computer-
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assisted personal interviewing and audio computer-assisted self- interviewing programs to increase the validity of respondents’ reports of drug use behaviors. Logistic regression of the study variables was conducted to identify those characteristics associated with a participant’s reported utilization of alcohol, marijuana, or cocaine.
Findings The average study participant in the 65 + age category was white, female, with a college level education, married, and living in a metropolitan area. Within the past year nearly 60% of those age 65 + reported using alcohol, 2.6% used marijuana, and 0.41% used cocaine. Among those who consumed alcohol, most reported their consumption rate to be more than 30 days within that year.
Implications The data suggest that the current rate of drug use among those 65 + is low; however, the rate for alcohol consumption is greater than 50% for both men and women. Continuing to conduct surveys such as this will allow for trending prediction as baby boomers approach retirement age. From Blazer, D.G. & Wu, L.T. (2009). The epidemiology of substance use and disorders among middle age and elderly community adults: National Survey on Drug Use and Health. American Journal of Geriatric Psychiatry, 17(3), 237.
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Nursing diagnoses The following list identifies nursing diagnoses that may be used for older adult patients who abuse substances:
• Ineffective Family Therapeutic Regimen Management
• Anxiety
• Ineffective Thermoregulation
• Acute Confusion
• Ineffective Coping
• Interrupted Family Processes
• Imbalanced Nutrition: Less Than Body Requirements
• Self-Care Deficit (Bathing, dressing, feeding or toileting)
• Disturbed Body Image
• Disturbed Sleep Pattern
• Impaired Social Interaction
• Risk for Self-Directed Violence
• Risk for Other-Directed Violence
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Nursing management Interventions
Multidisciplinary interventions are appropriate for all individuals overcoming addictions and related disorders because no single intervention is appropriate. Effective interventions attend to the multiple needs of individuals, not just their drug or substance use. Interventions must address medical, nursing, psychological, social, vocational, and legal problems.
Interventions and treatment options include brief therapy, intensive outpatient or inpatient treatment, and residential treatment. Brief therapy is usually provided by a trained professional in a community drug treatment center. Goal setting, self-monitoring, and identifying high-risk situations are specific learned behaviors that help stop or reduce patients’ substance abuse. Intensive outpatient programs allow patients to remain at home and continue working while they participate in treatment in an unrestricted setting for 4 to 5 hours every day. Intensive inpatient treatment is provided in the emergency department or acute care inpatient units to patients at risk of severe withdrawal symptoms, those who are psychiatrically disabled, and those who have not responded to less intensive treatment efforts. Residential treatment programs are downsizing and closing because third- party reimbursement is rapidly decreasing. Traditionally, treatment lasted 7 to 21 days and offered a safe and structured environment to those who lacked social and vocational skills and drug-free social supports to be abstinent in a less restricted setting (Fontaine, 2003).
Older adults resist referrals to substance abuse programs and are more comfortable in senior-oriented programs. Some are unable or unwilling to leave their homes; thus, programs should be specific for older adults and use special approaches such as slow-paced and emotionally supportive therapy instead of the confrontational style used with younger adults.
Complementary or alternative therapies (herbs and nutrients)
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and a nutritional supplement called SAMe (pronounced “sammy”) may be helpful in addictions and related disorders. SAMe (S- adenosylmethionine), a compound made by every cell in the body, helps produce diphenylchlorarsine, 5-hydroxytryptamine, and norepinephrine. SAMe may be used for depression that accompanies withdrawal from psychoactive substances. It may also reverse some of the effects of alcoholic hepatitis and cirrhosis (Brown & Gerbarg, 2000). Acupuncture is another treatment used for addictions and related disorders. It eases the symptoms of withdrawal, decreases the intensity of cravings, and decreases the number of relapses. Acupuncture is a safe and relatively low-cost form of treatment. However, more research is necessary before complementary and alternative therapies can be recommended as treatment modalities for addictions and related disorders (Behere, Muralidharam, & Benegal, 2009).
Evaluation The evaluation of the treatment of older adults who abuse substances consists of the assessment of safe detoxification, adherence to the sobriety treatment plan, and outpatient support. Detoxification is safe if a patient has been weaned from the abused substance without seizures, delirium tremens (DTs), changes in vital signs, or other complications of withdrawal. Adherence is measured by noting if the patient is abstaining from substance use and attending meetings (e.g., Alcoholics Anonymous [AA] or Narcotics Anonymous [NA]) and individual or family group sessions. Finally, outpatient support is assessed to determine whether the patient is maintaining the relationship with a sponsor. A sponsor is someone who can be a mentor and support the patient during abstinence.
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Commonly abused substances in older adults Alcohol Prevalence Alcohol abuse may be difficult to assess as a result of the drug’s legal status and socialization as a recreational activity in the United States. The difficulty in identifying alcohol abuse notwithstanding, the incidence of alcohol abuse identified in the older adult population is from 6% to 15%. The prevalence rate of alcohol abuse is projected to increase as baby boomers reach retirement age. The pattern of illicit drug use may change and become a major concern (Colyar, 2003; Morris, 2001).
Some heavy drinkers with early-onset addiction survive into old age; others are late-onset drinkers, who may have started drinking in late middle age and began to exhibit health problems related to alcohol abuse as they moved into older adulthood. Older adults who have used alcohol in the past without abuse or addiction may experience problems with alcohol consumption as changes occur in their bodies as a result of normal aging (e.g., decreased liver function or changes in body composition) (Morris, 2001).
Assessment Older adults who abuse alcohol may display symptoms of anxiety, nervousness, memory impairment, depression, blackouts, confusion, weight loss, and falls. In addition, physical examination of an older adult may indicate the effects of alcohol on the various body systems. Table 20-9 shows age-related and alcohol-related changes in select body systems of older adults. The nurse should assess carefully for the following signs and symptoms: impaired sensations in the extremities, poor coordination, confusion, facial edema, alcohol on the breath, liver enlargement, jaundice, ascites, trembling or fidgeting, lack of attention to personal hygiene, and poor eating habits. Secondary problems may include malnutrition,
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cirrhosis, compromised hepatic function, osteomalacia as a result of compromised metabolism of vitamin D, cardiomyopathy, atrophic gastritis, and a decline in cognitive status, especially with regard to memory and information processing. Laboratory evaluation should include assessment of liver function and levels of electrolytes, glucose, and magnesium, as well as electrocardiography (ECG) (Videbeck, 2004).
Table 20-9 Age- and alcohol-related changes in body systems of older adults
Age-Related Changes Corresponding Alcohol-Related Changes Decline in liver function Hepatotoxicity Delayed neurologic conduction Increase of Parkinson disease symptoms, altered balance Idiopathic tremors Tremors related to withdrawal Predisposition to falls Predisposition to falls Loss of short-term memory Impairment of short-term memory Decreased glucose tolerance Inhibition of glycogenesis Decreased secretion of hydrochloric acid Impaired absorption of nutrients Slowed peristalsis Impaired absorption of nutrients Decreased saliva production Impaired absorption of nutrients Increase in cholesterol levels and cardiovascular disease Increased plasma triglyceride levels Less efficient cardiovascular function Risk of congestive heart failure Increased incidence of arthritis and gout Increased uric acid levels Decline in immunologic competence Increased susceptibility to infection
Developed from Coffey, C.E. & Cummings, J.L. (1994). Textbook of geriatric neuropsychiatry. Washington, D.C.: American Psychiatric Press; Solomon, K., Manepalli, J., Ireland, G. A., & Mahon, G. M. (1993). Alcoholism and prescription drug abuse in the elderly: St. Louis University Grand Rounds. Journal of the American Geriatric Society, 41, 57-69.
Alcohol abuse may not be accurately assessed in older adults also because many alcohol abuse symptoms such as falls, bruises, cardiovascular problems, hypertension, and memory problems, may resemble other disease processes. Therefore, if an older adult displays these symptoms, it is imperative the nurse assess for the possibility of alcohol abuse in addition to medical illness and disease (see Box 20-2 for information about the medical and psychological manifestations of substance abuse in older adults).
After obtaining a health history and conducting a physical examination, the nurse should begin to assess specifically for alcohol abuse. The CAGE, MAST, MAST-G, or BMAST screening tools may help the nurse determine the amount and frequency of alcohol consumption. Input from family and friends should also be
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obtained. Family and friends may deny the problem; therefore, it is imperative that the nurse obtain the history of alcohol use in a detail-oriented, nonjudgmental manner (Pokorny et al., 1972; Knight & Mjelde-Mossey, 1995).
The nurse should be able to distinguish alcohol intoxication from alcohol withdrawal to apply the appropriate nursing interventions. Signs associated with alcohol intoxication include the scent of alcohol on the breath, slurred speech, lack of coordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor or coma (APA, 2013). Assessment of the signs and symptoms of alcohol withdrawal is essential in providing the appropriate treatment and preventing DTs and seizures. Indications of alcohol withdrawal are elevated blood pressure, elevated pulse, and autonomic hyperactivity. In addition, fever, increased hand tremors, insomnia, nausea and vomiting, transient visual, tactile, or auditory hallucinations or illusions, psychomotor agitation, anxiety, and grand mal seizures may occur (APA, 2013). Withdrawal symptoms begin 4 to 12 hours after alcohol use has been stopped or reduced. Symptoms tend to peak 48 to 72 hours after a patient’s last drink (APA, 2013). It is important to assess older patients for the possibility of alcohol withdrawal if agitation, hallucinations, anxiety, or seizures develop 2 or 3 days after hospitalization (see Emergency Treatment box).
Emergency treatment
Delirium Tremens The following nursing interventions should be implemented for patients who experience delirium tremens (DTs):
1. Assessment of vital signs
2. Provision of a safe environment (padded side rails, decreased stimulation)
3. Close observation
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4. Administration of prescribed medications such as benzodiazepines, beta-blockers, clonidine, and anticonvulsant drugs
Interventions Nursing interventions for older adults who abuse alcohol vary, depending on whether the patient is in detoxification or rehabilitation. Nurses should observe and document signs of withdrawal, provide an environment of low stimulation (e.g., dim lights and a quiet atmosphere), and initiate seizure precautions (e.g., padded side rails and the bed in lowest position) during the detoxification process. In addition, the nurse should administer drugs, such as benzodiazepines, beta-blockers and anticonvulsants, which are used to reduce symptoms of withdrawal and prevent complications. During the rehabilitation stage, recommended nursing interventions include patient education; continued administration of medications; group, individual, and family therapy; and introducing the patient to the 12-Step Program. The nurse supports the patient with (1) education on the harmful effects of alcohol on the body and the effects of alcohol taken with prescription and nonprescription medications (Tables 20-10 and 20- 11), (2) various methods to overcome potential triggers for future substance abuse, and (3) plans to maintain sobriety in the community setting. The nurse should also educate family members on the potential changes in family dynamics resulting from the patient’s sobriety. In addition, the nurse should encourage the recognition that chemical dependency is a “family disease” and abstinence is affected by the family process. All family members need education to help identify triggers to avoid relapse and strategies for dealing with triggers (Fontaine, 2003; Mahgoub, 2009).
Table 20-10 Selected significant alcohol–drug interactions
Substances Interacting With Alcohol
Mechanism Possible Effect(s)
I. Antihistamines, antidepressants, opioid analgesics, sedative-hypnotics, antianxiety agents, antipsychotic drugs
Additive Enhanced CNS depressant effects
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II. Aldehyde dehydrogenase inhibitors A. Disulfiram (Antabuse) B. Other agents • Cefamandole and some other oral second- and third- generation cephalosporins • Chlorpropamide (Diabinese) and other oral antidiabetic agents to varying degrees
Inhibition of aldehyde dehydrogenase in metabolism of alcohol, leading to acetaldehyde accumulation (disulfiram or a “disulfiram-type reaction”)
Most severe effects seen with disulfiram and alcohol: flushing, stomach pain, head throbbing, increased heart rate, hypotension, sweating, nausea, and vomiting With antidiabetic agents: mild to severe hypoglycemia
• Griseofulvin (Fulvicin) • Metronidazole (Flagyl) • Procarbazine (Matulane) III. Phenytoin (Dilantin) Increase or decrease in liver metabolism With chronic alcohol abuse: possible decrease
in antiseizure effect caused by increased metabolism With acute alcohol use: a possible decrease in metabolism, causing increased serum levels of phenytoin leading to toxicity
IV. Nonsteroidal antiinflammatory agents (NSAIDs)
Additive Increased gastrointestinal irritability and bleeding
• Salicylates • COX-1 and COX-2 inhibitors (e.g., ibuprofen) V. Nitrates • Nitroglycerin
Additive Vasodilation leading to hypotension, syncope
From McKenry, L.M. Mosby’s pharmacology in nursing (22nd ed.). 2005. St. Louis, MO: Mosby.
Table 20-11 Over-the-counter (otc)–prescription drug interactions
OTC Drug Prescription Drug Possible Clinical Effect Alcohol Central nervous
system (CNS) depressants
Enhanced depression
Aspirin Gastrointestinal bleeding Antacids Phenothiazines Inhibition of phenothiazine absorption
Tetracycline Divalent cations (e.g., calcium present in formulations impairs absorption of tetracycline)
Aspirin Methotrexate Enhanced clinical effects of methotrexate Anticoagulants Enhanced anticoagulant effects Probenecid Reduced uricosuric effect
Agents with anticholinergic effects (e.g., antihistamines, cold and cough preparations)
CNS depressants, anticholinergics
Enhanced anticholinergic effects
Phenylephrine Pseudoephedrine
Monoamine oxidase inhibitors
Enhanced effects of these and other adrenergic agonists (e.g., possible hypertensive crisis)
From Jannus, S. Pharmacological aspects of aging. In: Rosenbloom, A.A. (Ed.). (2007). Rosenbloom & Morgan’s vision and aging. St. Louis, MO: Butterworth-Heinemann.
Many pharmacologic interventions have been used to inhibit drinking behaviors, with varying results. Medications for recovery may include disulfiram, naltrexone, acomprosate, or topiramate. Disulfiram, when taken with alcohol, causes vomiting; naltrexone interferes with the pleasure derived from drinking; acomprosate reduces the craving for alcohol; and topiramate may alter the
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stimulating effects of alcohol. Thiamine may have to be added to improve nutritional status.
Evaluation The evaluation of the treatment of an older adult patient who abuses alcohol includes safe detoxification, adherence to a treatment plan for sobriety, and outpatient support. Safe detoxification consists of weaning from alcohol without seizures, DTs, or other withdrawal complications. The nurse also assesses whether the patient is adhering to the sobriety protocol of abstinence and attendance at AA meetings and individual or family therapy. In addition, a continued relationship with the patient’s sponsor and the patient’s progress as reported by home health nurses provide the opportunity for evaluation of the patient’s transition back into the community (Fontaine, 2003).
Prescription Medications Prevalence Abuse of prescription medications among older adults is two to three times higher than in the general population. The number of medications prescribed is directly correlated to the risk of their inadvertent misuse. As a result, the possibility of polypharmacy is high (Figure 20-4). Prescription drugs commonly used by independent older people are cardiovascular medications, benzodiazepines, diuretics, cathartics, antacids, thyroidal medications, and anticoagulants. Opioid and benzodiazepine dependence is the most common occurrence, and the drugs may have been prescribed for long periods (Coogle, Osgood, & Parham, 2000). Because of the cross-tolerance between benzodiazepines and alcohol, the potential for cross-addiction is increased. The nurse may be the person who recognizes the possible existence of prescription medication abuse. The rapport between the nurse and the patient allows the patient to feel comfortable discussing medications. Therefore, it is imperative that the nurse assess for prescription medication abuse in older adults.
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FIGURE 20-4 Older adults’ concurrent use of many prescription medications may lead to polypharmacy. (Courtesy of Loy Ledbetter, St.
Louis, MO.)
Assessment Nursing assessment for prescription drug abuse in older adult patients is similar to the assessment used for alcohol abuse. The nurse should begin the assessment by taking a careful history, using the CAGE, MAST, BMAST, or MAST-G screening tools (Morton et al., 1996). The nurse should remember to substitute the term prescription medications for alcohol. In addition, the nurse should assess for a tendency to repeatedly lose prescriptions or pills (e.g., “I threw it away by accident,” “I didn’t think I would use them so I flushed them down the toilet”), prescriptions from multiple physicians, frequent emergency department visits, strong preferences for particular medications (e.g., “Only X medication works for pain for me,” “I’m allergic to Y, so I can only take X”), and above-average knowledge about medications, as well as the severity of the complaint matching the clinical presentation. Finally, the nurse should assess the patient for signs associated with withdrawal, for example, anxiety, irritability, insomnia, fatigue, headache, tremors, sweating, dizziness, decreased concentration, nausea, depression, and visual or tactile hallucinations (Fontaine,
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2003; Neushotz & Fitzpatrick, 2008).
Interventions The interventions for prescription drug abuse are similar to the interventions associated with alcohol abuse. First, if prescription drug abuse is suspected, the nurse should ask the patient or a family member to bring in all medications the patient is currently using and inform the physician so that a plan for safe detoxification can be established. The patient should be informed that by bringing in all medications currently being used, he or she is ensuring that the health care team can develop a comprehensive care plan to address the patient’s needs. This also enables the physician to prevent any untoward drug interactions resulting from prescribing a new medication that is contraindicated because of an existing prescription. The nurse should document any signs of withdrawal, provide an environment of low stimulation, and implement seizure precautions. In addition, the nurse should administer, on a planned reduction schedule, any medications prescribed to minimize withdrawal symptoms. Nutritional support interventions should also be implemented for patients with compromised nutritional status. Agents used to treat opioid dependence are methadone, buprenorphine, naloxone, and clonidine. Although these harm- reduction pharmacologic treatments are widely used for opioid addicts, no studies of the use of these medications in the older adult population have been performed (Trevisan, 2008). Finally, after discussion within the multidisciplinary team, concerns about prescription drug abuse and treatment options such as AA, NA, or individual or group therapy should be presented to the patient and family members in a patient-care conference (Fontaine, 2003).
Evaluation The evaluation of nursing interventions for prescription drug abuse includes assessment of safe detoxification, participation in a rehabilitation treatment plan, and decreased drug-seeking behaviors. The nurse should also observe and document the patient’s response to any teaching regarding appropriate medication use and the effects of medication misuse on the body.
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Nicotine Prevalence Tobacco use is the single greatest cause of preventable disease and disability in the United States. Tobacco use is a risk factor in 6 of the 13 leading causes of death in older adults. In the United States alone, approximately $50 billion is spent annually on medical costs that are attributed directly to tobacco use. Many tobacco users 50 years or older express the desire to quit; however, only those older adults with chronic illnesses tend to have the motivation to do so. Older adults who stop tobacco usage may improve quality of life and possibly increase life expectancy.
Assessment The nurse should thoroughly assess a patient’s tobacco use pattern and also assess for signs of nicotine withdrawal. A helpful assessment tool is the Fagerström Test for Nicotine Dependence (Figure 20-5) (Fagerström, Tejding, Westin, & Lunell, 1997). The patient’s responses allow the nurse to plan appropriate interventions. Older adult patients should be monitored for signs of nicotine withdrawal such as depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, and increased appetite (APA, 2013).
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FIGURE 20-5 The Fagerström Test for Nicotine Dependence. (Copyright 1991, Karl Fagerström.)
Interventions and Evaluation Nursing interventions for patients who abuse tobacco include monitoring for signs of withdrawal, administration of nicotine replacement, behavior modification, and education. The type of nicotine replacement used is determined by the physician; options include gum, inhaler, lozenge, nasal spray, or patch. The replacement period lasts from 6 weeks to several months and reduces the craving for cigarettes by weaning the patient from nicotine and preventing withdrawal symptoms. Patients who do not tolerate nicotine replacement may respond to clonidine.
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Clonidine is an antihypertensive that blocks the neurologic symptoms that produce nicotine withdrawal; although evidence supporting the use of clonidine is limited, it might be useful in patients who do not respond to nicotine replacement (Gourlay, Stead, & Benowitz, 2008).
Patient/family teaching
Safe Use of Medications Know the name, amount, type, frequency, purpose, and side
effects of both the prescription and nonprescription drugs that you are taking.
If you see more than one care provider, always bring all your medications to every provider visit you make.
Never borrow medications from anyone else or share your medications with anyone else.
Make sure your family members can safely self-administer medications; adequate vision, memory, judgment, and coordination are all essential.
Supervise medication administration for those people who cannot safely self-administer. Talk to the doctor or advanced practice nurse about simplifying the medication regimen by using a daily dosing schedule set for once or twice a day.
Never mix alcohol with any medication.
Use a single pharmacy for filling all prescriptions to reduce the potential for interactions as well as abuse and misuse.
Another medication that has been an effective aid in smoking cessation is sustained-release bupropion, marketed under the trade name Zyban. The nurse should obtain a detailed patient history regarding the existence of any seizure disorder because bupropion is contraindicated in such cases and another medication or technique should be recommended. Furthermore, the nurse must
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carefully assess the bupropion candidate for any history of alcohol abuse; these patients are at increased risk for seizures (Hurt, 1997; Evans, 2003). Varenicline, along with education and counseling, may also be effective in helping people stop smoking. Varenicline is in a class of medications called smoking cessation aids. It works by blocking the pleasant effects of nicotine on the brain. Some people have experienced changes in behavior, hostility, agitation, depression, suicidal ideation, and worsening of preexisting psychiatric illness while taking varenicline (Ogbru, 2012).
Older adults should also be educated on the effects that tobacco has on prescription medications (Table 20-12).
Table 20-12 Clinically significant pharmacodynamic drug interactions with smoking
Drug Pharmacodynamic Effect of Interaction Considerations Benzodiazepines Decreased sedation and drowsiness Smokers may require higher doses Beta-blockers Less pronounced heart rate and blood
pressure effects Smokers may require higher doses
Chlorpromazine Less orthostatic hypotension and sedation
May experience increased sedation and hypotension upon smoking cessation
Combined oral contraceptives
Increased risk of cardiovascular adverse events Risk is substantially increased in older women and with heavy smoking
Use is considered contraindicated in women who smoke ≥ 15 cigarettes per day and are over 35 years of age
Opioids Decreased analgesic effect Smokers may require higher opioid doses for pain relief
From Kroon, L.A. (2006. Drug interactions and smoking: Raising awareness for acute and critical care providers. Critical Care Nursing Clinics of North America, 18(1), 53-62 2006.
Evaluation of nursing interventions includes assessing for decreased use of tobacco, adherence to a plan to reduce tobacco use, and understanding of the effects that tobacco and nicotine have on the body.
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Future trends Current figures indicate 1% of older adults use illicit drugs; however, prevalence is expected to increase as more baby boomers reach retirement age. Prevalence is expected to double by 2020 (Wu & Blazer, 2012). Older adults should be screened for drug abuse. A simple, one-question screen, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” has been shown to accurately identify individuals using drugs in the outpatient setting; however, a trial has not been conducted in older adults (Smith, Schmidt, Allensworth-Davies, & Saitz, 2010).
Home care
1. Obtain a prescription medication inventory, including the physician sources of all prescriptions.
2. Mail-order prescription suppliers send large quantities of drugs to homebound older adults, which predisposes them to drug wasting, overdosing, and other misuse.
3. Assess the number of caregivers involved with medication administration to prevent overdosing and other administration errors.
4. Drug use patterns of homebound older adults, including the administration of prescription drugs, over-the-counter drugs, and home remedies, are influenced by cultural and ethnic health practices.
5. During assessment of homebound older adults, include an inventory of the use of caffeine, nicotine, and alcohol.
6. Assess high risk factors (e.g., social isolation and depression) that may predispose homebound older adults to addictions and related disorders.
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7. Assess for signs of addictions and related disorders in homebound older adults.
8. Encourage caregivers to attend support groups such as Alcoholics Anonymous (AA) to ease the burden of caring for a homebound older adult with addictions and related disorders.
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Summary Achieving positive therapeutic outcomes and reducing adverse drug events requires knowledge of age-related alterations that determine how older adults react to drugs, an understanding of the unique problems attributable to aging, and an awareness of resources to address problems and concerns related to medication use. Nurses must accept this responsibility if improved patient outcomes are to be realized.
The prognosis for untreated substance abuse in older adults is poor because of physiologic and psychological consequences. It is essential that nurses identify addictions and related disorders in older adults and examine their own attitudes about addictions and related disorders in this population. Early identification and intervention are essential for preventing misdiagnosis and ineffective, costly treatments. Nurses should recognize that older adults who abuse substances can be treated effectively. The first step in effective treatment is identification. After a problem is identified, a cost-effective treatment may be initiated to help an older adult return to a healthy lifestyle.
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Key points • Older adults consume a large proportion of pharmaceutical
products. The use of inappropriate medications results in significant morbidity and mortality and adds an economic burden to patients and health care systems.
• Older adults may be at risk for adverse drug reactions because of age-related changes, multiple chronic illnesses, polypharmacy, nonadherence, and lack of knowledge.
• A reduction in drug dosage is often required for older adults whose ability to excrete medications is decreased or in whom renal or hepatic function is reduced.
• Knowledge of clinically important drug interactions is essential in planning alternative medication regimens and preventing potentially serious ADEs.
• Medication problems should always be suspected in patients experiencing overt or subtle changes in cognitive or physical function.
• Psychotropics should be used judiciously in older adults; agents with the lowest side effect profiles should be preferred.
• Newer generation medications may offer opportunities for an improved quality of life for older adults.
• The nurse can play a key role not only in assessing patients for risk factors that may reduce compliance but also in developing strategies to reduce or to eliminate these risks.
• For most medications prescribed for older adults, it is necessary to start low, go slow, and periodically review medication regimens.
• The age-related physiologic changes of altered absorption, distribution, metabolism, and excretion affect drug usage and place older adults at an increased risk for addictions and related disorders.
• Psychological changes, primarily a result of the numerous losses
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older adults may experience in a relatively short time, place them at an increased risk for addictions and related disorders.
• Sociologic changes such as decreased finances, transportation, and social support, as well as sociocultural factors such as gender and race, may place older adult patients at risk for addictions and related disorders.
• The substances most often abused by the older adult population are alcohol, prescription medications, nonprescription medications, nicotine, and caffeine.
• The nurse should assess older adult patients for key medical and psychological manifestations of addictions and related disorders through their health history. Some of these key manifestations are falls, hypertension, memory loss, depressed mood, and social withdrawal.
• Screening tools such as the CAGE, MAST, MAST-G, and BMAST should be used to obtain the history of addictions and related disorders in older adult patients.
• Key nursing interventions for addictions and related disorders in older adult patients include assessing for signs of withdrawal, administering appropriate medications to provide safe detoxification, providing a safe environment, educating patients regarding harmful effects, and encouraging patients to participate in AA, NA, or individual, family, or group therapy.
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Critical thinking exercises 1. An 83-year-old man with a history of congestive heart failure is taking a number of prescription medications, including psyllium (Metamucil), digoxin (Lanoxin), phenytoin (Dilantin), and cimetidine (Tagamet). He is 5 foot, 9 inches tall and weighs 139 pounds. On the basis of potential drug interactions, identify the relevant assessment priorities. What factors place this patient at risk for drug toxicity?
2. A home care nurse is seeing an 82-year-old man who is taking a complex medication regimen. He cannot remember when he last took several of his medications, and his wife states she is confused by the recent switch of several drugs to other generic brands. What questions should the nurse ask to establish the patient’s risk for noncompliance?
3. A patient’s daughter wonders if she should have her dad use ginkgo and other herbals to help with his Alzheimer disease. How would you advise her?
4. Compare and contrast nursing assessments and interventions for prescription drug, nonprescription drug, and alcohol abuse. How are they similar and how are they different? How might assessment techniques be revised for the older adult population?
5. Analyze your own perceptions and attitudes regarding substance abuse in general. How do these perceptions and attitudes differ from those presented here with regard to substance abuse in the older adult population? What factors and assumptions contribute to these perceptions?
6. How might the DSM-5 criteria for substance abuse be revised to specifically address the older adult population?
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* Previous authors: June Felice Johnson, BS, PharmD, BCPS; Christopher Benjamin, MSN, RN, FNP, and Kathleen Fletcher, MSN, RN, APRN-BC, GNP, FAAN; and Jacqueline L. Rosenjack Burchum, DNSc, FNP-BC, APN, CNE.
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PA R T 6 Nursing Care of Physiologic and Psychologic Disorders
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C H A P T E R 2 1
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Cardiovascular Function Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C
Learning objectives
On completion of this chapter, the reader will be able to: 1. Explain the age-related changes in the structure and function of the cardiovascular system.
2. Identify contributing risk factors for cardiovascular disease.
3. Explain the pathophysiology and treatment regimen for cardiovascular conditions common in older adults.
4. List nursing interventions for older patients with cardiovascular conditions.
5. Implement the nursing process for older adults with cardiovascular conditions.
http://evolve.elsevier.com/Meiner/gerontologic
Heart disease is the leading cause of death in the United States and is a major cause of disability. Coronary heart disease is the principal type of heart disease. According to the Centers for Disease Control and Prevention (CDC), over 600,000 people die of heart disease in the United States each year, which is about 25% of all U.S. deaths (CDC, 2013a). In 2010, heart disease cost more than $300 billion, including health care services, medications, and lost productivity (CDC, 2013a). Risk factors for cardiovascular disease include high cholesterol levels, hypertension, diabetes mellitus, tobacco use, physical inactivity, obesity, alcohol use, age, and heredity (CDC, 2013a). As an individual ages, the chances of comorbid conditions increase. The reality is that atherosclerosis, the underlying cause of the majority of clinical cardiovascular problems, is typically present for years before the onset of a clinical
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event such as a heart attack or symptoms such as angina manifests themselves (Statistics Committee and Stroke Statistics Subcommittee, 2009).
This chapter examines the age-related changes and common problems and conditions of the cardiovascular system that affect older adults.
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Age-related changes in structure and function Aging alters the cardiovascular system both structurally and physiologically. However, increasing evidence suggests that lifestyle and diet may modify some of these age-related changes (Beers & Berkow, 2000; Deaton, Bennett, & Riegel, 2004; Ferebee, 2006). As people age, changes occur within the heart. For example, the heart rate decreases, the left ventricular wall thickens and results in an overall increase in oxygen demand, and there is increased collagen and decreased elastin in the heart muscle and vessel walls (Banasik, 2010b; Beers & Berkow, 2000; Blach, 2006; McCance & Huether, 2006; Morton, Fontaine, Hudak, & Gallo, 2005). The size of the left atrium increases, and aortic distensibility and vascular tone decrease. These changes decrease myocardial muscle contraction and, thus, cardiac output and cardiac reserve. Decreases occur in diastolic pressure, diastolic filling, and beta- adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure; and the muscle contraction, muscle relaxation, and ventricle relaxation phases are elongated (Banasik, 2013b; Beers & Berkow, 2000; Larsen, 2009). An S4 heart sound commonly occurs in older adults (McCance & Huether, 2006), and about 50% of older adults have a grade 1 or 2 systolic murmur (Jett, 2008).
Conduction System The sinoatrial (SA) node, atrioventricular (AV) node, and the bundle of His become fibrotic with age (Banasik, 2013b). The number of pacemaker cells located in the SA node decreases with age, which results in less responsiveness of the cells to adrenergic stimulation. Common aging changes that are reflected by electrocardiography (ECG) include a notched P wave, a prolonged P–R interval, decreased amplitude of the QRS complex, and a notched or slurred T wave (Banasik, 2013b).
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Vessels Calcification of vessels occurs, making them tortuous. The elastin in the vessel wall decreases, which causes thickening and rigidity, especially in the coronary arteries (Ball, Dains, Flynn et al., 2014). This increases the risk of atherosclerotic buildup, especially in those individuals with adverse lifestyle practices. Systolic blood pressure (SBP) is increased in older adults because of a loss of arterial distensibility because of arterial stiffening (Emerson & Lungstrom, 2013). The diastolic blood pressure (DBP) remains the same or may be elevated slightly; thus, the pulse pressure widens. Older adults are less sensitive to the baroreceptor regulation of blood pressure. This causes fluctuations in blood pressure and contributes to increased SBP. Isolated systolic hypertension (ISH) is common in the older adult population.
Response to Stress and Exercise Decreased cardiac output and cardiac reserve decrease the older adult’s response to stress. Decreased distensibility of the vessel walls, decreased heart rate, and decreased myocardial contractility affect the response to exercise. During stress or stimulation, the heart rate increases more slowly; however, once elevated, it takes longer to return to the resting rate (Banasik, 2013b; McCance, 2006). Nonetheless, this does not exclude older adults from participating in exercise programs.
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Common cardiovascular problems Cardiovascular disease (CVD) is the leading cause of death for both men and women in the United States, although women tend to be older when their CVD becomes apparent (Banasik, 2013a). In addition, CVD accounts for more hospital admissions than any other disease or condition. About half of the hospitalizations are attributed to coronary heart disease (CHD, also referred to as ischemic heart disease), and conditions such as strokes, hypertension, heart failure, arrhythmias (particularly heart blockage), valvular conditions, and peripheral vascular disease (PVD) account for other cardiovascular diseases (Banasik, 2013a).
The aging process varies among individuals, which may be attributed to factors of heredity. In addition, the effects of advancing age on cardiovascular structure and function are influenced by the presence of noncardiovascular disease and variations in lifestyle. It may not always be clear which changes in the cardiovascular system are from the normal aging process and which are caused by lifestyle (Banasik, 2013a). Many forms of CVD may be accelerated by unhealthy lifestyle choices such as smoking, physical inactivity, high-risk dietary behaviors, obesity, stress, and hormonal use by women. Chronic diseases such as hypertension and diabetes mellitus also play a role in accelerating changes.
Contributing Factors to Heart Disease Risk factors are classified as nonmodifiable and modifiable (Box 21- 1). Age, gender, and family history are risk factors that cannot be modified. Smoking, high blood pressure, a high-fat diet, obesity, physical inactivity, and stress are amenable to change. Research has demonstrated that the adoption of a healthier lifestyle has the potential to reduce or prevent the incidence of morbidity and death from ischemic heart disease and stroke. Health promotion and disease prevention are discussed in Chapter 8.
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Box 21-1
Risk factors for cardiovascular disease Nonmodifiable • Male gender
• Age (men > 45 years, women > 55 years)
• Heredity (including race)
• Family history of premature CVD (MI or sudden death < 55 years in father or other male first-degree relative or < 65 years in mother or other female first-degree relative)
Modifiable • Cigarette smoking
• Hypertension (> 140/90 mm Hg or on antihypertensive medication)
• Physical inactivity
• Obesity (BMI > 30 kg/m2) and overweight (BMI 25 to 29.9 kg/m2)
• Diabetes mellitus
• Atherogenic diet (high intake of saturated fats and cholesterol)
BMI, Body mass index; CVD, cardiovascular disease; kg/m2, kilograms per square meter; MI, myocardial infarction. Modified from National Cholesterol Education Program. (2002). Third report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Washington, D.C.: National Institutes of Health.
Blood Pressure High blood pressure, or hypertension, is a major modifiable risk factor that contributes to the incidence of coronary artery disease (CAD) and stroke. It also contributes to the development of congestive heart failure (CHF), renal failure, and PVD. It is estimated that one in three adults have high blood pressure. Data collected by the National Center for Health Statistics in the 2010 to
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2011 survey showed that more than 30% of all Americans had hypertension (CDC, 2013b). During this same period, an additional 15.8% of U.S. adults had prehypertension and were not being treated. Over one third (39.4%) of people with high blood pressure do not know they have it, and it is more prevalent among blacks than whites (CDC, 2013b). Lowering blood pressure by changes in lifestyle or by medication may lower the risk of heart disease and heart attack (CDC, 2013b).
A 90% lifetime risk of hypertension exists for people with normotensive ranges at age 55 (Seventh Joint National Committee [JNC 7], 2003). ISH, in which the SBP is 140 mm Hg or higher while the DBP is 90 mm Hg or more, is the predominate subtype of hypertension in persons aged 55 years or older (Emerson, 2013). This has changed the theory of treating older persons more cautiously for hypertension; they should receive the same treatment as others to prevent complications.
Diet An elevated serum cholesterol level is a major risk factor for coronary heart disease in both men and women. A total cholesterol level of 150 milligrams per deciliter (mg/dL) is the point at which atherosclerosis begins to accelerate. The age-adjusted mean serum cholesterol levels among adults aged 20 to 74 years declined from 222 mg/dL in 1960 to 1962 to 204 mg/dL in 1999 to 2002 and further declined to 199 mg/dL in 2005 to 2006 (Schober, Carroll, Lacher, & Hirsch, 2007). However, in 2005 to 2006, 16% of adults had serum cholesterol levels of 240 mg/dL or greater. A cholesterol level below 200 mg/dL is optimal. A woman’s chance of experiencing recurrent myocardial infarction (MI) is nine times greater with a cholesterol level of 275 mg/dL or higher than with a cholesterol level below 200 mg/dL. The serum levels of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) are also important to monitor. LDL carries cholesterol to the walls of the arteries (a positive risk factor), and HDL represents the cholesterol being carried from the cells (a negative risk factor). In the average man, HDL cholesterol levels range from 40 to 50 mg/dL. In the average woman, they range from 50 to 60 mg/dL. An HDL cholesterol level of 60 mg/dL or higher is
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believed to provide some protection against heart disease (American Heart Association [AHA], 2008). Lower levels of LDL cholesterol are equated with lower risk of heart attack and stroke. An optimal level for LDL is less than 100 mg/dL, whereas a range of 100 to 129 mg/dL is considered a near optimal range (AHA, 2008).
Decreasing fat content in the diet is the first step in reducing cholesterol levels. The AHA recommends reducing the risk of cardiovascular disease by limiting the intake of saturated fat to less than 7% of energy, trans fat to less than 1% of energy, and cholesterol to less than 300 mg/day (Lichtenstein, Appel, Brands, et al, 2006). Research supports the fact that older persons can make and sustain lifestyle changes. Because of the increased risk of cardiovascular disease in older adults, even seemingly small improvements in risk factors (e.g., small reductions in blood pressure and LDL cholesterol level through diet and lifestyle changes) would be of great benefit. However, the AHA warns that because older individuals have decreased energy needs while their vitamin and mineral requirements remain constant or increase, they should be counseled to select nutrient-dense choices within each food group (Lichtenstein et al., 2006).
Smoking Smoking continues to be a major risk factor in the development of heart disease. Although a decline has been seen in the use of tobacco largely as a result of health promotion campaigns, clean air environments, and peer pressure, smoking continues to be a major risk factor for heart disease in the United States. Cigarette smoking doubles an individual’s risk of stroke, and smokers are two to four times more likely to develop CHD than nonsmokers (CDC, 2013a). Smoking increases platelet aggregation and causes coronary artery spasms. Nicotine increases blood pressure and cardiac demands. Carbon monoxide in tobacco smoke decreases the oxygen-carrying capacity of the blood. Smoking is a significant cardiac risk factor.
Smoking a few cigarettes a day greatly increases cardiac risk. Smoking cessation decreases the risk of MI. After 10 years of abstinence, an individual’s risk is the same as that of a nonsmoker. Smoking cessation should be encouraged at every encounter. The
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Agency for Health Care Policy and Research has established recommendations for smoking cessation (see Chapter 22 for smoking cessation information).
Physical Activity A sedentary lifestyle is another modifiable cardiac risk factor. The AHA recommends 30 minutes of moderate-intensity exercise four or five times a week (Lichtenstein et al., 2006). Health care professionals should encourage patients to exercise and promote ways to increase activity with daily routines such as parking the car a little farther from the store, using the stairs to go up or down one floor, or walking to places that are close enough. It is recommended that anyone beginning an exercise program should first consult a physician for guidelines.
Older adults should begin an exercise program with a 10-to 15- minute warm-up to achieve 75% of their maximum heart rate safely. Too many people want to progress too quickly, which increases their chance for injuries. Walking is the best aerobic exercise for older adults. They may set their own pace, decide the location, and avoid injuries. When beginning an exercise program, older adults should start with 5 to 10 minutes two or three times a week and gradually increase to the recommended 30 minutes four or five times a week (Lichtenstein et al., 2006).
Obesity Obesity is another modifiable cardiac risk factor. Obesity is usually associated with a sedentary lifestyle and a high-fat diet, which add to the individual’s cardiac risk profile. A healthy body weight is currently defined as a body mass index (BMI) of 18.5 to 24.9 kilograms per square meter (kg/m2). Overweight is a BMI between 25 and 29.9 kg/m2, and obesity is BMI 30 kg/m2 or greater. Currently, about one third of adults are overweight, and an additional one third are obese (Lichtenstein et al., 2006; Roberts & Barnard, 2005). The National Health and Nutrition Examination Survey (NHANES) III data show that more than 65 million Americans have a BMI of more than 25 (NHANES III, 2006). Excess body weight increases cardiovascular risk factors (e.g., by
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increasing LDL, blood pressure, and blood glucose levels and by reducing HDL levels).
Diabetes Hyperglycemia is related to the incidence of cardiovascular heart disease, stroke, peripheral vascular disease, cardiomyopathy, and heart failure (Lichtenstein et al., 2006). Individuals with diabetes mellitus were two to four times more likely to die of cardiovascular causes, and the presence of diabetes is associated with an increased prevalence of hypertension and dyslipidemia (Eckel, Kahn, Robertson, & Rizza, 2006). Silent MI is more common in individuals with diabetes mellitus and in older adults. Thus, older adults with diabetes should be monitored closely for other symptoms of CVD.
Stress At one time, stress was thought to be associated with the type A behavior of the goal- and task-oriented high achiever. This belief is now being modified, and researchers are examining the individual’s adaptation to stress from other perspectives, for example, anger control and the support of family, friends, and significant others, and the means by which individuals cope with stress.
Stress can be decreased in many ways, and much literature is available on the topic. Yoga, meditation, relaxation tapes, visualization, and physical activity are a few of the methods used. It is imperative that research continue to examine the effects of stress on those age 65 or older and that nurses examine factors in the patient’s environment that are amenable to change. For example, an older patient may not be able to prepare meals because of physical limitations or safety reasons. Referral to a Meals on Wheels program or a community-based program in which individuals share meals is just one example of simple modification. Older individuals living in an apartment, sharing their meals, and dividing tasks of shopping, meal preparation, and clean-up are other popular concepts. This way, older patients can maintain balanced diets and enjoy the companionship of peers.
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Hormone Usage Before menopause, estrogen is believed to have a protective effect by helping to maintain adequate levels of HDL cholesterol and relaxing the smooth muscles of arteries, which helps maintain normal blood pressure. However, it is believed that these beneficial effects are lost after menopause, and this corresponds to the time when the rate of heart disease–related death for women begins to increase (National Institute of Nursing Research, 2006).
Hypertension Hypertension has been termed the silent killer because much of the population with high blood pressure is unaware of having this condition, despite the availability of advanced screening programs. The detection and treatment of hypertension have increased over the years. In spite of this, the incidence of complications of hypertension has not decreased. These complications include stroke, end-stage renal failure, and heart failure (CDC, 2013b).
Prevention of hypertension is a realistic goal, based on improving the average blood pressure in the general population. The tools available to accomplish this lifesaving goal are contained in a large body of evidence, which has increased greatly in the past two decades and implicates key aspects of modern lifestyle in the epidemic of hypertension. Adoption of a healthier lifestyle, starting in childhood and youth, may prevent and reverse abnormal blood pressure patterns.
Evidence-based practice Repetition in Patient Teaching Is Beneficial Sample/Setting Five hundred participants from a telemetry unit were randomly assigned to an intervention group (247 subjects) or a control group (253 subjects).
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Methods During the initial hospitalization, the control group was given the standard discharge instructions of medication information and a follow-up appointment without additional teaching. The intervention group was given the standard discharge instructions and viewed a video with written information and a copy of the patient’s latest electrocardiography (ECG) results. The patients were given instructions to place the information near their phone and to bring their ECG results to their next follow-up visit or emergency department visit.
Findings The researchers found no significant difference for the three outcome variables between the control and intervention groups. The three outcome variables were percentage of patients who came during the first hour from symptom onset, percentage of patients using emergency medical services, and the median time interval from symptom onset to emergency department arrival during the return visit.
Implications Patient teaching should be a continuous process, rather than a one-time event such as at the time of hospital discharge. Teaching should be reinforced at every opportunity. The goal of patient teaching should be to provide information and change behavior. From Blank, F.S. & Smithline, H.A. (2002). Evaluation of an educational video for cardiac patients. Clinical Nursing Research, 11(4), 403.
Hypertension is the most prevalent CVD in the United States today. Blood pressure and pulse pressure increase progressively with age. According to Framingham data, adults at age 55 with normal blood pressures have an estimated 90% lifetime risk for developing hypertension (JNC 7, 2003; Vasan, 2002). Blood pressure screening must be done during every health care encounter with an older adult to detect hypertension and prevent its complications.
Hypertension stage 1 is classified as an SBP of 140 to 159 mm Hg and a DBP of 90 to 99 mm Hg; it indicates the necessity for taking
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antihypertensive medications. The diagnosis is made after at least two subsequent visits after the initial visit. Blood pressure is measured with the patient in the supine or sitting position and then in the standing position (except for those patients whose SBP is greater than 210 mm Hg and DBP is greater than 120 mm Hg; these individuals are deemed to have high blood pressure after one visit). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provides new guidelines for hypertension prevention and management. These findings are summarized below (JNC 7, 2003).
• In persons older than 50 years, SBP greater than 140 mm Hg is a much more important CVD risk factor than DBP.
• The risk of CVD beginning at 115/75 mm Hg doubles with each increment of 20/10 mm Hg.
• Individuals with an SBP of 120 to 139 mm Hg or a DBP of 80 to 89 mm Hg should be considered prehypertensive and require health-promoting lifestyle modifications to prevent CVD.
• Thiazide-type diuretics should be the drugs used for treatment in most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (e.g., angiotensin-converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], beta-blockers [BBs], and calcium channel blockers [CCBs]).
• Most patients with hypertension will require two or more antihypertensive medications to achieve their goal blood pressure (< 140/90 mm Hg or < 130/80 mm Hg for patients with diabetes or chronic kidney disease).
• If blood pressure is greater than 20/10 mm Hg above the goal blood pressure, consideration should be given to initiating therapy with two agents, one of which usually should be a thiazide-type diuretic.
ISH is more common in older adults, as SBP rises disproportionately to DBP because of increased arterial stiffness and rigidity. In the past, it was argued that hypertension was a
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normal process of aging and did not require therapy. However, data from the Framingham Heart Study confirm that cardiovascular risk escalates dramatically in older adults. The addition of risk factors such as smoking, glucose intolerance, hypercholesterolemia, and left ventricular hypertrophy significantly elevates risk.
The phenomenon of pseudohypertension, that is, falsely elevated blood pressure, is found in the older adult population. Pseudohypertension is a result of the calcification and thickening of the arterial wall. Rigidity in the brachial artery leads to ineffective compression of the brachial artery with a sphygmomanometer. Pseudohypertension may be suspected without evidence of target organ damage despite elevated blood pressure readings or if hypotensive symptoms develop with therapy while blood pressure readings remain high. The Osler maneuver is a screening test for pseudohypertension. It involves palpating the brachial or radial artery after inflating the sphygmomanometer above the systolic pressure. A positive Osler test reveals a palpable pulse (Lookinland & Beckstrand, 2003).
Hypertension has been classified into two types: primary and secondary. Primary hypertension is the most common form. Although the exact cause is unknown, the contributing factors are family history, age, race, diet (e.g., foods high in saturated fats and salt or decreased potassium, magnesium, and calcium intake), smoking, stress, alcohol and drug consumption, lack of physical activity, and hormonal intake.
Secondary hypertension refers to elevated blood pressure caused by underlying disease such as renal artery disease, renal parenchymal disorders, endocrine and metabolic disorders, central nervous system (CNS) disorders, coarctation of the aorta, and increased intravascular volume.
All prescription and over-the-counter (OTC) medications need to be assessed for possible causes of elevated blood pressure. Drug- induced hypertension has occurred with the administration of amphetamines and glucocorticoids. Decongestants, phenobarbital, rifampin, and nonsteroidal antiinflammatory drugs (NSAIDs) may adversely affect the action of some medications for hypertension. NSAIDs have been found to cause elevated blood pressure in
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normotensive older adults (Tucker, 2003). Many older adults are taking NSAIDs for various musculoskeletal problems. These individuals should have their blood pressure closely monitored.
A positive correlation exists between obesity and high blood pressure. Advancing age is associated with a loss of lean body mass and an increase in adipose tissue. Excess fat in the upper body or a waist circumference of 35 inches or greater in women or 40 inches or greater in men increases the risk for hypertension. Metabolic syndrome includes abdominal obesity, glucose intolerance, high triglyceride levels, and low HDL levels. A 10% reduction of total weight will decrease blood pressure in many overweight individuals. This factor has significance because it underscores the importance of weight reduction in the older adult population (JNC 7, 2003).
Research data have correlated increased sodium intake and high blood pressure. It has been shown that a reduction in sodium to 100 millimoles per day (mmol/day) may reduce SBP by 2 to 8 mm Hg. The Dietary Approach to Stop Hypertension (DASH) diet may reduce SBP by 8 to 14 mm Hg. These results were higher in older adults and those with increased blood pressure (JNC 7, 2003).
The pathophysiology of hypertension is complex because various environmental, structural, renal, hormonal, and homeostatic mechanisms contribute to blood pressure maintenance, especially in the aging population. A detailed description of the mechanisms involved is outside the scope of this text.
Hypertension has been associated with arteriolar thickening, vascular smooth muscle constriction, and elevated vascular resistance. With age, peripheral vascular resistance increases significantly. It is also possible that functional alterations in the vascular smooth muscle contribute to these changes. The alpha- adrenergic responsiveness of the vascular smooth muscle does not change with age; however, the beta-adrenergic responsiveness declines with age with a consequent decrease in the relaxation of the vascular smooth muscle. Renal vascular resistance appears to be increased and renal blood flow appears to be decreased. Left ventricular hypertrophy occurs as an adaptation to longstanding hypertension and may lead to CHF. Once this occurs, there is a
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significant increase in cardiovascular risk, particularly for ventricular arrhythmia and sudden death.
In mild to moderate hypertension, the patient may be asymptomatic. As the disease progresses, the patient may experience fatigue, dizziness, headaches, vertigo, and palpitations. In severe hypertension, the patient may experience throbbing occipital headaches, confusion, visual loss, focal deficits, epistaxis, and coma.
It is imperative that the practitioner assess for other target organ damage and symptoms. Hypertension may lead to damage in various organs, resulting in the following conditions:
• Heart: CHF, ventricular hypertrophy, angina, MI, sudden death
• CNS: transient ischemic attack, stroke
• Peripheral vessels: PVD, aneurysm
• Kidney: serum creatinine greater than 133 mmol/L (1.5 mg/dL), proteinuria, microalbuminuria
• Eye: hemorrhage or exudates, with or without papilledema The diagnostic tests and procedures search for secondary causes of hypertension and assess for end-target organ damage. In assessments for comorbidity, older adults are likely to have coexisting cardiac, vascular, and renal disease.
The health care provider should obtain a history regarding lifestyle factors and should conduct an in-depth physical examination. The following tests should be included: hemoglobin and hematocrit to exclude anemia or polycythemia; urinalysis to investigate for proteinuria or other signs of renal failure; serum sodium, potassium, and creatinine levels; fasting plasma glucose level to determine whether antihypertensive therapy may be affecting diabetes mellitus, a cardiac risk factor; serum total cholesterol and HDL levels to assess for hyperlipidemia; electrocardiography (ECG); chest radiography; and possibly, echocardiography to assess left ventricular function and hypertrophy.
The physical examination should include examination of the neck
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(to detect carotid bruits, jugular vein distention, or an enlarged thyroid), the heart (to detect abnormalities in rate and rhythm, heaves, lifts, murmurs, and third or fourth heart sounds), the lungs (to detect rales), the abdomen (to detect bruits, masses, and aortic pulsations), and the extremities (to detect peripheral pulses and edema).
Pharmacologic Treatment One of the most important considerations in drug therapy in older adults is that blood pressure should be lowered gradually, beginning with low doses of a single agent. The various steps involved in the treatment of blood pressure are as follows:
1. Both nonpharmacologic interventions and lifestyle modifications should be employed. Older adults respond to modest sodium reduction and weight loss.
2. Select an appropriate agent with consideration for comorbidity. On the basis of clinical trials, the use of diuretics and beta-blockers are first-line medications.
3. Increase the dose of the first drug, then add a second drug of a different class or substitute a drug from another class.
4. Continue adding agents from other classes. Consider referral to a hypertension specialist.
The general principles for managing high blood pressure in older patients include the following:
• The goal of treatment is a blood pressure less than 120/80 mm Hg. For those with significant systolic hypertension, an interim goal of less than 160/90 mm Hg may be necessary. The results of the Hypertensive Optimal Treatment Study were released after the JNC’s Seventh Report on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7, 2003).
• ISH (SBP over 160 mm Hg and DBP of 85 to 90 mm Hg) should be treated.
• Older adults are more likely to experience an orthostatic drop in blood pressure than younger adults. Blood pressure should
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always be taken with the patient both sitting and standing.
• When pharmacologic therapy is used, the initial daily dose should be half that recommended for middle-aged adults.
• Thiazide diuretics or beta-blockers in combination with a thiazide (e.g., atenolol [Tenormin] with hydrochlorothiazide) are recommended because they decrease morbidity and mortality.
• Diuretics are the preferred treatment for ISH.
• The choice of an alternative first- or second-step drug should be based on the patient’s individual characteristics.
• After blood pressure has been controlled for 1 year, the dosage of the drug should be stepped down, if possible.
The use of antihypertensive drugs has been shown to be effective and well tolerated in older adults. The prescription is “to proceed slowly and with caution” and to monitor for adverse reactions. If this principle is adhered to, side effects will be minimal in older adults. Table 21-1 provides the classifications of antihypertensive drugs, their adverse effects, and the nursing implications.
Table 21-1 Classification of antihypertensive drugs, adverse effects, and nursing implications
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Adapted from Joint National Committee. (2003). The seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. <http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm> Accessed April 2014; and Tierney, L.M., McPhee, S.J., & Papadakis, M.A. (2004). Current medical diagnosis and treatment (43rd ed.). New York: McGraw-Hill. ACEIs, Angiotensin-converting enzyme inhibitors; BUN, blood urea nitrogen; CVD, cardiovascular disease; ETOH, ethanol; GI, gastrointestinal; HDL, high-density lipoprotein; K, potassium; LDL, low-density lipoprotein; MI, myocardial infarction; NSAIDs, nonsteroidal antiinflammatory drugs.
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Diuretics The thiazide diuretics hydrochlorothiazide and chlorthalidone continue to be the most commonly prescribed antihypertensive agents for older adults. The initial dosage should be 12.5 to 25 mg/day. Loop diuretics such as furosemide are not used unless the patient has renal impairment or CHF.
The primary concern related to diuretic therapy is hypotension or hypokalemia. Patients should be carefully monitored for hypokalemia. If hypokalemia becomes difficult to manage, an alternative antihypertensive agent is indicated. Hypomagnesemia, hyperglycemia, and increased uric acid may also occur. Increases in blood glucose are generally minor with low doses of a thiazide diuretic.
Beta-Blockers Beta-blockers are effective in lowering morbidity and mortality in older adults. Beta-adrenergic blockage decreases heart rate and contractility. This decreases cardiac output and is cardioprotective. Atenolol and metoprolol are beta-blockers that are cardioselective. They may be better tolerated in older adults with lung disease or PVD.
Angiotensin-Converting Enzyme Inhibitors ACEIs inhibit the converting enzyme that is responsible for the formation of angiotensin II, a potent vasoconstrictor that stimulates the release of aldosterone. These drugs decrease mortality in older adults with decreased left ventricular function and preserve renal function in those with diabetes mellitus. Side effects of these drugs include rash, cough, taste disturbance, neutropenia, and proteinuria. ACEIs should not be used if acute renal failure or bilateral renal artery stenosis is suspected.
Calcium Channel Blockers CCBs inhibit the inward movement of calcium across the cell membrane of the vascular smooth muscle, which results in vasodilatation of peripheral, coronary, and renal arteries. They may
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cause orthostatic hypotension in older adults. These drugs typically have vasodilator effects such as headache, flushing, dizziness, and weakness. Constipation may also occur. CCBs are useful agents in the treatment of older adults and may be used when diuretics are not tolerated or are contraindicated.
Prognosis Hypertension, if unrecognized and untreated, significantly increases the risk of coronary disease, heart and renal failure, and stroke. Risk increases with smoking, glucose intolerance, hyperlipidemia, left ventricular hypertrophy, male gender, black race, and increasing age. With an individual pharmacologic and nonpharmacologic treatment program based on assessment of total cardiovascular risk, the risk of cardiovascular-related death from stroke and heart attack may be reduced. The degree of end-organ damage affects overall morbidity and mortality (JNC 7, 2003).
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Nursing management Assessment
The majority of patients with hypertension are asymptomatic. Symptoms that do occur are variable, depending on the progression of disease in target organs. Vague discomfort, fatigue, headache, epistaxis, and dizziness may be early indicators. Severe hypertension may result in a throbbing occipital headache— particularly prevalent in the morning but disappearing several hours later—as well as confusion, vision loss, focal deficits, and coma. Symptoms of heart failure such as dyspnea may be present. If the kidneys are affected, hematuria or nocturia may occur.
Objective data are obtained from a thorough assessment of blood pressure on three separate occasions. Blood pressure readings should be recorded with the patient in both the sitting and standing positions. The patient’s arms should be bared and supported at heart level. The nurse should instruct the patient not to ingest caffeine or smoke for 30 minutes before the blood pressure reading. The proper cuff size must be used. The bladder of the cuff should surround a minimum of 80% of the arm. Many older individuals will require a large cuff. If these steps are not taken, blood pressure readings may be inaccurate.
Diagnosis Nursing diagnoses for an older adult patient with hypertension include the following:
• Deficient Knowledge, related to new diagnosis of hypertension, self-care management, and interventions
• Ineffective Coping, related to perceived limitations of diagnosis
• Ineffective Family Therapeutic Regimen Management, related to lack of knowledge of diagnosis
• Imbalanced Nutrition: More Than Body Requirements, related to
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high fat, caloric, and sodium intake
Planning and Expected Outcomes Expected outcomes for an older patient with hypertension include the following:
1. The patient will identify personal risk factors.
2. The patient will explain the disease process and its effects on health and well-being.
3. The patient will incorporate nonpharmacologic treatment measures into daily living.
4. The patient will verbalize purpose, dose, action, and significant and reportable side effects of medications prescribed for hypertension.
5. The patient will increase social interaction, as evidenced by participation with others in activities outside the home two or three times a week.
6. The patient will eat a low-fat, low-cholesterol, and reduced- calorie diet, as evidenced by weight loss of 1 to 2 pounds (lb) a week.
Intervention Knowledge levels vary among patients with hypertension. The teaching plan should incorporate an explanation of the disease process and therapeutic (nonpharmacologic and pharmacologic) interventions. An explanation of the physical examination and appropriate tests should be given to allay anxiety. Anxiety, depression, denial, and fear are often involved in a chronic condition. Although these emotions diminish as the condition is controlled, the patient’s ability to absorb this information and make the required changes is initially hampered because the patient may still be in denial. For older adults, participation in community- based programs by the AHA or other agencies may be beneficial. It is crucial that any interventions take into account the physiologic
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changes of aging, for example, by using large print and making sure that printed material is appropriate for the patient’s culture and educational level.
Patient education includes providing information regarding the disease process; signs and symptoms of hypertension; treatment regimen; medications and their actions and side effects, including sexual dysfunction; and the need for frequent monitoring of blood pressure and risk factors. The nurse should explain the importance of a low-sodium, high-potassium, low-fat, reduced-calorie diet. Weight loss should be encouraged, if indicated. A dietitian may assist with meal planning, preparation, and label reading. Foods are healthier if prepared by baking, broiling, or steaming. The nurse should also discuss the importance of alcohol restriction and smoking cessation; explain the relationship between stress, anxiety, anger, and hypertension; identify stressful situations at the patient’s home and work; and teach meditation and relaxation techniques. Exercise is beneficial for weight and stress reduction. Initially, the patient should walk 10 to 15 minutes a day, gradually increasing to 1-hour walks three or four times a week. Other activities include mall-walking and water aerobics. Encourage the patient to reduce or eliminate smoking through a smoking cessation program. Therapeutic medications and aids are available. Other alternatives for smoking cessation include hypnotism or behavior modification. Positive reinforcement should be provided, whenever possible.
Evaluation Evaluation consists of determining the patient’s achievement of the expected outcomes. The patient’s blood pressure should decrease and return to optimal levels. The patient should be able to maintain the treatment plan without side effects or complications. Outcome measures related to quality of life are also important because of the chronic nature of hypertension. The nurse must determine the patient’s perception of any change in quality of life resulting from the prescribed therapeutic regimen. Documentation includes accurate records of blood pressure, weight, exercise, and activity patterns; 24-hour dietary intake; cholesterol levels; and any blood
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pressure monitoring results outside the clinical encounter.
Coronary Artery Disease CAD, or ischemic heart disease, refers to a broad group of conditions that partially or completely obstruct blood flow to the heart muscle. Obstruction of coronary arteries may result in ischemia (an imbalance between the oxygen supply and demands of the heart) or infarction (death or necrosis) of the myocardium. Ischemia and infarction occur when the oxygen supply is unable to meet the demands of the heart. Atherosclerosis is the usual cause of CAD; angina, MI, and sudden death may be the final outcomes.
Atherosclerosis usually begins in childhood and is characterized by a local accumulation of lipid and fibrous tissue along the intimal layer of the artery. Lipids accumulate and infiltrate the area, forming a raised fibrous plaque over the site. Eventually, the plaque becomes calcified, which causes the vessel to lose its elasticity and dilatory qualities. Progressive narrowing of the artery occurs, resulting in compromised blood flow to the area of myocardium supplied by that vessel. In advanced stages of the disease, hemorrhage into the atheromatous plaque, thrombus formation, embolization of a thrombus or plaque fragment, and coronary arterial spasm may cause additional insult to the body. Although the development of atherosclerosis appears to be a normal process of aging, the severity of this process may be accelerated with the adverse lifestyle behaviors of smoking, physical inactivity, and obesity, as well as elevated serum cholesterol levels, hypertension, and diabetes mellitus. Promoting healthy lifestyles in younger and older individuals is an important aspect of care in the prevention of CAD. The adoption of healthier lifestyles by an older adult may be difficult because of long-term habits; however, healthy behavior changes may slow or halt the progression of the disease.
CAD is the major cause of morbidity, disability, and mortality in the older adult population. Coronary alterations are more likely to create a “cardiac cripple” in the older adult than other disease processes (Touhy & Jett, 2012).
Angina is caused by inadequate blood flow to the myocardium.
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The classic symptom is chest pain during activity that is relieved with rest or nitroglycerin. MI is caused by total disruption of blood flow to the myocardium; it is characterized by more severe, more intense chest pain for a longer time than that associated with angina. Other symptoms that may accompany MI include nausea, diaphoresis, shortness of breath, dizziness, and weakness.
An older adult may not exhibit CAD and its sequelae in a similar manner as younger adults. Often, an older adult does not have the typical chest pain. Diminished activity level, compared with that of younger adults, is one reason for this. Neuropathies and changes in pain recognition in older adults also limit the use of chest pain as a diagnostic sign for older adults (Banasik, 2013a). However, other symptoms may occur as the initial symptoms in older adults (Box 21-2). Women, especially older women, may not exhibit the classic signs of CAD, and the nurse needs to be aware of this to adequately assess female patients (Blach, 2006; National Institute of Nursing Research, 2006).
Box 21-2
Symptoms associated with atypical presentation of coronary artery disease in older adults Shortness of breath
Fatigue
Syncope
Confusion
Abdominal or back pain
Because symptoms of angina or MI may be vague and atypical of textbook symptoms, older adults may not recognize their seriousness and may not seek medical attention as soon as they
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should. Their families may not think the symptoms are as serious as they are. This may cause a delay in seeking medical attention. Unrecognized MI may cause cardiac damage and precipitate complications of heart failure and pulmonary edema (National Institute of Nursing Research, 2006).
Diagnostic Tests and Procedures Diagnosis is based on patient history, alterations on the ECG, and serum cardiac enzyme levels.
• Serum cardiac enzymes of creatinine phosphokinase (CPK). Serum CPK values rise shortly after infarction as a result of myocardial damage, peak at 24 hours, and return to normal levels within 72 hours (Banasik, 2013a; Blach, 2006). Cardiac- specific isoenzymes confirm a diagnosis of MI.
• Cardiac troponin levels (a component of the myocardium). Levels rise when infarction causes cell membrane permeability changes. Cardiac troponin T increases 3 to 5 hours after MI and remains elevated for 14 to 21 days. Cardiac troponin I rises within 3 hours, peaks at 14 to 18 hours, and remains elevated for 5 to 7 days (Banasik, 2013a; Blach, 2006).
• ECG to obtain information on rate, rhythm, hypertrophy, and myocardial injury (ischemia or infarction); and to assess for Q waves, ST segment elevation, ST segment depression, and T wave inversion.
• Complete blood cell count (CBC) to determine whether angina is caused by anemia.
• Serum electrolytes, particularly sodium, potassium, and calcium. Elevated or reduced levels of these electrolytes can lead to fluid imbalance, ventricular arrhythmias, or asystole.
• Chest radiography to determine overall size, shape, and position of the heart. In older adults, however, EKG may be superior in assessing cardiac chamber size and ventricular function.
• Myocardial imaging (using thallium), multiple-gated acquisition cardiac pool imaging, or digital subtraction angiography to evaluate myocardial perfusion or ventricular abnormalities.
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• Cardiac catheterization to detect the presence, location, and extent of lesions in coronary arteries.
• Exercise stress test to determine activity tolerance. Stress tests may be combined with myocardial imaging to identify changes in myocardial perfusion during exercise. In the absence of an acute cardiac event such as MI, an exercise stress test may be troublesome for older adults with coexisting diseases such as arthritis, PVD, and chronic obstructive pulmonary disease (COPD). Pharmacologic stress tests may be a better choice in these older individuals (Akinpelu & Gonzalez, 2008; Crowder, 2009).
• Holter monitor or EKG may be used in older adults who may not tolerate test completion because of debilitating conditions such as musculoskeletal or CNS impairments.
Pharmacologic Treatment Treatment is directed toward restoring the balance between myocardial oxygen demand and oxygen supply for the prevention of CAD. Pharmacologic agents play a major role. Normal changes with aging (e.g., alterations in body mass, water composition, liver size, renal system, and plasma protein concentration) tend to increase the concentration and prolong the excretion of standard drug doses, so smaller doses are generally prescribed for older adults.
Nitrates Nitrates are used for the prevention and termination of anginal attacks and for reducing the pain associated with myocardial ischemia. These agents decrease the preloading and afterloading of the circulatory system, which reduces the myocardial demand for oxygen because of the vasodilating effects on coronary arteries and peripheral vessels. Intravenous, sublingual, and aerosol preparations have a rapid onset of action (1 to 3 minutes) and are used to prevent or terminate an anginal attack. Daily doses of oral or dermal preparations have a prolonged and continual onset of action and are used to prevent anginal attacks; however, tolerance
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to these preparations reduces drug effectiveness, and periods of discontinuation are recommended. Headache, flushing, dizziness, hypotension, syncope, and tachycardia are side effects attributed to the vasodilating effects. Nitrates are effective in older adults; however, aggressive therapy to reduce the preloading and afterloading may trigger reflex tachycardia and severe orthostatic hypotension. Older adults should take rapid-acting nitrates in the sitting position or supine to prevent falls and should sit up slowly with assistance. Older adults with predictable angina (i.e., with a specific activity) may take sublingual nitroglycerin before the activity to increase exercise capacity (Deaton, Bennet, & Riegel, 2004).
Beta-Blockers BBs are used to prevent attacks in patients with stable angina or to reduce the size of infarction and complications of MI. Reduced heart rate, stroke volume, and contractility and decreased myocardial requirements are attributable to decreased sympathetic nervous stimulation through blockage of the beta-adrenergic receptors in the heart. Side effects include bradycardia, hypotension, dyspnea, dizziness, syncope, gait difficulties, sexual dysfunction, CHF, heart block, bronchoconstriction, and depression. For patients with lung disease, metoprolol and atenolol are safer medications. Sudden cessation of therapy may induce myocardial ischemia. Older adults are more sensitive to decreased heart rate. This may decrease exercise performance and cause syncope. Older persons are underrepresented in clinical trials with BBs, so it is recommended that they are started at a low dose and gradually increase (Deaton et al., 2004).
Calcium Channel Blockers CCBs are used to treat stable and variant angina and to increase coronary perfusion, reduce blood pressure, and decrease myocardial contractility in individuals with MI. These drugs decrease the myocardial oxygen demand and increase coronary perfusion by blocking the entry of calcium ions into vascular muscle cells. Adverse reactions are bradycardia, hypotension,
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flushing, dizziness, syncope, headaches, dyspnea, palpitations, and peripheral edema. Verapamil and diltiazem are not recommended for older adults because they decrease the heart rate and increase the incidence of heart block. Amlodipine (Norvasc) is recommended for older adults because of its once-daily dosing schedule and its blood pressure–lowering properties and because it is safe to use in heart failure, whereas other nonvasoselective CCBs are contraindicated in systolic heart failure (Deaton et al., 2004; Hunt, 2005).
Fibrinolytics, Anticoagulants, and Antiplatelets These agents are used to prevent, reduce, and dissolve thrombi around atherosclerotic plaques by altering blood-clotting mechanisms. Fibrinolytic or thrombolytic agents are given intravenously within 6 hours of the onset of symptoms. Patients must be observed for arrhythmia, allergic reactions, and bleeding. Older adults have an increased risk for bleeding with fibrinolytics. Heparin followed by oral anticoagulation should be administered after cessation of fibrinolytic therapy to prevent secondary clot formation.
Heparin and warfarin (Coumadin) are anticoagulants used to prevent the enlargement of existing thrombi and new clot formation after MI. Therapeutic effects of heparin are monitored by partial thromboplastin times (PTTs); the antidote is protamine sulfate. Warfarin is monitored by the international normalized ratio (INR); the antidote is vitamin K. Patients who initially receive heparin for anticoagulation and who need oral anticoagulation for maintenance usually take both forms of medication for 3 to 5 days to develop therapeutic blood levels. Bleeding is a complication. Patients need to be taught bleeding precautions.
Studies have shown that aspirin decreases the mortality rate of acute MI. It inhibits platelet aggregation and facilitates fibrinolysis. Its effects on platelets occur within 20 minutes of administration. A number of aspirin preparations are available, but patients in the United States are typically prescribed either 81 mg/day or 325 mg/day to prevent cardiovascular disease (Campbell, Smyth, Montalscot, & Steinhubl, 2007).
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Antihyperlipidemics Antihyperlipidemics are used to lower serum lipid levels by preventing absorption of cholesterol and promoting its secretion. A common side effect is gastrointestinal upset. Older adults are prone to constipation. These agents are given to prevent CAD and should be prescribed if dietary and activity measures are ineffective. Older adults may benefit from cholesterol-lowering treatment.
Nonpharmacologic Treatment Older adults with risk factors of inactivity, obesity, and smoking should be encouraged to eliminate or reduce these factors and to control the comorbid conditions of diabetes mellitus and hypertension. Elimination of these factors has the potential to reduce the progression of CAD by half.
Percutaneous Transluminal Coronary Angioplasty (PTCA) PTCA involves the insertion of a specially designed balloon-tipped catheter under fluoroscopy through advancement from the femoral or brachial artery. When situated over the stenotic or occluded area, the balloon is inflated to compress the obstructing plaque, resulting in a larger vessel lumen and improved blood flow to the myocardium.
Stents A stent is made of stainless steel. It is placed in the obstructed artery after PTCA is performed. This keeps the vessel open and maintains blood flow through the artery.
Coronary Artery Bypass Graft (CABG) CABG is a surgical procedure that grafts portions of the saphenous vein or internal mammary artery to sites above and below the obstructed coronary artery to bypass the stenotic vessel and supply blood to the ischemic myocardium.
Prognosis
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Age-related physiologic changes, long duration of adverse lifestyle behaviors, and the presence of other conditions in older adults may complicate the progress and treatment of CAD; however, advances in the medical and surgical treatment of CAD and the adoption of healthier lifestyles have the potential to influence the course and outcome of this disease in older adults.
CAD is the leading cause of death and disability in women older than 40 years. It is estimated that every minute in the United States a women dies of heart disease (Holcomb, 2004). Women have smaller coronary arteries that occlude more easily. Women have a lower hematocrit and blood volume, which decreases the oxygen- carrying capacity of the blood. Women also have a higher heart rate at rest, higher stroke volume at rest, and lower left ventricular end- diastolic pressure compared with men. These findings contribute to a higher incidence of false-positive stress tests. Women experience more epigastric pain and shortness of breath than typical chest pain.
Differences in treatment between women and men with CAD include the following: Women experience a longer interval between emergency department admission and performance of EKG. Women are less likely to be admitted to an intensive care unit (ICU). Women are less likely to receive thrombolytic therapy. Women have a higher incidence of total occlusion after PTCA. Women have an increased incidence of CABG after PTCA. Women experience more recurrent angina, heart failure, recurrent infarction, and strokes after MI. Women are referred less often for cardiac rehabilitation. Women have poorer attendance at cardiac rehabilitation if they are referred. Women typically are 10 years older than men when diagnosed with cardiac disease and experience worse outcomes than men (Tecce, Dasgupta, & Doherty, 2003).
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Nursing management Assessment
Assessment of an older adult with CAD begins with a complete health history and physical examination. Complaints of dyspnea, fatigue, syncope, vertigo, and confusion warrant further investigation. Subjective data may have to be collected when vital signs are stable and discomfort is relieved (Box 21-3).
Box 21-3
Assessment of patients with chest pain Subjective Data Chest pain (location, intensity, radiation, onset, and duration)
Precipitating factors (activity, emotions, rest, hot or cold exposure, and eating)
Associated symptoms (diaphoresis, dyspnea, vomiting, weakness, palpitations, and indigestion)
Relieving symptoms (rest and nitrates)
Prior hospitalization (for angina, MI, and other disorders)
Medications
Family history (parents or siblings with CAD onset before age 50)
Modifiable cardiac risk factors (smoking, high cholesterol level, hypertension, diabetes mellitus, obesity, and physical inactivity)
Psychosocial state (denial, anxiety, fear, or anger)
Activity levels
Support systems
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Objective Data Behaviors (nervous, lethargic, rubbing chest, or grimacing)
Changes in vital signs
Changes in cardiac rhythm
Associated symptoms (diaphoresis, pallor, or cold and clammy skin)
Peripheral pulses (radial, femoral, and pedal)
Heart sounds and murmurs
Respiratory rate and breath sounds
Jugular vein distention
Diagnostic test results (cardiac enzymes, ECG, chest radiography, CBC, and electrolyte levels)
CAD, Coronary artery disease; CBC, complete blood cell count; ECG, electrocardiogram; MI, myocardial infarction.
Specific health questions during the assessment (e.g., “Are you able to shop for groceries?”) may elicit more detailed responses than open-ended questions (e.g., “Do you have any difficulties with activities at home?”). When gathering objective data on older adults, the nurse should remember that slower heart rates, irregular heart rhythms, the presence of a third or fourth heart sound, systolic ejection murmurs, higher SBPs, and wider pulse pressures may be a result of the normal aging process, not the current ischemic episode (Ball et al., 2014).
Diagnosis Nursing diagnoses common for an older patient with CAD include the following:
• Pain, related to an imbalance between oxygen need and supply
• Decreased cardiac output, related to decreased pumping ability of the heart
• Activity Intolerance, related to decreased cardiac output
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• Deficient Knowledge, related to new diagnosis of CAD and treatment plan
• Anxiety, related to fear of death
Planning and Expected Outcomes As with all patients, older adults with CAD should be included in the planning of care. Family should also be included in the planning process; however, older adults should be consulted to determine the extent of the family involvement. Discharge planning should begin on admission to the hospital, and special attention should be given to the necessary support services in the home.
Expected outcomes for an older patient with CAD include the following:
1. The patient will verbalize pain relief, as evidenced by reduction in anginal episodes.
2. The patient will maintain adequate circulation, as evidenced by stable vital signs, mental alertness, urine output greater than 30 milliliters per hour (mL/hr), no ECG changes, and clear breath sounds.
3. The patient will tolerate activity, as evidenced by stable vital signs and no chest pain or dyspnea.
4. The patient will explain the disease process and therapeutic plan, including causes and risk factors for CAD; precipitating and alleviating factors for angina; and names, dosages, actions, and side effects of medications.
5. The patient will describe actions to take in the event of chest pain.
6. The patient will express fears and have reduced anxiety.
Intervention Interventions for an older adult with CAD focus on relieving pain, improving myocardial blood flow, decreasing myocardial workload, and educating the patient.
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Cardiovascular, respiratory, renal, and neurologic assessments should be conducted on a regular basis to detect progress and prevent complications. Diagnostic testing, especially of potassium levels because older patients are prone to hyperkalemia, should be conducted and evaluated daily, and any adverse changes in patient status should be reported to the physician.
Older adults and their family members may express concern about emergency measures such as resuscitation or life support. The nurse should be sensitive to these needs and initiate discussion with the patient, family, and physician to establish a plan of action.
Older adults should be encouraged to participate in cardiac rehabilitation programs to restore their physical and mental health to the highest level of function. Cardiac rehabilitation promotes restoration, diminishes the effects of disease, and encourages optimal physical, psychological, and social functioning. Cardiac rehabilitation consists of three phases. Phase 1 begins in the hospital and includes early ambulation and patient and family education. Phase 2 lasts about 12 weeks and takes place in a supervised outpatient setting. Phase 3 is a maintenance phase that lasts indefinitely; it includes counseling, exercise, education, and socialization.
Exercise should be gradually increased during recovery. Older adults should be taught to monitor their pulse rate to evaluate tolerance to activity. Walking, with a progressive increase in duration and frequency, is recommended. Heavy lifting should be avoided. Activities should be paced throughout the day. Older adults may benefit from a written plan of progressive activities. Properly designed exercise programs for older adults incorporate longer times for the return to a resting heart rate after exercise. Orthostatic hypotension is more common in the older population because of decreased baroreceptor sensitivity. Thermoregulation is impaired; thus, exercise must be reduced in hot and humid environments. A heart rate of 50% to 70% of the maximum heart rate achieved at exercise testing with no discomfort during exercise is recommended (Touhy & Jett, 2012).
Activities that are encouraged should be those that build endurance and self-reliance to increase the level of self-care and
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quality of life. Activities that may be suggested include walking, swimming, water aerobics, bowling, and dancing. Older adults with unstable angina should not exercise. Those who require cardiac monitoring during rehabilitation include those who have an ejection fraction of less than 39%, a resting complex ventricular arrhythmia, or decreased blood pressure during exercise. They also include those who escape sudden death, survivors of MI (complicated by heart failure or shock), and those who demonstrate inability to self-monitor their heart rates because of physical or intellectual impairment.
In spite of the documented benefits of cardiac rehabilitation programs, compliance with them remains low. About 50% of patients drop out before completing the program. Reasons for this include other medical problems, lack of transportation, personal and financial factors, and conflicts with work schedules. Women have been documented as showing the poorest adherence to the program (Touhy & Jett, 2012). The interdisciplinary team should recognize these issues and make every effort to assist patients with these problems.
The resumption of sexual activity should be discussed with older adults. It is generally safe to resume sexual activity within 4 to 6 weeks of MI, as long as an older adult is symptom free during his or her usual daily activities. The equivalency or expenditure of energy for sexual activity correlates with the same energy expenditure required for climbing a flight of stairs or walking around the block. The pamphlet Sex and Heart Disease produced by the AHA may be used to supplement counseling (AHA, 2012).
Visiting nurse programs provide education, support, and supervised activities in the home environment if older patients are unable to attend outpatient services. Home care services are usually available to assist older patients with activities of daily living (ADLs). Both programs may require physician referral.
Local heart associations are excellent sources for learning materials and community programs on CAD. Some heart associations offer educational and support programs for patients recovering from CAD (e.g., Heart to Heart) or surgery (e.g., Mended Hearts), and they usually provide direction for community
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programs on risk factor reduction, cardiopulmonary resuscitation (CPR), and mall-walking.
Evaluation
Evaluation and documentation of the progress of an older patient with CAD focus on the achievement of goals outlined
Nursing care plan
Myocardial Infarction Clinical Situation Mrs. S is an 84-year-old widow who was admitted to the hospital from a nursing facility with complaints of fatigue, weakness, and vertigo. Staff at the nursing facility became concerned after two episodes of syncope. Mrs. S suffered a stroke 4 years ago that left her with severe weakness in her left arm and left leg. She was unable to care for herself at home; her daughter encouraged her to enter the nursing facility. She has been following a diet low in saturated fat and cholesterol and takes enteric-coated aspirin daily, as well as levothyroxine (Synthroid) for hypothyroidism. Mrs. S is mobile with the use of a walker.
Routine electrocardiography (ECG) showed pathologic Q waves. Cardiac enzymes were tested. Creatinine phosphokinase (CPK) levels were normal, but lactate dehydrogenase was elevated. She was diagnosed with an inferior myocardial infarction (MI). Because she did not meet the time criteria for fibrinolytic therapy, the physician instituted prophylactic measures with oral anticoagulants on a daily basis. Mrs. S developed occasional premature contractions and periodic bouts
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of atrial fibrillation. Digoxin and nitroglycerin were added to her regimen. She became agitated in the coronary care unit about being a burden to her family and declined invasive treatment procedures. The nurse organized a meeting with the physician, daughter, and patient to discuss her anxiety, and a “no resuscitation” order was written. Lorazepam 1 milligram (mg), as needed three times a day, was added to the protocol.
Currently, Mrs. S denies having chest pain and is able to walk short distances with her walker. She follows a low-cholesterol, low–saturated fat diet, and she is scheduled for echocardiography later in the week. Her blood pressure is in the low to normal range, and her pulse is irregular at 102 beats per minute (beats/min). Atenolol has been added to the regimen to reduce her heart rate.
Nursing diagnoses Anxiety, related to threat of death and change in health status
Risk for Decreased Cardiac Tissue Perfusion
Decreased Cardiac Output, related to electrical dysfunction
Activity Intolerance, related to imbalance of myocardial oxygen supply and demand and left peripheral limb weakness
Deficient Knowledge, related to lack of exposure to disease process and treatment plan
Outcomes The patient will verbalize reduced anxiety, as evidenced by a
slower heart rate, reduced apprehension, and participation in self-care.
The patient will obtain pain relief, as evidenced by verbal statements.
The patient will maintain adequate circulation, as evidence by stable vital signs, mental alertness, clear lung sounds, and urine output greater than 30 milliliters per hour (mL/hr).
The patient will tolerate activity, as evidenced by stable vital signs; absence of pain, weakness, fatigue, and vertigo; and
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participation in activity.
The patient will demonstrate knowledge of the disease process, symptoms of ischemia with appropriate responses, and the treatment plan, as evidenced by explanation of and participation in the plan.
The patient will demonstrate an accurate pulse-taking method.
Interventions Explain equipment, procedures, and unit routine.
Encourage verbalization of feelings.
Teach relaxation techniques and guided imagery to alleviate anxiety.
Supervise tolerance to visitation.
Offer lorazepam, as needed.
Encourage participation in care, and emphasize improvements in health status.
Encourage relaying of pain sensations to the nurse.
Explain how sensations of fatigue, weakness, and vertigo may be symptoms of ischemia and that these symptoms need to be reported to the nurse.
Encourage the patient to take nitroglycerin at the onset of chest pain or at sensations of ischemia.
Obtain vital signs during episodes, and contact the physician if the medication is ineffective.
Offer oxygen, if needed.
Monitor therapeutic effects of nitrates and atenolol, observing for hypotensive effects.
Measure blood pressure, apical pulse, and rhythm every 4 hours. Auscultate heart and lungs every 8 hours.
Monitor ECG for reversion to normal sinus rhythm, international normalized ratio (INR), and digoxin and electrolyte levels.
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Administer and evaluate the effects of warfarin, digoxin, and atenolol.
Observe for signs of hemorrhage, shock, heart failure, and emboli.
Assist with ADLs, as needed.
Remind the patient to perform leg exercises every hour and range-of-motion exercises. Apply antiembolic stockings.
Before the patient ambulates, encourage the patient to do leg exercises and sit at the bedside for 3 to 5 minutes before standing.
Gradually increase the distance and frequency of walking.
Monitor vital signs before and after activity.
Ensure that call bell and walker are within reach.
Encourage the patient to wear shoes with good support and to walk in lighted areas.
Balance activity with rest.
Teach the patient to count her own pulse.
Encourage the patient to recognize sensations of ischemia and cease activity when they occur.
Include the patient’s daughter in teaching sessions.
Describe the disease and healing process of MI using pictures, models, and large printed material.
• Describe the patient’s sensations of ischemia, and teach the appropriate use of nitrates and rest.
• Discuss and provide written information for medication dosage, purpose, side effects, and special precautions for warfarin, digoxin, and atenolol.
• Encourage a progressive increase in activity.
• Assess emotions and reassure the patient that depression is common.
• Teach the patient to take a radial pulse and to monitor it before, during, and after activity.
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in the planning process. Older adults should demonstrate adequate circulation, ability to perform ADLs, and control of symptoms. Documentation should focus on the older adult’s risk factor profile and progress, and measures should be aimed at reducing risks because a reduction of behaviors associated with the identified risks will reduce morbidity and mortality (see Nursing Care Plan: Myocardial Infarction).
Arrhythmia Arrhythmia is an abnormal heart rate or rhythm caused by a disturbance in automaticity, conductivity, or both. Arrhythmias can originate in the atria, ventricles, or atrioventricular junctions and may result in decreased cardiac output and impaired perfusion of coronary arteries.
Older adults may develop any type of arrhythmia; however, atrial fibrillation, sick sinus syndrome, and heart block occur more often in the older population because of fewer pacemaker cells and extensive deposits of fat and fibrous tissue throughout the conduction system. Further, older adults may have other conditions that weaken the heart muscle (e.g., hypertension or diabetes) and place them at risk for arrhythmias (National Heart, Lung, and Blood Institute, 2009), The incidence of atrial fibrillation increases with age and is the most common contributing factor for ischemic stroke in older adults. This is caused by an embolus from the heart that occludes a cerebral vessel. The 5-year incidence of stroke from atrial fibrillation is 44% in patients ages 60 to 70, 80% in patients ages 71 to 80, and 63% in patients age 81 to 90 (Frost, Anderson, Godtfredsen, & Mortensen, 2007). Atrial fibrillation is characterized by chaotic depolarization of 400 to 700 beats per minute (beats/min) within the atria and an irregular ventricular response. Older adults need increased diastolic filling pressures to compensate for structural changes within the heart and to maintain cardiac output, so chaotic or quivering depolarization within the atria diminishes this atrial kick needed for adequate ventricular filling (Ball et al, 2014).
Atrial fibrillation may occur during intense emotional stress,
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exercise, or alcohol intoxication. Chronic atrial fibrillation tends to occur in patients with hypertension, CAD, rheumatic heart disease, cardiac valve disease, CHF, pericarditis, COPD, and cardiomyopathy; it increases the risk for pulmonary, peripheral, and cerebral thromboembolism. Thyroid disorders may also precipitate atrial fibrillation (Frost et al., 2007).
Sick sinus syndrome is characterized by alternating episodes of bradycardia (less than 60 beats/min), normal sinus rhythm (60 to 100 beats/min), tachycardia (greater than 100 beats/min), and periods of long sinus pauses that fail to stimulate the atria or ventricles. Sick sinus syndrome tends to occur in patients with CAD, rheumatic heart disease, and hypertension.
Heart block is characterized by delayed or blocked impulses between the atria and ventricles and is classified as first-, second-, or third-degree heart block, each respective classification of which increases in severity. First-degree block is common in older adults with or without CAD and is a common complication of MI. Digitalis preparations may also cause first-degree heart block. Second- and third-degree blocks may be caused by degeneration within the conduction system, ischemia, enhanced vagal tone, electrolytes, and effects of drugs (e.g., digoxin and BBs).
Symptoms of arrhythmia are weakness, fatigue, forgetfulness, palpitations, dizziness, hypotension, bradycardia, and syncope, all of which predispose older patients to falls and injuries. Patients with first-degree block and fibrillation may have no symptoms, whereas patients with atrial fibrillation have an irregular pulse.
Diagnostic Tests and Procedures Arrhythmias are diagnosed on the basis of ECG evaluation. When an arrhythmia is diagnosed, a variety of tests may be performed to determine a causative factor. Continuous ECG monitoring provides the most efficient and reliable method of detection. A Holter monitor is also often used.
Treatment Treatment should be limited to symptomatic patients with
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significant arrhythmias.
Atrial Fibrillation The treatment of atrial fibrillation has two objectives: (1) to control the rate with maintenance anticoagulation therapy and (2) to convert the rhythm to a normal sinus rhythm. The most commonly used drugs for rate control with exercise and at rest include the BBs atenolol and metoprolol and the CCBs diltiazem and verapamil. Digoxin (Lanoxin) is only effective at rest and is not considered a drug of choice. Half the usual dose should be given to older adults with renal insufficiency. The risk of digitalis toxicity increases with renal insufficiency and hypokalemia. Elective cardioversion should be used if pharmacologic treatment is not effective. Oral anticoagulants are prescribed to reduce the risk of thromboembolic events. If arrhythmia is severe, a pacemaker may be inserted to control the ventricular response (Snow, Weiss, Le Fevre, et al, 2003).
Sick Sinus Syndrome Treatment may include the administration of vagolytic agents such as atropine to block vagal impulses, resulting in an increased heart rate. A pacemaker is the treatment of choice for symptomatic patients.
Heart Block Treatment for first-degree heart block includes observation to prevent deterioration into severe heart block as well as correction of the causative factor (e.g., electrolyte imbalance or drug toxicity). With second- and third-degree blocks, vagolytic and sympathomimetic agents are usually used to increase heart rate and conduction. Pacemakers may also be inserted to correct arrhythmia.
Prognosis Older adults with the arrhythmias of sick sinus syndrome or heart block have an excellent prognosis when these arrhythmias are corrected. Patients with atrial fibrillation have ischemic stroke as a complication.
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Nursing management Assessment
Older adults should be assessed for a history of CAD, heart failure, hypertension, cardiac valve disease, and current medications (e.g., cardiac, diuretic, and supplemental electrolyte), which may be causative factors of arrhythmias. Symptoms of weakness, forgetfulness, palpitations, dizziness, and syncope should be investigated for frequency, length, precipitating factors, and home treatment remedies.
Objective data include heart rate and rhythm, blood pressure, peripheral pulses, urine output, and sensorium. Measuring the apical pulse for 60 seconds yields the most accurate measurement of heart rate. Apical and radial rates should be compared to assess peripheral perfusion. Electrolyte, hemoglobin, and hematocrit values should be assessed for imbalances and anemia.
Diagnosis Nursing diagnoses common for an older patient with arrhythmia include the following:
• Decreased Cardiac Output, related to altered heart rate and rhythm
• Activity Intolerance, related to altered heart rate and cardiac output
• Risk for Injury, related to potential thrombus and emboli formation
• Deficient Knowledge, related to lack of information about disease process, medications, and treatment plan
Planning and Expected Outcomes The overall goals for a patient with arrhythmia are to maintain
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ADLs and adequate heart rate, sustain cardiac output, and prevent complications. Expected outcomes include the following:
1. The patient will maintain an adequate cardiac output, as evidenced by heart rate and rhythm within normal range, stable blood pressure, adequate peripheral pulses, mental alertness, urine output of 30 mL/hr, and clear breath sounds.
2. The patient will tolerate activity, as evidenced by stable vital signs and no complaints of dizziness, fatigue, or syncope.
3. The patient will remain free from injury.
4. The patient will verbalize increased knowledge about his or her diagnosis, treatment plan, and health maintenance behaviors.
Intervention Vital signs should be monitored every 15 to 60 minutes if the patient’s condition is acute and every 4 hours if it is stable. Heart rate and rhythm should be monitored continuously with a telemetry unit or Holter monitor. The patient should be encouraged to promptly report symptoms of weakness, dizziness, and palpitations to the nurse for comparison with electrical cardiac activity. Cardiovascular, respiratory, and neurologic systems, as well as intake and output measurements, should be assessed on a regular basis. Benefits and adverse reactions of prescribed drugs should be evaluated. Older patients with slow or fast ventricular responses to atrial fibrillation, long periods of sinus arrest with sick sinus syndrome, and second- or third-degree heart blocks are at risk for asystole and sudden death, so the nurse should be prepared to administer cardiopulmonary resuscitation (CPR).
Sensations of weakness, fatigue, dizziness, or dyspnea affect a patient’s tolerance of activity. The nurse may assist patients with the identification of factors that increase or decrease activity tolerance, and he or she may develop activity patterns that are spaced with adequate rest. Physiologic responses to activity should be monitored.
Tachycardia, bradycardia, and long periods of sinus pause
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reduce cardiac output and place patients at a higher risk for fainting and falls. Interventions to prevent injury include (1) having the patient sit for 3 to 5 minutes before an activity and (2) protecting the patient from objects with sharp or protruding edges by rearranging or padding objects in the patient’s environment.
The disease process and the dosage and side effects of all medications should be reviewed with the patient. Older patients taking anticoagulants should be taught ways to prevent injury, for example, not going barefoot, using a soft toothbrush, shaving with an electric razor, having blood drawn at the proper times, and taking medication at the same time every day.
If older patients anticipate difficulty with home recovery, a home health agency may be consulted. Heart associations are excellent sources for information and community programs. The family or significant others should be encouraged to attend
Patient/family teaching
Pacemaker Maintain follow-up care with the health care provider to evaluate
pacemaker function.
Watch for signs of infection at the incision site (e.g., redness, swelling, or drainage). Report these to the health care provider.
Avoid activities that would cause direct blows to the generator site (e.g., contact sports or use of a rifle).
Avoid close proximity to high-output electrical generators or to large magnets such as magnetic resonance imaging (MRI) scanners. These devices will reprogram the pacemaker.
Microwave ovens are safe to use and do not threaten pacemaker function.
Travel without restriction is allowed. The metal case of a small implanted pacemaker rarely may set off airport security alarms.
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Have the pacemaker identification handy.
Take the radial pulse at the same time daily. Contact the health care provider if the rate is below the setting of the pacemaker.
Carry a pacemaker identification card at all times. Information should include the type and brand of pacemaker, Inter-Society Commission on Heart Disease code, and settings.
Sexual activity may be resumed, as tolerated and as directed by the provider.
Engage in normal activities of daily living.
Discuss all medications, including herbal, prescription, and over- the-counter drugs with the provider.
Do not lean over gasoline engines or motors. Avoid direct contact of pacemaker generator with electrical appliances.
From Blach, D.A. (2013). Management of clients with problems of the cardiovascular system. In Ignatavicius, D.D. & Workman, M.L. (Eds.). (2013). Medical surgical nursing: Patient centered collaborative care (7th ed.). St. Louis, MO: Saunders; Canobbio, M.M. (2005). Mosby’s handbook of patient teaching (3rd ed.). St. Louis, MO: Mosby; Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., et al. (2011). Medical surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby.
CPR programs. All patients should be encouraged to wear medical- alert bracelets to identify the arrhythmia, the use of a pacemaker, and any medications they use (see Patient/Family Teaching Box: Pacemaker).
Evaluation Older adults with arrhythmias or pacemakers should maintain a cardiac rhythm that supports adequate cardiac output. Implantable cardioverter–defibrillators (ICDs) may also be used. If the patient receives a shock from the device, he or she should sit or lie down immediately and contact the provider (Blach, 2006). The ability to resume ADLs, knowledge of the therapeutic plan, and achievement of expected outcomes define an older adult’s readiness for independence in his or her care. Documentation focuses on a patient’s response to the treatment plan, specifically, how well symptoms are controlled. Hemodynamic stability is reflected in
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documented trends in the patient’s vital signs.
Orthostatic Hypotension Orthostatic hypotension is a major risk factor for syncope and falls in older adults. Orthostatic hypotension is defined as a drop in blood pressure of 10 to 20 mm Hg on assuming the upright posture. After changing from the lying position to the standing position, approximately 300 to 800 mL of blood moves into the lower extremities (Bradley & Davis, 2003). It is even more common among persons with certain risk factors such as autonomic dysfunction, low cardiac output, and hypovolemia. The use of certain medications such as sedatives, antihypertensives, vasodilators, and antidepressants also predisposes older adults to orthostatic hypotension. A drop in SBP is sometimes more pronounced on arising in the morning because of diminished baroreceptor function after prolonged recumbence. Orthostatic hypotension in older adults may be caused by an increase in sedentary activity and blunting of autonomic reflexes.
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Nursing management Assessment
Assessment of an older patient begins with taking of a complete health history and physical examination. Reports of syncope, falls, and near falls should be investigated in relation to meals, medications, and environmental factors. Hydration status should be evaluated along with a CBC and serum glucose level. Dehydration, anemia, and hypoglycemia can also cause syncope and falls.
To assess for orthostatic blood pressure changes, the nurse should first determine blood pressure with the patient in the recumbent position. Then the nurse should help the patient to a sitting position, with feet dangling or flat on the floor, and repeat the blood pressure reading. Then, if the patient can stand, the nurse should auscultate a third blood pressure in this position, noting the differences in the blood pressures and recording all three in the patient’s record.
All prescribed and OTC medication and herbal preparations should be reviewed carefully. Special attention should be given to medications known to induce hypotension in older adults, for example, amitriptyline, antidepressants, antihypertensives, bromocriptine, alpha-blockers and BBs, diphenhydramine, diuretics, insulin, marijuana, minor tranquilizers, monoamine oxidase inhibitors, narcotics or sedatives, nitrates, phenothiazines, sildenafil, sympatholytics, sympathomimetics (with prolonged use), tricyclic antidepressants, vasodilators, and vincristine (Bradley & Davis, 2003).
Diagnosis Nursing diagnoses common for an older adult with orthostatic hypotension include the following:
• Risk for Injury, related to transient hypoperfusion of the brain
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• Deficient Knowledge, related to lack of previous exposure to techniques to lessen the impact of orthostatic hypotension
• Impaired Physical Mobility, related to the fear of falling
Planning and Expected Outcomes Expected outcomes for an older adult with orthostatic hypotension include the following:
1. The patient will remain free of injury.
2. The patient will verbalize and correctly demonstrate measures to prevent symptoms of orthostatic hypotension.
3. The patient will verbalize fears and identify coping measures.
Intervention The nurse should teach an older adult at risk for or with orthostatic hypotension to move slowly from the recumbent position to the sitting position. The patient should then remain sitting for several minutes before attempting to stand.
Exercising the lower legs and ankles facilitates venous return and raises the blood pressure. Elastic stockings help in the same way. In some instances, a higher salt diet may increase blood volume and ameliorate orthostatic changes. The nurse should work with the patient and physician to eliminate unnecessary medications that may contribute to orthostatic hypotension; the nurse should also encourage the patient to limit alcohol intake, avoid large meals, and monitor and control diabetes mellitus, which is associated with peripheral autonomic dysfunction.
Environmental safety remains important. Grab bars, nonskid surfaces, and an uncluttered living space minimize injuries. In long- term care settings, low beds are sometimes used for cognitively impaired individuals with orthostatic hypotension and a history of falls.
Postfall syndrome produces fear that frequently causes older adults to limit activity. In addition, caregivers may also fear injury
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for an older adult and feel compelled to limit the older person’s freedom. This leads to a cycle of disuse, atrophy, and increased frailty, with a concomitant increased risk of injury. Educating the patient on the proper technique of standing aids in alleviating this fear. Encouragement and support are also important means for relieving fear.
Evaluation Evaluation is based on achievement of the expected outcomes and the safe performance of ADLs. Documentation of the patient’s blood pressure trends in the three positions aids in evaluating the effectiveness of the recommended treatments.
Syncope with Cardiac Causes Syncope is a transient loss of consciousness with spontaneous recovery. Syncope accounts for approximately 3% of emergency department visits and 6% of general hospital admissions (Pavri & Ho, 2003). Syncope usually results from acutely diminished cerebral blood flow. Causes of syncope are broadly grouped into the categories of neurologic, cardiac, neurocardiogenic, and psychiatric disease (Hauer, 2003). Cardiovascular causes of syncope are more prevalent among older adults, whereas vasovagal syncope is more prevalent among younger persons. The most frequent cardiovascular causes of syncope in older adults are cardiac arrhythmias, sick sinus syndrome, atrioventricular block, carotid hypersensitivity, aortic stenosis, and postprandial and orthostatic hypotension (Pavri & Ho, 2003).
Vasovagal syncope occurs when fright, pain, or nausea stimulate the vagus nerve (Blach, 2006). Signs and symptoms include nausea, diaphoresis, anxiety, and a feeling of warmth. These same signs may also be part of the atypical presentation of MI in an older adult. Vasovagal syncope may also be caused by straining during a bowel movement and by pushing up in bed without assistance. Vasovagal attacks usually occur in the upright position, and the patient regains consciousness when he or she lies down. Usually, a
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prodromal period is present, and during this time, the older adult may feel dizzy or flushed, experience mild nausea, and occasionally experience palpitations and tightness in the throat (Porter, Kaplan, Homeier, & Beers, 2005).
Cardiac arrhythmias are often first seen as a loss of consciousness that occurs without warning. Ectopic beats, whether supraventricular or ventricular, increase in frequency with age. Specific arrhythmias include supraventricular and ventricular tachycardias and a variety of bradyarrhythmias.
Atrial fibrillation is a supraventricular arrhythmia recognized by the lack of a clear P wave on ECG and an irregular ventricular rate. Because atrial fibrillation is associated with an increased risk of cerebral embolism, anticoagulation should be considered in any older adult with this arrhythmia (Beers & Berkow, 2000). Atrial fibrillation may cause syncope if the ventricular rate becomes too fast for adequate ventricular filling during diastole. In addition, with this type of arrhythmia the loss of atrial kick, which accounts for 30% of ventricular filling, may be enough to cause lower cardiac output and thus syncope.
Ventricular tachycardia is a medical emergency. It is usually seen as a regular tachycardia with a wide QRS complex, often up to rates of 300 beats/min. Again the problem is inadequate ventricular filling during diastole, leading to significantly diminished cardiac output and syncope if not quickly treated. Ventricular tachycardia associated with hypotension or syncope requires immediate electrical cardioversion (Beers & Berkow, 2000). Long-term control of this type of arrhythmia is accomplished through medication and implantable automatic defibrillators.
Bradyarrhythmias are more common in older adults because of intrinsic conduction system disease and a higher prevalence of acute illness such as MI and digitalis toxicity. Bradyarrhythmias that require pacemakers are Mobitz type II, third-degree heart block, and sick sinus syndrome if the bradycardia is symptomatic (Beers & Berkow, 2000). Structural problems of the heart such as aortic stenosis, cardiomyopathy, and acute MI may also cause syncope.
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Nursing management Assessment
The assessment of an older patient with syncope begins with a complete history and physical examination. Family members or other witnesses to the patient’s syncopal episode should be asked to describe what the patient was doing just before losing consciousness. A witness may describe the older adult as having cold hands and pale skin just before the loss of consciousness. The older adult should be examined for evidence of acute infarction and arrhythmias with the use of a 12-lead ECG. The carotid arteries should be auscultated for bruits. Blood work should include CBC and electrolyte and glucose levels (Beers & Berkow, 2000).
Diagnosis Nursing diagnoses for an older adult with syncope include the following:
• Decreased Cardiac Output, related to inadequate left ventricular filling, arrhythmia, or orthostasis
• Anxiety, related to near or full loss of consciousness
Planning and Expected Outcomes Syncope with cardiac causes is often an emergency situation requiring sophisticated intensive care for the older patient. It is hoped that a health care proxy is available if the patient can no longer speak for himself or herself. In any event, communication with the medical team and family or other caregivers is very important.
Expected outcomes for an older patient with syncope include the following:
1. The patient will regain a normal range of cardiac output as
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demonstrated by stable vital signs and alert and oriented sensorium.
2. The older adult and family will verbalize understanding of the cause of syncope and the therapeutic treatment plan.
Intervention Emergency measures such as CPR and defibrillation should be employed, when needed, to correct life-threatening arrhythmias. Oxygen should be administered, and oxygen saturation should be evaluated.
The nurse needs to help older adults identify causes of syncope such as straining during defecation. Constipation is a common complaint among older adults. Measures to avoid constipation include an increase in fiber, adequate fluid intake, and exercise. The nurse should instruct the patient to lie down if he or she becomes dizzy or experiences other prodromal symptoms. Psychological and spiritual care may become especially important when patients are faced with the possibility of death from their condition.
Evaluation Evaluation is based on achievement of the expected outcomes and a positive change in the clinical picture of the older adult. Older adults should be able to identify the cause of their syncope and methods of prevention, including methods of preventing injury if syncope occurs.
Valvular Disease Valvular disease occurs when the cardiac valves do not completely open (stenosis) or close (regurgitation insufficiency), which prevents efficient circulation of blood through the heart and increases the myocardial workload. Valvular disease is more common in the mitral and aortic valves.
Stenosis of the mitral valve impedes blood flow from the left
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atrium to the ventricle during diastole. With time, the left atrium becomes accustomed to increasing volumes and pressure, which causes dilation and hypertrophy. Stenosis of the aortic valve obstructs blood flow from the left ventricle to the aortic arch during systole. With time, hypertrophy of the left ventricle occurs as a result of increased pressures and volumes. Both stenotic conditions may eventually lead to hypertrophy of pulmonary vessels and decreased cardiac output.
Mitral regurgitation allows ejected blood to flow back into the left atrium from the ventricle during systole, resulting in dilation and hypertrophy of the left atrium and ventricle. Aortic regurgitation allows ejected blood to flow back into the left ventricle from the aorta during diastole, leading to volume overloads in dilation and hypertrophy of the left ventricle. Mitral valve prolapse (a form of valvular insufficiency) occurs when one or both cusps prolapse into the left atrium during ventricular systole. The prolapse is normally benign but may progress to severe regurgitation with ventricular dilation.
Rheumatic fever is the most common cause of valvular disease, although the incidence of rheumatic fever has declined since the introduction of antibiotics. Inflammatory, infective, connective tissue disorders, and atherosclerosis are other causes. Mitral regurgitation and aortic stenosis may also be attributed to degeneration or calcification of valves.
Aortic insufficiency, mitral stenosis, and mitral valve prolapse are more common in younger individuals than in older ones. Pulmonary and tricuspid valvular disorders do not often occur in older individuals. In older adults, aortic stenosis and mitral regurgitation are more common as a result of the degenerative process.
Individuals with valvular disease may be asymptomatic for many years, but with the deterioration of the valves and hypertrophic changes in the atria or ventricles, symptoms become evident (Box 21-4). Exertional dyspnea is frequently the initial symptom. Other symptoms include dizziness, fatigue, weakness, and palpitations. Atrial fibrillation is often associated with mitral disorders from distention of the left atria, and symptoms of angina are more
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common with aortic disorders because of decreased cardiac output. Symptoms of valvular disease may be difficult to recognize in older adults because symptoms may mimic those of CAD, which is common in the older adult population.
Box 21-4
Examples of clinical manifestations of valvular heart disease Mitral Stenosis Dyspnea on exertion, orthopnea, fatigue, loud accentuated opening snap, low-pitched rumbling, diastolic murmur heard at apex
Mitral Regurgitation Weakness, fatigue, dyspnea, palpitations, soft S3 often present, high-pitched pansystolic murmur with a harsh, blowing quality that radiates to the axilla
Aortic Stenosis Angina, syncope, heart failure, soft prominent S4, crescendo– decrescendo harsh ejection systolic murmur that radiates to carotids
Aortic Regurgitation Exertional dyspnea; orthopnea; nocturnal angina; soft or absent S2, S3, or S4, soft decrescendo high-pitched diastolic murmur; wide pulse pressure Data from Kennedy, E.B. & Ignatavicius DD. (2013). Interventions for clients with cardiac problems. In Ignatavicius, D.D. & Workman, M.L. (Eds.). (2013). Medical surgical nursing: Critical thinking for collaborative care (7th ed.). St Louis, MO:, Saunders; Ott, B.B. & DeFrancesco-Loukas, M.A. (2009). Management of clients with structural cardiac disorders. In J.M. Black & J.H. Hawks (Eds.). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Saunders; Porter, R.S., Kaplan,
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J.L., Homeier, B.P., & Beers, M.H. (2005). The Merck manuals online medical library: Palpitations. <http://www.merckmanuals.com/professional/palpitations.html> Accessed April 2014.
Diagnostic Tests and Procedures Chest radiography and ECG are initial diagnostic tests that may suggest valvular disease or evaluate damage to the heart from valvular problems. EKG with Doppler and ultrasonography, provides the most detailed information on the valve’s structure, function (abnormal cusp movement), and chamber enlargement. Cardiac catheterization may be done to assess the severity of the valve disorder (i.e., valve size, pressure changes within the chamber, and pressure gradients across valves) and additional effects on the heart. Exercise tests may also be conducted to evaluate the patient’s symptomatic response to exertion and the heart’s capacity to function (Segal, 2003a).
Treatment Treatment is directed toward the management of presenting symptoms and correction of the cause of the valvular disorder. Treatment for symptoms of heart failure consists of digoxin therapy, diuretics, vasodilating agents, restricted sodium intake, and oxygen therapy. Symptoms of decreased cardiac output related to atrial fibrillation are treated with digoxin, BBs, CCBs, cardioversion, or anticoagulant therapy. Symptoms of decreased cardiac output related to ischemia are treated with vasodilating agents. Prophylactic antibiotics before invasive procedures (e.g., surgery, invasive tests, and dental work) are recommended for all patients with valve replacement to prevent infective endocarditis. For patients with valvular disorders resulting from degenerative processes, medical treatment of symptoms tends to be unsuccessful over time and surgical repair or replacement of diseased valves may be necessary.
Prognosis Mortality and morbidity rates are higher for older adults requiring valve surgery. This is because older adults often have more advanced disease and more coexisting chronic diseases. Valvular
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surgery on older adults has steadily increased during the past decade and has increased the quality of life for older adults (Segal, 2003b).
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Nursing management Assessment
Assessment should include the history of prior episodes of rheumatic fever, infective endocarditis, staphylococcal and streptococcal infections, and family history of cardiac disease. Symptoms of valvular disease (e.g., fatigue, dyspnea, palpitations, dizziness, weakness, syncope, peripheral edema, distended neck veins, periods of memory loss or confusion, and chest pain) or related complications (e.g., arrhythmia, angina, and heart failure) should be noted, as well as the patient’s level of fatigue, toleration of activity, and current medications.
Objective data should be obtained primarily from cardiovascular and respiratory assessments. Cardiovascular data include blood pressure, pulse pressure, heart rate and rhythm, weight loss or gain, peripheral pulses, presence of peripheral edema, neck vein distention, and heart sounds. Different heart sounds are heard with each valvular disorder, and auscultation should be performed for identification of abnormalities or changes. Respiratory data include rate, depth, and breath sounds.
Aortic stenosis is the most common valvular disorder among older adults because of calcification of the valve with aging. Stenosis of this valve tends to occur without fusion of the cusps, resulting in a spray of blood through the valve rather than forceful propulsion. Physical examination may reveal softer and more musical heart murmurs that may be associated with the normal aging process rather than with a valvular disorder. Older adults may require diagnostic testing to support a diagnosis of valvular disease.
Diagnosis Nursing diagnoses common for an older patient with valvular disease include the following:
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• Decreased Cardiac Output, related to altered blood flow through the heart
• Activity Intolerance, related to decreased cardiac output
• Anxiety, related to diagnosis, treatment plan, and uncertain outcome
• Deficient Knowledge, related to lack of previous exposure to information about disease process, medications, and treatment plan
Planning and Expected Outcomes Expected outcomes for an older patient with valvular disease depend on the severity and extent of the disease. Outcomes include the following:
1. The patient will maintain adequate cardiac output, as evidenced by stable vital signs, mental alertness, urine output of 30 mL/hr or greater, and clear breath sounds.
2. The patient will tolerate a usual level of daily activity, as evidenced by stable vital signs and no dyspnea.
3. The patient will experience reduced anxiety, as evidenced by verbalization of decreased anxiety, the ability to express specific fears, and stable vital signs.
4. The patient will correctly explain the disease process, therapeutic plan, and preventive precautions.
Intervention Cardiovascular and respiratory assessments should be conducted on a regular basis to detect progress and to prevent complications. The nurse should monitor patients for therapeutic and adverse reactions to the medications prescribed; monitor blood pressure, heart rate, respirations, heart sounds, breath sounds, and cardiac rhythm; ensure that the patient maintains bed rest when ordered and performs range-of-motion exercises to prevent complications; elevate the head of the bed to maximize thoracic excursion; and
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administer oxygen, as prescribed. The nurse should also assess a patient’s activity level and balance
activity with rest periods; organize care to provide rest periods and advance activity according to the patient’s tolerance; and assist the older adult with ADLs to prevent fatigue. Older adults are more prone to dizziness with position changes because of decreased sensitivity of baroreceptors (Ball et al, 2014). The patient should rise slowly and stay in the sitting position for a few minutes before standing. Older adults require secure footwear and handrails for support.
Older patients should understand the disease process and treatment plan and should recognize the signs and symptoms of heart failure and when to notify a health care provider. The patient’s low-sodium diet, as well as the bleeding precautions if the patient is receiving anticoagulant therapy, should be reviewed. Antibiotics for invasive procedures, including all dental work, should be discussed. Appropriate oral hygiene should be explained to older patients to prevent trauma and infective endocarditis.
For patients who do not respond to medical treatment, valvular surgery may be necessary to improve cardiac performance. Older patients benefit more from surgery when their condition is stabilized and the procedure is performed on an elective basis. Patients scheduled for valvular surgery are subjected to extensive diagnostic tests and blood studies, which should be explained to the patient and family to alleviate anxiety. The patient and family should also be oriented to the ICU or coronary care unit (CCU) and the equipment that will be used postoperatively. Postoperative assessment activities and treatments should be explained.
After surgery, older patients should be monitored closely for complications of MI, heart failure, thromboembolism, hemorrhage, arrhythmia, and infection. Older patients have a greater risk for complications compared with younger individuals. Older adults are also prone to the development of acute confusion or delirium after surgery because of multiple factors, including the stress of the procedure, drug and other treatment modalities, and environmental alterations. The presence of the family and familiar belongings and the use of personal hearing aids or eyeglasses may
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alleviate episodes of delirium.
Recovery from valvular surgery is generally complete within 6 to 8 weeks; however, recovery may be delayed in older adults as a result of a higher incidence of complications. Exercise and ADLs should be gradually resumed during the first 6 weeks of recovery. Patients should be taught to monitor their pulse and respiratory rate to evaluate tolerance to activity. Walking with a progressive increase in duration and frequency is recommended, and patients should avoid lifting heavy objects. Driving a car may impede the healing of the sternal incision. Prophylactic use of antibiotics should be explained to the patient. Anticoagulants may be prescribed for patients with prosthetic valves, and special precautions should be explained. Signs, symptoms, and complications of valvular disease should be reviewed with the patient because patients may develop deteriorating symptoms that necessitate valve replacement; patients with valve replacement may need new valves inserted over time.
Evaluation Evaluation of an older patient with valvular disease focuses on achievement of the expected outcomes. Older adults should demonstrate adequate cardiac output, the ability to perform ADLs within limitations, and control of symptoms. The nurse should also note the patient’s and family’s ability to manage the care requirements and resolve any problems appropriately. Documentation should accurately reflect the care delivered in the preoperative and postoperative periods and the older adult’s response. Assessment of the progress toward self-care and the degree of functional ability must also be documented on an ongoing basis because the older adult’s recovery depends in large part on returning to the prior level of functioning.
Congestive Heart Failure Approximately 5.8 million people in the United States suffer from heart failure. About 550,000 new cases are diagnosed each year. More than 287,000 people in the United States die each year of heart
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failure. Hospitalizations for heart failure have increased substantially (CDC, 2006). The number increased from 402,000 in 1979 to 1,101,000 in 2004. The most common causes of heart failure are coronary artery disease, hypertension or high blood pressure, and diabetes. About 7 of 10 people with heart failure had high blood pressure before being diagnosed. About 22% of men and 46% of women will develop heart failure within 6 years of having a heart attack (CDC, 2006).
CHF is the inability of the heart to pump an adequate cardiac output to meet the body’s metabolic demands (Touhy & Jett, 2012). CHF is not a disease in itself, but it has several precipitating factors. Some of these contributing factors include age, hypertension, CAD, rheumatic heart disease, valvular heart disease, arrhythmias, renal disease, diabetes mellitus, thyrotoxicosis, MI, cardiomyopathy, pulmonary embolism, infection, anemia, liver disease, emotional stress, and other factors related to biologic, socioeconomic, iatrogenic, and lifestyle considerations (CDC, 2006).
Age-associated cardiovascular and renal changes that affect the clinical course of CHF and responses to treatment include decreased renal and systemic blood flow, increased arterial stiffness and peripheral resistance, reduced ventricular compliance, and reduced maximum aerobic capacity. In older adults, the inability to maintain function because of pulmonary and systemic congestion may create a cycle of decreased activity that leads to a decreased ability to provide self-care.
Diagnostic Tests and Procedures The Agency for Health Care Policy and Research (AHCPR) has established the following guidelines for testing: ECG to detect MI and arrhythmia, CBC to rule out anemia, urinalysis and serum creatinine and blood urea nitrogen (BUN) levels to rule out renal disease, serum albumin level to differentiate edema caused by hypoalbuminemia, serum brain natriuretic peptide (90% specificity and sensitivity for heart failure), thyroid tests to rule out thyroid disease, and EKG to determine left ventricular ejection fraction (Shamsham & Mitchell, 2000). (See Evidence-Based Practice box.)
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Evidence-based practice Assessing Heart Failure Admissions
Sample/Setting After careful review of eligibility, researchers accepted 499 patients into the study. Participants’ eligibility included age older than 60 years, history of heart failure, and a brain natriuretic peptide (BNP) level of 400 picograms per milliliter (pg/mL) or higher, among others. Older study participants had overall more severe symptoms and higher BNP levels at the initial time of entry into the study.
Method Study participants were randomly assigned to two groups. One group was treated according to symptoms, and the second group was treated according to the BNP level. Participants did not know to which group they were assigned. Within each treatment group, results were further broken down into ages: 60 to 74 years and 75 years or older. Follow-up occurred in outpatient visits at 1, 3, 6, 12, and 18 months. The main focus of the study was prevention of hospitalization related to heart failure by 18 months.
Findings No significant difference in being hospitalized for any reason existed between treatment groups during the study time frame. Hospitalization related to heart failure symptoms occurred less often in the BNP-guided treatment group. All participants had an improvement in symptoms regardless of treatment group, but of interest was that the younger age cohort benefited most from the BNP-guided treatment. The authors also noted that no one medication in particular could be identified as having the greatest effect on symptom improvement.
Implications
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Heart failure is one of the most common cardiovascular problems and reasons for hospital admission of older adults. Nurses should be skilled at assessing patients and identifying symptoms that may be reported to the physician for enhanced treatment. Reduction in symptoms and costly hospitalization is necessary if quality of life is to be improved for those affected by this illness. Evidence that BNP-guided therapy does not benefit older adults may save costs in laboratory fees while not increasing hospitalization for symptoms. From Pfister, M. et al., (2009). BNP-guided vs. symptom-guided heart failure therapy: The trial of intensified vs. standard medical therapy in elderly patients with congestive heart failure (TIME-CHF) randomized trial. Journal of the American Medical Association, 301(4), 383-392.
Treatment Management of CHF in older adults requires careful control of precipitating factors, pharmacologic therapy (Table 21-2), a low- sodium diet, restriction of fluids, and appropriate rest and exercise. The American College of Cardiology (ACC) and the AHA established practice guidelines for the management of CHF (Jessup, Abraham, Casey, et al, 2009).
Table 21-2 Selected medications for congestive heart failure
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Data from Lehne, R.A.: (2013). Pharmacology for nursing care (8th ed.). Philadelphia: Saunders; Chavey W. E., et al. (2001). Guideline for the management of heart failure caused by systolic dysfunction. Part 2: Treatment. American Family Physician, 64(6), 1045.
CAD, Coronary artery disease; GI, gastrointestinal disease; IHSS, idiopathic hypertrophic subaortic stenosis; MI, myocardial infarction.
Systolic CHF ACEIs are the first-line therapy; these are generally given in large doses as long as the older adult can tolerate them. Diuretics are used with the ACEIs. Sodium restriction is critical. Digoxin is effective for moderate to severe CHF. Low-dose dobutamine infusion may benefit patients with refractory CHF. Anticoagulation is indicated if atrial fibrillation is present. Exercise, as tolerated, is also encouraged.
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Diastolic CHF The goal is to reduce ventricular filling pressure and control symptoms. Diuretics and nitrates are the first-line therapy. CCBs, BBs, and ACEIs may be beneficial. Because its positive inotropic effects also increase myocardial oxygen demand, digoxin is not used.
ACEIs These drugs inhibit the progression of heart failure and reduce the chance of mortality in older adults. They block the conversion of angiotensin I into angiotensin II, a potent vasoconstrictor that also promotes the release of aldosterone. These drugs decrease afterloading and preloading.
Diuretics Diuretics reduce preloading; they reduce the symptoms associated with pulmonary and systemic vascular congestion. Loop diuretics are the most commonly prescribed and provide predictable and controllable diuresis in severe heart failure. Hypokalemia needs to be monitored, especially if an older adult is also taking digoxin. Older patients with early, mild CHF characterized by normal renal function and only minimal ankle edema might do well with a thiazide diuretic.
Digitalis Systolic dysfunction and atrial fibrillation are the principal indicators for digitalis in the older patient. Digoxin is used when ACEIs are used at maximum doses and more relief is needed. In a randomized clinical trial conducted between 2001 and 2003, the Digitalis Investigation Group concluded that increasing age is associated with progressively worse clinical outcomes in patients with heart failure, but the beneficial effects of digoxin in reducing all-cause admissions, heart failure admissions, and death or hospitalization due to heart failure are independent of age (National Heart, Lung, and Blood Institute, 2005). Thus, digoxin remains a useful agent in the adjunctive treatment of heart failure
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caused by impaired left ventricular systolic function in patients of all ages. However, more research is needed on the management of heart failure in older adults (Yusuf & Durand, 2005). Digoxin improves symptoms and reduces hospitalization in patients already taking ACEIs and diuretics, an effect that is greater in patients with end-stage disease (Zaman, 2001). However, the risk of toxic effects is increased in those taking large doses of diuretics, which predispose them to hypokalemia (Zaman, 2001).
Beta-Blockers The use of these drugs in the treatment of CHF has increased. Carvedilol, a nonselective BB used for the treatment of CHF, has demonstrated a reduction in the mortality rate and need for hospitalization in patients with class II or III CHF (Zaman, 2001). BBs decrease the sympathetic stimulation to the heart that is believed to aid in the progression of the disease. As a class, BBs exert negative inotropic effects (slowing of heart rate), so caution should be used if they are given with agents that also depress contractility (e.g., CCBs and antiarrhythmics).
Sympathomimetics These medications mimic the sympathetic nervous system. They increase the force of myocardial contraction, which is the rationale for their use in CHF. Tachycardia may occur.
Prognosis The Framingham study has associated CHF with a poor prognosis. As reported by Kannel (2000), the median survival is only 1.7 years for men and 3.2 years for women; only 25% of men and 38% of women survive 5 years, which reflects a mortality rate four to eight times that of the general population of the same age. Valvular disease that is surgically corrected has a better prognosis than CHF caused by cardiomyopathy.
Classifying CHF can be done in several ways. The categories for CHF are as follows:
1. Right or left failure—Although left ventricle failure is more
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prevalent, a number of individuals, especially those with chronic disease, experience failure in both ventricles. In left ventricle failure, the left ventricle fails to pump an adequate stroke volume. This leads to pulmonary congestion, and pulmonary symptoms predominate. Generally, right ventricle failure is caused by increased pulmonary pressure that results from left ventricle failure. This prevents the right ventricle from pumping adequately, which causes generalized systemic symptoms to appear. Older adults with chronic CHF tend to exhibit signs of both left-sided and right-sided heart failure.
2. Acute or chronic failure—Acute heart failure results from a sudden reduction in cardiac output and inadequate organ perfusion; it may lead to pulmonary edema and circulatory collapse. Compensatory mechanisms do not activate. Chronic heart failure occurs slowly, often as a result of hypertension, valvular or ischemic heart disease, or chronic lung disease. Hypervolemia occurs, sodium and water are retained, and the ventricle dilates and becomes hypertrophied. The heart may be able to activate compensatory mechanisms to minimize clinical symptoms, but this compensation may be short or minimized among older adults, who may also have other comorbid diseases (Beers, 2004; Kennedy & Ignatavicius, 2013).
3. Systolic or diastolic failure—Systolic heart failure is caused by decreased left ventricular contractility. Cardiac output decreases, and the ventricle becomes hypertrophied. CAD is a cause of this type of heart failure. Diastolic heart failure is caused by decreased compliance of the ventricle; it becomes stiffer and cannot accept adequate blood volume. As a result, stroke volume and cardiac output decrease. Hypertension is a cause of this type of heart failure (Box 21-5).
Box 21-5
New york heart association functional
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classification of heart failure Class Definition I Asymptomatic: Normal daily activity does not initiate symptoms. II Moderate daily activity initiates the onset of symptoms of shortness of breath or fatigue, but the patient is
comfortable at rest. III Very mild activity initiates symptoms; the patient is usually symptom-free at rest. IV The patient is exhausted, and any type of activity initiates symptoms; symptoms are present at rest, sitting still,
or lying down.
Adapted from Blach, D.A. (2006). Management of clients with problems of the cardiovascular system. In D.D. Ignatavicius & M.L. Workman (Eds.). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). St. Louis, MO:, Saunders; Morton, P.G., Fontaine, D.K., Hudak, C.M., & Gallo, B.M. (2005). Critical care nursing: A holistic approach (8th ed.). Philadelphia:, Lippincott Williams & Wilkins; Porter, R.S., Kaplan, J.L., Homeier, B.P., & Beers, M,H. (2005). The Merck manuals online medical library: Palpitations. <http://www.merckmanuals.com/professional/geriatrics/drug_therapy_in_the_elderly/drug- related_problems_in_the_elderly.html> Accessed April 2014.
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Nursing management Assessment
Older adults should be assessed for a history of CAD, rheumatic heart disease, hypertension, cardiac valve disease, infection, and current medications. The initial physical evaluation of an older adult suspected of having CHF includes measurement of blood pressure, evaluation for pitting edema of the legs and ankles, assessment of jugular venous pressure, heart and lung auscultation, and percussion of the lung for effusions. Assessment for orthopnea, fatigue at rest, paroxysmal nocturnal dyspnea, nocturnal urination, and edema is also important. The nurse should also determine how symptoms have affected ADLs for older adults (Box 21-6).
Box 21-6
Congestive heart failure Systolic Heart Failure Dyspnea initially on exertion, but also at rest as the congestive
heart failure worsens
Orthopnea Paroxysmal nocturnal dyspnea
Weakness and fatigue
Diminished exercise tolerance
Crackles on auscultation of the lungs
S3 gallop
Pulsus alternans (alternating intensity of the pulse)
Diastolic Heart Failure
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Fatigue with a low exercise tolerance
Edema that worsens in a dependent position and subsides with rest and elevation; usually occurs in lower extremities and is bilateral
Weight gain
Extra heart sounds: S3 and S4 Nausea, anorexia, and abdominal distention
Hepatomegaly
Nocturia
Jugular vein distention Adapted from Bollinger, K. & Sadar, A.M. (2003). Care and management of the patient with right heart failure secondary to diastolic dysfunction: An advanced practice perspective and case review. Critical Care Nursing Quarterly, 26(1), 22-27.
Diagnosis Common diagnoses for an older adult patient with CHF include the following:
• Decreased Cardiac Output, related to decreased contractility and increased preloading
• Impaired Gas Exchange, related to pulmonary venous congestion
• Excess Fluid Volume, related to increased sodium and water reabsorption
• Anxiety, related to perceived threat to self
• Activity Intolerance, related to decreased cardiac output and fatigue
• Ineffective Coping, related to knowledge deficit and fear of uncertain outcome
• Disturbed Sleep Pattern, related to nocturnal dyspnea
• Deficient Knowledge, related to lack of previous exposure to disease process, medications, and treatment plan
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Planning and Expected Outcomes Expected outcomes are aimed at maximizing myocardial function and assisting with the lifestyle modifications and emotional adjustments imposed by the disease. Expected outcomes for an older adult with CHF include the following:
1. Cardiac output will be maximized, as evidenced by vital signs within an acceptable range, no arrhythmia, adequate cardiac output, urine output greater than 30 mL/hr, and alert mental state.
2. Gas exchange will be improved, as evidenced by decreased or no reported dyspnea, normal respiratory rate, lungs clear on auscultation, no evidence of central or peripheral cyanosis, and a patient report of improved activity tolerance.
3. Excess fluid volume will be reduced, as evidenced by reductions in water weight, dependent edema, and abdominal girth.
4. The patient will experience less anxiety, as evidenced by communication of fears to nurse and self-report of the use of coping skills.
5. Activity will be restored to its level before the illness, as evidenced by fewer or no reports of fatigue with usual activities and no reports of symptoms induced by select activities.
6. The patient will experience adequate coping, as evidenced by the naming of two coping skills used in the past and a self-report of feeling positive about the future.
7. The patient will experience an acceptable sleeping pattern, as evidenced by reports of sleep uninterrupted by dyspnea and a feeling of being rested on awakening.
8. The patient will demonstrate an adequate knowledge level, as evidenced by the ability to correctly state information about the disease process; treatment plan; and medication indication, dosage, frequency, and side effects.
Intervention
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It is essential that the nurse assess blood pressure, apical pulse, heart rate, heart and lung sounds, and peripheral edema to detect early signs and symptoms of decreased cardiac output. The intake and output and daily weights should be monitored and recorded. The older adult should be weighed at the same time daily to monitor accurately for fluid loss or retention. The nurse should increase the older patient’s activity according to tolerance and provide time for rest; while in bed, the patient should maintain the Fowler position. The older adult may need more than one pillow to sleep with at night. The nurse should instruct the patient to take his or her diuretic in the morning so sleep is not disturbed. The nurse should encourage the older patient to take slow deep breaths during dyspneic episodes and maintain a calm environment.
The nurse should instruct the patient about restricted sodium and fluid intake. A dietitian may be consulted. Older adults should be instructed to avoid canned foods and prepared foods from the frozen food section and to use salt sparingly. A weight gain of 3 lb in 48 hours and a return of any symptoms should be reported to the health care provider immediately. Electrolyte levels, especially potassium, and signs and symptoms of electrolyte imbalance should be monitored.
The nurse should give older adults instructions on their condition, procedures, diet, and risk factors in a clear, simple manner, using proper language, reading level, and cultural considerations. The nurse should maintain an environment that is as relaxed and quiet as possible, explain all procedures before the beginning, and answer questions clearly and concisely. The nurse should also provide opportunities for older patients and family members to verbalize their concerns.
Referral to a home health agency for assistance with ADLs and referral to Meals on Wheels may be necessary for some individuals. The older adult may wish to enter a cardiac rehabilitation program to monitor activity tolerance in a secure environment.
Evaluation Older adults should demonstrate that ventricular function is
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improved through unlabored respirations, no peripheral edema, no cough or orthopnea, and a normal urine output. The patient should increase activity without experiencing dyspnea and should demonstrate an ability to return to usual ADLs. Documentation of trends is critical for older adults with heart failure, especially in regard to assessment findings and treatment responses (see Nursing Care Plan: Congestive Heart Failure).
Nursing care plan
Congestive Heart Failure
Clinical Situation Mr. H, an 86-year-old man who is widowed and lives alone, arrives in the emergency department complaining he has had difficulty breathing, especially at night, associated with nausea, for the past week. He states that he must sleep with two pillows to breathe more easily at night and still does not get a good night’s rest. He also complains of a cough that is worse at night and relieved by nothing. Mr. H is concerned he has pneumonia. Assessment of Mr. H reveals the following:
• Vital signs: temperature, 98 ° F; apical heart rate, 86 beats/min and irregular; respiratory rate, 36 breaths/min and labored; and blood pressure, 170/96 mm Hg
• Skin—pale, cool, and diaphoretic
• Inspiratory bibasilar crackles that do not clear with coughing
• S3 heart sound on auscultation
• Visible jugular vein distention
• 3 + bilateral pedal edema
Twelve-lead electrocardiography (ECG) and a chest radiography are ordered. An intravenous line is started at a
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“keep vein open” (KVO) rate. Oxygen via mask is administered. Intravenous furosemide is given, and Mr. H is admitted with a diagnosis of congestive heart failure (CHF).
Nursing diagnoses Decreased Cardiac Output, related to ineffective myocardial
contractility Excess Fluid Volume, related to sodium and water retention
Impaired Gas Exchange, related to increased fluid in pulmonary vasculature
Deficient Knowledge, related to lack of previous exposure to disease process and treatment plan
Outcomes Cardiac output is maximized, as evidenced by vital signs within
acceptable limits, controlled arrhythmias, clear breath sounds, fewer dyspneic episodes, and alert mental status.
The patient will demonstrate normal fluid balance, as evidenced by clear breath sounds, reduced pedal and pretibial edema, an intake greater than output, and a loss of water weight with a stable dry weight.
The patient will correctly verbalize prescribed sodium and fluid restrictions.
The patient will demonstrate improved gas exchange, as evidenced by activity tolerance, absence of shortness of breath and nocturnal dyspnea, and clear breath sounds.
The patient will describe CHF and reasons for limitations, identify his own risk factors, and explain techniques to initiate lifestyle changes.
The patient will participate in the treatment plan.
Interventions Monitor and document heart rate, rhythm, blood pressure,
respirations, and lung and heart sounds hourly and as needed.
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Assess for edema and jugular vein distention every 2 to 4 hours.
Monitor intake and output hourly.
Assess skin temperature and color, and assess for the presence of diaphoresis at regular intervals.
Provide a restful environment.
Administer cardiac medications, as ordered; document patient’s response.
Monitor intake and output hourly.
Weigh daily, using the same scale at the same time of day.
Care plan Administer diuretics as ordered; document patient’s response.
Assess levels of electrolytes, blood urea nitrogen (BUN), and creatinine, as well as symptoms of imbalance.
Instruct the patient to elevate extremities when sitting.
Instruct the patient on sodium and fluid restrictions.
Assess respiratory status hourly and as needed (rate, rhythm, use of accessory muscles, and lung sounds).
Maintain the patient in the semi- or high-Fowler position to aid breathing.
Administer oxygen, as ordered, monitoring oxygen saturation.
Instruct the patient to avoid strenuous and taxing activities and to take advantage of peak energy periods.
Discuss the normal function of the heart and how CHF alters this.
Discuss diet and fluid restrictions and medications.
Discuss specific risk factors and the patient’s role in modifying them.
Review signs and symptoms that need to be immediately reported to a health care provider.
Provide an environment that allows the patient to verbalize feelings and ask questions.
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Discuss the benefits of increased activity (e.g., a walking program).
Refer the patient to community resources and support groups.
Encourage the patient to obtain annual flu immunization.
Peripheral Artery Occlusive Disease Peripheral artery occlusive disease (PAOD) is any disturbance in the systemic arteries that impairs tissue perfusion. Arteriosclerosis (hardening or thickening of arterial walls) and atherosclerosis (the usual cause of arteriosclerosis, involving plaque formation within the arterial wall) are common disturbances affecting the arterial vasculature. Atherosclerosis is the most common cause of arteriosclerosis obliterans, which is the narrowing or obstruction of arterial walls. Although the exact cause of atherosclerosis is unknown, several risk factors have been identified. These include smoking, elevated serum cholesterol levels, hypertension, diabetes mellitus, physical inactivity, obesity, and family history.
Atherosclerosis involves the development of atheromatous plaques on the intimal layer of arterial vessels. These lesions progressively narrow the artery lumen and lead to the formation of thrombi and aneurysms.
Arteriosclerosis obliterans is a chronic occlusive disease of the arteries caused by plaque formation. As the lumen narrows, partial or complete obstruction may occur, leading to inadequate tissue perfusion beyond the lesion and ischemia. Common sites for atherosclerotic lesions are the aortoiliac vessels, femoropopliteal vessels, and popliteal–tibial arteries. Symptoms appear when the artery is unable to supply the tissues with adequate oxygenated blood flow.
Thrombi that develop at the site of the atherosclerotic lesion or within arterial aneurysms may break loose and circulate through the arterial system. Thromboemboli also originate in the heart as a result of atrial fibrillation, MI, or mitral stenosis. Thromboemboli tend to block arteries at bifurcation points of the femoral and popliteal arteries. Impaired blood flow and ischemia occur at sites
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distal to the occlusion.
As the atheromatous plaque progresses, the medial layer of the wall calcifies and loses elasticity, which weakens the arterial wall. As the vessel wall weakens, pouches or aneurysms form. Pressure within the arteries, especially in the presence of hypertension, may further dilate the aneurysm until it ruptures. Aneurysms commonly occur in large arteries such as the abdominal aorta. Multiple aneurysms may develop in the popliteal artery. Thrombi may form within the aneurysm and circulate to smaller distal vessels in the arterial system.
Signs and symptoms of arterial insufficiency depend on the site, extent of occlusion, and degree of collateral circulation. Collateral circulation often develops with the gradual elevation of plaque formation.
Intermittent claudication (muscle ischemia) is one of the initial symptoms with atherosclerosis obliterans. Pain in the foot or calf is experienced with exercise and subsides with rest. As the disease progresses, the distance walked becomes shorter before pain is felt. Burning pain in the foot at rest or during sleep indicates a severe form of the disease. Cold, numbness, and tingling may accompany the pain. The foot appears pale when elevated and red in dependent positions. Dry skin, thickened toenails, loss of pedal hair, and cool skin may result from poor circulation. Painful arterial ulcers may be noticed on the toes, between the toes, or on the upper aspect of the foot. Cold extremities with mottling, delayed filling of capillaries, and absent pedal pulses are indicative of acute arterial insufficiency and should be treated immediately. Care should be taken to examine both extremities for comparison. Advanced stages of ischemia lead to necrosis, ulceration, and gangrene of the toes.
The pain with arterial emboli is sudden and severe. The affected extremity appears pale and cool, and distal pulses are absent. Impaired motor and sensory function is evident. Shock may develop if large arteries are occluded.
With abdominal and peripheral aneurysms, usually no overt signs and symptoms are evident until rupture or acute thrombosis. A pulsating mass may be palpated in the abdominal area with
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aortic aneurysms, and patients may sense abdominal or back pain.
Diagnostic Tests and Procedures Routine screening for PAOD in asymptomatic patients is not recommended in the U.S. Preventive Services Task Force guidelines (Kuznar, 2004).
Doppler ultrasonography detects and measures the velocity of blood flow through the arterial segments and grafts. Duplex imaging uses a Doppler system that maps a region of an artery in which blood is flowing. Radionuclide scanning consists of the injection of dye and scanning at intervals to determine radionuclide accumulation in the damaged vessel. With this procedure, blood flow through the vessel and graft is assessed, perfusion pressures calculated, and the vascular system visualized. Arteriography is performed to determine the exact location and extent of arterial occlusion. Contrast material is injected into the arterial system through a specialized catheter inserted into the brachial or femoral artery, and a series of radiographic studies trace the dye through the arterial system.
Treatment The first line of treatment includes aspirin, 81 to 325 mg/day with food. Antiplatelet medications such as aspirin inhibit the adherence and aggregation of platelets along damaged vessels. Ticlopidine (Ticlid) and clopidogrel (Plavix) are antiplatelet drugs that decrease platelet activity. Pentoxifylline (Trental) reduces blood viscosity, enhances the flexibility of red blood cells (RBCs), and improves tissue perfusion. Cilostazol (Pletal) reduces platelet activity and is an arterial vasodilator. These prophylactic drugs may help reduce blood viscosity. Thrombolytics are also used for acute conditions (Kuznar, 2004).
Surgical Procedures Percutaneous transluminal angioplasty involves gaining access to the arterial system with a specialized balloon-tipped catheter. The catheter is advanced under fluoroscopy to the atherosclerotic lesion
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and inflated over the site to compress the plaque and improve blood flow. Arterial bypass and reconstruction may be performed to increase blood flow. Intravascular stents keep the vessel open. Endarterectomy is the opening of the artery and removal of the plaque. Advanced cases of atherosclerosis and gangrene of the extremities necessitate amputation of the limb.
Prognosis Pharmaceutical agents are not particularly effective in the treatment of PAOD; surgical interventions, however, have been more successful. The key to preventing or halting the progression of PAOD and subsequent complications appears to be controlling the risk factors for atherosclerosis. Death seldom results from PAOD (see Patient/Family Teaching box: PAOD).
Patient/family teaching
Peripheral Artery Occlusive Disease (PAOD) Prevention is the key to the management of PAOD.
Control risk factors: Stop smoking; lose weight; control hypertension and diabetes mellitus; eat a low-fat, low- cholesterol diet; and exercise daily by walking.
Do not cross legs while sitting; do not stand or sit for long periods.
Do not wear constricting garments.
Foot care is essential. Inspect the feet daily, and keep them clean and dry. Do not soak feet. Use mild soap and a washcloth to clean. Check water temperature with a thermometer or elbow, but do not use your toes. After bathing, dry well between toes; lubricate feet with lotion daily. Avoid walking barefoot, and wear proper-fitting footwear that is flexible yet protective.
Immediately notify the health care provider of changes in color,
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temperature, or sensation of the affected area or of damage to skin integrity.
From Blach, D.A. & Ignatavicius, D.D. (2013). Interventions for clients with vascular problems. In D.D. Ignativicius and M.L. Workman (Eds.). (2013). Medical surgical nursing: Patient centered collaborative care (7th ed.). St. Louis, MO: Saunders; Black, J.M. (2009). Management of clients with vascular disorders. In J.M. Black & J.H. Hawks (Eds.). (2009). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Saunders; Morton, P.G., Fontaine, D.K., Hudak, C.M., & Gallo, B.M. (2012). Critical care nursing: A holistic approach (10th ed.). Philadelphia: Lippincott Williams & Wilkins; Sieggreen, M.Y. & Kline, R.A. (2011). Vascular ulcers. In S. Baranoski & E.A. Ayello (Eds.). (2011). Wound care essentials. Philadelphia: Lippincott Williams & Wilkins.
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Nursing management Assessment
Assessment of an older adult with PAOD begins with a complete history and physical examination. Assessment data should reflect the presence of acute or chronic arterial insufficiency.
Subjective and objective assessment of a patient with PAOD is outlined in Box 21-7.
Box 21-7
Assessment of older adults with peripheral artery occlusive disease Subjective Data Pain in extremities (location, intensity, onset, and duration) Precipitating factors (activity or rest)
Relieving factors (activity or rest and position)
Presence of intermittent claudication (frequency and distance)
Modifiable risk factors (smoking, high cholesterol levels, hypertension, diabetes mellitus, obesity, and physical inactivity)
Personal and family history (of CAD and PAOD)
Psychosocial state (anxiety, fear, or depression)
Objective Data Skin changes (color, temperature, appearance, and sensations)
Condition of nails
Circulation (peripheral pulses, bruits, and capillary filling)
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Muscle tone
CAD, Coronary artery disease; PAOD, peripheral artery occlusive disease.
Diagnosis Nursing diagnoses for older adults with PAOD include the following:
• Ineffective Peripheral Tissue Perfusion, related to decreased arterial blood flow
• Activity Intolerance, related to an imbalance between tissue need and blood supply
• Risk for Impaired Skin Integrity, related to decreased tissue perfusion and sensation
• Deficient Knowledge, related to lack of previous exposure to disease process, medication, and treatment plan
Planning and Expected Outcomes Older patients with PAOD and their family members should be included in the planning of care. Discharge planning should begin as soon as an older patient is admitted to the hospital because this type of patient typically needs additional support services during home recovery.
Expected outcomes for an older patient with PAOD include the following:
1. The patient will manifest reduced signs and symptoms of arterial insufficiency, as evidenced by warm skin temperature over the affected area, the presence of pedal pulses, and decreased claudication in the affected extremities.
2. The patient will successfully participate in activities within limits imposed by the disease. 3. The patient will demonstrate protective behavior and self-care measures to prevent injury to the skin.
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4. The patient will correctly describe the disease process and treatment plan, including medication action, dosage, and side effects.
5. The patient will identify personal risk factors and methods to reduce these factors.
Intervention Nursing interventions include the initiation of a graduated, regular exercise program to enhance collateral circulation. Patients should be encouraged to balance activities with rest and may need assistance to develop a schedule of paced activities. Patient education is also important for preventing injuries.
Evaluation Evaluation of an older patient with PAOD focuses on the achievement of expected outcomes. Short-term evaluation focuses on those interventions aimed at reducing risk factors. Long-term evaluation is based on trends in progress toward improving tissue perfusion and viability. The older adult’s and family’s willingness to participate is a crucial factor in achieving a successful outcome over time (see Nursing Care Plan: PAOD).
Venous Disorders PVD is any disturbance that impairs tissue perfusion. The most common underlying causes of PVD are (1) varicose veins, (2) deep vein thrombosis, and (3) venous ulceration.
Nursing care plan
Peripheral Artery Disease
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Clinical Situation Mrs. A, a 72-year-old woman, is complaining of a decreased activity level because of pain in her right leg when walking. This has been getting worse over the past few months, and it is now difficult for her to go to her mailbox without pain. She states that sometimes her toes tingle at night. She does not complain of chest pain or shortness of breath. She denies smoking and takes amlodipine for high blood pressure and aspirin as needed for arthritis.
Assessment of Mrs. A reveals the following:
• Vital signs: temperature, 98.4 ° F; heart rate, 84 beats/min and regular; respiratory rate, 16 breaths/min and not labored; blood pressure, 160/84 mm Hg
• Height: 5 ft, 6 in; weight: 164 lb
• Skin: warm and dry
• Right foot pale and cooler than left
• Pedal pulse: right foot 1 +; left foot 2 +
• Femoral pulse: 2 + bilateral
• Able to move toes equally
Pentoxifylline (Trental) is ordered, and an exercise program is prescribed. Doppler studies are scheduled.
Nursing diagnoses Activity Intolerance, related to pain when walking
Impaired Skin Integrity, related to decreased circulation
Ineffective Health Maintenance, related to lack of knowledge of the disease and the treatment plan
Outcomes The patient will identify factors that cause pain.
The patient will participate in a plan to increase activity and decrease claudication.
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The patient will demonstrate no sign of skin breakdown or impairment of skin integrity.
The patient will identify the risk factors of the disease, describe lifestyle changes, and participate in the treatment plan.
Interventions Plan activities to include a walking program.
Have the patient increase the walking regimen daily, up to 30 minutes per day.
Have the patient walk until experiencing pain, rest until pain abates, and then walk again.
Encourage the patient, and give reassurance that activity does not harm painful tissue.
Assist the patient in identifying, reducing, and eliminating risk factors (e.g., reducing weight and controlling hypertension).
Assess for ischemic ulcers.
Have the patient report ulcers or darkened areas on her skin to the health care provider.
Teach foot care measures, including daily inspection, daily washing using mild soap, and drying well; the patient may use lotion but should avoid use between the toes.
Teach the patient to cut her nails straight across, wear proper- fitting shoes, avoid going barefoot, avoid sandals, always wear socks with shoes, and eat a well-balanced diet that is low in saturated fat.
Explain the importance of pertinent risk factors (e.g., smoking, high cholesterol level, obesity, and hypertension).
Explain the importance of walking; help develop a walking program.
Instruct the patient to keep the extremity warm but not to use heating pads and hot water bottles.
Explain medications and when to call the health care provider.
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Identify available community resources.
Varicose veins of the leg occur particularly in women and may be divided into primary and secondary varicose veins. Primary varicose veins are more common, and the varicosity, which occurs in the wall of the vein, may be related to weakness of the wall or to incompetent valves of the saphenofemoral junction or perforating veins. Underlying causes include obesity, estrogenic hormones, and, in older adults, a previous occupation that required long periods of standing. Secondary varicose veins are the result of thrombosis in the deep system, which may subsequently occur with obstruction of the valves. The signs and symptoms of varicose veins are protrusion of veins on the legs, aching, ankle swelling, night cramps, skin changes such as itching, varicose eczema, and (in extreme cases) hemorrhage. The majority of cases may be treated with conservative therapy, including the use of elastic support bandages, regular exercise, and weight reduction. In more severe cases, surgical intervention such as sclerotherapy and ligation may be required.
Deep vein thrombosis (DVT) is a common and serious disorder and has been associated with 600,000 hospitalizations each year in the United States. Approximately 60,000 to 200,000 individuals die each year as a result of pulmonary embolism. Immobility (prolonged bed rest), advancing age (older than age 45), obesity, hormonal usage, and cigarette smoking are contributing factors. Medical conditions predisposing individuals to DVT include blood dyscrasias, cancer, systemic infection, dehydration, heart disease, stroke, inflammatory bowel disease, and incompetent venous valves. Patients at highest surgical risk are those undergoing knee or hip surgery; 10% to 40% of these patients develop thrombosis (Crowther & McCourt, 2004).
Venous ulceration occurs in patients who have chronic venous insufficiency. The superficial system is subjected to high pressure, which results in poor tissue oxygenation of the lower limbs. Venous ulcers occur on the medial side of the lower half of the leg. The ulcer is usually painful, may easily be infected, and, if left untreated, may involve the circumference of the leg. The management of venous ulceration depends on relieving the
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hypertension occurring in the superficial system through bed rest, elevation of the limb, and compression bandaging. A characteristic brownish discoloration of the skin develops from deposits of melanin and hemosiderin. Older adults often complain of heaviness in the legs.
Diagnostic Tests and Procedures Indirect methods to detect obstruction include Doppler ultrasonography, plethysmography, venous duplex ultrasonography, and contrast venography. Doppler ultrasonography measures venous obstruction and reflux of blood by changes in the frequency of sound waves. Laboratory work includes a platelet count, prothrombin time, PTTs, and INR.
Treatment The therapeutic aim of treatment of PVD is to preserve not only the limb but also its function. Interventions range from palliative measures to ease symptoms to the use of pharmacologic and surgical strategies to enhance blood flow and prevent clot formation.
Palliative measures are important for maintaining comfort. Preservation of skin integrity is of prime importance in maintaining the overall health of the limb. Pharmacologic intervention is directed at increasing blood flow and preventing clot formation. Specifically, anticoagulation therapy, with heparin and warfarin, is used to prevent further clot formation. For prophylaxis, rather than treatment during the acute phase, low-molecular-weight heparins (LMWHs) such as enoxaparin sodium (Lovenox) are used for their antithrombotic action. This class of medication has a lower risk of bleeding and does not require laboratory monitoring for therapeutic doses. Typically, LMWHs are given subcutaneously once or twice a day. A variety of surgical procedures may be performed to reduce the effects of PVD. Surgical procedures include those involving the superficial venous system and the deep venous system, as well as surgery for venous obstruction (Crowther & McCourt, 2004).
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Prognosis The prevalence, risk factors, and mortality rate for PVD in the older adult population have received limited attention in the literature, but varicose veins are known to be one of the most prevalent conditions in this population. DVT is diagnosed in 2.5 million people per year; 200,000 are first-time episodes. It is estimated that the mortality rate from DVT is 13% to 21% for a lower extremity and 48% for an upper extremity (Crowther & McCourt, 2004). Prevention, awareness, and immediate treatment are essential in avoiding complications or death.
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Nursing management Assessment
Assessment of an older adult with PVD begins with a complete history and physical examination. Subjective data include pain in the extremity, precipitating factors, relieving factors, modifiable risk factors, and personal and family history. Objective data include skin color, hair distribution, atrophy, edema, varicosities, petechiae, lesions, and ulcerations. Table 21-3 provides more information for the assessment of peripheral arterial and venous disease.
Table 21-3 Differentiating arterial and venous insufficiency
Assessment Arterial Disease Venous Disease Acute pain Sudden and severe Little or no pain; tenderness along
inflamed vein Chronic pain
Intermittent claudication; rest pain Heaviness; fullness
Hair Hair loss distal to occlusion No hair loss Nails Thick and brittle Normal Sensation Possible paresthesia Normal Skin texture Thin, dry, shiny Stasis dermatitis; veins may be visible;
skin mottled Skin color Pallor or reactive hyperemia (pallor when limb is elevated; rubor
when limb is dependent) Brawny (reddish brown); cyanotic, if dependent
Skin temperature
Cool Warm
Skin breakdown (ulcers)
Severely painful; usually on or between toes or on upper surface of foot over metatarsal heads or other bony prominence
Mildly painful, with pain relieved by leg elevation; usually in ankle area
Edema None or mild, usually unilateral Typically present (usually foot to calf); may be unilateral or bilateral
Pulses Diminished, weak, or absent Normal
Adapted from Lewis, S.L., et al., (2011). Medical surgical nursing: Assessment and management of clinical problems (8th ed.). (2011). St. Louis, MO: Mosby; Springhouse. (2007). Cardiovascular care. Philadelphia: Lippincott Williams & Wilkins; Centers for Disease Control and Prevention (CDC). (2012). Vital signs: Awareness and treatment of uncontrolled hypertension among adults - United States, 2003-2010. MMWR: Morbidity & Mortality Weekly Report, 61, 703-709.
Diagnosis Nursing diagnoses for an older adult with PVD include the following:
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• Risk for Impaired Skin Integrity, related to venous stasis and fragility of small blood vessels
• Ineffective Peripheral Tissue Perfusion, related to interruption of venous flow
• Pain, related to inflammatory processes
Planning and Expected Outcomes Expected outcomes for an older patient with PVD include the following:
1. Skin integrity will be maintained or improved.
2. The patient will exhibit no ulceration or signs of the inflammatory process.
3. Tissue perfusion will be improved, as evidenced by decreased edema and fewer complaints of discomfort.
Intervention Nursing interventions for an older patient with venous disease include assessment of skin integrity (e.g., skin texture, skin temperature, pain, color, edema, and pulses). The nurse should use a Doppler sensor if pulses seem to be absent. The affected extremity should be elevated to facilitate venous circulation, and the size of the affected limb should be measured and recorded at least daily. Elastic compression stockings may also be ordered; it is helpful to demonstrate their application and removal and require a return demonstration to assess the patient’s ability. Devices are available through medical supply companies for assistance with application, if necessary. Stockings should be replaced every 3 to 6 months in the absence of any evidence of excess wear.
If a patient has a DVT, bed rest is usually prescribed for several days. An older adult is at even greater risk for development of the complications associated with bed rest, so the nurse must implement measures based on the patient’s individual risk factors to prevent the hazards of immobility. The patient and family
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should be reassured that the activity restrictions are for a limited period.
Managing venous stasis ulcers involves healing the ulcers and preventing recurrence (see Chapter 28 for a full discussion of ulcer treatment options). Prevention of ulcer formation is of prime importance. The nurse should encourage ambulation to enhance collateral circulation. In fact, a progressive exercise program should be prescribed. Patients should be instructed to wear elastic or support stockings before walking and to avoid standing for prolonged periods. Instruction on foot care is an important part of the prevention plan. The skin should be inspected daily, washed gently in tepid water with a neutral soap, and patted dry, and special attention should be paid to adequately drying between the toes. A lubricant should be applied after washing to aid in retaining moisture. A professional should perform nail care. Shoes should fit well and provide good support.
Evaluation Evaluation focuses on the patient’s progress in improving skin integrity and venous circulation and reducing pain and discomfort, which is measured by a decrease in signs and symptoms. If skin is intact and edema is minimal, education has been successful. Documentation emphasizes accurate recording of the skin assessment, including measurements of the affected extremity.
Anemia Anemia is defined as a low RBC count, decreased quantity of hemoglobin, and decreased hematocrit. Anemia is not a diagnosis but a condition caused by some other pathologic condition. Because oxygen is carried on the hemoglobin molecule, anemia causes a decreased oxygen-carrying capacity of blood. The severity of the symptoms of anemia depends on the ability of compensatory mechanisms to respond. If the blood count drops quickly, these mechanisms are unable to fully correct the situation. The body adjusts by increasing cardiac output and respirations, increasing the
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release of oxygen from hemoglobin, and redistributing blood to the vital organs (Tefferi, 2003). An older adult’s compensatory mechanisms may be slower to respond because of coexisting chronic disease, which then causes symptoms of anemia to appear more quickly.
Anemias are classified according to the changes in the RBCs. The terms microcytic and macrocytic describe the size of the RBC: microcytic cells are smaller than normal, and macrocytic cells are larger than normal. The term chromic describes the color of the cell: hypochromic cells are pale. The three major classes of anemia are (1) normocytic normochromic, (2) macrocytic normochromic, and (3) microcytic hypochromic.
In normocytic normochromic anemia, the size of the RBCs and the amount of hemoglobin they contain are normal. Acute blood loss and anemia of chronic disease are examples. In macrocytic normochromic anemia, the RBCs are large but have normal amounts of hemoglobin. Vitamin B12 and folic acid deficiencies cause this type of anemia. In microcytic hypochromic anemia, the RBCs are smaller than normal and have a decreased amount of hemoglobin. Iron deficiency causes this type of anemia.
Symptoms vary in frequency and severity. Fatigue is a frequent complaint of older patients with anemia. Pallor is another common sign. Skin color is not a good indicator of pallor because of varying pigmentation. Oral mucous membranes as well as conjunctivae and nail beds are better indicators. Headaches, dyspnea, and dizziness are other common symptoms of anemia. Older adults may exhibit symptoms of anemia (e.g., fatigue and dizziness) but attribute these to the aging process or to other chronic diseases. The nurse should be aware of this so that detection and treatment can be initiated as soon as possible.
Anemia of chronic disease and nutritional anemias are common in older adults. Altered iron metabolism, deficiency of erythropoietin, and a shortened life span of RBCs are causes of anemia from chronic disease. Nutritional deficits and blood loss (commonly gastrointestinal) cause iron-deficiency anemia. Inadequate intake or inadequate absorption of folic acid and altered
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absorption of vitamin B12 are causes of macrocytic anemias.
Diagnostic Tests, Procedures, and Treatment With iron-deficiency anemia (microcytic hypochromic), the CBC with differential test shows decreased mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC). Iron and ferritin levels are decreased. Stool is tested for occult blood and is positive in anemia caused by gastrointestinal blood loss. The treatment includes dietary or supplemental intake of iron. Ferrous sulfate (325 mg) is given three times a day. Iron therapy should be given for 3 to 6 months to rebuild the iron stores.
With anemia of chronic disease (normocytic normochromic), the CBC with differential test shows normal MCV and MCHC. The iron level is decreased, but the ferritin level is normal or increased. The treatment focuses on the underlying disease. Blood transfusion for low hemoglobin is determined by the patient’s condition and coexisting diseases.
With folic acid deficiency, the CBC with differential shows an elevated MCV. The serum B12 level is normal, but the folic acid level is decreased. Gastric analysis reveals the presence of free gastric acid. Treatment includes an increased dietary intake of folic acid; older adults with alcoholism usually require a higher dose of folic acid.
With pernicious anemia, the CBC with differential shows an elevated MCV. The serum B12 level is normal. The gastric analysis shows no free gastric acid, and on gastroscopy the gastric mucosa appears pale and gray. The treatment is vitamin B12 (cyanocobalamin) given intramuscularly for life.
Prognosis The prognosis for anemia depends on the cause. With medications and dietary changes, the prognosis is usually good.
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Nursing management Assessment
The assessment of an older adult with anemia focuses on the underlying cause and its effects on functional ability (Box 21-8).
Box 21-8
Assessment of older adults with anemia Subjective Data History (gastric surgery, liver or renal disease, recent blood loss,
or trauma)
Current medications (over-the-counter vitamins and minerals, NSAIDs)
Nutritional habits
Alcohol intake
Change in bowel habits (color, consistency)
Weight loss
Complaints (fatigue, palpitations, dyspnea, paresthesia, painful tongue, dizziness, headache, or tinnitus)
Objective Data Pallor (of nail beds, conjunctivae, or oral mucous membranes)
Tachycardia
Tachypnea
Syncope
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Systolic murmur
Confusion
Unsteady gait
Stomatitis
CHF (severe anemia)
CBC values
CBC, Complete blood cell count; CHF, congestive heart failure; NSAIDs, nonsteroidal antiinflammatory drugs.
Diagnosis Nursing diagnoses for an older adult with anemia include the following:
• Activity Intolerance, related to an imbalance between oxygen supply and demand
• Imbalanced Nutrition: Less Than Body Requirements, related to malabsorption or decreased intake of vitamins, minerals, and nutritious foods
• Deficient Knowledge, related to lack of exposure to information about condition and treatment plan
Planning and Expected Outcomes Expected outcomes for the older adult include the following:
1. The patient will experience increases in activity without dyspnea or other previous symptoms over a period of 3 to 6 weeks.
2. The patient will consume a well-balanced diet with foods high in minerals and vitamins, as evidenced by weight increases of 1 lb per week.
3. The patient will verbalize an understanding of the cause of anemia and an understanding of the treatment plan.
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Intervention Nursing interventions for an older adult with anemia focus on dietary management, a balance of rest and activity to support functional ability, and education about the condition. Environmental safety issues are also important for an older patient experiencing symptoms that increase the risk of injury.
The patient and family should be instructed about appropriate food selection and meal preparation to promote RBC formation. The nurse should provide a list of foods high in iron, folic acid, and vitamin B12 to incorporate into the daily meal plan. The physician or nurse practitioner may order supplemental iron preparations and, if so, should assess the patient’s tolerance of the preparation. Side effects include gastrointestinal upset, constipation or diarrhea, and green or black stools. It may be helpful to recommend taking the iron preparation after meals to minimize gastrointestinal upset.
In addition to dietary recommendations, the gerontologic nurse should ensure that the older patient has adequate income to purchase necessary foods, the functional ability to purchase and prepare foods, and adequate oral health, including properly fitting dentures. The nurse should also be alert to the presence of other variables that may adversely affect the older adult’s ability to eat, such as loneliness, grief, depression, or alcoholism.
Nutritional considerations
DASH Diet Daily Food Group Servings Significance of EACH Food Grains 6 to 8 Energy and fiber Vegetables 4 to 5 Potassium, magnesium, and fiber Fruits 4 to 5 Potassium, magnesium, and fiber Low-fat or nonfat dairy foods
2 to 3 Calcium and protein
Lean meats, poultry, and fish
6 or less Protein and magnesium
Nuts, seeds, and legumes 4 to 5 per week Energy, magnesium, potassium, protein, and fiber Fats and oils 2 to 3 The DASH study had 27% of calories as fat, including fat in or added to
foods.
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Sweets and added sugars 5 or less per week
Sweets should be low in fat.
DASH, Dietary Approaches to Stopping Hypertension.
Modified from National Institutes of Health, National Heart, Lung, and Blood Institute. (2006). Your guide to lowering your blood pressure with DASH, NIH Publication No. 06– 4082. Washington, D.C.: U.S. Department of Health and Human Services.
Older patients and their families should also be instructed about balancing rest and activity. It is helpful for older adults to identify peak energy periods during waking hours and carry out desired or important activities during those times. However, patients should not carry out activities to the point of fatigue or dyspnea; rather, they should rest at intervals until activities are completed. Refer to Chapter 12 for interventions related to the safety of older adults who experience falls as a result of anemia.
Evaluation Evaluation focuses on the patient’s progress toward meeting the expected outcomes. Specifically, the older patient should have fewer complaints of dyspnea, fatigue, and dizziness, and weight should be within the established norm. Normal values of the older adult’s hemoglobin, hematocrit, and RBC count indicate the success of interventions. The older patient’s symptoms, weight trends, and activity levels are documented, along with any patient and family teaching.
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Summary CVD remains the leading cause of death in the United States. In the older adult population, it is often difficult to clearly distinguish between CVD and normal aging. The presentation and effects of CVD may vary widely from person to person. Older adults often display atypical symptoms of CVD and allow the disease process to advance before treatment is initiated. The challenge for the nurse is to obtain an accurate and complete assessment of an older adult patient that allows the planning and initiation of appropriate physical and psychosocial care. The nurse should focus on assisting older patients in modifying risk factors and optimizing health status.
Home care
1. Homebound older adult patients, spouses, family, significant others, and caregivers should be included in all aspects of the care planning process in the home setting.
2. Older patients value education in the home care setting, and this should continue as an important focus of care after hospitalization.
3. Older adult patients dealing with chronic disease management in the home setting often experience anxiety, frustration, and depression. This factor should be taken into consideration when providing home care services, and appropriate interagency referrals should be initiated.
4. The fear of dying is often a major factor for homebound older adults with cardiovascular disease, particularly congestive heart failure (CHF). Counseling and referral to agencies should be provided.
5. Homebound older adults have a high anxiety level about
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needing help and not being able to obtain it. Establishing a link with an emergency community service such as a lifeline program may alleviate some anxiety.
6. The nurse should direct teaching of homebound older adults toward the anatomy and physiology of the heart, modifiable risk factors, medication regimens (especially in regard to dosage and side effects), exercise tolerance, daily weight monitoring, and dietary factors (e.g., low-sodium and low-fat diets and fluid restriction).
7. Caregivers need to be educated about signs that suggest deterioration in status.
8. Assistance with activities of daily living (ADLs) may be required, especially for those homebound older adults who live alone or are responsible for household tasks. Often, these older adult patients do not request assistance, so the nurse should offer these services where appropriate.
9. Participation in a cardiac rehabilitation program or activities such as walking or swimming should be encouraged by the home care nurse.
10. Homebound older adult patients should be encouraged to wear medical alert bracelets that identify their conditions and medications.
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Key points • CVD is the leading cause of death among both men and women.
• For those older than age 65, mortality rates for CVD rise sharply, and it is anticipated that the actual number of deaths resulting from CVD will escalate as the proportion of the older adult population increases.
• Older adults who stay physically fit have twice the work capacity and a lower amount of body fat than older adults who are sedentary.
• Smoking cessation in older adults significantly reduces the risks of coronary events and cardiac death within 1 year of quitting. The risk continues to decline gradually for many years thereafter.
• Smokers have twice the chance of developing CAD and four times the chance of sudden death compared with nonsmokers.
• It is estimated that more than 45% to 50% of the population older than age 65 has high blood pressure, and the consequences are the most common causes of morbidity and mortality, including MI, CHF, and PVD.
• Older adults may have difficulty adopting healthier lifestyles because of long-term habits; however, healthy behavior changes may slow or halt the progression of disease.
• Older adults have more atypical signs of CAD.
• Older adults may not recognize the onset of ischemia. Initial symptoms may consist of sudden dyspnea, confusion, fatigue, weakness, vertigo, syncope, vomiting, and exacerbation of heart failure.
• The incidence of atrial fibrillation increases with age and is the most common contributing factor to ischemic stroke in older adults.
• Atrial fibrillation, sick sinus syndrome, and heart block appear more often in the older adult population as a result of fewer pacemaker cells and extensive deposits of fat and fibrous tissue
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throughout the conduction system.
• Orthostatic hypotension is a major risk factor for syncope and falls in older adults.
• Older adults are prone to dizziness with position changes, resulting from decreased sensitivity of baroreceptors.
• CHF is the leading cause of hospitalization in the older adult population.
• Older adults may exhibit symptoms of anemia that are attributed to the aging process or to a variety of chronic diseases.
• Nursing interventions (e.g., education on the role of cardiovascular risk factors, preventive measures, and treatment regimens) may enhance the quality of life of older patients, reduce hospitalization, and positively affect the cost-effectiveness and efficiency of cardiovascular programs.
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Critical thinking exercises 1. You are preparing to teach an 85-year-old woman about the actions and side effects of nitroglycerin for the treatment of angina. What aspects of teaching would you emphasize, given the patient’s age?
2. A 78-year-old woman has a long-standing history of atrial fibrillation. She takes digoxin (Lanoxin) (0.125 mg) and warfarin (2.0 mg) daily. She recently read of the advantages of taking aspirin and started taking four tablets daily. How would you intervene in this situation, and why?
3. What specific assessment findings indicate that an older adult patient being treated for CHF is not responding to digoxin, furosemide (Lasix), and vasodilator therapy? How would you differentiate between expected, adverse, and toxic side effects?
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* Original authors: Darlene Stevens, PhD, MHSA, BSN, BA, RN, & Rhonda Kirk-Gardner, MSN, RN, BSN, BAd; Revised: Leann Eaton, MSN, RN, ANP; Lynn Ferebee, MSN, RN, FNP; and Barbara D. Powe, PhD, RN.
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C H A P T E R 2 2
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Respiratory Function Sue E. Meiner, EdD, APRN, BC, GNP
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe anatomic changes in the lungs resulting from the normal aging process.
2. Describe age-related changes in ventilation.
3. Identify nursing interventions and outcomes for older adults with various respiratory alterations.
4. Discuss smoking cessation methods and interventions.
5. Identify risk factors for the development of tuberculosis in older adults.
6. List the benefits of pulmonary rehabilitation for older adults with chronic obstructive pulmonary disease.
7. Identify age-related changes to sleep patterns and disorders.
http://evolve.elsevier.com/Meiner/gerontologic
The respiratory system is responsible for gas exchange between the environment and blood and involves two processes: ventilation and oxygenation. Ventilation is the movement of air into and out of the lungs and consists of inhalation and exhalation. During inhalation, oxygen-rich air is moved into the lungs, and then during exhalation carbon dioxide (CO2)-rich air is moved out. During oxygenation, CO2 is transferred from the vasculature to the pulmonary side of the lungs and oxygen is transferred from the pulmonary side to the vasculature, where it is loaded onto hemoglobin. The process of respiration, including rate and depth, are controlled by chemoreceptors in the medulla oblongata, the
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arch of the aorta, and in the carotid artery and are sensitive to oxygen levels and pH. Respiration depends on adequate structures for moving air during ventilation, an environment where oxygen and CO2 can transfer, and chemoreceptors sensitive to the maintenance of oxygenation and pH levels.
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Age-related changes in structure and function Normal aging results in changes to the ribs and vertebrae. The ribs become less mobile, and chest wall compliance decreases. Osteoporosis and calcification of the costal cartilage lead to increased rigidity and stiffness of the thoracic cage. If kyphosis or scoliosis is present, degeneration of the intervertebral disks occurs, resulting in a shorter thorax with an increased anteroposterior diameter. Advanced cases may result in marked limitation of thoracic movement because of the rib cage resting on the pelvic bones. Progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and the opposing forces of the chest wall also are present. The lung becomes less elastic as collagenic substances surrounding the alveoli and alveolar ducts stiffen and form cross-linkages that interfere with the elastic properties of the lungs. Any and all of these structural changes makes it more difficult for the older person to ventilate. It requires more energy. Table 22-1 summarizes various changes in the aging respiratory system.
Table 22-1 Age-related changes in the respiratory system
Respiratory Function
Pathophysiologic Changes Clinical Presentation
Mechanics of breathing
Increased chest wall compliance Decreased vital capacity
Loss of elastic recoil Increased reserve volume Decreased respiratory muscle mass and strength Decreased expiratory flow rates
Oxygenation Increased ventilation–perfusion mismatch Decreased PaO2 Decreased cardiac output Increased A–a oxygen gradient Decreased mixed venous oxygen Increased physiologic dead space Decreased alveolar surface area available for gas exchange Reduced CO2 diffusion capacity
Control of ventilation
Decreased responsiveness of central and peripheral chemoreceptors to hypoxemia and hypercapnia
Decreased Vt Increased respiratory rate Increased minute ventilation
Lung defense mechanisms
Decreased number of cilia Decreased ability to clear secretions
Decreased effectiveness of mucociliary clearance Increased susceptibility to infection Decreased cough reflex Increased risk of aspiration Decreased humoral and cellular immunity
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Decreased IgA production Sleep and breathing
Decreased ventilatory drive Decreased upper airway muscle tone Decreased arousal
Increased frequency of apnea, hypopnea, and arterial oxygen desaturation during sleep Increased risk of aspiration Snoring Obstructive sleep apnea
Exercise capacity
Muscle deconditioning Decreased muscle mass
Decreased maximum oxygen consumption
Decreased efficiency of respiratory muscles Breathlessness at low exercise levels Decreased reserves
Breathing pattern
Decreased responsiveness to hypoxemia and hypercapnia
Increased respiratory rate Decreased Vt
Change in respiratory mechanics Increased minute ventilation
Modified from Pierson, D.J. & Kacmarek, R.M. (Eds.). (1992). Foundations of respiratory care. New York: Churchill Livingstone. A–a, Alveolar–arterial; IgA, immunoglobulin A; PaO2, partial pressure of arterial oxygen; Vt; tidal volume.
Muscle strength declines with age, and as respiratory muscles weaken, it becomes increasingly more difficult to exert inspiratory and expiratory forces. The combination of an increasingly stiffer skeletal structure and weaker muscles results in additional effort and energy to breathe. The diaphragm, a major respiratory muscle, flattens and becomes less efficient in patients with advancing chronic obstructive pulmonary disease (COPD). Because of this, older adults use the less efficient accessory muscles of respiration such as the abdominal, sternocleidomastoid, and trapezius muscles. As the abdominal muscles become more important to older adults, their breathing patterns may become much affected by positioning and increased abdominal pressure.
Respiratory rates generally are faster and shallower in older adults: a normal rate is 16 to 25 breaths per minute. This combination results in a relatively unchanged arterial CO2 pressure (PaCO2). However, shallow breathing patterns may result in hypoxemia and hypercapnia as the alveoli at the base of the lungs are under-ventilated, which, in turn, results in a decreased ventilation–perfusion ratio and less effective alveolar gas exchange. Age-related reductions in cardiac output and mixed venous oxygen content compound the effect of the ventilation–perfusion imbalance in older adults. In healthy older adults, the number of alveoli remains relatively unchanged but their structure is altered. As a result, the number of functioning alveoli decreases. With age, alveolar supporting structures deteriorate, which leads to a progressive loss of the intraalveolar septum. As the alveolar septal
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walls become thinner, the alveoli enlarge because of dilation of the proximal bronchioles, but fewer capillaries are available for gas exchange. The increase in physiologic dead space is seen as the capillary structures surrounding the alveoli diminish. The result is a decrease in the surface area available for gas exchange from the normal 80 square meters (m2) at age 20 to about 65 to 70 m2 by age 70. As such, less surface area is available for gas exchange to take place, which contributes to the systemic reduction in the partial pressure of arterial oxygen (PaO2).
Older adults have a decrease in the number and effectiveness of cilia in the tracheobronchial tree, which results in increasing difficulty clearing secretions. Older patients also have decreased immunoglobulin A (IgA), which is found in the nasal respiratory mucosal surface that neutralizes viruses. The combination of decreased IgA and an increase of pooling secretions make infections more likely. With repeated respiratory tract infections or smoking, the effectiveness of the ciliary action and the number of cilia are significantly decreased, which results in an ineffective mucociliary escalator (Brashers, 2012).
One of the primary functions of the respiratory system is gas exchange. For a healthy adult, the normal PaO2 is 80 to 100 mm Hg. However, after the age of 60, the PaO2 drops by 1 mm Hg per year. Therefore, a PaO2 of 70 mm Hg for a 70-year-old is relatively normal, which is how the phrase “70 at 70” originated. The expected decrease in PaO2 is most likely caused by some of the factors previously discussed—reduced tidal volume, less alveolar surface area, and increased residual volume.
The oxygen-carrying capacity of blood is reduced with age. Hemoglobin is the molecule most responsible for oxygen transport to peripheral tissues, but its levels are diminished in older adults. The alveolar–arterial (A-a) oxygen gradient, a measure of the efficiency of oxygen transfer from lungs to the blood, compares the partial pressure of oxygen in alveolar air (PAO2) with the PaO2. With rapid diffusion in a healthy adult the net difference is close to zero. This gradient normally increases in older adults, most likely because of the ventilation–perfusion mismatch (Brashers, 2012).
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The arterial pH of the older person remains within the normal adult range of 7.35 to 7.45 unless influenced by an acute illness or comorbidity. Despite an increase in residual volume, PaCO2 does not normally rise, primarily because of increased ventilation. However, older adults do not react as quickly to changes in either hypoxemia or hypercapnia. The normal clinical response to hypoxemia is an increase in the rate and depth of respiration as well as an increase in heart rate and blood pressure. Older patients show less increase in heart rate and a lower response to increasing CO2. In fact, their ventilatory responses to hypoxia and hypercapnia may be diminished by as much as 50% in comparison with adults in their 20s largely as a result of a reduced sympathetic nervous system response. Therefore, careful assessment is crucial. The most sensitive clinical indicator for hypoxia and hypercapnia in older adults is mental status changes and complaints of occipital headaches or forgetfulness that are not otherwise explained. Finally, dyspnea on exertion is an increasing problem because any increased oxygen demand may lead quickly to symptomatic hypoxia (Brashers, 2012).
As previously described, many of the changes in pulmonary functions in older adults are related to the changes in elastic recoil and musculoskeletal changes of the chest wall. Table 22-2 lists the lung volumes measured, the normal findings, and alterations related to aging. The ability to determine accurate pulmonary function by testing requires patience on the part of the health care provider as an older patient may not be able to perform quickly. Ensure adequate time for this assessment of the older adult patient.
Table 22-2 Pulmonary function changes in older adults
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Although the total lung capacity (TLC) remains relatively unchanged, the individual volumes that comprise TLC change dramatically. Tidal volume (Vt) is decreased in older adults. Vital capacity (VC) is also decreased as a result of decreased mobility of the chest wall and altered inspiratory and expiratory capabilities. The rate of reduction of VC is greater in older men than in older women. The inspiratory capacity of older adults is affected by the decreased ability to take deep breaths. Decreased compliance of the thorax accounts for the increase in residual volume (RV) and expiratory reserve volume (ERV). RV is also reduced because of decreased muscle strength and a shallow breathing pattern. As a result, functional dead space ventilation is increased from one third to as much as one half of each breath, which results in a decrease in the volume of air that can participate in gas exchange (Brashers, 2012).
Air flow in the tracheobronchial tree is affected by the size of the airway, resistance in the airway, muscle strength, and elastic recoil. When measured in the older patient, all of these indices are decreased. Forced expiratory volume in 1 second (FEV1) is reported to drop between 25 and 30 milliliters (mL) per year after age 30. Changes in the air flow measures are related to the stiffness of the chest wall and the loss of elastic recoil of the lungs. The decrease in thoracic muscular strength contributes to the decreased force of the air moved, and as much as a 50% reduction may occur in the maximum voluntary ventilation and FEV between ages 30 and 90.
At low tidal volumes, small airways tend to close early because of the loss of elastic recoil and decreased flow rates caused by
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increased airway resistance, trapping air in the alveoli. Closing capacity (CC), the volume at which the smallest airways close, increases with age, and by age 65 it exceeds the functional residual capacity (FRC) when in the upright position. This contributes to early airway closure. Other factors contributing to early airway closure include increased time in a supine position and shallow breathing.
In younger adults, pulmonary vascular circulation is a relatively low pressure system with high distensibility and low resistance. As adults age, these vessels become less distensible and more fibrous, which results in increased pulmonary artery diameter and greater thickness of the vessel wall; in turn, these increases result in increased pulmonary vascular resistance and increased pulmonary artery pressure. The alveolar capillary membrane also thickens, which further reduces the surface area available for gas exchange. The number of functional capillaries declines, which results in decreased alveolar vascularity; this, in combination with a diminished cardiac output, causes a decrease in pulmonary capillary blood flow (Brashers, 2012).
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Factors affecting lung function Exercise and Immobility Exercise has a positive effect on the respiratory and cardiovascular systems. However, the ability of older patients to perform exercise is affected by the changes in cardiac output, skeletal muscle function, joint function, and overall coordination.
Increased oxygen demands during exercise periods may well exceed the abilities of older patients, and for those with COPD, activity intolerance is exacerbated. In addition, older patients are more likely to have comorbidities involving the cardiovascular and respiratory systems. Strength and endurance may also be reduced, which leads to increased immobility and increased breathlessness when activity is attempted. Older patients with COPD and immobility may benefit from a program of regular exercise to increase strength and endurance and decrease breathlessness as the respiratory muscles become trained (see Health Promotion/Illness Prevention box).
Smoking Smoking damages the lungs. Prolonged exposure to secondhand smoke has also been shown to damage the lungs of
Health promotion/illness prevention The Respiratory System • Avoidance of cigarette and secondhand smoke
• Avoidance of environmental and air pollutants
• Healthy diet and exercise plan
• Immunizations
• Avoidance of allergens
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• Use of mask, scarves, and filters to protect against community- acquired illnesses
• Stress management and relaxation for breathing control
• Early diagnosis and treatment of respiratory tract infections
• Careful monitoring and adherence to medical regimen for chronic respiratory illnesses
• Maintenance of a clean environment (e.g., dusting regularly, changing air filters in furnace every 3 months, changing toothbrush every 3 to 4 months and after an illness)
• Maintenance of adequate hydration (at least 64 ounces of water daily)
nonsmokers. Heavy smokers may demonstrate a nine times increase in the reduction of FEV1 over normal expected reductions. Cilia, which are paralyzed by nicotine, are unable to protect and clean the lungs, and, when coupled with the increased mucus production of goblet cells that is induced by tobacco, respiratory infections become more likely. Cigarette smoke also causes bronchoconstriction, increased airway resistance, and increased closing volumes and interferes with gas exchange because carbon monoxide, a byproduct of tobacco, competes with oxygen for the hemoglobin molecule. Many medications are also affected by smoking, which decreases clearance and increases serum drug levels. Some drugs altered by smoking include antidepressants, propranolol, theophylline, aminophylline, insulin, erythromycin, and lidocaine (Fiore et al., 2000; Sarna & Bialous, 2010).
During an assessment of social behaviors, a smoking history needs to include pack-years, that is, the number of packs smoked per day multiplied by the number of years the patient has smoked. An example is someone who has smoked two packs per day from age 15 through age 40, but increased to 3 packs until quitting smoking at age 62. Subtract 15 from 40 and multiply by 2; then, subtract 40 from 62 and multiply by 3. Add the two numbers and the total is 106 pack-years (Sarna & Bialous, 2010).
Smoking Cessation
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Smoking cessation is imperative. The five components (five As) of smoking cessation consist of asking, advising, assessing, assisting, and arranging. At each encounter, the patient is asked about tobacco use. This gives the health care worker an opportunity to advise and discuss the health benefits and promote smoking cessation. When speaking to older adults, the nurse should use strong, clear, and personalized language. The nurse should
Evidence-based practice Multicomponent Smoking Cessation Intervention
Sample/Setting A convenience sample was taken of 85 patients who had been admitted to a pulmonary unit in the acute care setting.
Methods The intervention was shaped by the Transtheoretical Model. All participants were prescribed a nicotine replacement therapy medication and individual and group counseling and were supported by the nurse–patient relationship. Interventions were accomplished during hospitalizations and via telephone at 1 week, 1 month, 3 months, 6 months, and 1 year after discharge.
Findings Of the patients, 39% reported continued abstinence throughout the study and 52% were not smoking at the 12-month period.
Implications Nurses should use every nurse–patient interaction to motivate and educate their smoking patients to try to quit. (From Jonsdottir, H., Jonsdottir, R., Geirsdottir, T., et al. (2004). Multi-component individualized smoking cessation intervention for patients with lung disease. Journal of Advanced Nursing, 48(6):594–604.)
assess older adults for their willingness to give up smoking and determine how soon they are ready to start the process. Then the
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nurse assists older adults with smoking cessation by encouraging them to set a quit date, reviewing preparations for quitting (e.g., removing associated objects such as ashtrays), recommending nicotine replacement therapy, providing advice on successful quitting (e.g., avoid constant exposure to other smokers), providing supplemental educational materials, and offering appropriate skills training and support. Finally, the nurse arranges for follow-up (Agency for Health Care Research and Quality [AHCRQ], 2000).
Many new treatments are available to older smokers to assist with quitting. These include the use of bupropion hydrochloride, nicotine gum, nicotine patches, and nicotine inhalation systems. Bupropion hydrochloride is given for 3 days at 150 milligrams (mg) per day and then increased to 150 mg twice a day, with doses 8 hours apart and the first dose in the morning. Older patients are allowed to smoke during the first week of treatment and encouraged to set a quit-smoking date before the end of the first 14 days of treatment. Nicotine inhalation systems, gums, and patches are used to replace the patient’s need for nicotine. While using these nicotine substitutes, the older adult patient should not smoke. Gradually, over a 6- to 8-week period, the frequency of usage is decreased.
Obesity Obesity results in a decrease in chest wall compliance and reduction in FRC, VC, and ERV because the additional weight of the relatively stiffer chest is harder to move. Pulmonary functions are reduced, and breathlessness increases. The combination of decreased ability to take a deep breath, early airway closure, and the increased likelihood of immobility puts the older patient at high risk of developing atelectasis and upper and lower respiratory tract infections.
Excessive weight may result in sleep apnea caused by interference with normal ventilation. Hypoventilation is seen in morbidly obese persons whether awake or asleep. Fluid retention is another rationale for rapid weight gain and is associated with decreased pulmonary gas exchange.
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Sleep Older adults typically have more difficulty falling asleep, spend less time in the deeper stages of sleep, have irregular and early morning awakenings, and have less total sleep time. Diminished cough and arousal reflexes increase the likelihood of aspiration during sleep.
Older adults are also more likely to have primary sleep disorders, take medications that interfere with sleep, and suffer from sleep apnea. Older males with pathologic conditions of the prostate have increased nocturia. In short, older adults are at increased risk of insomnia. Older adults are also more likely to have hypertension and to be overweight, both of which make sleep apnea more likely. If a primary sleep disorder is suspected or physical functioning becomes impaired, formal sleep studies may be appropriate (Bloom, Ahmed, Alessi et al., 2009).
Anesthesia and Surgery An older patient undergoing surgery has an increased risk of aspiration as a result of loss of laryngeal reflexes. If surgery is an emergency, this risk is increased because of the older patient’s delayed gastric emptying and the potential for a full stomach. Even younger, healthier adults have the risk of postoperative atelectasis because of general anesthesia and the inability or unwillingness to cough and deep breathe because of incisions, pain, and drowsiness. In the older adult, these risks are amplified because of decreased muscle strength, a decreased cough reflex, and a greater likelihood of alterations in consciousness. Postoperative immobility decreases ventilation and increases the risk of airway clearance problems. The older adult has a reduced thirst sensation. A healthy adult patient tends to be slightly “dry” after surgery, but the reduced thirst sensation of the older adult increases the risks of hypovolemia and resultant thickened secretions that are difficult to clear. Promotion of deep breathing for effective pain management, adequate hydration, frequent position changes, and early mobility will decrease the risk of developing atelectasis.
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Respiratory symptoms common in older patients Respiratory symptoms common in older patients include alterations in breathing patterns, dyspnea, and coughing. Abnormal breathing patterns in older patients may also be indicative of other metabolic and respiratory illnesses. An early sign of respiratory problems is a change in mental status. Because the physiologic responses to hypoxemia and hypercapnia are blunted in older patients, compensatory changes in heart rate, respiratory rate, and blood pressure may be delayed and cerebral perfusion may suffer. Mental status changes may include subtle increases in forgetfulness and irritability. Older patients may also complain of an occipital headache or confusion when awakening from sleep. If these signs persist, a more in-depth evaluation of the older patient’s respiratory status is indicated.
Complaints of dyspnea or breathlessness in older patients are often associated with underlying respiratory and cardiac disease. Dyspnea is a perception of breathlessness that is difficult for the older patient to quantify; dyspnea may therefore be dismissed, especially when no clinical evidence can be attributed to the complaint. Older patients most often describe their breathlessness as a sensation of an inability to get enough air, difficulty taking a deep breath, breathing rapidly, or a choking or smothering feeling. Dyspnea at rest is most often associated with an acute respiratory or cardiac illness, whereas dyspnea on exertion may be related to immobility and respiratory muscle deconditioning. Older patients with COPD may experience dyspnea on exertion initially and dyspnea at rest as the disease progresses (see Evidence-Based Practice box: COPD and Dyspnea). Dyspnea is a common complaint in older patients with pulmonary disease. However, older patients usually do not complain of dyspnea until it begins to interfere with their activities of daily living (ADLs) and then only if those activities are important to them. For example, it may become difficult to use the stairs. An older patient may simply choose the elevator or escalator and not consider reporting the shortness of
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breath associated with stair climbing. It is important to determine which ADLs an older patient no longer participates in and why.
Evidence-based practice Chronic Obstructive Pulmonary Disease (COPD) and Dyspnea
Sample/Setting The sample consisted of 41 hospitalized subjects with COPD from an urban medical center in the northeastern region. The average age of the subjects was 70 years, with a range of 43 to 89 years.
Methods The subjects were all asked five questions about dyspnea by the nurses, who recorded the subjects’ responses verbatim. The last question asked the subjects to numerically rate their level of dyspnea during their acute attack using the Modified 0–10 Borg Scale.
Findings Common themes from the subjects’ answers to question 1 included fear, helplessness, and urgency. The question 2 theme was presence. The theme of question 3 was legitimacy and preoccupation with breathing. The theme of question 4 was external demands. The range of scores for the dyspneic episode was 7 (very severe breathlessness).
Implications Nurses need information to help them address the subject’s pathophysiologic components and the psychological components that accompany dyspnea. (From Heinzer, M. M., Bish, C., & Detwiler, R. (2003). Acute dyspnea as perceived by patients with chronic obstructive disease. Clinical Nursing Research, 12(1):85.)
The cough mechanism in older patients is altered because of the
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loss of elastic recoil and decreased respiratory muscle strength. Causes of coughing in older patients include postnasal drip, chronic bronchitis, acute respiratory tract infections, aspiration, gastroesophageal reflux disease (GERD), congestive heart failure (CHF), interstitial lung disease, cancer, and angiotensin-converting enzyme inhibitor (ACEI) medications for hypertension and CHF. Because of the age-related changes that affect an older patient’s coughing mechanism, it is important to recommend cough suppressants with caution. Suppression of the cough and depression of any respiratory function could lead to retention of pulmonary secretions, plugged airways, atelectasis, and aspiration.
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Respiratory alterations in older patients Chronic respiratory disease affects not only older patients but also their families (Kanervisto, Paavilainen, & Heikkil, 2007). Many patients with respiratory illness feel a loss of control over their lives because of breathlessness on exertion and at rest. They may become demanding and controlling in dealing with their families and friends. The quality of older patients’ lives depends on their feelings about and control of the disease. Support groups sponsored by the American Lung Association and local hospitals are available to help patients and families deal with anger, loss of control, and hopelessness. The family or a significant other needs to be included in all aspects of planning and care for an older patient with respiratory illness. The patient’s success in complying with the medical recommendations may depend on the assistance he or she receives in getting to the physician’s office, getting to the pharmacy for medications, administering medications, and performing ADLs. Older patients with respiratory disease need a good family support system and a health care team to support both them and their families (see Evidence-Based Practice: COPD and Family Dynamics).
Evidence-based practice Chronic Obstructive Pulmonary Disease (COPD) and Family Dynamics Sample/Setting The study included 35 patients with severe COPD and 30 families.
Methods Data were collected with the use of the Family Dynamics
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Questionnaire—Family Dynamics Measure 2. The frequency, percentage distributions, and cross tabulations were calculated.
Findings Poor self-identity, isolation from others, and a lack of flexibility to varying conditions may weaken the ability of families to manage normal life events.
Implications Family nursing can have an impact on patients and their families. Assess the families’ understanding of their roles and expectations and support them and provide referrals, as necessary. (Kanervisto, M., Paavilainen, E., & Heikkil, J. (2007). Family dynamics in families of severe COPD patients. Journal of Clinical Nursing, 16(8), 1498–1505.)
Respiratory disease is divided into two categories: (1) obstructive pulmonary disease and (2) restrictive pulmonary disease. Obstructive lung diseases are characterized by changes in expiratory air flow rates and obstruction of the airway. The lumen of the airway may be decreased by mucus, edema of the airway lining, or constriction of the muscles surrounding the airway, causing bronchoconstriction. Restrictive lung disease is characterized by decreased ability to expand the chest, impaired inhalation, and decreased lung volumes. Changes in the chest wall, lung parenchyma, pleural space, and extrapulmonary factors such as body mass may result in restrictive lung disease. Examples of these diseases include bronchogenic carcinoma and tuberculosis. Other respiratory diseases seen in older patients include bronchopulmonary infections, pulmonary edema, and pulmonary emboli (CDC, 2012c).
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Obstructive pulmonary disease Asthma Asthma is a chronic inflammatory disease that affects the airways and is characterized by reversible airway obstruction, airway inflammation, and increased airway responsiveness to a variety of stimuli. Asthma has higher morbidity and mortality rates in older adults than in other age groups. Older patients diagnosed with asthma have lower expiratory flow rates and fewer symptom-free periods. Because of other comorbidities a diagnosis of asthma may be delayed by the provider. Asthma occurs in about 8.3% of older adults after age 65. Many of these older adults have asthma as a continuing chronic disorder (Centers for Disease Control and Prevention [CDC], 2012b).
Airway inflammation contributes to airway hyperresponsiveness; air flow limitations, including acute bronchoconstriction, airway edema, and mucous plug formation; airway wall remodeling; respiratory symptoms; and disease chronicity (National Heart, Lung, and Blood Institute [NHLBI], 2007). Inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, often at night or early in the morning. Blood vessel dilation and capillary leakage is caused by inflammation of airway mucous membranes. This leads to tissue swelling and increased secretions with mucus production (Brashers, 2012).
Recent evidence suggests that persistent abnormalities in lung function are associated with subbasement membrane fibrosis in some patients. Patients with asthma, especially older patients who may not have had this disease through most of their lives, require careful education to include self-management, how to adjust medications during exacerbations, and the correct way to prepare themselves for exposure to known triggers.
An asthma attack may be precipitated by exposure to allergens or irritants such as changes in weather, odors, or stress. In older patients, asthma is often associated with viral respiratory infections. Signs and symptoms include dyspnea, audible wheezing,
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palpitations, tachypnea, tachycardia, use of accessory muscles of respiration, pulsus paradoxus, diaphoresis, and chest hyperinflation. Initially, a patient may hyperventilate and effectively blow off increasing CO2. Falling PaO2 and pH with rising PaCO2 are indicative of imminent respiratory failure. The increasing PaCO2 is a result of the patient’s exhaustion and inability to hyperventilate.
Prognosis The prognosis for an older adult with asthma is relatively good. Success is based on a partnership between the patient and the health care provider to properly use prescribed medications, avoid asthma triggers, identify early signs of exacerbation, and maintain a healthy lifestyle.
Treatment The goals of asthma therapy are to control asthma by reduction of impairment and risk, which may be achieved by (1) preventing chronic and troublesome symptoms such as coughing or breathlessness during the day, at night, or after exercise, (2) maintaining (near) normal pulmonary function, (3) maintaining normal activity levels, including exercise and attendance at work or school, (4) requiring infrequent use (≤ 2 days a week) of inhaled short-acting beta2-agonists (SABAs) and satisfying the patient’s and family’s expectations of asthma care, (5) preventing recurrent exacerbations and minimizing emergency department visits, and (6) providing optimal pharmacologic treatment with minimal or no adverse effects (NHLBI, 2007). A stepwise approach to pharmacologic management is recommended by the NHLBI (2007). The specific drug, dose, and frequency are dictated by the severity of the asthma attack at the time that therapy is initiated, and subsequently, the drug should be stepped down to maintain long- term control with the minimum medication necessary. Medications are classified into two categories: (1) long-term-control medications and (2) quick-relief medications.
Long-Term Control Medications
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Long-term control medications are taken on a daily basis and include antiinflammatory agents, long-acting bronchodilators, and leukotriene modifiers. Corticosteroids are the most potent and effective long-term-control medications in the treatment of mild, moderate, or severe persistent asthma. They are well tolerated and safe when used at the recommended dosage. Most of the benefit is achieved with relatively low doses, and the potential for side effects increases with the dose. However, for asthma not controlled with maintenance doses of corticosteroids, two options are now available. The first is to combine the corticosteroids with long- acting beta2-agonists (LABAs), and the second, most recent recommendation is to increase the dose of corticosteroids (NHLBI, 2007). The clinical response to corticosteroids is a reduction in airway inflammation, improvement in peak expiratory flow rate (PEFR), diminished airway hyperresponsiveness, prevention of exacerbations, and possible prevention of airway wall remodeling. Corticosteroids are generally inhaled twice a day.
LABAs act by relaxing the smooth muscle of the airways and stimulating beta2-receptors to increase cyclic adenosine monophosphate (cAMP). They are not recommended as a monotherapy for long-term control but, rather, are often prescribed in combination with corticosteroids. The duration of action is 12 hours for a single dose. These medications are also not indicated for acute exacerbation, although they may be used to prevent exercise- induced exacerbations; however, when beta2-agonists are used on a long-term basis before exercise, their effects last only 5 hours. An example of these medications is inhaled salmeterol (Serevent Diskus), or formoterol (Foradil).
Leukotriene modifiers are potent biochemical mediators that are released from mast cells, eosinophils, and basophils. They act on the lungs, causing airway smooth muscle contraction and increased mucous secretion; they also attract and activate inflammatory cells in the airways. Leukotriene antagonists improve lung function, diminish symptoms, and reduce the need for SABAs. They are an alternative, although not preferred, therapy for the treatment of mild persistent asthma. They may also be used with corticosteroids, although the LABAs are the preferred adjunct. An example of a
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leukotriene antagonist is montelukast (Singulair) or zafirlukast (Accolate). These drugs block the leukotriene receptors, whereas zileuton (Zyflo) prevents leukotriene synthesis. These drugs do not reverse symptoms during an asthma attack and should not be used as rescue medication (Workman, 2013).
Cromolyn and nedocromil stabilize mast cells. Although they are not the preferred method of treatment, they are also an alternative therapy for mild persistent asthma and may also be used before exercise or before a known exposure to a trigger.
The immunomodulators are monoclonal antibodies that prevent the binding of IgE to the receptor cells of the basophils and mast cells. They are used for the treatment of severe persistent asthma, especially if allergies are the primary trigger. The nurse should always be prepared and equipped to treat for anaphylaxis that may occur.
Quick-Relief Medications Quick-relief medications are used to treat acute symptoms and exacerbations such as chest tightness, coughing, and wheezing. This group of medications includes SABAs, anticholinergics, and systemic corticosteroids. SABAs are bronchodilators that provide smooth muscle relaxation within 30 minutes and are the drug of choice for treating acute asthma symptoms and preventing exercise- induced exacerbations (NHLBI, 2007). Older patients who use more than one canister per month do not have adequate control and need additional antiinflammatory therapy. Daily use of SABAs is not recommended.
Anticholinergics such as ipratropium bromide (Atrovent) may provide an additive benefit to inhaled beta2-agonists in the treatment of severe exacerbations. They may also be used as an alternative to SABAs in patients who do not tolerate them well. Finally, systemic corticosteroids, although not short acting, may be used in the treatment of moderate to severe asthma exacerbations as an adjunct to the SABAs. Their onset of action is more than 4 hours, and they act by preventing progression of the exacerbation, speeding recovery, and preventing early relapse (NHLBI, 2007).
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Asthma Medications Administered through a Stepwise Approach Step 1: No daily medication indicated. SABAs are used as required
(prn). If they are used more than two times a week, consider long-term control therapy.
Step 2: Daily low-dose inhaled corticosteroid.
Step 3: Daily low-dose inhaled corticosteroid used in conjunction with a long-acting bronchodilator. An alternative is to increase the corticosteroid dose to a medium level without the addition of a long-acting bronchodilator. If ineffective, a leukotriene modifier may be added to a low-dose corticosteroid. SABAs are used prn. With daily or increased usage, add additional long-term control therapy.
Step 4: Daily antiinflammatory, inhaled corticosteroid (medium dose), and a long-acting bronchodilator. If ineffective, a leukotriene modifier may substitute for the long-acting bronchodilator. SABAs are used prn. Add additional long-term control therapy if they are used daily or if there is an increase in use.
Step 5: Daily inhaled corticosteroid (high dose) plus a long-acting bronchodilator. Consider an immunomodulator for patients with allergies. Short-acting beta2-agonists are used prn. Add additional long-term control therapy with daily or increased usage.
Step 6: Daily inhaled corticosteroid plus long-acting bronchodilator plus an oral corticosteroid. Consider an immunomodulator for patients with allergies.
Patient education, environmental control, and quick management of comorbidities is required at each step. An asthma specialist should be considered at step 3 and implemented at step 4.
In older adults, asthma management may occur alongside management of chronic bronchitis or emphysema. A trial of systemic corticosteroids is useful in determining the presence of reversible air flow obstruction (NHLBI, 2007). An older adult may have medical conditions such as cardiac disease and osteoporosis that are aggravated by asthma medications. Older adults with
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ischemic heart disease may be more sensitive to beta2-agonist side effects such as tremors and tachycardia; the dosage may need to be adjusted, or different medications may need to be added as an adjunct.
Corticosteroids may cause confusion, agitation, and changes in glucose metabolism in older adults. The use of inhaled corticosteroids in older adults may predispose them to a reduction in bone mineral content, especially in the presence of preexisting osteoporosis, changes in estrogen levels affecting calcium utilization, and a sedentary lifestyle. The NHLBI (2007) recommends calcium and vitamin D supplements, as well as estrogen replacement therapy, when appropriate. An increased risk for adverse drug and disease interactions exists: Asthma may be exacerbated by the use of nonsteroidal antiinflammatory agents (NSAIDs) for arthritis, aspirin for circulation, nonselective beta- blockers for hypertension, or glaucoma eye drops that contain beta- blockers. Finally, it is imperative that older adults are carefully assessed for their ability to use prescribed medications appropriately and devices correctly as the increased risk of physical (arthritis, visual) or cognitive impairments could be challenging for them (NHLBI, 2007).
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Nursing management Assessment
Evaluation of respiratory symptoms includes effect on ADLs, quantity of breathlessness on a scale of 1 to 10 (Stupka & deShazo, 2009), presence of asthma triggers, and frequency of the need for bronchodilator therapy. Physical assessment includes inspection of the chest for shape and symmetry and determination of respiratory rate and pattern, body position, use of accessory muscles of respiration, and amount and color of sputum production. Palpation and percussion of the chest are indicated so that increased tactile fremitus, chest wall movement, and diaphragmatic excursion can be assessed. When the chest wall is auscultated, the older adult should be given enough time to take deep breaths comfortably without becoming dizzy. Determine the presence of any wheezing, the phase of respiration in which it occurs, and whether it is present during a forced expiratory maneuver. Determination of the PEFR with a peak expiratory flow meter (PEFM) is important in determining trends of airway resistance (Figure 22-1).
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FIGURE 22-1 A sample of a peak expiratory flow meter. This model displays results in colored areas. Faster exhalation rates in green, reduced exhalation rates in yellow, and seriously reduced exhalation rates in red. (From Ignatavicius, D.D. & Workman, M.L. (2013).
Medical-surgical nursing: Patient-centered collaborative care (7th ed.). St. Louis, MO: Elsevier.)
Diagnosis Nursing diagnoses common for an older patient with asthma include the following (Malone, 2011):
• Ineffective Airway Clearance, related to bronchospasm, excessive mucus production, tenacious secretions, adventitious breath sounds, or a combination of all of these
• Impaired Gas Exchange, related to alveolar–capillary membrane changes
• Deficient Knowledge, related to lack of information and education about asthma
The diagnosis of asthma is based on episodic symptoms of air flow obstruction that are partially reversible. Key indicators for the diagnosis of asthma include (1) wheezing, (2) a history of a cough that is worse at night, (3) recurrent difficulty breathing and chest
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tightness,(4) variation in PEFR of 20% or more, and (5) symptoms that worsen during exercise, with viral infection, in the presence of environmental irritants such as animal fur, dust mites, mold, smoke, pollen, changes in weather, airborne chemicals, or dust, during menses, or with strong emotional expression (NHLBI, 2007).
Pulmonary function tests (PFTs) are used to measure the presence and amount of airway obstruction. An FEV1–forced vital capacity (FVC) ratio of less than 65% indicates obstruction of air flow. Measurements of FEV1, FVC, and the FEV1–FVC ratio before and after inhaled short-acting bronchodilators are recommended. Other diagnostic procedures include methacholine, histamine, or exercise challenge; chest radiography; allergy testing; ear, nose, and throat evaluation for nasal polyps and sinus disease; evaluation for gastroesophageal reflux; a 1- to 2-week evaluation of diurnal variation in PEFR; and evaluation for vocal cord dysfunction (NHLBI, 2007).
The diagnosis and management of asthma in older patients is more difficult than in younger patients. The symptoms of asthma mimic other conditions such as myocardial ischemia or pulmonary embolus. Asthma may appear as late as the eighth or ninth decade of life. Older adults with asthma may not show allergic skin sensitivity; therefore, serum IgE and eosinophil levels may be more predictive. Incomplete reversibility of air flow obstruction is increasingly common. Older adult patients with asthma may only achieve a 12% improvement in their FEV1, even with optimally prescribed inhaled bronchodilators. In older patients with heartburn, coughing, nocturnal symptoms occurring early in the night, and resistance to routine therapy, gastroesophageal reflux disease should be considered (NHLBI, 2007).
Asthma is classified into three categories according to (1) severity of symptoms, (2) frequency of nighttime symptoms, and (3) lung function (Table 22-3). Asthma also occurs as seasonal asthma, cough variant asthma, and exercise-induced asthma.
Table 22-3 Classification of asthma by severity of disease before
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treatment*
From National Heart, Lung, and Blood Institute, National Institutes of Health (NIH). (2007). Clinical practice guidelines: Guidelines for the diagnosis and management of asthma. <http://www.nhlbi.nih.gov/health/health-topics/topics//asthma/treatment.htm> Retrieved April 2014. * After treatment, severity is measured by the minimum medications needed to maintain good health.
Planning and Expected Outcomes Older patients with asthma and their families should be included in care planning (NHLBI, 2007). It is important to incorporate the changes in ADLs that are required for ongoing monitoring and maintenance of patients with asthma. Expected outcomes include the following (Moorhead, Johnson, Maas, & Swanson, 2008):
1. The patient will maintain a patent airway.
2. The patient will maintain arterial blood gas (ABG) values at baseline.
3. The patient will be able to demonstrate proper use of the PEFM.
4. The patient will be able to demonstrate relaxation techniques to control breathing.
5. The patient will be able to list the significant and reportable signs and symptoms.
Well-controlled asthma results in temporary and reversible airway changes. Poorly controlled asthma leads to chronic inflammation, which may cause damage and hyperplasia of the bronchial epithelial cells and bronchial smooth muscle (Global Initiative for Asthma [GINA], 2010).
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Intervention Interventions for patients with asthma include health maintenance, lifestyle changes, administration of medications at designated time intervals, exercise, and promotion of hydration and good nutrition. Education is started at the time of diagnosis and is integrated into every aspect of care. Emphasis is placed on asthma self- management; basic facts about asthma; roles of medications; environmental control measures; the use of inhalers, spacers, and PEFMs; and a daily written action plan for management of exacerbations (NHLBI, 2007). Additional topics include smoking cessation, weight gain or loss, exercise requirements, and breathing retraining.
In addition to the basic interventions already described, older patients may require special considerations. The nurse should be accommodating to any neurologic changes such as altered senses, decreased fine motor movements, and memory loss. These expected changes may be managed with a number of strategies: Make treatment plans simple. Use short explanations and easily explained graphs. Make sure instructional materials are in large type, and use color-coded PEFM diaries. Increase lighting, and speak in a low- pitched, clear voice. Have the patient read and then repeat the instructions, and allow sufficient time for instruction, demonstration, and return demonstrations (NHLBI, 2007).
Evaluation Physical evaluation is based on normal breath sounds and the ability to clear secretions and maintain airways with a normal respiratory rate. The evaluation of self-management is based on the patient’s success in following through with the plan. Determine the frequency of rescue inhaler use, success at avoiding triggers, and the patient’s ability to monitor and address lifestyle changes. Making permanent changes rather than temporary adjustments, although initially difficult for older adults, will be more likely to be achieved after thorough education. Continue to stress the need for regular follow-up with the primary care provider. Pictures and
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instructions on the use of multiple inhaler devices are available for download at www.ginasthma.org/Guidelines.
Chronic Bronchitis Chronic bronchitis is a clinical syndrome characterized by excessive mucous production with a chronic or recurrent cough on most days for a minimum of 3 months of the year for at least 2 consecutive years in a patient in whom other causes have been ruled out. Hypertrophy of the bronchial mucous gland, increase in the number of goblet cells, and decrease in the effectiveness of the mucociliary escalator all occur, usually as a result of repeated infections. Cigarette smoking is the single most important factor that exacerbates chronic bronchitis. Chronic bronchitis is associated with right-sided heart failure, cor pulmonale, polycythemia, hypoxemia, and respiratory insufficiency. Clinical symptoms include a persistent cough, dyspnea on exertion, purulent sputum, cyanosis, crackles on auscultation, tachycardia, pedal edema, unexplained weight gain, and a decreased PaO2 with a normal or elevated PaCO2.
Emphysema Emphysema usually occurs between ages 60 and 70 and is characterized by progressive destruction of the alveoli and their supporting structures. The alveoli distal to the terminal bronchioles become enlarged. Loss of connective tissue supporting the alveoli leads to permanent obliteration of the peripheral airways. Physical signs include the classic barrel chest appearance and the use of accessory muscles of respiration. Emphysema is often associated with a history of smoking. The clinical presentation includes dyspnea on exertion or at rest, decreased weight, a chronic cough with little sputum production, digital clubbing, hyperresonance of the chest on percussion, an elevated hemoglobin level, crackles and wheezes on auscultation, and abnormal PFTs with decreased VC, increased TLC, increased FRC, and decreased FEV1.
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Chronic Obstructive Pulmonary Disease COPD is characterized by progressive air flow limitation that is not fully reversible and, during the course of the disease, lung tissue that becomes abnormally inflamed. The changes manifested include peripheral airway inflammation, airway fibrosis, hypertrophy of smooth muscles, hyperplasia of goblet cells and resultant mucus hypersecretion, and eventually, the destruction of the lung parenchyma (Barnett, 2009). The two reversible components in COPD are airway diameter and expiratory flow rate. COPD is a broad term that describes two obstructive airway diseases: chronic bronchitis and emphysema. Asthma may also be included in COPD, especially if a component of airway hyperreactivity exists; however, it may be difficult to differentiate between the two, especially if a history of cigarette smoking is present (Malone, 2011).
COPD is a progressive and ultimately fatal disease. The fatality rate for COPD is more than two times higher in men than in women between the ages of 65 and 74 and three times higher between the ages of 75 and 84. The number of women with COPD has been increasing since 1991 (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2014). This is most likely a result of the increase in the number of women who smoke. Risk factors for COPD include age, male gender, reduced lung function, air pollution, exposure to secondhand smoke, familial allergies, poor nutrition, and alcohol intake. COPD is often a comorbid factor in deaths from pneumonia and influenza, it accounts for increased physician visits (GOLD, 2014), and it is preventable and treatable.
Signs and Symptoms The characteristic symptoms of COPD are chronic and progressive dyspnea, coughing, and sputum production. Chronic coughing and sputum production may precede limits on air flow by many years, which provides a real opportunity for intervention before it becomes a major health problem. It is also possible that air flow limitations may develop without either a chronic cough or excess sputum production (GOLD, 2014).
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Diagnostic Tests and Procedures A diagnosis of COPD should be considered based on a history of exposure to tobacco smoke or other occupational irritants and progressive dyspnea, a chronic cough, and chronic sputum production; the diagnosis should then be confirmed with spirometry testing. COPD is staged based on the percent of the predicted value of FEV1 (Table 22-4).
Table 22-4 Staging chronic obstructive pulmonary disease by level of air flow
Stage % Predicted Fev1 Description I: Mild ≥ 80% Mild air flow limitation. Possibly cough and sputum but possibly not.
Patient may be unaware of altered lung function. II: Moderate
≥ 50% and < 80% Worsening air flow. Shortness of breath especially on exertion. Cough and sputum may be present but not always. Usually the stage where people seek medical help.
III: Severe ≥ 30% and < 50% Further worsening of air flow. Increased shortness of breath and dyspnea on exertion. Fatigue. Repeated exacerbations that impact quality of life.
IV: Very severe
< 30% or < 50% plus presence of chronic respiratory failure
Severe airflow limitation. Respiratory failure is defined as PaO2 < 60 mm Hg at sea level. Cardiac complications may occur (e.g., cor pulmonale). Quality of life is appreciably affected, and exacerbations are frequent and life threatening.
(Modified from Rabe, K.F., et al., (2007). Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American Journal of Respiratory Critical Care Medicine, 176, 532-555.) FEV1, Forced expiratory volume in 1 second; PaO2, partial pressure of arterial oxygen.
Most patients seek medical treatment because of progressive dyspnea leading to breathlessness and anxiety. Chronic coughing is often the first sign of COPD, but the absence of coughing does not rule it out. Initially, chronic coughing is intermittent, and patients may describe “good days and bad days.” As the disease progresses, the cough is present every day. Wheezing and “chest tightness” may vary from day to day and may vary throughout a single day. Once again, an absence of tightness or wheezing does not rule out COPD. Weight loss, anorexia, depression, and anxiety often accompany the pulmonary signs of COPD (GOLD, 2014).
Treatment
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Managing COPD focuses on increasing treatment, depending on the disease severity; the clinical status of the patient with air flow limitations provides a general guide. Treatment is focused on symptom management through education about the disease and active engagement of the older patient in care management. Aspects of management include smoking cessation, a stepwise approach to pharmacotherapy, limited occupational exposure to toxins and air pollution, and a healthy lifestyle, including regular exercise and weight control. Proper nutrition is essential for promoting efficient respiratory muscle work. Pneumococcal and annual influenza vaccinations are recommended for older patients. During peak influenza season, older patients with COPD should avoid crowds to decrease the risk of contracting influenza.
The single most important and cost-effective intervention is smoking cessation. Smoking cessation improves FEV1 and helps relieve symptoms. Benefits to smoking cessation include reduction in the number of respiratory infections, improvement in the function of the mucociliary clearance of the lungs, decreased coughing and dyspnea, increased appetite, and decreased sputum production. Older patients with COPD should also avoid secondhand smoke, as it may also cause bronchospasm and coughing. Many pharmacotherapies are now available to help the older patient quit smoking. Nicotine replacement drugs and some antidepressants (bupropion and nortriptyline) may increase smoking abstinence rates but should be used as part of an overall program of abstinence (GOLD, 2014).
Pulmonary pharmacotherapy is recommended in a stepwise approach based on the severity of airway obstruction and patient symptoms. None of the medications modify the long-term decline of the patient and thus are only used to reduce symptoms and complications. Bronchodilators are key in managing the symptoms of COPD and are given for both long-term therapy and during acute exacerbations; they include beta-adrenergic drugs, anticholinergics, and methylxanthines. Once a patient reaches stage 3, the addition of inhaled glucocorticosteroids is appropriate. However, chronic treatment with systemic glucocorticosteroids is not recommended.
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Bronchodilators Bronchodilators are the central pharmacologic tool used in managing the symptoms of COPD. They may be prescribed for long-term maintenance or short-term exacerbations. Inhaled medications are preferred because the systemic complications they cause are both less severe and more rapidly reversed. However, with inhalation therapy, proper training is essential. The primary bronchodilators used are the beta2-agonists, anticholinergics, and the methylxanthines. The choice of drug will depend on the patient’s response.
Beta2-Agonists These sympathomimetic drugs work by stimulating the beta2- receptors in the lungs, which results in bronchial dilation, increased mucociliary clearance, and possibly increased diaphragmatic function. The drugs may be administered by metered-dose inhaler (MDI) with a spacer or by aerosolized therapy (Figure 22-2). Beta2- agonists should be used with caution in the older patient with ischemic heart disease. Examples of beta2-agonists include albuterol (Proventil, Ventolin), metaproterenol sulfate (Alupent, Metaprel), and pirbuterol acetate (Maxair).
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FIGURE 22-2 Commercial spacers for metered-dose inhalers (MDIs): Top, AeroChamber; bottom, InspirEase. (From Dettenmeier, P.
(1992). Pulmonary nursing care. St. Louis, MO: Mosby.)
Anticholinergics Inhaled anticholinergics—ipratropium bromide or oxitropium bromide—are used to treat chronic bronchitis. They work by inhibiting vagal stimulation of the lungs, preventing contraction of the smooth muscle, and decreasing mucous production. A combination of an SABA and an anticholinergic results in a greater and more sustained improvement than with either drug alone (GOLD, 2014).
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Glucocorticosteroids Inhaled glucocorticosteroids do not reduce the decline of the older adult with COPD, but for those patients with advanced disease (stage 3 or 4), they have been shown to reduce the frequency of exacerbations and improve overall health status. Oral steroids are no longer recommended because they may lead to steroid myopathy, which is associated with muscle weakness and respiratory failure (GOLD, 2014). Steroid therapy may not be well tolerated in older patients.
Vaccines Influenza vaccines reduce both morbidity and mortality rates in patients with COPD by 50% (GOLD, 2014). Vaccines containing killed or live inactivated viruses are recommended for older adults, and the pneumococcal polysaccharide vaccine is recommended for those older than 65 years.
Oxygen Therapy Long-term oxygen therapy increases survival rates and improves hemodynamics, exercise and lung capacity, and mental status. Supplemental oxygen therapy is indicated for patients with resting PaO2 55 mm Hg or less or saturation of arterial oxygen (SaO2) 88% or less with or without hypercapnia. Oxygen therapy may also be indicated if the patient’s PaO2 is between 55 and 60 mm Hg, the SaO2 is 88% or less, or evidence of pulmonary hypertension, peripheral edema, or polycythemia (hematocrit level > 55%) exists. The primary goal of oxygen therapy is to increase baseline PaO2 to at least 80 mm Hg and SaO2 to at least 90%.
Pulse oximetry recognizes hemoglobin saturation, which normally is between 95% and 100%. The pulse oximeter uses infrared light waves and a sensor that is usually placed on the finger of the patient. It may be placed on toes, earlobes, or even the nose if circumstances do not permit a finger to be used. Pulse oximetry can detect desaturation before physical appearance of dusky skin, pale mucosa, or pale nail beds are noted (DeMeulenaere, 2007).
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Antibiotics No evidence suggests that the prophylactic long-term use of antibiotics has any beneficial effect. Antibiotics should only be used when concomitant bacterial infection is present.
Surgical Options Surgical options consist of a bullectomy, which reduces dyspnea and improves lung function by allowing previously compressed lung tissue to expand. Another option is a lung volume reduction surgery, which, thus far, shows some promise for those with upper lobe emphysema and low exercise capacity. A lung transplantation is the final surgical option and does improve quality of life. All three procedures are extremely expensive and somewhat controversial because all are essentially palliative by nature (GOLD, 2014).
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Nursing management Assessment
Dyspnea is the hallmark symptom of COPD. It is the primary reason that patients seek treatment and the major cause of disability and anxiety. As such, spirometry remains the primary tool in determining the severity and staging of COPD. Evaluation of respiratory symptoms also includes assessing their effect on ADLs, quantifying breathlessness on a scale of 1 to 10, and identifying environmental and social factors that may be contributing to the symptoms. The nurse also identifies the type of onset of the symptoms—whether sudden or insidious—and any precipitating factors such as exercise, temperature changes, and stress. Physical assessment includes assessment of the shape and symmetry of the chest, respiratory rate and pattern, pulse oximetry, body position, use of accessory muscles of respiration, color, temperature, appearance of extremities, and the color, amount, consistency, and odor of sputum.
To assess cyanosis in darkly pigmented older adults, the nurse should examine the patient with favorable lighting conditions (e.g., use over-bed light or natural sunlight). The nurse should be attentive to factors that may mask cyanosis by causing vasoconstriction. These include environmental conditions (e.g., air conditioning and mist tents) and patient behaviors (e.g., smoking and taking medications causing vasoconstriction). Examine the usual places in which cyanosis is found, that is, the lips, nail beds, around the mouth, cheek bones, and earlobes. Be aware that the darker skin may mask the underlying cyanosis and that the region around the mouth is often darker in people of Mediterranean descent. When cyanosis is questionable, apply light pressure to create pallor. In cyanosis, tissue color returns slowly from the periphery to the center. Normally, color returns in 1 second, from below the pallid spot as well as from the periphery. Cyanosis of an extremity may become more recognizable if the elevation of an extremity is changed.
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The nurse should observe for other clinical manifestations of decreased oxygenation of the brain. These include changes in the level of consciousness, increased respiratory rate, the use of accessory muscles of respiration, nasal flaring, positional changes, and other manifestations of respiratory distress.
The nurse should use palpation and percussion of the chest to assess for increased tactile fremitus, chest wall movement, and diaphragmatic excursion. When auscultating the chest wall, the nurse must give an older adult enough time to take deep breaths comfortably without becoming dizzy.
Diagnosis The primary nursing diagnoses common for an older patient with COPD include the following (Malone, 2011):
• Ineffective Airway Clearance, related to retained secretions
• Impaired Gas Exchange, related to an altered oxygen supply
• Imbalanced Nutrition: Less than body requirements
• Insomnia, related to anxiety, dyspnea, depression, hypoxemia or hypercapnia or both, paroxysmal nocturnal dyspnea, and orthopnea
• Risk for Infection, related to inadequate primary and secondary defenses and chronic disease
Planning and Expected Outcomes As with all patients, older patients with COPD should be included in the care planning. It is important to include the spouse or significant other, family, and any other caregivers in the planning process. Discharge planning should begin as soon as an older patient is admitted to the hospital. If an older patient requires special equipment for home care such as supplemental oxygen therapy or aerosolized therapy, the patient and his or her family will benefit from learning the new skills in the acute care setting. Expected outcomes for the older patient with COPD include the
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following (Moorhead et al., 2008): 1. The patient will maintain a patent airway.
2. The patient will maintain a stable weight.
3. The patient will maintain ABG values at baseline.
4. The patient will maintain a balanced intake and output.
5. The patient will be able to effectively clear secretions.
6. The patient will be able to demonstrate diaphragmatic and pursed-lip breathing.
7. The patient will be able to demonstrate relaxation techniques to control breathing.
8. The patient will maintain a respiratory rate between 16 and 25 breaths per minute.
9. The patient will be able to list significant and reportable signs and symptoms.
Intervention Interventions for patients with COPD include maximizing the effects of bronchodilator therapy, administering medications at designated intervals, and promoting hydration, good nutrition, and increased mobility (Bulechek, Butcher, & Dochterman, 2008). The majority of nursing care for the patient with COPD involves extensive education. Topics include normal respiratory anatomy and changes associated with the disease; medical intervention, including tests and medications; and lifestyle changes such as smoking cessation, weight gain or loss, exercise, and breathing retraining (see Nursing Care Plan: COPD).
Nursing care plan
Chronic Obstructive Pulmonary Disease
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Clinical Situation Mr. W is an 80-year-old retired truck driver admitted to the medical intensive care unit (ICU) for exacerbation of his COPD. He lives with his wife, who is 78 years old. Mr. W continues to smoke one to two packs of cigarettes per day, as he has done since the age of 15.
Over the past week, Mrs. W has noticed a decrease in Mr. W’s activity level and attention span. He has a productive cough of thick tenacious sputum, averaging 1 cup per day. Over the past week the sputum has become yellow. His appetite has decreased, and he has difficulty sleeping at night, often awakening and gasping for breath. Mr. W is having increasing difficulty in bathing and dressing.
Physical examination reveals a thin man with weight of 138 pounds (lb). He has a barrel chest and uses his accessory muscles of respiration to breathe. Auscultation of the chest reveals diminished breath sounds with scattered coarse crackles bilaterally and no wheezes. Mr. W’s blood pressure is 138/68 mm Hg, his pulse is 92 beats per minute, and his respiratory rate is 35 breaths per minute. His oral temperature is 101 ° F (38.3 ° C).
Laboratory tests show arterial blood gases (ABG) measurements as follows: pH, 7.40; PaCO2, 41 mm Hg; PaO2, 55 mm Hg; SaO2, 90%; and bicarbonate (HCO3), 28. Mr. W has a white cell count of 12,000. Sputum cultures reveal Haemophilus influenzae. A diagnosis of H. influenzae pneumonia is made.
Because of increasing shortness of breath and decreasing oxygenation, Mr. W is intubated and begins receiving mechanical ventilation according to the couple’s wishes. Intravenous antibiotic therapy is started, and bronchodilator therapy is initiated to reduce airway resistance and promote pulmonary hygiene. Mr. W receives mechanical ventilation for 6 days until he is successfully weaned off of the ventilation and then transferred to the medical division.
He remains in the medical division for 10 additional days. Mr. W is sent home with home oxygen therapy and bronchodilators
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and is told absolutely not to smoke.
Nursing diagnoses Activity Intolerance, related to decreased strength and endurance Ineffective Airway Clearance, related to retained secretions
Impaired Gas Exchange, related to alveolar hypoventilation
Impaired Spontaneous Ventilation, related to infection and decreased respiratory muscle endurance
Impaired Verbal Communication, related to endotracheal intubation
Deficient Knowledge, about home oxygen therapy and smoking cessation, related to inexperience with concepts
Outcomes The patient will be able to safely and comfortably perform ADLs.
The patient will be able to effectively clear secretions with coughing or suctioning.
The patient will maintain ABG levels at baseline, as evidenced by the ability to adhere to techniques and perform activities that maximize ventilation–perfusion matching.
The patient will be able to maintain spontaneous ventilation without mechanical assistance.
The patient will be able to effectively communicate with caregivers and family.
The patient and family will be able to demonstrate the use of the home oxygen equipment.
The patient and family will be able to verbalize oxygen safety measures.
The patient and family will be able to verbalize the need to quit smoking and techniques for achieving success.
Interventions Provide active and passive range-of-motion exercises to maintain
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mobility.
Assess the need for supplemental oxygen to enhance activity tolerance.
Arrange for physical and occupational therapy consultation.
Pace activities to provide rest and decrease episodes of breathlessness.
Teach the patient to reduce activities that exacerbate fatigue.
Provide chest physiotherapy (CPT) to promote secretion removal and chest expansion, as tolerated.
Provide hydration to maintain fluid volume status and to decrease viscosity of secretions.
Turn every 2 hours to promote ventilation and to help drain pulmonary secretions.
Monitor ABGs, as ordered.
Monitor pulse oximetry continuously.
Provide mechanical ventilation during an acute phase.
Suction as needed based on assessment findings; maintain patent airway.
Monitor peak airway pressure every 2 hours.
Monitor ventilator settings every 2 hours.
Provide reassurance for the patient and family.
Provide oral care every 2 hours.
Provide rest periods.
Schedule care activities based on the patient’s energy level.
Provide an alternative method of communication such as a picture board, talking board, or alphabet board.
Speak in clear, short sentences, and ask questions that only require a short response.
Provide the patient and family with information about home oxygen therapy, liter flow, and equipment for home use.
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Provide instruction about oxygen safety.
Instruct the patient and family in smoking cessation techniques and how this relates to oxygen safety.
Provide information about local smoking cessation programs.
Pulmonary Rehabilitation Patients with COPD at all stages benefit from exercise training programs; they also need to be taught how to breathe effectively and how to adapt their lifestyles and ADLs. Pulmonary rehabilitation programs are designed to provide the patient with exercise training, breathing retraining, education, smoking cessation, medications, and nutrition information. The exercise component should include 20 to 30 minutes of moderate intensity exercise three to five times a week, as well as strength training, and could result in increased exercise tolerance and decreased dyspnea and fatigue. It may also reduce cardiovascular disease risks, improve musculoskeletal functioning, help control weight or promote weight loss, and may help prevent bone loss in older patients (Covey & Larson, 2004). One of the best exercises is walking or using a treadmill. It strengthens both the legs and the upper body, especially if the arms are used. Exercise on a stationary bicycle is also useful, but it does not have the benefit of overall body conditioning that can be achieved with walking. Older patients with COPD may start a program in small increments, for example, walking or biking for 3 to 5 minutes daily. It is important to develop an exercise program that is achievable for an older patient. Targets are based on desired outcomes. The appropriate exercise intensity for health benefit is maintaining a heart rate of at least 55% of the maximum rate for a patient’s age (i.e., a rate of 88 beats per minute [beats/min] for a 60-year-old and 80 beats/min for a 75-year-old).
Another benefit of a formal pulmonary rehabilitation program is the social aspect. The classes and exercise times usually allow many patients to participate at once. This helps motivate older patients, provides emotional support, and offers them an opportunity to get out of the house. The exercise sessions are often mini–support
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groups. As a patient progresses, 1- to 2-pound (lb) weights may be added while walking to help strengthen the upper body. Pulmonary rehabilitation may help reduce health care costs by reducing the frequency of hospitalizations and helping older patients and their families learn to cope with the disease process (Covey & Larson, 2004).
Smoking Cessation Smoking cessation is the best and most cost-effective way to reduce exposure to risk factors. Older patients with COPD who continue to smoke increase their risk of repeated respiratory infections and progression of the underlying disease process. Older patients should be offered an opportunity for smoking cessation, and it should be offered at every opportunity. It is important to provide support for older patients attempting to quit smoking. Success depends in part on the support of family and friends. Many older patients find it impossible to stop smoking completely. They should be encouraged to reduce the amount and frequency of their smoking. Although smoking reduction is not ideal, it may help decrease some of the symptoms associated with respiratory illness. Programs are available through the American Lung Association, the American Cancer Society, and many community hospitals. The U.S. Public Health Service provides a framework for cessation (Fiore et al., 2000) (Table 22-5).
Table 22-5 How to help the patient who is willing to quit smoking
ASK Identify all tobacco users at every visit. For every patient, regardless of setting, tobacco usage is queried and documented.
ADVISE Strongly urge them to quit. Be clear. Be caring. Be personable.
ASSESS Determine the patient’s readiness to quit. Ask every patient at every opportunity if he or she is willing to try to quit.
ASSIST Help patient with a quit plan. Provide counsel. Provide support. Help patient obtain treatment. Help patient with approved pharmacotherapy.
ARRANGE Schedule follow-up contact either in person or by phone.
Adapted from Fiore, M.C., Bailey, W.C., Cohen, S.J., et al; and The Tobacco Use and Dependence Clinical Practice Guidelines Panel, Staff, and Consortium Representatives. (2000). A clinical practice guideline for treating tobacco use and dependence: A U.S. Public Health Services report. Journal of the American Medical Association, 283, 3244- 3254.
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Nutrition Older patients should be instructed on the benefits of eating nutritious meals. Adequate nutrition is often difficult to maintain in older patients (see Chapter 10), and those with COPD have the additional problem of breathlessness. The patient should be instructed to eat frequent small meals, avoid gas-producing foods, reduce carbohydrates to only 50% of the diet (the breakdown of carbohydrates has been shown to increase the CO2 load, thereby increasing the work of breathing, especially in those with CO2 retention), eat high-protein foods, and reduce the intake of fat (see Nutritional Considerations Box).
Nutritional considerations
Respiratory System Nutrient requirements for patients with respiratory disease are as follows:
Calories—25 to 35 kilocalories per kilogram (kcal/kg) of body weight for maintenance; 35 to 40 kcal/kg for replacement and building
Protein—1 to 1.5 grams (g)/kg of body weight for maintenance; 1.5 to 2 g/kg for replacement and building; 25% to 50% of caloric intake
Carbohydrates—50% of caloric intake; the breakdown of carbohydrates increases the carbon dioxide (CO2) load and may increase the work of breathing, especially in older patients with CO2 retention
Fats—20% to 25% nonprotein calories
Breathing Retraining The goals of breathing retraining include decreasing the work of breathing, improving oxygenation, increasing the efficiency of
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breathing patterns, and promoting patient control of breathing. Two of the most commonly taught techniques are diaphragmatic breathing and pursed-lip breathing (Boxes 22-1 and 22-2; Figures 22-3 and 22-4).
Box 22-1
Diaphragmatic breathing 1. Lie in the supine or semi-Fowler position.
2. Place one hand on the middle of the stomach below the sternum.
3. Place the other hand on the upper chest.
4. Inhale slowly through the nose. The stomach should expand. (Note the movement of the hand over the stomach.)
5. Exhale slowly through pursed lips. The stomach should contract.
6. Rest.
7. Repeat.
Box 22-2
Pursed-lip breathing 1. Assume a comfortable position.
2. Inhale slowly through the nose, keeping the mouth closed.
3. Remember to use the diaphragmatic breathing technique.
4. Pucker the lips as if blowing out a candle, kissing, or whistling.
5. Exhale slowly, blowing through pursed lips (exhalation should
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be at least twice as long as inhalation).
6. Rest.
7. Repeat.
FIGURE 22-3 Diaphragmatic breathing.
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FIGURE 22-4 Pursed-lip breathing. (Courtesy of Ursula Ruhl, St. Louis, MO.)
Diaphragmatic breathing increases the patient’s awareness of breathing patterns and improves the efficiency of breathing. Pursed-lip breathing increases expiratory pressure, improves oxygenation, helps prevent early airway closure, increases exhalation time, reduces the respiratory rate, and allows the patient to slow the breathing.
Chest Physiotherapy Chest physiotherapy (CPT) includes chest percussion, postural drainage (PD), and vibration and rib shaking and is used for patients who have difficulty clearing their own secretions. Contraindications include hemoptysis, pulmonary emboli, osteoporosis, and bleeding disorders. PD consists of positioning the patient in a head-down position after CPT to facilitate drainage of pulmonary secretions. Older patients may not tolerate the head- down position of PD or the percussion of CPT. The nurse should explain to patients that they may experience increased breathlessness as a result of the mobilization of secretions and
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increased coughing as they try to clear the airway. To help decrease the discomfort associated with chest percussion, the nurse should place a bath towel over the area being percussed.
Pulmonary Hygiene Pulmonary hygiene consists of hydration, deep breathing exercises, and coughing techniques (Box 22-3). Older patients are prone to dehydration and therefore are at risk for airway plugging. The nurse should encourage a volume of oral fluids of 4 to 6 quarts a day, if not contraindicated by cardiovascular disease; the nurse should also instruct older patients to sip fluids all day to decrease the chance of feeling full by drinking a large amount at one time. Older patients also need to be taught the signs and symptoms associated with a respiratory infection; these include sputum color changes, fever, chills, and a change in breathing pattern.
Box 22-3
Effective coughing techniques Cascade Cough 1. Take a deep breath, and hold it for 1 to 3 seconds.
2. Cough out forcefully several times until all air is exhaled (usually two to six coughs).
3. Inhale slowly through the nose.
4. Repeat once, if necessary.
5. Rest.
6. Repeat, as needed.
Huff Cough 1. Take a deep breath, and hold it for 1 to 3 seconds.
2. Keeping glottis open, cough out several times until all air is
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exhaled (usually two to six coughs). Sometimes, it helps to say the word huff while coughing.
3. Inhale slowly through the nose.
4. Repeat, as necessary.
End-Expiratory Cough 1. Take a deep breath, and hold it for 1 to 3 seconds.
2. Exhale slowly.
3. At the end of the exhalation, cough once.
4. Inhale slowly through the nose.
5. Repeat, as necessary.
6. Follow with a cascade or huff cough, in which secretions are moved from smaller to larger airways.
Augmented Cough 1. Take a deep breath and hold it for 1 to 3 seconds.
2. Perform one or more of the following maneuvers:
a. Tighten knees and buttocks to increase intraabdominal pressure.
b. Bend forward at the waist to increase intraabdominal pressure.
c. Place hand flat on the upper abdomen just under the xiphoid process, and press in and up abruptly during the cough or exhalation, or place hands on the lateral rib cage and quickly press in and release with each cough (this is called rib springing).
d. Keep hands on the chest wall and press inward with each cough.
3. Inhale slowly through the nose.
4. Rest, if necessary.
5. Repeat, as needed. (Dettenmeier, P. (1992). Pulmonary nursing care. St Louis, MO: Mosby.)
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Medications Patient education regarding medications includes the purpose of the medication, dosage, side effects, and schedule of administration. Medications are administered by mouth, MDI (Box 22-4), or nebulizer. Inhaled medications are only as effective as the delivery. Simple human errors that affect delivery of inhaled medications include failure to shake the inhaler before use, failure to exhale slowly before inhaling, lack of mechanical coordination of compression of the inhaler and inhaling, rapid inhalation or lack of deep inhalation, not waiting at least 30 seconds between puffs, failure to clean the MDI periodically, holding the MDI upside down, and failure to remove the cap before spraying the medication (Self, Kilgore, & Shelton, 2003).
Box 22-4
Using a metered-dose inhaler 1. Select the appropriate canister of medication.
2. Shake the inhaler 15 to 20 times.
3. Hold the inhaler directly in front of the mouth about 2 to 3 inches from the lips. When a spacer is used, place the inhaler in the spacer and place the mouthpiece directly into the mouth.
4. Take a deep breath and exhale completely.
5. Open the mouth wide. When a spacer is used, seal the lips around the mouthpiece.
6. Activate the inhaler.
7. Inhale slowly and deeply.
8. Hold breath for a count of 10. 9. Exhale slowly.
10. Wait 1 to 5 minutes between puffs. Repeat the steps for each puff ordered.
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Home Oxygen Therapy Oxygen therapy decreases morbidity and mortality rates for patients with COPD when used more than 18 hours a day. A patient’s acceptance of oxygen therapy and attitude about the disease determine the level of compliance with treatment. Oxygen is a medication, and patients and their families need to be taught the correct administration, which includes proper liter flow, the times that oxygen is to be used, and the proper use of the equipment.
Home oxygen therapy is available in E-cylinders, concentrators, and liquid systems. A liquid oxygen system with portability is the most easily transported and may provide older patients with more mobility. However, it is the most expensive option. The concentrator is a machine about the size of small bedside table. It is stationary and usually accompanied by an E-cylinder for limited portability. The E-cylinder, a small green tank that can be pulled on a cart similar to a luggage rack, is economical, although it is a little less portable because of its size.
All the persons involved in a patient’s care—patient, family, physician, and nurse—should discuss the patient’s level of activity and select the right system to support his or her lifestyle. Social workers may be helpful in determining the amount and type of insurance coverage the patient has available for home oxygen therapy. Many third-party payers do not cover liquid oxygen systems unless the patient is active and spends a good portion of the day out of the home. If an older patient is homebound, only leaving the home for medical appointments, the most economical system is the concentrator with an E-cylinder.
Evaluation Evaluation of an older patient with COPD focuses on air flow as measured by spirometry, the ability to accomplish ADLs, and minimization of exacerbations. Older patients may need additional caregivers in the home because the spouse or significant other is most likely of a similar age and may also have chronic health problems. Older patients may need more time to learn the
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educational materials; however, once taught, they should have a good understanding and be able to adapt these techniques to their lifestyle.
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Restrictive pulmonary disease Restrictive lung disease results in loss of functioning alveoli, loss of lung volume, and decreased chest wall compliance. Restrictive lung disease may be the result of extrapulmonary factors such as excessive weight and muscle mass, a chest splint, or a restrictive dressing. Mechanisms of restrictive lung disease include pleural- based diseases, impaired lung expansion, impaired neuromuscular contraction, and thoracic deformities.
Lung Carcinoma Lung cancer is the leading cause of cancer deaths, accounting for 28% of cancer deaths. Approximately 224,210 new cases of lung cancer are reported annually in the United States. It is rare in patients younger than 44 years of age but increases in incidence between ages 60 and 70, and the average age at diagnosis is 71 years (National Cancer Institute [NCI], 2014). The increase in smoking by women has raised the rate of death from lung cancer to the point that it now exceeds the rate of death from breast cancer.
Risk factors for development of lung cancer include tobacco use, marijuana use, recurring inflammation, or exposure to asbestos, talcum powder, or minerals; less frequently, radon exposure, heredity, vitamin A deficiency, and exposure to air pollution may be risk factors. The leading cell types of lung cancer are small-cell lung carcinoma (SCLC), which accounts for 20% of cases, and non– small-cell lung carcinoma (NSCLC), including squamous cell carcinoma and adenocarcinoma, which accounts for 79%, and other specified and nonspecified types, which account for about 1% of cases (NCI, 2014). The most lethal type of lung cancer is SCLC, which usually has a 5-year survival rate of 6.3%. SCLC is an aggressive cancer that metastasizes to the central nervous system (CNS), bones, and liver. NSCLC is a slower growing and less aggressive cancer that has a 5-year survival rate of 17.5% (NCI, 2014).
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Diagnostic Tests and Procedures Diagnosis is based on the clinical history and chest radiography. The initial workup includes a complete blood cell (CBC) count, carcinoembryonic antigen (CEA) level, chest radiography, computed tomography (CT), ABG measurements, PFTs, and an electrocardiography (ECG). Sputum cytology is used to determine the cell type. If metastasis is suspected, additional diagnostic tests include magnetic resonance imaging (MRI) of the brain, bone scintigraphy, exercise PFTs, quantitative ventilation–perfusion scanning, treadmill exercise test, Doppler echocardiography, and carotid Doppler ultrasonography. Fiberoptic bronchoscopy is used to obtain tissue confirmation of the diagnosis. Surgical diagnosis includes cervical mediastinoscopy, mediastinotomy, and thoracotomy. PFTs are used to determine impairment in ventilation and help predict functionality if surgery is a consideration. On the basis of diagnostic testing, the stage of NSCLC involvement is determined (Table 22-6). SCLC is not staged because it is extremely aggressive and is always assumed to be systemic once diagnosed.
Table 22-6 Staging of non–small-cell lung carcinoma
Stage Description 1a Tumor < 3 cm, localized, no lymph node involvement 1b Tumor > 3 cm, invading local areas, no lymph node involvement 2a Tumor < 3 cm, lymph node involvement on same side of chest 2b Tumor > 3 cm, lymph node involvement on same side of chest, tissue involvement of local organs 3a Spread nearby (chest wall, pleura, pericardium) and to regional lymph nodes 3b Extensive tumor (heart, trachea, esophagus, scalene, and supraclavicular lymph nodes 4 Distant metastasis
(Adapted from National Cancer Institute. (2014). Lung cancer. < www.cancer.gov/cancertopics/types/lung> Retrieved April 2014.)
Treatment Treatment is based on histologic analysis and staging. SCLC has a median survival of 2 to 4 months from diagnosis and is very aggressive. It is much more responsive to chemotherapy and radiation therapy, but a cure is very difficult. The treatment of NSCLC depends on the staging and is basically divided into three groups of patients. The first group contains those patients with cancer that is resectable. Generally, this is stage 1 and 2 and some
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stage 3 cancers. These patients have the best prognosis. The second group of patients includes the remainder of NSCLC patients with the exception of those with stage 4 cancer. This second group may benefit from a mixed modality of surgery, radiation therapy, and chemotherapy. The final group is those with stage 4 cancer, and they receive palliative treatment that includes chemotherapy, radiation therapy, and endobronchial laser therapy (NCI, 2014). If an older patient has significant lung disease, resection of the lung or segmental resection may not be possible. The decision to perform a surgical resection depends on the amount of functional lung tissue that would remain after the surgery.
Careful management of pain, nausea, vomiting, and chemotherapy-related side effects is important for providing as much physical comfort as possible for the patient and mental comfort for the family. Older patients may not be able to tolerate a complex medical regimen, especially with other organ involvement or underlying disease processes.
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Nursing management Assessment
Assessment includes the identification of risk factors for lung cancer. The clinical presentation of lung cancer may easily be mistaken for other chronic lung diseases such as chronic bronchitis. Often, no symptoms are present, or the symptoms are ignored or attributed to smoking or a preexisting lung disease. Common early signs include coughing, chest pain, and hemoptysis. It is also important to assess the patient’s and the family’s understanding of the numerous diagnostic tests that will be performed shortly. An assessment of the anxiety level is also appropriate.
Diagnosis Nursing diagnoses for lung cancer include the following (Malone, 2011):
• Impaired Gas Exchange, related to altered blood flow and alveolar–capillary membrane changes
• Acute Pain and Chronic Pain, related to the pressure of the tumor on surrounding structures
• Imbalanced Nutrition: Less Than Body Requirements
• Anxiety, related to a lack of knowledge of the diagnosis or unknown prognosis and treatment
• Hopelessness, related to failure or deterioration of physiologic condition and long-term stress
Evidence-based practice Patient Education Needs Related to Treatment of Lung Cancer
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Sample/Setting All registrants to NexCura’s Lung Cancer Treatment Option Tool between August 2004 and March 2005 were invited to participate in a survey 3 to 9 months after they had completed the electronic tool. Of 10,317 that were invited, 1362 (13.2%) agreed to participate.
Methods A variety of satisfaction questions were asked of the respondents, and results were compared.
Findings Of the respondents, 23.7% were older than 70 years. Dissatisfaction was greatest in the areas of psychosocial stress (29.4%) and hearing loss (27.5%). The area with the least dissatisfaction was nausea and vomiting (10.6%).
Implications Clinical nurses need to know what is most troubling to their patients and focus their interventions accordingly. (From Davis, B., & Peterson, J. (2006). Examining patient education needs related to treatment of lung cancer: Age-related analysis in 9 nursing sensitive patient outcomes. Oncology Nursing Forum, 33(2), 461–462.)
Planning and Expected Outcomes Planning includes developing interventions and expected outcomes for the patient that focus on improving gas exchange, promoting airway clearance, increasing comfort, and reducing anxiety. Expected outcomes include the following (Moorhead et al., 2008):
1. The patient will be able to maintain ABG values at baseline.
2. The patient will be able to sustain spontaneous respiration.
3. The patient and family will be able to verbalize their feelings related to the diagnosis of lung cancer.
4. The patient’s pain will be controlled.
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5. The patient will report a decrease in the number of episodes of breathlessness.
6. The patient’s lungs will be clear on auscultation.
7. The patient will maintain a stable weight.
8. The patient will report feeling a decrease in fatigue.
9. The patient will maintain a realistic level of activity.
Intervention Nursing care of an older patient with lung cancer includes relief of pain, emotional support, counseling, and discussion of options and alternatives. The older patient may have fewer friends and family members for support. Interventions include providing factual information concerning the diagnosis, treatment, and prognosis, encouraging an attitude of realistic hope as a way of dealing with feelings of helplessness, acknowledging the patient’s spiritual and cultural background, and encouraging verbalization of feelings, perceptions, and fears (Bulechek et al., 2008). The nurse needs to be sensitive to the values of older patients and how they see the diagnosis affecting their quality of life. Many older patients may be more concerned about immediate survival and quality-of-life issues than the 5-year postoperative survival rate.
Evaluation Symptom management is evaluated by assessing how often symptoms occur, how the patient has been able to incorporate changes into his or her lifestyle, and how the symptoms alter the patient’s ADLs. The nurse should determine the success of pain management and the level of patient comfort. Older adults may not have the same tolerance for pain and discomfort as younger patients. The nurse should help patients quantify their pain on a scale of 1 to 10 (see Chapter 14). This will help both the nurse and the patient monitor the effectiveness of pain management. The nurse should also evaluate the older adult’s use of pain medication. Many older adults are concerned about becoming addicted to their
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pain medication and may not use it as prescribed. The nurse should ensure that the older patient understands that the dose and frequency of medications will be carefully monitored. In addition, many older adults may become depressed after a diagnosis of cancer and should be monitored for signs of depression; a referral should be made if depression is suspected.
Tuberculosis Tuberculosis (TB) is caused by the organism Mycobacterium tuberculosis. TB is most often seen in populations living in crowded quarters and in those with little or no health care or preventive care. It is the number one fatal and communicable disease in the United States. TB is divided into primary and active varieties. TB is transmitted by inhalation of infected droplets aerosolized in the air from the cough or sneeze of an infected person. The body’s immune system responds to the local inflammation by walling off the bacteria. When active, the patient with TB is seen with symptoms of inflammation of the airway that led to the development of a lesion and necrosis of the tissue. TB may remain inactive in the body for decades. A greater number of older adults are infected by the bacillus than causes active TB. However, active TB may be present in any patient admitted with pneumonia, pleural effusion, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), weight loss, cancer, or alcohol or substance abuse (CDC, 2012a; Knechel, 2009).
In an older patient, the presence of TB may be a reactivation of a dormant organism that has been present in the individual for some time. As patients age, changes in the immune system increase the risk of reactivation of TB. Medical risk factors that substantially increase the risk of TB include silicosis, gastrectomy, jejunal bypass, weight more than 10% below ideal body weight, chronic renal failure, diabetes mellitus, and hematologic disorders such as leukemia, lymphomas, and other malignancies. Older residents of nursing homes and other long-term care facilities are at increased risk of developing TB; they have a two to seven times greater incidence of the disease compared with older adults in the general population (CDC, 2014c).
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In 2006, 19% of all new cases of TB were in those older than 65 years (CDC, 2012d), and more than 50% had sputum smears that tested positive for acid-fast bacilli (AFB), which are capable of transmitting the infection to other persons. Many older adult patients have underlying lung disease that puts them at higher risk of morbidity and mortality should they become infected. Most nursing home and long-term care facility residents are older adults. These concentrations of older adults, many of whom are infected and some of whom are immunocompromised, create high-risk situations for transmission of TB. An estimated 1.1 million (13%) of the 8.6 million people who developed TB in 2012 were HIV positive. About 75% of these cases were in the African region (World Health Organization [WHO], 2012).
Diagnostic Tests and Procedures Older patients with any of the following symptoms should alert the practitioner to a high probability of TB: night sweats, atypical pneumonia, low-grade fever, nonproductive coughing, hemoptysis, anorexia, and weight loss. However, tuberculin skin testing in older patients is an unreliable indicator of TB because they are more likely to have false-negative results because of reduced immune system activity. If skin testing is used, it is recommended that the standard 5 tuberculin unit (5 TU) Mantoux test be given and then repeated to create a booster effect. The second test may be a 5 TU or a second strength 250 TU test. If the size of the induration is 10 mm or greater (or ≥ 5 mm in an HIV-positive patient), the purified protein derivative (PPD) is positive. In the event of a positive PPD with symptoms, chest radiography is recommended within 72 hours.
A positive chest radiography result with the following strongly indicates TB: infiltration in the posterior and apical segments of the upper lobes or in the superior segments of the lower lobes, cavitation, nodular infiltrates, atelectasis, fibrotic scarring with retraction of the hilum, and deviation of the trachea. Older adults may show lower lobe nodular infiltrates without cavitation. Diffuse, finely nodular, uniformly distributed lesions characterize hematogenous TB. Any persistent infiltrate in older patients must
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be suspected as having TB. Although the aforementioned radiographic changes are most common, TB may produce almost any form of pulmonary radiographic abnormality. Older patients should be questioned about potential exposure to TB and should be tested for HIV infection and screened for other symptoms such as chronic osteomyelitis, chronic urinary tract infections, and any of the aforementioned symptoms not present on initial examination. If a patient has a positive PPD and is asymptomatic, prophylaxis with isoniazid for 4 months is indicated (CDC, 2014c).
For older patients with a positive PPD, symptoms, and a positive chest radiography, a number of additional laboratory tests, and referrals are indicated. These include CBC count, erythrocyte sedimentation rate, chemistry panel, sputum test for AFB performed three times, and bone marrow biopsy. A referral to an infectious disease specialist is also recommended, especially if the patient has been determined to have multiple drug-resistant TB (MDR-TB) or extensively drug-resistant TB (XDR-TB).
Treatment Treatment with the standard four-drug anti-TB therapeutic regimen will cause a rapid reduction in the number of viable mycobacteria (CDC, 2012d). A reduction in the viable organism load is seen within 2 weeks. Cultures will convert to negative within 3 months in patients compliant with therapy. Medications include a combination of bactericidal drugs. The most common drugs are isoniazid, rifampin, ethambutol, streptomycin, and pyrazinamide (CDC, 2014c). Other drugs used in the treatment of TB include ethionamide, kanamycin, paraaminosalicylic acid, cycloserine, and rifabutin. Fluoroquinolones such as ciprofloxacin are also being used to treat TB.
Monitoring of liver function on a monthly basis is recommended because older adults are at greater risk of developing hepatitis. Isoniazid may lead to toxic hepatitis and peripheral neuropathy, especially in malnourished or diabetic older adults.
The incidence of multiple drug-resistant (MDR)TB rose 6.8% between 1993 and 2002. From 1993 to 1996, a relatively stable level
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of resistance to isoniazid and a reduction in MDR-TB was observed (CDC, 2012d). The CDC recommends anti-TB drug–susceptibility testing on initial Mycobacterium tuberculosis isolated from all patients with TB. MDR-TB is more common in patients who have spent time with someone with MDR-TB, in those who do not take their medicine regularly or do not take all their prescribed medication, in those who redevelop TB after having been treated, and in those who come from areas high in MDR-TB incidence, for example, Mexico (25.6%), the Philippines (11.6%), Vietnam (8.4%), India (7.7%), and China (4.8%) (CDC, 2012d). Resistance to treatment with isoniazid and rifampin extends the usual 6-month treatment to 18 to 24 months, and the cure rate is only 60% in that case.
Prognosis The prognosis for an older patient with TB is good if the patient follows the medical regimen and maintains good nutrition. The greater problems are the side effects of isoniazid and the risk of spreading TB to other vulnerable older adults.
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Nursing management Assessment
Signs and symptoms include fatigue, weight loss, weakness, night sweats, low-grade fever, purulent sputum, and sputum positive for AFB. Older adults may not always manifest all the classic symptoms of TB, so the nurse should suspect TB when an older patient complains of weight loss and a chronic cough. If the disease has progressed, the patient may have hemoptysis, lung consolidation, crackles and wheezes on auscultation, upper lobe patchy infiltrates, and cavitation on chest radiography. Sibilano (1996) developed the Tuberculosis Index of Suspicion Tool (TIST) to assist in the assessment of patients at risk for TB. The tool includes assessment of symptoms, a high-risk group assessment, and a diagnostic workup.
Diagnosis Nursing diagnoses for an older patient with TB include the following (Malone, 2011):
• Ineffective Breathing Pattern, related to decreased lung capacity
• Ineffective Health Maintenance, related to lack of knowledge about the disease process and therapeutic regimen
• Noncompliance, related to lack of knowledge of disease process, lack of motivation, and long-term nature of treatment
• Imbalanced Nutrition: Less Than Body Requirements, related to chronic poor appetite, fatigue, and productive cough
Planning and Expected Outcomes Planning for older patients with TB must include the patient and the family. If a patient is a resident in a nursing or extended care facility, the medical and nursing directors need to be included in
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planning as well. Expected outcomes include the following (Moorhead et al., 2008):
1. The patient will be able to demonstrate safe coughing techniques.
2. The patient and family will be able to verbalize the medication regimen.
3. The patient and family will be able to verbalize the side effects of the anti-TB medications.
4. The patient will be able to verbalize the need for continued medication.
5. The patient and family will be able to state how TB is transmitted.
6. The patient will be able to verbalize feelings related to social isolation.
Intervention Nursing measures for patients with TB include education about TB and how it is transmitted. Patients and families should be educated about the measures necessary to prevent further TB transmission, the importance of continued medication administration, and good nutrition. Table 22-7 lists the most common drugs used to treat TB, their dosages, adverse reactions, and nursing considerations. The nurse should teach the patient that if any of the adverse reactions named in Table 22-7 occur, he or she should call the doctor or nurse immediately. Patients should not drink alcohol while taking isoniazid.
Table 22-7 Antituberculosis medications
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g/day, Gram per day; mg/kg/day, milligram per kilogram per day; po, by mouth.
Other TB drug side effects to report to the health care practitioner include skin rashes, easy bleeding, aching joints, dizziness, tingling or numbness around the mouth, easy bruising, blurred or changed vision, ringing in the ears, and hearing loss. Nurses should inform older adults that rifampin may cause urine, stool, saliva, sputum, sweat, and tears to turn red or orange and may stain clothes or contact lenses (University of Wisconsin, 2003).
Older adults may view TB as a socially unacceptable disease. They may remember the stigma of TB in the early 1900s when a person with TB was required to be separated from family and friends and placed in a sanatorium. Finally, the nurse must address the need for psychosocial interaction and support.
Evaluation Evaluation of an older patient with TB includes assessment of compliance because older adults may find it difficult to adhere to the lengthy medication regimen. The nurse should also evaluate compliance with public health measures such as wearing a mask in public. Evaluation also includes monitoring of hepatic and renal function and repeated sputum cultures for AFB. The patient’s mood should be evaluated for depression because of social isolation.
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Bronchopulmonary infection Influenza Older patients are prone to complications from the influenza virus, especially if they have underlying diabetes or cardiac or pulmonary comorbidities. Changes related to the normal aging process decrease an older adult’s ability to clear secretions and to protect the airway. Older patients account for 90% of all influenza-related deaths, and this number is expected to continue to rise as the population ages (CDC, 2013a). The influenza season in the United States is from November until April, and peak activity occurs between January and February. It takes about 1 to 2 weeks to develop antibody protection after receiving the influenza vaccine. Because of normal changes in an older adult’s immune system, older adults have a decreased response to influenza immunization (CDC, 2014b).
Diagnostic Tests and Procedures Diagnosis includes obtaining a history of fever, chills, anorexia, and general malaise, which may be blunted or atypical in older adults.
Treatment Much of the illness and death associated with influenza can be prevented with annual influenza vaccination. The vaccine is recommended for all older patients and for patients with any chronic diseases, immunosuppression, or severe forms of anemia. A few individuals may be allergic to the media in which the virus was grown and may be intolerant to a specific vaccine. Each batch of vaccines is labeled with potential allergens that could cause a reaction. In older patients and those with chronic medical conditions, the vaccine is mostly effective in reducing the severity of the illness and the risk of serious complications and death (CDC, 2014a).
Treatment includes rest, hydration, and careful monitoring for progression to a more serious illness. Antibiotics are often used to
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prevent a secondary bacterial infection, especially in older patients with underlying respiratory and cardiac disease (Holman, 2003).
Although annual vaccinations are the best way to prevent influenza, the use of antiviral agents such as amantadine, rimantadine, or the use of a neuraminidase inhibitor (oseltamivir [Tamiflu]) may be effective at prevention and treatment and may reduce the severity and shorten the duration of some influenza strains in healthy adults when administered within 48 hours of onset. It is unknown whether either of these antivirals will prevent complications in high-risk groups. Side effects of amantadine and rimantadine include behavioral changes, delirium, hallucinations, agitation, and seizures. They are associated with a high plasma drug concentration, which occurs most often in older adult patients and patients with renal insufficiency. Side effects of oseltamivir include gastrointestinal upset, bronchitis, headaches, insomnia, vertigo, and fatigue. This medication should be used with caution in patients who have hepatic impairment or chronic cardiac or respiratory disease.
Prognosis The goals for nursing in the treatment of influenza are supportive. The nurse should focus on symptom relief and preventing the spread of influenza and secondary infections. Of all influenza- related deaths, 90% occur in the older adult population (CDC, 2013a), and as such, older adults with an underlying illness may require hospitalization.
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Nursing management Assessment
It is difficult to recognize infection in older patients. The signs associated with infection may be subdued or absent. Changes in mental status, exacerbation of underlying chronic conditions, and subnormal temperature may indicate infection in older patients. Subnormal temperature accompanied by hypotension, a rapid pulse, and cool, clammy skin are signs of sepsis in older patients. General fatigue, malaise, and decreased appetite and fluid intake may indicate influenza in older patients. The nurse should examine a patient’s chest for decreased breath sounds, wheezing, and clinical signs of pneumonia; the nurse should also assess tissue turgor and oral mucosa to determine whether an older patient is dehydrated (CDC, 2014a).
Diagnosis Nursing diagnoses for patients with influenza include the following (Malone, 2011):
• Ineffective Breathing Pattern, related to decreased energy or fatigue
• Fatigue, related to increased energy requirements for ADLs
• Risk for Deficient Fluid Volume, related to altered intake and factors influencing fluid needs
Planning and Expected Outcomes Planning for an older adult with influenza must include the patient and family. If the patient is a resident in a nursing or extended care facility, the medical and nursing directors need to be included in developing a plan to prevent transmission to other residents. Expected outcomes for an older patient with influenza include the following (Moorhead et al., 2008):
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1. The patient will maintain a patent airway.
2. The patient will have a decrease in complaints of fatigue.
3. The patient will have clear lungs on auscultation.
Evidence-based practice Respiratory Syncytial Virus (RSV) in Older Adults and High-Risk Adults
Sample/Setting A convenience sample of 608 healthy older patients was assessed for RSV.
Methods For four consecutive winters, all healthy older adults (65 years or older) and high-risk adults (those with lung or heart disease) were assessed for RSV infection.
Findings In this study, the incidence was similar to influenza A: 3% to 7% of healthy older adults were diagnosed with RSV.
Implications RSV is an important illness in older adults. An effective vaccination for RSV might be helpful for this population. (From Falsey, A. R., Hennessey, P. A., Formica, M. A., et al. (2005). Respiratory syncytial virus in elderly and high-risk adults. The New England Journal of Medicine, 352(17), 1749– 1761.)
Intervention Nursing care includes hydration, rest, and symptomatic relief. NSAIDs are used to treat muscle aches and fever. These should be given with food or milk to prevent gastrointestinal upset in older adults. One of the greatest risks is dehydration. Older patients
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should be encouraged to drink eight 8-ounce glasses of water per day, which many find difficult to do. Encouraging older adults to drink small glasses of water when passing the sink may help in ensuring an adequate intake. Other sources of fluids include juices, Jell-O, popsicles, and replacement drinks such as Gatorade. The nurse should also monitor the older patient’s mucous membranes, skin turgor, thirst, intake and output, presence or absence of vertigo on rising, blood pressure, heart rate, and weight during the acute phase and recovery period (Bulechek et al., 2008).
During peak influenza season, older patients should avoid crowds to decrease the risk of contracting influenza. The nurse should encourage patients to do shopping and other errands early in the morning when it is less crowded or to have someone else shop for them. The older adult should be alerted to the fact that the holidays are particularly problematic with regard to crowds. The use of a scarf across the nose and mouth may help reduce transmission of airborne viruses.
Evaluation The nurse’s evaluation is based on the improvement of the clinical picture, the resolution of symptoms, and the prevention of complications. Failure to improve may indicate the development of a secondary bacterial infection such as pneumonia. The nurse should monitor hydration by evaluating vital signs, daily weight, and skin turgor. The development of congestion, crackles, or dullness on chest percussion should alert the nurse to possible pneumonia.
Pneumonia Pneumonia is an inflammation of the lung parenchyma, usually associated with the filling of the alveoli with fluid. Pneumonia may be viral or bacterial or caused by aspiration, which occurs more frequently in older adults. In fact, for the older adult, pneumonia is an extremely serious illness that often results in death. Increased risk of mortality in the older adult is related to the normal age-
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related deterioration of the immune system, increased likelihood of underlying chronic illnesses, weakened cough reflex, and decreased mobility. However, the diagnosis of pneumonia in the older adult may be missed because the symptoms may be obscured by a coexisting disease or the chronic use of corticosteroids or antiinflammatory drugs. In addition to the typical pneumonia signs and symptoms, an older patient may also manifest altered mental status, dehydration, and a failure to thrive. The patient may require hospitalization and admission to the intensive care unit (ICU) with subsequent intubation and mechanical ventilation. The incidence of pneumonia in older adults in long-term care institutions is three times higher than it is among older adults in the community (CDC, 2014a); Dobbin & Howard, 2011; Norman & Yoshikawa, 2006).
Community-Acquired Pneumonia Community-acquired pneumonia (CAP) is a lower respiratory tract infection that has an onset in the community or within the first 2 days of hospitalization. Classic symptoms of community-acquired or bacterial pneumonia include fever, cough, sputum production, general feelings of fatigue and malaise, and shortness of breath. Older patients do not always exhibit fever and coughing but often have symptoms of dehydration, confusion, and a respiratory rate greater than 26 breaths per minute. Other signs include tachycardia, chest discomfort, dyspnea, headache, nausea, vomiting, myalgia, arthralgia, fatigue, weakness, abdominal pain, diarrhea, and anorexia (Mandell, Wunderink & Anzueto, 2007). In multiple-lobe pneumonia, a chest radiography may show incomplete consolidation of the lung. Some older patients manifest dramatic symptoms, resembling septic shock or adult respiratory distress syndrome (ARDS). Streptococcus pneumoniae is the leading cause of CAP in older adults, accounting for approximately 25% of pneumonia cases; its associated death rate is 30% to 40% among older adults (CDC, 2013b). About 5% to 15% of cases are caused by Haemophilus influenzae, Moraxella (Branhamella) catarrhalis, and Legionella pneumophila (Table 22-8).
Table 22-8 Criteria for severe community-acquired pneumonia (cap)
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(From Mandell, L.A., Wunderink, R.G., Anzueto, A., et al. (2007). Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Diseases, 44S, 27-72.)
Note: Either one major criteria or three minor criteria qualifies for ICU admission. BUN, Blood urea nitrogen; ICU, intensive care unit, WBC, white blood cell.
Health Care–Associated Pneumonia, Hospital- Acquired Pneumonia, and Ventilator-Associated Pneumonia Health care–associated pneumonia (HCAP) is new-onset pneumonia. It is seen in a patient who (1) was hospitalized in an acute care facility after 2-days or longer within 90 days of the infection; (2) resided in a long-term care facility; (3) received recent intravenous antibiotic therapy, chemotherapy, or wound care within a month of the current infection; or (4) was seen in a hemodialysis facility. Hospital-acquired pneumonia (HAP) occurs within 48-hours or longer after hospital admission but not found to be incubating at the time of admission. Ventilator-associated pneumonia (VAP) occurs more than 48-hours after endotracheal intubation. These infections increase the incidence of death from pneumonia. The costs associated with these diagnoses and longer hospital stays are significantly higher than a direct admission for pneumonia treatment alone. A major problem with treatment for any of these diagnoses is multidrug resistance (MDR). The virulence of the organisms may significantly reduce the available and appropriate antimicrobial therapy (Norris, 2011).
Nosocomial Pneumonia Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli most often cause nosocomial pneumonia. Older patients have an incidence of nosocomial pneumonia three times higher than younger patients probably because of the age-related decline in the immune system and a high incidence of
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comorbidities. In addition, older adults are more likely to be in high-risk areas such as residential centers, hospitals, and extended care facilities for other coexisting diseases.
Viral Pneumonia Viral pneumonia in older patients is most often associated with a history of the influenza A virus. Older adults are especially susceptible to secondary bacterial infections from S. aureus and H. influenzae (CDC, 2014a).
Aspiration Pneumonia Aspiration pneumonia is commonly associated with clinical situations such as stupor, coma, cardiopulmonary resuscitation, alcohol or drug intoxication, neurologic illness, nasogastric feeding, and general anesthesia. Aspiration of gastric contents into the airway may result in obstruction, chemical pneumonitis, or infection. Older adults are especially prone to aspiration pneumonia because of decreased coughing and gagging reflexes. In addition, positioning, feeding, and the use of a feeding tube place older patients at increased risk for aspiration pneumonia. The use of narcotic medications, alcohol, and sedatives increases the risk of aspiration.
Diagnostic Tests and Procedures The diagnosis of pneumonia is made based on a history of colds and influenza and the clinical presentation. Signs and symptoms include fever, chills, pleuritic chest pain, crackles on auscultation, and a productive cough with purulent sputum. Atypical pneumonia is first seen with a fever, constitutional symptoms, a dry cough, and headache. Laboratory sampling includes total white blood cell (WBC) count, blood cultures, Gram stain, and sputum culture. Of older patients, 20% to 25% fail to demonstrate leukocytosis, and about one third are unable to produce a sputum sample. Chest radiography (posterior, anterior, and lateral) is performed to identify infiltrates and assess for complications such as effusions or lung abscess. Chest radiography is the gold standard for diagnosis. If the patient is dehydrated, infiltrates may not be evident even if they are
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present (Norris, 2011; Mandell et al., 2007).
Treatment Treatment consists of administration of the appropriate antibiotics, hydration, good nutrition, and rest. The length of treatment with antibiotics may range from 10 to 14 days, depending on the causative organism. The initial management of immunocompetent patients with CAP emphasizes empiric treatment instead of extensive testing because of the difficulty in determining the etiologic pathogen in the disease.
The severity of the illness, site of acquisition (e.g., community or nursing facility), age, and the presence of comorbid illnesses are all considerations in determining initial antibiotic therapy. Therapy is aimed at pneumococcal and atypical pneumonia. Antibiotics used include macrolides such as azithromycin and clarithromycin for outpatients. For patients with advanced age and comorbidity, a second-generation cephalosporin such as cefuroxime or a combination agent such as trimethoprim–sulfamethoxazole is added. If an older patient is hospitalized, a second-generation or third-generation cephalosporin or a beta-lactam or beta-lactamase inhibitor is used in combination, with or without a macrolide. Patients with resistant or severe CAP may need an aminoglycoside, an antipseudomonal agent, or quinolone (Mandell et al., 2007).
The American Thoracic Society Criteria for Assessing Pneumonia Severity established guidelines for ICU admission of older patients. To qualify for admission, the patient must meet either one major or at least three minor criteria (see Table 22-8), including a respiratory rate of 30 beats/min or more, PaO2 or fractional concentration of oxygen in inspired gas (FiO2) of 250 mm Hg or less, multilobe infiltrates on chest radiography, and hypotension requiring fluid resuscitation (Mandell et al., 2007). Health care providers may use various guidelines that attempt to quantify the risk factors of individual patients when determining whether the patients should be hospitalized (Table 22-9). Some of the factors in these indexes include age greater than 65 years, presence of coexisting illness, altered mental status, chronic alcohol abuse, dehydration, malnutrition, nursing facility residency, aspiration, history of
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cigarette smoking, recent upper respiratory tract infection or influenza, and previous hospitalization within 1 year (Singanayagam, Chalmers, & Hill, 2009) (see Table 22-9). Clinical signs include unstable vital signs, extrapulmonary involvement, leukopenia, hypoxemia, and PaO2 of 60 mm Hg or less.
Table 22-9 Variables used to calculate pneumonia risk and to determine hospitalization
(Adapted from Singanayagam, A., Chalmers, J.D., & Hill, A.T. (2009). Severity assessment in community-acquired pneumonia: A review. Quarterly Journal of Medicine, 102, 379- 388.)
BUN, Blood urea nitrogen; CHF, congestive heart failure; mEq/L, milliequivalents per liter; mmol/L, millimoles per liter; PaO2, partial pressure arterial oxygen; SBP, systolic blood pressure.
Prognosis Clinical improvement usually occurs between 3 and 5 days of the initiation of treatment. Patients failing to respond to therapy will require aggressive evaluation to assess for noninfectious causes, complications, or MDR causes. Pneumonia remains the most common cause of death in older adults because of the altered immune response related to aging, underlying chronic disease, and a diminished cough reflex.
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Nursing management Assessment
A history of generalized fatigue, malaise, decreased appetite and fluid intake, or a recent viral infection may indicate a bronchopulmonary infection in an older adult. Fever, chills, shortness of breath, sputum production, and an abnormal chest examination suggest pneumonia. The nurse should assess the chest for decreased breath sounds, wheezing, dullness to percussion, egophony, and increased vocal and tactile fremitus. The nurse should also assess for symptoms of dehydration and confusion and other signs and symptoms such as tachycardia, tachypnea, chest discomfort, dyspnea, headache, nausea, vomiting, myalgia, arthralgia, fatigue, weakness, abdominal pain, diarrhea, and anorexia.
The nurse must be alert to signs and symptoms suggestive of an increasing severity of illness and a potential need for intensive care. These include tachypnea (30 to 35 breaths per minute or more); severe respiratory failure (PaO2 or FiO2 of 250 mm Hg or less); shock (diastolic hypotension of 60 mm Hg or systolic hypotension of 90 mm Hg or less); fever (temperature over 39.3 ° C); decreased urine output (20 milliliters per hour [mL/hr]); and abnormal laboratory values for blood urea nitrogen (BUN over 20 milligrams per deciliter [mg/dL]), creatinine (over 1.2 mg/dL), WBCs (4000 or over 30,000), hemoglobin (9 grams per deciliter [g/dL]), PaO2 (60 mm Hg), or PaCO2 (over 50 mm Hg) (Mandell et al., 2007). Another sign is a rapid change in chest radiography that consist of spreading infiltrates and extrapulmonary sites of infection. An older patient with such indications needs close monitoring, ongoing nursing care, and possibly even short-term mechanical ventilation for respiratory support.
Diagnosis Nursing diagnoses for a patient with bronchopulmonary infection
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include the following (Malone, 2011):
• Ineffective Airway Clearance, related to decreased energy and tracheobronchial infection, obstruction, and secretions
• Impaired Gas Exchange, related to altered oxygen supply and alveolar–capillary membrane changes
• Ineffective Breathing Pattern, related to respiratory muscle fatigue
• Risk for Deficient Fluid Volume, related to altered intake and factors influencing fluid needs
• Acute Pain, related to inflammation as well as ineffective pain management, comfort measures, or both, as evidenced by patient report of pleuritic chest pain and presence of pleural friction rubbing and shallow respirations
Planning and Expected Outcomes Planning for an older adult with pneumonia should include the patient and family. It is important to focus on supporting respiratory function, promoting good pulmonary hygiene, and maintaining adequate oxygenation. Expected outcomes for an older patient with a bronchopulmonary infection include the following (Moorhead et al., 2008):
1. The patient will maintain a patent airway.
2. The patient will maintain a PaO2 of 80 mm Hg by ABG analysis or an arterial oxygen saturation (SaO2) greater than 90% by pulse oximetry.
3. The patient will have decreased complaints of fatigue.
4. The patient will have clear lungs on auscultation.
5. The patient will be able to clear secretions effectively.
6. The patient will be able to sleep through the night without episodes of breathlessness or coughing.
7. The patient will maintain baseline vital signs and weight.
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Intervention Nursing management of an older patient with a bronchopulmonary infection includes maintenance of hydration, promotion of effective airway clearance, and proper positioning. Other interventions include monitoring fluid status (see Intervention under the Influenza section), monitoring vital signs and oxygenation parameters, maintaining a clean environment, and assisting the patient with airway clearance by encouraging coughing or by suctioning (Bulechek et al., 2008). Because of the ventilation– perfusion imbalance in the lung, it is important to position the patient with the “good lung down.” This promotes drainage of secretions from the lung with the pneumonia and increases the perfusion of the healthy lung, which results in improved oxygenation. It may be a challenge to keep the older patient positioned on the appropriate side (Bulechek et al., 2008).
The key to pneumonia prevention is early vaccination. Antibodies to most pneumococcal vaccine antigens remain elevated in healthy adults for at least 5 years. Antibody declines have been shown in older adults after 5 to 10 years (CDC, 2013b). Therefore, all persons age 65 or older should receive the pneumococcal vaccine, including all persons who have not previously been vaccinated and those who have not received the vaccination within 5 years and were 65 or younger at the time of their last vaccination. Vaccination is recommended for all persons with unknown vaccination status (CDC, 2013b). Revaccination is recommended for immunocompromised patients age 65 or older, including those with HIV infection, leukemia, lymphoma, Hodgkin disease, generalized malignancy, chronic renal failure, and organ or bone marrow transplantation, and those taking long-term systemic corticosteroids or undergoing immunosuppressive chemotherapy (CDC, 2012a).
Nurses should assess older patients for their potential for aspiration. Nursing care planned to prevent aspiration focuses on careful assessment of residual volumes of feedings and proper positioning of the older patient during and after eating. Minimize the use of sedatives and hypnotics if a meal will follow afterward. Provide a 30-minute rest period before eating. If assisting the older
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patient with meals, nurses should alternate between solid and liquid boluses. Determine the food viscosity that is best tolerated for each patient. Be aware of which patients have aspirated previously. Clinical signs of aspiration include a sudden appearance of coughing, cyanosis, or voice changes. Notify the provider if suspicion of aspiration exists (Eisenstadt, 2010; Tanner, 2010).
Evaluation Evaluation includes achievement of the expected outcomes, return of sputum to preinfection color and consistency, and return to baseline respiratory status. The nurse should monitor the patient for adequate hydration by assessing vital signs, body weight, and tissue turgor. Dehydration contributes to secretion retention and an inability to clear the airways. The effectiveness of an older adult’s cough should be monitored because a weaker cough is common in older adults and ineffective coughing may contribute to fatigue and result in aspirated secretions. The nurse should also monitor the patient’s lungs for adventitious lung sounds and monitor the respiratory pattern for effective breathing and use of accessory muscles of respiration.
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Other respiratory alterations Severe Acute Respiratory Syndrome Severe acute respiratory syndrome (SARS) may be deadly to the older adult. The mortality rate has been estimated at 10% in the population at large, but some estimate that rate to be close to 50% for those older than age 64. The first outbreak of SARS initially occurred in China in 2003 but then spread to Canada. SARS- associated coronavirus has recently moved from the animal kingdom to the realm of humans. The patient’s history of foreign travel is imperative to determine if he or she had exposure or close contact within 10 days of symptoms with a person known to have or suspected of having SARS (Dreher, Dean, Moriarty, Kaiser, et al., 2004). The patient may be asymptomatic or have a mild respiratory illness. The signs and symptoms of a moderate respiratory illness include a temperature over 100.4 ° F, coughing, shortness of breath, dyspnea, or hypoxemia. A severe respiratory illness includes the latter and radiographic evidence of pneumonia or ARDS.
The detection of antibody to SARS coronavirus (CoV) drawn during the acute illness or 21 days after the onset of illness confirms the diagnosis (Marthaler, Keresztes, & Tazbir, 2003). Other diagnostic tests include chest radiography, CBC, ABG analysis, pulse oximetry values, clotting profile, respiratory viral panel for influenza and syncytial viruses, metabolic profile, cross-reactive protein (CRP) test, and Legionella and pneumococcal urinary antigen testing. The patient should wear a mask, universal precautions should be observed, and patients and exposed staff should be quarantined. Researchers are in the process of trying to develop a vaccine for SARS (Simmerman, Chu, & Chang, 2003). No new cases of SARS have been reported since 2004.
Cardiogenic and Noncardiogenic Pulmonary Edema Pulmonary edema (PE) is an abnormal increase in the amount of
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fluid in the alveoli and interstitial spaces of the lungs and may be a complication of many cardiac and lung diseases. The most common form of PE is a result of left ventricular failure. Left ventricular failure commonly occurs in older adults, especially in persons age 85 or older, because of coronary artery disease, mitral stenosis and insufficiency, and aortic stenosis. Cardiogenic PE is the most common form of PE and is caused by the increased capillary hydrostatic pressure that results from myocardial infarction, mitral stenosis, decreased myocardial contractility, left ventricular failure, or a fluid overload. Other predisposing factors include CHF, infusion of excessive volumes or an overly rapid infusion of intravenous fluids, impaired pulmonary lymphatic drainage from Hodgkin disease or obliterative lymphangitis after radiation, inhalation of irritating gases, left atrial myxoma, pneumonia, and pulmonary venoocclusive disease. A rise in pulmonary capillary pressure occurs as a result of elevated left ventricular end-diastolic filling pressure, elevated left atrial pressure, and elevated pulmonary venous pressure.
The clinical presentation of acute cardiogenic PE includes acute shortness of breath; orthopnea; frothy, blood-tinged sputum; cyanosis; diaphoresis; and tachycardia. Physical findings include crackles in the bases on auscultation, fremitus, and dullness on percussion.
Noncardiogenic PE results from a variety of noncardiac causes. Examples of noncardiogenic PE include ARDS, reexpansion PE, and neurogenic PE.
Cardiogenic Pulmonary Edema Diagnostic Tests and Procedures Diagnosis is based on clinical presentation and diagnostic testing. ABG measurements are drawn to determine arterial PO2, arterial PO2 saturation, and pH. A reduced oxygen tension and saturation and a resultant acidity related to retained CO2 would be expected with PE. Hemodynamic measurements reveal decreased cardiac output, increased pulmonary artery pressure, and right-sided heart pressure in biventricular failure. Because older patients have
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difficulty maintaining normal hemoglobin levels, it is important to take blood samples judiciously.
Treatment The nurse must help reduce preloading and afterloading and correct the underlying process if possible. The first step is supplemental oxygen administration; mechanical ventilation should not be used unless necessary. Myocardial function is improved by reducing preloading, which is the quantity of blood returned to the heart. This is accomplished through diuresis (furosemide) and pulmonary or cardiac dilation (nitroglycerin). Morphine is also a mainstay of treatment; it reduces anxiety and therefore reduces oxygen demand. Afterloading (the force the heart pumps against) is reduced through peripheral vasodilation (nitroprusside, enalapril, captopril) (Mayo Clinic, 2014). If PE is extensive, an older patient may require transfer to the ICU, initiation of mechanical ventilation, and insertion of a pulmonary artery catheter.
Prognosis The prognosis for a patient with cardiogenic PE is good when symptoms are easily reversed and cardiac complications are controlled. However, older adults usually have one or more comorbidities such as underlying cardiac or lung disease, which increases their risk for complications. With extensive rehabilitation and physical therapy, older adults may be able to return to independent living and baseline ADLs.
Noncardiogenic Pulmonary Edema: Adult Respiratory Distress Syndrome Diagnostic Tests and Procedures The most commonly used test is the ABG, which determines the degree of hypoxia. Other tests include chest radiography, CT, CBC, and hemodynamic measurements. Older patients may need intubation and mechanical ventilation. In addition, the placement of
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an arterial line and pulmonary artery catheter may be indicated so that oxygenation and cardiopulmonary hemodynamics can be monitored.
Treatment Treatment consists of supplemental oxygen therapy, ventilation support, and maintenance of hemodynamics. Neuromuscular blocking agents, sedatives, and narcotics may be used to reduce anxiety, decrease the work of breathing, decrease oxygen consumption, and increase oxygen delivery. Positive end- expiratory pressure may be added to mechanical ventilation to improve oxygenation.
A pulmonary artery catheter is used to monitor fluid volume status. Fluids and vasopressors may be indicated for the maintenance of adequate blood pressure. If a bacterial infection is evident, antibiotic therapy may be added. Corticosteroids are reserved for ARDS caused by a chemical injury or fatty emboli.
Prognosis The prognosis is fair to poor, and the mortality rate is approximately 30% to 60%. Comorbidity, frailty, and nosocomial infections put older adults at increased risk for complications. If an older adult does not require mechanical ventilation, the prognosis is good to fair, depending on underlying disease states and complications. Extensive rehabilitation, physical therapy, and retraining of ADLs may be necessary to return the older adult to independent living (Farley, McLafferty & Hendry, 2009).
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Nursing management Assessment
The nurse should determine through the health history whether the patient has risk factors for the development of PE. Assessment begins with the evaluation of respiratory and cardiac status. The nurse should observe the older patient for signs and symptoms of PE. Nonspecific signs may include insomnia, wandering, anorexia, nausea, delirium, weakness, and weight gain.
Assessment for noncardiogenic PE involves identifying predisposing factors, which include aspiration of gastric contents, pneumonia, thoracic injury, pulmonary contusions, smoke inhalation, multiple blood transfusions, uremia, cardiopulmonary bypass surgery, fracture of long bones, and sepsis. The clinical presentation of noncardiogenic PE includes refractory hypoxemia, crackles on auscultation, hypotension, cyanosis, tachypnea, hyperventilation, and increased tracheobronchial secretions.
Diagnosis Nursing diagnoses for an older patient with PE include the following (Malone, 2011):
• Ineffective Breathing Pattern, related to decreased energy
• Impaired Gas Exchange, related to alveolar–capillary membrane changes and altered blood flow
• Ineffective Airway Clearance, related to decreased energy and tracheobronchial obstruction
• Excess Fluid Volume, related to a compromised regulatory mechanism
• Impaired Spontaneous Ventilation, related to metabolic factors and respiratory muscle fatigue
• Risk for Infection, related to inadequate primary and secondary
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defenses
• Activity Intolerance, related to generalized weakness and imbalance of oxygen supply and demand
• Deficient Knowledge, related to a lack of previous experience with cardiogenic PE or noncardiogenic PE
Planning and Expected Outcomes Planning includes developing interventions and expected outcomes for older patients that focus on restoration of the oxygen supply and demand balance. The patient and family must be included to help the patient achieve the expected outcomes. It is important that both the patient and the family know about expected outcomes and necessary interventions such as oxygen administration or mechanical ventilation. Expected outcomes include the following (Moorhead et al., 2008):
1. The patient will maintain ABG values within normal limits.
2. The patient will maintain oxygenation within normal values.
3. The patient will have a cardiac output within normal values.
4. The patient will be able to verbalize feelings related to the illness.
5. The patient will maintain a patent airway.
6. The patient will maintain a balanced intake and output.
7. The patient will have an alternative method of communication if receiving mechanical ventilation.
8. The patient will maintain skin integrity.
9. The patient will be able to sustain spontaneous ventilation without mechanical ventilation.
10. The patient will have stable hemodynamics.
Intervention The effect of PE may be severe in older adults because of its
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associated functional disability secondary to activity intolerance, drug therapy, and frequent rehospitalizations. The nurse should be alert to these factors and plan interventions that include daily weight assessments, energy-conserving ADLs, elevation of the feet and legs, reduction in or elimination of sodium intake, and use of diuretics. The nurse should assess the patient for adventitious lung sounds, respiratory muscle fatigue and the use of accessory muscles of respiration, and airway patency. The patient should be positioned to facilitate ventilation–perfusion matching and to minimize respiratory efforts. This can be accomplished by adding pillows at the back and under the arms and encouraging the patient to sit up straight with legs and feet elevated. The patient should be encouraged to cough effectively, which may require splinting and analgesic interventions; the patient should also be encouraged to change positions frequently and practice slow, deep breathing (Bulechek et al., 2008).
Inpatient interventions for PE include positioning the patient to improve ventilation by elevating the head of the bed 30 degrees. If the patient is producing large amounts of frothy sputum, he or she should be turned to the side to facilitate drainage; frequent suctioning then becomes appropriate. The nurse should reassure the patient and family or significant other and, if necessary, prepare them for intubation and mechanical ventilation, which may be particularly frightening for an older patient. An integral part of planning nursing care for older patients requiring intensive care is a discussion about the patient’s wishes in regard to high-technology medical care. The patient and family should be asked if they have any advance medical directives (AMDs) or durable powers of attorney in case the older patient becomes unable to speak. If the patient is unaware of AMDs but expresses an interest, a family conference including the physician, nurse, social worker, and pastoral caregiver should be planned to help the older patient express his or her wishes. If the older patient has an AMD or a durable power of attorney, a copy should be filed in the medical record and reviewed with the older patient, family, physician, and any other caregivers. It is important to understand and respect the wishes of older patients and families before initiating high- technology medical care (see Chapter 3).
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Interventions include supplemental oxygen, mechanical ventilation, and nursing measures to promote oxygen balance. Monitoring PaO2 saturation helps the nurse determine which activities deplete oxygen saturation. Interventions such as suctioning, turning, and positioning have been well documented as increasing oxygen consumption and decreasing arterial and mixed venous oxygen levels. The nurse should plan care to decrease the number of interventions performed at one time so as to minimize oxygen consumption and stress. It is important to provide an alternative means of communication for older patients receiving mechanical ventilation. If a patient has a hearing aid, it may be difficult for him or her to hear over the noise of the technology in the intensive care setting (Bulechek et al., 2008).
Older patients in the ICU often need to be reoriented to time. The ICU provides no cues as to day and night. Older patients are particularly sensitive to continuous stimuli in the unit—sound, sights, smells, and textures—and may become confused and combative. The nurse should try to establish a regular nighttime routine with older patients, for example, vital sign assessment, oral care, and toileting. The lighting should then be reduced as much as possible to promote rest and sleep while allowing for safe care. This helps older patients establish a routine or pattern that they are able to recognize as “time to sleep.”
Evaluation Evaluation is based on improvement in the clinical picture, resolution of symptoms, and prevention of further complications. The nurse should monitor the patient’s vital signs, cardiac function, and oxygenation status for stability and improvement. The nurse should also monitor the older adult’s reaction to frightening therapies and invasive interventions. Older adults need continual reassurance and information to reduce their anxiety. The nurse should constantly monitor the airway for effective clearance of secretions. Careful evaluation of daily weight and the patient’s intake and output will help determine whether the patient is retaining additional fluids. The nurse should monitor the patient’s
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subjective measure of dyspnea using the dyspnea scale.
Pulmonary Emboli A pulmonary embolus is a blockage of pulmonary arteries by a thrombus, fat, or air embolus. Often, in the older patient, the blockage is a result of a deep vein thrombosis. The thrombosis breaks loose, becoming an embolus, and travels to the lungs through the venous system, where it is trapped in a small vessel of pulmonary circulation. Occlusion of the lung with a large embolus causes pulmonary infarction, which results in necrosis of the lung tissue. The embolus, which is composed of platelets, red blood cells (RBCs), and WBCs, releases vasoactive substances that cause bronchial constriction, ventilation–perfusion mismatch, and hypoxia. The amount of physiologic dead space—ventilation in excess of perfusion—is increased, which leads to an increase in intrapulmonary shunting and hypoxia.
Risk factors for the development of pulmonary emboli include an age older than 40 years, immobility, recent surgery, recent trauma, a history of hospital or nursing home confinement, central venous catheter placement, neurologic disease with extremity paresis and a history of vascular disease, COPD, heart disease, diabetes mellitus, malignancy, and previous pulmonary emboli. Thromboembolism is more common in older patients who have a natural tendency for hypercoagulation (Farley et al., 2009).
The clinical presentation includes coughing, dyspnea at rest, hypotension, hypoxia, hemoptysis, tachycardia, anginal or pleuritic chest pain, decreased PaO2, and S3 or S4 gallop (Koschel, 2004).
Diagnostic Tests and Procedures Diagnosis is based on ventilation–perfusion lung scanning (VQ scan) or pulmonary angiography. ABG measurements may reveal hypoxemia with PaO2 between 60 and 80 mm Hg. ECG may show a right axis deviation, right bundle branch block, tall peaked P waves, a depressed ST segment, and supraventricular tachycardia if the emboli are extensive. Massive pulmonary emboli may result in electromechanical dissociation, in which electrical conduction
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continues without heart muscle response or cardiac output. Chest radiography may reveal an elevated hemidiaphragm; atelectasis, consolidation, or both; and pleural effusion.
Treatment Fast-acting heparin is the drug of choice for treatment of pulmonary emboli (Farley et al., 2009). Heparin is administered subcutaneously or intravenously to achieve a prothrombin time of 1.5 to 2.5 times control. Thrombolytic therapy such as the use of streptokinase, urokinase, or tissue plasminogen activator (TPA) is used in patients with extensive pulmonary emboli that exhibit unstable hemodynamic situations. Although this therapy is useful, data showing a reduction in mortality or morbidity rates in older patients are scant (Andrews & Habashi, 2010). Patients with a likelihood of recurring pulmonary emboli are treated on a long- term basis with warfarin (Coumadin) and monitoring of their international normalized ratio (INR). The goal range of the INR is 2.5 to 3.0. Patients with recurrent pulmonary emboli are candidates for Greenfield vena cava filters.
Prognosis The prognosis for pulmonary emboli is guarded. Older adults are at increased risk for deep vein thrombosis (DVT) and pulmonary emboli because of decreased mobility. Often, the diagnosis is made on postmortem examination.
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Nursing management Assessment
Assessment begins with the identification of risk factors for the development of pulmonary emboli. In older adults, dehydration and immobility are leading causes. If an older patient has a history of recent fracture of a long bone or a pelvic fracture secondary to falling, fat emboli should be suspected. Clinical signs and symptoms include sudden dyspnea, chest pain, restlessness, a weak and rapid pulse, tachypnea, and tachycardia.
Diagnosis Diagnoses for an older patient with pulmonary emboli include the following (Malone, 2011):
• Impaired Gas Exchange, related to altered blood flow and oxygen supply
• Risk for Decreased Cardiac Tissue Perfusion, related to interruption of arterial flow
• Impaired Spontaneous Ventilation, related to metabolic factors
Planning and Expected Outcomes Planning includes developing interventions and expected outcomes for the older patient that are aimed primarily at improving oxygenation and reducing pain. Expected outcomes include the following (Moorhead et al., 2008):
1. The patient will maintain ABG values within normal limits.
2. The patient will maintain adequate respiratory muscle function.
3. The patient will be able to sustain spontaneous ventilation without mechanical ventilation.
4. The patient will maintain adequate oxygenation.
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5. The patient will have adequate pain control.
6. The patient will maintain adequate cardiac output.
7. The patient will maintain adequate vital signs.
Intervention The primary goals of treatment are to stop the clot from getting bigger and to prevent new clots from forming. Although treatment is focused on these goals, maintaining effective oxygenation and ventilation is paramount. The nurse should monitor tissue oxygen delivery, signs and symptoms of respiratory failure, laboratory values for changes in oxygenation or acid–base balance, and hemodynamic parameters and respiratory pattern for symptoms of respiratory difficulty (Bulechek et al., 2008). Oxygen therapy is administered to improve oxygenation and decrease breathlessness. Heparin therapy is initiated to prevent formation of future clots. Older patients need reassurance and careful monitoring of vital signs. Sedation relieves pain and anxiety and reduces oxygen demand. If an older patient is dehydrated or has hypotension, intravenous fluids are administered. The nurse may use vasopressors if hypotension cannot be reversed with fluids.
The patient needs to be monitored for bleeding complications from anticoagulant therapy. The nurse should observe the urine for color changes, check the stool for occult blood, and monitor for other complications, including bruising, gastric bleeding, hemorrhaging, and cerebrovascular accident.
Because immobility is a risk factor for the development of pulmonary emboli, it is important to promote mobility as soon as medically possible. The nurse should use antiembolic stockings and passive and active range-of-motion exercises during the acute phase. The older patient should be encouraged to move about as soon as is medically feasible.
Education topics for the older patient and his or her family include signs and symptoms of pulmonary emboli, long-term anticoagulant therapy (warfarin), and the importance of exercise and mobility. Education on anticoagulant therapy includes
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elimination of aspirin or NSAIDs, elimination of green leafy vegetables, cautionary use of over-the-counter medications that potentiate the anticoagulation effect, and prompt reporting of any bleeding. An electric razor is recommended for male patients. The nurse must also help the patient understand the importance of regular monitoring of the INR and the importance of taking anticoagulation medication at the same time every day.
Evaluation Evaluation is based on successful achievement of the expected outcomes. The nurse should monitor the older patient’s response to oxygen therapy, respiratory support, and effective pain management and relief by using a pain scale. The nurse should also monitor the patient for follow-up care with INR blood draws, dietary restrictions, and medication compliance. With older adults, it is especially important to evaluate the patient’s ability to recall the signs of excessive anticoagulation.
Obstructive Sleep Apnea Obstructive sleep apnea syndrome (OSAS) is the result of partial or complete upper airway closure in the pharynx and an imbalance between the forces that dilate the pharynx and the forces that promote pharyngeal closure. Obstruction of air flow results when the soft palate and tongue fall backward and partially or completely obstruct the pharynx (Bloom et al., 2009; Halpin, Bunting, Selecky, et al., 2008). OSAS produces adverse physiologic and neurobehavioral effects. Pathogenic factors include intermittent hypoxemia or hypercapnia, mechanoreceptor activation during obstructed efforts, chemoreflex activation through chronic body and CNS excitability, and arousal that results from abnormal breathing (Bloom et al., 2009). These changes result in partial awakening of the patient with a startle response of snorts and gasps, which move the tongue and soft palate and relieve the obstruction. This cycle of apnea and arousal may occur as many as 200 to 400 times in 8 hours of sleep (Norris, 2011). Chronic effects on the cardiovascular system are a result of increased sympathetic
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nervous system activity. During obstructive apnea, large fluctuations in intrathoracic pressure occur, causing changes in venous return, left ventricular filling, cardiac output, baroreflex, and release of volume-regulatory peptides (Bloom et al., 2009; NHLBI, 2009).
Obesity is the dominant risk factor for OSAS in both men and women. OSAS is twice as common in men as in women and the risk increases with age. Other risk factors include family history, genetic syndrome, smoking, alcohol use, employment requiring shift rotation or sleep restrictions, medications, and ethnicity (blacks, Hispanics, and Pacific Islanders have a higher incidence of OSAS compared with whites) (Bloom et al., 2009; NHLBI, 2009).
Diagnostic Tests and Procedures The diagnosis of OSAS is made on the basis of the history and the objective measurement obtained by performing polysomnography in a sleep laboratory. Diagnostic criteria include complaints of excessive daytime sleepiness, frequent episodes of obstructed breathing during sleep, loud snoring, morning headaches, and dry mouth on awakening. Sleep study criteria include more than five episodes of obstructive apnea longer than 10 seconds in duration per hour of sleep and one or more of the following: frequent arousal from sleep, bradycardia, tachycardia, and arterial oxygen desaturation associated with apneic episodes. It is important to differentiate between sleepiness and fatigue or tiredness, which does not always predispose a person to sleep (Landis & Heitkemper, 2011). Patients with OSAS often report falling asleep while driving.
Treatment Treatment starts conservatively and involves teaching the older patient to avoid alcohol or sedatives at bedtime, humidify the air, and wear a dental device to keep the jaw forward; weight loss should also be encouraged. These interventions may relieve sleep apnea problems in some individuals (NHLBI, 2009). The next line of treatment for patients with OSAS is nasal continuous positive airway pressure (CPAP). It provides immediate prevention of
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upper airway collapse and leads to correction of ABG derangements, improved sleep continuity, improved cognition, and reduction of sleepless symptoms (Bloom et al., 2009). The most critical factor in the use of nasal CPAP is the patient’s level of compliance. Some studies have shown a compliance rate of 46% for use of CPAP for 4 hours, 5 nights a week. Alternatives to nasal CPAP include weight reduction; sleep position training; and avoidance of alcohol, sedative-hypnotic and narcotic medications, cigarette smoking, and sleep deprivation (Landis & Heitkemper, 2011).
Surgical interventions include tracheotomy or uvulopalatopharyngoplasty (UVPP or UPPP). The goal of UVPP or UPPP is to remove obstructing tissue of the soft palate, uvula, and posterolateral pharynx, thereby eliminating obstruction. The procedure may eliminate snoring but may not reduce the apneic episodes (Bloom et al., 2009).
Prognosis The prognosis for a patient with OSAS is good. Patient commitment to medical management, such as weight loss and daily use of nasal CPAP, is essential for a good outcome. Older adults may have difficulty with weight reduction. They may also find the nasal CPAP machine annoying and disruptive to their sleep and therefore not wear it consistently at night. Although surgery may be an option, comorbidity may preclude its use in some older adults.
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Nursing management Assessment
The nurse should assess the patient for the presence of chronic loud snoring, gasping or choking episodes during sleep, excessive daytime sleepiness (especially when driving), automobile or work- related accidents attributed to fatigue, and personality changes or cognitive difficulties. Clinical signs include obesity, systemic hypertension, nasopharyngeal narrowing, and, in rare cases, pulmonary hypertension and cor pulmonale (Bloom et al., 2009).
Diagnosis Nursing diagnoses for a patient with OSAS include the following (Norris, 2011):
• Fatigue, related to increased energy required for ADLs
• Disturbed Sleep Pattern, related to sensory alterations
• Ineffective Breathing Pattern, related to decreased energy or fatigue
Planning and Expected Outcomes Expected outcomes for an older patient with OSAS include the following (Moorhead et al., 2008):
1. The patient will verbalize a feeling of rest and well-being.
2. The patient will verbalize an improvement in quality of life.
3. The patient will report an absence of sleepy episodes during the day.
4. The patient will have increased ability to concentrate.
5. The patient will have increased endurance, as evidenced by ability to participate in ADLs.
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6. The patient will maintain adequate vital signs.
7. The patient will maintain adequate oxygenation and ventilation during sleep, as evidenced by continuous pulse oximetry monitoring.
8. The patient will achieve or maintain appropriate body weight.
Intervention Interventions for a patient with OSAS include monitoring the patient’s sleep pattern, noting physiologic and psychological circumstances that interrupt sleep, and implementing sleep- promoting therapies such as massage, lifestyle changes, bedtime routines, and the use of CPAP (Figure 22-5). The nurse should assist the patient with nutrition counseling, weight reduction, and exercise plans. Exercise may be especially difficult for older adults with underlying orthopedic problems and decreased activity. Exercise programs that incorporate water aerobics may be helpful for older adults with joint problems. The nurse should encourage older adults to eat more fresh fruits and vegetables and less processed and prepackaged foods. Again, this may be difficult for older adults who live alone and do not cook regularly.
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FIGURE 22-5 Management of sleep apnea often involves sleeping with a nasal mask in place. The pressure supplied by air coming
from the compressor opens the oropharynx and nasopharynx. (From Lewis, S.M., Dirksen, S., Heitkemper, M.M., et al., (2011). Medical-surgical nursing:
assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby.)
Evaluation Evaluation is based on achievement of the expected outcomes and improvement in the patient’s perception of sleep. The nurse should evaluate the patient’s daytime somnolence and ability to complete ADLs, note the frequency of naps, and monitor for lower extremity edema, fluid retention, and weight gain.
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Summary Neurochemical control and the respiratory muscles are involved in the process of respiration. The structures of the lungs include upper and lower airways, as well as extrapulmonary and intrapulmonary structures. Age-related changes in pulmonary structure and function include elastic recoil and musculoskeletal changes of the chest wall and decreased compliance of the thorax. Asthma, chronic bronchitis, emphysema, and pneumonia are respiratory conditions common in older adults. Chronologic age and tobacco use put older patients at risk for bronchogenic carcinoma. Nursing management of older patients with respiratory alterations focuses on a complete and accurate physical assessment, minimization of risk factors for disease development, development of partnerships with the patient to successfully implement lifestyle changes and treatment regimens, and, most important, pulmonary hygiene and airway patency.
Home care
1. Encourage homebound older adult patients with respiratory disease to drink 8 to 10 glasses of water a day, if not contraindicated.
2. Encourage homebound older adult patients with respiratory disease to exercise within their capacity to promote thoracic muscle conditioning.
3. Monitor homebound older adult patients for smoking and exposure to secondhand smoke. Encourage family members to refrain from smoking in the presence of the patient.
4. Encourage homebound older adult patients to use pursed-lip breathing to control breathlessness and improve oxygenation.
5. Monitor pulse oximetry to assess oxygenation.
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6. Encourage frequent small meals to reduce breathlessness associated with eating.
7. If a patient is using home oxygen, assess the home environment for potential safety hazards, including the possibility of the patient tripping over oxygen tubing.
8. Assess patients for confusion, occipital headaches, and forgetfulness. These symptoms may be indicative of carbon dioxide retention. Teach family caregivers these signs as well.
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Key points • Changes in lung functions that are associated with the aging
process, in the absence of primary pulmonary disease, are not associated with decreased activity or increased breathlessness.
• Older adults with chronic lung disease can lead active lives with proper medical and nursing management.
• Breathing retraining (e.g., pursed-lip breathing and diaphragmatic breathing) may result in decreased breathlessness and increased oxygenation.
• It is important to include the family in planning care for an older adult with chronic lung disease.
• An older patient with chronic lung disease may demonstrate unacceptable behavioral patterns because of the loss of control experienced with chronic illness.
• Smoking cessation may not be achievable for some older patients; interventions for these patients should focus on reducing the number of cigarettes smoked.
• Exercise plays an important part in overall lung function and has been shown to improve breathing in older patients.
• Care planning that includes the use of mechanical ventilation or other technology should include the patient and family.
• Primary nursing diagnoses for the older patient with respiratory disease focus on increasing airway clearance, decreasing breathlessness, and improving oxygenation.
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Critical thinking exercises 1. How might pulmonary hygiene measures be revised for a frail older adult with a history of CHF and osteoporosis?
2. You are caring for a 71 year-old man who has a history of smoking 75 pack-years. He has COPD but continues to smoke, stating that it would be impossible to quit now and besides, “It’s too late”. How would you assist this patient?
3. Think about your own personal views regarding advanced life support measures for the older adult population. What are the ethical implications of placing (or not placing) an 80 year-old person on mechanical ventilation for acute respiratory failure? How would you assist patients and/or family members faced with decisions of this nature?
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* Previous authors: Pamela Becker Weilitz, MSN(R), CS, ANP; Lynn Ferebee, MSN, RN, FNP; and Thomas J. Hendrix, PhD, RN.
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C H A P T E R 2 3
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Endocrine Function Sue E. Meiner, EdD, APRN, BC, GNP; , Dr.Jean Benzel-Lindley, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Discuss the normal age-related physiologic changes that occur in the endocrine system.
2. Describe the major characteristics of common endocrine diseases in older adults: metabolic syndrome, diabetes mellitus – type 2, hyperthyroidism, hypothyroidism, osteoporosis, and sexual dysfunction.
3. Apply the nursing process in caring for an older adult with an endocrine disorder.
http://evolve.elsevier.com/Meiner/gerontologic
Previously dominated by diabetes and thyroid disease, gerontologic endocrinology has recently been redefining itself through the use of innovative insights developed from the mapping of the human genome (Bergman, Heindel, Kasten et al., 2013). Our knowledge of aging endocrine physiology and genetic influences (Garinis, van der Horst, Vijg, & Hoeijmakers, 2008) has begun to grow at a very fast pace. New animal models (Toivonen & Partridge, 2009) and genomic endocrine-related trait studies (Walter, Atzmon, Demerath et al., 2011) have led to a robust subspecialty often referred to as the endocrinology of aging (Michael, 2010). Andropause, circadian dysrhythmias, dehydroepiandrosterone (DHEA) replacement, erectile dysfunction, glucagon-like peptide 1 (GLP-1) replacement, male osteoporosis, menopause, metabolic syndrome, and metabolic presbycusis have joined the traditional topics of diabetes and thyroid disease in the newly emerged subspecialty.
Endocrinology’s new “ensemble view of neuroendocrine aging”
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is now discussed in terms of decreased estrogen production in women (menopause), decreased testosterone production in men (andropause), decreased adrenal function (adrenopause), and decreased growth hormone (GH)–insulin-like growth factor (IGF) (somatopause) (Paltsev, Kvetnoy, Polyakova, Knetnaiya, & Trofimov, 2011). Endocrinologic aging involves increased molecular disorderliness of the endocrine regulatory mechanisms that results in reduced vitality of the overall person. This molecular dysregulation of neurohormones from or with the central nervous system (CNS) is one of the earliest measurable characteristics of endocrine aging. Many believe natural endocrine aging is not a disease to be cured; others believe that our knowledge can provide important “antiaging” therapies that will benefit humans as a whole (Blagosklonny, 2009).
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Endocrine physiology in older adults Composed of ductless glands (Figure 23-1, A), which secrete 40 major hormones (Moore, Dalley, & Agur, 2010) that control numerous processes throughout the body (Table 23-1), the endocrine system uses a delicate balance of chemical messengers in the bloodstream to excite and regulate mood, growth, organ function, metabolism, and sexual activity (Goodman, 2009). Dependent on a complex interplay of factors, many hormones are secreted in a cyclic pattern of minutes, hours, days, or months. Feedback control processes (see Figure 23-1, B) of these intricate gland–hormone–organ–tissue systems depend on secretion and degradation of hormones classified by chemical structure and cell receptor type (Steil, Palerm, Kurtz et al., 2011).
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FIGURE 23-1 A, Endocrine feedback loops involving the hypothalamus–pituitary gland and end organs (endocrine
regulation). B, Feedback-regulating systems where the target gland hormone feeds back to the hypothalamus. Pituitary release of the tropic hormone follows. Top left, Corticotropin-releasing hormone
(CRH). Top right, Gonadotropin-releasing hormone (GnRH). Bottom, TSH-releasing hormone (TRH).
ACTH, Adrenocorticotropic hormone; CG, chorionic gonadotropin; FSH, follicle-stimulating hormone; LH, luteinizing hormone; TSH,
thyroid-stimulating hormone (thyrotropin). (A, From Phipps, W., Sands, J., & Marek, J. (1999). Medical-surgical nursing (6th ed.). St. Louis, MO: Mosby. B,
From Price, S.A. & Wilson, L.M. (1997). Pathophysiology (5th ed.). St. Louis, MO: Mosby.)
Table 23-1 Principal endocrine glands
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(Data from Beers, M.H. & Berkow, R. (Eds.). (2014) Merck manual of geriatrics. Whitehouse Station, NJ: Merck. <http://www.merckmanuals.com/professional/geriatrics.html> Accessed 04/30/2014.; Copstead, L.E. & Banasik, J.K. (2005). Pathophysiology (3rd ed.). St, Louis, MO: Elsevier.)
Apoptosis (cell death) is a theme that has dominated cellular research on the physiology of aging and some age-related diseases since 1972 (Mobbs & Hof, 2009). Additionally, three basic categories are used to classify endocrine pathology: hyposecretion, hypersecretion, and hyporesponsiveness; the system is elaborate and increases in complexity with the aging process (Table 23-2). In addition, clinical manifestations in the older person may be altered by disease processes in other body systems such as in the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, which occurs with many types of tumors. Therefore, this chapter discusses the typical aging changes of menopause, andropause, adrenopause, and somatopause physiology without discussion of other potential superimposed pathophysiologic states.
Table 23-2 Aging changes in the endocrine system
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Andropause and Menopause Older men and women experience a decline in the biosynthesis and balance of their sex hormones from the cholesterol precursor as they age (Mobbs & Hof, 2009). In both genders, the hypothalamus– anterior pituitary–testes or ovary system declines, although the timing is gender specific. Both genders may experience hot flashes, night sweats, depression, and sexual dysfunction in response to age-related declines in androgen or estrogen. In contrast to the previous gender similarities in symptoms, laboratory values to determine the endocrine decline are unique to each sex: luteinizing hormone (LH) and testosterone are of primary importance in men, whereas follicle-stimulating hormone (FSH) and estrogen are of primary importance in women.
Hormone replacement therapy, in both genders, is a hotly debated topic among health care providers because risks and benefits are unique to each patient. Ongoing debate over whether aging is a disease contributes to the controversy. Those who advocate testosterone replacement cite the benefits of improvements in relation to bone density, libido, muscle mass, strength, visuospatial skills, depression, fatigue, hot flashes, irritability, mood, and sleep (Seal, 2009). Testosterone replacement in andropause is complicated by adverse lipid effects, the risk of promoting prostate cancer, worsening of sleep apnea, potential hepatotoxicity, increased aggressive behavior, and the risk of erythrocytosis. Menopausal and postmenopausal hormone replacement (HR) practices continue to change on the basis of larger, more rigorous research studies. The presence or absence of a uterus and ovaries guides clinicians on the types of hormones used in perimenopausal women (Simpson, 2012). The 2002 Women’s
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Health Initiative findings of increased breast cancer, heart disease, stroke, and blood clots from perimenopausal HR have been confirmed (Schierbeck, Rejnmark, Tofteng et al., 2012) and joined by evidence of improved metabolic syndrome indices (Kilic, Yilmaz, Erdogan et al., 2010) and bone health with phytoestrogen HR (Giroux, Bussières, Bureau, & Rousseau, 2012), brain health (Berent- Spillson, Persad, Love et al., 2010), and weight control. Although many clinicians continue to prescribe perimenopausal HR, most agree that long-term HR is no longer clinically justifiable (Scuster, Rhodes, Gostout et al., 2010).
Adrenopause Weighing approximately 4 grams (g), the adrenal glands sit on top of the kidneys and are composed of the adrenal medulla and cortex. A total loss of adrenocortical function causes death within days; however, age-related decreases in mineralocorticoids, glucocorticoids, and androgenic hormones manifest changes in body composition, skeletal mass, muscle strength, body weight, and metabolism (Mobbs & Hof, 2009). Age-related decreases in DHEA and norepinephrine may produce fluid and electrolyte imbalances and changes in glucose, protein, and fat metabolism. The decline of DHEA with age parallels that of growth hormone, so by age 65, the human body makes only 10% to 20% of what it made at age 20 (Szkrobka, Krysiak, & Okopieri, 2008). These declines closely parallel declines in the GH–IGF-1 axis, a process now referred to as somatopause.
Somatopause Somatopause is often spoken of from a neuroendocrine point of view because certain neurons in the hypothalamus secrete hormones (neurosecretion). Somatopause focuses on the neuron– hypothalamus–pituitary axis and the failure of CNS integration of the endocrine and nervous systems, which causes peripheral endocrine gland insufficiency contributing to a disrupted feedback axis in aging (Di Somma, Brunelli Savanelli, Scarano et al., 2011). Specifically, somatotropin secretion from the hypothalamus–
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pituitary axis influences many age-related changes in nutrition, metabolism, body temperature, and circadian rhythms, circulation, salt–water balance, growth, and reproduction. Current antiaging researchers who believe “you are as young as your oldest part” (Liantonio, Gramegna, Carbonara et al., 2013) have focused on various secretagogue compounds that stimulate pulsatile GH secretion and increase IGF-1 in the older adult to levels approximating those found in young adults.
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Common endocrine pathophysiology in older adults The Metabolic Syndrome–Diabetes Continuum Pathophysiology Metabolic syndrome is a common multifactorial syndrome of aging (the incidence is 26 per 1000 person-years) (Suzuki et al, 2008), which varies among racial and ethnic groups and is strongly associated with abdominal obesity in America (Flegal, Carroll, Ogden, & Curtin, 2010). Suspected endocrine influences on the syndrome include corticosteroid axis derangement, polycystic ovary syndrome, and dysglycemia. Recent epidemiologic research has identified, defined, and measured the metabolic syndrome as a significant antecedent to illness trends in diabetes and heart disease in the United States (Chen, Lu, Pang, & Liu, 2013). Insulin resistance causes increased production of inflammatory cytokines correlating with the development of diabetes mellitus - type 2 and atherosclerotic vascular disease. The primary risk factors for the syndrome are abdominal obesity, insulin resistance, physical inactivity, and hormonal imbalance (Look AHEAD Research Group et al., 2010). Additionally, some evidence exists for genetic influences through a variety of gene polymorphisms (Dupuis, Langenberg, Prokopenko et al., 2010).
Signs and Symptoms Clinical criteria include increased waist circumference (population specific) plus any two of the following: (1) blood pressure greater than 129/84 mm Hg or taking hypertension medication, (2) plasma triglyceride levels over 149 milligrams per deciliter (mg/dL) or taking triglyceride medication, (3) high-density lipid levels less than 40 mg/dL in men or less than 50 mg/dL in women or taking high-density lipoprotein cholesterol (HDL-C) medication, (4) fasting glucose greater than 99 mg/dL (including patients with
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diabetes).
Medical Management The reduction of risk factors for diabetes and atherosclerotic disease are the primary therapeutic objectives in metabolic syndrome (Pattyn, Cornelissen, Eshghi, & Vanhees, 2013). The therapeutic lifestyle changes (TLCs) that will improve all metabolic risk factors are detailed in (Box 23-1). Nutritional management for metabolic syndrome should include meticulous attention to the amounts of low-saturated fats, trans fat, cholesterol, and simple sugars. A slow, modest weight loss of 7% to 10% of body weight through calorie restriction and physical activity has significant health benefits. When the risk is high, drug therapy for elevations in blood pressure, low-density lipoprotein cholesterol (LDL-C), and glucose levels should be incorporated into the regimen.
Box 23–1
Steps every 6 weeks in therapeutic lifestyle changes Visit 1: Begin weight reduction, encourage physical activity, refer
to dietitian.
Visit 2: Evaluate weight, waist circumference, low-density lipoprotein (LDL), high-density lipoprotein (HDL-C), triglyceride levels, blood pressure, and fasting glucose. Reinforce therapeutic lifestyle changes (TLCs). Consider meal replacements.
Visit 3: Evaluate weight, waist circumference, LDL, HDL-C, triglyceride levels, blood pressure, and fasting glucose. Reinforce TLCs. Consider meal replacements.
Visit 4: Evaluate weight, waist circumference, LDL, HDL-C, triglyceride levels, blood pressure, and fasting glucose. Reinforce TLCs. Consider meal replacements. If no
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improvement in parameters, consider drug therapy. Intensify weight management and physical activity.
Visit 5: Monitor adherence to TLCs and medications, if used.
Visit 6: Reevaluate TLCs, and make adjustments to plan, as needed.
Nursing Process Applied to Metabolic Syndrome The nursing process is applied to the metabolic syndrome by initially focusing on the root causes of improper nutrition and inadequate physical activity, as detailed in Table 23-3.
Table 23-3 Metabolic syndrome
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(Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.)
Diabetes Mellitus – Type 2 Pathophysiology Metabolically distinct genetic influences play a pivotal role in geriatric diabetes and require a different approach (Cigolle, Lee, Langa et al., 2011). Often starting with metabolic syndrome, the disease ultimately produces dysfunction and failure of various organs such as the heart, kidneys, nerves, eyes, and blood vessels (Grundy, 2009). Age-related changes combine with genetics and lifestyle factors to produce a hyperglycemic state. Current evidence suggests that the hyperglycemia of diabetes mellitus - type 2 is caused by impaired carbohydrate metabolism, changes in pulsatile
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insulin release, and resistance to insulin-mediated glucose disposal (Nathan, Buse, & Davidson et al., 2009). As with metabolic syndrome, the most important variables associated with diabetes mellitus - type 2 are obesity and insulin resistance. Starting with a compensatory hyperinsulinemia that affects insulin receptors on target tissues, which leads to insulin resistance that produces hyperglycemia, diabetes mellitus - type 2 is a disorder of relative insulin insufficiency. The pathophysiology of diabetes mellitus - type 2 in contrast to type 1 diabetes mellitus involves defects in the cell membrane, receptors, or intracellular pathways (Figures 23-2 and 23-3). Genetic defects of beta-cell function and insulin action interact with lifestyle factors to make diabetes one of the most common chronic conditions: It affects 40% of the older adult population (Samuel, Petersen, & Shulman, 2010).
FIGURE 23-2 Pathophysiology of insulin deficiency. (From Monahan, F.D., Sands J.K., Neighbors M., Marek, J.F., et al. (2007). Phipps’ medical-surgical
nursing: Health and illness perspectives (8th ed.). St. Louis, MO: Mosby.)
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FIGURE 23-3 Insulin defects in type 1 and type 2 diabetes mellitus. (From Monahan, F.D., Sands, J.K., Neighbors, M., Marek, J.F., et al.
(2007). Phipps’ medical-surgical nursing: Health and illness perspectives (8th ed.). St. Louis, MO: Mosby.)
Signs and Symptoms At the time of diagnosis, uncontrolled diabetes mellitus - type 2 may be associated with symptoms of excessive thirst, hunger, and urination (i.e., polydipsia, polyphagia, and polyuria, respectively). However, the older individual with type 2 diabetes often does not have classic symptomatology and will not complain of weight loss or fatigue along with these classic symptoms (Rejeski et al., 2012). Often, an older individual with newly diagnosed type 2 diabetes will describe symptoms of fatigue, blurred vision, weight change (gain or loss), and infections. When questioned, both men and women often attribute these changes to “aging.” Individuals are
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often diagnosed with diabetes during a concurrent infection such as a major foot or leg wound, vaginitis, or urinary tract infection, or they may present with sexual dysfunction, numbness of the extremities, or changes in vision.
Medical Management Current medical management focuses on the disease process and utilizes multiple medication classes to control hyperglycemia if greater than 5 years of longevity is expected (Nathan, Buse, Davidson et al., 2009). Data from recent research indicate that the sulfonylureas, insulin, and biguanides do not prevent a loss of beta- cell function, so current therapy recommendations use drug combinations that include thiazolidinediones to preserve beta-cell function while controlling serum glucose levels (Figure 23-4). Five different oral drug classes are currently available for use in diabetes management (Box 23-2). Some medications prescribed for comorbid problems may make glucose control more difficult.
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FIGURE 23-4 Medical management of type 2 diabetes. DM, Diabetes mellitus; FPG, fasting plasma glucose; HbA1c,
hemoglobin A1c; NPH, neutral protamine Hagedorn.
Box 23-2
Oral antidiabetic agents Classification Medications Thiazolinediones Rosiglitazone
Pioglitazone Biguanides Metformin
Metformin extended release (Fortamet) Alpha-glucosidase inhibitors Acarbose, miglitol Sulfonylureas Chlorpropamide
Glipizide Glimepiride
Nonsulfonylurea secretagogues Nateglinide, repaglinide
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Fixed-dose combinations Metformin/glyburide
Metformin/glipizide Metformin/rosiglitazone
(Data from Wyne, K.L., Drexler, A.J., Miller, J.L., & Bell, D.S. (2003). Constructing an algorithm for managing type 2 diabetes. Postgrad Med Spec, No:63-72.)
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Nursing management The nursing process in diabetes mellitus - type 2 addresses the core defects of impaired insulin secretion and insulin action, as well as prevention of vascular and microvascular complications of the eyes, heart, kidneys, and feet (see Figure 23-3). TLCs are incorporated into the geriatric plan of care based on the patient’s cognitive capacity and functional limitations.
Assessment Comprehensive nursing assessment of the older adult includes a thorough review of past medical, surgical, and family histories. The nurse should ask a client about current medications, particularly diuretics, beta-blockers, anticonvulsants, antihypertensives, and steroids. Patients bringing in their prescription and over-the- counter (OTC) medications would help the nurse assess for potential problems related to drug interactions or for drugs that alter blood glucose levels.
The nurse should determine the medication’s name, type, dose, and schedule; if possible, the nurse should try to observe medication administration. Self-care abilities or restrictions, self- monitoring of blood glucose levels, and any history of hypoglycemia or hyperglycemia should be assessed.
Nutritional assessment includes a current weight measurement and recent patterns of loss or gain, typical dietary patterns, changes in the sense of taste or smell, dentition, and ability to shop for and prepare foods. Because uncontrolled diabetes affects the fluid and food balance, the nurse should assess patients for signs and symptoms of nausea, vomiting, hunger, and thirst, keeping in mind that hyperglycemia may produce subtle symptoms in older adults.
Assessment of elimination in an older adult with diabetes includes obtaining a history of urinary incontinence, urinary frequency, nocturia, polyuria, sexual dysfunction, and pain during urination. The nurse should evaluate for the presence of fecal
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incontinence, constipation, and diarrhea. Stress incontinence, which is more common in older adults, may be intensified by hyperglycemia.
Assessment of current living conditions is essential. The nurse should ask if the individual lives alone or with others, if living arrangements afford the ability to prepare food, and if adequate financial resources are available for food and shelter. Older adults who live alone may eat little and be malnourished because of social isolation or functional impairments (Nieuwenhuizen, Weenen, Rigby, & Hetherington, 2010). The nurse should determine whether transportation to health care services is available to the older adult patient.
It is important to assess a patient’s ability to learn before assessing knowledge of diabetes and its management. Cognitive function and learning styles vary, so knowing the patient’s preferred learning style facilitates education. Some individuals prefer to learn by visual methods, others by listening, and still others by experiencing contact in a hands-on approach.
Diabetes mellitus - type 2 is associated with increased depression and memory problems in older adults (Brown, Meltzer, Chin, & Huang, 2008). These problems are often aggravated by uncontrolled diabetes or hyperglycemia. It is important for the nurse to evaluate current and past blood glucose results. The nurse should assess both the older adult’s ability to remember simple facts and his or her mood and level of anxiety. For example, the nurse may ask a patient to explain content that was just presented. If the patient cannot recall, the nurse needs to determine whether a learning or memory problem exists. Memory testing may be accomplished simply by asking patients to repeat number sequences or by making a short- or long-term memory assessment (see Chapter 4). The nurse should ask the older patient about neurologic symptoms such as numbness, tingling, blurred vision, headaches, and the inability to sense temperature, especially in the feet.
The nurse should assess the patient’s skin condition, paying particular attention to the skin on the feet, legs, and elbows because these areas are at greatest risk for skin breakdown from pressure. The nurse should assess the skin for intactness, color, presence of
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swelling, discharge, odor, turgor, dryness, peeling, and lesions. Assessment of the skin in the perianal area may provide information on current skin status and general hygiene practices. Patients with hyperglycemia are prone to yeast and fungal infections in this area. Poor hygiene may predispose an individual to urinary or vaginal infections.
To assess circulation, the nurse should take an apical pulse, noting rate and rhythm; check pedal pulses bilaterally; and note the presence of hair on the lower extremities. The nurse should take blood pressure measurements with the patient in both the recumbent position and the sitting position; note any dizziness associated with a change of position; and assess the respiratory rate, depth, and chest sounds.
Diagnosis Nursing diagnoses for an older patient with diabetes mellitus - type 2 include the following:
• Imbalanced Nutrition: More Than Body Requirements, related to overeating habits or lack of regular exercise patterns
• Imbalanced Nutrition: Less Than Body Requirements, related to inadequate intake of nutrients or metabolic imbalance
• Ineffective Peripheral Tissue Perfusion, related to decreased or interrupted arterial flow
• Sexual Dysfunction, related to metabolic alterations
• Ineffective Coping, related to metabolic alteration or feelings of distress
• Deficient Knowledge, related to lack of exposure to diabetes self- management and skills
• Risk for Impaired Skin Integrity, related to impaired circulation
• Ineffective Coping, related to lack of social support or feelings of distress
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Planning and Expected Outcomes The goal of nursing management for the older adult with diabetes mellitus is the achievement and maintenance of desired blood glucose control, prevention of symptoms and complications, and self-care management, when feasible. Expected outcomes for the plan of care include the following:
1. The patient follows the plan of care by taking action on the basis of professional advice, as evidenced by:
a. Reports of following the prescribed regimen.
b. Correct modification of the regimen as directed by a health professional.
c. Performance of self-screening currently and routinely.
2. The patient shows evidence of successful individual coping, as evidenced by:
a. Verbalization of a sense of control.
b. Verbalization of acceptance of the situation.
c. Use of available social support.
3. The patient demonstrates increased knowledge of the American Diabetes Association (ADA) diet, as evidenced by:
a. Verbalization of the rationale for a prescribed diet.
b. Setting of goals for the diet.
c. Selection of foods recommended in the diet.
4. The patient demonstrates understanding of medication administration, as evidenced by:
a. Statement of correct medication name, dose, and schedule.
b. Correct demonstration of drawing up and self-injection of insulin.
c. Description of side effects of medication.
5. The patient maintains peripheral circulation, as evidenced by:
a. Pink, warm extremities without lesions or ulcers.
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b. Verbalization of the need for daily skin and extremity inspections.
6. The patient correctly demonstrates foot care regimen of foot cleansing and inspection techniques.
7. The patient verbalizes satisfaction with the degree of sexual functioning and ability.
The family or significant others should be involved in the care planning because they so often provide the support and reinforcement needed for long-term management of such a chronic condition.
Interventions The nursing care of an older adult patient with diabetes mellitus - type 2 is often complex. Usually, many issues must be dealt with; therefore, it is important to prioritize patient problems. In general, emergent issues or life-threatening crises such as severe hyperglycemia, hypoglycemia, and sepsis are top priorities. Once crises are resolved, the nurse may provide education to support diabetes management.
Education The nurse provides or coordinates education on a variety of recommended diabetic topics such as medication, pathophysiology of diabetes, monitoring of blood glucose levels, hypoglycemia and hyperglycemia, sick day management, foot care, eye care, complications, the diabetic diet, product supplies, and instructions on when to contact the health care team. Teaching is facilitated if older patients and significant others are actively involved in learning (e.g., having patients demonstrate glucose monitoring or insulin injection techniques to the nurse). Teaching aids such as booklets and handouts may enhance learning. Resources for patient educational handouts may be obtained from the American Dietetic Association (ADA), the National Diabetes Information Clearinghouse, and commercial sources.
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Diet Although diet is the cornerstone of therapy for diabetes, it may be difficult to persuade an older adult to change his or her dietary pattern. Other factors that may affect dietary adherence include limited finances, social isolation, and lack of motivation (Brown et al, 2008). Dietary planning with a registered dietitian may be helpful in achieving dietary goals. Dietary goals include achieving good nutrition and reaching or maintaining ideal body weight while decreasing the risk of hyperlipidemia, atherosclerosis, and hypertension. When a diet plan is established, nursing interventions are directed at supporting the dietitian’s recommendations through assessment of the patient’s understanding of and adherence to the plan (see Nutritional Considerations box).
Nutritional considerations
Nutritional Goals for Patients with Diabetes Mellitus
Calories Based on achievement and maintenance of ideal body weight
Protein Approximately 12% to 20% of total calories
Recommended daily allowance: 0.8 grams per kilogram (g/kg) of body weight for adults. (Most adults consume twice the amount of protein needed.)
Carbohydrates Approximately 45% to 60% of total calories
Emphasis placed on total carbohydrate intake rather than eliminating simple sugars
Modest sucrose intake perhaps acceptable based on metabolic
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control
Consistent mealtime carbohydrate intake
Fats No more than 30% of total calories
May need further reduction depending on lipid profile
Polyunsaturated fats: 6% to 8%
Saturated fats: 10%
Monounsaturated fats: remaining percentage
Fiber 25 g per 1000 kilocalories (kcal) for low-calorie intake
Up to 40 g/day
Sodium 3000 milligrams per day (mg/day) or less
May be reduced for medical conditions such as hypertension, congestive heart failure, and edema
Vitamins and Minerals No specific recommendations (From Muñoz-Pareja, M., León-Muñoz, L., Guallar-Castillón, P., Graciani, A., López-García, E., Banegas, J., & Rodríguez-Artalejo, F. (2012). The diet of diabetic patients in Spain in 2008- 2010: Accordance with the main dietary recommendations—a cross-sectional study. Plos One, 7(6), e39454.)
Insulin and Other Medications An older patient’s cognitive function, vision, motivation, ability to accurately draw up and self-administer insulin, access sites, and family support need to be considered before insulin therapy is initiated (Karter, Subramanian, Saha et al., 2010). Written instructions about the medication regimen should be provided for a patient and his or her significant other.
The nurse should observe the patient and his or her significant other preparing the prescribed insulin dosages; observe the patient
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actually injecting insulin; and note if the patient draws up an accurate amount of insulin, injects it into an appropriate site, and discards the sharp needle in a puncture-proof container. Vision or manual dexterity problems common among older adults that may interfere with proper insulin delivery may be identified through observation. The patient’s physician should be notified of visual concerns in order to obtain appropriate medical equipment for visually impaired persons.
Sometimes, an older adult patient is placed on a sliding scale of insulin dosage. This system of insulin dosage indicates specific blood glucose ranges and doses of regular insulin. For example, the instructions to the patient may be to give 4 units of regular insulin for blood glucose values ranging from 250 to 300 mg/dL. However, for blood glucose values between 301 and 350 mg/dL, the patient may be instructed to give 6 units of regular insulin.
Older patients often require two insulin injections a day to adequately control blood glucose levels. Splitting the intermediate insulin dose or adding short-acting insulin may help prevent hypoglycemia and offer flexibility for older adults with eating pattern variations or decreased renal function. Home care or visiting nurse services may be useful to older adults in the initial phases of insulin therapy (Farmer, Hardeman, Hughes et al., 2012).
Oral hypoglycemic agents (OHAs) such as the sulfonylureas are frequently used to lower blood glucose concentrations in older adults with diabetes mellitus - type 2. Glyburide and glipizide are well tolerated by older adults, but the long-acting drug chlorpropamide increases the risk of hypoglycemia, which does not respond well to simple carbohydrates (Thompson, Vande, Linnebur, & Saseen, 2013). Recent studies indicate that metformin, classified as a biguanide, may be the drug of choice for overweight patients. Side effects such as anorexia, nausea, and abdominal discomfort may, however, limit its use in older adults (Munshi, Maguchi, & Segal, 2012). Review Table 23-4 for a list of common oral medications for diabetes mellitus - type 2.
Table 23-4 Common oral medications for diabetes mellitus - type 2
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Because hypoglycemia is the major complication of OHA therapy, patients should be instructed about this complication. OHAs are associated with other adverse effects such as rashes, itching, nausea, vomiting, liver damage, and increased urinary frequency and urgency. Routine medical visits that include laboratory testing for complications are important. Patients taking medications that lower glucose levels should recognize the symptoms of mild hypoglycemia and test their blood glucose accordingly; if the result is abnormal, they should ingest a source of rapid-acting carbohydrate such as 4 ounces of orange juice. The early recognition and treatment of mild hypoglycemia prevents the more serious neuroglycopenic symptoms associated with moderate and severe hypoglycemia. Unrecognized and untreated hypoglycemia puts an individual with diabetes at risk for seizures
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and even death.
Emergency Identification Patients should be advised to carry medical emergency identification. In the event that an individual who takes OHAs experiences a major complication such as severe hypoglycemia, medical emergency identification facilitates treatment of the condition by health care workers or others (Table 23-5).
Table 23-5 Hypoglycemia levels, symptoms, and treatment
Hypoglycemia Level
Symptoms Treatment
Mild Hunger, diaphoresis, nervousness, shakiness, tachycardia, and pale skin
15 grams (g) of carbohydrate 4 ounces (oz) of juice (no sugar added)
Moderate Headache, irritability, fatigue, blurred vision, and mood changes 15 g of carbohydrate; may repeat Severe Unresponsiveness, confusion, coma, and convulsions Glucagon; intravenous glucose
Monitoring Monitoring the blood glucose level is recommended for older patients with diabetes mellitus - type 2 because they tend to have higher renal thresholds. Blood glucose monitoring is used to achieve and maintain desired glucose goals, detect complications such as hyperglycemia and hypoglycemia, and educate patients about the effects of diet, medications, activity, and stress (Mbaezue, Mayberry, Gazmararian et al., 2010). Blood glucose monitoring is particularly important for individuals taking medications that lower blood glucose levels (e.g., OHAs and insulin). Glucose monitoring devices are generally easy to use and reliable; however, practicing the glucose-monitoring technique is important for ensuring the accuracy of test results.
Exercise Exercise is a strategy for decreasing insulin resistance and hyperglycemia. It is beneficial for older adults from both physiologic and psychological perspectives. The assumption that older persons are not physically capable of or willing to exercise may result in neglect of this important aspect of care. Once the
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patient’s capabilities and limitations are considered, an exercise program is personalized to the patient. Older adults may derive the greatest benefit from morning exercise because that is the time of greatest insulin resistance (Davidson, Hudson, Kilpatrick et al., 2009). Teaching topics should include the safety rules of exercising, which include wearing a medical alert bracelet, checking blood glucose before exercise, identifying signs and symptoms of hypoglycemia, carrying a source of carbohydrate, and avoiding dehydration. Exercise-related complications or injuries are more likely to occur in this population as a result of preexisting conditions such as cardiac, musculoskeletal, and ophthalmic diseases. Precautions and exercise modifications for older adults are therefore indicated to help prevent problems.
Lifestyle Changes Lifestyle changes are often required for individuals with diabetes. It is difficult to manage a chronic illness that affects diet, exercise, weight, medication, sexuality, and finances. Proper management of diabetes requires knowledge, skills, and the organization of a team of experts that includes the patient as the core of the team. Avoidance of smoking and alcohol is believed to improve diabetes management. An older patient’s ability to adapt to lifestyle changes needs to be evaluated frequently so that additional support can be provided, when needed.
Sick Day Management Older adults have a high incidence of chronic illness, and those with diabetes need to take special measures for “sick days.” Sick days are generally defined as illness days that necessitate an alteration of typical treatment strategies (e.g., increasing medications [insulin doses], meals, and fluids) or the initiation of medical interventions (e.g., antibiotics for infections). For example, when an individual with diabetes becomes ill with “stomach flu,” the stress of even this common illness may precipitate severe hyperglycemia. The individual may detect significant hyperglycemia during routine blood glucose testing and should contact the health care provider for specific instructions on how to
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increase the insulin dosage. Individuals with nausea and vomiting are generally instructed to take 8 ounces of fluids (nondiet beverages) hourly and increase monitoring of blood glucose levels. Instructions from the provider usually indicate the levels of blood glucose that require an immediate call to the provider or a visit to the emergency department (see Emergency Treatment box).
Emergency treatment
Sick Day Management for the Individual with Diabetes Mellitus The term “sick days” refers to episodes of acute illness in individuals with diabetes, involving complications such as nausea, vomiting, and diarrhea. Illnesses trigger stress hormone production and result in hyperglycemia. With the onset of gastrointestinal symptoms, individuals with diabetes become easily dehydrated. If the patient’s meal plan cannot be tolerated, easily digested foods such as plain soda, soups, popsicles, and crackers are taken instead. This diet may be supplemented with noncaloric liquids such as water or diet sodas to keep up with fluids lost from vomiting or diarrhea.
Individuals with diabetes must continue taking prescribed medications such as insulin or oral hypoglycemic agents, ensure adequate hydration, and test blood more often. Urine should be tested for ketones whenever the blood glucose level is greater than 240 milligrams per deciliter (mg/dL). Other recommendations include taking temperature and weight and recording all values and interventions. Patients with diabetes should contact their health care provider whenever they have questions or concerns or the treatment regimen is not working, as evidenced by worsening fever, decreasing alertness or ability to think, vomiting more than once, diarrhea that persists for 6 or more hours, blood glucose values of 250 mg/dL or greater despite additional insulin, or ketones in urine.
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Sick day management is important in individuals with diabetes mellitus - type 2 because an untreated illness may lead to a complication called hyperglycemic hyperosmolar nonketotic coma (HHNC). This hyperglycemic condition is more common in older patients with diabetes mellitus - type 2, whereas patients with type 1 diabetes mellitus are more likely to experience diabetic ketoacidosis. HHNC is characterized by severe dehydration and hyperglycemia (blood glucose values ≥ 600 mg/dL; and hyperosmolarity of blood: ≥ 340 milliosmoles per liter [mOsm/L] of water]). Treatment for this condition consists of insulin, intravenous fluids, and identification and treatment of the precipitating event (e.g., infection or cardiovascular problems) in the intensive care setting of a hospital.
Skin Alterations Lower extremity amputations are a common yet preventable problem for individuals with diabetes. About 50% to 70% of all foot amputations are performed on individuals with diabetes (Figure 23- 5). Prevention of foot ulcers is the key to proper foot management in older patients with diabetes. This is achieved through daily cleansing of the feet with nondrying agents, inspection of the feet, and prompt treatment of problems (see Patient/Family Teaching box). When older adult patients are unable to inspect their own feet because of mobility or vision problems, significant others should be taught how to perform thorough inspections.
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FIGURE 23-5 How foot lesions of diabetes can lead to amputation. (From McCance, KL & Huether, SE. (2010). Pathophysiology (6th ed.). St. Louis, MO: Mosby; Levin, M.E., O’Neal, L.W., & Bowker, J.H. (1993). The
diabetic foot (5th ed.). St. Louis, MO: Mosby.)
Patient/family teaching
Prevention of Foot Ulcers in Individuals with Diabetes Mellitus Perform daily foot inspection.
Perform daily foot hygiene using warm (not hot) soapy water to wash feet; pat feet dry.
Gently apply mild skin cream to feet if dry or rough; do not apply between toes.
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Keep toenails trimmed straight across.
Wear proper-fitting shoes, and do not go barefoot.
Break in new shoes gradually.
Do not wear tight shoes or stockings that bind.
Exercise regularly and maintain ideal body weight.
Avoid smoking because it impairs circulation to the feet.
Seek early interventions to problems (e.g., tenderness, redness, swelling, leakage of fluid).
Foot care is the same for older adults as for other persons with diabetes. Daily inspection and cleansing of feet with nondrying agents is important to eliminate potential infectious organisms. Lubrication of the feet (but not between the toes, where heat and lotions may be trapped and lead to infections) with unscented lotions is often needed to help decrease skin dryness and cracking. Appliances such as corn pads and drying agents such as alcohol should be avoided because they impair the integrity of the skin. Shoes need to be tested for good fit. Patients or caretakers should cut nails straight across to prevent complications. Individuals with diabetes who have foot neuropathy, significant hyperglycemia (blood glucose values of ≥ 250 mg/dL), or a history of foot infections should seek care at the first sign of a foot wound or infection.
Wound Infections Older adults with diabetes are at a higher risk for foot complications than those without diabetes because of changes in nerves and blood vessels. Because these foot problems are so common, the phrase diabetic foot syndrome has come into use to describe the vascular and neurologic pathology associated with diabetes. Inadequate blood flow to the feet and nerve damage contribute to the development of ulcers and infections. Hyperglycemia also plays a role in foot problems because blood glucose levels of 200 mg/dL or greater are associated with an altered immune system leukocytic response.
The clinical symptoms of foot infections vary from no symptoms
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to fever, erythema, warmth, discharge with ulceration, and leukocytosis (Peters, Lipsky, Berendt et al., 2012). The skin over and around the infection may appear to be white, pink, red, or shades of blue. Blood vessels may be distended and pronounced over the infection site. Nail beds may be pale and show slowed capillary refilling when pressed. The shape of the foot may be altered by infection as a result of significant soft tissue swelling. Superficial inspection of a lesion may be deceptive because the outside appearance often does not reflect the extent of the problem beneath the skin surface. Wound infections in older adults with diabetes are common and are serious events that require immediate attention. Infections may manifest symptoms such as pain, swelling, and redness or may be symptom free and remain undetected until they are at an advanced stage. Significant delays may occur before the health care provider is contacted and treatment is initiated, and infection may spread from the skin to fat, muscle, fascia, and bone.
Evaluation The nurse evaluates the effectiveness of the care plan for an older patient with diabetes by frequently measuring the achievement of established specific outcomes. For example, nutritional outcomes include food selection consistent with the prescribed meal plan. Achievement of weight change goals is measured over time with weight graphs. The patient may be asked to log his or her exercise and medication compliance to enable monitoring of progress with each activity.
Insulin injection site rotations may be tracked on a chart. The patient logs blood glucose values, which are then compared with corresponding laboratory results. Patients are examined to see whether they are wearing or carrying medical alert bracelets or other emergency information. Patients may be asked to review their recent experiences with sick days and their management of fluids, nausea, vomiting, medication, and testing.
An important principle of diabetes management is having the patient “take control” of the diabetes. Self-care activities such as daily inspection of the feet and basic diabetic foot care support this
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self-care approach. The nurse may help a patient evaluate the effectiveness of self-care activities by direct examination and through interview techniques.
The nurse should positively reinforce effective diabetes management strategies used by an older patient. For example, when an older patient improves in foot care or the technique for insulin injections, the nurse needs to acknowledge the patient’s skill. If a patient does not comply with management strategies, the situation needs to be reassessed so that adaptations can be made. An older patient may have cognitive, financial, or social support problems that are obstacles to compliance.
Nursing care plan
Diabetes Mellitus with Foot Infection
Clinical Situation Mr. J notices that his right foot aches slightly. Taking off his shoe, he can see that his foot is red and swollen with a small amount of purulent fluid draining from a lesion on his small toe. He can even see the indentations from his shoes on the skin of his feet. He is surprised that his foot looks this bad when he had no problems earlier. He makes an appointment with his primary care physician. The appointment is 2 days after he first noticed the problem. During those 2 days Mr. J becomes increasingly tired. Despite drinking fluids continuously, he is thirsty all the time. At the visit with his physician, Mr. J is found to have 3 + edema in the affected foot, temperature of 101 ° F, and blood glucose level of 250 milligrams per deciliter (mg/dL). He is diagnosed with a diabetic foot infection. Mr. J first learns of his diagnosis of diabetes mellitus at this time.
The physician sends Mr. J to the local community hospital for inpatient admission. Hospitalization is necessary to treat the foot infection and his newly diagnosed diabetes.
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Nursing diagnoses Impaired Skin Integrity, related to altered metabolic state
Pain, related to treatments for foot ulcer (e.g., biopsy, curettage, and débridement)
Deficient Knowledge, related to new experience with recently diagnosed diabetes mellitus
Deficient Knowledge, related to new experience with foot care management
Outcomes Wound healing will occur, as demonstrated by decreasing size of
wound and less purulent drainage, as well as laboratory values of complete blood cell count with differential and electrolytes within normal limits.
Circulation to affected area will be maintained, as evidenced by normal skin color and temperature, presence of pedal pulses, and no evidence of edema.
The patient will verbalize comfort after débridement procedures.
The patient will maintain stable vital signs before, during, and after the procedure.
The patient will verbalize and demonstrate understanding of diabetes and diabetes management, as evidenced by making appropriate diet selections, correctly and safely administering medications, and accurately testing his blood glucose level.
The patient will verbalize appropriate sick day management regimen.
The patient will demonstrate daily foot care regimen of inspecting, cleansing, and using emollients.
The patient will verbalize when to contact a physician if complications occur.
The patient will achieve an optimal level of physical mobility, as evidenced by the ability to safely meet self-care needs.
The patient will protect the affected extremity, as evidenced by
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the ability to adhere to weight-bearing restriction.
The patient will verbalize reduced levels of anxiety with increasing knowledge and skill acquisition.
Interventions Assess the wound at each dressing change for wound stage,
epithelialization, color, edema, and discharge.
Assess vital signs.
Administer antibiotics, as prescribed.
Administer physician-ordered intravenous fluids, insulin, and medications.
Notify the physician of signs and symptoms of increased pain, swelling, drainage, or fever.
Change linens, as needed, to maintain a clean wound environment.
Provide pain control during débridement by medicating before procedures.
Assess patient’s vital signs and level of consciousness before administering medications.
Assess pain level, vital signs, and level of comfort and sedation after medication.
Document the patient’s tolerance of the procedure.
Assess patient understanding of the condition.
Monitor readiness and determine best methods for teaching and learning.
Provide diabetes teaching, including topics such as diabetes mellitus - type 2; ADA diet; exercise; medications; sick day management; monitoring; lifestyle factors (e.g., smoking and alcohol); complications, especially of hypoglycemia and hyperglycemia; and eye, kidney, nerve, foot, and vessel problems.
Provide proper foot care teaching with demonstration, including
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topics such as daily inspection and cleansing, wearing shoes, avoidance of tape and drying chemicals, use of proper foot gear, applying emollients, keeping feet dry, and safe nail cutting.
Have the patient perform a return demonstration.
Instruct the patient on reportable signs and symptoms such as fever, pain, swelling, redness, and breaks in skin integrity.
Instruct the patient not to bear weight on the infected foot.
Set up the room to maximize patient independence in ADLs.
Assess the patient’s mood and coping mechanisms.
Allow the patient to verbalize feelings about the diagnosis of the chronic disease of diabetes.
Support the patient in self-care and management of diabetes by (1) encouraging involvement in self-care activities, (2) providing an environment conducive to relaxation, and (3) reassuring the patient when he safely or accurately performs self-care skills and techniques.
Documentation of assessments, including patient responses to treatment measures, patient comprehension of teaching, and patient ability to self-manage treatment measures and diet, as well as other nursing interventions, is an essential component of care for older adult patients with diabetes.
Hyperthyroidism Pathophysiology Primary hyperthyroidism involves hypersecretion (hyperfunctioning) of thyroid hormones, which is usually associated with an enlarged thyroid gland. Although aging causes slight decreases in thyrotropin-releasing hormone synthesis and free triiodothyronine (T3), neither of these changes leads to thyroid- stimulating hormone (TSH) values outside the normal range (Suzuki, Nishio, Takeda, & Komatsu, 2012). Recently, new data have confirmed original 1985 Framingham study estimates of
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hyperthyroidism incidence of 2.5% to 6% in the geriatric population, depending on the indigenous iodine supply. Hyperthyroidism in seniors is often caused by multinodular and uninodular toxic goiter rather than Graves disease, which is the most common cause in younger adults (De Groot, 2013). Thyroid nodules are identified in 5% of people older than age 60, and 90% of nodules are benign (Figure 23-6). Iodine-induced hyperthyroidism is another common type of hyperthyroidism among older patients using amiodarone, a cardiac drug containing iodine, which deposits in tissue and delivers iodine to the circulation over long periods.
FIGURE 23-6 Simple goiter. (Courtesy of Bergman LV and Associates, Cold
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Spring, NY. In Monahan, F.D., Sands, J.K., Neighbors, M., Marek, J.F., et al. (2007). Phipps’ medical-surgical nursing: Health and illness perspectives (8th ed.). St. Louis,
MO: Mosby.)
Subclinical hyperthyroidism, a condition in which an otherwise healthy, asymptomatic patient has a suppressed serum TSH level with normal thyroxine (T4) and T3 levels, has been associated with an increased incidence of atrial fibrillation and decreased bone mineral density. Thyroid storm is a life-threatening syndrome consisting of fever, severe tachycardia, altered mental status, dehydration, and irritability. It is most commonly seen in persons with Graves disease, but it may result from other causes of hyperthyroidism. It may be precipitated by a concurrent illness, withdrawal from antithyroid drugs, or treatment with radioactive iodine (Cho et al., 2011).
Signs and Symptoms The classic geriatric presentation includes tachycardia, fatigue, tremors, and nervousness in contrast to tachycardia, heat intolerance, and fatigue in younger patients (Hampton, 2013). An enlarged, palpable goiter is present in 60% of older adults with hyperthyroidism. The most common complication, occurring in 27% of geriatric hyperthyroid patients, is atrial fibrillation that does not convert back to sinus rhythm when a euthyroid state is achieved.
Medical Management Treatment of subclinical hyperthyroidism in older adults is controversial unless established heart disease or osteoporosis exists. The treatment of choice for hyperthyroidism in older adults is generally radioactive sodium iodine. It is safe and simple to use but not particularly suited in cases of toxic goiter (McPhee, Papadakis, & Rabow, 2012). Patients must be rechecked every 6 months after initial treatment for the rest of their lives. Surgical treatment of seniors with toxic goiter has recently been shown to be a safe, definitive cure (Venturoni, Mongelli, Amicucci, & Leardi, 2009) because of the slow and prolonged treatment regimen needed for radioactive sodium iodine. Propranolol or other beta-blockers are frequently used to manage hyperthyroid- induced tachycardia.
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Nursing management Assessment, diagnosis, planning, intervention, and evaluation for hyperthyroidism focus on the primary human response to the hypersecretion of thyroid hormone, as detailed in Table 23-6.
Table 23-6 Hyperthyroidism
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(Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.)
Hypothyroidism Pathophysiology A common hypofunctioning endocrine state that results from inadequate thyroid hormone function is hypothyroidism. Diagnosis is based on sensitive, reliable assays of serum TSH and T4 levels. The most sensitive indication of hypothyroidism caused by primary thyroid gland failure is an elevation of the serum TSH level. The most specific test finding is a subnormal serum free T4 level because it corrects for abnormalities in the T4-binding proteins. As the thyroid gland ages, it develops moderate atrophy, fibrosis, colloid nodules, and lymphocyte infiltration (Garg & Vanderpump, 2013). The production of T4 decreases by about 30% between young adulthood and advanced age, but serum levels are usually maintained because of the body’s decreased use of T4 as a correlate to the age-related decline in lean body mass. Hypofunctioning
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thyroid states may result from defects in hormone production, target tissues, or receptors. When the defect involves a hypofunctioning peripheral gland like the thyroid, it is called primary hypothyroidism. If the hypothyroid state is a result of a nonfunctional anterior pituitary gland, the condition is called secondary hypothyroidism. Tertiary hypothyroidism results from a defect in the hypothalamus.
Autoimmune thyroiditis is the most common cause of primary hypothyroidism in older persons. It is diagnosed in 5% of older women and in 2% of men of the same age. Drug-induced hypothyroidism may occur with the use of lithium carbonate, amiodarone, and iodine. Other causes of hypothyroidism include ablation of the thyroid gland with radioiodine or surgery for the treatment of hyperthyroidism and postsurgical or radiation treatment of head and neck cancer. Hypothalamic or pituitary problems are rarely originating causes (Schlumberger et al., 2012).
Signs and Symptoms The clinical symptoms of hypothyroidism in older people are atypical compared with those of younger adults. Almost all cases (99%) of hypothyroidism in older adults are subclinical, inconspicuous, and progress slowly toward thyroid failure. Because the condition is insidious, the symptoms are often attributed to old age. Older patients are seen with complaints of fatigue, cold intolerance, weight gain, muscle cramps, paresthesia, and confusion (Konishi et al., 2010) (Table 23-7).
Table 23-7 Hypothyroidism
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(Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.)
Medical Management Serum TSH screening every 5 years is recommended for all men older than 65 years and for all women older than 35 years (Khan, Waguespack, & Hu, 2011). The treatment of choice is T4 replacement with levothyroxine sodium at an average dosage for senior patients of 0.075 to 0.1 milligrams per day (mg/day) by mouth. Medication is increased by 0.0125 mg/day every 2 weeks or by 0.025 mg/day every 4 weeks. About 1 to 2 months after reaching a dose of 0.075 mg/day, the patient should have his or her serum TSH level measured by TSH assay.
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Nursing management Assessment, diagnosis, planning, intervention, and evaluation for hypothyroidism focus on the human age-related response to the core defect of decreased thyroid hormone, as detailed in Table 23-7.
Primary Osteoporosis Pathophysiology Osteoporosis is a legitimate concern in postmenopausal women and andropausal men because of the influence of systemic sex hormones on bone (Eastell, 2013). Found six times more frequently in women, osteoporosis is a disease characterized by low bone mass leading to fragile bones that break easily. The geriatric skeleton is a metabolically active organ that experiences continuous remodeling, which provides structural integrity, support to the body, protection of vital organs, and a reservoir of calcium and other minerals (Griffith & Bao, 2013). Low bone mass may result from a failure to reach peak bone mass as a young adult, increased bone resorption, or decreased bone formation; all three of these mechanisms are believed to play a role in osteoporosis in today’s older adults.
Genetic influences on osteoblast function have recently improved our understanding of osteoporosis pathogenesis. Researchers have suggested that 50% to 80% of peak bone mass is genetically determined, which supports the importance of family history in determining an individual’s risk.
Parathyroid hormone has also been shown to increase skeletal resorption in estrogen-deficient menopausal women; this same mechanism is believed to influence male osteoporosis (Raisz, 2005). In addition, low vitamin D status in older persons contributes to bone loss mediated by the aging parathyroid gland, low daily exposure to natural sunlight, and reduced dietary intake. The primary role of calcium alone in maintaining bone mass in older persons continues to spur controversy. Osteopenia precedes osteoporosis, which is defined as bone mass less than 2.5 standard deviations below that of a young control population. Osteoporosis
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generally occurs in those in the sixth decade or older. Divided into primary and secondary types based on etiology, osteoporosis involves both the appendicular and axial skeleton. Other endocrine disorders such as parathyroid disease, Cushing syndrome, hypogonadism, alcohol abuse, liver disease, and amenorrhea may cause secondary osteoporosis. Osteoporosis is diagnosed by dual x- ray absorptiometry (DEXA) of the proximal femur and lumbar spine because these scans are sensitive to subtle changes in mineral density.
Signs and Symptoms Spontaneous fractures or those caused by minimum trauma in addition to loss of height necessitate DEXA scanning in older patients because of the high incidence of occult osteoporosis. Because of its low cost and portability, ultrasonographic densitometry is frequently used on the heel; however, it is not considered as reliable as DEXA scanning. A history of fractures after age 40, family history of osteoporosis, cigarette smoking, and low body mass index have all been shown to correlate strongly with osteoporosis. Dorsal kyphosis, chronic back pain, and loss of height are common signs of primary osteoporosis in older persons (Van Meirhaeghe, Bastian, Boonen et al., 2013).
Medical Management Calcium and vitamin D supplementation, exercise, and antiresorptive therapy are the cornerstones of medical therapy in primary osteoporosis (Papaioannos et al., 2010). In the United States, the recommended intake for older adults is at least 1200 mg/day of elemental calcium and at least 400 international units per day (IU/day) of vitamin D in two divided doses to maximize gastrointestinal absorption. Weight-bearing and muscle- strengthening exercises add minimally to bone density, but significant benefit is seen in improved posture, balance, and reduced falls. Estrogens, bisphosphonates, selective estrogen receptor modulators, and calcitonin are used in antiresorptive therapy on the basis of the older patient’s risk profile. In addition, some physicians choose a thiazide diuretic for those with
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hypertension as a comorbid condition because it decreases urinary calcium excretion, which slows bone loss.
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Nursing management Assessment, diagnosis, planning, intervention, and evaluation for osteoporosis focuses on the response to the core defect of decreased bone mass, as detailed in Table 23-8.
Table 23-8 Osteoporosis
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(Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.)
Sexual Dysfunction Erectile dysfunction (ED) and female sexual dysfunction (FSD) have garnered increased interest and research dollars in recent years as many older people strive to retain the vitality of their younger years. Previously, sexual dysfunction was discreetly minimized or overlooked in the professional literature. A recent cross-sectional study of males 40 to 88 years demonstrated the overall prevalence of ED to be 49.4% (Hatzimouratidis, Amar, Eardley et al., 2010). FSD remains ill defined, even though a relatively high rate of sexual dysfunction exists among postmenopausal women (higher than men) (Cumming, Mauelshagen, & Parrish, 2010). A marked decline occurs in female sexual interest and frequency of sexual activity after menopause. This decline may be caused by a number of psychosocial factors, although vaginal dryness and dyspareunia seem to be driven primarily by declining estradiol. The effects of menopause appear to be incremental and additional to those characteristic of aging. Sildenafil (Viagra) provided a simple and effective treatment for male ED and has produced a demand for finding an equally simple and effective treatment for women.
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Pathophysiology Hormonal changes associated with ED begin at 40 years old in the aging man and include decreased testosterone, decreased bioavailability of testosterone, increased sex hormone–binding globulin, decreased DHEA, mildly increased estradiol-17-beta, decreased melatonin, and decreased growth hormone and IGF-1 (Gratzke, Angulo, Chitaley et al., 2010).
The female sexual response cycle comprises a neuroendocrine- mediated vascular and nonvascular smooth muscle relaxation, which results in increased pelvic blood flow, vaginal lubrication, and clitoral engorgement. As in men, these mechanisms in women are mediated by a combination of neuromuscular and vasocongestive events. More cases of women with FSD are seen by urologists. Some researchers think that androgen deficiency or relative inactivity of the adrenal enzyme 17, 20-lyase in women is the pathophysiologic entity responsible for FSD, which is often characterized by diminished libido, diminished arousal and orgasmic capabilities, and deficient androgen levels.
Signs and Symptoms ED is the persistent inability to achieve or sustain an erection firm enough for sexual intercourse and penetration (Wincze & Carey, 2012). ED ranges from mild to severe and occurs in 50% of 65-year- old men and 75% of men 80 years or older.
FSD is a sexual arousal disorder that may develop as women age. Menopause and declining estrogen produce a thin and dry vaginal vault. As a result, the ability to become aroused may decline because of pain during sexual intercourse. In addition, in FSD, neuroendocrine physiologic impairments interfere with the normal female sexual response and frequently bring about complaints of diminished sexual arousal, libido, genital sensation, and ability to achieve orgasm. Other physical contributors to FSD include vaginitis, cystitis, endometriosis, hypothyroidism, and diabetes mellitus. Drugs such as oral contraceptives, hormone replacement, antihypertensives, antidepressants, or sedatives can cause a sexual arousal disorder as a side effect.
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Medical Management Medications for other medical problems often contribute to ED in older men (Park, Hwang, & Kim, 2011; Sharifuddin, Abdul-Aziz, Hamzah et al., 2011). Patients who are taking antihypertensives, antidepressants, sedatives, cimetidine, digoxin, lithium, and antipsychotics are warned of ED as a possible side effect. Often, these medications must continue to be taken, and additional medicine is added to address ED. Sildenafil, phentolamine, yohimbine, testosterone, and alprostadil are a few of the medications prescribed to increase blood flow to the penis and thus correct ED.
Most men with ED may achieve erections by using a constriction device, with or without a vacuum device (Hellstrom, Montague, Moncada et al., 2010). These devices are among the least expensive treatments for ED, and they enable a man to avoid the side effects of drug treatment. Constriction bands or rings made of metal, rubber, or leather are placed at the base of the penis to slow the outflow of blood. A constriction band used alone may produce an erection in a man with mild ED, especially if the problem is maintenance of erection. If that does not work, a constriction device may also be used in combination with a vacuum device. A vacuum device consists of a hollow chamber attached to a source of suction that fits over the penis, creating an air seal. Then suction applied to the chamber draws blood into the penis, producing an erection; a binding device is then applied to maintain the erection. Surgical implantation of firm rods or pump-operated devices is an option for men with a low risk of postoperative complications, who find the 3-day hospital stay and 6-week recovery acceptable. Recently, sensate focus psychotherapy has gained some popularity because of its ability to mitigate compounding psychological factors that may overlie physiologic ED.
Medical management of FSD includes watchful waiting, dose reduction of causative medications, testosterone replacement, sensate focus psychotherapy, and prescription of bupropion, buspirone, or sildenafil. Researchers have treated women with androgen deficiency by administering 50 mg/day DHEA for 6 months; increased spontaneity, decreased time to achieve arousal,
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return of sexual fantasies, and an increase in desire were the significant benefits. Adverse effects were mild and limited to acne and breast tenderness (Graziottin, 2010).
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Nursing management The nursing process in sexual dysfunction requires a biopsychosocial approach to the issues in ED and FSD, as detailed in Table 23-9.
Table 23-9 Sexual dysfunction
(Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.)
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Summary This chapter discussed endocrine aging as an increased molecular disorderliness of the regulatory mechanisms, which results in reduced vitality of the overall person. It described a new ensemble view in terms of decreased estrogen production in women (menopause), decreased testosterone production in men (andropause), decreased adrenal function (adrenopause), and decreased GH–IGF-1 (somatopause). This chapter included current literature on aging endocrine physiology showing current knowledge. Finally, the nursing process was applied to some of the most common endocrine diseases affecting older adults.
Home care
1. Regularly assess homebound older adults diagnosed with endocrine disorders for signs and symptoms indicating exacerbation or instability.
2. Instruct caregivers and homebound older adults about reportable signs and symptoms related to the endocrine problems being monitored and about when to report these changes to the home care nurse or health care provider.
3. Instruct caregivers and homebound older adults on types, dosage, and technique of administering insulin. Have caregivers and homebound older adults do a return demonstration of this skill. Ensure that they receive written instructions to assist them in the learning process.
4. Instruct caregivers and homebound older adults about laboratory indications used to evaluate endocrine disorders. Inform them of the results of the tests after the health care provider has been notified.
5. Instruct caregivers and homebound older adults on safety tips
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related to insulin injection. Injecting Humulin insulin and then switching to beef or pork insulin without a physician order results in altering the times of insulin action, initiation, peak insulin action, and duration of insulin action.
6. Instruct caregivers and homebound older adults on diabetes management.
7. Instruct caregivers and homebound older adults on the proper dosage of medications used to treat hormone imbalances associated with endocrine disorders.
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Key points • The endocrine system is regulated by feedback systems that
involve a chemical connection between structures of the brain, peripheral glands, and hormones. The feedback loops regulate hormone production.
• A hypofunctioning state is one that results from inadequate endocrine secretions.
• A hyperfunctioning state is one that results from excessive secretion of hormones.
• Endocrine pathology may also be manifested in the form of hormone resistance, a condition in which the tissue response to hormones is inadequate. Resistance may be caused by a genetic defect or may be acquired, as in the case of diabetes mellitus - type 2.
• Older adults experience andropause and menopause when a decline in biosyntheses of their dominant sex hormones occurs.
• Adrenopause and somatopause are changes that occur as the result of aging.
• Metabolic syndrome is rapidly increasing in the older population. It is caused by improper nutrition, inadequate physical activity, and obesity.
• Diabetes mellitus - type 2 is very common in the older population.
• The most important variables associated with diabetes mellitus - type 2 are obesity and insulin resistance.
• Older individuals with diabetes mellitus - type 2 should strive for proper control of their blood glucose levels to reduce the risk for potential complication.
• A comprehensive nursing assessment of older patients with diabetes mellitus - type 2 includes assessment of the patient’s feet, the patient’s knowledge of diabetes management (e.g., diet, desirable weight, exercise, medications, and treatment of
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hypoglycemia and hyperglycemia), the patient’s learning style, and emergency identification.
• Management of serious wounds in older patients with diabetes optimally needs to involve a multidisciplinary health team.
• Thyroid disorders are more common among older adults and more difficult to diagnose than in the younger population.
• Primary hypothyroidism in older persons may often remain unnoticed or indiscernible. Symptoms of mild depression, apathy, decreased appetite, weight loss, and weakness should be investigated.
• Thyroid hormone replacement should always be carefully monitored; follow-up appointments are essential for incremental dosing over several weeks.
• Hyperthyroidism may have an atypical presentation in older adults. Symptoms often include apathy, tiredness, weakness, anorexia, weight loss, angina, heart failure, atrial fibrillation, and absence of thyroid changes.
• Older adults need to be taught the actions and side effects of prescribed medications and the need for lifelong monitoring of thyroid status.
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Critical thinking exercises 1. Compare the endocrine gland function of a 72-year-old man with that of a 30-year-old man.
2. A 65-year-old woman was recently diagnosed with metabolic syndrome. She is sedentary, has a body mass index more than 30, and has abdominal obesity. What three issues would you prepare to teach the patient about her condition?
3. A 74-year-old man was recently diagnosed with insulin- dependent diabetes mellitus. While teaching him to administer 70/30 Humulin insulin, you note that he is unable to draw up the correct number of units into a syringe. What further information do you need about your patient before proceeding with your teaching plan?
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* Previous authors: Catherine Hill, DNP, RN, GNP-BC, Ann Peterson, MSN, RN, CDE, Karen Baker, MSN, RNC, and Carol Green-Nigro, MN, RN, PhD.
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C H A P T E R 2 4
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Gastrointestinal Function Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe the age-related physiologic and functional changes in the gastrointestinal system.
2. Explain primary and secondary preventive care related to the gastrointestinal tract for older patients and the rationalizations for such care.
3. Discuss the alterations of normal structure and function accompanying common gastrointestinal diseases of older adults.
4. Describe appropriate evaluation of older patients with symptoms related to a gastrointestinal disorder.
5. Describe the cause, incidence, and pathophysiology of the various types of gastrointestinal disorders, including cancer and liver disease.
6. Discuss the nursing management of gastrointestinal disorders in older adults.
7. Write an appropriate care plan for an older patient with a gastrointestinal disorder.
http://evolve.elsevier.com/Meiner/gerontologic
The gastrointestinal (GI) system functions in the ingestion, digestion, and absorption of nutrients as well as in the excretion of solid wastes from the body. The accessory organs of digestion, salivary glands, liver, pancreas and gallbladder, aid in the absorption of nutrients by secreting enzymes involved in the digestive process. GI system–related symptoms and complaints are
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common with advancing age, and the nurse is often the first health care provider to identify and acknowledge them. Therefore, knowledge of normal and age-related changes in the GI system is essential in providing appropriate nursing care.
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Age-related changes in structure and function Although many health-related complaints from older adults pertain to the GI system, these complaints are rarely responsible for death. Older adults are usually aware of alterations in GI function, and many of these changes can be alleviated through appropriate self- care practices. Some changes in the GI tract are caused by normal aging; however, multiple factors such as polypharmacy, stress, poor nutrition, multiple comorbidities, and poor hygiene may all contribute to alterations in GI function. Misinformation about changes in GI function may lead to more complex problems because of failure to seek health care or engage in appropriate preventive and treatment measures. The nurse has the responsibility for teaching health promotion and disease prevention strategies to these patients.
Many of the systemic changes in the digestion and absorption of nutrients from the GI tract result from changes in the older adults’ cardiovascular and neurologic systems, rather than their GI systems. For example, atherosclerosis and other cardiovascular problems may cause a decrease in mesenteric blood flow, leading to a decrease in absorption in the small intestine. Additionally, the central and peripheral nervous systems affect the motility of the entire GI system, and any change may alter peristalsis, thereby altering transit time. A decrease in mobility, often seen in the older adult, may also affect GI function.
Oral Cavity and Pharynx Changes in the oral cavity have an effect not only on an older person’s well-being, comfort, and health, but also on overall nutrition and digestion. The most obvious change in the mouth is the loss of teeth. One fourth of adults who are 65 or older are edentulous (without teeth). Periodontal gum disease, caused by bacterial infection and inflammation under the gum line, damages bone and connective tissue. Teeth become loose, chewing becomes
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more difficult, and often the teeth must be extracted (Centers for Disease Control and Prevention [CDC], 2009a).
Taste buds both decrease in number and atrophy beginning at age 60, resulting in decreased ability to discriminate among salty and sweet followed by bitter and sour. This may contribute to decreased enjoyment of food, resulting in poor eating habits and nutritional deficiencies. Medications such as diuretics, anticholinergics, certain antidepressants, and antipsychotics reduce saliva production, leading to xerostomia (dry mouth). A reduction in saliva increases the risk for tooth decay and gum disease. Saliva normally protects the oral tissues by cleaning teeth and neutralizing acids (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011).
Healthy People 2020 reflects on the importance of oral health as an integral component of health and well-being. Poor oral health and periodontal disease lead to pain and disability. One of the goals of Healthy People 2020 is to improve access to preventive oral care and early treatment efforts for older adults (Healthy People 2020 website, 2013).
Esophagus Age-related changes in the smooth muscle lining the esophagus contribute to a decrease in the strength of esophageal contractions and lower esophageal sphincter weakness leading to decreased food transit time. Esophageal sphincter weakness causes older adults to be more prone to reflux of acid from the stomach, or gastroesophageal reflux (LeMone & Burke, 2008). Neurogenic, hormonal, and vascular changes secondary to comorbidities may also contribute to a decrease in esophageal motility. These changes may lead to complaints of dysphagia, heartburn, or vomiting of undigested foods. Subsequently, poor nutrition, dehydration, and decreased food intake result.
Stomach Age-related changes in the stomach include decreased production of gastric acid, pepsin, bicarbonate, prostaglandins, and mucus. By
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the age of 60, gastric secretions decrease to 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion, whereas a decrease in hydrochloric acid and intrinsic factor may lead to malabsorption of iron, vitamin B12, calcium, and folic acid. Altered absorption and decreased gastric acid production, combined with altered gastric defense mechanisms, increase the incidence of pernicious anemia, peptic ulcer disease (PUD), and stomach cancer. Gastric emptying time is increased secondary to decreased elasticity of the stomach wall (Lewis et al., 2011). The stomach of an older adult is not able to accommodate large amounts of food resulting in a feeling of fullness or early satiation.
Small Intestine Age-related changes in the small intestine include atrophy and broadening of the villi leading to a decrease in absorptive surface. This results in a decrease in the absorption of lipids. Aging may also lead to a decrease in the production of lactase, resulting in intolerance to dairy products. As individuals age, they may also experience an increase in the overpopulation of certain intestinal bacteria leading to bloating, pain, and weight loss. The increase in intestinal bacteria may also lead to a decrease in the absorption of calcium, folic acid, and iron (Shaheen, 2006).
Large Intestine The main function of the large intestine is storage, propulsion, and evacuation of feces. Age-related changes in the large intestine include atrophy of the muscle layers and mucosa. These normal changes with aging may lead to a decrease in contraction of the muscle wall when the rectum is filled with feces, resulting in constipation. In addition, the incidence of diverticuli is increased in older adults. Diverticuli are prevalent in nearly half of people older than 60 years (Shaheen, 2006). Diverticuli are small outpouchings of the colon, where it bulges at weak spots in the intestinal wall.
Gallbladder
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The gallbladder and bile ducts are unaffected by aging. However, the incidence of gallstones does increase with age. Bile may become more lithogenic with advancing age, possibly because of an increase in biliary cholesterol related to diet and hormonal changes that affect cholesterol metabolism. The bile salt pool also decreases as a result of a decrease in bile salt synthesis. These predispositions for stone development, along with a tendency for dehydration in older adults, explain the increased incidence of cholelithiasis and cholecystitis in older adults. The complications of cholelithiasis in older adults include empyema, perforation, and choledocholithiasis (calculi in the common bile duct). These complications are often seen in persons older than age 65 and those with diabetes (Lewis et al., 2011).
Pancreas The pancreas shows some age-related changes such as fibrosis, fatty acid deposits, and atrophy; weight, but not size, is affected (Lewis et al., 2011). Evidence suggests that the volume of pancreatic secretions (chymotrypsin and pancreatic lipase) decline with age. This decrease in enzyme activity affects the digestion of fats and may account for a vague intolerance of fatty foods in older adults. The incidence of pancreatic cancer and pancreatitis increases in older adults.
Liver The liver is a sturdy organ and retains most of its functions throughout the life span. Although the liver size decreases after age 50, liver function tests may remain within normal limits. A decline in cardiac output associated with aging contributes to a decrease in hepatic blood flow. As hepatic blood flow slows, drug metabolism is reduced, which leaves the aging liver more susceptible to drugs and toxins. Older persons have a decreased ability to compensate for infectious, immunologic, and metabolic disorders (Lewis et al., 2011). Some evidence suggests that normal aging may adversely affect liver tissue regeneration. The mechanism of this effect is not fully known, but it may be a result of a generalized slowing of
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repair or an inadequate response to regeneration of liver tissue.
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Prevention Although some changes in the GI system are associated with aging, strategies for both primary and secondary prevention of problems arising from these changes are available (Tables 24-1 and 24-2). Nurses caring for older patients should include instruction regarding these strategies.
Table 24-1 American cancer society guidelines on screening and surveillance for the early detection of colorectal adenomas and cancer—average-risk women and men ages 50 or older
Test Interval (Beginning at Age 50)
Comment
Fecal occult blood test (FOBT) and flexible sigmoidoscopy
FOBT annually and flexible sigmoidoscopy every 5 years
Flexible sigmoidoscopy together with FOBT is preferred compared with FOBT or flexible sigmoidoscopy alone. All positive test results should be followed up with colonoscopy.*
Flexible sigmoidoscopy FOBT
Every 5 years Annually
All positive test results should be followed up with colonoscopy.* The recommended take-home multiple sample method should be used. All positive test results should be followed up with colonoscopy.*†
Colonoscopy Every 10 years Colonoscopy provides an opportunity to visualize, sample and/or remove significant lesions.
Double-contrast barium enema (DCBE)
Every 5 years All positive test results should be followed up with colonoscopy.
(Data from Smith, R., Cokkinides, V., & Brawley, O, (2009). Cancer screening in the United States, 2009: A review of current American Cancer Society Guidelines and issues in cancer screening. CA: A Cancer Journal for Clinicians, 59(1), 27-41.) * If colonoscopy is unavailable, not feasible, or not desired by the patient, DCBE alone or the combination of flexible sigmoidoscopy and DCBE are acceptable alternatives. Adding flexible sigmoidoscopy to DCBE may provide a more comprehensive diagnostic evaluation than DCBE alone in finding significant lesions. A supplementary DCBE may be needed if the colonoscope fails to reach the cecum, and a supplementary colonoscopy may be needed if a DCBE identifies a possible lesion or does not adequately visualize the entire colorectum. † No justification for repeating FOBT in response to an initial positive finding.
Table 24-2 American cancer society guidelines on screening and surveillance for the early detection of colorectal adenomas and cancer—women and men at increased risk or at high risk
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(From Smith, R., Cokkinides, V., & Brawley, O, (2009). Cancer screening in the United States, 2009: A review of current American Cancer Society Guidelines and issues in cancer screening. CA: A Cancer Journal for Clinicians, 59(1), 27-41.)
A supplementary DCBE may be needed if the colonoscope fails to reach the cecum, and a supplementary colonoscopy may be needed if a DCBE identifies a possible lesion or does not adequately visualize the entire colorectum. * If colonoscopy is unavailable, not feasible, or not desired by the patient, double-contrast barium enema (DCBE) alone or the combination of flexible sigmoidoscopy and DCBE are acceptable alternatives. Adding flexible sigmoidoscopy to DCBE may provide a more comprehensive diagnostic evaluation than DCBE alone in finding significant lesions.
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Common gastrointestinal symptoms No clear-cut GI diseases can be attributed directly to the aging process. However, many conditions show a higher incidence in older adults and have a greater effect on their physical and social well-being. These complaints may be related to normal physiologic changes associated with aging but must be distinguished from pathologic problems that increase in frequency with aging.
Older adults may report GI symptoms not related to a specific diagnosis. Any symptom reported by an older patient needs thorough assessment by the nurse. What follows are the most frequently reported GI symptoms experienced by older adults. The sections include information on their definitions, assessment, nursing interventions, and self-care measures.
Nausea and Vomiting Vomiting is controlled through a central vomiting center in the medulla. This center is close to the pain and respiratory centers; it is also near the centers that control vestibular and vasomotor function. Occasionally, stimuli from one center spill over to another and symptoms may become mixed (Figure 24-1).
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FIGURE 24-1 Stimuli involved in the act of vomiting. CTZ, Chemoreceptor trigger zone. (From McKenry, L., Tessier, E., & Hogan, M.
(2006). Mosby’s pharmacology in nursing (22nd ed.). St. Louis, MO: Mosby.)
Nausea may be difficult for patients to describe; many use the phrase “I feel sick” to convey the symptom of nausea. It is important to keep in mind that although nausea usually precedes vomiting, it may also be an isolated symptom. In general, nausea in the absence of vomiting is of central, rather than peripheral, origin (i.e., the symptom is initiated centrally in the brain rather than peripherally in the GI tract). Central nausea is usually a response to a metabolic disorder.
It is important to obtain a detailed description of events surrounding a complaint of nausea and vomiting. Data should be elicited about precipitating factors (e.g., the relationship of nausea
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and vomiting to food intake, medications, and activity). The patient should be questioned about the presence of nausea and vomiting, as well as diarrhea or constipation. It is important to obtain information about the amount and characteristics of the emesis and whether the vomitus contained food particles, bile, or blood (bright red or the color of coffee grounds). Other symptoms such as a fever, sweating, pallor, dizziness, and pain should be determined. Because older adults are at particular risk for dehydration and electrolyte imbalances, it is essential to establish the frequency and amount of vomiting and to examine patients for signs and symptoms of fluid and electrolyte imbalances.
Nursing interventions include establishing many self-help measures, including dietary changes such as drinking clear liquids, progressing from eating bland foods to solid foods, and small, frequent meals. If vomiting occurs, fluid replacement should be a priority. Sips of fluids every 15 minutes until more can be tolerated may decrease episodes of dehydration. Older adults are at high risk for aspiration, and they should be placed in the semi-Fowler or side-lying position when drinking liquids. It is important that older adults be made aware of the signs and symptoms of dehydration and electrolyte imbalances, as well as when to seek medical care. Any episodes of prolonged nausea or vomiting require careful evaluation by a health care provider. In addition, it should be made clear that pharmacologic therapy used to treat nausea and vomiting may cause sedation, confusion, and delirium in the older adult.
Anorexia Anorexia as a symptom should not be confused with anorexia nervosa, which is an eating disorder of psychiatric significance. The term anorexia literally means “lack of appetite.” Hunger and appetite are not synonymous; hunger is related to the physiologic need for food. It is important for the nurse to ascertain whether food intake is decreased truly because of loss of appetite. Once that is determined, the nurse must ask questions regarding other symptoms, including weight loss, nausea, vomiting, abdominal pain, diarrhea, and constipation. In addition, psychosocial factors such as stress, grief, pain, and concomitant illnesses may also need
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to be assessed. Older adults are often faced with limited financial resources resulting in a decreased overall ability to purchase adequate food (Lewis et al., 2011).
Nursing interventions for older patients with anorexia include monitoring of intake, output, and weight. It is important to acknowledge a patient’s symptoms and provide gentle encouragement to eat for nutritional purposes. Small, frequent meals may be helpful. Encouraging older patients to seek medical attention for anorexia is also important because patients may not be aware of the problem.
Abdominal Pain Abdominal pain as a symptom is often difficult to assess in a complete manner. With older adults, it may be even more difficult, even for a skilled clinician. The assessment of pain may be made easier by thinking in terms of the three pathways for pain impulses. The first are the visceral pain pathways, which are activated by receptors in the wall of the abdominal viscera and develop from stretching or distending the abdominal wall or from inflammation. This type of pain is often diffuse, is poorly localized, and has a gnawing, burning, or cramping quality. The second are somatic or parietal pathways, which are activated by receptors in the parietal peritoneum and other supporting tissues. This type of pain is usually sharp, more intense, constant, and better localized than visceral pain. The third are referral pathways, which account for referred pain (i.e., pain felt at a different site than the source of the pain but sharing the same dermatome). This type of pain is usually sharp and well localized; it may resemble somatic pain (Figure 24- 2).
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FIGURE 24-2 Common sites of referred abdominal pain. GERD, Gastroesophageal reflux disease. (From Jarvis, C. (2008). Jarvis physical examination and health assessment (5th ed.). St. Louis, MO: Saunders. Copyright
Pat Thomas, 2006.)
In assessing any type of pain, the nurse should elicit information about its duration, location, mode of onset (sudden or gradual), intensity, quality, rhythm, relationship to food, alleviating and aggravating factors, and radiation (e.g., back, neck, or groin), as well as the older patient’s ability to pass stool and gas. Older persons may complain of vague symptoms and wait much longer than their younger counterparts to seek medical care. Older adults are also less likely to exhibit leukocytosis (increased white blood cell [WBC] count), fevers, rebound tenderness, or local rigidity (Tazkarji, 2008).
Nursing interventions include measures to increase comfort and pain relief. The nurse should encourage older patients to see their health care provider for a complete evaluation of the abdominal pain. Abdominal pain that is severe is often referred to as an acute abdomen. Nursing procedures for acute abdomen include (1) starting intravenous fluids, as ordered; (2) placing a nasogastric tube for decompression of the stomach; (3) monitoring and recording vital signs and reporting abnormal findings; (4) monitoring intake and output accurately every hour; and (5) completing an assessment on the onset of pain, presence of vomiting or diarrhea, and presence of fever and taking an accurate
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medical and surgical history.
Gas Belching, bloating, fullness, and flatus are some of the complaints associated with gas. About 99% of the gas present in the GI tract of adults comprises five gases: nitrogen, oxygen, hydrogen, carbon dioxide, and methane. The percentage of each individual gas depends on the source; these sources include swallowing, diffusion of gas from the bloodstream to the intestinal lumen, and processing of food. All these gases are odorless; the unpleasant odor associated with flatus is probably a result of hydrogen sulfide that is metabolized from sulfur-containing foods. A frequency of 7 to 20 expulsions of gas a day is considered normal. Intestinal gas is frequently accompanied by intense abdominal pain, which may be relieved by repositioning or walking.
Although belching primarily comes from the unconscious swallowing of air, it is important to assess patients for other symptoms suggestive of gastritis or PUD. Many complaints of bloating and fullness are related to a motility disorder or malabsorption; however, in older adults, the complaints must be taken seriously. Further assessment through questioning about changes in bowel function, pain, and other GI tract symptoms is required.
Although the expulsion of flatus is a normal event, excessive flatus may have several causes. Some patients form more gas within the gut, some swallow more air, and others may have excessive flatus because of the nature of the foods consumed. Common culprits include beans, cabbage, legumes, raisins, and artificial sweeteners. In addition, patients who are lactose intolerant may produce more gas. Careful questioning may reveal one or a combination of these causes.
Nursing interventions focus on patient education about the cause and nature of intestinal gas. The keys to treatment are changes in dietary factors (e.g., focusing on eating more slowly and avoiding gas-producing foods) and a routine exercise plan.
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Diarrhea Diarrhea is an increase in the frequency of defecation, but many definitions also include a change in the consistency of feces (e.g., watery stools). Diarrhea may be caused by increased bowel motility or interference in the normal absorption of water and nutrients from the GI tract. When an older adult reports diarrhea, it is important to ascertain exactly what is meant. Keep in mind that the description of diarrhea is useless unless a patient’s normal bowel habits are known.
The nurse should ask about precipitating events (e.g., travel out of the country or eating at a restaurant), timing (intermittent or continuous), associated factors (fever, weight loss, abdominal pain, vomiting, dietary or medication changes, and any systemic diseases), characteristics of the diarrhea (frequency, consistency, volume, foul smell, presence of mucus or blood, incontinence, awakening from sleep [e.g., nocturnal diarrhea usually points to an organic cause rather than a functional or infectious cause]), and whether the onset was sudden. All these questions help assess the diarrhea further to aid in determining the cause.
Nursing care focuses on maintaining adequate fluid and electrolyte balance, assessing for complications, and providing emotional support as necessary. Usual water loss accompanying bowel movements is 150 milliliters per day (mL/day); severe diarrhea can account for up to 5 to 10 liters (L) of water loss daily. Therefore, assessing for signs and symptoms of dehydration and volume depletion in older patients is important. Patients and their families need to be taught to report complications such as increased thirst, weakness, dizziness, palpitations, and fatigue. If fluid and electrolyte imbalances occur, either oral or parenteral therapy may be required because diarrhea in older adults may be life threatening. Nursing interventions should also be aimed at identifying and correcting the cause. Administration of antibiotics may be necessary for infectious diarrhea. Depending on the causative factor, antispasmodic and antidiarrheal medications may also be used. Education of patients and their families should include instruction on dietary changes: older patients with chronic diarrhea should avoid gas-forming foods, vegetables, spices, and
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milk products, and patients with acute diarrhea should consume bland foods, such as the BRAT (bananas, rice, applesauce, toast) diet and clear liquids.
Constipation Constipation is a common problem among older adults secondary to physiologic changes and is often a complication of polypharmacy. Among those older than 65, women are affected more often compared with men. Constipation is often defined according to the patient’s perception of abnormal bowel function (Berman, Brooks, & Silver, 2007). Typical definitions of constipation also include hard, dry stools that are difficult to pass. Bowel movements less than three times a week are often associated with constipation. However, normal bowel patterns differ greatly among individuals.
Common causes of constipation in older adults include diet (decreased fiber intake), mechanical obstruction (fecal impaction and cancer), medication side effects (aluminum- and calcium-based antacids, iron preparations, anticholinergics, narcotic pain medications, antidepressants, antipsychotics, calcium channel blockers, and overuse of laxatives), multiple comorbidities, and mobility and functional issues (Ginsberg, Phillips, Wallace, & Josephson, 2007). Perhaps the most widespread cause of constipation in older adults is diet. It is usually a lack of certain foods, rather than the addition of certain foods, that leads to the problem. For example, many foods such as fresh fruits and vegetables contain natural laxatives, although older adults may have difficulty eating these foods because of dental problems. A second dietary cause of constipation is the lack of fiber or bulk and a decrease in fluid intake. In general, unrefined foods have more fiber than the refined foods that are popular in American society.
It is important to keep in mind that constipation might be a result of overuse or improper use of laxatives because of an older adult’s excessive concern about the frequency of defecation. In this instance, the nurse may reinforce with a patient and family that as long as the consistency is normal and the bowel movements occur
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at regular intervals, it is not necessary to take laxatives.
Limitations on mobility may greatly affect the ability of an older person to feed themselves and to reach the toilet. They may feel awkward about depending on others for these functions. Subsequently, they may ignore the urge to defecate rather than ask for help to get to the toilet. They may also decrease fluid intake in an effort to prevent urinary incontinence. These factors may greatly influence regular bowel patterns (Lewis et al., 2011).
Constipation is treated through dietary measures such as increasing fluid intake and increasing fiber, combined with light exercise and development of a regular toileting routine that includes responding to the urge to defecate. In teaching older adults about dietary changes, the nurse should educate them about fiber being a “food,” rather than a “medicine.”
Multiple medications are available to treat constipation, and many of them are available over the counter. Laxatives are defined as drugs used to facilitate or stimulate the passage of feces and are classified as bulking agents (bran, psyllium), surfactants (stool softeners), emollients (mineral oil), contact stimulants (cascara, castor oil, bisacodyl), saline cathartics (magnesium hydroxide [Milk of Magnesia], citrate, sodium or potassium phosphate), and osmotic agents (lactulose, sorbitol). Laxatives may also be categorized by speed of action: (1) group I drugs (castor oil, saline laxatives in high doses) act in 2 to 6 hours and produce watery stool; (2) group II drugs (other contact stimulants, low-dose saline laxatives) act in 6 to 12 hours and produce a semiformed stool; and (3) group III medications (bulking agents, surfactants, lactulose) produce soft stools in 1 to 3 days.
In addition to oral laxatives, several rectal agents are available. Enemas provide immediate relief but should be limited in their use for long-term treatment. Soapsud enemas should never be used because they lead to mucosal irritation. Small-volume enemas such as Fleets are the easiest to use. Rectal suppositories (bisacodyl, glycerin) may also be used, but they must be retained for 20 to 30 minutes for optimal results and so may be more difficult for older patients to use.
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Fecal Incontinence Fecal incontinence, the involuntary passing of feces, may be acute or chronic, and it demands evaluation. For older adults, the loss of bowel control is devastating and may significantly alter their quality of life. Fecal incontinence may be a result of colorectal lesions (perianal disease, proctitis, and tumors), neurologic problems (dementia, stroke, and spinal cord lesions), laxative abuse, unrecognized lactose intolerance, diabetic neuropathy, poor dietary habits, or immobility (Kane, Ouslander, Abrass, & Resnick, 2009).
Nursing interventions focus on education concerning the prevention and treatment of incontinence in older adults. Examining the cause of the incontinence is important for the nurse, patient, and family. Laxative abuse is completely preventable and treatable with education and reassurance to the patient that being “regular ” does not necessarily mean one or two bowel movements a day.
Regardless of the cause, a program of bowel control (see Patient/Family Teaching box) may usually help an older patient who is aware of and distressed by incontinence. It is important to reassure older patients that control and retraining are achievable because many older adults believe that fecal incontinence is the first step on the road to permanent institutionalization. Other nursing interventions include methods to deal with the embarrassment caused by the incontinence, ways to decrease fecal odor, use of adult diapers, and skin care.
Patient/family teaching
Bowel Training for the Patient with Incontinence
Overview Bowel incontinence refers to the inability to voluntarily control defecation. It may result from decreased anal muscle tone,
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disturbances in the neural innervations of the rectum, loss of cortical control, rectal prolapse, diarrhea, constipation with overflow related to impaction, or altered cognition.
Goal Control of bowel elimination
Actions • Record and evaluate patient’s fecal elimination pattern.
• Establish consistent time to toilet based on pattern.
• Position patient in best physiologic position for defecation: sitting with normal posture.
• Have patient lean forward or prop feet on stool to increase intraabdominal pressure.
• Instruct patient to bear down and attempt to defecate.
• Record results; ensure patient does not develop fecal impaction.
• If necessary, stimulate anorectal reflex with glycerin suppository 30 to 45 minutes before scheduled fecal elimination.
• Supplement toilet activities with exercise and good fluid (minimally 1500 milliliters per day [mL/day]) and fiber intake, unless contraindicated.
(From Eliopoulos, C. (2005). Gerontological nursing (6th ed.). Philadelphia: Lippincott Williams & Wilkins.)
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Common diseases of the gastrointestinal tract The following is an overview of common GI disorders seen in older patients, including the related nursing care. Table 24-3 provides an explanation of the diagnostic tests used in this section.
Table 24-3 Diagnostic studies: gastrointestinal system
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From Lewis, S., Dirksen, S., Heitkemper, M., Buchner, L., & Camera, I. (2011). Medical- surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby.
Gingivitis and Periodontitis The gingivae, or gums, are subject to localized and systemic diseases, problems caused by drug therapy, poor oral hygiene, and poor nutrition. Gingivitis, an inflammation of the gums surrounding the teeth, may result in pain and bleeding; it may lead to periodontitis, a spreading of the inflammation to the underlying tissues, bones, or roots of teeth. This is the most common reason for tooth loss with advancing age. Gingivitis resulting from overgrowth of the gingivae may occur in people taking phenytoin (Dilantin) on a long-term basis.
Candida albicans, or thrush, is an infection causing white lesions on the oral mucosa. It is often seen in persons with compromised immune systems and in those with suppressed immunity such as individuals taking immunosuppressant drugs and antibiotics. The condition is most common in denture-bearing tissues of the mouth. The patient may complain of an unpleasant taste, burning, or
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itching or may be asymptotic (Duthie, Katz, & Malone, 2007).
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Nursing management Assessment
Assessment begins with a good history of dental care and dental hygiene practices. A complete health history focusing on other illnesses and concomitant medications, as well as a physical assessment of the mouth, is necessary.
Diagnosis The most common nursing diagnoses for an older patient with gingivitis or periodontitis include the following:
• Impaired Oral Mucous Membrane
• Impaired Dentition
• Ineffective Health Maintenance
• Imbalanced Nutrition: Less Than Body Requirements, related to pain
Planning and Expected Outcomes An older adult must understand the relationship between oral health and overall health and well-being. The nurse must determine a patient’s feelings and attitude about performing the self-care necessary to achieve the desired goals.
Expected outcomes for an older patient with gingivitis or periodontitis include the following:
1. The patient will maintain a comfortable and functional oral cavity.
2. The patient will establish and maintain a mouth care routine, including regular professional dental care.
3. The patient will maintain normal body weight and nutritional status.
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Intervention Nursing management of an older patient with gingivitis or periodontitis includes promotion of regular oral hygiene, regular preventive dental care, and maintenance of nutritional status. In addition, assessing the patient’s knowledge of the importance of oral hygiene and frequently reinforcing oral hygiene practices are important roles for the nurse. Oral hygiene includes flossing regularly, brushing teeth or dentures, and using saline mouth rinses, as needed. Professional dental care should be sought routinely every 6 months or more often, as needed. Proper fit of dentures initially and at all subsequent visits to both the dentist and the primary health care provider is also encouraged. Pain relief, which will facilitate adequate nutrition, may be managed with nonnarcotic pain medications (e.g., acetaminophen), frequent mouth rinses, and a liquid or soft diet.
The key to treatment of gingivitis and periodontitis is prevention. Although good oral hygiene needs to begin early in life, it is never too late for an older patient to begin routine dental care and oral hygiene. The nurse should discuss with the patient the use of nutritional foods that are nonirritating, for example, soft foods such as pudding or custard, and the use of nutritional supplements such as Ensure.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, establishment and maintenance of regular dental care and oral hygiene practices, and prevention of infection. Evaluation focuses on an older adult’s ability to carry out the recommendations and whether any changes in self-care have occurred as a result. Findings of an oral cavity inspection should be noted, as should any instructions or explanations given to the patient. The patient’s response to recommended treatment measures should also be documented.
Dysphagia
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Dysphagia (difficult swallowing) is a common problem in the older adult population. Weakened esophageal smooth muscle and incompetent sphincter function are contributory in the older adult who develops dysphagia. Dysphagia is a symptom with many underlying causes, including stroke, neurologic disease (e.g., Alzheimer disease and Parkinson disease), local trauma or tissue damage, and tumors that may obstruct the flow of food and liquids in the esophagus. Symptoms may range from mild to severe to a complete inability to swallow (Lewis et al., 2011). Dysphagia may compromise the nutritional status in the older adult, increase the risk of aspiration pneumonia, and lead to a decreased quality of life.
Nursing care is aimed at ensuring the patient receives adequate evaluation, nutrition, hydration, and safe positioning during meals to prevent aspiration. Dietary modification may be recommended following speech–language pathologist evaluation and modified barium swallow.
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Nursing management Assessment
Assessment begins with an accurate and precise history that focuses on whether the dysphagia occurs with liquids, solids, or both, as well as the time-frame for the progression of the dysphagia. A thorough physical examination includes (a) neurologic assessment; (b) assessment of oral cavity and salivary glands; (c) observation of swallowing capability, both liquid and solid substances; and (d) examination of neck and thyroid glands.
Diagnosis Nursing diagnoses for an older patient with dysphagia include the following:
• Imbalanced Nutrition: Less Than Body Requirements
• Risk for Aspiration, related to abnormal swallowing
• Acute Pain, related to odynophagia (painful swallowing in the mouth or esophagus)
• Fear, related to the diagnosis and prognosis
Planning and Expected Outcomes It is essential to determine whether an older patient is ready and able to learn the self-care measures necessary to reduce the symptoms associated with dysphagia. Determining the extent of a patient’s specific fears created by learning of the nature of interventions is important because the type and degree of fear affects the nurse’s specificity in intervention strategies.
Expected outcomes for an older patient with dysphagia include the following:
1. The patient will maintain weight within 10% of ideal body weight.
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2. The patient will remain free from aspiration.
3. The patient will learn techniques to swallow that minimize aspiration and pain.
4. The patient will be free from epigastric discomfort.
5. The patient will be able to verbalize fears related to the diagnosis and prognosis.
Intervention Nursing management of an older patient with dysphagia includes maintenance of hydration and nutritional status, prevention of aspiration, and provision of emotional support and information regarding the diagnosis and prognosis. Additionally, the nurse provides support and reassurance directed at a patient’s fear of eating related to pain, difficulty swallowing, and frequent regurgitation. Optimizing nutritional status and preventing weight loss are important because fear of eating may lead to chronic weight loss. Instruction regarding eating habits and swallowing techniques, and maintaining weight and nutrition is important. For example, small, frequent meals, pureed or soft high-protein, high- calorie foods, taking only small sips of fluid or using thickened liquids, and turning head to the side are helpful. The nurse should instruct the patient to elevate the head of the bed to prevent nocturnal aspiration.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of aspiration, and maintenance of nutrition. Evaluation of how the patient is coping with the diagnosis may be assessed through a patient’s resumption of activities and ability to verbalize feelings. Additionally, evaluation focuses on a patient’s ability to satisfactorily incorporate and adhere to the dietary recommendations and modify behaviors and lifestyle to reduce symptoms.
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Gastroesophageal Reflux and Esophagitis Gastroesophageal reflux disease (GERD) is a prevalent condition found in 20% to 25% of the older adult population. Causes are lower esophageal sphincter dysfunction, delayed gastric emptying, hiatal hernia, and increased intraabdominal pressure. Older adults also take medications that increase the symptoms of GERD. Examples of such medications include tetracycline, alendronate, potassium chloride, quinidine, aspirin, ascorbic acid, nonsteroidal antiinflammatory drugs (NSAIDs), clindamycin, and theophylline. Older adults often take medications in the supine position and with inadequate fluids, which may worsen symptoms (Wolfe, 2006).
Esophagitis refers to inflammation of the esophagus. Most often this results from gastroesophageal reflux caused by either prolonged vomiting or an incompetent lower esophageal sphincter. The amount of mucosal damage is related to the contact time between the esophageal mucosa and the gastric contents, as well as the acidity and quantity of gastric secretions. Additional causes of esophagitis include viral, fungal, or bacterial infections.
Symptoms of GERD and esophagitis include heartburn, retrosternal discomfort, and the regurgitation of sour, bitter material. Symptoms are often precipitated by the ingestion of a large amount of fatty or spicy foods or alcohol. Strictures, caused by esophageal scarring, may develop and make food passage difficult. Dysphagia for both liquids and solids occurs as scar tissue builds and the esophageal lining stiffens, leading to esophageal narrowing. If regurgitation occurs often, substernal pain may result, occasionally mimicking a heart attack. Reflux may be aggravated by postural changes such as sleeping in the supine position but may occur in any position. Pulmonary aspiration as a result of reflux is common; when severe, it may lead to pneumonia.
Hiatal Hernia In hiatal hernia (diaphragmatic or esophageal hernia), a major cause of reflux and esophagitis, part of the stomach protrudes through an opening of the diaphragm (Figure 24-3). The condition may be intermittent or continuous. The continuous type is least
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common, accounting for only about 10% of cases. Either part or all of the stomach, and even the intestines, may herniate, causing dyspepsia, severe pain, and often a gastric ulceration. The intermittent type, or sliding hernia, occurs with changes in position or with increased peristalsis. The stomach is forced through the opening of the diaphragm when the person is prone and moves back to its normal position when the person stands up. Most hiatal hernias are asymptomatic and require no treatment. Symptoms, when they arise, include heartburn, gastric regurgitation, dysphagia, and indigestion. These symptoms are accentuated (1) when assuming the supine position after meals, (2) after overeating, (3) after physical exertion, or (4) with a sudden change in posture (Lewis et al., 2011).
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FIGURE 24-3 Hiatal hernias. A, Normal esophagus. B, Sliding hiatal hernia. C, Rolling or paraesophageal hernia. (From Price, S.A. & Wilson, L.M. (2003). Pathophysiology: Clinical concepts of disease processes (6th
ed.). St. Louis, MO: Mosby.)
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Nursing management Assessment
Assessment begins with a history of symptoms and possible aggravating factors. Older patients may use terms such as indigestion or heartburn, rather than pain, and these terms need to be clearly defined. Patients also may not understand what regurgitation means, especially in relationship to vomiting. Older persons may have atypical symptoms, including hoarseness, chest pain, postprandial fullness, respiratory symptoms, and belching. Alcohol and drug use must also be determined, as these are contributing factors. Drug and diet histories are also important components of the assessment.
Diagnosis Nursing diagnoses for an older patient with gastroesophageal reflux include the following:
• Risk for Aspiration, related to regurgitation
• Imbalanced Nutrition: Less Than Body Requirements, related to pain or dysphagia
• Deficient Knowledge, related to lack of exposure to disease process and treatment modalities
Planning and Expected Outcomes It is essential to determine whether a patient is ready to learn the preventive measures necessary for reducing symptoms. The presence of additional health problems may affect an older patient’s ability to participate in an educational plan or carry out the interventions.
Expected outcomes for an older patient with gastroesophageal reflux include the following:
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1. The patient will remain free from aspiration.
2. The patient will maintain weight within 10% of ideal body weight.
3. The patient will verbalize an understanding of the disease process and treatment approaches.
Intervention Nursing management of older patients with GERD includes maintenance of adequate nutrition, prevention of aspiration, and instruction to patients and their families about the disease process and treatment approach. Nonpharmacologic treatment includes avoiding foods that increase symptoms, maintenance of health, and smoking cessation. Support from caregivers, spouses, or significant others is key to success.
Evaluation Evaluation includes documentation of achievement of expected outcomes, prevention of complications, and appropriate dietary and lifestyle changes. Because most patients improve after 1 month of conservative management with antacids and lifestyle changes, it is important for the nurse to ascertain whether symptoms have subsided. If they have not, referral for further medical management is warranted.
Vitamin B12 Deficiency Vitamin B12 deficiency is a condition present in over 20% of older adults. Malabsorption causes the majority of cases; however, pernicious anemia accounts for about one fifth of known cases. Causes of malabsorption include gastritis, alcoholism, gastric surgery, inflammatory bowel disease, autoimmune disorders, and long-term use of proton-pump inhibitors (PPIs) or histamine-2 (H2) blockers (Chaparro & Mauricio, 2013). In pernicious anemia, degeneration of the parietal cells in the gastric mucosa leads to a
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decrease in production of the intrinsic factor, resulting in reduced absorption of vitamin B12. Vitamin B12 deficiency impairs the production of red blood cells (RBCs). This results in large, oval, fragile cells that have a short lifetime. Persons with pernicious anemia are typically treated with injections of vitamin B12 as oral vitamin B12 is not well absorbed (Lewis et al., 2011). However, supplementation with 1000 micrograms (mcg) cyanocobalamin orally has been shown to elevate B12 levels, even in those with pernicious anemia. Oral supplementation is preferred for older adults with malabsorption or other causes of B12 deficiency (Nettina, 2009).
Gastritis Gastritis refers to inflammation of the gastric mucosa and occurs in acute or chronic forms. The amount of gastric acid secretion might not be excessive in cases of gastritis (Table 24-4).
Table 24-4 Gerontologic differences in assessment: gastrointestinal system
Expected Aging Changes Differences in Assessment Findings Gingival retraction Loss of teeth, presence of dentures, difficulty chewing Decreased taste buds, decreased sense of smell Diminished sense of taste (especially salty and sweet) Decreased volume of saliva Dry oral mucosa Atrophy of gingival tissue Poor-fitting dentures Esophagus Lower esophageal sphincter pressure decreased, motility decreased
Epigastric distress, dysphagia, potential for hiatal hernia and aspiration
Abdominal Wall Thinner and less taut More visible peristalsis, easier palpation of organs Decrease in number and sensitivity of sensory receptors
Less sensitivity to surface pain
Stomach Atrophy of gastric mucosa, decrease in blood flow Food intolerances, signs of anemia as result of cobalamin
malabsorption, decreased gastric emptying Small Intestines Slight decreases in secretion of most digestive enzymes and motility
Complaints of indigestion, slowed intestinal transit, delayed absorption of fat-soluble vitamins
Liver Decreased size and lower in position Easier palpation because of lower border extending past costal
margin Decrease in protein synthesis, ability to regenerate decreased
Decrease in drug metabolism
Large Intestine, Anus, Rectum Decreased anal sphincter tone and nerve supply to rectal area
Fecal incontinence
Decreased muscular tone, decreased motility Flatulence, abdominal distention, relaxed perineal musculature Increase in transit time, sensation to defecation Constipation, fecal impaction
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decreased Pancreas Pancreatic ducts distended, lipase production decreased, pancreatic reserve impaired
Impaired fat absorption, decreased glucose tolerance
From Lewis, S., Dirksen, S., Heitkemper, M., Buchner, L., & Camera, I. (2011). Medical- surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby.
Acute gastritis causes transient inflammation, hemorrhages, and erosion into the gastric mucosal lining. Although the cause may be undetermined, it is frequently associated with alcoholism, aspirin or NSAID ingestion, smoking, and severely stressful conditions such as burns, trauma, central nervous system (CNS) damage, chemotherapy, and radiotherapy.
Chronic gastritis involves inflammation of the stomach lining that may occur repeatedly or continue over a period of time. Among its possible causes are ulcers, hiatal hernias, vitamin deficiencies, chronic alcohol use, gastric mucosal atrophy, achlorhydria, and peptic ulceration. The continual loss of gastric mucosa eventually decreases gastric secretion and may lead to pernicious anemia, PUD, or gastric cancer.
The major symptom of gastritis is abdominal pain. Other symptoms include indigestion, distention, decreased appetite, nausea, and vomiting. Many patients with chronic gastritis are asymptomatic.
Stress-Induced Gastritis Stress-induced gastritis or erosion, may occur in critically ill patients such as those with burns, sepsis, multiorgan failure, major surgery, or head injury. These erosions are superficial defects of the stomach mucosa that usually do not penetrate the muscularis layer; however, they may result in significant blood loss.
Two mechanisms are thought to produce stress ulcers: (1) mucosal ischemia resulting from a lack of blood supply to the gastric mucosa during the poststress period and (2) a decrease in mucosal bicarbonate concentration leading to increased sensitivity of the gastric mucosa to hydrochloric acid and pepsin.
The major clinical manifestation of stress ulcers is painless, gastric bleeding. Because of the danger of bleeding after acute stress
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and the difficulty of stopping it once it has started, preventive measures are routinely used to decrease hydrogen ion secretion and neutralize gastric acid. These include administration of antacids, as well as histamine blockers, sucralfate, or both.
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Nursing management Assessment
Assessment begins with a history and review of systems, which may include complaints of indigestion, abdominal or epigastric discomfort, nausea, vomiting, or anorexia. Questioning patients about possible GI blood loss (e.g., hematemesis or melena) is also important. With acute gastritis, signs of dehydration may be present.
Diagnosis Nursing diagnoses for an older patient with gastritis include the following:
• Acute Pain, related to epigastric discomfort, cramping secondary to acidity, or both
• Deficient Fluid Volume, related to decreased intake, vomiting and blood loss, or both
• Deficient Knowledge, related to the disease process
Planning and Expected Outcomes Because most patients receive treatment on an outpatient basis, the nurse must determine an older patient’s ability to adhere to the recommended treatment strategies. Expected outcomes for an older patient with gastritis include the following:
1. The patient will experience relief of epigastric symptoms.
2. The patient will maintain adequate fluid and electrolyte balance.
3. The patient will verbalize understanding of the disease and factors that contribute to the disease.
Intervention
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Nursing management of an older patient with gastritis includes acid-suppressant medications, as ordered; small, frequent, easily digested meals; maintenance of a calm environment to decrease the effects of stress; monitoring of fluid and electrolyte status; and teaching the older patient about precipitating and contributory factors. GI bleeding is a possible complication of gastritis, and prevention and early diagnosis are important. An older patient must understand the necessity of limiting or eliminating alcohol and tobacco use, avoiding aspirin and other NSAIDs, and seeking prompt medical attention for symptoms of indigestion and epigastric pain.
Evaluation Evaluation includes documentation of achieved expected outcomes, a decrease in symptoms, and no evidence of GI hemorrhaging or other complications. The nurse should note an older patient’s adherence to necessary lifestyle changes.
Peptic Ulcer Disease Peptic ulcer disease (PUD) is an ulcerative condition caused by the erosion of the GI mucosa resulting from the digestive action of hydrochloric acid and pepsin. Although PUD refers to injury anywhere in the GI tract, the most common occurrence is in the stomach and duodenum (Figure 24-4).
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FIGURE 24-4 Peptic ulcers, including an erosion, an acute ulcer, and a chronic ulcer. (From Price, S.A. & Wilson, L.M. (2003). Pathophysiology:
Clinical concepts of disease processes (6th ed.). St, Louis, MO: Mosby.)
The exact cause of peptic ulcers is unclear, but research has identified conditions that predispose individuals to their development. Helicobacter pylori infection plays a central role in the development of peptic ulcer disease in nearly 70% of PUD cases in older adults (Pilotto, Franceschi, Maggi et al., 2010). The infection leads to bacterial gastritis and subsequent gastric atrophy. Long- term effects of gastric mucosal atrophy include decreased gastric acid production, intestinal metaplasia, and gastric carcinoma. The organism secretes urease, which generates free ammonia, and a protease that breaks down the gastric mucus. These substances mediate inflammation in the gastric mucosa, which makes it more vulnerable (Lewis et al., 2011). Gastric ulcers and duodenal ulcers (DUs) are typically associated with NSAID use. Other drugs associated with PUD include warfarin, selective serotonin reuptake inhibitors (SSRIs), and bisphosphonates (Pilotto et al., 2010).
Both genetic and environmental factors have been proposed as the cause of peptic ulcers because both gastric ulcers and DUs tend to occur in families. At present, no direct evidence exists that indicates dietary or occupational factors as causes of ulcer disease. In addition, although psychological factors such as anxiety or stress play a role in the response of peptic ulcers to treatment, little evidence supports the common belief that only a person with the type A personality, who is constantly striving for perfection,
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develops ulcers. However, prolonged stress may produce a stress ulcer in anyone.
Gastric Ulcers In gastric ulcers, the level of hydrochloric acid secretion is usually normal or reduced. The problem lies in the increased rate of diffusion of gastric acid back into the tissue. Patients with benign gastric ulcers should be encouraged to receive frequent follow-up and monitoring because these ulcers can become malignant. Risk factors for the formation of gastric ulcers include H. pylori infection, NSAID use, cigarette smoking, and alcohol abuse. Caffeine and excessive stress may aggravate symptoms.
The most common symptom with gastric ulcers is gnawing or burning pain in the epigastric region that comes and goes; eating may lead to pain relief. Pain may be worse on an empty stomach. If the ulcer has eroded through the mucosa, food aggravates symptoms, rather than alleviating them (Lewis et al., 2011). Nausea, vomiting, and weight loss are common. Perforation may lead to hemhorrage and peritonitis. Healing and recurrences are common. A lack of healing or failure to decrease in size suggests malignancy.
Duodenal Ulcers In contrast to gastric ulcers, people with DUs have a normal back diffusion of gastric acid but an increased rate of gastric acid secretion. They also have an increased emptying rate of acid from the stomach to the duodenum. If the increase in acid is not buffered in the stomach, the acid is propelled into the duodenum, which leads to irritation of the duodenal mucosa. Most of these ulcerations occur in the first part of the duodenum, close to the pylorus. It is believed that the bacterium H. pylori migrates from the stomach to the duodenum in the presence of dysplastic changes in the duodenal mucosa.
Typically, the symptoms of DUs are patterned by periods of exacerbation and remission and follow a pain–food–relief pattern. The pain begins 2 to 4 hours after meals, and is immediately relieved by food or antacids. The pain is located in the
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midepigastrium and may be described as a burning or cramplike pain (Lewis et al., 2011). The pain may manifest as back pain. Other GI symptoms include heartburn and regurgitation of sour acidic juice into the back of the throat. Anorexia and weight loss are rare because the patient usually seeks food to relieve the pain. A DU may rupture because of erosion through the duodenal wall, and this leads to contamination of the peritoneal cavity (peritonitis). A slowly bleeding ulcer may reveal guaiac-positive stools. On physical examination, the only abnormality observed is possibly a tender epigastrium.
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Nursing management Assessment
Assessment begins with evaluation of a patient’s complaint of abdominal or epigastric pain, the most common symptom of peptic ulcers. The pain should be assessed for presence, location, character, and especially alleviating and precipitating factors. Peptic ulcer pain is usually described as gnawing, burning, or aching, usually in the epigastric area, and may radiate around to the back. The pain usually begins when the stomach is empty and may disappear with the ingestion of food or an antacid. Because of this, the pain often occurs at night when the stomach is empty, especially with DUs. A patient may also exhibit signs of complications of the peptic ulcer. Hemorrhaging may be manifested as either melena or hematemesis. Older adults typically have a blunted presentation.
Diagnosis The most frequently used nursing diagnoses for an older patient with PUD include the following:
• Acute Pain, related to mucosal lesions
• Deficient Knowledge, related to lack of exposure to disease process and treatment
• Ineffective Family Therapeutic Regimen Management, related to complexity of health care regimen
Planning and Expected Outcomes Because not all older patients with PUD have the same set of symptoms, the nurse must determine individual patient needs with regard to education and other interventions. Expected outcomes for an older patient with PUD include the following:
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1. The patient will report a decrease in abdominal or epigastric pain.
2. The patient will adhere to the prescribed dietary, activity, and medication regimen.
3. The patient will acknowledge aggravating factors such as smoking, alcohol use, stress, or frequent use of aspirin or NSAIDs.
Intervention Nursing management for an older patient with PUD includes education of the patient on lifestyle changes, dietary modifications, and medications that may be used in the treatment plan. Lifestyle changes include cessation of smoking, cessation of alcohol consumption, and avoidance of other irritants such as aspirin- containing products and NSAIDs. In addition, stress reduction techniques such as exercise, relaxation training, biofeedback, and other appropriate outlets should be explored and individualized, depending on patient needs and wishes. Dietary changes include avoiding foods that irritate the mucosa of the stomach, for example, caffeine and foods that cause pain.
Medications need to be taken as prescribed. An older patient needs to be instructed that antacids work quickly to neutralize acid in the stomach and are only to be used intermittently for heartburn and acid indigestion. Medications to reduce or prevent acid production (H2 receptor antagonists and PPIs) should be taken exactly as ordered, but these agents take longer to provide relief. The patient should also understand that antacids last only 20 to 30 minutes, whereas medications to reduce or prevent acid production have a long-term effect. Another important point to discuss with the older patient is the effect of ulcer medication on other drugs. For example, cimetidine, a H2 receptor antagonist, interferes with the metabolism of warfarin, theophylline, and phenytoin.
If surgery is performed, more dietary modifications may be necessary because of a reduction in the size of the stomach. A response known as dumping syndrome is common after gastric resection; it is manifested by dizziness, nausea, and diaphoresis
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after meals. The institution of small, frequent meals that are low in carbohydrates will diminish the incidence of these symptoms. Resting after eating and drinking fluids between (rather than during) meals will also help alleviate these symptoms. Maintaining adequate nutrition and fluid and electrolyte balance is especially important for older patients and may be achieved by making these dietary modifications.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of complications, elimination of symptoms, and an increased knowledge base regarding PUD. Any complications from recommended medical treatments should be noted.
Enteritis Enteritis, or gastroenteritis, refers to an inflammatory process of the stomach or small intestine. Bacteria, viruses, medications, radiation, ingestion of foods that irritate the gastric mucosa, or allergic reactions may cause it. Bacterial enteritis, commonly known as “food poisoning,” is often caused by ingestion of food contaminated by bacteria containing toxins. Examples of these bacteria include Staphylococcus aureus, Salmonella, and Clostridium botulinum.
In addition, enteritis may result from parasitic infections such as amebiasis and trichinosis. Amebiasis is caused by a protozoal parasite that primarily invades the large intestine. The inactive form, a cyst, is ingested through food or water that is contaminated by feces and passes into the intestines. There, the active form is released and enters the intestinal wall, causing ulceration of the intestinal mucosa. Amebiasis is prevalent primarily in tropical countries and in places with poor sanitation.
Trichinosis is transmitted through improperly cooked pork and is caused by the larvae of a roundworm that became imbedded in the striated muscles. When the contaminated pork is eaten, gastric acid
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releases the larvae from cysts; they develop into adults in the host’s intestine. The adult females release larvae which move toward the host’s muscles, where they may remain for many years. Acute enteritis is a result of direct bacterial or viral infection or the effect of the toxins produced by bacteria. This results in either an increased secretion of water into the intestinal lumen or an increase in motility, causing large amounts of food and fluid to be excreted. In general, enteritis causes inflammatory changes in the intestinal mucosa, which return to normal when the offending agent is removed.
The pathologic process has varying manifestations resulting in symptoms of abdominal cramping, profuse diarrhea, and vomiting. With profuse diarrhea, large amounts of fluid and electrolytes may be lost, which leads to dehydration and electrolyte imbalances of hyponatremia and hypokalemia. Older adults are particularly at risk for dehydration and electrolyte imbalance. Prompt treatment is required.
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Nursing management Assessment
Assessment begins with a history of recent food intake; nausea; vomiting; and diarrhea, including amount, duration, frequency, and stool characteristics. The nurse should inquire about recent drug use, especially antibiotics, and recent travel. If food poisoning is suspected, the nurse should also question the patient regarding possible sources of contamination. Physical examination includes inspection of mucous membranes and assessment of orthostatic blood pressure, temperature, and abdominal tenderness. A urine specimen for specific gravity may be helpful in assessing hydration.
Diagnosis The most common nursing diagnoses for an older patient with enteritis include the following:
• Deficient Fluid Volume, related to vomiting and diarrhea
• Diarrhea, related to intestinal inflammation
Planning and Expected Outcomes Expected outcomes for an older patient with enteritis include the following:
1. The patient will maintain adequate fluid volume and electrolyte balance.
2. The patient will have a continual decline in the number of liquid, nonformed stools until baseline is achieved.
Intervention Nursing management of an older patient with enteritis includes maintenance of hydration and monitoring of fluid and electrolyte
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status. With severe vomiting and diarrhea, intravenous hydration and hospitalization are required. With milder forms of enteritis, clear liquids may be offered at home. In all cases, monitoring for signs and symptoms of dehydration is imperative. In addition, it is important for the nurse to determine whether an older patient has someone nearby to assist him or her or summon for help if the condition worsens. Older patients need to be educated about the signs and symptoms of dehydration and when to seek further medical care. Prevention of bacterial and parasitic enteritis should also be discussed, and the need for thorough hand washing, especially before meals and food preparation, should be stressed.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of complications, and return to baseline status. The nurse should monitor the older patient for reduction of symptoms as the problem resolves. Careful monitoring of oral intake and tolerance of advancing diet is also documented.
Intestinal Obstruction Intestinal obstruction occurs whenever partial or complete blockage of the GI tract occurs in either the small intestine or the large intestine. This may be the result of several conditions, which are usually classified as mechanical or paralytic ileus.
Mechanical obstructions are the most common and are primarily caused by tumors, adhesions, or hernias (Figure 24-5). Another mechanical cause of intestinal obstruction is volvulus, or the twisting of a part of the intestine. Although this is a rare cause of obstruction overall, it is more common in older adults because the mesenteric ligaments weaken over time.
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FIGURE 24-5 Bowel obstructions. A, Adhesions. B, Strangulated inguinal hernia. C, Ileocecal intussusception. D, Intussusception
from polyps. E, Mesenteric occlusion. F, Neoplasm. G, Volvulus of the sigmoid colon. (From Lewis, S., Dirksen, S., Heitkemper, M., Buchner, L., & Camera, I. (2011). Medical-surgical nursing: Assessment and management of clinical
problems (8th ed.). St. Louis, MO: Mosby.)
Paralytic ileus involves decreased or absent peristalsis resulting from neurologic or vascular disorders. Peristalsis becomes diminished or absent because of a triggering of the inhibitory reflex by noxious stimuli such as anesthesia, peritoneal injury, interruption of the nerve supply, abdominal injury or surgical manipulation, intestinal ischemia, electrolyte imbalances, or side effects of certain medications such as antidepressants or pain medications. Neurologic causes, which may be overlooked, include diabetes-related neuropathy, multiple sclerosis, stroke, or Parkinson disease. It is a common postoperative problem, especially after abdominal surgery.
Vascular disorders may cause intestinal or mesenteric ischemia resulting in obstruction. Prolonged ischemia results in death of the surface of the villi and epithelial cells, which, in turn, impairs the absorption of nutrients. In addition, the mucosal layer becomes necrotic, and peristalsis diminishes. Although intestinal or mesenteric ischemia is relatively rare, its high mortality rate and predominance in older adults make it important for nurses caring
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for older adults. Some degree of intestinal ischemia is present in all patients who have a history of other forms of ischemia, thrombosis, or infarction or in patients who have chronic ischemia, for example, those with atherosclerosis. The majority of these patients have a history of cerebrovascular disease, peripheral vascular disease, coronary heart disease, or all of these conditions. Ischemic bowel disease comprises a spectrum of acute and chronic syndromes that usually affect older adults. The major syndromes of ischemic intestinal disease include acute embolic ischemia, acute thrombotic occlusion (ischemic colitis), nonocclusive ischemia, chronic intestinal ischemia (abdominal angina), and venous occlusive disease.
Whatever the cause of intestinal obstruction, after the blockage occurs, the bowel becomes distended by gas and air proximal to the area of blockage. If the process continues, gastric, biliary, and pancreatic secretions, along with water, electrolytes, and serum proteins, begin to accumulate in the area, causing an increase in intraluminal pressure. A third space shift may occur when the circulating blood volume decreases as a result of the movement of water into the intestinal lumen, which may lead to dehydration, electrolyte imbalances, and hypovolemia.
Clinical findings with an obstruction include the acute onset of severe cramping pain that correlates roughly to the area or level of obstruction. The pain may decrease in severity as the distention of the bowel increases. In mesenteric ischemia, the clinical presentation is initially nonspecific and may mimic other, more common abdominal problems such as diverticulitis, appendicitis, and cholecystitis. Although the major symptom is abdominal pain, the clue to mesenteric ischemia is that the pain is out of proportion to what is found on physical examination. Atherosclerotic ischemia may create an angina-like cramping abdominal pain that becomes worse after meals and then dissipates. In colonic ischemia the pain is worse in the left lower quadrant. Vasospasm and emboli produce an acute, severe abdominal pain with associated vomiting and diarrhea.
Abdominal distention will be present, especially if the obstruction is in the lower small intestine or colon. Percussion will
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elicit a tympanic sound because of the accumulation of gas and air in the bowel. Hyperactive bowel sounds are present above the site of a mechanical obstruction as the intestine attempts to push the contents downward. The increase in the rate and force of peristalsis may cause borborygmi (loud and high-pitched bowel sounds); these may progress to an absence of bowel sounds as the condition persists. Bowel sounds below the obstruction will be absent. Vomiting is almost always present and may (rarely) be bilious or feculent, depending on the level of the obstruction. Diarrhea may occur if the obstruction is not complete, allowing watery contents to pass. The patient may develop signs of dehydration and shock.
Complications of intestinal obstruction include perforation of the bowel, chemical or bacterial peritonitis, hypovolemic shock, and septic shock. The increased pressure on the mucosa of the affected bowel segment may lead to bowel necrosis, resulting in changes in the permeability of the bowel wall. Normal bacteria of the intestine may then escape into the peritoneal cavity, causing peritonitis that may escalate to bacteremia. Perforation of the thinned intestinal wall results in the loss of fluid into the abdominal space, chemical peritonitis, and possible abscess formation. Infection and loss of fluid and electrolytes are major problems. Hypovolemic shock may result when there is a shift of fluid greater than 10% of body weight. Septic shock may also occur as a result of the contamination of the bloodstream when the bowel ruptures or becomes gangrenous. Sepsis and hypovolemic shock are life threatening and must be treated aggressively.
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Nursing management Assessment
Assessment begins with a thorough history of the precipitating event; the nurse should focus on the type and frequency of vomiting and diarrhea (e.g., profuse or fecal) and the location and character of pain (e.g., cramping, constant, or diffuse). A sudden change in a patient’s description of abdominal pain from generalized and dull to localized and sharp must be taken seriously; this is a characteristic presentation of peritonitis. Physical examination should focus on the presence and character of bowel sounds (e.g., loud, frequent, absent, or weak), the presence of abdominal distention, vital signs, and urinary output. A sudden elevation of temperature is another classic sign of peritonitis.
Diagnosis Nursing diagnoses for an older patient with bowel obstruction or ileus include the following:
• Deficient Fluid Volume, related to loss of body fluids and inadequate fluid volume intake
• Imbalanced Nutrition: Less Than Body Requirements, related to vomiting and obstruction
• Nausea, related to gastrointestinal irritation
• Constipation, related to decreased motility or obstruction
Planning and Expected Outcomes Expected outcomes for an older patient with an ileus or intestinal obstruction include the following:
1. The patient will maintain adequate fluid volume and electrolyte balance.
2. The patient will verbalize a tolerable level of discomfort.
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3. The patient will regain and maintain adequate nutrition, as evidenced by achievement of preillness body weight.
4. The patient will state relief from nausea.
5. The patient will maintain passage of soft, formed stool
The older adult with bowel obstruction requires careful and close observation because the classic signs of pain and fluid loss may be blunted.
Intervention Nursing management of an older patient with intestinal obstruction or ileus includes maintenance of hydration and promotion of comfort. Dehydration may be prevented through the provision of intravenous fluids and electrolytes, as ordered. Monitoring intake and output and specific gravity of urine, as well as monitoring for signs of fluid overloading or dehydration, is important. Nasogastric or nasointestinal tubes are usually required for decompression, and maintenance of their patency and placement is imperative. Pain relief measures may include medication; however, narcotics are sometimes not allowed because of their effects on the bowel and their masking of important symptoms. Other comfort measures include repositioning, mouth care, skin care, and music or meditation. If surgery is required, preparation of the patient and family concerning what should be expected is also important.
Evaluation Evaluation includes documentation of achievement of expected outcomes and prevention of complications (see Nursing Care Plan: Ileus). Vital signs, intake and output, bowel sounds, and bowel elimination patterns should also be recorded. If surgery was performed, monitoring of the incision site and wound healing status is necessary.
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Nursing care plan
Ileus: Obstruction Resulting from Diverticulitis Clinical Situation Mrs. M is a 78-year-old retired seamstress, who was recently admitted to the emergency department with abdominal pain. Her son and daughter-in-law with whom she lives brought her in. Her son reported that his mother had been complaining of abdominal pain for the past 24 hours, and because it did not subside, he encouraged her to seek medical attention. Over the past 24 hours, Mrs. M reported left-sided lower abdominal pain, nausea, and, more recently, vomiting. She was unsure whether she had a fever. Her daughter-in-law added that her mother-in- law had had a lot of constipation recently, for which Mrs. M had taken various types of laxatives.
Her medical history included hypertension (for which she takes nifedipine extended release and hydrochlorothiazide) and hypercholesterolemia (for which she takes lovastatin on a daily basis). Her son also remembered the doctor telling his mother a few years ago that she had diverticulosis, which was diagnosed from an incidental finding on radiography. Her only past surgery was an uncomplicated cholecystectomy about 20 years ago for cholecystitis. Mrs. M stated that she was on no particular diet and did not have much weight fluctuation over the past few years.
Physical examination revealed a thin woman, weighing 128 pounds (lb), with a temperature of 100.9 ° F (38.3 ° C) (orally), pulse of 98 beats per minute (beats/min), respiratory rate of 24 breaths/min, and blood pressure of 140/84 mm Hg. She was lying on the stretcher curled in a semifetal position. Her abdomen was not obviously distended, and her only scar was a midline incisional scar from her previous cholecystectomy. She had loud, high-pitched bowel sounds, but no audible bruits. Her abdomen was tender and a firm mass was palpable in the lower left quadrant. She had no elicitable rebound tenderness. She had tenderness on rectal examination and was thought to have stools
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high up in her rectal vault. Her Hemoccult test was guaiac negative.
Laboratory tests revealed a white blood cell count of 90,000 microliters (µL) and a normal hemoglobin count. Urinalysis was normal, as were serum electrolyte levels. Serum amylase was 500 units per deciliter (units/dL). Plain abdominal radiography revealed air–fluid levels but no free air on the abdomen. She was given the diagnosis of ileus or obstruction resulting from diverticulitis.
Mrs. M was admitted to a general medical unit and had a surgical consultation. She was started on intravenous fluids, restricted to NPO (nothing by mouth) status, and had a nasogastric tube placed on high intermittent suction. Intravenous antibiotic therapy was begun and continued for the remainder of her hospitalization. She was monitored closely and managed medically. She was found to have an ileus only and never required surgery for a small bowel obstruction or perforation. She was discharged to home on the eighth day after admission. She resumed her previous medications.
Nursing diagnoses Deficient Fluid Volume, related to active loss of body fluid
secondary to nasogastric tube output
Imbalanced Nutrition: Less Than Body Requirements, related to prolonged NPO status
Constipation, related to decreased mobility, daily ingestion of constipating medications, and lack of dietary fiber
Deficient Knowledge, related to lack of exposure to knowledge about prevention and complications of diverticular disease
Pain (abdominal), related to reluctance to take pain medication
Outcomes The patient will maintain adequate fluid volume and electrolyte
balance.
The patient will maintain preadmission weight.
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The patient will establish a regular pattern of fecal elimination.
The patient and family will be able to verbalize dietary changes and be able to prevent constipation and further complications.
The patient will obtain pain relief.
Interventions Monitor vital signs every 4 hours or as ordered.
Maintain intravenous therapy, as ordered.
Monitor intake and output (hourly); skin moisture, color, and turgor; specific gravity of urine (every 4 hours); serum electrolyte levels; and level of consciousness.
Weigh the patient every day or as ordered.
Monitor serum albumin and protein levels.
Administer intravenous total perineal nutrition, as ordered.
When the patient is no longer NPO, encourage high-protein, high- calorie foods.
Administer stool-softening medications, if ordered.
When the patient is no longer NPO, encourage a daily fluid intake of 2 liters (L) and consumption of high-fiber foods. Teach the patient about fiber-rich foods to be included in the diet.
When the patient is able, encourage her to increase her activity level.
Teach about constipating side effects of medications.
Provide the patient and family with written and verbal information concerning the importance of a high-fiber diet, the need to maintain an adequate fluid intake, and the need for light exercise.
Provide the patient and family with written and verbal information concerning complications of diverticulosis, such as diverticulitis.
Assess and monitor the degree of pain every 4 hours.
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Provide the patient with verbal and written instruction about analgesics.
Provide other measures of pain relief, such as guided imagery, repositioning, and diversional activities.
Provide encouragement by informing the patient that the pain will decrease as the ileus improves.
Diverticula Diverticula are saclike protrusions of the mucosa along the GI tract. These small sacs are formed by herniation of the mucous membrane outward through a separation in circular muscle fibers of the intestine where blood vessels penetrate the muscle layer. Diverticula are a result of increased intraluminal pressure and can develop in any part of the digestive tract. They occur most often in the descending and sigmoid colon. Colonic diverticula are usually multiple.
The exact cause of diverticula is unknown. Because of the frequency of diverticula in older adults, it is thought that they are related to the blood supply or nutrition of the bowel. Lack of dietary fiber or roughage and decreased fecal bulk have also been correlated with this process. With an increase in food bulk (as with consumption of dietary fiber), the pressure in the colon decreases. In contrast, when little waste is present in the colon, stronger muscle contractions are necessary to excrete it, and the pressure increases. This increase in pressure leads to muscle hypertrophy and the development of diverticula. In this manner, diverticula have also been linked to chronic constipation and obesity in older adults. Atrophy of the musculature of the bowel wall may weaken the intestine and be another factor in the development of diverticula in older adults. The presence of multiple diverticula that are not inflamed is termed diverticulosis. This is a disease of middle age and old age. The incidence of diverticulosis increases with age, and represents the fifth most important gastrointestinal disease in Western countries in terms of direct and indirect health care costs. It is the most common disease of the colon in industrialized countries, and the highest rates are reported in the United States, Europe, and
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Australia (Petruzziello et al., 2006). Diverticulosis may be symptom free and is often diagnosed as an incidental finding on radiography or sigmoidoscopy. When symptoms are present, it may be associated with vague abdominal discomfort, constipation, or diarrhea.
Diverticulitis is an inflammation of or around a diverticular sac that is usually caused by the retention of undigested food, stool, and bacteria. In diverticulitis, stasis leads to inflammation, infection, or both. The mucous membranes may erode or perforate blood vessels, causing bleeding. Obstruction of the large intestine, fistulae, and abscesses may result. Rupture of the infected material into the peritoneal cavity may result in peritonitis. Approximately 10% to 25% of those with diverticulosis develop diverticulitis (Chapman, Davies, Wolff et al., 2005).
Clinical manifestations of symptomatic diverticular disease include constipation or diarrhea, left-sided lower abdominal pain, and fever. Over half of patients with diverticulitis experience some change in bowel habits; most complain of constipation. Other symptoms include flatulence, nausea, and vomiting. Older adults with diverticulitis may be afebrile and have little abdominal discomfort. Complications include perforation and peritonitis, ureteral obstruction, and significant lower GI bleeding. Surgery may be necessary if an obstruction or perforation is suspected.
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Nursing management Assessment
Assessment begins with an older patient’s history of elimination patterns and changes in these patterns such as frequency of defecation, stool characteristics (e.g., color, size, and consistency), toileting habits, and course (e.g., improving or worsening and recurrent or chronic changes in bowel habits). Exercise patterns, pain, bloating, nausea, vomiting, medical history (e.g., hemorrhoids or bowel surgery), and family history of bowel problems such as polyps or colon cancer are also important. With diverticulitis the patient may have fever and chills. A physical examination may be unremarkable, but it may also reveal left lower quadrant tenderness or a guaiac-positive stool.
Diagnosis The most common nursing diagnoses for an older patient with diverticulosis or diverticulitis include the following:
• Risk for Constipation, related to decreased fluid, bulk in the diet, or both
• Acute Pain, related to bowel obstruction
• Deficient Knowledge, related to lack of exposure to disease process, prevention, and treatment
Planning and Expected Outcomes Expected outcomes for an older patient with diverticulosis or diverticulitis include the following:
1. The patient will experience fewer episodes of constipation, as evidenced by establishment of a regular pattern of bowel activity.
2. The patient will verbalize pain relief and remain free from abdominal pain.
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3. The patient will verbalize self-care practices to minimize symptoms of diverticulosis and prevent complications of diverticulitis.
Intervention Nursing management of an older patient with diverticulosis or diverticulitis includes the prevention and elimination of constipation and the initiation of dietary changes. This includes teaching the patient and family about the development of diverticula and the escalation to diverticulitis. In addition, teaching should include the importance of eating high-fiber foods, which include beans, whole grains, brown rice, fruits (e.g., apples, bananas, and pears) and vegetables (e.g., broccoli, carrots, corn and squash). Patients should be encouraged to drink eight cups of fluids each day, unless contraindicated by cardiac status.
An older patient with diverticulitis needs pain management (with antispasmodics, analgesics, or other measures such as a heating pad), bowel rest (intravenous fluids if given NPO [nothing by mouth] status), and hospitalization if acutely ill. The nurse should teach self-care practices that promote bowel regularity and administration of stool softeners (such as docusate), as necessary. Preventing constipation is of the utmost importance.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of complications, and maintenance of regular bowel patterns and habits. Asking an older adult to verbalize how he or she has incorporated the self-care practices into daily life is an effective way to ascertain whether the patient understands the disease and is able to take measures to prevent complications.
Colon Polyps Colon polyps are growths on the mucous membranes of the GI tract. A polyp may be sessile (flat, broad, and attached directly to
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the intestinal wall) or pedunculated (attached to the wall by a thin stem). The most common type of polyp are termed adenomatous polyps or adenomas. Adenomatous polyps may become cancerous. The larger the polyp, the more likely it is to be malignant (greater than 1 millimeter [mm]). Having numerous polyps increases the likelihood of developing cancer.
The most common nonmalignant polyps are of the hyperplastic type. These rarely grow large and never cause clinical symptoms. Many patients with polyps are asymptomatic. These growths are often discovered incidentally by sigmoidoscopy, colonoscopy, or barium enema. Occasionally, they may bleed, causing bright red blood in feces.
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Nursing management Assessment
Assessment begins with a thorough history of any changes in an older adult’s routine pattern of elimination and any symptoms such as blood in the stools or on the toilet paper. A detailed family history should be taken, and specific questions should be asked regarding polyps in family members. A physical examination may be unremarkable; however, guaiac-positive stools may be found on rectal examination.
Diagnosis The most common nursing diagnoses for an older patient with polyps include the following:
• Deficient Knowledge, related to lack of exposure to disease process, importance of treatment, and follow-up
• Anxiety, related to threat to health status
Planning and Expected Outcomes Expected outcomes for an older patient with polyps include the following:
1. The patient will verbalize knowledge of the disease process and potential outcomes.
2. The patient will obtain medical follow-up as suggested by the American Cancer Society (ACS) or a health care provider.
Intervention Nursing management of an older patient with polyps includes education and reinforcement of the guidelines suggested by the ACS for prevention and early detection of colorectal cancer.
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Teaching of a patient who is to undergo colonoscopy may need to include reinforcement of the importance of having the polyps removed. Reminders should be given to older patients regarding the time for a repeated screening sigmoidoscopy (according to their health care provider or ACS guidelines). Patients may also need to be reminded that, although polyps are often asymptomatic, they may bleed. The presence of any blood in the stool may indicate the need for a repeated sigmoidoscopy or colonoscopy.
Evaluation Evaluation includes documentation of achievement of the expected outcomes and prevention of complications such as invasive colorectal cancer.
Hemorrhoids Hemorrhoids are dilations of the veins in the mucous membrane inside the rectum or near the anal opening. These dilations are common and develop in susceptible people as a result of increase in pressure on the veins in the pelvic and rectal areas. Patients may be predisposed because of diarrhea or constipation, obesity, pregnancy, liver disease, prolonged sitting, pelvic tumors, and anal intercourse.
Internal hemorrhoids may cause bleeding with defecation. The dilated venous sacs may protrude into the anal canal, where they become exposed and result in pain; thrombus, ulcerations, and bleeding then develop. External hemorrhoids produce varying degrees of pain, as well as pressure, itching, irritation, and a palpable mass. Bleeding occurs only if the external hemorrhoid is injured or ulcerated. Usually, blood loss is insignificant; however, with persistent bleeding, anemia of chronic disease may develop.
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Nursing management Assessment
Assessment begins with an older patient’s history of constipation and symptoms of rectal pain or blood in the stools or on toilet paper. The physical examination may be unremarkable except for a painful anus and rectum—painful to the point where thorough examination may be difficult. However, a prolapsed hemorrhoid may be detected and should be assessed for swelling, thrombosis, and ischemia. Guaiac-positive stools may be found.
Diagnosis The most common nursing diagnoses for an older patient with hemorrhoids include the following:
• Risk for Constipation, related to pain on defecation
• Acute Pain, in the anal and rectal area related to swelling and inflammation
• Deficient Knowledge, related to lack of previous exposure to treatment and prevention
Planning and Expected Outcomes Expected outcomes for an older patient with hemorrhoids include the following:
1. The patient will experience fewer episodes of constipation.
2. The patient will establish a regular pattern of fecal elimination.
3. The patient will report a decrease in anal and rectal pain.
4. The patient will verbalize knowledge of self-care practices to minimize the occurrence of hemorrhoids.
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Intervention Nursing management of an older patient with hemorrhoids includes the prevention and elimination of constipation. This includes a review of high-fiber, high-roughage foods, including indigestible fiber such as whole grains, legumes, and fresh fruits and vegetables (Berman et al., 2007). Adequate intake of fluids is also important. Older patients should be encouraged to consume up to 2000 milliliters (mL) of fluids each day unless contraindicated. The nurse should encourage light exercise on a regular basis and review the importance of a regular toileting routine. Over-the- counter (OTC) anesthetic ointments and creams and sitz baths may be used for pain relief. Patients should be encouraged not to strain when defecating; this may worsen the hemorrhoids. The nurse should emphasize that it is important to report any rectal bleeding to rule out the possibility of a more serious disorder.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of complications, and maintenance of regular bowel patterns and habits.
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Disorders of the accessory organs Cholelithiasis and Cholecystitis Cholelithiasis is the presence or formation of gallstones in the gallbladder. When the gallbladder empties slowly or incorrectly, stasis occurs and encourages the aggregation of cholesterol crystals, eventually leading to stone formation. Gallstones are primarily composed of two main substances: cholesterol and calcium bilirubinate. The incidence of gallstones varies among racial groups (i.e., higher incidence in Hispanic and Native Americans) and countries; however, it is not known whether this is a result of environmental or genetic factors. Risk factors include obesity, female gender, multiparity, sedentary lifestyle, diabetes, medications (e.g., cholesterol lowering agents, estrogen, and antibiotics) and advancing age (Lewis et al., 2011). Additionally, persons who have undergone bariatric surgery are at increased risk of developing gallstones.
Gallstones may be present for many years without signs and symptoms. The classic symptom is right upper quadrant pain, which may radiate to the right scapular area. The pain may be sharp, crampy, or dull and begins suddenly, often directly after a meal. The pain may last from 15 minutes to 6 hours, and nausea and vomiting may occur. These attacks of pain may occur as infrequently as once every few years or as often as every few days. Often, these episodes are precipitated by the ingestion of fatty foods. The symptoms of biliary pain are caused by an obstruction of the cystic or common bile duct, causing increased pressure and distention of the gallbladder. Often, the pain is so severe that it is mistaken for a heart attack. When the stones lodge along the biliary tract, they obstruct the flow of bile. This may result in jaundice because of the blockage of the flow of bilirubin. When the common bile duct becomes blocked, the bile cannot enter the duodenum, and the stool is clay colored because the fecal matter lacks pigment. In addition, obstruction of the common bile duct may cause biliary pain, jaundice, pancreatitis, or cholangitis (inflammation of the bile ducts).
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Cholecystitis may be acute or chronic and is usually associated with gallstones or other obstructions of the biliary system. The inflammation in cholecystitis results in a thickening of the wall of the gallbladder. This can lead to ischemia, necrosis, gangrene, and possible perforation of the gallbladder itself, leading to peritonitis. In chronic cholecystitis, the walls become thickened and inefficient at emptying. This is a result of chronic chemical or mechanical irritation from stones exerting pressure on the mucosa or from biliary stasis.
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Nursing management Assessment
Assessment begins with a history of episodes of pain; the nurse should identify its location, quality, and duration. Associated symptoms include nausea and vomiting. Precipitating factors (e.g., large, fatty meals) and alleviating factors (e.g., pain relievers or changes of position) need to be documented. Physical examination may reveal a tender right upper quadrant and possibly jaundice.
Diagnosis The most common nursing diagnoses for an older patient with cholelithiasis or cholecystitis include the following:
• Acute Pain, related to gallbladder inflammation
• Deficient Knowledge, related to lack of previous exposure to the condition and treatment options
• Disturbed Sleep Pattern, related to pain
Planning and Expected Outcomes Expected outcomes for an older patient with cholelithiasis or cholecystitis include the following:
1. The patient will experience pain relief.
2. The patient will verbalize knowledge of the disease process, prevention of complications, and treatment options available.
3. The patient will verbalize feeling rested after nighttime sleeping.
Intervention Nursing management of an older patient with cholelithiasis or cholecystitis includes providing pain relief and instructing the
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patient and family about the disease process, treatment options, and potential complications. Older patients with cholelithiasis need to know that foods high in fat may precipitate an attack of pain. They need to be aware of treatment options, including types of surgery, medical dissolution, and lithotripsy, as well as the advantages and disadvantages of each. The patient with cholecystitis may require hospitalization and may receive intravenous fluids and antibiotics. If managed at home, patients need to be on a clear liquid diet until pain is resolved and then slowly advance to a regular diet, avoiding fatty foods. Signs and symptoms of complications need to be reviewed with both patients and their families. Additional nursing care is based on an older patient’s response to the initial treatment.
Evaluation Evaluation includes documentation of achievement of expected outcomes, prevention of complications, prevention of infection, and assessment of a patient’s knowledge of the disease process. The nurse also evaluates the patient’s response to food intake and monitors the patient’s food choices to ensure dietary compliance.
Pancreatitis Pancreatitis is an inflammation of the pancreas and often has no known cause. The disorder may be acute or chronic. In acute pancreatitis the organ returns to normal after treatment. In chronic pancreatitis, permanent and progressive destruction of the pancreas occurs, whereby the normal tissue is replaced by fibrous tissue.
Acute pancreatitis may be alcohol induced or related to biliary tract disease; however, in nearly a third of cases, the cause is unknown. In the older adult, acute pancreatitis is most often related to biliary tract disease. Other causes of acute pancreatitis include medications, surgery, trauma, and metabolic disorders.
Acute pancreatitis is believed to be caused by activation of pancreatic enzymes, which may cause autodigestion of the pancreas; activation of the enzymes is thought to result from reflux
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of bile into the pancreatic duct, obstruction of the pancreatic duct, ischemia, anorexia, trauma, and toxins.
The etiology of chronic pancreatitis is not as well understood (Evans & Draganov, 2006); however, the majority of cases are caused by chronic alcohol abuse. Additional factors in the development of chronic pancreatitis include hereditary pancreatitis, cystic fibrosis, elevated triglycerides, cholelithiasis, and medications.
Symptoms include severe abdominal pain in the epigastric to the right upper quadrant area, occasionally radiating through to the back. Pain is usually more intense in the supine position, and the patient often remains in a flexed position to relieve pain. Nausea, vomiting, abdominal distention, and fever are common. In chronic pancreatitis, the pain may be continuous and accompanied by weakness and jaundice. In addition, in chronic pancreatitis the stools often become bulky, fatty, and foul smelling; weight loss may occur because of malabsorption. Glucose intolerance is a late sign of chronic pancreatitis. The development of easily identifiable chronic pancreatitis may take years. Calcification of the pancreas may take decades to develop, and diabetes (glucose intolerance) and steatorrhea may only develop after 10 to 20 years of disease progression (Forsmark, 2008).
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Nursing management Assessment
Assessment begins with an older patient’s history of precipitating factors such as alcohol abuse or the presence of gallstones. Symptoms of abdominal pain, anorexia, nausea, and vomiting need to be assessed in detail. The patient may be in tremendous pain and unable to answer, so reliance on information from a family member may be necessary. Depending on the patient’s pain, a physical examination may be difficult.
Diagnosis The most common nursing diagnoses for an older patient with pancreatitis include the following:
• Deficient Fluid Volume, related to nausea or vomiting; restricted oral intake
• Acute Pain, related to obstruction of the pancreatic tract
• Imbalanced Nutrition: Less Than Body Requirements, related to anorexia and vomiting
Planning and Expected Outcomes Expected outcomes for an older patient with pancreatitis include the following
1. The patient will maintain adequate fluid volume and electrolyte balance.
2. The patient will obtain pain relief.
3. The patient will stabilize and maintain weight.
4. The patient will not experience complications.
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Intervention Nursing management of an older patient with pancreatitis includes maintenance of fluid and electrolyte balance, establishing pain relief measures, and prevention of complications. This includes monitoring intravenous therapy, vital signs, intake and output, serum electrolyte values, and weight. Pain management may be extremely difficult, especially for patients with chronic pancreatitis. Often, the expertise of a pain consultant is necessary.
An important consideration in acute pancreatitis is the prevention of recurrence. When pancreatitis results from alcohol abuse, teaching should focus on the need to avoid alcohol consumption to prevent future acute episodes. Referral and counseling may be needed. For the patient with pancreatitis resulting from biliary tract disease, information on maintaining a low-fat diet is important. Providing information and emotional support is important for patients who may need surgery.
Evaluation Evaluation includes documentation of achievement of expected outcomes, prevention of complications, prevention of recurrence (for acute pancreatitis), and maintenance of adequate nutrition and hydration. Older adults who are addicted to alcohol may go through withdrawal, requiring the nurse to carefully monitor and record patient responses to treatment of this secondary problem.
Hepatitis Hepatitis is a general term referring to inflammation of the liver. It may be caused by a variety of factors such as drugs, chemicals and alcohol, but the most common cause is viral infection. Although five major viruses (and possibly a sixth), as well as mononucleosis and cytomegalovirus, may act as the causative agents for hepatitis, hepatitis A, B, and C viruses are the most common causative agents in the United States.
Hepatitis A virus (HAV), a ribonucleic acid (RNA) virus, causes
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hepatitis A. The primary mode of transmission of this organism is the fecal–oral route, commonly through ingestion of contaminated food or water. Risk groups for hepatitis A include institutional populations such as patients in day care centers, and travelers to endemic areas. The clinical disease tends to be mild and of short duration. No residual liver disease after recovery and no indications of a chronic state are present. The rate of hepatitis A is decreasing in the United States, as routine vaccination is now given to all children, travelers to certain countries, and persons at risk for the disease (CDC, 2009b).
Hepatitis B virus (HBV), a deoxyribonucleic acid (DNA) virus, causes hepatitis B. This virus is transmitted through blood and body fluids, and risk factors include intravenous drug use and sexual contact. It is considered a sexually transmitted disease (STD) by the CDC. Hepatitis B follows a more severe course compared with hepatitis A and has an increased risk for liver disease (e.g., cirrhosis and cancer). A 5% to 10% incidence of a chronic state, defined as continuing to test positive for the viral antigen for 6 months or longer, is present. Affected individuals may be asymptomatic or have subclinical symptoms; however, they remain contagious as long as the antigen is present. Hepatitis D virus (HDV) is an obligate virus with HBV; this virus is spread by the same mechanisms as HBV, and results in severe acute illness and life-threatening chronic liver disease.
Hepatitis C is caused by a small RNA virus, hepatitis C virus (HCV), and represents 85% to 90% of transfusion-related hepatitis cases. The clinical course is usually milder than that of hepatitis B, and the affected person may even be asymptomatic. The major concern about hepatitis C is the development of a chronic condition occurring in more than 75% of individuals. In an Italian study, the time to the development of cirrhosis as a complication of hepatitis C infection was shorter if the infection was acquired at an older age. Investigators also found this to be the result in a study published in Japan. Hepatitis C acquired through blood transfusion at an advanced age progresses more rapidly to the chronic state with the associated complications (Mindikoglu & Miller, 2009).
The pathophysiologic events leading to the liver inflammation
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seen in hepatitis are similar for all of the viruses. Once the virus is introduced into the individual by its specific mode of transmission, it enters the circulation and seeks out hepatic tissue. The virus enters the cell and uses the host cell’s DNA to reproduce itself. This may directly injure or kill the hepatocyte, which is believed to be the primary cause of cell damage in hepatitis A, or the responding immunologic cells may harm the liver cell in the process of destroying the virus, which is the probable pathologic cause in hepatitis B and C (Table 24-5).
Table 24-5 Viral hepatitis
From Centers for Disease Control and Prevention (CDC). (2009b). Viral hepatitis. <http://www.cdc.gov/hepatitis/Resources/HealthProf.htm> Accessed 04/10/2009.
Hepatitis E virus (HEV) is mainly prevalent in Asia and is transmitted via the fecal–oral route (e.g., contaminated water), in much the same manner as HAV. The infection is self-limiting and does not result in chronic liver disease. Hepatitis G virus (HGV) is similar to HCV with regard to mode of transmission and disease progression; however, HGV is not recognized by all medical communities as a causative organism for hepatitis (Davis, 2012).
The clinical picture of hepatitis is essentially the same for disease caused by all the viruses, but the overall course is shorter for hepatitis A. Typically, the illness is divided into three phases. In the prodromal phase, patients have generalized symptoms of malaise,
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fatigue, possible right upper quadrant pain, nausea and vomiting, anorexia, and a low-grade fever. Patients often think they have the flu, or the infected individuals do not recall experiencing the symptoms as they are very mild. The second phase, in which jaundice and dark urine appear, is termed the icteric phase. Sometimes, jaundice does not occur. Patients may actually start to feel better during this phase. Finally, in the convalescent phase, jaundice and other symptoms disappear, and patients feel fully recovered. It is important that patients understand that it will take 3 to 6 months for the liver to return to its normal functioning status. Care should be taken with regard to rest and drug and alcohol consumption during this phase; a relapse is possible.
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Nursing management Assessment
Assessment begins by reviewing with the patient any possible exposure to a hepatitis virus. The nurse should ask questions about recent travel, food intake, blood transfusions, and close contact with persons who may have had hepatitis in the past. Assess for clinical manifestations such as jaundice, right-upper quadrant tenderness, fatigue, and malaise. The nurse should question the patient about changes in functional status; for example, whether the patient’s activity level and ability to perform activities of daily living (ADLs) have decreased from baseline levels. The nurse should also review nutritional intake and assess for anorexia, as well as question changes in the way clothes fit and ask if family and friends have noticed weight loss in the patient. Palpation of the abdomen may reveal an enlarged liver.
Diagnosis Nursing diagnoses for an older patient with hepatitis include the following:
• Ineffective Health Maintenance, related to deficient knowledge about hepatitis, the treatment regimen, and prevention of spreading the virus
• Activity Intolerance, related to generalized weakness and fatigue
• Imbalanced Nutrition: Less Than Body Requirements, related to anorexia, nausea, and liver dysfunction
• Ineffective Family Therapeutic Regimen Management, related to lack of knowledge
Planning and Expected Outcomes Expected outcomes for an older patient with hepatitis include the
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following:
1. The patient will verbalize the causes of hepatitis, the treatment plan, and mechanisms to prevent spreading the virus to others.
2. The patient will participate in ADLs without experiencing fatigue.
3. The patient will consume a well-balanced, high-calorie diet, as evidenced by a food diary.
4. The patient will demonstrate self-care activities as much as possible within physical limitations.
Intervention The nurse must teach patients and their significant others about the spread of hepatitis and mechanisms for prevention. Depending on the specific mode of transmission of the particular virus, the nurse should also discuss hygiene practices in the home, especially with regard to feces; instruct men and women on condom use; discuss proper disposal of needles; instruct the patient and family on purchase and preparation of certain foods such as shellfish (i.e., eating raw shellfish should be avoided) and avoidance of alcohol and medications containing acetaminophen.
Frequent rest periods are necessary. The nurse should explain that rest is an important treatment in hepatitis, and activities such as visiting, cooking, and housework need to be curtailed. A patient with hepatitis best tolerates a high-carbohydrate, low-fat diet. Several small feedings throughout the day will help alleviate the effect of anorexia. Fluid intake should increase to 2000 to 3000 mL/day unless contraindicated by cardiovascular status.
The cause of jaundice should be explained, and the patient should be warned that changes in the colors of urine, skin, and sclera may be seen; this is a temporary condition that will resolve once the acute phase of illness has run its course.
If the jaundice causes pruritus (common in chronic HCV), the nurse should discuss the use of non–alcohol-based lotions, soft clothes and linens, and tepid baths using as little mild soap as
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possible. The nurse should instruct patients and caregivers about keeping patients’ fingernails short to avoid injury from scratching.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, coupled with the patient’s successful self-management of the disease. Careful attention to an older adult’s food intake, weight trends, and activity tolerance is crucial.
Alcoholic Cirrhosis Cirrhosis is a general term referring to a chronic disorder of the liver in which permanent, irreversible destruction of the hepatocytes and the normal architecture of the organ occurs. The causes for this disease are many and include fatty liver, hepatitis, cystic fibrosis, and primary biliary cirrhosis; however, about 80% of cases in the United States are attributed to alcohol abuse.
The progressive loss of functioning liver tissue is manifested by the appearance of general signs and symptoms of liver failure; over time, other manifestations of declining liver function appear (Figure 24-6). Early signs and symptoms of liver failure from cirrhosis are similar to those of hepatitis. The patient experiences fatigue, malaise, anorexia, changes in fecal elimination pattern (either diarrhea or constipation), nausea and vomiting, and dull, heavy pain in the right upper quadrant. Later symptoms include jaundice and edema in peripheral sites. Ultimately, serious complications such as bleeding, portal hypertension, ascites, and encephalopathy develop. Bleeding tendencies are the result of declining clotting and coagulation factors. One of the many functions of the liver is the production of clotting factors V, VII, IX, and X, as well as the production of fibrinogen and prothrombin. Decreased amounts of these proteins result in a bleeding diathesis in any patient with advanced liver disease, regardless of cause.
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FIGURE 24-6 Systemic clinical manifestations of liver cirrhosis. (From Lewis, S., Dirksen, S., Heitkemper, M., Buchner, L., & Camera, I. (2011).
Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby.)
Ascites is the accumulation of serous fluid in the abdominal cavity. It is the result of several factors relating to poor liver function, but the most important of these is the decreased production of albumin by the liver. Insufficient amounts of this major plasma protein in the blood cause the escape of plasma fluid into the abdominal space. Another factor is the increased venous pressure from portal hypertension, which forces the fluid out of the vessel. The most serious effect of ascites is respiratory compromise, which occurs when the diaphragm is pushed upward by increasing abdominal fluid, thus decreasing thoracic space for pulmonary excursion.
Portal hypertension is an increase in pressure in the portal vein and its feeders as a result of liver congestion or obstruction. In addition to contributing to the development of ascites, portal
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hypertension and the backflow of venous blood cause severe problems with hemorrhoids, splenomegaly, and esophageal varices. The effect of portal hypertension on the esophageal veins is the most dangerous because these vessels are fragile and susceptible to rupture with any increase in intraabdominal pressure. Patients who bleed from esophageal varices are gravely ill. One third of all deaths from cirrhosis are from esophageal varices.
A late-stage event in long-term liver disease is the development of encephalopathy, which is caused by the diseased liver’s inability to carry out its function of detoxifying metabolic byproducts. One of the most critical of these is ammonia, an end-product of protein metabolism. Although it is not clear whether the ammonia is directly toxic to the brain or interferes with glucose uptake, decreasing blood ammonia levels is correlated with successful treatment. A patient with high ammonia levels will begin to exhibit changes in behavior, irrationality, agitation, combativeness, and muscle tremors (asterixis). If the condition remains untreated, hepatic coma ensues and has a mortality rate of 90%.
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Nursing management Assessment
Assessment of the patient with cirrhosis involves a careful history of the onset and duration of symptoms. The nurse should question the patient about changes in the color of the stool, rectal bleeding, and bloody emesis. A thorough physical assessment of all body systems, especially the skin and abdomen, and respiratory and mental status is indicated. Assessment of nutritional status is also important.
Diagnosis Nursing diagnoses for an older patient with cirrhosis include the following:
• Risk for Impaired Skin Integrity, related to pruritus, edema, and ascites
• Ineffective Breathing Pattern, related to increased pressure on the diaphragm secondary to ascites
• Risk for Injury, related to decreased clotting factors
• Acute Confusion, related to increased serum ammonia levels
• Imbalanced Nutrition: Less Than Body Requirements, related to anorexia, nausea, and vomiting
• Risk for Situational Low Self-Esteem, related to guilt about damage done to self and significant others
Planning and Expected Outcomes Expected outcomes for an older patient with alcoholic cirrhosis include the following:
1. The patient will be free from skin breakdown.
2. The patient will demonstrate the ability to pace activity and
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ADLs within current ventilatory function.
3. The patient will remain free from injuries and bleeding.
4. The patient will demonstrate resolution of cerebral dysfunction, as evidenced by no injury to self or others; achieve an appropriate sleep–wake pattern; communicate meaningfully with others; and be oriented to time, person, and place.
5. The patient will maintain or gain weight to an appropriate level.
6. The patient will identify positive aspects about self and express an optimistic outlook regarding relationships.
Intervention Interventions for an older adult with cirrhosis may be multiple and complex; a major focus is preventing complications. Skin care is a priority. The nurse should inspect the skin daily for signs of breakdown or redness. The skin should be kept clean and dry, especially after toileting. The nurse should use pressure relief devices on a patient’s bed and chair. The nurse must also teach patients and caregivers the importance of changing position every 2 hours. A bed trapeze may facilitate lifting and position changes.
The nurse should position the patient in the semi-Fowler or high Fowler position to promote maximum chest expansion and maintain oxygen supplementation as indicated. Lung sounds must be assessed at least daily.
To prevent bleeding, the nurse should limit the number of venipunctures and use the smallest needle possible. A soft toothbrush or oral swabs may be used for mouth care. Male patients should use an electric razor to shave. The environment should be kept free of clutter.
Orientation and psychomotor function should be assessed. The nurse should reorient the patient on a consistent basis. The number of new people who enter the room should be limited. Mouth care should be provided before meals. The environment should be conducive to eating. Small, bland feedings may be given, especially if the patient complains of nausea. The nurse should consider the
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patient’s food preferences and remember that a high-carbohydrate, no-protein or low-protein, low-fat diet will be ordered. The nurse should also remember that fruit juices are often well tolerated by individuals with anorexia.
The nurse should encourage the patient to discuss feelings about self-esteem while maintaining a judgment-free environment at all times. The nurse should also reinforce positive abilities and traits and help the patient identify negative automatic behaviors. Resources such as pastoral care may be used, as indicated.
Evaluation Evaluation includes documentation of achievement of the expected outcomes and prevention or early detection of complications. Given the long-term nature of the condition, the nursing care plan should be reviewed and updated on a regular basis.
Drug-Induced Hepatitis The older adult population has an increase in the incidence of polypharmacy and alterations in pharmacodynamics and pharmacokinetics leading to drug-induced hepatitis (Duthie et al., 2007). Because one of the major functions of the liver is the metabolism and detoxification of chemicals, including drugs, this organ is subject to potential damage from these substances. Hepatic injury may result from direct toxicity, conversion of a drug to a toxic metabolite, or immune mechanisms responding to the presence of a “foreign” invader.
Some agents cause liver cell damage in all individuals at a predictable dose level. A common example of a dose-related toxic drug is acetaminophen. With overdose of these agents, the normal metabolic pathway is exhausted and alternative means are used to clear the drug from the body. These mechanisms yield toxic byproducts.
Drugs that cause liver damage in an unpredictable manner are said to have idiosyncratic toxicity. These reactions are unrelated to dose and occur only in a small percentage of susceptible
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individuals. Idiosyncratic toxicity is manifested in a variety of ways. Massive hepatocellular injury may occur. Drugs such as isoniazid, halothane, and benoxaprofen may cause liver necrosis and possibly hepatic failure, especially in older patients. Ingestion of poisonous mushrooms causes massive cell destruction. Substances such as vinyl chloride lead to sclerosis of the portal venules and portal hypertension. Another hepatic response to toxic exposure is cholestasis, an arrest or cessation of normal bile flow. Drugs such as anabolic steroids, oral contraceptives, phenothiazines, and oral antidiabetes drugs cause this response. Other manifestations of liver disease from idiosyncratic toxicity include fatty changes in the liver and mass lesions such as liver cell adenoma and hyperplasia.
The clinical manifestations of drug induced hepatitis are similar to those of viral hepatitis. At first, GI and influenza-like symptoms appear. Patients may be seen with jaundice, especially with the cholestatic presentation. Hepatomegaly and other signs of liver damage may also appear. The onset of symptoms may be immediate or several weeks to months after exposure to the hepatotoxic agent. In some cases, the onset of liver failure is abrupt, and the clinical course lasts only a few days, with outcomes ranging from resolution, to organ transplantation, to death.
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Nursing management Assessment
In addition to the previously discussed assessments related to liver disease, it is essential that information be obtained regarding the exact name of the ingested substance, the dosage and amount taken, and the length of time since ingestion occurred. History of emesis after ingestion is also pertinent.
Diagnosis The most common nursing diagnoses for an older patient with drug-induced hepatitis include the following:
• Deficient Knowledge, related to lack of exposure to disease cause, treatment regimen, and outcome
• Risk for Injury, related to end-stage liver failure
• Deficient Knowledge, related to medications and interactions
Planning and Expected Outcomes Expected outcomes for an older patient with drug-induced hepatitis include the following:
1. The patient will verbalize his or her understanding of the disease process and interventions.
2. The patient will not experience life-threatening complications of liver failure.
3. The patient will verbalize understanding of current medications and their interactions.
Intervention Nasogastric suction, if required, needs to be explained and
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performed in a calm manner. The nurse should also discuss the adverse effect of certain medications with the patient and provide written material as reminders to avoid these drugs. The nurse must monitor the patient carefully for signs and symptoms of liver failure, percuss liver size, assess the skin and sclera of the eyes, and monitor the level of consciousness.
Interventions for older adults presenting with complications of liver failure are discussed in the section on Alcoholic Cirrhosis.
Evaluation Evaluation includes documentation of achievement of the expected outcomes and prevention of complications.
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Gastrointestinal cancers Cancers of the GI system account for more than 25% of cancer deaths in the United States each year. Cancers of the GI tract are one of the top three causes of cancer deaths in both men and women. Most tumors of the GI tract are adenocarcinomas, with the exception of tumors of the esophagus and anus, where squamous cell malignancies predominate. Although the GI tract begins at the oral cavity and ends at the anus, oral cancer is considered along with head and neck cancers. Discussion of GI cancer will begin with cancer of the esophagus.
Esophageal Cancer Early esophageal cancer usually remains asymptomatic. Medical evaluation is typically sought when symptoms such as dysphagia, choking when eating, hoarseness, heartburn, unintentional weight loss, and fatigue develop. Many people with esophageal cancer attribute these signs and symptoms to some of the more common disorders that affect older adults and fail to seek treatment. Because of this fact, patients with esophageal cancer have a 5-year survival rate of about 20%.
Risk factors for the development of adenocarcinoma include obesity, GERD, and a history of Barrett esophagus; for squamous cell carcinoma, risk factors include heavy alcohol consumption, cigarette smoking, diet low in fruits and vegetables, and infection with human papilloma virus (HPV). Additionally, those older than 55, men, and African Americans are at a higher risk for developing esophageal cancer.
The two main forms of esophageal cancer are adenocarcinoma and squamous cell carcinoma. Adenocarcinoma is the most prevalent form in the United States, most often affecting older white males. It typically develops at the distal portion of the esophagus. Worldwide, squamous cell carcinoma is the most common, affecting the middle of the esophagus. The tumor often metastasizes to the lungs, the liver, and the CNS.
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Persons with known Barrett esophagus are urged to seek screening for esophageal cancer. The proximity of the tumor to the aorta and the trachea, in addition to the potential for metastasis, results in a generally poor prognosis. The natural history of the disease includes esophageal obstruction, coughing, hiccups, bleeding, malnutrition, cachexia, pneumonia, and death.
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Nursing management Assessment
Assessment begins with an accurate history that focuses on risk factors for esophageal cancer. A review of systems may reveal symptoms of dysphagia, eating difficulties, and aspiration. A physical examination will probably reveal few findings definitive of the diagnosis. However, in advanced disease, the nurse may find palpable lymph nodes and perhaps organ enlargement resulting from metastasis. Other findings include significant and recent weight loss and substernal epigastric pain radiating to the neck, jaws, ears, and shoulder (Lewis et al., 2011).
Diagnosis Nursing diagnoses for an older patient with esophageal cancer include the following:
• Imbalanced Nutrition: Less Than Body Requirements, related to inadequate intake of nutrients in the diet because of dysphagia
• Risk for Aspiration
• Fear, related to uncertain prognosis, possible disfigurement, and loss of ability to eat
Planning and Expected Outcomes Expected outcomes for an older patient with esophageal cancer include the following:
1. The patient will initially stabilize weight and then achieve an individually determined weight gain.
2. The patient will remain free from aspiration.
3. The patient will verbalize fears related to the diagnosis and prognosis.
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The medical treatments of radiotherapy, chemotherapy, and surgery will require additional, specific nursing interventions. The nurse should include the older adult and family in planning all aspects of nursing care related to any one or a combination of these modalities.
Intervention Nursing management of an older patient with esophageal cancer includes maintenance of hydration and nutritional status, prevention of aspiration, maintenance of comfort, and provision of emotional support. Optimizing nutritional status and preventing further weight loss is accomplished with small, frequent feedings; high-protein, high-calorie foods; supplements such as Ensure; and tube feedings, if necessary. Nursing care to prevent aspiration focuses on assessment of respiratory status, assessment of difficulty with eating and drinking, and proper positioning during and after eating. The risk of aspiration increases in older adults when the bed is kept in the horizontal position.
The nurse’s role in the prevention and early detection of esophageal cancer may lead to early identification and perhaps an improved prognosis for older patients. Persons with risk factors for esophageal cancer should be instructed on means to reduce or eliminate these factors. Counseling on the need for frequent medical follow-up, proper nutrition, and elimination of smoking and alcohol consumption is important for prevention. Older patients with frequent upper GI complaints should be advised to seek medical attention immediately.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of aspiration, and maintenance of adequate nutrition (see Nursing Care Plan: Esophageal Cancer).
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Nursing care plan
Esophageal Cancer Clinical Situation Mr. B, a 66-year-old retired salesman, has come to the outpatient clinic with a complaint of dysphagia. Within the past 4 months he has had pain and difficulty swallowing solid food; he therefore proceeded to eating soft, then liquid foods. However, within the past month, the problem has progressed to difficulty with swallowing even liquids. He reports one episode of nocturnal regurgitation this last week. Other symptoms include a loss of 20 pounds (lb) over the past 6 months, fatigue, and a dull backache. Mr. B admits that he still smokes but has cut down from two packs to one pack a day. In addition, he admits to ingestion of beer and hard liquor, although he has cut down in amount and frequency over the past few years since his retirement.
His medical history is otherwise unremarkable. He lives alone but near his daughter, who convinced him to come to the clinic when he did not eat anything at her recent Easter dinner.
Physical examination reveals a thin, older man, with a weight of 140 lb, temperature of 98 ° F (36.6 ° C), pulse of 80 beats per minute (beats/min), respiratory rate of 18 breaths/min, and blood pressure of 120/82 mm Hg. Inspection of his oropharynx reveals no abnormalities except for poor dentition. Examination of his abdomen and rectal area is also unremarkable. Laboratory values reveal iron deficiency anemia, but initial screening is otherwise unremarkable. He is scheduled for an endoscopy the next day. He returns to the clinic 1 week later to get his results, and his diagnosis is esophageal cancer. He is scheduled for radiotherapy and possibly surgery once the tumor has shrunk in size.
Nursing diagnoses Imbalanced Nutrition: Less Than Body Requirements, related to
inadequate intake of nutrients secondary to dysphagia
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Impaired Swallowing, related to mechanical obstruction secondary to tumor
Fear, related to uncertain prognosis, possible disfigurement, and loss of ability to eat
Risk for aspiration, related to dysphagia
Outcomes The patient will stabilize weight.
The patient will swallow safely without gagging or aspirating.
The patient will maintain adequate nutrition and hydration.
The patient and family will identify sources of fears and acquire knowledge to deal with the fears.
Interventions Encourage small, frequent meals. Encourage the use of high-
protein, high-calorie foods and the use of supplements such as Ensure. Refer to a dietitian, if necessary, for specific recommendations.
Discuss the possibility of the use of tube feedings with the patient to supplement nutrients or as the sole means of delivering necessary nutrients.
Arrange for a speech therapist consultation to provide instruction regarding swallowing.
Instruct the patient and family regarding the need for upright positioning during and after eating.
Instruct the patient and family to rotate the patient’s head toward the affected side to facilitate swallowing.
Provide rest periods before, during, and after feedings.
Provide thick liquids first, adding thin liquids last; begin with cold liquids and progress to hotter ones.
Instruct the patient to begin with pureed foods, progressing to soft ones, while taking small bites.
Encourage the patient and family to verbalize fears.
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Provide information to reduce distortions in perceptions.
Encourage the patient and family to attend cancer support groups.
Instruct the patient and family about impending treatments such as surgery and radiotherapy.
Assess the patient’s ability to eat and drink.
Assess respiratory status before, during, and after eating.
Monitor for signs of aspiration: dyspnea, coughing, wheezing, tachycardia, and elevated temperature.
Observe and record the color and character of sputum.
Instruct the patient and family to keep the patient’s head elevated during and after eating or feedings.
Gastric Cancer As with other forms of GI cancer, gastric cancer is insidious. Symptoms may be vague until the cancer has infiltrated and spread throughout the body, when the overt signs of cancer become evident. In addition, stomach cancer mimics other diseases such as ulcers and gastritis, so misdiagnosis and self-medication for chronic “stomach problems” are common and may delay the diagnosis and treatment of stomach cancer.
Gastric cancer is relatively uncommon in the United States; the highest incidence is currently found in Japan and China. The incidence of gastric cancer increases with age, and most individuals are diagnosed in their seventies (Rubin & Reisner, 2009). In the United States, a slight male predominance is seen. It occurs twice as often among black men and women as among whites and seems to have a familial connection. The reasons for these geographic and cultural incidences are unclear.
The cause is unknown, although the incidence is higher when gastric acid is low, as with chronic gastritis and pernicious anemia. Gastric cancer is also associated with environmental and genetic factors, including diet (e.g., diets high in salt, nitrate preserved
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foods and smoked foods, and diets low in fruit and vegetables), smoking, heavy alcohol consumption. It may also be precipitated by polyps or degenerative changes in gastric ulcers, previous stomach surgery, as well as achlorhydria. Finally, occupational risks such as those faced by rubber and coal workers and those working in nickel refineries also have a role. A relationship exists between gastric cancer and infection with H. pylori.
Adenocarcinomas account for more than 90% of stomach cancers. Adenocarcinomas arise from the mucosal lining of the stomach. Additional types of stomach cancer are (1) lymphomas, (2) gastrointestinal stromal tumors, (3) carcinoid tumors, and (4) rarely squamous cell carcinomas or small cell carcinomas. Adenocarcinomas may metastasize by extension and infiltration along the mucosa into the stomach wall and lymph nodes. The tumor may metastasize to the lung, bone, liver, spleen, pancreas, peritoneum, and esophagus. Once the tumor has spread outside of the stomach, cure is not possible.
Because of its elusive nature, gastric cancer is usually well advanced when symptoms begin to appear. When they do manifest, they are vague and of variable duration. Because of this, people usually delay seeking medical attention for a few months after the initial onset of symptoms. Initially, the patient may complain of a vague, uneasy sense of fullness, indigestion, and distention after meals, which may be passed off as stomach upset. As the disease progresses, anorexia, nausea, and vomiting may develop and lead to weight loss. Other symptoms include dysphagia, back pain, weakness, fatigue, hematemesis, and a change in fecal elimination patterns. Unfortunately, definitive clinical signs occur mostly with advanced disease and include weight loss, pain, vomiting, anorexia, dysphagia, and a palpable abdominal mass. Prognosis is best for tumors in the lower stomach (antrum) and worse for tumors that occur higher in the stomach (fundus).
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Nursing management Assessment
Assessment begins with a thorough history and review of symptoms pertaining to the GI system, particularly symptoms that an older patient may not report unless asked. These include indigestion, discomfort after eating, nausea, anorexia, vomiting, or any chronic “stomach problem.” In addition, the nurse should question older adults regarding changes in dietary or bowel patterns and habits, use of prescription and OTC medications, and use of home remedies. A physical examination may reveal no obvious abnormalities except that when advanced, the tumor may be palpable, especially through the thin skin and musculature of an older patient’s abdomen. In addition, lymph nodes may be palpable when metastases have occurred.
Diagnosis The most common nursing diagnoses for an older patient with gastric cancer include the following:
• Grieving, anticipatory, related to a poor prognosis
• Imbalanced Nutrition: Less Than Body Requirements, related to gastric distress
• Acute Pain, related to gastric distress and discomfort
Planning and Expected Outcomes Expected outcomes for an older patient with gastric cancer include the following:
1. The patient will discuss thoughts and feelings related to the diagnosis with appropriate people.
2. The patient will use appropriate resources for support counseling.
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3. The patient will maintain adequate nutrition, as evidenced by stabilization and maintenance of weight and consumption of a well- balanced, high-calorie diet.
4. The patient will effectively manage pain, as evidenced by verbalization of comfort and pain relief after analgesic use.
Intervention Nursing management of an older patient with gastric cancer includes maintenance of hydration, nutrition, and fluid and electrolyte balance and provision of emotional support to the individual and family. Many patients and their families feel guilty and negligent about the delay in seeking medical attention for the vague symptoms of gastric cancer. The nurse may support patients and families by dispelling misconceptions and offering a realistic sense of hope.
Nursing care should also focus on the prevention and early diagnosis of gastric cancer, including encouragement for all older patients with GI symptoms, however trivial, to seek medical attention. In addition, identifying those at risk and encouraging them to seek medical care for evaluation on a regular basis is also important.
Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of malnutrition, maintenance of comfort, and continued family support. As the disease advances and the older patient becomes more debilitated, the focus of care will change, requiring the nurse to collaborate and coordinate with other health care team members regarding alternative care arrangements.
Colorectal Carcinoma Cancer of the colon and rectum accounts for 14% of all cancers; it is the second cause of cancer death in the United States. Cancer of the large intestine is the third most common cause of death from a
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malignancy for both men and women. Colorectal cancer affects both genders equally, and the probability of developing it increases with age. Therefore, age is a significant risk factor for colorectal cancer; two thirds of cases occur in people older than 65 years (Barker & Zieve, 2007).
Although the cause of colorectal cancer is unknown, research has indicated that diet, environment, smoking, heavy alcohol use, obesity, sedentary lifestyle, and genetics all play important parts in the development of the disease, as do a personal history of colon polyps and inflammatory disease of the bowel. Colon cancer is more prevalent in the United States, probably because the typical American diet is low in fruits and vegetables and high in red meat. A diet high in fat and refined carbohydrates and low in roughage is considered a risk factor for colorectal cancer. Genetic studies also suggest an inheritable susceptibility to colorectal cancer. Individuals with first-degree relatives diagnosed with colorectal cancer have double the risk for the development of adenomatous polyps, which are considered precursors of carcinoma.
Adenocarcinoma accounts for 95% of the carcinomas of the colon. The tumors tend to grow slowly and may remain asymptomatic for a long time. Cancer of the rectum is manifested as bright red bleeding from the rectum, along with changes in the characteristics of the stool. Carcinomas in the sigmoid and descending colon tend to grow around the bowel, encircling it and leading to an obstruction. For these patients, a change in fecal elimination pattern is a common symptom. On the right side, few symptoms are seen. If present, crampy abdominal pain may be difficult to pinpoint. Anemia may also be present.
Clinical manifestations of colorectal cancer depend on the location and extent of the tumor. Left-sided lesions often cause melena, diarrhea, constipation, and a feeling of retained stool. Right-sided tumors often cause weakness, malaise, and weight loss. Abdominal pain is rare with either type and may result from obstructions or nerve involvement. An obstruction is often the first sign of the disease. Often, if a mass is palpated on physical examination or a routine rectal examination, the stool is guaiac positive. Although the duration of symptoms is not effective in
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predicting the degree of tumor advancement, the early diagnosis of cancer in asymptomatic persons has been shown to be related to improved chances of survival. Colorectal cancer in stages I, II, and III is considered curable; if the cancer does not return in 5 years following treatment, it is considered cured. Stage VI cancer is not considered curable. Should metastases occur, they are primarily to the liver and lymphatic system, although other sites include the brain, lungs, bones, and adrenal glands.
Colorectal cancers produce a wide variety of tumor antigens; the carcinoembryonic antigen (CEA) is the most well known. The CEA level is used to gauge the effectiveness of therapy and may be useful at the time of diagnosis for prognostic value. In addition, it is used to monitor for recurrence. The current use of the CEA level in mass screening and detection is limited.
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Nursing management Assessment
Assessment begins with an older patient’s history of symptoms such as diarrhea, constipation, abdominal pain, blood in stools, or melena. Generalized symptoms may have been overlooked by an older patient; these include malaise, weight loss, weakness, and fatigue. Eliciting a family history of colorectal cancer, polyps, and any previous bowel surgeries is also important. Because of the potential for multiple losses with colorectal cancer, the nurse must also assess an older patient’s coping skills and abilities. A physical examination may reveal a mass in the abdomen or guaiac-positive stools, or it may be unremarkable.
Diagnosis The most common nursing diagnoses for an older patient with colorectal cancer include the following:
• Imbalanced Nutrition: Less Than Body Requirements, related to anorexia
• Acute Pain, related to GI distress
• Disturbed Body Image, related to a colostomy
Planning and Expected Outcomes Expected outcomes for an older patient with colorectal cancer include the following:
1. The patient will maintain recommended weight and adequate nutrition.
2. The patient will verbalize comfort after taking an analgesic.
3. The patient will verbalize acceptance of permanent or temporary body changes resulting from a colostomy.
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Intervention Nursing management of an older patient with colorectal cancer depends on the stage of the disease and the treatment modalities necessary. In general, older patients are at risk for weight loss and malnutrition as a result of the cancer and symptoms of vomiting or diarrhea. Eating small, frequent, high-calorie, high-protein meals should be encouraged. Allowing patients to eat some of their favorite foods on a regular basis may help maintain the recommended weight. The use of supplements such as Ensure or nighttime tube feedings may be necessary to maintain adequate nutrition. Not every patient with colorectal cancer complains of pain, but if present, pain can be managed with both pharmacologic and nonpharmacologic relief measures. If an older patient requires a colostomy either for treatment or as a palliative measure, the patient should be encouraged to verbalize and express feelings on a regular basis. Referral to a support group or counseling may be necessary. Having an older patient speak with or visit someone with a colostomy may help reduce anxiety, concerns, and fears associated with it. If the colorectal cancer is completely resected, reminding, and encouraging, the older patient to have follow-up examinations and procedures to check for recurrence is of the utmost importance.
Nursing care should also focus on the prevention and early diagnosis of colorectal cancer. Nearly all colorectal cancers begin as polyps. Colonoscopy screening should begin at age 50. When caught in the early stages, colorectal cancer is nearly always curable. Older adults with identified risk factors should be taught the importance of dietary changes (e.g., low-fat, high-fiber diets) and lifestyle changes (e.g., weight loss and increased physical activity).
Evaluation Evaluation includes documentation of achievement of the expected outcomes and prevention of complications. In addition, documentation of the patient’s methods of coping with the lifestyle
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changes imposed by the various treatment modalities is essential.
Pancreatic Cancer Pancreatic cancer accounts for approximately 2% of all cancer in the United States. Slightly more than 20% of affected individuals survive for 1 year after diagnosis, and the 5-year survival rate is less than 5%. Pancreatic cancer is lethal. The disease usually affects older adults; the incidence of pancreatic cancer is slightly higher in men than in women and higher in African Americans than in whites. Additional risk factors include smoking, obesity, diabetes, cirrhosis, and a family history of pancreatic cancer. An increased risk attributable to environmental factors has been suggested because the incidence is higher in those who are exposed to industrial pollutants or who live in urban areas.
Cancer of the pancreas is primarily an adenocarcinoma. Although the head, body, or tail of the pancreas may be involved, it is primarily a disease of the exocrine portion of the gland. It arises in the head of the organ in 60% to 70% of cases.
As tumor growth advances within the pancreas or on lymph nodes along the biliary tree, obstruction and compression of the common bile duct results. Eventually, the carcinoma may infiltrate the duodenum, stomach, transverse colon, spleen, kidney, and surrounding blood vessels. Invasion by the celiac nerve plexus accounts for the severe pain associated with cancer of the body or tail of the pancreas. Cancer of the pancreas grows rapidly, so at the time of diagnosis, the cancer has invaded locally or metastasized in 90% of individuals. Metastasis occurs through the bloodstream and by peritoneal seeding, frequently causing cancers in the lungs and bone.
Symptoms generally occur late in the course of the disease and are vague and insidious in onset. Manifestations of the disease differ according to the location of the tumor within the pancreas: pain and weight loss (tail of the pancreas), steatorrhea, weight loss, and jaundice (head of the pancreas). Nonspecific findings include anorexia, fatigue, digestive problems, blood clots, and diarrhea.
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Nursing management Assessment
Assessment begins with a history of symptoms and a review of possible risk factors pancreatic cancer. An accurate assessment of the pain pattern is also important. The nurse should obtain a symptom analysis for any of the usual symptoms of nausea, vomiting, weight loss, weakness, and stool changes. A physical examination may be unremarkable.
Diagnosis Nursing diagnoses for an older patient with pancreatic cancer include the following:
• Acute Pain, related to abdominal discomfort
• Ineffective Coping, related to diagnosis of terminal stage
• Compromised Family Coping, related to diagnosis of terminal stage
Planning and Expected Outcomes Expected outcomes for an older patient with pancreatic cancer include the following:
1. The patient will verbalize adequate relief of pain or ability to cope with incompletely relieved pain.
2. The patient and family will verbalize concerns and feelings related to the diagnosis and prognosis.
3. The patient and family will demonstrate improved coping strategies, as evidenced by incorporation of alternative coping behaviors and techniques in their interactions.
Intervention
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Nursing management for an older patient with pancreatic cancer focuses on provision of pain relief and encouragement to verbalize feelings. Pain relief may require narcotics, and the patient and family may require teaching concerning their prolonged use. Other nonpharmacologic measures of pain relief (e.g., diversional activities, repositioning, meditation, and massage) need to be offered. The patient and family may benefit from attending a support group for cancer patients. However, because of the poor prognosis, encouraging families to spend time with the older patient is also important. Assisting the patient and family in dealing with an imminent death may also be necessary.
Evaluation Evaluation includes documentation of achievement of expected outcomes, prevention of complications, and provision of a comfortable environment.
Liver Cancer The incidence of primary liver cancer (hepatocellular carcinoma) is less than 5% in the United States; however, in countries where hepatitis is endemic, the incidence of primary liver cancer is as high as almost 50%. In addition to hepatitis, risk factors for the development of hepatocellular carcinoma include alcoholic cirrhosis, hemochromatosis, fatty liver disease, obesity, diabetes, anabolic steroid use, and exposure to aflatoxins (poisons produced by molds). Additionally, hepatocellular carcinoma is more common in men, Asian Americans, and Pacific Islanders.
Metastatic cancer in the liver is named after the organ in which it began (e.g., metastatic breast cancer). In the case of metastatic disease, the common original sites are the lungs, breasts, kidneys, and other organs in the GI tract. Most often, multiple masses are present in the liver and spread throughout the organ via its vascular system. The diagnosis of liver metastasis is usually an indicator that the primary cancer is incurable. Weight loss is a common early finding in cases with metastatic liver disease. Signs
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and symptoms of liver involvement are the late signs of organ failure (e.g., ascites and portal hypertension); by the time of the diagnosis of metastasis, the overall prognosis is poor. The 5-year survival rate is 5%; if untreated, death will occur 6 to 8 weeks after diagnosis. The cause of death is most often pneumonia, malnutrition, emboli, hepatic failure, or hemorrhage.
Nursing management of older patients with metastatic liver disease is similar to that for patients with alcoholic cirrhosis.
Home care
1. Regularly monitor and assess the diagnosed gastrointestinal (GI) disease or disorder for signs and symptoms indicating exacerbation or instability.
2. Weigh at regular intervals to monitor weight loss or gain; encourage homebound older adults to use nutritional supplements, if indicated.
3. Teach caregivers and homebound older adults appropriate dental hygiene practices.
4. Instruct caregivers and homebound older adults on reportable signs and symptoms related to the GI problem or disorder and when to report these symptoms to the home care nurse or health care provider.
5. Instruct caregivers and homebound older adults on the name, dose, frequency, side effects, and indications of both prescribed and over-the-counter medications used to treat the identified GI problem.
6. Instruct caregivers and homebound older adults about laboratory indices used to evaluate GI disturbances. Inform them of the results of any tests after the health care provider has been notified.
7. Assess and instruct older adults on the importance of
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maintaining hydration in the presence of GI disturbances.
8. Instruct caregivers and homebound older adults on all aspects of any treatments used to provide nutritional support in the absence of a functioning GI system (e.g., enteral nutrition, total parenteral nutrition, and formula supplements).
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Summary Many older adults’ health concerns are related to the GI system. Because these problems are often amenable to appropriate self-care practices, the nurse is responsible for teaching prevention and self- management strategies to these patients. However, the nurse must also teach older adults that GI-related symptoms should not be dismissed as part of the normal aging process; they should be reported so that an accurate determination can be made and timely interventions instituted.
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Key points • A decline in normal function of the GI tract may occur with aging
without any effect on physiologic processes.
• A significant decrease of liver function is not an inevitable outcome of aging, but because the incidence of chronic disease increases with advancing age, liver disorders are more common in older adults.
• Any weight loss or complaint of dysphagia, indigestion, heartburn, vomiting, change in appetite, or change in stool in an older patient warrants prompt evaluation by the health care provider.
• Primary and secondary prevention of problems in the GI tract should be part of the care for all older patients (e.g., colonoscopy and dental examination).
• Smoking, alcohol, obesity, and dietary factors are important risk factors for the development of GI cancers in older patients.
• Gastric ulcers have a higher incidence of becoming malignant compared with DUs.
• Intestinal ischemia should be included in the differential diagnosis of an older patient who has a history of cardiovascular disease and complains of abdominal pain.
• Guaiac-positive stools in an older adult should be considered pathologic until proven otherwise.
• Intestinal polyps and a positive family history of polyps are the main risk factors for the development of colorectal cancer.
• Although 60% of polyps and cancers are visualized with flexible sigmoidoscopy, a colonoscopy is necessary to detect any suspected cancers in the right colon.
• Although treatment of asymptomatic gallstones is not currently recommended, the rise in new therapeutic treatment options for cholecystitis should lead to a decline in morbidity and mortality previously associated with cholecystectomies in older adults.
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• GI cancers present a common concern in that the symptoms are often overlooked or self-treated until the disease has become well established.
• Although the incidence of pancreatic cancer is increasing in the United States, treatment remains palliative.
• The high correlation between polypharmacy, increased drug consumption, and age makes the older person more prone to drug-induced liver disorders.
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Critical thinking exercises 1. Your patient, a 69-year-old man, has smoked at least a pack of cigarettes a day for the past 33 years. At present, he is being treated for gastric ulcers. What relationship, if any, exists between his age, smoking history, and a GI disorder?
2. Your 83-year-old neighbor confides in you that she has recently had bright red blood in her stools but thinks it is because of hemorrhoids. She is reluctant to see her doctor because she does not want to be admitted in the hospital. What advice should you give her? Why are bloody stools of particular importance in older adults? What would the plan of care be since she is older than 80 years?
3. A 65-year-old man is admitted to the hospital with a diagnosis of cirrhosis of the liver. During the shift report, his primary care nurse states that he has been agitated and anxious but has not exhibited any manifestations of alcohol withdrawal. What assumptions did the nurse make? Are these assumptions valid? Explain.
4. Discuss the nursing care measures that would be similar for an older adult patient with cirrhosis and one with hepatitis.
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Eliopoulos C. Gerontological nursing. 6th ed. St Louis: Lippincott Williams & Wilkins; 2005.
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Ginsberg D, Phillips S, Wallace J, Josephson K. Evaluating and managing constipation in the elderly. Urol Nurs.
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Jarvis C. Jarvis physical examination and health assessment. 5th ed. St Louis: Saunders; 2008.
Kane R, Ouslander J, Abrass I, Resnick B. Essentials of clinical geriatrics. 6th ed. New York: McGraw-Hill; 2009.
LeMone P, Burke K. Medical surgical nursing: Critical thinking in patient case. 4th ed. Upper Saddle River, NJ: Prentice Hall; 2008.
Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I. Medical-surgical nursing: Assessment and management of clinical problems. 8th ed. St Louis: Mosby; 2011.
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Mindikoglu A, Miller R. Hepatitis C in the elderly: Epidemiology, natural history, and treatment. Clinical Gastroenterology and Hepatology. 2009;7(2):128–134.
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* Previous authors: Sharon Dudley-Brown, PhD, MS, RN, C, FNP; Sally Brozenec, RN, PhD; Linda A. Stamm, APRN, BC, CON; and Robyn A. Levy, MSN, RN, BC, ANP; Laurel A. Wiersema Bryant, RN, ANP, BC; and Cassandra Ward, RN, ANP-C.
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C H A P T E R 2 5
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Musculoskeletal Function Laurie Kennedy-Malone, PhD, GNP-BC, FGSA; Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe the normal structure and function of the musculoskeletal system.
2. Discuss the age-related changes in the musculoskeletal system.
3. Discuss the nursing management of patients with fractures of the hip, wrist, clavicle, and vertebra.
4. Distinguish differences among osteoarthritis, rheumatoid arthritis, gout, and polymyalgia rheumatica.
5. Identify the nursing interventions associated with osteoarthritis, rheumatoid arthritis, gout, and polymyalgia rheumatica.
6. Discuss the pathophysiology, treatment, and nursing management of osteoporosis.
7. Describe the indications for amputation in older adults and the nursing management of these patients.
8. Discuss the causes and management of common foot problems in older adults.
http://evolve.elsevier.com/Meiner/gerontologic
Musculoskeletal problems are common among older adults. Recent reports have indicated that one out of five Americans has been diagnosed with arthritis. With the aging of the population, coupled with the high incidence of obesity in this country, it is anticipated that the number of activity limitations attributable to arthritis and the number of people actually diagnosed with arthritis
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will continue to rise (Cheng, Hootman, Murphy et al., 2010). Complaints in the musculoskeletal system are common because normal aging predisposes people to the development of diseases such as osteoarthritis and osteoporosis. Diseases of the musculoskeletal system are usually not fatal but may lead to chronic pain and disability. Chronic conditions of the musculoskeletal system may contribute to impaired function and disability in older adults in the areas of self-care and mobility. They may suffer impairments in the ability to perform activities of daily living (ADLs) such as bathing, dressing, and eating, and impairments in the ability to perform instrumental activities of daily living (IADLs) such as managing finances, preparing food, managing transportation, and keeping house. Functional impairment of ADLs and IADLs may be devastating to older adults who desire to maintain independence. When dependence occurs, it may result in loss of self-esteem, the perception of decreased quality of life, and depression (see Cultural Awareness box) (Netz, Wu, Becker, & Tenenbaum, 2005).
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Age-related changes in structure and function The musculoskeletal system is affected in numerous ways by the aging process. A pronounced decrease in muscle mass and muscle strength occurs gradually over time. The actual number of muscle cells decreases, and they are replaced by fibrous connective tissue. As a result, muscle mass, tone, and strength decrease. The elasticity of ligaments, tendons, and cartilage decreases, as does bone mass, which results in weaker bones. The intervertebral disks lose water, causing a narrowing of the vertebral space. This shrinkage may result in a loss of 1.5 to 3 inches of height. The lordotic or convex curve of the back flattens, and both flexion and extension of the lower back are decreased. Posture and gait change. Posture, as a result of the changes in the spine, assumes a position of flexion. Changes in posture result in a shift in the center of gravity. In men, the gait becomes small stepped with a wider-based stance. Women become bowlegged (genus varus), have a narrow standing base, and walk with a waddling gait (Loeser & DelBono, 2009; Williams, 2009). The articular cartilage erodes in older adults. It is unknown whether this is a result of the aging process or the result of wear and tear on the joints.
Cultural awareness
Biocultural Variations in the Musculoskeletal System
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Data from Overfield, T. (1995). Biologic variation in health and illness: Race, age, and sex differences (2nd ed.). Boca Raton, FL:, CRC Press.
All the changes mentioned may cause pain, impaired mobility, self-care deficits, and increased risk of falls for older adults. Approximately one third of those age 65 or older have falls each year. A recent report from the Centers for Disease Control and Prevention (CDC) found that in 2010, 2.3 million nonfatal falls resulted in emergency room care and more than 662,000 required hospitalization related to the injury sustained (CDC, 2010); moderate to severe injuries included hip fractures, lacerations, and traumatic brain injury (Sterling, O’Connor, & Bonadies, 2001).
It has been estimated that residents have a 50% to 75% incidence of falls in nursing homes. The mean incidence is 1.5 falls per bed
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per year. Falls are the most common cause of accidental death in older adults. When falls result in injury and hospitalization, the risk of iatrogenic illness and immobility may lead to a downward trajectory, which may ultimately result in death. Falls may also cause a cycle of disuse. This pattern of disuse usually occurs after the individual has experienced repeated falls. The fall experience causes a fear of falling. To avoid falls, the individual decreases mobility; with decreased mobility, muscle strength decreases, joints become stiff, and pain develops, resulting in disability, loss of independence, and frailty (Gray-Miceli, Strumpf, & Johnson, 2006).
Current research has documented that some of the diseases and decline in the musculoskeletal system may be reduced or prevented through the use of regular programs of active exercise and resistive muscle strengthening (Chen, Tseng, Chang, Huang, & Li, 2013).
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Common problems and conditions of the musculoskeletal system Fractures are common problems for older adults that often result in some loss of functional ability. A fracture is a break or disruption in the continuity of the bone. Fractures may occur because of trauma to a bone or joint, or they may be the result of pathologic processes such as osteoporosis or neoplasms that contribute to bone fragility (Ensrud, 2013; Recker, Kendler & Recknor, 2007). When bones are subjected to more stress than can be withstood, a fracture occurs. Stresses on bones may be from major trauma such as automobile accidents or falls. Falls are the most common cause of fractures in older adults. The most frequently occurring fractures among older adults are hip fractures, fractures of the proximal femur, Colles (wrist) fractures, vertebral fractures, and clavicular fractures. Fractures are classified as open or closed by the location and type of fracture (Ensrud, 2013) (Figure 25-1).
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FIGURE 25-1 Types of fractures. A, An avulsion is a fracture of bone resulting from a strong pulling effect of tendons or ligaments at
the bone attachment. B, A comminuted fracture is a fracture with more than two fragments. The smaller fragments appear to be
floating. C, A displaced (overriding) fracture involves a displaced fracture fragment that is overriding the other bone fragment. The
periosteum is disrupted on both sides. D, A greenstick fracture is an incomplete fracture with one side splintered and the other side bent.
The periosteum is not torn away from the bone. E, An impacted fracture is a comminuted fracture in which more than two fragments are driven into each other. F, An interarticular fracture is a fracture
extending to the articular surface of the bone. G, A longitudinal fracture is an incomplete fracture in which the fracture line runs
along the axis of the bone. The periosteum is not torn away from the bone. H, An oblique fracture is a fracture in which the line of the
fracture extends in an oblique direction. I, A pathologic fracture is a spontaneous fracture at the site of a bone disease. J, A spiral
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fracture is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone. K, A stress fracture is a fracture occurring at the site of a muscle attachment. It is caused by
a sudden, violent force or repeated, prolonged stress. L, A transverse fracture is a fracture in which the line of the fracture
extends across the bone shaft at a right angle to the longitudinal axis. (From Lewis, S., Kirksen, S., Heitkemper, M., Bucher, L., Camera, I. (2011). Medical-surgical nursing: Assessment and management of clinical problems. (8th
ed.). St. Louis: Mosby, Elsevier.)
The completed process of bone healing is termed union. After fractures occur, regenerative cells (fibroblasts and osteoblasts) move to the fracture site and lay down a fibrous matrix of collagen—the callus. This process usually occurs within 7 days of the injury. As the healing process takes place, the callus bridges the fracture site and the distance between the bone fragments decreases. In the final stage of bone healing, remodeling (absorption of excess cells and calcification) occurs.
The history given by a patient with a fracture usually includes trauma followed by immediate local pain. Tenderness, swelling, muscle spasms, deformity, bleeding, and loss of function are also seen with fractures (see Emergency Treatment box). However, it is important for the nurse to carefully evaluate vital signs and level of consciousness after a patient sustains a fall to determine what may have been the preceding factors leading up to the fall. Was the patient aware that he was falling? Did the patient know why he fell, slipped, or tripped over an object? Was the patient incontinent just prior to the fall? Could he move the extremities without pain? (Williams, 2009).
Emergency treatment
Fractures If a fracture is suspected, assess injured area for the following:
• Movement
• Pain
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• Color
• Temperature
• Pulse
• Sensation
If fracture is open and bleeding is present:
• Apply pressure.
• Apply sterile dressing.
• Immobilize the fracture site.
Hip Fracture Hip fractures are the most disabling type of fracture for older adults. They usually are caused by falls and result in direct trauma to the hip. Approximately 25% of patients with hip fractures die within 1 year after the injury (Farahmand, Michaelsson, Ahlbom, Ljunghall, & Baron, 2005). The complications of hip fractures are generally related to immobility. They include pneumonia, sepsis from urinary tract infections, and pressure ulcers. With the growing number of older adults, especially those older than 75, it is expected that the incidence of hip fractures will increase (Ensrud, 2013).
Hip fractures are classified according to their locations. Intracapsular fractures, or subcapital fractures, occur within the hip capsule. Extracapsular fractures occur outside or below the capsule and are referred to as intertrochanteric and subtrochanteric locations (Miller, Christmas, & Magaziner, 2009) (Figure 25-2).
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FIGURE 25-2 Fractures of the hip. A, Subcapital fracture. B, Transcervical fracture. C, Impacted fracture of the base of the neck.
D, Intertrochanteric fracture. E, Subtrochanteric fracture. (From Monahan, F.D., Neighbors, M., Sands, J., et al. (2007). Phipps’ medical-surgical
nursing: Health and illness perspectives (8th ed.). St. Louis, MO: Mosby.)
After the fall or injury that results in the fractured hip, the patient has an affected extremity that is usually externally rotated and shortened. Tenderness and severe pain at the fracture site may be present. Immediately after the injury, the joint should be immobilized. Buck or Russell traction (Figure 25-3) is used until the patient is stabilized. After the patient is stabilized, surgical repair, the preferred treatment, is performed. The type of surgical repair depends on the location and type of fracture and may include internal fixation with pins, plates, and screws, or prosthetic
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replacement of the femoral head (Schneider, Williams, Brancati, et al., 2013) (Figure 25-4).
FIGURE 25-3 Buck extension. Heel is supported off bed to prevent pressure on heel, weight hangs free of bed, and foot is well away from footboard of bed. The limb should lie parallel to the bed
unless prevented, as in this case, by a slight knee flexion contracture. (From Monahan, F.D., Neighbors, M., Sands, J., et al. (2007).
Phipps’ medical-surgical nursing: Health and illness perspectives (8th ed.). St. Louis, MO: Mosby.)
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FIGURE 25-4 A, Neufeld nail and screws, used in the repair of intertrochanteric fracture. B, Küntscher nail (intramedullary rod)
used in repair of midshaft femoral fracture. (Modified from Monahan, F.D., Neighbors, M., Sands, J., et al. (2007). Phipps’ medical-surgical nursing: Health and
illness perspectives (8th ed.). St. Louis, MO: Mosby.)
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Nursing management Assessment
Hip fractures are most often related to falls. After any fall or other injury that may cause hip trauma, the nurse assesses the hips and lower extremities for evidence of fracture. This includes inspecting the site for direct evidence of fracture, shortening of the extremity, and abnormal rotation. Also assessed is the presence of tenderness, swelling, or ecchymosis at the site of the injury. Note if the patient reports pain with any motion. Given that injury was severe enough to sustain a fracture, the patient should be assessed for other injuries. A careful assessment of the patient’s vital signs and level of consciousness is imperative (Williams, 2009).
Diagnosis Nursing diagnoses for a patient with a hip fracture include the following:
• Pain, related to discomfort from the muscle and bone trauma
• Impaired Physical Mobility, related to immobilization of the fracture and the healing process
• Risk for Impaired Skin Integrity, related to the immobilization required for healing
• Risk for Infection, related to possible impaired wound healing, compromised nutrition, and effects of immobility
• Bathing/Dressing/Feeding/Toileting Self-Care Deficit, related to discomfort and impaired mobility
• Impaired Home Maintenance, related to decreased independence and recovery period needed for fracture healing
Planning and Expected Outcomes Nursing care of a patient with a hip fracture involves the
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perioperative, postoperative, and rehabilitation periods. Each of these stages of treatment and recovery requires specific nursing interventions and includes the following expected outcomes:
1. The patient will report minimum discomfort and an adequate level of pain control.
2. The patient will remain free from postoperative complications such as altered skin integrity and wound infection.
3. The patient will adhere to the prescribed physical therapy regimen to regain function of the affected joint.
4. The patient will be able to participate in physical and occupational therapies.
5. The patient will be able to safely demonstrate use of assistive devices for mobility and ADLs.
6. The patient will be able to return to the preinjury level of independence with appropriate support and assistive devices.
Intervention On arrival in the acute care setting, the patient has his or her medical condition and hip fracture assessed and stabilized. Surgical intervention is usually recommended but is considered elective and therefore requires stability of major health conditions. During this preoperative period, the nurse’s main focus is on keeping the patient comfortable and hydrated and preventing complications of immobility. Preoperatively, hip fractures may produce severe muscle spasms, causing intense pain. Pain medications, traction, or immobilization and proper positioning are used to manage the pain. Preoperative education should include information regarding the surgical procedure, postoperative treatments, potential complications, and expected outcomes for rehabilitation and recovery.
The immediate postoperative period requires monitoring of vital signs and intake and output. Turning, deep breathing, and coughing are used to prevent respiratory complications. The operative site is monitored for signs of infection and bleeding.
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Movement, circulation, and sensation of the extremity are assessed to determine impaired circulation. Mental status should be assessed and any changes noted. Postoperative delirium may occur in older patients after a hip fracture; the effects of surgery, anesthesia, analgesic medications, loss of familiar surroundings, pain, and immobility may increase the potential for delirium. Care planning should include familiarizing the patient with his or her surroundings, providing for safety, instituting comfort measures, decreasing anxiety, and assisting with maintaining a sense of independence and identity (see Evidence-Based Practice: Changes to Home Environment after Identifying the Location of Home Falls).
Evidence-based practice Changes to Home Environment after Identifying the Location of Home Falls
Sample/Setting This study reviewed the logs of falls experienced by 124 participants of a randomized controlled trial. A total of 639 falls were reviewed from the diaries over a 6-month period.
Methods Participants were given a log to maintain for 6 months with questions to complete that described the circumstances around the falls. Participants were mailed the log each month and received phone call reminders at specific times.
Findings A total of 124 qualifying participants recorded 639 falls. The locations of 80% of falls were in the home. When falls occurred, patients were walking (45%), standing (32%), transferring (21%), or had slipped out of bed or a chair (2%). Seventeen falls (3%) required treatment and were considered serious. Many combinations of activities were attributed to falling, for example,
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tripping while walking or stepping backward while standing. Misjudgment, distraction, fatigue, and dizziness were also identified as reasons for falls.
Implications Physical therapy can be specifically designed to address the reasons for an individual’s falls. Nurses caring for patients with Parkinson disease must be aware that falls may occur even when standing or reaching out. The home environment may be designed to accommodate reach distances and other individual needs. Data from Ashburn, A., Stack, E., Ballinger, C., Fazakarley, L., & Fitton, C. (2008). The circumstances of falls among people with Parkinson’s disease and the use of falls diaries to facilitate reporting. Disability and Rehabilitation, 30(16), 1205-1212.
Pain is managed through careful administration of pain medication. Because of the normal physiologic aging changes that affect pharmacokinetics and pharmacodynamics, older adults are at risk for developing changes in mental status, respiratory depression, and sedative effects with the use of narcotic analgesics. These problems are prevented with the use of lower initial doses of narcotics than those used with younger adults. The individual’s response to the pain medication and the pain are closely monitored. After determining the patient’s level of tolerance, the dose may be carefully increased. Keeping the affected extremity in alignment during turning also decreases pain. This is done with the use of pillows between the knees or an abduction splint.
Another common problem a patient recovering from hip surgery has is constipation and often has a fecal impaction because of the side effects of the analgesics and the hazards of immobility. Assess the patient’s frequency of bowel movements and determine if medication is needed to relieve constipation.
Patients who have their fractures repaired with hemiarthroplasty are at risk for dislocation. The nurse should give the patient and family instructions on preventing dislocation. Dislocation may occur when the joint is adducted and internally rotated. Activities to avoid include crossing the legs and feet while seated, sitting on low seats, and adducting the legs when lying on the nonoperated
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side. The patient is instructed not to put on socks or shoes without the aid of assistive devices, not to cross the legs, not to lie on the affected side, to use a raised toilet seat and a shower chair, and to use a pillow between the legs while in bed. Activities that may cause dislocation should be avoided for 6 weeks until muscles surrounding the joint are healed and the joint is stabilized. Symptoms of dislocation are sudden severe pain and external rotation of the leg.
After the devastating events of hip fracture and surgery, comprehensive interdisciplinary rehabilitation focuses on returning the patient to the prior level of function and preventing disability (Della Rocca, Moylan, Crist et al., 2013). Specific areas of treatment are gait and transfer training, muscle strengthening through active assistive exercises, teaching the use of adaptive techniques for dressing, and teaching the correct use of assistive devices. Walkers and canes will be used by the patient (Figure 25-5), and the nurse must ensure that the patient uses a safe technique with either device (see Patient/Family Teaching box: Correct Use of Walkers).
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FIGURE 25-5 Walking with a walker. The walker is moved about 6 inches in front of the resident. Both feet are moved up to the walker. (From Potter, P.A. & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis,
MO: Mosby.)
Patient/family teaching
Correct Use of Walkers • A walker should always rest on all four legs, never on only two.
• Correct body position should be maintained:
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• Posture erect
• Elbows slightly bent
• Wrists extended
• Shoulders relaxed
• Sturdy, comfortable, hard-soled shoes should be worn.
• Walker and affected leg should be moved together.
• Be alert for hazards such as uneven surfaces or wet floors.
The loss of independence and decreased functional ability should also be addressed during rehabilitation. These losses may lead to depression. The nurse’s role is to identify the patient’s strengths, give positive feedback, and reinforce the progress made in achieving goals. Discharge planning focuses on using family and social support networks and ongoing therapy programs.
Evaluation Successful achievement of the expected outcomes after hip fracture will allow the patient to return to a preinjury level of function. Those living independently should be successful in meeting goals of therapy and should regain their self-care abilities, which will allow for returning home. Home health agencies may also be useful in successfully returning the patient to the community.
Patients who were living in other types of health care facilities before the injury should be expected to return to their previous level of activity. Complications will prolong the recovery period and may lead to long-term changes in the level of independence. Patients should report minimum pain at the fracture or surgical site and intact skin integrity. Muscle strength, joint movement, level of mobility, and degree of safety while performing ADLs should be continually evaluated throughout the recovery period. Continued physical and occupational therapies may be required to achieve goals and expected outcomes (see Nursing Care Plan: Fractured Hip).
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Colles Fracture Colles fracture is a fracture of the distal radius that is usually a result of reaching out with an open hand to break a fall. This fracture is seen most often in perimenopausal women, and while the incidence increases following menopause, the rate of Colles fractures remains relatively stable beginning at age 65 (Ensrud, 2013; NIH, 2005). Patients with a Colles fracture have pain at the site of the fracture that begins immediately after the traumatic episode; local edema, swelling, and a visible deformity from the displacement of the distal bone fragment are also present. Treatment of a Colles fracture is usually closed reduction and immobilization with a forearm splint or cast. Nursing measures include elevating the extremity to decrease edema and neurovascular assessment to monitor for complications. The patient is instructed to actively move the thumb and fingers to improve venous return and decrease edema. Range-of-motion exercises for the elbow and shoulder prevent stiffness of the extremity.
Nursing care plan
Fractured Hip
Clinical Situation Ms. W, an 86-year-old who still works as an executive secretary, is admitted to the skilled nursing unit of the local hospital for restorative care after surgical repair of a fractured left hip. The hip was repaired with femoral head prosthesis. Ms. W had a fall when getting on the city bus. Before this incident, Ms. W worked 3 days a week. Her general health status is good. She lives alone on the second floor of a two-story building. Her only family is a niece who lives 60 miles away.
On admission, Ms. W is a slender woman who looks younger than her stated age. She is in no acute pain. The left hip incision is clean and dry with the staples intact. Ms. W transfers with the
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moderate assistance of two people. During the transfer, she becomes tense and tells the nurses that she is afraid of falling and that she has to get on her feet so that she can get back to work. Because the surgical procedure has caused decreased range of motion and weakness in her left leg, Ms. W requires assistance with bathing and clothing of her lower extremities.
Nursing diagnoses Impaired Physical Mobility, related to alteration in
musculoskeletal function as a result of fracture and surgical repair
Bathing and Dressing Self-Care Deficit (bathing and dressing lower extremities), related to alteration in musculoskeletal function secondary to fracture and surgical repair
Deficient Knowledge, related to limited exposure to home care programs
Outcomes The patient will walk 50 feet with a pickup walker.
The patient will bathe and dress her lower extremities with the use of assistive devices.
The patient will verbalize knowledge of home care programs.
The patient will verbalize satisfaction with the discharge plans.
Interventions Consult with a physical therapist for a program of muscle
strengthening, transfer training, and gait training.
Reinforce physical therapy training.
Give positive feedback for gains made.
Instruct the patient to take deep breaths and relax before transfers.
Assist with transfers.
Give specific instructions before transfers. Instruct on hip precautions.
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Teach the use of a walker.
Give pain medication 30 to 60 minutes before physical therapy.
Consult with the occupational therapist for specific assistive devices.
Teach the use of assistive devices. Allow adequate time for bathing and dressing.
Assess support systems and the need for home services.
Instruct on wound care, home safety, and home exercise programs.
Plan for discharge with the patient and team members.
Use community services, visiting nurse, physical therapy, and niece for assistance.
Clavicular Fracture Fractures of the clavicle, like Colles fractures, may occur after a fall on an outstretched hand or on a fall to the shoulder. The majority of these fractures occur in the middle third of the clavicle. The patient with a fractured clavicle has point tenderness, local edema, and crepitus. The shoulder is noticeably deformed, dropping downward, forward, and inward. Treatment of a clavicular fracture includes reduction of the fracture and immobilization with a sling or cast. Nursing measures include monitoring for neurovascular complications such as compartment syndrome, elevating the extremity, and instructing the patient in actively moving the hand and fingers.
Casts and Cast Care Casts are one type of device used to immobilize an injured body part. At the same time, casts provide a means of providing pain relief and protect the injured bone from becoming contaminated (Boyd, Benjamin, & Asplund, 2009). They maintain proper positioning of the injured area, prevent further deformity, protect realigned bones, and promote healing. Used on the lower extremities, they may also allow for earlier weight bearing.
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Casting materials include plaster of Paris or synthetic materials such as fiberglass. After application, plaster of Paris casts should be left uncovered to air dry. Drying time depends on the size and thickness of the cast and may take up to 48 hours. The nurse should support this type of cast with the palms of the hands rather than with the fingers to prevent indentations in the cast during the drying time. Synthetic cast materials harden quickly during and after application. The surface of this type of cast may be rough and may be covered with stockinette (Boyd et al., 2009).
Patients are instructed to keep both types of casts dry; plastic or purchased cast protectors may be used during showering or bathing. Synthetic casts are immersed in water only with physician approval and should be dried thoroughly afterward. A hair dryer set at a low temperature may be used for this purpose.
Patient/family teaching
Cast Care Keep casted extremity elevated for the first 24 hours.
When cast is wet, lift with palms of hands.
Observe the extremity for swelling, color changes, movement, and sensation.
If any changes occur, contact health care provider.
Do not put anything inside the cast.
Do not get plaster cast wet; cover with plastic for bathing.
Patients are instructed to keep the extremity elevated to the level of the heart to decrease edema. The patient should also be instructed to maintain movement of the extremity to prevent muscle atrophy and joint stiffness above or below the cast (see Patient/Family Teaching box: Cast Care). Nursing care includes assessment for potential areas of skin irritation or breakdown. The patient should be instructed to report any redness or discomfort
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along the edges of the cast and any signs of drainage or odor coming from the cast.
Neurovascular assessment of the extremity is done to determine that the cast is not constrictive. Excessive constriction caused by the cast could result in compartment syndrome, leading to ischemia and tissue destruction of the extremity. Any change in capillary refilling, skin color, skin temperature, or excessive pain not controlled with medication should be immediately reported to the physician.
Casts are generally used to immobilize fractures for 6 to 8 weeks. A variety of assistive devices may be used for patients with lower extremity casts (Figure 25-6). The nurse prepares the patient for self-care and prevention of complications during this treatment period.
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FIGURE 25-6 Assistive devices. A, Cane. B, Quad cane offers more support than a single-stem walker. C, Walker with front wheels allows constant contact with the ground. D, Walker with adjustable front wheels. (From Cameron, M.H. & Monroe, L. (2007). Physical rehabilitation:
Evidence-based examination, evaluation, and intervention. St. Louis, MO: Saunders.)
Osteoarthritis Osteoarthritis, also known as degenerative joint disease, is a noninflammatory disease of joints that is characterized by progressive articular cartilage deterioration and the formation of new bone in the joint space. This is the most common type of arthritis seen in older adults and the leading cause of disability in the United States (Lawrence, Felson, Helmick et al., 2008).
The exact cause of osteoarthritis is not well understood. The degeneration of the joint is not caused by aging alone. Age, trauma, lifestyle, obesity, and genetics have been cited as predisposing factors in the development of osteoarthritis. The underlying pain associated with osteoarthritis is related to pressure of the ligaments, bone spur formation, and the stretching of the joint capsule (Ling & Rudolph, 2006).
In osteoarthritis, the articular cartilage thins and is lost, particularly in areas of increased stress. As the cartilage deteriorates, proliferation of bone occurs at the margins of the joints. When the joint cartilage is lost, the two bone surfaces come
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into contact with each other. This results in joint pain. The distal interphalangeals, proximal interphalangeals, the carpometacarpal joint, first metatarsophalangeal joint, knees, hips, and spine are the joints most commonly affected by osteoarthritis (Shelton, 2013).
The most common symptom is a gradual onset of joint pain. The pain occurs with activity and is relieved with rest. Stiffness may occur on wakening or after periods of inactivity that resolves with movement. Crepitus, a grating sound and sensation, may be heard and felt with range of motion in affected joints. Affected joints also have a decreased range of motion. The degeneration of the joint structure may result in muscle spasms, gait changes, and disuse of the joint. Bony enlargements, called Heberden nodes (Figure 25-7), may be seen on the distal interphalangeals, and Bouchard nodes are the nodules of the proximal joints (LeBlond, Brown, & DeGowin, 2009).
FIGURE 25-7 Right hand of a 71-year-old woman with osteoarthritis and Heberden nodes. (From Kamal, A. & Brockelhurst, J.C.
(1991). Color atlas of geriatric medicine (2nd ed.). St. Louis, MO: Mosby.)
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Nursing management Assessment
Nursing assessment of a patient with osteoarthritis begins with taking a thorough history of the problem. Data gathered include information about the onset, location, quality, and duration of the joint pain. Inquire from the patient about the sensation of joint locking as in the knee. Determine if any associated muscle spasms have occurred (Swagerty & Hellinger, 2001). Questions about precipitating factors; medications used to relieve pain, including prescription and over-the counter (OTC) agents; nonpharmacologic interventions such as heat or cold therapy and exercise; and impact on functional abilities should be asked. Affected joints should be inspected for tenderness, swelling, redness, crepitation, and range of motion. Note the presence of muscle atrophy in surrounding muscles.
Diagnosis Nursing diagnoses for the older adult patient with osteoarthritis include the following:
• Pain, related to inflammation and deterioration of the joint cartilage
• Impaired Physical Mobility, related to lower extremity joint stiffness
• Self-Care Deficit (specify), related to limitations in joint movement and strength
Planning and Expected Outcomes The focus of the nursing care plan is to protect and preserve joint motion and function. Expected outcomes for the patient are individualized and specific to the joints affected. Outcomes include the following:
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1. The patient will verbalize an improved level of comfort with activities.
2. The patient will be able to successfully use various adaptive devices in maintaining independence in ADLs and IADLs.
3. The patient will demonstrate safe use of assistive devices for ambulation.
4. The patient will demonstrate understanding of the use of orthotics.
Intervention Instructions on joint protection and energy conservation are given. For patients with mild pain, a gentle exercise program that improves muscle tone and prevents joint stiffness may be used. Water therapy has been found to be effective in alleviating osteoarthritic pain and improve overall function (Ringdahl & Pandit, 2010). Rest periods between activities are recommended. Heat or cold therapy to the joints may also be used to decrease joint pain. Simple measures such as a warm bath or shower in the morning may help reduce the early morning stiffness that may accompany the pain. Other pain relief interventions may be incorporated into the treatment plan (see Evidence-Based Practice box: Osteoarthritis and Benefits of Regular Exercise).
Evidence-based practice Osteoarthritis and Benefits of Regular Exercise Background Age is the most strongly associated factor in the development of osteoarthritis. Health care professionals commonly agree that physical activity is a major facet of a healthy life at any age. This study examined the relationship between activity (intermittent or lifelong) and the development of osteoarthritis in later life.
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Sample/Setting Data sources to answer the posed research question that physical activity is a factor in the development of osteoarthritis were mapped from Ovid MEDLINE and EMBASE databases. Potential studies were eliminated if the mean age of the subjects was less than 55 years. A total of 15 prospective cohort studies and randomized controlled trials served as the sample for this exploration.
Methods Information from each portion of the sample was compared for risks, outcomes, subjects involved, and interventions.
Findings The authors judged that too wide a set of variations existed in how the exercise regimens were conducted to allow for clear comparisons between programs and outcomes. No direct association was observed between physical activity as a risk factor and the development of osteoarthritis. Each study that was examined suggests that sufficient supporting evidence may exist with regard to the benefits of some form of exercise regimen in the management of osteoarthritis.
Implications Nurses can impact the overall level of physical activity in those with osteoarthritis by advocating for a routine of some form of regular exercise. Data from Hart, L.E., Haaland, D.A., Baribeau, D.A., et al. (2008). The relationship between exercise and osteoarthritis in the elderly. Clinical Journal of Sports Medicine, 18(6), 508.
The physician may also prescribe various nonsteroidal antiinflammatory drugs (NSAIDs) and nonopioid analgesics to control the pain. Patients may initially be given OTC medications and then gradually be advanced to a prescription antiinflammatory agent. The use of a topical antiinflammatory gel to an affected area such as the knee has been shown to reduce pain (Baraf, Gloth, Barthel et al., 2011). Other medical treatment options for more
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severe pain may include directly injecting the painful joint with steroids. This may be done two or three times yearly for chronic pain. More recent developments in arthritis treatment include the injection of hyaluronic acid into a painful knee joint if more conservative measures have not been effective. The nurse should educate the patient about these conservative measures for treating the symptoms of arthritis. Information regarding correct dosing of oral medications, contraindications, side effects, and adverse effects should be provided.
When conservative measures for treating chronic arthritis pain fail and the patient becomes more disabled, surgical procedures may be considered. The main indications for surgery are severe pain and increasing disability. The surgical procedure most often used is arthroplasty, a surgical replacement of the involved joint. Joint replacement surgery is currently successful for many joints that may be involved with arthritis, including the shoulders, elbows, fingers, hips, and knees. Other surgical options include arthroscopic procedures and joint fusion surgery. These procedures do not replace the joint but may result in improved function and reduced pain.
For patients undergoing joint replacement surgery for the hip or knee, the preoperative period focuses on education about the surgical procedure, its risks, any potential complications, and the postoperative course. After surgery the goals of nursing care are to prevent complications, relieve surgical pain, and assist the patient in achieving a higher level of function and activity. Major complications after joint replacement surgery may include thromboembolism (deep venous thrombosis [DVT]), joint or wound infection, blood loss, nerve injury, joint dislocation, and surgical pain. The risk of DVT is highest between the first and second week after surgery (Ramzi & Leeper, 2004). Nursing interventions in the postoperative period include measures to prevent infection, control pain, and assist with daily activities. Aseptic precautions should be taken with surgical wound dressings, urinary catheters, and surgical drains to prevent infection. The patient may be given prophylactic antibiotics for a short time (24 hours) after surgery.
Infection of the site of joint replacement is a serious complication.
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The incidence of deep infection of joint replacement sites is 0.5% to 1%. The infection may be a result of contamination during surgery, hematoma formation, or delayed wound healing, or it may be hematogenous from a distant site, as with urinary tract infection. The most common contaminants are staphylococci and gram- positive aerobic streptococci. Because the new joint is a foreign body, pathogens may be introduced and will persist on the metal or plastic surfaces of the prosthesis, leading to chronic deep infection of the joint.
Patients with rheumatoid arthritis (RA), diabetes mellitus, or poor nutritional status and those receiving long-term corticosteroid therapies are at increased risk for developing joint infections. If infection occurs in a joint replacement, long-term intravenous antibiotic therapy is instituted for at least 6 weeks. In some cases, the infected joint may be replaced. Joint infections may lead to increased disability and prolonged rehabilitation. Various prophylactic measures should be ordered to prevent DVT. These may include various lower extremity compression devices, oral or injectable anticoagulants, and physical therapy to mobilize the patient (Ramzi & Leeper, 2004).
Pain control during the first 24 to 48 hours may be accomplished with intravenous or epidural administration of narcotic analgesics. Patient-controlled analgesia is frequently used to provide adequate pain control. As the patient’s pain decreases, oral analgesics should be ordered. Mild analgesics may be required for up to 6 weeks postoperatively as the surgical site heals.
Patients who have total hip replacement surgery are at risk for hip dislocation. The hip should be maintained in a position of abduction and neutral alignment. Some physicians may require the use of pillows or abduction splints while the patient is in bed. Nurses should reinforce hip precautions as described in the Patient/Family Teaching box: Precautions after Hip Surgery.
Patient/family teaching
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Precautions after Hip Surgery Sit with your hips at a 90-degree or greater angle.
Do not bend forward more than 90 degrees.
Do not lift the knee on the operated side higher than your hip.
Do not cross legs at knees or ankles.
Keep pillows between your legs when lying on your side or your back.
Do not bend to put on shoes; use a long shoehorn.
Do not bend down to reach items on the floor.
Do not sit in low chairs.
The goal of total knee replacement surgery is to restore at least 90 degrees of knee flexion. For patients to achieve this, active and passive physical therapy is instituted. In addition, the physician may order a continuous passive motion device, which continuously moves the knee through a preset range of flexion and extension. Rehabilitation for a patient with a joint replacement begins within 24 to 48 hours of the surgical procedure and includes muscle strengthening and range-of-motion exercises. The patient is instructed on the use of a cane, walker, or crutches. Occupational therapy provides the patient with instructions for independence in daily activities. A short stay in a rehabilitation facility may follow the acute hospital stay. However, many patients are able to quickly return to their own home with continued home therapy services.
Evaluation The goals in caring for a patient with osteoarthritis are to relieve pain and restore function. Patients should report minimum pain and improved ability to perform ADLs. Conservative measures (as outlined earlier) will improve mobility and increase comfort for many older patients. If surgical intervention is used, the patient needs to understand the expected outcomes, as well as the risks associated with the procedure. Patients with osteoarthritis may benefit from support groups and group exercise programs
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especially designed for patients with arthritis. The patient’s self- care practices should include regular exercise, the use of adaptive devices, if necessary, and adherence to prescribed medication regimens. Understanding the disease process and treatment measures will assist an older adult in maintaining function and independence.
Spinal Stenosis Symptomatic osteoarthritic changes of the spine leading to functional limitation and pain in older adults are becoming more common. Lumbar spinal stenosis is one of the most frequently encountered, clinically important degenerative spinal disorders in the aging population (Markman & Gaud, 2008). Degenerative spinal stenosis is a bony overgrowth of the facet joints of the vertebrae, which leads to narrowing of the spinal canal and possible compression of the nerve roots. Although spinal stenosis may occur at any level of the spine, it is most frequently seen in the lumbar region at levels L3 and L4 (Figure 25-8). Degeneration of the vertebral joints and disks of the spine, along with nerve compression, leads to progressive back pain and possible weakness of lower extremities. Patients with spinal stenosis may develop claudication-like symptoms of burning and numbness in their lower extremities (Briggs, Kaplan, Eskander, & Franklin, 2010; Pacala & Sullivan, 2010).
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FIGURE 25-8 Three-dimensional illustration of segmental stenoses. A, Anatomic. B, Segmental. C, Pathologic. (Redrawn from
Ciric, I., Mikhael, M.A., Tarkington, J.A., & Vick, N.A. (1980). The lateral recess syndrome: A variant of spinal stenosis. Journal of Neurosurgery, 53, 433-443.)
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Nursing management Assessment
Goals of nursing assessment focus on the patient’s symptoms. The exact location of pain or numbness, the duration of the symptoms, and successful pain relief measures should be identified. Pain caused by degenerative spinal stenosis tends to occur primarily in the back and buttocks, but it may also radiate into the thighs, calves, and feet. The pain may be unilateral or bilateral and generally worsens with prolonged standing or activity. Symptoms are generally relieved with flexion of the spine. Patients may usually report specific positions or activities that aggravate or reduce their symptoms. They may report that activities such as leaning over a grocery cart lessen their pain. Comfort levels during routine ADLs should always be assessed.
Diagnosis Nursing diagnoses for an older patient with spinal stenosis include the following:
• Chronic Pain, related to spinal nerve root narrowing
• Impaired Physical Mobility, related to discomfort with walking and movement
• Risk for Activity Intolerance, related to chronic pain
• Risk for Injury, related to pain and difficulty with ambulation
Planning and Expected Outcomes The focus of the nursing care plan for a patient with spinal stenosis is management of chronic pain, maintenance of strength and mobility, and promotion of independence with daily activities. The severity of symptoms and assessment of current limitations of activity will determine the individual needs of patients with
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degenerative spinal stenosis. Expected outcomes include the following:
1. The patient will report a minimum or tolerable level of pain.
2. The patient will demonstrate improved mobility and tolerance of activity.
3. The patient will be able to incorporate a plan for lifestyle modifications that includes activity and rest.
4. The patient will demonstrate safe use of assistive devices and make necessary environmental changes to promote safety.
Intervention Nursing care for an older patient with spinal stenosis depends on the severity of spinal cord narrowing, the patient’s state of health, and the degree of pain and immobility. For the patient being treated conservatively, the nurse should instruct him or her to allow sufficient periods of rest and to limit activities that produce pain. Physical therapy for range of motion and muscle strengthening may be ordered by the physician. Pain relief measures should be initiated and then evaluated for their effectiveness. The physician may order NSAIDs, analgesics to include injectable steroid treatments for more severe pain (Briggs et al., 2010). The use of pain assessment scales will help determine pain patterns, the severity of pain, and the effectiveness of pain relief measures.
Other nursing measures to relieve pain include the use of heat or cold applications to the back, massage therapy, relaxation techniques, and position changes for the patient while in bed. Older patients with unrelieved chronic pain may be considered for pain team consultation and multidisciplinary treatment efforts. In many patients with chronic pain, depression may accompany and increase the intensity of the pain symptoms. A physician consultant may recommend the use of mild antidepressant medication in addition to the other pain relief measures.
Evaluation
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The patient’s ability to perform ADLs independently with minimum discomfort should be evaluated by self-report and observation. The effectiveness of pain relief measures should be discussed with the patient, and changes should be made when medications have lost their effectiveness. For patients undergoing epidural injections or surgical procedures, the nurse should reinforce instructions about precautions and activities. The older patient should be able to verbalize potential complications and expected outcomes of treatment. Documentation of patient interactions should include the use of an appropriate pain scale and information about current activity levels and restrictions.
Rheumatoid Arthritis Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease that causes joint destruction and deformity and results in disability. The onset of the disease most commonly occurs in the third or fourth decade. However, RA may also develop in older adults, known as elderly onset rheumatoid arthritis (EORA). The disease is usually a chronic problem for 1% of the population, and the occurrence of the EORA has equal gender distribution compared with RA in the younger adult population (Olivieri, Pipitone, D’Angelo, Padula, & Salvarani, 2009).
The cause of RA is not known. The most widely accepted theory is that it is an autoimmune disease that causes inflammation, most often in the joints but sometimes also in connective tissue. Joint involvement most often starts with the proximal interphalangeals, metacarpophalangeals, and wrists; in the later stages of the disease, knees and hips are affected.
In the initial phase of RA, the synovial membrane becomes inflamed and thickens, and production of synovial fluid is increased. The change is called pannus. As pannus tissue develops, it causes erosion and destruction of the joint capsule and subchondral bone. These processes result in decreased joint motion, deformity, and finally ankylosis, or joint immobilization.
The course of RA is variable. Generally the onset is gradual, and the course is one of remissions and exacerbations. The symptoms
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are painful, stiff joints, decreased range of motion in the joints, joint swelling, and deformity (Figure 25-9). The joint stiffness is present in the morning and lasts from 30 minutes to 6 hours. On examination, the affected joints are warm and swollen. Deformities of the joints include ulnar deviation of the wrists, boutonnière deformity caused by contractures of the distal and proximal interphalangeal joints, and swan-neck deformity caused by contractures of the distal interphalangeal joint (Figure 25-10). Patients may also develop subcutaneous nodules which feel firm and fixed often found on the proximal side of the elbow (LeBlond et al., 2009).
FIGURE 25-9 Rheumatoid arthritis of the hand. A, Early stage. B, Moderate involvement. C, Advanced stage. (From Brashear, H. & Raney,
R. (1986). Handbook of orthopaedic surgery (10th ed.). St. Louis, MO: Mosby.)
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FIGURE 25-10 Typical deformities of rheumatoid arthritis. A, Ulnar drift. B, Boutonnière. C, Hallux valgus. D, Swan-neck deformity.
(From Lewis, S., Kirksen, S., Heitkemper, M., Bucher, L., Camera, I. (2011). Medical- surgical nursing: Assessment and management of clinical problems. (8th ed.). St.
Louis: Mosby, Elsevier.)
Systemic symptoms may include fatigue, malaise, anorexia, weight loss, and anemia. RA in older adults may appear atypically; that is, large joints are affected more often, and the onset may be more sudden than in younger adults. Fatigue, weakness, and fever may be present (Table 25-1). Patients with long-term RA may develop comorbidities such as Sjögren syndrome, Felty syndrome, and pericarditis (Manno & Bingham, 2011).
Table 25-1 Differentiating rheumatoid arthritis from osteoarthritis
Rheumatoid Arthritis Osteoarthritis Age at onset 3rd and 4th decades 5th and 6th decades Onset Gradual Gradual Disease course Exacerbations and remissions Variable, progressive Duration of stiffness 1 to 24 hours 30 minutes or less Joint pain Worse in morning Worse after activity Joints involved Proximal interphalangeal Distal interphalangeal
Metacarpophalangeal Knees, hips Metatarsophalangeal Lumbar, cervical Knees, hips, wrists Spine
Symmetric pattern Almost always Occasionally Constitutional manifestations Present Absent Synovial fluid Increased cells Few cells
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Decreased viscosity Normal viscosity Radiography findings Abnormalities present Abnormalities present Erythrocyte sedimentation rate Almost always elevated Occasionally elevated Positive rheumatoid factor Almost always Never
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Nursing management Assessment
A careful nursing history is taken. Questions are asked about family history and constitutional symptoms, including fever, anorexia, weight loss, fatigue, and duration of the joint stiffness. On physical examination, the affected joints are inspected for symmetric involvement, pain, tenderness, swelling, heat, erythema, and deformity. For patients with long-term complicated RA, assessment should also include examination of the eye for scleritis and corneal ulcers, lungs for pneumonitis, and a cardiac examination for presence of pericarditis (Manno & Bingham, 2011).
Diagnosis Nursing diagnoses for a patient with rheumatoid arthritis include the following:
• Pain, related to swollen, inflamed joint tissue
• Impaired Physical Mobility, related to the joint deformities and inflammation
• Fatigue, related to the systemic disease process
• Imbalanced Nutrition: Less Than Body Requirements, related to loss of appetite
• Bathing/Dressing/Feeding/Toileting Self-Care Deficit, in ADLs related to the loss of motion and strength in painful, swollen joints
• Disturbed Body Image, related to the gradual onset of joint deformities
Planning and Expected Outcomes Prevention of joint deformities, control of symptoms, and maintenance of the patient’s abilities to have an active lifestyle are
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the focus of intervention for a patient with RA. Outcomes for the older patient include the following:
1. The patient will maintain normal joint motion in affected joints, with minimum deformities.
2. The patient’s pain related to inflammation will be well controlled.
3. The patient will be able to maintain optimal functional status.
Intervention Older patients with RA and their families require extensive education to cope effectively with the chronic nature of this disease. The nurse needs to discuss with them pain management, drug therapies, maintenance of self-care activities, promotion of safe mobility, methods of joint protection and precautions, and management of overall health.
Education on pain management includes information on appropriate medications that have been prescribed and OTC remedies that a patient may be using. The patient should be informed that stress and anxiety may cause muscle tension that may worsen joint pain. Progressive relaxation and guided imagery are taught to decrease anxiety and stress. Application of heat and cold to the affected joints decreases cutaneous nerve stimulation. Ice packs are applied to joints during periods of acute inflammation. Moist heat is useful in relaxing muscles and increasing joint mobility.
The role of the nurse in medication management is to teach the older patient about the action, side effects, and special precautions related to the specific medications. Table 25-2 presents multiple drugs classically used in the treatment of arthritis. In addition to those medications listed in Table 25-2, newer pharmacologic and biologic agents are being researched and developed for use in patients with RA.
Table 25-2 Drugs, rationale, side effects, and nursing implications of classic medications
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Modified from Moore, K.A. (1996). Arthritic disorders. In S.W. Salmond, N.E. Mooney, & L.A. Verdisco (Eds.), Core curriculum for orthopaedic nursing (3rd ed.). Pitman, NJ: National Association of Orthopaedic Nurses.
CBC, Complete blood cell count; NSAIDs, nonsteroidal antiinflammatory drugs.
The drug management of RA is directed at disease management and at symptom control. Medications selected for relief of the pain and inflammations include corticosteroids, analgesics, and NSAIDs. Corticosteroids along with medications known as disease-modifying antirheumatic drugs (DMARDs) are prescribed to aid with disease control. Concern exists about extended corticosteroid use because of the multiple side effects of long-term use such as infection, peptic ulcer disease, and osteoporosis.
The early DMARDs, which suppress the immune response, include medications such as methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. The newer DMARDs, which are biologic agents, are administered subcutaneously, intravenously, and orally. Medications known as tumor necrosis factor (TNF) receptor antagonists are effective for the treatment of RA with methotrexate. Numerous side effects are reported to be caused by TNF receptor antagonists and include infections, potential worsening of heart failure, and demyelinating disease. Despite the side effects of these medications, studies have shown that anti-TNF agents could be administrated to older adults with RA with similar effectiveness and tolerability as in younger patients
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(Aletaha, Neogi, Silman et al., 2010). Nurses need to educate patients about the numerous side effects of these medications and stress the importance of not taking any OTC medications without the permission of their health care provider.
Fatigue and decreased mobility of the joints of the upper extremities contribute to self-care deficits. Occupational therapists work with older patients to improve joint function and prevent disability. The modalities used include exercises, splints, methods to protect joints, and assistive devices. Splints may be used to protect joints, maintain joint function, and decrease pain. The nurse reinforces the use of these devices and monitors correct use.
Limitations of mobility because of pain and joint stiffness may lead to disuse and greater disability. To prevent excessive disability, the patient is taught body mechanics and proper body alignment and is given recommendations for an exercise program. Using good body mechanics and keeping the body in a position of optimal alignment decrease joint stress and fatigue. Physical therapists prescribe individualized therapeutic exercise programs, which include strengthening and stretching exercises, range-of-motion exercises, and endurance training.
Fatigue is a common constitutional symptom of RA. Fatigue may interfere with the older adult’s achievement of optimal functional independence. Methods used to decrease fatigue include balancing rest with activity, scheduling short rest periods (1 to 2 hours), practicing relaxation techniques, and adapting the environment to simplify work. Coping with chronic illness, pain, deformity, and alterations in body image may predispose a patient to depression. If clinical depression occurs, medical evaluation and treatment are indicated.
The joint deformities and alteration in body image may negatively impact sexual function. The nurse should be aware of this and openly discuss issues of sexuality and methods of maintaining physical intimacy. Suggestions may include using analgesics before sexual activity, planning rest periods before sexual activity, assuming alternative positions, and encouraging alternative methods of maintaining physical intimacy.
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Adults with RA require many supports to cope with this chronic, disabling disease. The nurse’s role is to provide the older adult with information about resources that are available so that optimal levels of functioning can be reached.
A good resource is the Arthritis Foundation (1330 W. Peachtree St., Atlanta, GA 30309; [800] 283–7800; www.arthritis.org), which publishes educational materials that address exercise programs, work simplification, and the disease process. Support groups and self-help classes taught in 6-week sessions are conducted by local chapters. The content of the classes includes self-efficacy, exercise, pain management, depression, stress management, and nontraditional therapies.
Evaluation The older adult with RA should experience minimum discomfort and be able to maintain an acceptable level of function and mobility. With advances in drug therapy and active participation by the patient in activities to prevent joint deformities, the patient should experience less deformity, increased comfort levels, and understanding of the disease process.
Gouty Arthritis Gout is a disease in which acute attacks of arthritis pain occur as a result of elevated levels of serum uric acid. During acute gout attacks, joint inflammation is caused by sodium urate crystals in the joint. Gout is classified as primary or acquired. Primary gout is an inborn disease of purine metabolism. Acquired gout is caused by medications that affect excretion of uric acid. These medications include diuretics, levodopa-carbidopa and low-dose aspirin (McAdams, Maynard, Baer et al., 2012; Neogi, 2011). Gout usually occurs in the middle years but also affects older adults; it is more prevalent in men than in women.
In gout, an excessive production or a decreased urinary excretion of uric acid may occur. The excess monosodium urate salts are deposited in joints and surrounding connective tissue. The deposits
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of the uric acid crystals are called tophi, often found on the helix of the ear, on the olecranon bursa and over the Heberden nodes in patients with coexisting osteoarthritis (Figure 25-11).
FIGURE 25-11 Tophaceous gout. (From Roberts, J.R. & Hedges, J.R. (2009). Clinical procedures in emergency medicine (5th ed.). Philadelphia:
Saunders.)
Gout may manifest as an acute or a chronic condition. The onset of gout is sudden and is manifested by an acute attack of pain in one or more joints. The most commonly affected area is the great toe, known as podagra. Other joints and periarticular structures affected by gout include the ankle, knee, wrist, and the olecranon bursa (Ning & Keenan, 2011). The affected joint becomes hot, reddened, and tender. The pain may be severe and interfere with mobility, self-care, and functional abilities. Chills and fever may also be present. Acute attacks of gout usually subside in 7 days regardless of treatment. In chronic gout, the uric acid crystals cause bone destruction and deformity. Uric acid crystals may also be deposited in the kidney and cause nephrolithiasis.
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Nursing management Assessment
The onset of an acute gout attack is identified by the presence of warmth, swelling, cutaneous erythema, and severe pain in the affected joint. The initial attack is usually in one joint, and in nearly half of patients it will involve the first metatarsophalangeal joint. In older women, however, the initial presentation often begins in multiple joints (Ning & Keenan, 2011). The pain is intense, and the joint is sensitive to even the slightest touch. Other symptoms may include fever, chills, and malaise. Intervals between initial attacks and subsequent acute episodes will vary, but the attacks usually become more frequent and involve more joints.
Patients with chronic gouty arthritis usually report 10 or more years of previous acute gout attacks. The involved joints are chronically uncomfortable and swollen, although the intensity of the pain is less than in the acute episodes. Tophi may or may not be detected on a physical examination.
Nursing assessment should identify other risk factors or conditions that may predispose the patient to development of gout. These factors include obesity, hypertension, alcohol ingestion, use of diuretics, recent trauma, hyperlipidemia, diabetes mellitus, chronic kidney disease, and organ transplant (Neogi, 2011).
Diagnosis Nursing diagnoses for a patient with gouty arthritis include the following:
• Pain, acute or chronic, related to joint inflammation and swelling
• Impaired Physical Mobility, related to joint deformity and discomfort secondary to the disease process
• Risk for Activity Intolerance, related to pain
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Planning and Expected Outcomes The overall management plan for an older adult with gouty arthritis, either acute or chronic, is to decrease the pain and other associated symptoms. Expected outcomes for a patient with gout include the following:
1. The patient will verbalize increased comfort and pain relief with the use of appropriate analgesics and NSAIDs.
2. The patient will be able to verbalize understanding of the disease process.
3. The patient will incorporate appropriate diet modifications and lifestyle changes such as weight loss and avoidance of alcohol and food products high in purine.
4. The patient will modify his or her activity and rest pattern based on limitations imposed by the pain.
5. The patient will incorporate health practices to minimize recurrent attacks.
Intervention In the acute phase, the goal of nursing management is to relieve pain. During an acute attack of gout, the pain may be so severe that the patient is unable to bear weight or to tolerate clothing or blankets on the affected joint. Colchicine is an effective medicine for the treatment of pain and inflammation of acute gout; severe pain subsides within 48 hours. The use of NSAIDs, especially indomethacin, provides relief comparable with that provided by colchicine. Other pain relief measures include analgesics, elevation of the affected extremity, immobilization of the joint, and heat or ice packs to the area.
Nursing interventions for chronic gout also focus on pain relief measures and prevention of recurrent attacks of gout. This is accomplished through patient education. Because obesity and diets high in protein have been linked to gout, information about the role of dietary habits should be provided. Foods that are high in
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purines, for example, shellfish and organ meats, should be avoided. Alcoholic beverages should also be avoided. Obese patients should have weight reduction diets or programs recommended. A consultation with a dietitian for diet modifications may be helpful.
A xanthine oxidase inhibitor such as allopurinol or febuxostat is the medication of choice for patients with chronic gout symptoms (Fravel & Ernst, 2011). Probenecid, a uricosuric agent, is another medication that may be used. Patients must be closely monitored for renal function during drug therapy. To discourage the formation of renal stones, the patient should be encouraged to have a daily intake of 2 to 3 liters (L) of fluid unless contraindicated. The patient should also be instructed to avoid salicylates, which could inhibit drug effects.
Evaluation Patients with acute or chronic gout should be able to maintain a healthy lifestyle, incorporating the changes suggested during treatment. The patient must understand the drug therapy for acute attacks and chronic treatments. Pain management should allow a patient to participate fully in ADLs and allow for full mobility.
Osteoporosis Osteoporosis is considered the most common metabolic bone disorder, affecting more than 10 million people in the United States (National Osteoporosis Foundation [NOF], 2013). Common among postmenopausal women, bone fractures occur every year secondary to osteoporosis (Rahmani & Morin, 2009). The disease primarily affects women but also occurs in 1 of 6 men. Osteoporosis is commonly referred to as porous bone disease or brittle bone disease and is characterized by reduction in bone mass and loss of bone strength.
Bone is constantly remodeling itself throughout life, and the process of bone maintenance is constant. Old bone cells are removed (resorbed) by osteoclasts, and new bone cells are formed by osteoblasts. The complete process of bone remodeling takes 4 to
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8 months. Bone mass is accumulated in the early part of life; bone mineral density (BMD) increases until approximately age 30, when peak bone mass is attained. Anything that interferes with the normal process of bone remodeling may lead to the development of osteoporosis. Conditions that contribute to this process include renal or hepatic failure and endocrine disorders such as hyperthyroidism, hyperparathyroidism, type 1 diabetes mellitus, RA, and chronic kidney disease. Other risk factors include heredity and genetic predisposition, lifestyle factors, and age. With osteoporosis, the bone remodeling process is altered, and the rate of bone resorption exceeds the rate of bone formation, which leads to decreased bone mass.
Osteoporosis is classified as primary osteoporosis and secondary osteoporosis. Although the cause of primary osteoporosis is not clearly understood, it is further classified into postmenopausal (type 1) osteoporosis and age-associated (type 2) osteoporosis. Type 1 osteoporosis is related to menopausal estrogen deficiency and is seen in women between ages 51 and 75. In type 1, the trabecular bone in the vertebral column, hips, and wrists is weakened. Because type I osteoporosis is related to estrogen deficiency, it is seen six times more often in women than in men. Type 2 osteoporosis occurs in both men and women older than age 70 and causes a gradual loss of cortical bone. Because this cortical bone provides support in the body, weakening of the bone is a predisposing factor in hip fractures. Age-related changes in vitamin D synthesis that result in decreased calcium absorption are thought to be the cause of type 2 osteoporosis.
Secondary osteoporosis, seen in 15% of cases, is the result of diseases such as hyperthyroidism, hyperparathyroidism, gastrointestinal disorders, neoplasms, and alcoholism. In women, early oophorectomy is a cause of secondary osteoporosis. Long- term use of corticosteroids, methotrexate, aluminum-containing antacids, phenytoin, and heparin may result in secondary osteoporosis. Prolonged immobility, which causes calcium excretion, is also a cause of secondary osteoporosis.
Certain risk factors for the development of osteoporosis have been identified (Box 25-1). Risk factors that can be modified with
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lifestyle changes involve calcium intake, exercise, cigarette smoking, and consumption of alcoholic beverages. Age, race, gender, and body frame are risk factors that cannot be changed. The nurse may educate the older patient about these risk factors, making suggestions to modify lifestyle and nutrition. Three key essentials in preventing osteoporosis throughout life are appropriate diet, exercise, and lifestyle changes (Passmore, Burke, & Lyons, 2007).
Box 25-1
Risk factors for development of osteoporosis • Female gender
• Increasing age
• White race
• Thin body frame
• History of bilateral oophorectomy
• History of anorexia
• Family history of osteoporosis
• Long-term use of certain medications such as corticosteroid, phenytoin, and phenobarbital
• Chronic conditions such as hyperthyroidism, hyperparathyroidism, rheumatoid arthritis
• Alcoholism
• Cigarette smoking
• Calcium intake below daily requirements
Osteoporosis is called a “silent killer” because frequently no clinical symptoms appear until fractures occur. The initial
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complaint may be back pain or fatigue. The fatigue results from the increased demand on muscles to keep the body in an upright position with a decreased bone mass. Osteoporotic fractures are most commonly seen in the vertebrae of the thoracic spine, the femoral neck, and the wrist. Fractures may occur with routine activities such as bending, lifting, coughing, and straining during defecation. Osteoporosis of the spinal vertebrae causes a loss of height of 1 to 2.5 inches. Also seen is the “dowager’s hump,” or kyphosis, which results from the vertebrae sliding on top of each other (Figure 25-12). Conventional radiography may provide evidence of osteoporosis, although this is often done retrospectively after a fracture. Unfortunately, at least 30% of bone mass must be lost before the disease is apparent on standard radiography. For evaluation of bone mass in individuals suspected of having osteoporosis or in those considered at risk for development of the disease, a determination of BMD appears irrefutable. Bone densitometry is commonly done with dual-energy x-ray absorptiometry (DEXA). This procedure is simple, is noninvasive, uses a low radiation dose, and is completed in less than 30 minutes. Many physician offices are now equipped with a DEXA machine for quick and simple screening of patients. Measurement sites include the hip or lumbar spine and peripheral sites such as the wrist. Scores computed from the testing compare the older patient’s score with those of normal young adults for peak bone mass and also compare the older patient’s score with those of gender- matched and age-matched control subjects. The T-score obtained from DEXA is a measure of how much an individual’s bone mass differs (in standard deviation) from the bone mass of a healthy 20- to 29-year-old. The score obtained defines bone loss as normal, osteopenia, or osteoporosis. If a patient’s T-score is 2.5 or less, it is indicative of severe osteoporosis (Watts, 2011).
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FIGURE 25-12 Abnormal spinal curvatures. A, Lordosis. B, Kyphosis. C, Scoliosis. (From Thibodeau, G.A. (2009). The human body in
health & disease (5th ed.). St. Louis, MO: Mosby.)
To more clearly establish the candidacy of patients for pharmacologic treatment of osteoporosis, the NOF recommends that clinicians use the Fracture Risk Assessment Tool (FRAX) developed by the World Health Organization (Watts, 2011). FRAX can be accessed as a web-based algorithm that combines risk factors for developing osteoporosis with BMD results. The tool has been designed to be used in postmenopausal women and in men aged 40 to 90 years old. (Siris, Baim, & Nattiv, 2010).
Laboratory blood studies are obtained to differentiate osteoporosis from other diseases that may cause bone loss. Complete blood cell count (CBC) and levels of serum calcium, serum phosphorus, alkaline phosphatase, and urinary calcium are all normal in osteoporosis.
Measures to address osteoporosis should be directed at minimizing bone loss in older adults and preserving the current level of bone mass. Patient education and development of awareness of the disease are critical for prevention and risk reduction. Elimination of lifestyle risk factors, nutritional
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counseling, and pharmacologic management are strategies used to prevent osteoporosis.
Adequate nutritional intake of calcium should be instituted in early childhood and continued throughout the life span. The current recommendation for daily calcium intake is 1000 mg for men and premenopausal women ages 25 through 49, 1500 mg for postmenopausal women who are not taking estrogen, 1000 mg for postmenopausal women taking estrogen, and 1500 mg for men and women older than age 65 years. Milk, either low-fat or nonfat, is a good source of calcium and vitamin D. Table 25-3 identifies dietary sources of calcium. Many of these food items are also good sources of vitamin D, which is essential for the synthesis of calcium.
Table 25-3 Dietary sources of calcium
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Modified from U.S. Department of Agriculture: Human nutrition information service. (1985). Home and Garden Bulletin No 323, 72.
oz, Ounce; tbsp, tablespoon.
For individuals unable to consume adequate calcium, supplements are recommended. Various forms of calcium supplements are available. Calcium carbonate is thought to be the best supplement because it contains 40% elemental calcium, is the least expensive, and requires taking the least number of tablets. Patients, however, may find calcium citrate, which contains only 20% elemental calcium, to cause less gastrointestinal side effects, thus more tolerable for long-term therapy. Calcium supplements should be taken with meals and followed by at least 10 ounces (oz) of water to promote absorption. No more than 600 milligrams (mg) of calcium should be taken in a single dose because absorption is compromised with higher doses. The NOF currently recommends that patients at risk take vitamin D replacement 800 to 1000 international units per day in addition to calcium (NOF, 2013).
Exercise programs that include weight bearing and resistance have been shown to prevent bone loss. Exercises should be done three times a week for 30 to 60 minutes for the best results. Postural exercises to prevent or minimize kyphotic deformity are also of benefit to older adults. Moderation in any exercise program is always recommended.
According to the NOF’s Clinician’s Guide to Prevention and Treatment of Osteoporosis, pharmacological treatment for osteoporosis is recommended for patients who have had a vertebral or hip fracture, a T-score of 2.5 or less and a 10-year high probability of hip fracture (> 3%) or a 10-year probability of any osteoporosis-related fracture from occurring (> 20%), as indicated by the score on the U.S. adapted FRAX score (NOF, 2013). Initial treatment for osteoporosis generally begins with the bisphosphonates (alendronate, risedronate, and zoledronic acid) or denosumab, a RANK ligand (RANKL) inhibitor (Watts et al., 2010). The bisphosphonates, which are classified as antiresorptive medications, are known for their ability to slow bone breakdown by inhibiting the osteoclasts, thereby preventing bone resorption. Bisphosphonates are recommended by the U.S. Food and Drug
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Administration (FDA) for the prevention and treatment of osteoporosis. Nurses need to instruct patients on the importance of following medication guidelines when taking oral bisphosphonates. Special instructions include taking the medication daily, 1 hour before any food or medication. It must be taken with 6 to 8 ounces of water and the patient must remain upright for at least 30 minutes after taking the drug. Nurses should also instruct patients about the long-term side effects of bisphosphonates, including bone, which patients may not recognize as a medication side effect but misinterpret as progression of the disease. Denosumab, also recommended for prevention and treatment of osteoporosis, is an injectable agent that needs to be administered twice a year. It is contraindicated in patients with a known history of hypocalcemia, so calcium and vitamin D deficiencies need to be corrected before a patient is started on denosumab (NOF, 2013).
Recommendations for treatment following first-line medications include the bisphosphonate ibandronate and raloxifene, a selective estrogen receptor modulator (SERM) that has an estrogen-like effect on bone metabolism (Watts et al., 2010). Side effects of raloxifene include hot flashes, deep vein thrombosis (DVT), and pulmonary embolism. Patients should not only be educated on the side effects of this medication, they should also be advised to notify their health care provider if they anticipate any long-term immobility while on this medication because of the risk of thromboembolic events (NOF, 2013). Teriparatide, a parathyroid hormone that helps stimulate bone formation, is indicated for the treatment of patients at high risk of fracture from osteoporosis. This medication has been shown to be effective in increasing bone mineral density in patients with osteoporosis related to long-term glucocorticoid therapy (Khosla, 2010; Saag, Zanchetta, Devogelaer et al., 2009).
Another antiresorptive drug used to treat osteoporosis is calcitonin, in a parenteral or nasal spray preparation. Oral administration is not appropriate because the drug is a polypeptide hormone and is destroyed in the gastrointestinal tract. The nasal spray preparation is a formulation of synthetic salmon calcitonin, and it has been approved for use in the treatment of osteoporosis in women who are at least 5 years postmenopausal, have low bone
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density, and are not candidates for estrogen replacement therapy (ERT). Calcitonin is generally taken daily in one puff alternatingly through the nares. Because the drug may elicit a systemic allergic reaction in certain individuals, intradermal skin testing should precede delivery of the initial dose. Systemic adverse effects of the nasal route are reported as being minimal but may include nasal discomfort, occasional rhinitis, and itching of the nasal mucosa.
Since it was first reported, on the basis of the findings of the Women’s Health Initiative, that an increased risk for breast cancer, myocardial infarction, stroke, invasive breast cancer, pulmonary embolism, and DVT, it has been recommended that the use of estrogen or hormone replacement therapy in postmenopausal women with moderately severe menopausal symptoms be limited. Nonestrogen therapies are recommended first for the treatment of osteoporosis (NOF, 2013).
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Nursing management Assessment
Nursing assessment of older patients should include taking a thorough family health history and determination of the presence of risk factors, the level of exercise, alcohol and caffeine intake, and smoking. Women should be assessed for age of onset of menopause, use of ERT, date of last mammography, and history of breast or uterine cancer. All patients should be asked about their lifelong intake of calcium, history of fractures, presence of pain, and history of falls. A physical examination includes determination of the presence of kyphosis, gait impairments, muscle weakness, and cognitive impairments.
Diagnosis Nursing diagnoses for an older patient with osteoporosis include the following:
• Imbalanced Nutrition: Less Than Body Requirements, related to a decreased intake of calcium and vitamin D
• Risk for Injury, related to weakening of the bones
• Pain, related to inadequate pain relief secondary to bone fractures
• Disturbed Body Image , related to spinal deformities and loss of height
• Deficient Knowledge, related to lack of previous exposure to disease process, risk factors, and measures of prevention
Planning and Expected Outcomes Awareness of the risk factors and education about the lifetime prevention of osteoporosis and its complications such as falls and fractures are the most important aspects of planning the care of older adults with osteoporosis. Expected outcomes for a patient
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with osteoporosis include the following:
1. The patient will demonstrate taking precautions at home and in the community to prevent falls and activities that may result in fractures.
2. The patient will report an adequate level of pain control in the presence of bone fractures.
3. The patient will consume nutritional supplements, food products, and medications recommended or prescribed for meeting dietary needs, as evidenced by a diet log.
4. The patient will verbalize acceptance of changes brought about by the disease and an understanding of the treatment and prevention of further deformities (see Health Promotion box).
Health promotion/illness prevention Musculoskeletal Function: Osteoporosis
Health Promotion • Routine weight-bearing exercises that do not stress the joints,
such as walking
• Achievement of ideal body weight
• Initiation of a weight-training program
• Smoking cessation
• Decreased intake of alcohol and caffeine
Disease Prevention • Participation in regular program of weight-bearing exercises
• Avoidance of injury and falls
• Maintenance of adequate dietary intake of calcium and supplementation with oral calcium supplements, as indicated
• Consideration of hormone replacement therapy
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• Little to no intake of alcohol and caffeine
• Avoidance of smoking
Intervention The nurse’s role focuses on patient education about the disease process, strategies to prevent further injury or deformity, and measures to promote decreased loss of bone. Education should emphasize the identification and minimization of controllable risk factors. These include cigarette smoking, excessive consumption of alcohol, and caffeine intake. Exercise programs that will place some stress on the bones and, thus, strengthen them, for example, walking and lifting light weights, are recommended. Additional information for osteoporosis education and programs can be found through the NOF (1150, 17th Street NW, Washington, D.C. 20036; [202] 223–2226; www.nof.org).
Compression fractures of the vertebrae may cause pain, loss of function, and disturbance in body image brought about by the gradual loss of height caused by multiple fractures. Control of pain is achieved through the use of analgesics, NSAIDs, positioning, and relaxation techniques. Other pain management modalities include transcutaneous electrical nerve stimulation (TENS), various back supports or braces, and formal pain management consultation. Positive body image may be promoted through discussions of acceptance of changes that have occurred but with a focus on prevention of further injury and deformity (MacLean, Newberry, Maglione et al., 2008).
Nursing care of the older adult with a hip fracture or other fracture secondary to osteoporosis includes the interventions previously noted in this chapter.
Evaluation An older patient with osteoporosis should be able to describe measures that can be taken to decrease the potential for further bone loss as well as measures that can be taken to maintain a safe
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living environment so that the risk of injury resulting from falls is reduced. The patient will be able to describe the benefits of appropriate diet, lifestyle modifications, and diet supplements or medications, if needed. The older adult will also be able to participate in regular exercise programs and to identify resources available for prevention of disease (see Nursing Care Plan: Osteoporosis with Fractured Thoracic Vertebrae).
Nursing care plan
Osteoporosis with Fractured Thoracic Vertebrae
Clinical Situation Mrs. R is a 79-year-old widow, who has severe osteoporosis and who recently fractured her T4 and T5 vertebrae. After the fracture, she complained of severe pain, which has limited her daily activity and caused her to spend most of the day in bed. The period of bed rest has left her weak. Before the fracture she was independent in mobility and self-care. She drove and participated in activities with her friends on a regular basis. She is referred to the home care agency for pain management and physical therapy to upgrade her skills for performing activities of daily living (ADLs) and to promote endurance.
Mrs. R has no other health problems. She lives alone in a two- story house. The bathroom is on the second floor. Since the fracture, Mrs. R has stayed on the second floor all day except for one trip a day to the kitchen on the first floor to fix a meal. Mrs. R’s major support is her daughter, who lives in another state. She has several close friends, but they are unable to help her because of their health problems.
On the admission visit, the nurse finds Mrs. R’s house to be in an unsafe condition. The rooms and stairs are cluttered with papers, boxes, and other objects. Mrs. R tells the nurse that her pain is somewhat improved, but it still limits her ability to take
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care of herself and her home. She also tells the nurse,” I don’t understand this osteoporosis; how did that cause my fractures?”
Nursing diagnoses Risk for Injury, related to unsafe environment Deficient Knowledge, related to lack of exposure to osteoporosis
Impaired Physical Mobility, related to pain and musculoskeletal impairment
Pain, related to inadequate knowledge of pain management
Bathing and Dressing Self-Care Deficit (bathing and dressing lower extremities), related to pain and prolonged immobility
Outcomes The patient will remain free from fractures or other injuries and
will verbalize unsafe features of her home and a plan to correct.
The patient will verbalize basic information about the disease process, outcomes, and treatment.
The patient will safely walk 100 feet using a pickup walker and will participate in a daily exercise program.
The patient will verbalize that pain is tolerable. Pain will not interfere with the ability to participate in daily activities.
The patient will bathe and dress her lower extremities with the use of assistive devices.
Interventions Discuss outcomes of an unsafe environment: risks of falling and
fracture as a result of cluttered environment.
Use homemaker and friends to reduce clutter and encourage use of safety aids.
Teach safe transfer and ambulation techniques, wearing of sturdy supportive footwear, avoidance of lifting heavy objects, and how to bend from the knees when lifting.
Provide information and instruction on osteoporosis, including
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the pathophysiology of the disease, treatment regimen, and medication schedule, doses, and side effects.
Stress the importance of dietary intake of calcium and provide information on foods that are high in calcium.
Consult with physical therapy for a program of muscle strengthening, endurance development, stair training, and regular exercise.
Reinforce physical therapy training.
Give positive feedback for gains made.
Instruct the patient to make limited trips up and down stairs until strength is improved.
Instruct the patient on taking pain medication before the exercise program and the need for regular rest periods throughout the day.
Assess pain and the effectiveness of prescribed medications.
Instruct the patient to take pain medication before activities and on a regular basis until pain diminishes.
Instruct the patient on the use of diversional activities and relaxation techniques.
Assist the patient in setting short-term, realistic goals.
Consult with an occupational therapist for specific assistive devices.
Instruct the patient on the use of assistive devices.
Provide assistance, supervision, and teaching, as needed, to promote self-care.
Paget Disease Paget disease (osteitis deformans) is an inflammatory disease of the bone, in which both osteoclasts and osteoblasts proliferate. The processes of bone formation and bone resorption do not always proceed at the same rate. The cause of Paget disease is not known. Recent evidence supports the theory that a viral infection of the
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osteoclasts causes the disease. A possible familial predisposition to Paget disease also exists. This disease occurs most often in men older than age 40; a higher incidence occurs in individuals older than 80 years. Paget disease is predominant in people of European descent; it is a condition that is rarely found in Asians and Africans (Ralston, 2013).
Increased activity of osteoclasts leads to increased bone resorption. Bone formation is increased to compensate. This abnormal remodeling causes deformed and enlarged bones. Vascularity in the abnormal bones is increased, which results in excessive warmth over the bones involved. Bones affected by the disease are structurally weak and prone to pathologic fractures (Ralston, 2013).
The onset of Paget disease is insidious. Bones most often involved are the pelvis, femur, skull, tibia, and spine. The first symptom is bone pain, which is not relieved with rest and movement. The intensity of the pain varies from mild to severe; the quality may be stabbing or dull. If the bones of the skull are involved, headaches and conductive hearing loss may occur. Barreling of the chest, kyphosis, skull enlargement, and bowing of the tibia and femur are commonly seen bone deformities. The bowing of legs and kyphosis lead to reduction in height.
The prognosis for patients with Paget disease is not favorable because of the complications that may develop. These include pathologic fractures and loss of hearing related to changes in the temporal bone. The overgrowth of the spinal vertebrae may cause cord compression and paralysis.
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Nursing management Assessment
Nursing assessment should include taking a thorough health history; information about a known family history of the disease should also be elicited. The nurse should assess for warmth, deformity, pain, and erythema over the long bones; assess the range of motion in joints; and evaluate the presence of any weakness, ataxia, or hearing loss.
Diagnosis Nursing diagnoses for an older patient with Paget’s disease include the following:
• Pain, related to bone deformity and possible joint involvement
• Impaired Mobility, related to bone deformity, fracture, or pain
• Risk of Injury, related to limitations of mobility and altered bone metabolism
• Disturbed body image, related to bone deformities and disturbance in function
Planning and Expected Outcomes Nursing care of the patient should focus primarily on pain management, if necessary, and the issues of chronic disease. Addressing the alterations in body image and impaired mobility are also critical. Expected outcomes include the following:
1. The patient will achieve a satisfactory comfort level with pain management techniques and medications.
2. The patient will modify the home environment and take precautions in the community to prevent injuries.
3. The patient will verbalize an understanding of the chronic nature
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of the disease and appropriate therapies.
4. The patient will make positive coping statements related to a potential altered body image.
Intervention Nursing care of a patient with Paget disease includes education regarding the disease and treatment. Pain management should be addressed; pain is usually the presenting symptom. The pain is usually a deep, aching type of bone pain that may worsen with activity, especially with weight-bearing activities in patients with spinal or lower extremity deformities. For symptomatic patients, first-line medications are nitrogen-containing bisphosphonates such as alendronate, pamidronate, risedronate, and zoledronic acid (Ralston, 2013). Patients may also be prescribed vitamin D if the 25- hydroxy vitamin D level is found to be subclinical (Ralston, 2013). Various methods of pain relief may be tried, including use of NSAIDs and analgesics. Other nursing interventions include instructing an older patient on the use of heat or cold therapy, rest, and other pain relief measures.
The patient’s safety and mobility issues should be assessed. Instruction on simple exercises and the use of assistive devices or consultation with physical or occupational therapists may be of benefit. Occasionally, the patient’s disease may involve the hip or knee joint, resulting in chronic, severe pain and deformity. Arthroplasty may be recommended to correct the deformity and relieve pain.
Helping the patient maintain mobility and independence with daily activities may also positively affect the patient’s body image and attitude toward the chronic disease. Discussions of long-term prognosis and treatment may offer encouragement.
Evaluation Nursing evaluation of a patient with Paget disease includes documentation of the patient’s ability to perform ADLs and his or
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her understanding of the importance of therapy for prevention of pain, deformity, and loss of function. Nurses should specifically evaluate the patient’s need for adaptive equipment such as canes, walkers, or shoe lifts when limb shortening has occurred (Ralston, 2013).
Osteomyelitis Osteomyelitis is an infection of the bone that may be either acute or chronic. Acute osteomyelitis resolves in 4 weeks when treated with antibiotics. Chronic osteomyelitis lasts longer than 4 weeks and does not respond to initial treatment with antibiotic.
Invasion of bone by microorganisms is the cause of osteomyelitis. Microorganisms enter the body directly through an open fracture or stage IV pressure ulcer. Bloodborne bacteria from distant sources such as urinary tract infections may indirectly inoculate bone. Staphylococcus aureus is the most common bacterium seen in osteomyelitis. Other causative agents are gram-negative bacteria such as Escherichia coli and Pseudomonas aeruginosa. Osteomyelitis is seen most often in older adults as a complication of a stage IV pressure ulcer (Cunha, 2002).
Bacteria infiltrate bone through the blood supply and lodge in an area of bone where circulation is sluggish. The bacteria multiply, resulting in an inflammatory response. Pus and vascular congestion develop, causing increased pressure in bone, which leads to ischemia and vascular compromise. Necrotic bone separates from living bone. The devitalized areas are called sequestra.
In an older adult with osteomyelitis associated with a bone injury, the presenting signs are localized pain, tenderness on palpation, erythema, warmth to the touch, and edema. In osteomyelitis associated with infected pressure ulcers, the symptoms may be subtle changes in mental status, low-grade fever, chills, and increased purulent wound drainage. These signs and symptoms may go unnoticed until sepsis occurs (Cunha, 2002).
If treated early, osteomyelitis has a good prognosis. The older adult may not have the classic signs of infection. Often, the first sign of osteomyelitis may be sepsis; in these cases, the prognosis is poor.
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Nursing management Assessment
The nurse caring for older adults with osteomyelitis or for those at risk of developing osteomyelitis involves being aware of the subtlety of the presenting signs and symptoms of infection. Presenting symptoms vary in older adults and range from severe, acute onset to a clinical picture of chronic, subacute illness with minimal pain. Nursing assessment should focus on identifying risk factors predisposing a patient to osteomyelitis, examining any preexisting incisions, especially those related to insertion of a prosthetic device, wounds, decubitus ulcers or ulcers related to peripheral vascular disease or infections carefully, and monitoring vital signs and diagnostic test results. Another potential site for the development of osteomyelitis is the oral cavity in association with poor dentition and periodontal disease (Cunha, 2002). Close inspection of the mouth to look for eroding teeth and ill-fitting dentures and partials, which may contribute to dental abscesses, is important for the prevention of mandibular osteomyelitis (Cunha, 2002).
Diagnosis Nursing diagnoses for a patient with osteomyelitis include the following:
• Pain, related to swelling and tenderness
• Impaired Skin Integrity, related to infected wounds
• Impaired Physical Mobility, related to lower extremity pain
Planning and Expected Outcomes Planning care for a patient with osteomyelitis should include a multidisciplinary approach. Treatment for this condition may be prolonged and therefore may require additional emotional and
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physical support. The long-term treatment for this problem requires family and significant others to be involved in the planning process. Expected outcomes include the following:
1. The patient will report minimum discomfort and adequate pain control.
2. The patient will verbalize an understanding of the need for long- term therapy to eliminate infection.
3. The patient will demonstrate safe and independent mobility.
4. The patient will exhibit intact skin surfaces and no evidence of further infection.
Intervention Prevention of osteomyelitis includes using sterile technique during dressing changes and following strict wound precautions. A patient with infected pressure ulcers will most likely be functionally impaired and return to a long-term care setting for completion of intravenous antibiotic treatment. Older patients with osteomyelitis as a result of other causes will be discharged while receiving oral antibiotics. Discharge planning involves teaching about the importance of completing the course of oral antibiotics, methods of preventing infection, and specific techniques of wound management. An alternative treatment is a medication pump that is surgically implanted to deliver continuous antibiotic to the infection site.
The long-term treatment of chronic osteomyelitis creates psychological coping issues. Lengthy hospitalizations, immobility, and dependence may lead to feelings of anger and decreased self- worth. To help patients cope more effectively, the nurse should allow them to make informed decisions about care and should consult with therapeutic recreation specialists for diversional activities. The prolonged immobility may lead to the complications of immobility and self-care deficits. To prevent these problems, physical and occupational therapists should be consulted to provide individualized exercise programs that promote optimal functioning and prevent disability.
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Evaluation Patients with osteomyelitis should participate fully in all aspects of care. Any wounds or other potential sources of infection should show progressive healing. The patient should be able to verbalize understanding of the chronic nature of treatment, and documentation should include the patient’s involvement in wound care or antibiotic therapy. For older patients who may have difficulty adjusting to the extended hospitalization required for therapy, the nurse should facilitate appropriate consultations.
Amputation Amputation of the lower extremity is a common surgical procedure in older patients. The level of amputation depends on the extent of the disease process. Peripheral vascular disease (PVD), infections, neoplasms, and traumatic injury may all lead to lower extremity amputation; however, PVD is the most common cause in older adults.
In PVD caused by atherosclerosis and diabetes, circulation is inadequate to maintain cellular function. Atherosclerosis and diabetes are predisposing factors in the development of foot or extremity ulcers. The ulcers may be chronically infected. Osteomyelitis with bone destruction results in amputation of the extremity.
In PVD, chronic obstruction of the arteries results in inadequate circulation that causes tissue hypoxia. When the tissues are inadequately perfused for prolonged periods, atrophy of the underlying tissue occurs. This decreased circulation leads to delayed healing of injured feet or lower extremities. When ischemic ulcers do not heal, infection and necrosis or gangrene develops.
Gangrene manifests as a blackened area. The temperature in the affected area is lower than that of the unaffected area, and pain may be present. With the chronically infected extremity ulcer, the ulcer persists despite treatment with antibiotics.
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Nursing management Assessment
Before the surgical procedure, a complete nursing assessment is done to determine the presence of other diseases and their effect on function. The focus of this assessment is on mobility and self-care ability. How does the patient walk? Are assistive devices required? What is the extent of self-care abilities? Assessment of the affected limb includes determining peripheral pulses, temperature, sensation, and movement. The specific characteristics of the ulcer or gangrenous area are noted, including location, size, and color. The individual’s perception of the surgery is ascertained. Older patients should be asked how they feel about the impending surgical procedure and how they see the amputation affecting their health and lifestyle.
Diagnosis Nursing diagnoses for an older patient undergoing amputation include the following:
• Pain, secondary to the surgical procedure and phantom limb sensation
• Disturbed Body Image, related to amputation, impaired mobility, and prolonged immobilization
• Risk for Impaired Skin Integrity, related to the disease process, surgical procedure, and immobility
• Impaired Physical Mobility, related to loss of an extremity
• Activity Intolerance, related to immobility
• Ineffective Coping, related to loss
Planning and Expected Outcomes Nursing care of the patient undergoing amputation includes
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planning for the patient’s preoperative, postoperative, and rehabilitative periods. Multidisciplinary planning is critical for the patient’s recovery and long-term prognosis. Expected outcomes include the following:
1. The patient will report pain relief with the administration of analgesics.
2. The patient will demonstrate acceptance of body image changes, as evidenced by positive statements regarding the body and active involvement in treatment of the stump.
3. The patient’s incisional area will remain clean and without evidence of infection.
4. The patient will safely perform self-care activities within his or her activity and energy expenditure limitations.
Intervention Patient education is an important nursing role in preventing amputation. Because the majority of amputations are a result of PVD, patients need knowledge of how to control the factors that lead to amputation. Patients with diabetes and PVD are taught how to inspect and care for their feet and lower extremities. Instructions include information on promptly notifying a health care provider if changes occur in temperature, sensation, and color. If a sore develops, prompt treatment must be sought. Methods to protect the lower extremity from injury are included in the teaching plan.
Preoperative Care Amputation has a major negative impact on an individual’s body image and has the potential to lead to ineffective coping. To assist with adjustment in the postoperative phase, the nurse provides extensive information about the surgical procedure, including the purpose of the amputation, the potential use of prosthesis, and the rehabilitation program. To assist in the rehabilitation phase, the nurse teaches exercises to strengthen the upper extremities. Postoperative care, including positioning, turning, compression bandaging, and pain control, is discussed. Patients also require
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information about phantom sensations and phantom limb pain. Phantom limb sensation is the feeling of tingling, itching, or aching in the limb that no longer exists; phantom limb pain is a painful sensation that occurs in the limb that no longer exists; both these conditions may become chronic.
Postoperative Care Routine postoperative care is provided in the immediate postoperative period. Patients are monitored carefully for complications that may be a result of preoperative health problems. Complications include hemorrhages and infection. Postoperative dressing depends on the type of prosthesis that will be used. The patient has either an immediate prosthetic fitting or a delayed prosthetic fitting. Because older adults may be debilitated from multiple chronic illnesses and the chronic condition that caused the amputation, they will probably have a delayed prosthetic fitting. Dressings are either rigid or soft in delayed prosthetic fittings. The rigid dressing may be made from either plastic or plaster of Paris. The advantage of this type of dressing is that it decreases edema. Soft dressings consist of Kerlix gauze covered with an elastic wrap that acts as a compression dressing. The compression dressing is used to support the tissues, to decrease pain and edema, and to promote shrinking of the stump. The soft dressing is changed daily using a sterile technique. The wound is assessed for signs and symptoms of infection. A dry dressing is applied directly to the suture site.
In the immediate postoperative period (48 to 72 hours), pain medication is given on a regular schedule. Because of age-related changes in pharmacokinetics and pharmacodynamics, older patients receiving narcotic analgesics should be monitored closely for response and side effects. (See Chapter 20 for in-depth information.) The effect of narcotics may last longer and may also result in excessive sedation, confusion, or respiratory depression. Initial doses should be lower than those used for younger adults. However, on the basis of the individual’s pain relief and tolerance, doses may be increased. Morphine sulfate is the medication used most often in this phase of care.
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Rehabilitative Care The rehabilitative phase starts immediately after surgery with the application of the dressing. The dressing is important for prosthesis fitting because it shapes the stump for the prosthesis. The compression dressing is worn continuously and removed at least two times a day. Care is taken to properly apply the dressing. It should be wrapped snugly and securely but not so tightly that it impairs circulation. A stump shrinker, a continuous tube of elasticized fabric closed at one end, may be used instead of the wrap.
Physical therapy begins when the patient’s condition is stable. Nursing goals for this phase include preventing complications and assisting the patient in reaching an optimal level of functioning. The physical therapy program includes active range of motion, upper extremity strengthening, and gait training. In older adults, walkers are used for ambulation, rather than crutches, because crutches require greater upper extremity strength and endurance. The nurse reinforces the importance of the exercise program and assists the patient in practicing safe transfer techniques.
Prosthetic Fitting and Adaptation Not all older adults are candidates for prostheses. Multiple chronic illnesses may result in a state of debilitation in which the patient will not have the strength and reserve to complete a program of intense prosthetic training. These patients are taught transfer techniques and wheelchair mobility.
Prosthetic fitting is delayed until the stump is healed and well shaped. The fitting is done by a prosthetist (who makes a mold of the stump). As the stump shrinks, adjustments are made in the prosthesis. The patient is instructed to assess the stump daily for signs of irritation from an ill-fitting prosthesis.
The physical therapist and prosthetist instruct the older patient in the use of the prosthesis. The physical therapist also works on gait training. The nurse reinforces the teaching and provides the older patient with reinforcement on performance.
The individual who has had an amputation experiences loss and
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a major threat to body image. The normal response to loss is grief. The grieving process and adjustment to the loss are an individualized response characterized by vacillations in the recognized stages of grief: denial, isolation, anger, bargaining, depression, and acceptance.
Body image is an individual’s subjective perception of the body. Gradual changes in body image are easier to adapt to than those that have an abrupt onset, as in the case of change experienced by an individual who has had an amputation. The adaptation to the change in body image does not always reflect the extent of the injury, but it is related to that individual’s feelings toward himself or herself as a total person. The role of the nurse is to help the amputee discover a new self. Traumatic changes in body image may be characterized by revulsion in viewing the amputation. Viewing the amputation and looking in the mirror at the total self- picture may be difficult. Accepting the body changes is a gradual process. The nurse must allow the patient time to work through this process. The nurse may ask broad, open-ended questions about the body changes, for example, “How do you see yourself?” and “How do you think others see you?” (Ebersole, Touhy, Hess et al., 2008). Talking with other amputees on a one-on-one basis and in support groups is helpful for patients in adapting to changes in body image. The nurse should give positive but realistic feedback about the older patient’s progress in functional abilities (see Nursing Care Plan: Amputation).
Evaluation Evaluation is based on achievement of expected outcomes, as evidenced by the patient exhibiting a positive outlook about the body changes, performing self-care and other activities safely and adequately, and experiencing pain relief over time, until eventually analgesic pain medication is not needed. Documentation of these activities is critical for the multidisciplinary evaluation of the older patient’s progress and is used as the basis for further care planning.
Polymyalgia Rheumatica
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Polymyalgia rheumatica (PMR) is a chronic inflammatory condition characterized by sudden onset of muscle stiffness and aching (myalgia) in the neck, shoulders, and pelvic girdle. The disease occurs after the age of 50 years, most often in those 65 years or older. Women are affected more compared with men (Salvarani, Cantini, & Hunder, 2008). The cause of PMR is not known. Infection and an altered immune response have been suggested but not proven as the cause. Likewise, a genetic predisposition is suggested but not confirmed. The pathophysiology of PMR is not clearly understood.
The clinical presentation of PMR is similar to that of RA and osteoarthritis. Symptoms include muscle stiffness and aching in the neck, shoulders, and pelvic girdle. The muscle stiffness is present in the morning and lasts more than 1 hour. Constitutional symptoms such as fatigue, fever, often with night sweating, malaise, anorexia, depression, and weight loss may be present. Initially, the pain may be limited to one area, but it generally develops in a symmetric fashion. Objective signs of muscle weakness are not present on physical examination. Check for signs of carpal tunnel syndrome such as paresthesia of the thumb and index finger. Look for swelling with pitting edema in the ankles and the top of the feet (Salvarani et al., 2008). Diagnostics indicative of PMR are an elevated erythrocyte sedimentation rate (ESR) and cross-reactive protein (CRP). Patients with PMR generally are found to be anemic. PMR is treated with corticosteroids that are tapered over time. Symptoms of aching, stiffness, and fatigue may begin to resolve in about 1 to 2 days, and patients will remain on long-term corticosteroids until the laboratory values return to normal. This marked improvement so soon after initiation of treatment is not seen in RA or osteoarthritis.
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Nursing management Assessment
A thorough history of the patient’s symptoms, physical examination, and functional assessment are important in determining the effect of the disease on functional abilities.
Diagnosis Nursing diagnoses for a patient with PMR include the following:
• Pain, related to muscle stiffness and aching
• Impaired Physical Mobility, related to pain and muscle stiffness
• Fatigue, related to systemic symptoms
• Self-Care Deficit (specify), related to muscle stiffness
• Ineffective Coping, related to the chronic nature of the disease
Nursing care plan
Amputation
Clinical Situation Mr. C is a 78-year-old retired truck driver with a medical history of diabetes mellitus – type 2 peripheral vascular disease (PVD), and a chronic right foot ulcer. Because the foot ulcer did not respond to conservative treatment, he underwent a right below- the-knee amputation. Before this surgical procedure, Mr. C had been hospitalized for 3 weeks for treatment of the foot ulcer. During the hospitalization he became weak and deconditioned. He now requires assistance with eating and activities of daily living (ADLs) and maximum assistance for transfers. Mr. C
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complains of phantom limb pain and requires pain medication every 4 to 6 hours.
The prolonged illness, hospitalization, and amputation have caused Mr. C to feel hopeless. He has told the nurses he is tired of being in the hospital, sick, and in pain. Mr. C has also verbalized feelings about not being the man he once was. He does not initiate any self-care and needs encouragement to complete self- care. Mr. C has a supportive wife and family. His wife has rheumatoid arthritis and thinks it will be difficult for her to care for her husband unless he participates in his care and is rehabilitated with his prosthesis. Mr. C is stable 2 days postoperatively and is beginning physical therapy for preprosthetic training.
Nursing diagnoses Disturbed Body Image, related to amputation, impaired mobility,
and prolonged hospitalization
Pain, related to the surgical procedure and phantom limb sensation
Risk for Impaired Skin Integrity, related to disease process, surgical procedure, age-related changes, and immobility
Impaired Physical Mobility, related to below-the-knee amputation and prolonged immobility
Activity Intolerance, related to prolonged immobility, deconditioning, and disease processes
Ineffective Coping, related to amputation
Disabled Family Coping, related to spouse’s chronic illness and disability
Outcomes The patient will verbalize feelings of acceptance of change in body
image.
The patient will verbalize that pain is tolerable.
Pain will not interfere with ability to participate in ADLs.
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The incision will heal without signs or symptoms of infection.
Skin will remain free from pressure ulcers.
The patient will transfer independently and walk 10 feet with a pickup walker.
Range of motion will remain within normal limits.
Flexion contracture will not develop.
The patient will attend and participate in a daily therapy program with a normal physiologic response.
The patient will use effective coping strategies and participate in a rehabilitation program.
The family will use effective coping strategies and support the patient’s participation in the rehabilitation process.
Interventions Allow verbalization of feelings; actively listen to feelings.
Give positive feedback for progress made in self-care and mobility and for aspects of general appearance.
Encourage normal activities such as dressing in street clothes.
Encourage participation in support groups.
Assess pain and effectiveness of medications.
Administer pain medications, as ordered.
Provide diversional activities and alternative treatments such as relaxation techniques.
Assess incision and pressure areas (use a risk assessment scale) daily for signs of infection or pressure ulcers.
Change surgical dressing using aseptic technique.
Reposition every 2 hours; position to keep pressure off bony prominences.
Teach the patient how to change positions.
Provide adequate caloric, protein, and fluid intake.
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Wrap stump with compression dressing or stump shrinker.
Consult with physical therapy for a program of muscle strengthening, transfer training, and gait training.
Reinforce physical therapy training.
Give positive feedback for gains made.
Teach transfer techniques; assist with transfers.
Teach the safe use of a walker.
Give pain medications 30 to 60 minutes before therapy.
Do not elevate stump on pillows.
Keep stump in good alignment; prevent flexion contractures.
Reinforce the use of active range-of-motion exercises.
Encourage lying on the abdomen for 30 minutes two times a day.
Encourage participation in the therapy program.
Gradually increase activity.
Allow at least 60 minutes of rest after therapy.
Monitor vital signs before, during, and after therapy.
Assist the patient in identifying previously successful coping skills.
Suggest and describe effective coping skills.
Encourage activities that enhance self-esteem.
Encourage the use of support systems.
Encourage participation in an amputation support group; include the family, especially the spouse, in the support group.
Encourage the spouse’s verbalization of feelings when the patient is not present.
Suggest and describe effective coping skills to her.
Suggest taking time to care for herself.
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Planning and Expected Outcomes Expected outcomes for an older patient with PMR include the following:
1. The patient will report pain relief with initiation of treatment.
2. The patient will correctly describe pharmacologic therapy, including purpose, action, and side effects of prescribed drugs.
3. The patient will establish an activity and rest pattern based on limitations imposed by the disease.
4. The patient will incorporate effective coping strategies in disease management.
5. The patient will correctly state the treatment rationale and prognosis.
Intervention The medical diagnosis of PMR is difficult to make; because symptoms are similar to those of RA and osteoarthritis, it is often misdiagnosed. The older patient who has been to many physicians in an attempt to receive the correct diagnosis and proper treatment may be frustrated, angry, and worn out. The nurse should listen to the patient’s concerns and give information to the patient about the disease and the treatment plan. This includes information about the treatment with corticosteroids and their side effects. The nurse monitors the patient for the development of side effects from long- term corticosteroid use such as infection, osteoporosis, fractures, and diabetes mellitus. The older patient should be reassured that the dose of medication will be tapered and that eventually the symptoms will subside; however, it should be emphasized that the medication needs to be continued despite the patient becoming symptom free. Patients should also be informed that it is common to have a relapse of PMR and that, now being familiar with the disease presentation, they should report any new onset of symptoms right away to their care providers (Kremers, Reinalda, Crowson et al., 2005).
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Evaluation Patients with PMR need to understand the chronic nature of the disease and be able to maintain functional abilities. Pain management is necessary for the older patient to perform ADLs, so the patient will need to be familiar with the medications and their side effects. Providing appropriate education about the disease and symptom management will assist in acceptance. Documentation of education, pain assessment, and functional abilities is important for ongoing planning and care of the patient.
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Foot problems The foot is often overlooked in the assessment and care of older adults. Foot problems, especially pain, are common in older adults. The incidence and severity of foot problems increase with age. After age 65, 75% of the population complains of foot problems. More than 80% of those older than age 55 demonstrate arthritic changes on radiography. Foot problems may cause an unsteady gait and may result in falls (U.S. Department of Health and Human Services [USDHHS], 2008).
The foot is a complex structure composed of 26 bones, 33 joints, and numerous ligaments, tendons, and muscles. The foot is necessary for ambulation. During standing and ambulation, the foot provides body support and absorbs shock. Painful feet may be the result of congenital deformities, weak structure, injuries, and diseases such as diabetes, RA, and osteoarthritis. Ill-fitting shoes cause foot pain by crowding the toes and impeding normal movement. With aging, feet show signs of wear and tear. The cushioning layer of fat on the soles of feet becomes thin. Years of walking cause the metatarsal bones to spread and the ligaments to stretch, which results in widening of feet.
Corns Corns are thickened and hardened dead or hyperkeratotic tissue that develops over bony protuberances. Corns often cause localized pain. Corns are caused by ill-fitting or loose shoes that constantly place pressure on bony prominences. Soft corns are produced by the bony prominence of one toe rubbing against the adjacent toe in the web space between the toes. Soft corns are macerated because of moisture in the web space. Hard corns, also known as heloma duram, have a dry mass of keratosis with a central hard core (Figure 25-13). Heloma duram are found on the plantar side of the foot often over the fifth metatarsal and the surrounding metatarsal head (Schalock & Sober, 2009). Warm water soaks are used to soften corns before gently rubbing with a pumice stone or callus file. Another
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treatment is gentle débridement by a podiatrist. To relieve pain and prevent the development of corns, moleskin or cotton pads are placed over areas subjected to rubbing and pressure. Wider and softer shoes are recommended; wearing high-heeled shoes should be avoided by older women (Bennett, 2006). Use of topical applications of salicylic acid should be avoided in older adults because these may cause irritation, burns, or infection, especially in those with diabetes and impaired circulation.
FIGURE 25-13 Hard corn with keratotic buildup. (Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD. From Porter, D.A. & Schon,
L.C. [2008]. Baxter's the foot and ankle in sport [2nd ed.]. St. Louis: Mosby.)
Calluses Calluses, or plantar keratoses, are dead tissue found on the plantar
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surfaces of the feet. They form under the metatarsal heads, most commonly the second and third heads. Calluses are also common in people who have bunions (Freeman, 2002). About 50% of people older than 65 years have some degree of plantar calluses. The aging changes of decreased toe function and decreased fat padding contribute to their development. Soft-soled shoes with additional cushioned insoles are recommended. Treatment is the same as for corns.
Bunions Bunions, or hallux valgus, have the greatest prevalence among those older than 50 years, and women experience them four times more often compared with men because women tend to wear narrow, pointed, high-heeled shoes. Arthritis and other age-related changes such as ligament and tendon atrophy predispose older adults to bunions.
Bunions appear as bony protuberances on the side of the great toe (Figure 25-14). With bunions, the large toe angles laterally toward the second toe. As the great toe rubs against the shoe, the bursa becomes inflamed, which results in bursitis and pain. Initial treatment of bunions involves wearing soft leather shoes that are flat and wide and that are laced up. Walking or running shoes with a wide toe box prevent rubbing on the bunion. Moleskin bunion pads may be used to protect the bony protrusion. NSAIDs may be prescribed to reduce inflammation and pain. Surgical interventions are used after conservative treatment has failed. The surgical procedure includes removal of the bursa sac and correction of the bony deformity.
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FIGURE 25-14 Hallux valgus angulation of first three toes; overlapping of middle toe on fourth toe; and wide, flat metatarsus. (From Mann, R.A. & Coughlin, M.J. (1993). Surgery of the foot and ankle (vol 1, 6th
ed.). St. Louis, MO: Mosby.)
Hammertoe Hammertoe is a deformity of the second toe. In this deformity, the metatarsophalangeal joint is dorsiflexed, the proximal interphalangeal joint is plantar flexed, and callus formation occurs on the dorsum of the proximal interphalangeal joint and the end of the affected toe. The result is a toe that has a clawlike appearance (Figure 25-15). Improperly fitted shoes, muscle weakness, and arthritis are causes for hammertoe. Symptoms include pain and
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burning on the bottom of the foot and problems walking in shoes. Initially, pain may be relieved with the use of a moleskin toe pad. Other treatments for hammertoe include metatarsal arch support, orthotics, splints, and passive manual stretching of the proximal interphalangeal joint. Surgical correction is done if conservative treatment is ineffective.
FIGURE 25-15 Hammertoe associated with hallux valgus. (From Crenshaw, A.H. (Ed.). (1992). Campbell’s operative orthopaedics (vol 4, 8th ed.). St.
Louis, MO: Mosby.)
Nail Disorders Toenail problems are common in older adults. Older adults with problems of the nails should be referred to a podiatrist.
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Onychauxis is described as hypertrophic nails whose borders curve into the soft tissue of the toes. This disorder may cause nail bed ulcers, infection, and pain.
Onychomycosis is a localized fungal infection of the toenail that is seen most frequently in older adults. Degeneration of the nail plate causes changes in the growth and appearance of the nail. Onychomycotic nails may have simple scaling or may be totally destroyed by the fungus. Initially, the nail becomes brittle and hypertrophic. The nails may be white, yellow, or brown in color. Ridges and pitting of the nail are common. Generally, the infection spreads between the nails. Predisposing factors for onychomycosis are moisture, ill-fitting footwear, recurrent trauma, and diabetes.
Treatment of onychomycosis is difficult because of the composition of the nail and the involvement of the nail matrix. Topical antifungals such as clotrimazole are generally used for several months. The oral antifungal agents such as terbinafine and itraconazole are generally not used in older adults because many older adults have a decreased pedal blood supply. The older patient with onychomycosis that does not respond to topical antifungal agents should be referred to a podiatrist. The podiatrist will débride the nail at periodic intervals.
Patient Education The nurse should educate the older adult about the predisposing factors, prevention, and treatment of onychomycosis and the need for ongoing foot care, including inspection of feet for signs of infection and application of the medication.
The nurse has an important role in educating patients about proper foot care and footwear. Well-fitting shoes are essential for the prevention of foot problems. The shoes should not crowd the toes and should be of the correct length and width. Shoes that are too short or narrow may force the great toe into a position of hallux valgus. Shoes should be wide enough to allow bending of the toes and movement of the foot muscles. Adequate arch support should be provided. Older women should avoid wearing high heels (Bennett, 2006).
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Patients should be taught foot care that includes daily hygiene and changing of socks. Socks or stockings should be loose enough to avoid the development of pressure ulcers. Toenails should be trimmed with nail clippers; patients with impaired vision, impaired mobility, or self-care deficits may require assistance to perform this task safely. The nails should be trimmed straight across so that the development of ingrown toenails and infections is prevented. If the foot problems persist, a podiatrist should be consulted.
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Muscle cramps Idiopathic muscle cramps without muscle weakness are common in older adults. The cramps may start during rest or after minor exercise. Muscle cramps generally affect the calf or foot muscles, producing plantar flexion of the foot or toes. They occur most frequently at night during sleep.
Muscle cramps may be prevented by stretching the affected muscles for several minutes at bedtime. If cramping occurs, stretching will generally relieve the discomfort. Calf muscles should be stretched, with two or three 1-minute intervals and 1-minute rest periods between stretches. Stretching exercises improve muscle flexibility and reduce the motor activity in the affected muscles.
Quinine sulfate is sometimes prescribed for muscle cramps; however, its effectiveness has been questioned. The side effects of quinine therapy for muscle cramps may increase the concentration of digoxin, and an overdose may cause confusion.
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Summary Problems of the musculoskeletal system may have a great effect on the day-to-day life of older adults. Conditions such as osteoarthritis, RA, osteoporosis, and fractures may result in functional disability, chronic pain, and a decreased quality of life. The role of the nurse working with older patients with musculoskeletal disorders is to promote safe, optimal functioning with regard to mobility and self- care. Interventions to promote comfort and to relieve pain are critical in the maintenance of function. To prevent serious disability, it is essential that patients resume activity as soon as possible after episodes of acute illness. A key nursing role is to educate patients about the importance of musculoskeletal activity in maintaining function.
Home care
1. Assessment of the musculoskeletal system includes examination of bones, muscles, and joints in homebound older adults.
2. Instruct caregivers and homebound older adults about reportable signs and symptoms related to the musculoskeletal system disease or disorder being treated and when to report these changes to the home care nurse or physician.
3. Instruct caregivers and homebound older adults on the name, dose, frequency, side effects, and indications of both the prescribed and over-the-counter medications being used to treat the identified musculoskeletal problem.
4. Musculoskeletal problems increase safety hazards (e.g., falls) in homebound older adults.
5. Assess for functional impairments such as inability to provide self-care and perform instrumental activities of daily living
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(IADLs). If necessary, have social worker identify community resources for additional assistance with identified impairments, such as transportation and food preparation.
6. Assess the activity tolerance level, which may be affected by musculoskeletal problems.
7. Instruct caregivers and homebound older adults about the diagnosed musculoskeletal disease or disorder, focusing on self-care measures that maintain or promote independence.
8. Have the physical therapist and the occupational therapist evaluate and teach caregivers and homebound older adults how to adapt the environment based on the specific musculoskeletal problem (e.g., gait training, use of handheld devices to assist with eating, splints, and prostheses).
9. Encourage ambulation in a safe manner. Stretching exercises that improve posture should be part of the nursing interventions.
10. An exercise program may be suggested after consulting with the physician.
11. Instruct caregivers and homebound older adults on the necessity of calcium supplements and exercise to maintain proper skeletal function and prevent bone loss.
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Key points • A high incidence of musculoskeletal disorders exists among older
adults.
• Musculoskeletal disorders are a major cause of functional impairments in older adults.
• Age-related changes in the musculoskeletal system may predispose older adults to falls.
• The most common sites of fractures in older adults are the hips, wrists (Colles fracture), and vertebrae.
• Demographic factors associated with osteoporosis include female gender, age, and white race.
• Lower extremity amputations in older adults are most often the result of PVD or diabetes.
• Symptoms of osteoarthritis, RA, gouty arthritis, and PMR are similar, but treatments differ.
• Physical activity and exercise are key to preventing disability from musculoskeletal disorders in older adults.
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Critical thinking exercises 1. An 83-year-old woman has suffered a musculoskeletal injury that requires a period of bed rest and limited mobility. How will age affect her ability to tolerate a period of decreased mobility? Explain.
2. You are caring for two patients: a 74-year-old man with gouty arthritis and a 68-year-old woman with RA. What aspects of their care will be similar? What aspects will be different?
3. A 72-year-old man lived a fairly sedentary lifestyle as an accountant. Now that he is retired, he recognizes the need to be active to maintain his health as long as possible. He is concerned, however, that it is too late for him to start exercising because he has never engaged in such activities. What encouragement, if any, can you give to him, and what suggestions can you make for an exercise program?
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* Previous authors: Karen Van Dyke Lamb, BS, MS, ND, CS; Marilyn Cummings, MS, RN; and Sue E. Meiner, EdD, APRN, BC, GNP.
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C H A P T E R 2 6
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Urinary Function Jennifer J. Yeager, PhD, RN
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe how aging affects normal bladder function.
2. List four possible causes of acute incontinence.
3. List the types of persistent incontinence and their clinical characteristics.
4. List the components of a continence history.
5. Discuss the role of functional and environmental assessment in the evaluation of urinary incontinence.
6. Discuss how the nurse can use tests of provocation in making a nursing diagnosis of patients with urinary incontinence.
7. Describe the behavioral interventions used to treat urinary incontinence in cognitively intact patients.
8. Develop a patient teaching plan for a patient with urge incontinence.
9. Develop a caregiver teaching plan for a patient with functional urinary incontinence resulting from dementia.
10. Describe the effects of normal aging on renal function.
11. Identify the possible causes of acute and chronic renal failure.
12. Identify the treatment options for patients with bladder cancer.
13. List supportive services for the individual who has undergone a cystectomy.
14. Differentiate between benign prostatic hypertrophy and prostate cancer.
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15. Identify the treatment options for patients with prostate cancer.
16. Apply the nursing process in the care of older adults with select urinary system conditions.
http://evolve.elsevier.com/Meiner/gerontologic
Urinary incontinence (UI) is one of the most common health problems affecting older adults. Urinary incontinence is an involuntary loss of bladder control that is sufficient to interfere with activities. It is a significant cause of disability and dependency. Physical health, psychological well-being, interpersonal relationships, social functioning, and health care costs are adversely affected by incontinence. Individuals with UI are at increased risk for urinary tract infection (UTI), skin problems (e.g., rashes, infections, and breakdown), and falls. Incontinence contributes to psychological distress and social isolation. It is a cause of caregiver burden and plays a significant role in the decision to place older adults in long-term care facilities. The cost of UI is staggering; the combined estimate of direct and indirect costs is upward of $65 billion per year (Ganz, Smalarz, Krupski et al., 2010).
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Age-related changes in structure and function UI is not a normal part of aging. Normal age-related changes in the lower urinary tract (Figure 26-1) increase older adult’s susceptibility to other insults in the lower urinary tract. As a result, these insults (e.g., drug side effects, UTIs, and conditions impairing mobility) are more likely to produce incontinence in older patients than in younger ones.
FIGURE 26-1 Male bladder. (From Lewis, S.M., Dirksen, S., Heitkemper, M.M., Bucher, L., & Camera, I.M. (2011). Medical-surgical nursing: Assessment and
management of clinical problems (8th ed.). St. Louis, MO: Mosby.)
With age, bladder capacity decreases, the prevalence of involuntary bladder contractions increases, and more urine is produced at night. The reduction in bladder capacity and increased involuntary bladder contractions may lead to urgency and frequency. Many older adults find that they have to empty their
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bladders more often than they did when they were younger. Increased urine formation at night leads to nocturia, defined as waking to urinate one or more times during the night (Boongird, Shah, Nolin, & Unruh, 2010). Nocturia occurs frequently in the older adult and is a major contributor to disruption in normal sleep patterns and falls.
Changes occur in the urethra because of the aging process and because of decreased levels of estrogen after menopause. Thinning and increased friability of the urethral mucosa may contribute to urgency and frequency. A decrease in muscle tone and bulk may decrease urethral resistance. In addition to the changes in the urethra, declining estrogen levels affect pelvic floor muscle tone and function.
As men age, the prevalence of benign prostatic hypertrophy (BPH) increases, with more than 50% experiencing BPH by the time they are over age 65. Enlargement of the prostate may interfere with bladder emptying and precipitate involuntary bladder contractions, resulting in incontinence or urinary retention.
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Prevalence of urinary incontinence UI is common in older adults, affecting approximately 30% of individuals (Onukwugha, Zuckerman, McNally et al., 2009). UI is more common among nursing facility residents, affecting 50% to 75% of all nursing facility residents (Offermans, Du Moulin, Hamers, Dassen, & Halfens, 2009). UI is an independent predictor for nursing facility admission and is associated with irritant dermatitis, pressure ulcers, falls, significant sleep interruptions, and UTIs (Halter et al., 2009).
Myths and Attitudes Despite the significant number of older adults with UI, most do not report the condition or seek medical treatment. This may be attributed to embarrassment, the belief that it is a normal consequence of aging, or the belief that it cannot be treated. Research studies have indicated that common beliefs about UI may lead older patients, particularly older women, to think that incontinence is not worth reporting to health care providers.
Many health care providers do not ask patients about incontinence. Even when patients inform them about incontinence, many providers ignore the problem and do not provide adequate diagnosis and treatment. Screening for urinary incontinence has increasingly become recognized as an indicator of quality of care (Halter et al., 2009); it has been suggested that assessment of continence status be incorporated as the “sixth vital sign” (Joseph, 2003).
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Common problems and conditions Acute Incontinence UI is generally classified as either acute (transient) or chronic (persistent). Acute incontinence has a sudden onset, is generally associated with some medical or surgical condition, and generally resolves when the underlying cause is corrected (Ouslander, 2003) (Box 26-1). Medication is a common cause and should always be suspected in cases of new-onset incontinence. Although the exact prevalence of acute incontinence is not known, any new onset of incontinence should be considered acute and possible precipitating causes ruled out.
Box 26-1
Causes of acute urinary incontinence • Restricted mobility
• Fecal impaction
• Atrophic vaginitis or urethritis
• Delirium
• Urinary tract infections
• Endocrine disorders:
• Poorly controlled diabetes mellitus
• Hypercalcemia
• Alcohol
• Caffeine
• Medications:
• Anticholinergics
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• Hormone therapy
• Alpha-adrenergic blockers
• Alpha-adrenergic agonists
• Calcium channel blockers
• Diuretics
• Psychoactive drugs
• Opioids
Chronic Incontinence Persistent incontinence is not related to an acute illness. It continues over time, often becoming worse. Major types of persistent incontinence include urge, stress, overflow, functional, and mixed incontinence (Shenot, 2012).
Urge Incontinence Urge incontinence is the most common type of incontinence in the older adult population (Shenot, 2012). Urge incontinence may be associated with an overactive bladder. Common causes of urge incontinence include local genitourinary conditions such as UTI, medications, bladder irritants (e.g., caffeine and carbonated drinks), bowel issues, dementia, stroke, Parkinson disease, and cancers of the uterus and the urinary system. Individuals with urge incontinence typically give a history of involuntary urine loss after a sudden urge to void. Urgency and involuntary urine loss may be precipitated by the sound of running water, cold weather, or the sight of a toilet. Urinary accidents are sometimes large. Urge incontinence is often accompanied by nocturia and complaints of daytime frequency, with individuals often needing to void more than seven times per day (Mayo Clinic Staff, 2011).
Stress Incontinence Stress incontinence is the second most common form of incontinence in women. Involuntary loss of urine follows a sudden increase in intraabdominal pressure. Stress incontinence occurs as
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pressure in the bladder (intravesical pressure) exceeds urethral resistance. This may be caused by lack of estrogen, obesity, previous vaginal deliveries, surgeries, or all of these factors (Halter et al., 2009). Individuals with stress incontinence often leak urine with physical exertion such as coughing, sneezing, laughing, lifting, and exercise. Older women may report leakage when they change position (e.g., get out of a chair) or lift small weights such as a small child. These activities increase intraabdominal pressure, which increases bladder pressure. If the urethra, supporting tissues, and bladder neck are abnormal, urethral resistance may be too low to withstand the increased pressure on the bladder, which results in involuntary urine loss. Stress incontinence is unusual in men, and it mainly occurs after transurethral surgery for benign conditions or after surgery or radiation therapy for lower urinary tract malignancy when the anatomic sphincters are damaged (Halter et al., 2009).
Overflow Incontinence Overflow incontinence occurs when bladder pressure in a chronically full bladder rises to a level higher than urethral resistance, causing involuntary loss of urine. On the basis of the history alone, overflow incontinence may be difficult to differentiate from stress or urge incontinence. It is the second most common form of incontinence in men (Shenot, 2012). Typically, individuals with overflow incontinence complain of constant dribbling. They may have both daytime and nighttime accidents. Overflow incontinence may result from urethral blockage (e.g., BPH, scar tissue, stones), weakened bladder muscles, nerve injury or damage (e.g., diabetes, Parkinson disease, and multiple sclerosis), constipation, or medications (Mayo Clinic Staff, 2011; Shenot, 2012).
Functional Incontinence In functional incontinence, incontinence results from physical, mental, psychological, or environmental factors interfering with the ability to make it to the toilet on time. Individuals with physical disabilities affecting their gait or their ability to undress may have
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difficulty reaching the bathroom on time and unbuttoning or unzipping clothes in a timely manner; individuals with cognitive impairment may not recognize their need to void or may have difficulty finding the toilet and preparing to void. Those with psychological problems such as severe depression may lack the motivation to toilet appropriately. Environmental factors may play a role in causing incontinence, especially in acute and long-term care settings. Residents confined to beds and wheelchairs, or restrained, are dependent on caregiver assistance for toileting. If that assistance is not available in a timely manner, the resident often becomes incontinent. This is especially true in the case of urgency. Functional incontinence should be a diagnosis of exclusion.
Mixed Incontinence Mixed incontinence is described as a combination of two or more other types: stress, urge, overflow, or functional incontinence. Among community-dwelling older adults, mixed urge incontinence and stress incontinence is common. Urge incontinence with functional incontinence is most common in residential facilities.
Diagnosis of Urinary Incontinence The purpose of the diagnostic evaluation for UI is threefold (Ouslander, 2003):
1. To identify potentially reversible factors that may be contributing to the incontinence
2. To identify individuals who need more than a basic evaluation
3. To determine the type of incontinence so that appropriate treatment can be initiated
The basic evaluation for all persons with UI includes a history, physical examination (to include pelvic examination for women and rectal examination), postvoid residual measurement, blood chemistry, and urinalysis. Urodynamic testing or cystoscopy may also be necessary (Shenot, 2012).
Incontinence can be cured, or the problem significantly
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alleviated, if treatable factors contributing to the incontinence are identified and appropriate medical and nursing interventions are implemented. As quality of life is significantly impacted by UI, efforts to restore urinary continence should be based on an older person’s satisfaction and tolerance of the interventions and strategies to achieve the outcome.
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Nursing management Assessment
The purpose of the nursing assessment is to determine the type of incontinence and contributing factors so appropriate nursing interventions can be planned and implemented. In addition, nursing assessment enables the nurse to identify patients needing referral to a physician or nurse practitioner for a more complete evaluation. Assessment consists of a history assessment, functional assessment, environmental assessment, psychosocial assessment, physical examination, tests of provocation, and evaluation of bladder habits.
History During the history assessment, information is collected about the patient’s incontinence symptoms and bladder habits, general health and functional status, medical problems, current medications, and past medical, surgical, and obstetric histories. If patients are able to provide the history, they are the most accurate source of data. In situations in which a patient has cognitive impairment, the nurse may need to rely on secondary sources such as family caregivers or medical records.
When taking the incontinence history, the following information should be collected:
• The onset of the incontinence
• The frequency and volume of accidents
• The circumstances that cause urine loss, including (1) any leaking of urine when the patient coughs, sneezes, laughs, changes positions, climbs steps, exercises, has an urge to void, hears running water, is cold, or is sleeping, (2) any involuntary urine loss caused by caffeine, alcohol, or any medication, and (3) whether the patient leaks urine and is not aware that it has occurred, has any postvoid dribbling, or leaks continuously
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• Bladder habits, including the frequency and volume of daytime and nighttime urination
• Daily fluid intake, including caffeine intake
• Self-management techniques the patient has used to manage the incontinence (e.g., frequent voiding, restricting the volume or type of fluid, incontinence products, urine collection devices)
• Previous evaluation and treatment of the incontinence, including the patient’s perception of the effectiveness of previous treatment measures
• Any other urinary tract symptoms, including urgency, burning, pain, hematuria, weakness of the urinary stream, intermittent stream, and difficulty emptying the bladder completely
• Bowel habits, including constipation, laxative use, and fecal incontinence
In addition to the incontinence history, the nurse should also obtain a general health history. The nurse should inquire about current medical problems, specifically problems that may affect bladder function (e.g., diabetes mellitus, congestive heart failure, bladder and kidney infections, strokes, Parkinson disease, depression, memory problems, mobility problems, problems with coordination, and other neurologic problems or injuries). The nurse should ask about current medications and treatments, including the use of over-the-counter (OTC) medications or complementary and alternative medications. The nurse should inquire about previous surgeries, including past urologic or gynecologic surgery. The nurse should ask men specifically about prostate surgery and radiation; the nurse should obtain from women their obstetric history, including information about the number of pregnancies, type of delivery, any complications during delivery, and birth weights of the infants. The nurse should inquire postmenopausal women about estrogen replacement therapy.
Functional Assessment Because functional problems often contribute to UI, functional assessment is one of the most important parts of the evaluation.
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Information should be collected about the patient’s ability to perform normal activities of daily living (ADLs), including grooming, dressing, getting in and out of bed, and walking. Patients who have difficulty performing these ADLs often have difficulty toileting. Functional status may be assessed by using unstructured questioning or by using a structured questionnaire such as the Older Americans Research and Service Center Instrument (OARS) (Duke University Center for the Study of Aging and Human Development, 1978) or the Katz Index of ADLs (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963).
Direct observation provides the most valuable information about the patient’s mobility and toileting ability. The following observational guidelines may be used in practice (Burgio & Goode, 1997):
1. Place the patient 15 feet from the toilet.
2. Ask the patient to approach the toilet, either on foot or in a wheelchair, and to prepare to take the position for voiding.
3. Note the time it takes the patient to reach the toilet and any difficulty in getting undressed or positioning for voiding.
4. If the patient is unable to toilet independently and a caregiver normally assists the patient, observe the toileting procedure with caregiver assistance.
Mental status should be assessed during the functional assessment. Cognitive ability may affect the patient’s ability to recognize the need to urinate, locate the toilet, and undress for toileting. In addition, knowledge of a patient’s cognitive status is essential in planning nursing interventions for incontinence. The most efficient way to assess cognitive status is to use a standardized instrument such as the Folstein Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975).
Environmental Assessment Environmental barriers may contribute to UI. For example, the bathroom may be too far away or inaccessible to the patient or the toilet may be too low or difficult for the patient to get on and off.
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The patient may need assistance in toileting, which may not be readily available. For these reasons, environmental assessment is an important component of the evaluation of UI. It is necessary to note the following:
• Proximity of the toilet
• Any barriers between the patient’s usual location and the toilet, for example, poor lighting, steps, furniture, or other objects
• The size of the bathroom: Is it large enough to accommodate the patient and any assistive devices (wheelchair or walker) that must be used?
• Toilet height: Is it adequate or too high or low?
• Presence of grab bars, if needed
• Availability of caregiver or nursing staff assistance, if needed
• Availability of a call bell, if needed
Psychosocial Assessment Psychosocial assessment focuses on the effect of incontinence on the patient’s life and on the availability and quality of caregiver assistance. The nurse should ask the patient how incontinence has affected social activities (e.g., visiting family and friends and attending social functions and church), self-esteem, mood, sexual activity, and family relationships; the nurse should also assess the patient’s desire and willingness to participate in a treatment program for incontinence. Effective nursing interventions for UI require active patient involvement, so motivation is an essential component of success. If a patient does not want treatment for incontinence, the reasons should be explored. What is the reason? For example, is it lack of knowledge; depression; or an overwhelming physical, social, or psychological problem?
If the patient depends on another person’s assistance in toileting, caregiver assessment is an essential component of the psychosocial assessment. Is the caregiver (1) physically able to assist the patient, (2) available on a consistent basis, and (3) willing to assist the patient? What is the caregiver’s attitude toward the patient and
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toward incontinence? Does the caregiver have an adequate understanding of the problem and its management?
Physical Examination The physical examination should include the following:
• Inspection of gait and balance
• Neurologic assessment of any weakness, paralysis, or sensory deficit in the lower extremities
• Abdominal examination for bladder distention, suprapubic tenderness (occurs in bladder infections), and costovertebral angle tenderness (occurs in kidney infections)
• Rectal examination for fecal impaction; rectal sensation and tone; and, in men, the size, shape, and consistency of the prostate gland
• Measurements of sitting and standing blood pressure to detect orthostatic hypotension and dizziness
• Pelvic examination, including inspection of the vagina for atrophic changes, vaginitis, cystocele, rectocele, or uterine prolapse
Tests of Provocation Additional useful information can often be gathered by a performance of simple tests of provocation while the patient has a full bladder. The physician or advanced practice nurse generally performs these during urodynamic testing. They may, however, also be performed if the patient has a full bladder from drinking fluids. A number of useful tests are listed in this section. During each maneuver, the nurse should note any involuntary urine loss either by direct observation or by checking a previously applied dry absorbent pad. If the patient leaks urine during any of the maneuvers, the patient should be asked to try to stop the flow of urine. This allows the nurse to evaluate pelvic floor muscle strength. Perform the following provocations:
1. Ask the patient to cough three or four times while in a supine
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position.
2. Ask the patient to stand; note any involuntary urine loss during the position change.
3. Ask the patient to cough three or four times while standing.
4. If the patient’s physical condition permits, ask him or her to bounce on the heels three or four times.
5. Have the patient listen to running water.
6. Ask the patient to walk to the bathroom.
7. Have the patient wash his or her hands.
The first four of these are stress provocations, whereas the fifth and seventh are urge provocations. Leaking when walking to the bathroom may be caused by urge incontinence (i.e., the patient experiences an urge to void) or stress incontinence (i.e., the physical activity of walking may result in leaking in some patients with severe stress incontinence).
Bladder Habits One of the most effective ways to assess bladder habits is to ask the patient or caregiver to keep a diary of the frequency of urination and any incontinent episodes, their relative volume, and the circumstances that precipitated their occurrence (e.g., coughing, sneezing, urgency, and changing position). Figure 26-2 shows a sample bladder diary. Bladder diaries may be used in the home, hospital, or nursing facility and may be kept by the patient or caregiver. They provide a more objective and accurate measure of a patient’s bladder habits than can be obtained by recall alone. They may be especially useful for a patient who has short-term memory problems. For bladder diaries to be accurate, patients and caregivers need careful instructions on their maintenance.
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FIGURE 26-2 Bladder diary. (Sample created by Sue E. Meiner et al., 2009.)
Collecting bladder diaries during assessment helps establish the type of UI and aids in planning nursing interventions.
Diagnosis The data collected during assessment and the nurse’s knowledge of UI often permit diagnosis of the type of incontinence. Sometimes, a more complex evaluation is needed to determine the cause and most appropriate treatment for UI. In any new case of incontinence the nurse should consider acute and potentially reversible causes. If acute incontinence is ruled out or treated and involuntary urine loss persists, a diagnosis of chronic incontinence must be considered.
The following nursing diagnoses are appropriate in patients with persistent incontinence: stress urinary incontinence, urge urinary
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incontinence, overflow urinary incontinence, and functional urinary incontinence.
Stress Urinary Incontinence History: The patient reports leaking urine with activities that
increase intraabdominal pressure (e.g., coughing, sneezing, laughing, lifting, position changes, walking, climbing steps, or exercise).
Objective observations: Leaking urine with stress provocation; signs of pelvic floor relaxation (e.g., cystocele, rectocele, or uterine prolapse) observed on pelvic examination
Bladder records: Documentation of urine loss during physical activities that increase intraabdominal pressure
Urge Urinary Incontinence History: The patient reports a sudden urge to void, followed by
involuntary urine loss; the patient may also report that running water or cold weather precipitates involuntary urine loss.
Objective observations: Leaking urine with urge provocation
Bladder records: Documentation of urine loss associated with urgency; frequent urination and nocturia also frequently recorded
Overflow Urinary Incontinence History: Patient histories vary, but they often show frequent
involuntary urine loss of small amounts. Urine loss may be associated with physical exertion. Complaints may include decreased force of the urine stream, hesitancy, a feeling of incomplete bladder emptying, and frequent urination of small amounts of urine. Patients may also have risk factors for urinary retention such as diabetes or the use of anticholinergic medications.
Objective observations: An elevated post-void residual (PVR) (> 100 mL) is the hallmark of overflow incontinence (Kelly, 2004; Vogel, 2001). This should be part of the initial evaluation of
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patients with UI. On abdominal examination a distended bladder may be detected on percussion or palpation. When overflow incontinence is associated with prostatic hypertrophy, an enlarged prostate can be detected on rectal examination. In women, a large cystocele observed during pelvic examination may suggest the cause of overflow incontinence.
Bladder records: Documentation of frequent small-volume urinary accidents
Functional Urinary Incontinence History: The patient or caregiver reports large-volume urine loss in
places other than the toilet, commode, bedpan, or urinal in the absence of symptoms of stress, urge, or overflow incontinence. The patient may be unaware of the need to void or have significant mobility impairment.
Objective observations: In pure functional incontinence, leaking is not seen with stress or urge provocation and the PVR result is normal. A mental status examination may reveal cognitive impairment. Functional assessment may reveal impaired mobility and toileting skills.
Bladder records: Documentation of involuntary urine loss (often large accidents) without symptoms of urge or stress incontinence
Planning and Expected Outcomes For all types of UI, the nurse must determine the patient’s and caregiver’s desire for treatment and willingness to carry out the recommended self-care practices and interventions.
Stress Urinary Incontinence The long-term goal is that the patient will reduce or eliminate the number of stress accidents. Short-term goals include the following:
1. The patient will master interventions (e.g., pelvic floor muscle exercises) designed to increase pelvic muscle tone.
2. The patient will recognize factors that precipitate stress accidents
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and use behavioral interventions to prevent accidents.
Urge Urinary Incontinence The long-term goal is that the patient will reduce or eliminate urge accidents. Short-term goals include the following:
1. The patient will master interventions (e.g., pelvic floor muscle exercises and bladder retraining) designed to increase pelvic muscle tone and decrease urge accidents.
2. The patient will recognize factors that precipitate urge accidents and use behavioral interventions to prevent accidents.
Overflow Urinary Incontinence The long-term goal is that the patient reduces or eliminates incontinence caused by urinary retention and overflow. Short-term goals for the patient vary, depending on the underlying mechanism responsible for the incontinence, but they might include the following:
1. The patient will seek urologic evaluation of incontinence.
2. If the patient has an atonic bladder, the patient will master in- and-out self-catheterization.
Functional Urinary Incontinence The long-term goal is that with caregiver assistance, the patient will reduce or eliminate urinary accidents. Short-term goals for the caregiver include the following:
1. The caregiver will provide timely assistance with toileting.
2. The caregiver will remove environmental barriers to proper toileting.
Intervention First-line nursing interventions for UI focus on lifestyle modifications and behavioral therapies. These therapies are effective for all types of UI and have limited to no side effects.
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Pharmacologic options are offered to patients with urge incontinence or mixed incontinence who have failed a trial lasting up to 3 months of lifestyle and behavioral therapies (Thayer et al., 2013). Despite the effectiveness of these techniques, many nurses are not skilled in their implementation. The most appropriate behavioral intervention depends on the type of incontinence and the patient’s cognitive status (Du Moulin, Hamers, Paulus, Berendsen, & Halfens, 2005).
Lifestyle Modifications Individuals with UI may decrease fluid intake in an effort to prevent accidents. This is not an effective method of managing incontinence and may lead to urinary tract infection, constipation, and dehydration. Patients and caregivers should be cautioned not to decrease fluid intake to less than six glasses a day.
Individuals with incontinence, particularly those with urge accidents, should be advised to eliminate or restrict caffeine intake. Products containing caffeine include coffee, tea, caffeinated colas, and chocolate. Caffeine has been shown to increase the occurrence of abnormal detrusor contractions, which are the cause of urge incontinence. Additionally, alcohol should be discouraged, as it is a bladder stimulant and causes increased urgency and frequency, sedation, and altered mobility.
Weight loss is another important lifestyle modification. Excessive weight increases pressure on pelvic floor muscles and the bladder. Although studies have not shown resolution of UI symptoms, significant decreases in frequency of episodes and cost of UI management have been demonstrated with decrease in weight (Cook & Sobeski, 2013).
Some older adults, even those who are continent, complain of frequent nocturia that disrupts their sleep. Getting up once at night is probably a normal effect of aging. For patients who get up more often and think that the quality of their sleep is disrupted, some measures such as restricting fluid intake in the evening may be helpful. Although it is important for patients to have adequate fluid intake, individuals with frequent nocturia should drink the bulk of
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this fluid before dinner. These individuals should be advised to eliminate caffeine in the evening. When an older adult goes to bed with swollen ankles and feet, nocturia frequently increases. Patients with such swelling should be advised to elevate their legs for several hours during the afternoon to limit the amount of edema present at bedtime (Box 26-2).
Box 26-2
Suggestions for management of nocturia • Restrict fluids after dinner. It is important to drink enough
fluids (usually six to eight glasses a day), but the bulk of fluids should be ingested during the day.
• Eliminate caffeine in the evening (e.g., caffeinated cola, tea, chocolate).
• Elevate the legs in the afternoon so the feet and ankles are not swollen when going to bed.
Frail older adults are at increased risk for constipation and fecal impaction, which may cause acute incontinence and exacerbate persistent incontinence. Nurses should assess bowel habits regularly and institute preventive measures such as increased fiber intake, adequate fluids, and increased activity levels.
UI increases the risk of skin rashes, infections, and skin breakdown. Frequent changes of incontinence pads and scrupulous skin care provide the best protection against these complications. For short-term use in conjunction with other treatment measures, incontinence pads or garments provide convenience and comfort. However, they are expensive for long-term use and may be associated with skin rashes and breakdown if not changed often. They should not be used as a substitute for the evaluation and treatment of incontinence.
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Cognitively Intact Patients Two behavioral interventions useful in cognitively intact individuals are bladder retraining and pelvic floor muscle exercises. These interventions may be used alone or in combination, depending on the type of incontinence.
Bladder Retraining The patient is encouraged to adopt a gradually expanding voiding schedule with the goal of 2 to 4 hours between toileting. Retraining is useful for correcting the habit of frequent toileting and for diminishing urgency. A schedule is established for voiding times; voiding because of urgency is discouraged. This procedure is most useful for patients with urge incontinence and frequent urination.
Pelvic Floor Muscle Exercises Pelvic floor muscle exercises were first reported as a treatment for UI by Kegel (1948). These exercises consist of alternating contraction and relaxation of the levator ani muscles, which are the muscles of the pelvic floor. These muscles, including the pubococcygeal muscle surrounding the midportion of the urethra, contract as a unit. In older adults, these muscles are often weak from disuse atrophy. Performed correctly, pelvic floor muscle exercises strengthen the muscles, increase urethral resistance, and allow the patient to use the muscles voluntarily to prevent urinary accidents (Wyman, 2003).
Clinicians often use verbal feedback during digital examination of the rectum or vagina to help patients identify their pelvic floor muscles. The nurse inserts two fingers into the vagina or one into the rectum (for men) and asks the patient to contract the pelvic floor muscles. Approximately one third of patients are able to correctly identify and contract their pelvic floor muscles on digital examination and can use this exercise as a successful intervention for UI. The majority of older patients, however, need additional help in identifying and learning to use their pelvic floor muscles. These patients often benefit from pelvic floor muscle biofeedback. Biofeedback is not a treatment in itself, but if appropriately used, it
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may facilitate acquisition of the ability to contract and use the pelvic floor muscles to prevent involuntary urine loss (Burgio & Goode, 1997). During biofeedback, the patient is given immediate auditory and visual feedback of pelvic floor muscle contractions.
A variety of techniques, including vaginal probes, rectal probes, and surface electromyography, have been used to provide biofeedback. This therapy is more effective when used in conjunction with Kegel exercises.
After training with biofeedback or verbal feedback, the patient must practice the pelvic floor muscle exercises at home. The patient should be instructed to practice contracting and relaxing the pelvic floor muscles at least 45 times a day, in three or four practice sessions. The patient should exercise lying down, sitting, and standing. This facilitates the patient’s ability to identify and use the muscles in any position. The nurse should remind the patient to relax the abdominal muscles when exercising as this is essential for successful performance of exercises. The nurse may ask patients to try occasionally to slow or stop their urine stream while voiding. This allows the patients to monitor their progress in using and strengthening the correct muscles (Box 26-3).
Box 26-3
Pelvic floor muscle exercise instructions • Do 45 pelvic floor muscle exercises every day.
• Do the exercises in three sets, 15 exercises at a time, 3 times a day:
• Do 15 lying down in the morning.
• Do 15 standing up in the afternoon.
• Do 15 sitting in the evening.
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• For each exercise, do the following:
• Squeeze for a few seconds.
• Pretend that you have to urinate, and then hold it.
• It's important to find the right muscles to tighten.
• Relax and tighten the muscles that control urine flow.
• Relax for a few seconds.
• Remember to relax all the muscles in the abdomen, and continue to breathe normally when doing these exercises.
Once patients master the exercises, they should be taught strategies to prevent involuntary urine loss (stress and urge strategies). Patients with stress accidents should be instructed to contract their pelvic floor muscles before and during activities that precipitate leaking such as coughing, sneezing, lifting, or changing position. Those with urge incontinence may be taught to contract their pelvic floor muscles to inhibit involuntary bladder contractions. A patient should respond to an urge to void by relaxing and contracting the pelvic floor muscles three or four times quickly. When the urgency subsides, the patient should walk to the toilet at a normal pace (Box 26-4).
Box 26-4
Urge strategies The nurse should instruct the patient to do the following when the patient has the urge to void:
1. Stop and relax.
2. Squeeze the pelvic floor muscles three or four times quickly; do not hold.
3. Wait for the urge to pass, and then walk slowly to the bathroom during the calm period.
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Pessaries are an option for older women with stress or mixed UI and those with prolapse. A pessary is a stiff ring or dishlike object inserted into the vagina; it pushes against the vaginal wall and helps reposition the urethra to reduce leakage. Pessaries must be removed and cleaned frequently; if the patient is unable to perform this care, it must be done in the clinic (Thayer et al., 2013).
Cognitively Impaired Patients The techniques already described (bladder retraining, pelvic floor muscle exercises, and biofeedback) require active patient involvement. Treating UI in individuals with cognitive impairment requires the use of other behavioral techniques that depend on the caregiver rather than the patient. These include scheduled toileting, habit training, and prompted voiding. The success of these techniques in large part depends on the availability and motivation of the caregiver and the dedication of the nursing staff.
Scheduled Toileting The patient is assisted in voiding on a regular, preset schedule. Family or professional caregivers simply take the patient to the toilet at the scheduled times, often every 2 hours.
Habit Training Patterned urge response training (PURT) is an example of habit training. Initially a patient’s baseline voiding pattern is assessed. Once the patient’s normal voiding pattern is established, the patient is assisted in voiding at the established times (Colling, Ouslander, Hadley, Eisch, & Campbell, 1992).
Prompted Voiding Prompted voiding is most successful with patients who can recognize the need to void. It depends on active caregiver and patient involvement. The goal is to increase a patient’s awareness of the need to void and increase the frequency of self-initiated toileting. Patients are approached on a regular schedule, asked if they are wet or dry, and then prompted to toilet (Box 26-5). A
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patient should never be forced to toilet or reprimanded for failing to toilet appropriately. Self-initiated toileting should not be discouraged. To relieve the stress that may occur because of sleep disruption for both caregiver and patient, toileting protocols may be modified for the nighttime hours.
Box 26-5
Prompted voiding instructions 1. Approach the patient at the scheduled times, and ask if he or
she is feeling wet or dry.
2. Check to see if the patient is wet or dry.
3. If the patient correctly identified his or her present continent status, give positive feedback.
4. Ask the patient if he or she prefers to use the toilet. If the response is yes, toilet the patient; if it is no, encourage the patient. Never force the patient to toilet.
5. Give positive feedback for appropriate toileting. Do not give any negative feedback.
Once contributing causes have been ruled out or treated, and if trials of scheduled toileting, habit training, and prompted voiding have failed, the use of pads and other protective garments may be the only feasible method of managing UI in the frail older adults and those with end-stage dementia (Thayer et al., 2013).
For men, external collection devices may be less expensive and less time consuming than incontinence pads or garments. However, they are associated with a number of complications including UTIs, skin breakdown, and ischemic disease resulting from penile constriction (U.S. Department of Health and Human Services [DHHS], 1996; Wyman, 2003). Practical external collection devices for women are not available.
The use of external collection devices requires proper preparation
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of the penile surface before application. The penis should be thoroughly washed and dried. It may be necessary to trim excessive hair from around the penile shaft. An adhesive-enhancing skin preparation should be applied to the penile shaft and allowed to dry before condom application. Self-adhesive condom catheters, although more expensive than regular condom catheters, eliminate the need for adhesive tape. The condom catheter should be removed daily, and the penis should be inspected for irritation or skin breakdown (DHHS, 1996). The skin should be washed and dried before reapplication. If any evidence of trauma or infection is present, the condom should not be reapplied. It should be noted that treatment for genital cancer and decrease in the size of the penis associated with atherosclerosis and collagen deposition make it difficult for many older adult males to properly fit a condom catheter. A retracted penis pouch may be more appropriate in these circumstances.
Penile compression devices have been used with some success in men with mild incontinence. Issues related to comfort and decreased penile blood flow occur with improper use; penile compression devices should not be used longer than 4 hours at a time. Potential complications include edema, pain, urethral erosion, and obstruction (Moore & Lucas, 2010).
Individuals with overflow incontinence should be referred to a urologist to correct treatable causes. If the cause of incomplete bladder emptying is not correctable, measures such as the Crede method may help empty the bladder. The Crede method is performed by applying pressure over the suprapubic area to aid in the elimination of residual urine during a voiding session. If this is ineffective in emptying the bladder, the treatment of choice is often intermittent in-and-out catheterization with the use of sterile technique. Because of the high risk of associated bladder infections and urinary sepsis, indwelling catheters should be used to treat incontinence only in select circumstances (Ouslander, 2003) (Box 26- 6).
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Box 26-6
Indications for use of indwelling catheters • Urinary retention that cannot be corrected medically or
surgically; cannot be managed practically by intermittent catheterization; and is causing persistent overflow incontinence, symptomatic urinary tract infections, and/or renal dysfunction
• Pressure sores or skin lesions that are being contaminated by incontinent urine
• Provision of comfort for terminally ill or severely impaired patients
Evaluation Evaluation is an integral, ongoing component of the management of UI. Patient goals are the focal point of evaluation. A patient’s perception of the effectiveness of and satisfaction with his or her treatment should be assessed and documented. A number of older adults with incontinence may require more than one treatment modality to achieve a satisfactory reduction in incontinence episodes. As a result, the care plan often evolves over time (see Nursing Care Plan: Mixed Incontinence and Nursing Care Plan: Functional Incontinence).
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Age-related renal changes The process of aging results in anatomic and functional changes in the renal system. Kidneys decrease in size and number of nephrons with aging. In addition, individuals with atherosclerosis experience decreased renal blood flow due to fibrous tissue and calcification hardening renal vasculature. These factors combine, leading to a decrease in glomerular filtration rate (GFR). Despite the anatomic and functional changes associated with age, the kidneys remain capable of performing their functions well into the ninth decade of life unless acute illness or comorbidities result in renal dysfunction.
Nursing care plan
Mixed Incontinence Clinical Situation Mrs. W is a 74-year-old retired teacher, who was discharged from the hospital after amputation of a gangrenous toe. The nurse sees her three times a week to change the dressing and assess wound healing. Mrs. W’s medical history includes type 2 diabetes mellitus for 26 years, complicated by peripheral neuropathy. She also has coronary artery disease (one myocardial infarction), hypertension, peptic ulcer, and rheumatoid arthritis. She has had bilateral hip replacement. She walks with a walker, and her gait is slow and sometimes unsteady. Her current medications include insulin glargine (Lantus), lansoprazole (Prevacid), acetaminophen (Tylenol), diltiazem extended release (Cardizem CD), triamterene and hydrochlorothiazide (Dyazide), nitroglycerin (Nitrostat), docusate sodium (Colace), and oxybutynin. Her over-the-counter medications include a multivitamin, Metamucil, Citracel, and Tums. She needs assistance with personal grooming and bathing.
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She has had problems with constipation but finds that daily Metamucil and Colace keep her regular. Mrs. W has been incontinent for 2 years. She describes both stress and urge accidents and states that she has about 14 accidents per week. She also experiences nocturia. She drinks three or four cups of regular coffee or tea a day and drinks a considerable amount of iced tea in the summer. She has seen a urologist, and he prescribed oxybutynin for her. She has been taking it for 2 years. Although it somewhat reduced the number of accidents, she does not think it is very effective. She finds the incontinence disturbing and wishes something more could be done.
Nursing diagnosis Impaired Urinary Elimination
Outcomes The patient will master pelvic floor muscle exercises.
The patient will experience a decrease in the number of urinary accidents.
Interventions Ask the patient to keep a baseline bladder diary before treatment.
Teach the patient pelvic floor muscle exercises using verbal feedback of pelvic floor muscle contractions during rectal examination.
Provide written instructions for practicing the exercises.
Ask the patient to continue to keep bladder diaries during treatment.
Review the diaries and assess the patient’s progress during weekly visits.
Once the patient has mastered the exercises, teach strategies to manage urge incontinence and then strategies for stress incontinence, if indicated by the diaries.
If the patient is unable to identify her pelvic floor muscles using verbal feedback or is not making adequate progress, refer her to
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the nurse specialist who deals with continence for biofeedback.
Advise the patient to substitute decaffeinated coffee and tea for the regular coffee and tea that she now drinks.
Nursing care plan
Functional Incontinence
Clinical Situation Mrs. B is an 83-year-old retired housekeeper who receives visits from a nursing agency for congestive heart failure. Mrs. B was diagnosed with mild Alzheimer disease 3 years ago. She lives with her niece, who is also her primary caregiver. Mrs. B is legally blind. She had a fall and fractured her right hip 1 year ago. She has a moderate amount of bilateral ankle and foot edema. She also suffers frequently from constipation. Her current medications include furosemide (Lasix), a calcium channel blocker, and a stool softener. She requires assistance with ambulation and activities of daily living (ADLs). She has had urinary incontinence for 3 years. Mrs. B generally feels the urge to void but has frequent accidents. Mrs. B now requires incontinence undergarments. She also has enuresis, and the pad is usually wet in the morning.
Nursing diagnosis Impaired Urinary Elimination
Outcomes The patient’s caregiver will master a prompted voiding and
toileting program with the patient.
The patient will experience a reduction in the number of episodes of incontinence.
Interventions
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Collect baseline bladder diaries to establish the frequency of urinary incontinence and precipitating factors.
Assess the caregiver’s willingness to participate in a behavioral program to treat the patient’s incontinence.
Teach the caregiver how to implement a prompted voiding program.
Assess the patient’s understanding by having her conduct a return demonstration of the technique.
Visit weekly to assess implementation and success of the program.
Have the caregiver keep the bladder diaries during treatment.
Assess the patient’s daily fluid intake.
If daily fluid intake is less than six to eight glasses of fluid per day, instruct the caregiver to increase the patient’s fluid intake.
Instruct the caregiver to restrict the patient’s fluids in the evening, providing the bulk of her fluids during the day.
Instruct the caregiver to restrict the patient’s caffeine intake and eliminate caffeine in the evening.
Instruct the caregiver to have the patient elevate her legs in the afternoon to reduce the amount of edema.
As persons age, renal mass decreases by 80 grams between 40 and 90 years of age. However, it has been determined decrease in renal mass corresponds to a decline in overall body surface area that occurs with aging. Renal blood flow decreases by 10% for every decade beyond the age of 40. With decreases in renal mass, functioning glomeruli, and blood flow, GFR is affected. GFR remains stable until about age 40, and then falls at a rate of 8 milliliters per minute (mL/min) per 1.73 square meters (m2) per decade. Individual variances affect age-related changes in the renal system and decline in GFR; no two people age in the same way (Weinstein & Anderson, 2010).
The effect of aging on the renal system has implications for clinical management. Changes in renal function affect all aspects of
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pharmacokinetics. Drug dosages should be adjusted on the basis of GFR or creatinine clearance. Older adults lack adaptive mechanisms; therefore, fluid and electrolyte alterations may occur in the setting of acute illness. It is also important for nurses to recognize comorbidities likely to affect renal function in the older adult population, for example, cardiovascular disease and diabetes.
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Common problems and conditions Acute Kidney Injury Acute kidney injury (AKI) is the sudden decline in renal function accompanied by fluid and electrolyte alterations, and acid–base disturbance. It may or may not be associated with oliguria. AKI is classified as prerenal, intrinsic, or postrenal based on causative factors (Box 26-7).
Box 26-7
Causes of acute kidney injury Prerenal • Hypovolemia:
• Dehydration • Hemorrhaging
• Burns
• Gastrointestinal loss (e.g., vomiting or diarrhea)
• Shock
• Cardiovascular failure:
• Myocardial infarction
• Arrhythmias
• Cardiogenic shock
• Heart failure
• Renal artery stenosis or thrombosis
• Altered peripheral vascular resistance:
• Neurogenic shock
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• Septic shock
• Anaphylactic shock
• Antihypertensive medications
Intrinsic • Acute glomerulonephritis
• Acute tubular necrosis
• Nephrotoxic medications
• Radiocontrast dye
• Renal ischemia
• Vasopressors
Postrenal • Mechanical:
• Renal calculi
• Strictures
• Prostatic disease
• Tumors
• Functional:
• Neurogenic bladder (Adapted from Copstead, L. Perspectives on pathophysiology. (1995). Philadelphia: Saunders.)
Prerenal failure occurs because of inadequate perfusion (e.g., fluid sequestration in liver failure or heart failure). It is not accompanied by parenchymal damage; therefore, restoring perfusion should restore renal function.
Intrinsic failure occurs as a result of abnormalities within the kidney and may be caused by ischemia, sepsis, inflammation, or injury. Acute tubular necrosis (ATN) is the most common cause of intrarenal failure. The three stages of ATN are as follows:
1. Initiation: Blood urea nitrogen (BUN) and creatinine levels rise
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and urine output decreases.
2. Maintenance: Continued decrease in renal function lasting for 7 to 21 days during which supportive therapy (e.g., dialysis) may be necessary.
3. Recovery: Urine output increases accompanied by a decrease in BUN and creatinine levels. During this time, regeneration of tubular epithelial cells occurs.
Postrenal failure results from an obstructive or mechanical process in the urinary tract (e.g., renal calculi or benign prostatic hypertrophy) that interferes with the outflow of urine. Removal of the obstructive process usually restores renal function.
In older adult patients who experience AKI, evaluation should begin with an attempt to determine the underlying cause. Once the cause is corrected, renal function is typically recovered. Clinical manifestations of AKI include fluid and electrolyte disturbances, metabolic acidosis, and uremic symptoms (e.g., anorexia, nausea, anemia, fatigue, edema, and crackles). The patient may also have a history of exposure to nephrotoxic substances, or recent infection. Mortality from AKI exceeds 60% (Murugan & Kellulm, 2011).
The diagnosis of AKI is made on the basis of elevated BUN level, elevation in serum creatinine, and decrease in creatinine clearance accompanied by decrease in urine output. In addition to correcting the underlying cause of AKI, treatment includes correction of acidosis and hematologic abnormalities, removal of nephrotoxic agents, and maintenance of fluid hemostasis.
Chronic Kidney Disease Chronic kidney disease (CKD) is the presence of kidney damage for more than 3 months accompanied by decrease in GFR (Box 26-8). The symptoms manifested depend on the extent of the disease. The five stages of CKD are as follows:
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Box 26-8
Causes of chronic kidney disease • Congenital disorders
• Cystic disorders
• Tubular disorders
• Infections
• Systemic disorders:
• Diabetes
• Hypertension
• Scleroderma
• Systemic lupus erythematosus
• Amyloidosis (Modified from Copstead, L. Perspectives on pathophysiology. (1995). Philadelphia: Saunders.)
1. Stage 1: Kidney damage with normal (> 90 mL/min/1.73 m2) or increased GFR
2. Stage 2: Kidney damage with GFR between 60 and 89 mL/min/1.73 m2 for 3 or more months
3. Stage 3: Moderately decreased GFR, between 30 and 59 mL/min/1.73 m2
4. Stage 4: Severely decreased GFR, between 15 and 29 mL/min/1.73 m2
5. Stage 5: Kidney failure with GFR less than 15 mL/min/1.73 m2; patients will require renal replacement therapy (RRT)
Patient/family teaching
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Chronic Kidney Disease The kidneys perform crucial functions that affect all parts of the body. The kidneys, in fact, keep the rest of the body in balance and working properly. When chronic kidney disease causes the kidneys to fail, the whole body stops functioning correctly and the person can become extremely ill unless the condition is treated.
How Do the Kidneys Work? The kidneys are the size of a person’s fist and are located on either side of the spine. Each kidney has about a million working units called nephrons. Nephrons are the kidney’s filters. Once blood is filtered, the waste products are removed from the body as urine.
The kidneys’ job is to cleanse the blood of wastes, excess fluid, and drugs; release hormones and vitamins; and control red blood cell production.
The kidneys are also responsible for regulating the body’s salt, potassium, and acid content.
What Causes Chronic Kidney Disease? Several different types and causes of chronic kidney disease exist. Glomerulonephritis, which is inflammation of the kidney, damages the nephrons. High blood pressure, whether a result of a kidney disorder or a cause of kidney disease, may hasten kidney failure. Diabetes mellitus, the leading cause of chronic kidney disease (CKD), results from damage to the kidney caused by chronically high blood sugar levels. Polycystic kidney disease is an inherited disorder in which cysts form on kidney tissue and eventually destroy the healthy kidney tissue. Physical abnormalities present at birth may cause obstructions, which may lead to infection and destruction of kidney tissue. Interstitial nephritis, usually caused by drug use, is an inflammation of kidney tissue and leads to eventual destruction of the kidney.
What Are the Signs of Kidney Failure? Because kidney failure sometimes gives no warning signs, it may
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go undiagnosed until it is well advanced. However, some warning signs may be present:
1. Decreased energy and fatigue
2. Trouble concentrating
3. Puffiness around the eyes
4. Loss of appetite
5. Nighttime muscle cramps
6. Swelling in feet and ankles
7. Dry, itchy skin
8. Urinating more frequently at night
9. Nausea and vomiting
How Is Kidney Failure Treated? In the early stage of kidney failure, the disease may be slowed by ensuring control of high blood pressure and control of other chronic diseases such as diabetes. Additionally, the patient may be asked to take medications to treat anemia, reduce swelling, lower cholesterol, and protect bones. The diet may be changed as well, to reduce waste products in blood. However, as the disease progresses and the kidneys no longer perform their duties of removing bodily wastes, other treatments must be used. Blood must be cleansed by using an artificial kidney (hemodialysis) three times a week at a special facility or at home or by introducing a cleansing solution into the abdomen (peritoneal dialysis), performed daily in the home. Kidney transplantation, in which healthy, donated kidneys replace the failed kidneys, may restore normal kidney function.
Outlook No cure exists for chronic kidney disease. Following the program prescribed by the health care provider is vitally important as it helps live with kidney failure. A large number of people with kidney disease manage to live active, productive lives. Adapted from The National Kidney Disease Education Program. (2012). Chronic Kidney
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Disease: What Does it Mean for Me? NIH Publication No. 12-7408. Retrieved 8/30/14 from http://nkdep.nih.gov/resources/kidney-disease-mean-for-me-508.pdf.
Typically, patients with CKD stages 1 to 3 are asymptomatic. On entering stages 4 and 5, patients may develop weakness, edema, fatigue, hypertension, heart failure, impaired cognition and immune function, dry skin and pruritus, anorexia, nausea, malnutrition, increased bleeding, anemia, peripheral neuropathy, and an overall decreased quality of life. Management strategies include treatment of the underlying cause of CKD, aggressive control of blood pressure (systolic blood pressure [SBP] ≤ 130 mm Hg and diastolic blood pressure [DBP] ≤ 80 mm Hg), treatment of hyperlipidemia, blood sugar control in diabetics (glycated hemoglobin [HbA1c] < 7%), avoidance of nephrotoxic medications (e.g., nonsteroidal antiinflammatory drugs [NSAIDs]) and use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in individuals with proteinuria (protein > 300 mg/24 hr). Additional management strategies include restricting sodium, potassium, and phosphorus in the diet, restricting protein in the diet, restricting fluid intake, weight management and promotion of exercise, and use of multivitamins and iron supplements (see Patient/Family Teaching: Chronic Kidney Disease).
The diagnosis of CKD is usually made based on an increase in creatinine and BUN, and a decrease in creatinine clearance. Additionally, tests are performed to evaluate blood sugar levels, parathyroid hormone and calcium levels, hematocrit and hemoglobin levels, other iron studies, and reticulocyte count. Urinalysis is performed to determine the amount of protein in urine. The remainder of the evaluation is identical to that in a patient with AKI. Treatment of renal failure in an older adult is initially conservative. Older adult patients with kidney failure generally have concomitant diseases such as diabetes, cardiac disease, or cancer.
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Nursing management Assessment
Assessment of an older adult with kidney disease should include thorough health history taking and physical examination; special attention should be paid to the medication history. Box 26-9 summarizes the nursing history and physical assessment data to be obtained.
Box 26-9
Nursing assessment of renal system History • Personal or family history of renal disease
• Recent surgeries or illnesses (predisposing to renal dysfunction) • Symptoms:
• Urine (e.g., frequency, color, amount, appearance)
• Nausea and vomiting
• Anorexia
• Weight loss
• Confusion
• Fatigue
• Pruritus
• Edema
• Medications (e.g., antibiotics, antineoplastics, and nonsteroidal antiinflammatory drugs)
• Diet
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• Current support systems
Physical Assessment • Neurologic status: altered mental status and presence of
asterixis • Cardiopulmonary status: rales and pericardial rub
• Gastrointestinal status: nausea and vomiting, abdominal discomfort, and intolerance to diet
• Musculoskeletal status
• Ophthalmoscopic examination and visual inspection
Diagnosis Appropriate nursing diagnoses for a patient with CKD include the following:
• Excess Fluid Volume, related to compromised urinary regulatory mechanisms
• Imbalanced Nutrition: Less Than Body Requirements, related to anorexia
• Risk for Infection, related to a compromised immune system
• Deficient Knowledge, related to lack of exposure to disease process, treatment regimen, and follow-up care
• Ineffective Coping, related to uncertain outcome of illness
• Activity Intolerance, related to fatigue
• Toileting Self-Care Deficit, related to weakness and fatigue
• Risk for Impaired Skin Integrity, related to pruritus and immobility
• Decreased Cardiac Output, related to fluid volume excess
• Alteration of Protective Mechanisms, related to nutritional deficiencies (anemia)
• Ineffective Sexuality Pattern, related to uremia and psychological effects of CKD
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Planning and Expected Outcomes The development of a care plan for an older adult with renal failure must include the patient and family or significant others because of the potential for self-care deficits. Expected outcomes include the following:
1. The patient will achieve a normal level of fluid volume use, as evidenced by reestablishment of baseline “dry” weight.
2. The patient will consume a well-balanced, appropriately restricted diet on a regular basis.
3. The patient will remain free from infection, as evidenced by an afebrile state during hospitalization.
4. The patient will demonstrate knowledge of the disease process and therapeutic regimen, as evidenced by adherence to prescribed self-care and other treatment measures.
5. The patient will demonstrate the use of effective coping strategies, as evidenced by verbalization of feelings and seeking of support.
6. The patient will demonstrate the ability to carry out ADLs without undue stress or fatigue.
7. The patient will maintain skin integrity, as evidenced by no reddened areas or broken skin.
8. The patient will have adequate cardiac output as evidenced by absence of pulmonary crackles.
9. The patient maintains hemoglobin above 10 g/dL.
10. The patient and partner express satisfaction with expression of intimacy.
Intervention Interventions for an older adult with renal failure should focus on maintaining fluid and electrolyte balances; monitoring nephrotic symptoms; educating about treatment regimens, dietary management, and medication usage; and managing fatigue and low
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energy levels. Patients and their significant others must be educated on the interventions. The typically prescribed diet is a low-protein, low-sodium, low-potassium, and low-phosphorus diet. At times the diet is less than palatable, so with the normal age-related changes in the sense of taste and smell, adherence to a renal diet presents a challenge. The use of spices and seasonings to enhance taste may be helpful. For those individuals with CKD who experience nausea resulting from uremic symptoms, it might be beneficial to administer a prescribed antiemetic before meals (Boxes 26-10 to 26- 12; and Patient/Family Teaching: Management of Renal Failure).
Box 26-10
Renal diet Managing the diet of a patient with renal failure (“renal diet”) is a challenge. A balance between sufficient calories and protein must be achieved. Patients in renal failure typically have a high metabolic demand that requires a high caloric intake. Sufficient amounts of protein and calories must be provided to prevent catabolism while preserving renal function. A renal diet is typically restricted in fluid, sodium, potassium, phosphorus, and protein. The extent of diet restriction depends on the degree of renal dysfunction. A dietitian should be involved to assist with diet modification. Following the diet prescribed by the physician will prevent further complications of renal dysfunction.
Calories Calories are important for maintaining energy and preventing weight loss. Much of the caloric intake may come from carbohydrates and unsaturated fat. If a need to increase caloric intake exists, margarine and oils that are low in cholesterol may be considered. Jams, jellies, sugar, and honey may also be added to the diet.
Potassium
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Alterations in potassium levels may cause significant illness and even life-threatening arrhythmias of the heart. It is important to maintain a low-potassium diet because in renal failure, the kidneys are unable to rid the body of potassium in normal quantities. Foods high in potassium include dried beans, nuts, fruits, vegetables, chocolate, mushrooms, potatoes, and prune juice.
Sodium Elevation in sodium levels causes fluid retention. This may lead to congestive heart failure and edema. It is very important to control the intake of sodium. Teaching patients to get into the habit of reading the labels on food packages is essential.
Fluid Fluid intake consists of anything that becomes liquid at room temperature. Too much fluid may lead to weight gain, congestive heart failure, edema, shortness of breath, and high blood pressure. The amount of fluid intake is dependent on the degree of renal dysfunction.
Vitamins and Minerals Vitamin supplementation is often necessary in patients with renal failure. Typically, supplements of folic acid, pyridoxine, and water-soluble vitamins are necessary. Adapted from Copstead, L. Perspectives on pathophysiology. (1995). Philadelphia: Saunders.
Box 26-11
What is peritoneal dialysis? Peritoneal dialysis is a type of dialysis that is performed when the renal system fails and can no longer adequately control the removal of waste products. It is indicated when medications and changes in diet and fluid intake can no longer control renal
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dysfunction.
A membrane in the abdomen, called the peritoneum, lines the abdominal organs and the abdominal wall. This membrane is porous and has a rich supply of blood. Before peritoneal dialysis can begin, a catheter is inserted into the peritoneal cavity; this permits the fluid to run in. A prescribed dialysate solution is run into the peritoneum and permitted to dwell for a certain period. During the dwell period, waste products are removed from the blood through the peritoneal wall into the dialysate solution.
The patient, in conjunction with his or her health care provider, chooses one of two types of peritoneal dialysis: (1) continuous ambulatory peritoneal dialysis (CAPD) and (2) continuous cyclic peritoneal dialysis (CCPD).
CAPD is done continuously, 7 days a week. It involves the use of an indwelling catheter, connective tubing, and dialysate. If the patient needs certain electrolytes, they can be added to the dialysate solution. During the dwell period, these substances move through the peritoneal membrane and into the patient’s blood supply to restore normal electrolyte concentrations. Dialysate dwells in the peritoneal cavity for 4 to 8 hours while “dialysis” occurs. The tubing is clamped, and the bag is rolled up under the patient’s clothing. Normal daily activities may be performed during the dwell time. Once the dwell period ends, the dialysate is drained and the peritoneum is filled with a new bag of dialysate.
In CCPD, an indwelling catheter, dialysate, and a cycling machine are used. Before the individual goes to sleep, he or she must be connected to the machine, which will cycle dialysate solution in and out of the peritoneum three to five times during the night, allowing for a prescribed dwell period. In the morning, the last cycle runs in and is permitted to dwell for the entire day. At the end of the day, the solution is drained, the patient is connected to the cycler, and the process is restarted.
Complications Complications associated with peritoneal dialysis include
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peritonitis, an infection of the peritoneal wall. Infections involving the catheter tunnel and the exit site of the catheter may also occur. It is important for the patient to recognize and immediately report signs of infection (e.g., abdominal pain, fever, and dialysate solution that appears cloudy after it is drained from the abdomen).
Outlook Peritoneal dialysis is an alternative for a failed renal system, but it does not cure the disease. Patients with chronic renal failure need to undergo some form of dialysis for the remainder of their lives or until they undergo successful transplantation. Many patients lead nearly normal lives with peritoneal dialysis and modifications in diet and fluid intake. Data from Halter, J., Ouslander, J., Tinetti, M., Studenski, S., High, K., & Asthana, S. (2009). Hazzard’s geriatric medicine and gerontology (6th ed). Philadelphia, PA: McGraw- Hill; Healthwise Staff. (2011). Information and resources: Peritoneal dialysis. Retrieved September 28, 2013, from, http://www.webmd.com/a-to-z-guides/peritoneal-dialysis- 4391.
Box 26-12
What is hemodialysis? Hemodialysis is a type of dialysis that is performed when the renal system can no longer clear wastes effectively. It is indicated when medications and alterations in diet and fluid intake are no longer effective in the management of kidney disease. Hemodialysis involves the use of an artificial kidney and a dialysis machine. Each hemodialysis treatment lasts 3 to 4 hours and typically is performed three times a week. Hemodialysis differs from peritoneal dialysis in that the clearance of waste products occurs outside the body and the treatments are done at an outpatient dialysis center rather than at home.
For hemodialysis, access to the bloodstream is necessary. This access could be a large intravenous tube placed in a vein in the
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neck or chest. If the patient has chronic kidney disease (CKD), a permanent access, termed a fistula or a graft, is surgically placed. During the hemodialysis treatment, the patient’s blood and a prescribed dialysate solution circulate continuously through the artificial kidney. Waste products are cleared and electrolytes are stabilized at this time, and cleaned blood is returned to the body. When the treatment is complete, the nurse removes the needle access to the fistula or graft. The first few hemodialysis treatments are slow and short to avoid any complications.
Complications Complications that may occur during or after hemodialysis treatment consist of low blood pressure, rapid heart rate, and dry mouth, which could indicate that too much fluid has been removed. The patient could also experience high blood pressure, fast heart rate, and shortness of breath, which could indicate that not enough fluid has been removed from the body. If these symptoms occur during treatment, the patient should notify the nurse immediately. If they occur after treatment and the patient is at home, it is just as important to notify the physician immediately.
Patient/family teaching
Management of Kidney Failure Patient education should include the following factors:
• Cause of the kidney failure
• Prescribed diet and fluid regimen
• Self-observation skills (e.g., measuring temperature, pulse, respiration, blood pressure, intake and output, and daily weight)
• Personal hygiene
• Exercise and rest programs
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• Medication regimen (e.g., name, purpose, dosage, dosing schedule, and adverse reactions)
• Schedule of medical follow-up Modified from Brundage, D.J. (1992). Renal disorders. St. Louis, MO: Mosby.
With the varied treatment options available to the individual with renal failure, it is important to educate patients and significant others about prescribed modalities. The National Kidney Foundation provides patient and family resources helpful to persons with CKD.
Evaluation Evaluation is an important component in the care of older adults with CKD. Subjective data include the patient’s reported symptoms and quality of life. Objective data include improved or stable renal function, as evidenced by stable levels of BUN and creatinine, hematocrit, and fluid and electrolytes.
Urinary Tract Infection UTI and asymptomatic bacteriuria are common in the older adult population. The prevalence of bacteriuria increases dramatically in women and men older than the age of 80. The incidence of bacteriuria is higher in women than men, partly because of the proximity of the urethral meatus to the rectum. The incidence is also higher for residents of long-term care facilities compared with those living at home. Higher rates of bacteriuria in nursing facilities are likely caused by the increased incidence of soiling, incomplete bladder emptying, and bladder catheterization. Risk factors for development of UTIs include brain attack, Parkinson disease, cognitive impairment and dementia, decreased functional status, bladder catheterization, and antibiotic use (Halter et al., 2009). Escherichia coli continues to be the most common infectious organism. Other common organisms are Proteus, Klebsiella, Enterobacter, Serratia, and Pseudomonas. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus
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(VRE), and fluoroquinolone-resistant gram-negative bacilli are becoming more prevalent as the causative organisms found in UTIs, especially in the long-term care setting (Phillips, Adipoju, Stone et al., 2012).
Clinical presentation of UTI in older adults includes dysuria, urgency, frequency, and hematuria secondary to damaged superficial blood vessels in the mucosa of the bladder. These symptoms are typical of lower UTIs. If the infection is in the upper urinary tract, older patients may manifest fever, chills, and flank tenderness in addition to mental status changes. If an older patient is also experiencing bacteremia, signs and symptoms of septic shock may be seen. Nurses are cautioned to remember the atypical presentation of acute illness in older adults.
Frequently, older adults present with bacteria on urinalysis (> 100,000 colony-forming units per milliliter [CFU/mL] in a clean- catch specimen) without accompanying symptoms of UTI; this is referred to as asymptomatic bacteriuria (ASB). Research has not demonstrated any benefit to treating ASB; the use of antibiotics in this situation has the potential for harm. Despite the evidence, residents in long-term care facilities frequently receive antibiotic therapy for ASB (Phillips et al., 2012). Nurses must work collaboratively with other care providers to avoid collecting urine cultures when symptoms of UTI are absent and eliminate the inappropriate prescribing of antibiotics for ASB, which leads to multidrug resistant bacteria, increases the likelihood of adverse drug events, and increases the cost of care (Zabarsky, Sethi, & Donskey, 2008).
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Nursing management Assessment
A subjective assessment of urinary elimination patterns should be completed, assessing for alterations in normal voiding patterns and symptoms such as burning, urgency, and frequency. The characteristics of the urine should also be noted. In addition, a mental status examination may be indicated, as older adults may experience altered mental status in the presence of UTI.
Diagnosis Nursing diagnoses for an older adult patient experiencing a UTI include the following:
• Pain, related to altered urinary elimination
• Impaired Urinary Elimination, related to the infectious process
• Deficient Knowledge, related to unfamiliarity with treatment of UTI.
Planning and Expected Outcomes Expected outcomes for an older patient with a UTI include the following:
1. The patient will experience adequate pain control, as evidenced by reports of no further dysuria or burning with urination.
2. The patient will resume a normal voiding pattern, free from frequency, urgency, and dysuria.
3. The patient or caregiver verbalizes knowledge of the causes and treatment of UTI.
Intervention
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Nursing management should focus on education of older adults, including appropriate perihygiene measures such as showering, front-to-back wiping techniques, adequate daily fluid intake, frequent bladder emptying, adherence to the prescribed medication regimen, and reportable signs and symptoms of a recurrent infection. Sterile technique should be used with urinary catheterization; use of indwelling catheters should be minimized.
Evaluation Evaluation includes ongoing assessment related to expected outcomes and documentation of findings. Documentation also includes routine vital signs, assessment of functional status, and other associated risk factors.
Bladder Cancer Bladder cancer is the most common form of cancer originating in the urinary system and is most often found in persons over 70 years of age. Approximately 90% of all bladder cancers are transitional cell carcinomas originating in the epithelial lining of the urinary tract. The other 10% are typically squamous cell carcinoma, and small cell carcinoma and adenocarcinoma. Most bladder tumors are easily resected but may metastasize to the bladder wall, pelvis, liver, lungs, or bone. The biggest risk factor for developing bladder cancer is cigarette smoking. Occupational exposures to dyes, rubber, chemicals used in processing leather, and paint are at high risk for developing bladder cancer. Chronic bladder irritation resulting from stones and chronic UTIs are risk factors for development of bladder cancer. Bladder cancer occurs more often in men than in women and more often in Caucasians than in other races. Genetics also play a role in the development of bladder cancer.
Painless hematuria is the most common symptom of bladder cancer. It may also be accompanied by dysuria, urgency, and frequency. If the tumor is large, late signs include suprapubic pain. A large tumor may also cause urinary obstruction, which, in turn,
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could cause low back and pelvic pain and predispose a patient to postrenal failure.
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Nursing management Assessment
Nursing assessment should include a thorough history with attention to changes in urinary elimination patterns. Subjective assessment should focus on the presence of pain, hematuria, dysuria, urgency, frequency, and voiding of small volumes. Objective assessment findings include gross or microscopic hematuria.
Diagnosis Nursing diagnoses appropriate for an older patient with bladder cancer include the following:
• Anxiety, related to an uncertain prognosis
• Impaired Urinary Elimination, related to surgical diversion
• Disturbed Body Image, related to surgical diversion
• Ineffective Coping, related to uncertain outcome of treatment
• Sexual Dysfunction, related to anatomic alterations
Planning and Expected Outcomes Developing a care plan for a patient with bladder cancer involves the patient, family, and significant others. Expected outcomes include the following:
1. The patient will experience reduced anxiety, as evidenced by a decrease in symptoms.
2. The patient will develop a routine for managing urinary diversion.
3. The patient will verbalize acceptance of urinary diversion and associated changes.
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4. The patient will demonstrate the use of effective coping strategies, as evidenced by verbalization of feelings and seeking of support.
5. The patient will verbalize concerns about sexuality.
6. The patient will express satisfaction with alternative positions for intercourse.
Intervention Nursing interventions for patients with bladder cancer focus on patient education, psychosocial support, management of pain, and maintenance of adequate fluid and nutritional intake. Surgery is performed to remove the cancer; the type of surgery depends on the stage of cancer. A transurethral resection of the bladder tumor removes noninvasive cancer. A partial or total cystectomy is used to remove invasive tumors. An ileal conduit as a means of urinary diversion is the most frequent means of managing urinary elimination following cystectomy. Social stigma associated with the excretion of body fluids into an external device compounds the patient’s fears and concerns regarding the diagnosis of cancer. Because patients may have difficulty coping, it is important to encourage them to verbalize fears and concerns and to refer them to the appropriate supportive services, if necessary.
If a patient requires chemotherapy, nursing interventions include monitoring for infection, irritative voiding symptoms, allergic reactions, and bone marrow suppression. Patient education should include instructions for follow-up care and the importance of cystoscopy every 3 months for 1 year, then every 6 months to 1 year thereafter. Patients who smoke should be counseled to stop smoking.
Evaluation Evaluation of nursing interventions is based on the achievement of expected outcomes. Documentation of ongoing biopsychosocial assessment is key in the provision of holistic nursing care.
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Benign Prostatic Hypertrophy Benign prostatic hypertrophy (BPH) is an age-related enlargement of the prostate gland that constricts the urethra and obstructs the outflow of urine. Approximately 80% of men may be diagnosed with BPH by the age of 80. The development of BPH is the result of structural, functional, and hormonal changes.
With early prostatic enlargement, the patient may be asymptomatic because the muscles compensate for increased urethral resistance. As the prostate gland enlarges, the patient begins to manifest symptoms of an obstructive process. Symptoms include hesitancy, a decrease in the force of the urinary stream, terminal dribbling, a sensation of a full bladder after voiding, and urinary retention. Urethral obstruction may cause urinary stasis, UTIs, hydronephrosis, and renal calculi.
The purpose of the diagnostic evaluation of BPH is to determine the extent of obstruction. Diagnostic evaluation includes a history and physical examination, digital rectal examination (DRE), urinalysis, and measurement of BUN and serum creatinine levels. Although BPH is not related to prostate cancer, a prostate-specific antigen (PSA) test may be ordered in some cases to rule out prostate cancer. Although not indicated as part of the initial evaluation of BPH, abdominal ultrasonography or cystoscopy may be indicated in persons with urinary retention, renal impairment, or suspected cancer.
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Nursing management Assessment
The purpose of the nursing assessment for an individual with BPH is to determine the extent of prostate enlargement and its effect on function so that appropriate nursing interventions can be planned and implemented. The assessment consists of history taking, physical examination, and evaluation of voiding patterns (Box 26- 13).
Box 26-13
Nursing assessment for benign prostatic hypertrophy History • General health
• Functional status • Medical and surgical history
• Current medications
• Voiding habits and patterns:
• The initiation and caliber of the urinary stream
• The presence of obstructive symptoms:
• Diurnal frequency
• Nocturia
• Hesitancy
• Urgency
• Urge incontinence
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• Incomplete bladder emptying
• Postvoid dribbling
• Signs and symptoms of urinary tract infection
• Dysuria
• Frequency
Physical Examination The physical examination is usually conducted by the physician or an advanced practice nurse and includes the following:
• Digital rectal examination (DRE) to evaluate the size, shape, and consistency of the prostate gland
• Abdominal examination to determine the presence of bladder distention, suprapubic tenderness, and costovertebral angle tenderness
Diagnosis Nursing diagnoses appropriate for the patient experiencing BPH include the following:
• Impaired Urinary Elimination, related to bladder outlet obstruction
• Risk for Infection, related to stasis
• Sexual Dysfunction, related to erectile dysfunction
• Deficient Knowledge, related to new diagnosis
Planning and Expected Outcomes Expected outcomes for a patient with BPH include the following:
1. The patient will maintain a regular schedule of complete bladder emptying.
2. The patient will remain free from UTIs, as evidenced by the use of measures to prevent infection.
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3. The patient will verbalize sexual concerns and describe measures to cope.
4. Patient demonstrates understanding of evaluation and treatment of BPH.
If surgery is indicated, expected outcomes might include the following:
1. The patient will have satisfactory pain control as indicated by 3 or less on a 0-to-10 scale.
2. The patient will regain urinary control similar to that experienced in the premorbid state.
Intervention Nursing interventions for BPH focus on patient education regarding the diagnosis and management of the disease. Education regarding the management of alterations in urinary elimination should include establishment of a frequent voiding schedules. The educational plan should also include teaching patients about the sympathomimetic actions of decongestant medications and diet pills, as they may cause acute urinary retention.
Nursing interventions must also take into account the treatment regimen. For patients treated with nonsurgical methods, interventions should focus on education about signs and symptoms of progressive BPH. As the prostate gland enlarges, the urine stream becomes weaker, hesitancy increases, and it becomes increasingly difficult to completely empty the bladder. Patient education should also focus on the medications used to relieve symptoms, their side effects, and drug interactions. For patients undergoing surgery, nursing interventions should initially focus on immediate postoperative care. Most surgical procedures require general anesthesia and a short hospitalization. Interventions should focus on maintaining patients’ levels of function and preventing postoperative complications related to immobility. Following discharge from the hospital, patients require education related to temporary activity restrictions, signs and symptoms of infection and urinary obstruction, and possible temporary incontinence.
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Surgical interventions may result in temporary sexual dysfunction; patients should be given the opportunity to verbalize concerns and to be referred to appropriate supportive services, such as a urologist or a certified sex therapist (see Patient/Family Teaching: Benign Prostatic Hypertrophy).
Patient/family teaching
Benign Prostatic Hypertrophy (BPH) BPH may alter the flow of urine. Any of the following symptoms could indicate BPH and should be reported to the physician immediately:
• Hesitancy or difficulty beginning urination
• Frequent need to urinate during the day and at night
• Leakage of urine
• Sensation of a full bladder after having just urinated
• Weaker-than-normal flow of urine
Evaluation Evaluation of interventions is based on the return of urinary function to the premorbid state, relief of urinary symptoms, avoidance or prompt management of UTIs, and a return to satisfactory sexual activity. Documenting the care of a patient with BPH includes noting the effectiveness of the nursing interventions, including validation the patient understands the disease process and treatment regimen and urinary elimination patterns.
Prostate Cancer The incidence of prostate cancer increases with age; by age 90, is it estimated 70% of men have some degree of prostate cancer. Prostate
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cancer is the most common form of cancer in men and the second leading cause of cancer-related death. The rate of mortality from prostate cancer is higher among black men than among white men. Risk factors include advancing age, family history of the disease, and black race.
Most prostatic cancers are adenocarcinomas; other forms include transitional cell carcinomas, small cell carcinomas, and sarcomas. Prostate cancer may metastasize through the lymphatic system and the bloodstream to the lymph nodes, bones, lungs, and liver.
Early prostate cancer is typically asymptomatic. As the tumor enlarges, it may cause symptoms of urinary obstruction. If obstruction of the urethra occurs, the patient may manifest symptoms of postrenal failure. Other symptoms may include perineal and rectal discomfort, weakness, nausea, hematuria, and lower extremity edema (with metastasis to pelvic nodes). Skeletal pain and pathologic fractures may indicate advanced disease with metastases.
It is extremely important for men to follow the recommendations of the American Cancer Society about screening for prostate cancer for early detection and initiation of treatment, if indicated, early in the course of the disease. Earlier detection of prostate cancer in the past decade has been associated with greater reduction in mortality rate compared with that of any other cancer (Sanda & Kaplan, 2009).
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Nursing management Assessment
Assessment of a patient with prostate cancer is essentially the same as that for a patient with BPH. The nurse should assess the patient’s health beliefs and fears related to a malignant process.
Diagnosis Appropriate nursing diagnoses for a patient with prostate cancer include the following:
• Impaired Urinary Elimination, related to bladder outlet obstruction
• Anxiety, related to uncertain prognosis
• Sexual Dysfunction, related to treatment measures
• Deficient Knowledge, related to lack of previous exposure to treatment modalities and prognosis
Planning and Expected Outcomes Expected outcomes for a patient with prostate cancer include the following:
1. The patient’s urinary elimination patterns will return to the premorbid state.
2. The patient’s expressions of anxiety about the diagnosis, treatment, and prognosis will be replaced with an understanding of the prognosis.
3. The patient and partner will have a mutually satisfying sexual relationship.
4. The patient will demonstrate knowledge of treatment methods and prognostic indicators.
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Intervention Nursing interventions for a patient with prostate cancer include educating the patient on diagnostic tests and treatment options. If surgery is indicated, nursing interventions should include the following:
1. Administration of analgesics for pain control
2. Suggestion of options for sexual counseling if the patient indicates a need
3. Education of the patient on the importance of a follow-up check of PSA levels and evaluation for disease progression
If hormonal therapy is indicated, the nurse should educate the patient on the administration of intramuscular or subcutaneous injections. If bone metastasis has occurred, the nurse should encourage safety measures around the home to decrease the incidence of pathologic fractures. The patient should be educated on when to report symptoms of worsening urethral obstruction, such as increased frequency, urgency, hesitancy, and urinary retention (see Nursing Care Plan: Prostate Cancer).
Nursing care plan
Prostate Cancer
Clinical Situation Mr. C is a 68-year-old black male. He has no major health problems at this time. At his annual physical examination, he was found to have prostatic enlargement; serum prostate-specific antigen (PSA) testing showed a level of 30 nanograms per milliliter (ng/mL). He then underwent magnetic resonance imaging (MRI) and was found to have a grossly enlarged prostate. A needle-guided biopsy was performed, and it showed adenocarcinoma of the prostate gland. Because of the large size of
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the prostate mass, evaluation for metastasis, consisting of bone scintigraphy and chest radiography, was performed. The evaluation did not show any metastatic disease.
Mr. C promptly scheduled a consultation with a urologist at a major medical center for the treatment of the prostate tumor. On evaluation, he was found to have stage C prostate cancer. The decision was made to treat the prostate tumor with radical prostatectomy.
Mr. C, his wife, and children are experiencing anxiety, fear, and anticipatory grief related to the diagnosis. Mr. C lost his father 5 years ago to prostate cancer and has many bad memories of his father’s illness and death.
Nursing diagnoses Anxiety, related to the diagnosis of cancer
Deficient Knowledge, related to lack of previous exposure to current treatment modalities and prognosis
Outcomes Expressions of anxiety about the diagnosis and prognosis will be
replaced by a realistic understanding of the disease and the likely prognosis, as evidenced by satisfactory engagement in activities.
The patient and family will verbalize understanding of the treatment regimen.
The patient and family will seek supportive services.
Interventions Reassure the patient and family that prostate cancers are typically
slow growing and treatable.
Reiterate the explanation of the diagnosis and treatment. Include the family in teaching, whenever possible.
Refer the patient and family to cancer support group services. Emphasize the importance of continuing present activities. Assist the patient in gaining awareness of anxiety.
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Teach the patient relaxation techniques.
Provide written information regarding prostate disease and treatment regimens.
Encourage the patient and family members to attend educational and supportive services provided by the American Cancer Society.
Evaluation Evaluation of interventions is based on a patient’s relief of symptoms from the obstruction and his return to the premorbid urinary elimination pattern. The patient should verbalize an understanding of the disease process, the staging of the tumor, and the recommended treatment. The patient and his partner should regain satisfactory sexual relations. Documentation should include all ongoing assessment findings related to expected outcomes.
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Summary The changes that occur in renal function with aging may be challenging. Impaired urinary elimination may cause problems that have a significant effect on day-to-day activities, self-concept, and functioning. The nurse’s role includes assessment, patient advocacy, emotional support, and appropriate referral. Individualized care plans should be developed that focus on promotion of self-care and functional ability (see Health Promotion box).
Health promotion/illness prevention Urinary Function Health Promotion • Adherence to prescribed bladder training program, exercises,
and techniques for urinary incontinence
• Adherence to a regularly scheduled program of monitoring of conditions as appropriate (e.g., prostate-specific antigen [PSA], blood pressure, urinalysis, and laboratory tests)
• Prompt treatment of urinary tract symptoms
Disease Prevention • Participation in a prostate cancer screening program, based on
risk established by the health care provider
• Drinking at least eight glasses of water daily, unless contraindicated by other chronic conditions
• Establishment of a routine pattern of urinary elimination
• Use of appropriate hygiene measures to avoid urinary tract contamination
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Key points • UI is one of the most common health problems of older adults.
• Although the aging process does affect lower urinary tract function, aging alone does not cause UI.
• Medications, including a number of OTC drugs, may cause acute UI.
• Functional and environmental assessments are important components of the evaluation of UI.
• Bladder diaries provide a more objective measure of the severity and type of incontinence than recall alone and should be part of the evaluation of UI.
• Behavioral interventions are the initial treatment of choice for many patients with UI.
• Cognitively intact patients with urge or stress incontinence often respond well to properly taught pelvic floor muscle exercises.
• Once a patient masters pelvic floor muscle exercises, the nurse may teach urge or stress strategies to prevent involuntary urine loss.
• Prompted voiding, habit training, and PURT may effectively reduce incontinence in patients with cognitive impairment, but the success of these methods depends on caregiver compliance.
• Aging affects renal function; however, impaired renal function is not a normal consequence of aging. Older adult patients must be assessed and attention directed to adequate hydration, adjusted medication dosages, and the existence of comorbidities that may lead to renal dysfunction.
• AKI, which is classified into three types, is a reversible process. The nurse must focus on education regarding proper diet and medications used to treat renal failure to halt the progression of AKI.
• CKD is not reversible but may be managed with medications and
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diet modification unless it has progressed to end-stage renal disease; in this case, dialysis is typically required as a bridge to successful transplantation.
• Alterations in urinary elimination pattern are common in men with BPH. The nurse must be prepared to educate patients about medications and Kegel exercises after surgery.
• The importance of PSA screening in black men older than age 40 and all other men older than age 50 cannot be stressed enough. Disease progression with prostate cancer may be very quick or very slow, and early detection is extremely important so that optimal treatment can be offered.
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Critical thinking exercises 1. Your 74-year-old female patient complains that she has leakage of urine during the day. What additional information do you need to assess her urinary function?
2. A 76-year-old man is admitted to the emergency department with complaints of nausea, fatigue, and poor appetite. The physician orders a urinalysis, BUN, and creatinine. Why does the physician suspect a urinary problem?
Home care
1. Regularly monitor and assess homebound older adults for signs and symptoms of exacerbation of the diagnosed renal or urinary disease or disorder.
2. Instruct caregivers and homebound older adults on reportable signs and symptoms related to the diagnosed renal or urinary system disorder and when to report these symptoms to the home care nurse or health care provider.
3. Instruct caregivers and homebound older adults on the name, dose, frequency, and side effects of medications prescribed to treat the diagnosed renal or urinary system disease or disorder.
4. Assess functional and environmental factors that contribute to urinary infection (UI) in homebound older adults.
5. Instruct caregivers and homebound older adults to keep a voiding diary to help the home care nurse establish the type of UI and plan nursing interventions.
6. Instruct caregivers and homebound older adults on behavioral interventions (e.g., bladder retraining and pelvic floor exercises) to treat UI.
7. If a homebound older adult is cognitively impaired, the success
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of behavioral techniques (e.g., habit training, patterned urge response training [PURT], and prompted voiding) used to treat UI will depend on the caregiver’s availability and motivation.
8. Instruct caregivers and homebound older adults on measures to reduce UI and maintain comfort.
9. Use indwelling catheters as a last resort to treat UI.
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aging: Diagnosis and treatment. Advances in Chronic Kidney Disease. 2010;17(4):e27–e40. doi:10.1053/j.ackd.2010.04.004.
Brundage DJ. Renal disorders. St Louis: Mosby; 1992.
Burgio KL, Goode PS. Behavioral interventions for incontinence in ambulatory geriatric patients. The American Journal of the Medical Sciences. 1997;314:257.
Colling J, Ouslander J, Hadley BJ, Eisch J, Campbell E. The effect of patterned urge-response toileting (PURT) on urinary incontinence among nursing home residents. Journal of the American Geriatrics Society. 1992;40:135–141.
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Du Moulin MF, Hamers JP, Paulus A, Berendsen C, Halfens R. The role of the nurse in community continence care: A systematic review. International Journal of Nursing Studies. 2005;42(4):479–492.
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Kelly CE. Evaluation of voiding dysfunction and measurement of bladder volume. Urology. 2004;6(Suppl. 1):S32–S37.
Lewis SM, Dirksen S, Heitkemper MM, Bucher L, Camera IM. Medical-surgical nursing: Assessment and management of clinical problems. 8th ed. St. Louis, MO: Mosby; 2011.
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prognosis?. National Review in Nehprology. 2011;7(4):209–217. doi:10.1038/nrneph.2011.13.
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Sanda MG, Kaplan ID. A 64-year-old man with low-risk prostate cancer: Review of prostate cancer treatment. JAMA: The Journal of the American Medical Association. 2009;301(20):2141–2150.
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C H A P T E R 2 7
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Cognitive and Neurologic Function Lois VonCannon, MSN, RN; Ramesh C Upadhyaya, RN, CRRN, MSN, MBA, PhD-C
Learning objectives
On completion of this chapter, the reader will be able to: 1. Compare and contrast structural changes in the brain and nerve function associated with aging.
2. Describe functional changes in the neurologic system during the aging process.
3. Compare normal, age-related changes of the neurologic system with those associated with cognitive and behavioral disorders.
4. Differentiate the symptoms of depression, delirium, dementia, and other cognitive disorders.
5. Describe the symptoms and diagnostic tests and interventions related to common neurologic disorders in older adults.
6. Use the nursing process in the development of a care plan for patients with common neurologic disorders.
7. Analyze evidence-based practice that enhances management of patients with neurologic disorders.
8. Apply the nursing process to older adult patients experiencing mental illnesses or disorders.
9. Identify appropriate nursing interventions when caring for older adults using psychotropic medications.
10. Evaluate mental health resources available for older adults.
http://evolve.elsevier.com/Meiner/gerontologic
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The number of older Americans (age 65 and older) continues to grow rapidly. It was numbered 40.4 million in 2010, which was an increase of 5.4 million or an increase of over 15% since 2000. The number of Americans in the age group to reach age 65 in the next two decades has increased by 31% during this decade. Over one in eight, or just over 13%, of the population in the United States is an older adult (Administration on Aging, 2012). In light of these statistics, it is imperative that nurses keep abreast of the most recent findings regarding the development, manifestations, and treatment of cognitive and neurologic problems among older adults. This knowledge will assist nurses in providing safe, effective, and evidence-based nursing interventions (CDC & NACDD, 2012).
The brain is a complex web of tissue and structures that allows for a series of intricate functions that continues to astonish the most advanced neuroscientists. Understanding the brain and its function has long been an interest for health care providers. For nurses caring for older persons, the understanding of basic neurologic changes and common disorders is crucial.
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Structural age-related changes of the neurologic system The nervous system is a network of complex structures that undergo many neurophysiologic changes with aging. Some changes that occur in the brain do not affect all older individuals equally, and the individual presentation of neurologic changes varies from person to person. An individual’s lifestyle, nutritional intake, genetic makeup, and tissue perfusion are some of the many factors that affect the neurologic system. To appreciate the significant changes that take place with aging, one requires a brief review of the neurologic system.
The central nervous system (CNS) is divided into three major functional components: higher level brain or cerebral cortex, lower level brain (basal ganglia, thalamus, hypothalamus, brainstem, and cerebellum), and spinal cord. The brain is divided into three major areas, which include the cerebrum, brainstem, and cerebellum. The cerebrum consist of two hemispheres (right and left); each hemisphere is divided into lobes (frontal, temporal, parietal, and occipital) (Figure 27-1). Specialized neurons located within the lobes include the hippocampus and the basal ganglia. These are the neurons that undergo structural and physiologic changes during the aging process. Another area of the CNS that undergoes significant changes in the normal aging process is the brainstem (midbrain, pons, and medulla oblongata). The reticular formation (RF) is a complex network of gray matter located primarily in the brainstem area of the CNS. The RF assists and controls many functions, including skeletal muscle movement and the sleep–wake cycle, another aspect that is altered in aging (Black, Hawks, & Hogan, 2005; Mander, Rao, Lu et al., 2013).
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FIGURE 27-1 A, Major divisions of the central nervous system (CNS). B, Diencephalon (thalamus and hypothalamus). (From Lewis,
S.M., Heitkemper, M.M., Dirksen, S.R., & O’Brien, B. (2007). Medical surgical nursing: Assessment and management of clinical problems (7th ed.). St. Louis, MO:
Mosby.)
Cellular and Structural Changes Neuron The neuron is the basic unit of the CNS and functions to transmit impulses. Some neurons are motor neurons, and some are sensory neurons. Each neuron has a cell body (soma), dendrites, and a single axon (Figure 27-2). Synapses are structural and functional junctions between two neurons. These are the points at which the nerve impulse is transmitted from one neuron to another or from neuron to efferent organ. The two types of synapses are electrical and chemical.
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FIGURE 27-2 Neuron with composite parts. (From Urden, L.D., Stacey, K.M., & Lough, M.E. (2002). Thelan’s critical care nursing: Diagnosis and
management (3rd ed.). St. Louis, MO: Mosby.)
Neurotransmitters Neurotransmitters are chemical substances that enhance or inhibit nerve impulses. These substances are necessary in the synaptic transmission of information from one neuron to another. In aging the function of these substances is altered because of the decrease of neurons. With aging, the number of neurons in various areas of the brain also decreases, and abnormal substances are deposited on the neuronal cellular structure (dendrites) (Sugarman & Huether, 2012). The loss of neurons is not as extensive in the process of aging as previously believed. In actuality, large neurons appear to shrink and few are lost. The changes in neuron function are associated with accumulation of lipofuscin (dark fluorescent pigment) granules and neuritic plaques in the cell body of some neurons and some cellular debris in neuroglia cells (Keller, 2006) (Table 27-1).
Table 27-1 Significant changes in the aging nervous system
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Ach, Acetylcholine; RAS, reticular activating system.
Neuroglia and Schwann Cells Neuroglia and Schwann cells are the supportive cells of the CNS, making up approximately half of the brain and spinal cord tissue. Their role is to protect the neurons. As individuals age, the number of these protective cells increases. Each of these cells serves a different function.
Neuroglia cells vary in size and shape and are divided into two main classes: the microglia and the macroglia (Figure 27-3). The microglial cells are phagocytic scavenger cells related to macrophages that respond to infection or trauma to the CNS. The macroglial cells include astrocytes, oligodendrocytes, and ependymal cells. Astrocytes (astroglia) are star-shaped cells that provide the physical support for the neurons. They also regulate the chemical environment and nourish the neurons. These cells respond to brain trauma by forming scar tissue.
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FIGURE 27-3 Types of neuroglial cells. (From Thompson, J.M., McFarlane, G., Hirsch, J., & Tucker, S. (1997). Mosby’s clinical nursing (4th ed.). St.
Louis, MO: Mosby.)
Oligodendrocytes and Schwann cells produce myelin within the CNS and peripheral neurons, respectively. Ependymal cells form the lining of the ventricles, choroid plexuses, and central canal of the spinal cord. These cells help in the regulation of cerebrospinal fluid (CSF) and the blood–brain barrier (Sugarman & Huether, 2012).
Cerebrospinal Fluid and Ventricular System CSF is a clear, colorless fluid. Approximately 135 milliliters (mL) of CSF circulates through the ventricles—a system of cavities within the brain—and within the subarachnoid space (80 mL in ventricles and 55 mL in the subarachnoid space). The brain and the spinal cord float in CSF, which absorbs shocks, cushions the CNS, and prevents the brain from tugging on meninges, nerve roots, and blood vessels. The choroid plexus (CP) is a group of blood vessels (capillaries) covered with a thin layer of epidermal cells. The CP is responsible for producing approximately 500 mL of CSF per day
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(Figures 27-4 and 27-5).
FIGURE 27-4 Production, flow, and absorption of cerebrospinal fluid.
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FIGURE 27-5 Flow of cerebrospinal fluid. (Modified from Thibodeau, G.A. & Patton, K.T. 2010). Anatomy and physiology (7th ed.). St. Louis, MO: Mosby.)
Several physiologic changes are known to occur in the CNS of aging individuals. These may include sensory motor changes such as difficulty retrieving explicit memories and altered vision, hearing, taste, smell, vibratory sensations, and position sense. As a result of neurotransmitters and hypothalamic changes in the aging process, the reticular activating system (RAS) that controls arousal and consciousness from the brainstem to the cerebral cortex is also altered. The neuroendocrine system plays a vital role in the function of the hippocampus. When any alteration occurs in this system, gradual changes in memory may be seen.
Hippocampus and the Hypothalamic–Pituitary– Adrenal Axis The hippocampus is a part of the temporal lobe that plays an important role in memory and learning. Normal aging is associated with changes in the ability to consciously learn and retain new information easily. This occurs as a result of structural changes, synapse loss in the neurons, decreased microvascular integrity,
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reduction in glucose metabolism, and alterations in the neuroglia cells with aging. As a result of changes in the secretory pattern of the hypothalamic–pituitary–adrenal (HPA) axis, additional alterations occur in the hippocampal area of the brain. The hippocampal area is strongly influenced by HPA hormones. The specific aspects altered by the aging process are the explicit memory (e.g., delayed recall), the ability to learn new information quickly, memory storage, and memory retrieval (Fadil, Borazanci, & Ait Ben Haddou, 2009; Keller, 2006).
Cerebrospinal Fluid A reduction in the turnover of CSF with age decreases the distribution and efficiency with which the necessary substances are delivered from the CP to the brain target sites. These substances include the hormones necessary for metabolism and appetite and the nutrients (e.g., transferrin, glucose, amino acids, and vitamins) necessary for nerve function. A reduction in the turnover of CSF may affect the removal of waste products, toxins (e.g., amyloid peptides and lactate), and drugs. The accumulation of these substances resulting from age-related changes may contribute to diseases causing cognitive decline. One significant factor that reduces the turnover secretion rate of CSF is the age-related increase in resistance from the vascular (sagittal venous sinus) system in the arachnoid (Redzic, Preston, Duncan et al., 2005). These changes occur in various degrees among aging individuals.
Balance and Motor Function Age-related neurodegenerative and neurochemical changes in the cerebellum are believed to be the underlying cause of decline in motor and cognitive function. The neurodegenerative and neurochemical changes, combined with inner ear and vestibular changes, cause many older adults to experience changes in balance. These changes may further contribute to postural hypotension because of an inability to quickly respond to changes in position. The symptoms of postural hypotension are dizziness or lightheadedness when changing positions rapidly. However, compensatory processes in the cortex and subcortical areas of the
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brain help aging individuals maintain relatively normal motor performance (Heuninckx, Wenderoth, & Swinnen, 2008).
Reticular Formation and Sleep Patterns The RF is a set of neurons that extends from the upper level of the spinal cord through the brainstem up to the cerebral cortex. The RF contains both motor and sensory tracts that are closely connected with the thalamus, basal ganglia, cerebellum, and cerebral cortex. This group of neural fibers has both excitatory and inhibitory capability. The RF contains a physiologic element, the RAS, which regulates sensory impulses that are transmitted to the cerebral cortex. The lower portion of the RAS in the brainstem assists in the regulation of the wake–sleep cycle and consciousness. Sleep disorders are common in aging individuals. Risk factors for sleep disturbances include physical illness, medications, changes in social patterns (e.g., retirement or death of a spouse or loved one), and changes in circadian rhythm. Some sleep disturbances may also be part of the normal aging process resulting from neural changes in the RAS.
Normal sleep is organized into different stages that cycle throughout the night. The sleep stages are classified into the following categories (Brannon, Carroll, Vij, & Gentili, 2008; National Institute on Aging [NIA], 2012e):
• Rapid eye movement (REM) sleep. This is the stage of sleep during which muscle tone decreases significantly. In advanced aging REM sleep is maintained without much decline.
• Non-REM sleep. This is subdivided into four stages. Stages 1 and 2 constitute light sleep, and stages 3 and 4 are deep sleep or slow- wave sleep. With aging, the duration of stage 1 sleep and the number of shifts into stage 1 sleep increase. Stages 3 and 4 decrease significantly with aging. Among the oldest-old people (older than 90 years), stages 3 and 4 may disappear completely. Some older women have normal or even increased stage 3 sleep, whereas men have normal or reduced stage 3 sleep.
As individuals age, they spend more time in bed to get the same amount of sleep they obtained when younger; however, the total
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sleep time is only slightly decreased, with an increase in nocturnal awakenings and daytime napping. Hence older persons often report having earlier bedtimes and increased sleep latency (time to fall asleep), with women taking longer than men, a 16% and 36% difference (NIA, 2012e).
Excessive daytime somnolence is not part of normal aging. Somnolence indicates the presence of a pathologic condition. Sleep apnea and certain movement disorders are serious sleep disorders, and older adults should be tested for these if they are having trouble with insomnia. Movement disorders, including restless leg syndrome, rapid eye movement sleep behavior disorder, and periodic limb movement disorder, are common among older adults (NIA, 2012e).
Sensorimotor Function The nervous system depends on specialized sensory receptors to gather information about the internal and external environment. These receptors include those needed for vision, hearing, smell, touch, equilibrium, and pain sensation. Gradual changes occur in these sensory receptor sites as the aging process take place.
Vision changes that occur with aging are significant. The lens of the eye thickens, becoming yellow, cloudy, and less elastic. The thickening of the lens reduces the amount of light passing through the lens. As the lens becomes less elastic, it loses its ability to focus on close objects. The change in elasticity also narrows the visual field and diminishes depth perception. The yellowing of the lens and changes in size and thickening of the cornea make it difficult to see at night. With aging, the fluid of the eye also becomes cloudy, reducing light sensitivity. These changes in the eyes lead to a gradual decrease in color perception, potentially affecting the ability of older individuals to distinguish between blue, green, and violet shades.
The ear consists of the outer ear, middle ear, and inner ear. Presbycusis is the hearing loss associated with the aging process. With presbycusis older persons are unable to hear high frequencies and are unable to clearly hear consonant sounds such as f, g, s, z, t,
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sh, and ch. Other age-related auditory changes involve the collapse and narrowing of the auditory canal and thickening of earwax, which increase hearing difficulty.
With aging, the number of taste and smell receptors decreases and nerve transmissions are slower, although these losses are highly variable. The loss of taste and smell receptors means that food is not as appetizing to the older adult. Aging adults are also less likely to detect the bad taste or smell of spoiled food. Their reduced ability to smell also may make them unable to detect smoke, gas leaks, or other toxic fumes immediately.
The somatic receptors respond to touch, pressure, cold, pain, and body position. These receptors also become less sensitive as aging occurs. Older individuals therefore experience a decreased ability to feel pain and cope with temperature changes. These and additional age-related changes are presented in Table 27-1.
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Assessment of cognitive function The assessment of neurocognitive function is an essential part of a comprehensive assessment in older adults. Neurocognitive function assessment includes several components and can be easily incorporated into the general assessment of older adults through history taking, physical examination, and the use of selected screening instruments. A complete mental status assessment should include attention, memory, orientation, perceptions, thought processes, thought content, insight, judgment, affect, mood, language, and higher cognitive functions.
Screening instruments are available to primary care providers for detecting mental disorders, but the actual diagnoses are based on criteria detailed in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association [APA], 2013). A multiaxial system involves assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict the outcome (APA, 2013).
Neurologic assessment includes the evaluation of cranial nerves, gait, balance, distal deep tendon reflexes, plantar responses, primary sensory modalities in the lower extremities, and cerebrovascular integrity. Complete neurocognitive examinations should be performed on all older adults to establish baseline function and to detect potentially reversible conditions causing mental and behavioral disturbances.
Few older adults recognize the symptoms of cognitive decline in themselves. It is often a friend or family member who reports these symptoms to the nurse or physician caring for the patient. An interview with the friend or family member, physical assessment, and the use of structured mental status assessments assist the nurse in identifying cognitive decline in older adults (Dick, 2013).
One of the early manifestations of cognitive decline may be observed in the functioning of older adults. It is important to include functional assessment as part of the assessment of older
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adults. Simple questions that may be asked in the history include their ability to perform activities of daily living (ADLs) such as bathing, dressing, toileting, and eating. Instrumental activities of daily living (IADLs) should also be addressed. These activities include the ability to clean house, shop, pay bills, and perform other functions that would allow patients to remain independent within their homes.
Selected Cognitive Function Screening Instruments Functional Assessment One screening tool that has been used to identify the presence and severity of dementia symptoms based on level of function and cognition in older adults is the Dementia Severity Rating Scale when administered by family or caregivers (DSRS). The DSRS is an 11-item instrument that can be easily and quickly administered and covers memory, orientation, judgment, community affairs, home activities, personal care, speech and language recognition, feeding, incontinence, and mobility or walking. A normal score on this instrument is four or less; the score increases as the older person’s cognition decreases (Harvey, Moriarty, Kleinman et al., 2005).
Mental Status Examination The Saint Louis University Mental Status (SLUMS) examination is a free for clinical use instrument for the identification of cognitive disorders. The Mini-Mental Status Examination (MMSE) was considered the gold standard in years past but is now a fee-based instrument (Folstein, Folstein, & McHugh, 1975; Family Practice Notebook, 2011). The Mini Cog is a 3-minute test that is used to screen for cognitive impairment in the older adult. It uses a three- item recall test as well as a clock drawing test. It is not as affected by ethnic differences, language, or education, as is the MMSE, and is more sensitive in detecting mild impairment (Hartford Institute for Geriatric Resources, 2013). The Blessed Dementia Scale, or Short Blessed Test (SBT), is another frequently used screening tool for the assessment of dementia; however, both aging and depression have
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an effect on the performance of the Blessed Orientation-Memory- Concentration (BOMC) test (Jorm & Jacob, 1989). The BOMC test, which is a shortened version of the SBT, consists of six questions and is used by many disciplines.
Depression Assessment Depression often occurs concurrently with other serious illnesses such as heart disease, stroke, diabetes, cancer, and Parkinson disease (PD). Because many older adults face these illnesses as well as various social and economic difficulties, health care professionals may mistakenly conclude that depression is a normal consequence of these problems, an attitude often shared by patients themselves. These factors together contribute to the underdiagnosis and undertreatment of depressive disorders in older people. Depression can, and should be, treated when it occurs with other illnesses, as untreated depression may delay recovery from or worsen the outcome of the other illnesses. The relationship between depression and other illness processes in older adults is a focus of ongoing research (National Institute of Mental Health [NIMH], 2013).
The Beck Depression Inventory (BDI) is a self-administered or caregiver-administered, 21-item instrument, which is helpful for uncovering depression and for rating severity and intensity (Osbourne & Saunders, 2012).
Cognitive Function and Memory in Typical Aging Forgetfulness as an inevitable consequence of aging is a myth that has had significant influence on society’s views of aging. Forgetfulness may affect both the young and old but should not be confused with true cognitive impairment. In reality, memory and delayed recall are not substantially decreased in older persons. If allowed time to learn new material, older persons experience no more memory loss than younger persons. Cognitive impairment involves mental status changes in addition to higher level cognitive functional changes such as failure to correctly spell common words, compute simple sums, balance a checkbook, drive a car safely, plan
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a meal, or follow grammatical conventions. A decline in cognitive function is an effect of disease, not an effect of the normal aging process.
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Cognitive disorders associated with altered thought processes Several cognitive disorders are associated with altered thought processes in older adults. These include the three Ds—depression, delirium, and dementia—as well as cranial tumors, subdural hematomas, and normal pressure hydrocephalus. It is often difficult to accurately diagnose the underlying cause of altered thought processes in older adults because of the similarity in their presentations. Nevertheless, accurate assessment and diagnosis are essential for ensuring appropriate treatment to improve or potentially reverse the underlying pathophysiologic condition contributing to the individual’s impaired cognition.
Depression As an individual ages, the rate of depression increases. The estimate is 20% to 25% of those older than 55 have evidence of a mental health disorder. These include anxiety, depression, dysthymic disorder, and severe cognitive disorders (APA, 2013; Centers for Disease Control and Prevention [CDC], 2012). The percentage of men older than the age of 85 reporting depressive symptoms is almost double that of men aged 65 to 74. Depression is associated with higher suicide rates among older adults than among younger persons with depression (CDC, 2012). Although older Americans make up 13% of the U.S. population, they account for 19% of all suicide deaths. Older men have the highest rates of suicide of any age group, and men 85 and older have rates of suicide at 45.23 per 100,000 (CDC, 2012). Dombrovski and Szanto (2005) reported that older adults in the United States, especially those that are depressed, are more likely to commit suicide than those in any other age group, although it is difficult to estimate the true incidence of suicide among older adults.
Clinical Manifestations Depression may manifest itself through more vegetative signs such
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as fatigue; constipation; psychomotor retardation; depressed mood; loss of interest, energy, libido, or pleasure; changes in appetite, weight, and sleep patterns; agitation; anxiety; or crying (APA, 2013; Kyomen & Whitfield, 2008). Depression is often first seen in older adults as cognitive impairment, particularly in the areas of attention and concentration. Depressed older adults may neglect eating or caring for a chronic medical condition, predisposing them to the development of delirium.
Depression is also a common response to serious illness of any kind, particularly multiple sclerosis, hypothyroidism, lupus, hepatitis, acquired immunodeficiency syndrome (AIDS), vitamin deficiencies, and anemia. These conditions may produce depression in a more direct biologic sense. Drugs may also contribute to depression (Box 27-1). Some general medical conditions such as myocardial infarction (MI) or a hip fracture are risk factors for depression. And individuals with these conditions as well as depression have a poorer outcome compared with those without depression (APA, 2013). Older adults require careful medical history taking and physical examination before the diagnosis of depression can be made. The loss of physical health, employment and income, family and friends, and house and comfortable environment are difficult to accept, especially if they all occur within a relatively short period. Retirement may be difficult and depressing for many, especially those who were involved in interesting, rewarding work. Comorbidity, or the presence of multiple chronic health problems, may prevent older adults from enjoying life and may lead to clinical manifestations of depression.
Box 27-1
Medications that may contribute to depression • Amphetamines
• Analgesics, narcotics
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• Antihypertensives
• Antimicrobials
• Antineoplastic agents
• Antiparkinsonian agents
• Barbiturates
• Benzodiazepines
• Digoxin
• Hypoglycemic agents (by causing hypoglycemia)
• Phenothiazides
• Steroids
• Sulfonamides
Late-life depression is often similar in presentation to, or may be concomitant with, cognitive impairment and dementia caused by neurochemical changes and awareness of the loss of physical or intellectual functioning. Symptoms common to both depression and dementia include irritability, inability to concentrate or feel pleasure, loss of interest in life, and lack of energy and initiative. The term pseudodementia has been used to describe depression masquerading as dementia. Pseudodelirium is the term used when an older adult is seen with acute confusion found to be caused by depression. With careful assessment, it is possible to make the appropriate diagnosis. Individuals with dementia are more likely to show signs of disorientation and loss of short-term memory and are less likely to feel sadness or guilt or to complain about pain, insomnia, and poor appetite. Table 27-2 compares selected features associated with dementia, delirium, and depression (Sullivan, 2008).
Table 27-2 Clinical features of depression, delirium, and dementia
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Delirium Delirium presents as a disturbance in attention (decreased awareness of the environment) with a reduced ability to focus, sustain, or shift attention (DSM-5: Neurocognitive Disorders [NCDs]). Cognitive changes (poor memory, disorientation, speech disturbance), perceptual disturbances, or both are distinct from preexisting, established, or evolving dementia. The onset of the disturbance is rapid (hours to days) and typically fluctuates over the course of the day. Delirium frequently represents a sudden and significant decline from a previous level of functioning and usually is evident following history taking, physical examination, or laboratory tests of a direct physiologic etiology of a general medical condition, substance intoxication or withdrawal, use of a medication, toxin exposure, or a combination of these factors (APA, 2013 Neufeld, Birenvenu, Rosenberg et al., 2011).
Delirium occurs in all settings, including homes, assisted living facilities, nursing facilities, and hospitals. Frequently, when an older adult becomes delirious in a community setting, it precipitates hospital admission, in part because of the underlying illness causing the delirium. It is not uncommon for hospitalized patients with cancer (25%) and hospitalized patients with AIDS (30% to 40%) to develop delirium. Approximately half of postoperative patients develop delirium, and the majority of those with terminal illness (up to 80%) develop delirium with impending
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death (Breitbart & Alici, 2012).
Risk Factors The risk factors for delirium include advanced age, CNS diseases, infection, polypharmacy, hypoalbuminemia, electrolyte imbalances, trauma history, gastrointestinal or genitourinary disorders, cardiopulmonary disorders, and sensory changes. These factors may lead to physiologic imbalances increasing the risk for confusion (Fick & Mion, 2008). Specific laboratory testing should be guided by clues in the history and physical examination so that the physiologic causes of delirium can be identified.
Clinical Manifestations Symptoms of delirium fluctuate and may include difficulty maintaining concentration or attention to external stimuli and a language disturbance, including slurred, forced, or rambling speech. Disorganized thinking demonstrated by tangential reasoning and conversation is often the presenting symptom. Other common symptoms of delirium include the following:
• Clouding of consciousness or fluctuation of awareness
• Misperceptions, illusions, or hallucinations
• Disorientation to persons, place, and time
• Memory problems
• Increased or decreased physical activity
• Impaired judgment
Management
Nonpharmacologic interventions A therapeutic environment would include frequent reassurance and reality orientation; clear communication; caregiver consistency; decreased stimuli (noise reduction, adequate lighting, not rushing the patient); decreased stress and anxiety through frequent reassurance and providing daily routine; maintaining comfort
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(eyeglasses, hearing aids, personal belongings); reestablishing sleep–wake cycle by controlling nighttime noise and unnecessary disruptions; ensuring adequate daily fluid intake; ensuring elimination needs are met; providing for physical activity, ambulation, and range of motion; and avoiding chemical or physical restraint. Medication should be used as a last resort (Tullmann, Fletcher, & Foreman, 2012).
Pharmacotherapy Data support the use of first-generation (e.g., haloperidol) and second-generation (e.g., olanzapine, risperidone, ziprasidone, and quetiapine) antipsychotic medications to control behavioral symptoms of delirium and prevent injury to self or others (Flaherty, Gonzales, & Dong, 2011; Gill, Anderson, Fischer et al., 2009). Cholinesterase inhibitors (e.g., donazepil) were not found to be more effective than placebo in managing the symptoms of delirium in a very small study; further study is needed (Overshott, Karim, & Burns, 2009). The avoidance of benzodiazepines except for specific indications (e.g., alcohol or gamma-hydroxybutyric acid [GHA] withdrawal delirium, delirium related to seizures) continues to be a recommendation.
Early delirium research focused on the timely identification of delirium in hospitalized older adults. Current research focuses on the identification of risk factors and prevention strategies. Multiple instruments have been developed to assess for delirium, but the Confusion Assessment Method (CAM) (Inouye et al., 1990) is probably the best known and standardized evidence-based method. The CAM-ICU is also available and has been translated into several languages. It does assess the presence or absence of delirium but does not assess severity, which is its limitation (Hartford Institute for Geriatric Resources, 2012).
In one study, a program was developed for the early detection and treatment of older persons who developed symptoms of delirium during hospitalization (Inouye, Zhang, Jones et al., 2007). Among the study participants older than age 70, 11.8% had delirium at discharge, as measured by the CAM. The predictive model used in this study found five risk factors for delirium: (1)
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cognitive impairment, (2) visual impairment, (3) functional impairment, (5) comorbidity, and (5) the use of physical restraints. The study validated the previously studied predictive model, and the authors concluded that at least four of the five risk factors for delirium are amenable to intervention. Table 27-3 outlines the assessment and intervention protocols used in the care of patients with delirium.
Table 27-3 Risk factors for delirium and intervention protocols
From Inouye SK: Risk factors for delirium and intervention protocols, N Engl J Med 340(9):669, 1999. * Orientation score consisted of results on first 10 items on the Mini-Mental State Examination (MMSE). † Sedative drugs included standard hypnotic agents, benzodiazepines, and antihistamines, used as needed for sleep.
A number of interventions are used to prevent delirium in hospitalized patients. Assessment with the use of a validated
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instrument such as the CAM is the first line in preventing and treating delirium. Delirium management includes rapid diagnosis and treatment of the underlying cause, management of disruptive behaviors, and supportive care. As discussed in the study by Inouye and colleagues (2007), assessment of changes in older persons’ cognition is paramount. Thorough history taking and physical examination are essential for the identification of the onset, cause, direct physiologic manifestations of a general medical condition, or intoxication with or withdrawal from substances that may be contributing to the onset of delirium (APA, 2013).
Dementia The number of people living with dementia worldwide is currently estimated at 35.6 million. This number will double by 2030 and more than triple by 2050 (World Health Organization [WHO], 2012). The phenomenon of potentially reversible dementia is not included in these statistics. The primary types of dementia include Alzheimer disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD).
Dementia is a syndrome of gradual and progressive cognitive decline. It has been defined as alteration in memory, in addition to acquired persistent alteration in intellectual function (e.g., orientation, calculation, attention, and motor skills) compromising multiple cognitive domains. In dementia, individuals are unable to do the things they used to do because of the mental changes associated with this disease process. Dementia may involve language deficits, apraxia (difficulty with the manipulation of objects), agnosia (inability to recognize familiar objects), agraphia (difficulty drawing objects), and impaired executive function (Alzheimer’s Association, 2013).
Although dementia is more common in older persons than in younger persons, it is not part of the normal aging process. Dementia is usually a condition occurring in later life because of changes in neurologic function caused by a disease process. Dementia has been linked to a variety of conditions. Research of the problem has been difficult because of the lack of a standard
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definition of mild dementia and difficulty in detecting symptoms of early dementia.
Reversible Dementia Reversible dementia is a phenomenon that occurs when other pathologic conditions masquerade as dementia. Causes of potentially reversible dementia are presented in Box 27-2. It is important to identify and treat the underlying causes of dementia symptoms, but even if these disorders are identified and treated, not all individuals with dementia symptoms will improve (Koedama, Pijnenburga, Deega et al., 2008).
Box 27-2
Causes of potentially reversible dementia • Medications
• Ethyl alcohol (ETOH) intoxication or withdrawal
• Metabolic disorders:
• Thyroid disease
• Vitamin B12 deficiency
• Hyponatremia
• Hypercalcemia
• Hepatic dysfunction
• Renal dysfunction
• Depression
• Delirium
• Neoplasia of the central nervous system
• Chronic subdural hematoma
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• Normal pressure hydrocephalus
Alzheimer Disease Adequate, accurate diagnosis of AD is essential. Some conditions such as AD have no specific cure, but it is essential to know whether the symptoms and behavior are reversible. Even those irreversible disorders can, and should be, treated with appropriate medications, if useful, and with effective communication techniques and environmental strategies, as needed.
AD is the most common form of dementia in older persons and accounts for 60% to 80% of individuals with the disease (Alzheimer’s Association, 2013). AD is a progressive, neurodegenerative disease characterized by the presence of neurofibrillary tangles composed of misplaced proteins within the brain, cortical amyloid plaques, and granulovascular degeneration of neurons in the pyramidal cell layer of the hippocampus. Over five million Americans have AD, and it is predicted that the number of individuals with AD could rise to 13.4 million by 2050 (Alzheimer’s Association, 2013). AD is the sixth leading cause of death in the United States (Alzheimer’s Association, 2013). Of those with AD, it is estimated that about 4% are under age 65, 13% are ages 65 to 74, 44% are ages 75 to 84, and 33% are over 85 (Alzheimer’s Association, 2013). See Appendix 27A for more information.
The personal and public costs of AD are high. Medicare costs for beneficiaries with AD are expected to exceed the ability to absorb the cost (Alzheimer’s Association, 2013). Costs are estimated to soar from $203 billion (including $142 billion for Medicare and Medicaid) this year to $1.2 trillion by 2050 for caring for patients with AD and other types of dementias (Alzheimer’s Association, 2013). Approximately 5% of people in the United States live in extended care facilities, and the lifetime risk of admission to an extended care facility is 25% to 50%. By 2040, as many as four million Americans will be living in long-term care settings. The incidence of dementia and other psychiatric disorders in this growing population will range from 51% to 94% (Zisook, 2008). The
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changing demographics of our society and the anticipated growth of the older adult population during the next few decades have created a need for nurse practitioners and other health care providers to develop age-related interventions that address the mental health needs of an aging population.
Risk Factors Research has focused on genetic, nutritional, viral, environmental, and other causes of AD. Age is the single most important risk factor for the development of AD, as the number of people with the disease doubles every 5 years beyond age 65.
Genetic Factors One risk factor for the development of AD is genetics, particularly in one type of early-onset AD occurring in people ages 30 to 60, but affecting less than 5% of all who have AD. This type is named familial AD (FAD) and is caused by one of any number of different single-gene mutations on chromosomes 1, 14, and 21. These mutations cause abnormal proteins to be formed
Evidence-based practice Using Trained Volunteers for Patients with Delirium
Background Delirium is a common issue for hospitalized older patients. It is associated with an increased risk of mortality and overall poor patient outcomes. This study sought to examine the effectiveness and cost impact of a volunteer-mediated delirium prevention program by looking at two main components. In the first study, patients were the focus of the data collection. The second study focused on how the nursing unit functioned as a result of the volunteer-mediated delirium program.
Sample/Setting
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In the first study, a total of 37 patients were enrolled over a 5- month period.
Methods Both studies were conducted utilizing a before-and-after framework. Study 1 examined the impact of trained volunteers on patients’ therapeutic activities against a control group who received the standard nursing care practices without a volunteer. Study 2 looked at the program data to assess the impact on the nursing assistants usually employed to provide one-on-one care for patients with delirium or dementia.
Findings The patients enrolled in the experimental group showed a lower incidence of delirium (6.3% versus 38.1%, p = 0.032), a reduction in the severity of the delirium, a decrease in the overall length of stay, and a decrease in the incidence of falls (control group 6.3% versus 19%, p = 0.26). The rudimentary cost analysis for the second study indicated that the savings related to a decrease in the length of stay would support the continuation of this pilot program to other geriatric acute care units.
Implications The economic crisis worldwide has placed acute care staffing on a razor edge with increased admissions of older adults. Utilization of volunteers trained to augment direct nursing care in those with delirium may be one method to decrease the morbidity of this condition.
Other Areas of Research A hypothesis that chronic mild cerebrovascular dysfunction may lead to Alzheimer disease (AD) and that other vascular risk factors such as diabetes and hypercholesterolemia, as well as hyperhomocystenemia, lead to increased beta-amyloid has been proposed. Chronic alcohol use may be a risk factor for AD, as similarities exist between alcoholic dementia and AD; however, Resveratrol, the compound found in red grapes, appears to have properties that may help protect the brain (NIA, 2012d).
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Inflammation is an important trigger of degeneration of the brain during aging and is considered a major part of the neurodegeneration of AD. An increasing body of evidence indicates that oxidative stress is caused by free radicals, which are found in the neurofibrillary tangles of the brain of the patient with AD. While free radicals are found in many older adults, demonstrating a normal aging process, the quantity is higher in patients with AD. (From Caplan, G.A. & Harper, E.L. (2007). Recruitment of volunteers to improve vitality in the elderly: The REVIVE study. Internal Medicine Journal, 37, 95.)
(NIA, 2012a). Research continues to be done that have helped identify key steps in the identification of brain abnormalities typical of AD, for example, the accumulation of amyloid in the living brain. Most cases of AD develop after age 60 and are a combination of lifestyle, genetics, and environmental factors. One genetic risk factor appears to increase the risk of developing the disease and that is related to the apolipoprotein E (APOE) gene found on chromosome 19 (NIA, 2012a). Genetic testing is being used in research settings and in some primary care offices at the present time, as it can identify which APOE alleles a person has, but it cannot predict who will or will not actually develop AD.
Clinical Manifestations Symptoms of AD that may be identified by family members and nurses include the individual repeating questions and statements, forgetting to pay bills or take medications, increasing problems with orientation, and geographic disorientation. Other symptoms of AD include pervasive forgetfulness and memory loss, language deterioration, impaired ability to mentally manipulate visual information, poor judgment, confusion, restlessness, and mood swings. Personality changes may include apathy or loss of interest in previously enjoyed activities. Eventually, AD destroys cognition, personality, and the ability to function.
Diagnostic Studies In 2012, both the NIA and the Alzheimer’s Association proposed new guidelines to assist pathologists in describing and categorizing
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brain changes with AD and other dementias. One guideline is that three stages of AD exist and that in the first stage symptoms such as memory loss are not noticeable; it may take up to 20 years before any symptoms develop. Another guideline describes biomarkers such as beta-amyloid and tau-amyloid in CSF and blood (Alzheimer’s Association, 2013). Although autopsy remains the gold standard for the definitive diagnosis of AD, clinical diagnosis has become increasingly accurate over the past several years (Alzheimer’s Association, 2013). Magnetic resonance imaging (MRI) and computed tomography (CT) are used in the medical workup mainly to rule out any other brain conditions and have been used to identify the hippocampal atrophy associated with the diagnosis of AD. As with any other medical diagnosis, a complete history, physical examination, blood work, and neurologic examination and tests are essential.
Treatment At this time, no cure exists for AD. Several pharmacologic options have been introduced to slow the progression of the disease. These medications have transformed the care of AD patients. Cholinesterase inhibitors are prescribed for mild to moderate AD and are used to delay or prevent symptoms from becoming worse for a limited time. They may also help control some behavioral changes. These medications include donepezil (Arecept), rivastigmine (Exelon), and galantamine (Razadyne). Tacrine (Cognex) was the first of the cholinesterase inhibitors, but because of the need to frequently monitor a patient’s liver function, its use is limited (Dichgans, Markus, Salloway et al., 2008). Namenda (memantine) is used to treat moderate to severe AD, and its main effect is to delay the progression of some of the symptoms. The expectation with this drug is that it allows patients to maintain certain daily functions longer than they would without the medications. Combining memantine with other AD drugs promises to be more effective than any single therapy (NIA, 2012b). Although cholinesterase inhibitors have been useful in older adults with AD, they have not been shown to have the same effects in those with other types of progressive dementia. At the time of publication, memantine is being reformulated with new dosages and
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instructions for use. Please review the most current drug handbook or prescription insert for the full information on this medication.
Nursing Management Previously the management of patients with dementia consisted of helping patients and their families through progression of the disorder while allowing them as much dignity and independence as possible. This is clearly still true. However, the focus is now on maintaining cognitive and global functioning early in the disease process to postpone the need for institutional care.
Vascular Dementia VaD is the second most frequently occurring type of dementia among older persons, causing dementia in 20% to 30% of people (Alzheimer’s Association, 2013). Often referred to as vascular cognitive impairment or multiinfarct dementia, depending on how it presents itself on scans, VaD is defined as a loss of cognitive function resulting from ischemic, hypoperfusive, or hemorrhagic brain lesions resulting from cerebrovascular disease or cardiovascular pathologic conditions. VaD is associated with the progressive loss of brain tissue as a result of a series of small brain attacks (infarcts) caused by occlusions and blockages within the arteries to the brain. Individuals who have experienced a cerebrovascular accident (CVA) have an even greater risk of VaD (Schneck, 2008; Zekry, 2009).
Pathophysiologically, asymmetric regions of cerebral softening and hemorrhage are diffuse and irregular. If a series of brain attacks occurs, the rate of decline in function increases. Some recovery of function may occur over time, but full recovery never occurs. As the damage from the infarcts progresses and accumulates, more widespread evidence of diminished mental ability exists.
Risk Factors Several medical problems place individuals at risk for the development of VaD. These include arteriosclerosis, blood dyscrasias, cardiac decompensation, hypertension, atrial
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fibrillation, cardiac valve replacements, systemic emboli for other reasons, diabetes mellitus, peripheral vascular disease, obesity, and smoking. Those at the highest risk are those with vasospasms in segments of the brain. Vasospasms are also referred to as transient ischemic attacks [TIAs] (Lewandowski, Rao, & Silver, 2008).
Clinical Manifestations The onset of VaD may be gradual or abrupt. Gradual-onset VaD occurs as a result of small lacunar infarcts that affect a very small area of the brain, causing memory, motor, or sensory perceptual function deficits. This phenomenon may not be obvious until several small infarcts have occurred. Abrupt-onset VaD presents with immediate neurologic symptoms such as one-sided weakness, gait abnormalities, or focal neurologic signs. Destruction of the brain tissue resulting from small emboli or brain attacks may be localized or diffuse. The usual progression of VaD follows a stepwise decline rather than the slow, steady decline associated with AD. Patients with VaD have an infarct, decline in function, and then experience a functional plateau before experiencing another insult and subsequent decline.
Symptoms of VaD depend on the location of the infarct and may include the following:
• Impaired learning and impaired retention of new information
• Impaired handling of new tasks
• Impaired reasoning ability
• Impaired spatial ability and orientation
• Impaired language
These impairments generally interfere with work and social functioning. Other symptoms may include wandering, getting lost in familiar places, moving with rapid, shuffling steps, losing bladder or bowel control, inappropriately displaying emotions, and having difficulty following instructions. Not all brain attacks result in intellectual impairment; some affect movement, vision, or other functions.
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Diagnostic Studies Neuroimaging with either CT or MRI usually reveals one or more areas of cerebral infarction. VaD is most often associated with diffuse or bilateral cortical or subcortical areas of infarction or microinfarction. Other than neuroimaging and clinical examination, no other diagnostic tests or biomarkers exist for the diagnosis of VaD.
Treatment Treatment for VaD is the same as for AD.
Lewy Body Dementia Dementia with Lewy body (DLB) is a progressive, degenerative brain disorder causing decline in thinking, reasoning, and independent functioning caused by abnormal small deposits in the brain matter. DLB is the third most common dementia, comprising 10% to 25% of all cases. Lewy bodies may be found in persons with AD and those with PD. Individuals with PD have a sixfold increased risk for the development of DLB compared with the general population (Alzheimer’s Association, 2013; Dodel et al., 2008).
Risk Factors No risk factors or causes are known for DLB at this time
Clinical Manifestations The clinical manifestations of DLB are similar to those of AD; however, DLB is often marked by prominent fluctuations in attention and ability to communicate and by the severity of psychiatric symptoms, particularly visual hallucinations. DLB, as compared with AD, tends to have more visual–spatial processing impairments and features of subcortical dementia. These include decreased attention and deficits in verbal fluency. Extrapyramidal features are also found in DLB, including rigidity, bradykinesia, flexed posture, and shuffling gait. Other symptoms may include the
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following:
• Excessive daytime sleepiness and altered arousal
• Periods of reduced attention and concentration
• REM sleep disorder
Diagnostic Studies No laboratory tests are available for the diagnosis of DLB. MRI shows less hippocampal activity than is seen in AD, but these are too minimal to be of diagnostic value. Diagnosis is based on the health care professional’s best judgment following neurologic examination and tests (Alzheimer’s Association, 2013; Bhasin, Rowan, Edwards, & McKeith, 2007).
Management Management of patients with DLB focuses on symptomatic relief when psychiatric and behavioral symptoms become distressing. Treatment for PD is essential in the event of gait and balance alterations. The use of cholinesterase inhibitors has been supported in DLB, as is the use of antidepressants, especially the use of selective serotonin reuptake inhibitors (SSRIs). Antipsychotic drugs should be used with extreme caution as these may cause serious side effects in around 50% of patients (Alzheimer’s Association, 2013). Since these patients also have sleep disorders involving REM sleep, clonazepam may be used.
Frontotemporal Dementia FTD is a clinical syndrome of exclusion associated with non-AD pathologic conditions and is relatively rare in the clinical setting. This syndrome includes the spectrum of non-AD dementias and is characterized by focal atrophy of the frontal and anterior temporal regions.
Risk Factors The risk factors for FTD are poorly understood.
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Clinical Manifestations FTDs are defined generally by the earliest symptoms: (1) progressive behavior and personality decline with a change in personality, emotions, behavior and judgment, called behavioral variant frontotemporal dementia or Pick disease; (2) progressive language decline, with early changes in language ability in speaking, reading, writing and understanding, called primary progressive aphasia; (3) progressive motor decline, characterized by difficulties with physical movement, including shaking, difficulty walking, frequent falls, and poor coordination (NINDS, 2013).
Diagnostic Studies Neuroimaging with CT or MRI may be useful in the diagnosis of FTD. Focal atrophy of the prefrontal or temporal regions confirms FTD; however, this finding is not always present. Positron emission tomography (PET) or single photon emission computed tomography (SPECT) may also assist in the confirmation of the clinical diagnosis (National Institute of Neurological Disorders and Stroke [NINDS], 2013).
Management In FTD, the interval between onset of symptoms and severe dementia ranges from 3 to 10 years. Currently, no treatments for FTD are available, but patients with FTD do benefit from a team approach with the use of speech therapists, physical therapists, day care, respite care, and the judicious use of medications to control symptoms (NINDS, 2013).
Other Dementia-Related Diseases Normal Pressure Hydrocephalus Normal pressure hydrocephalus (NPH) is a rare but potentially reversible condition; if left untreated, it leads to permanent cognitive impairment. In NPH, CSF circulates to the cerebral subarachnoid space, enlarging the ventricles but causing no rise in the CSF pressure. It is believed that the majority of cases of NPH
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are related to prior cerebral insults such as traumatic injury, viral insult, or previous surgery. NPH has a triad of symptoms that present together: (1) gait disturbance (e.g., ataxic or magnetic gait), (2) urinary incontinence, and (3) cognitive dysfunction. Patients who develop dementia before gait disturbance have poorer outcomes. Treatment involves placing a shunt to drain CSF (NINDS, 2013).
Dementia may also result from other diseases, including Huntington disease (formerly called Huntington’s chorea), Creutzfeldt-Jakob disease, and infection with human immunodeficiency virus (HIV). These diseases are less common among the older adult population.
Subdural Hematomas A subdural hematoma is bleeding between the cranium and the cerebral cortex. The pressure created by this bleeding may cause cognitive impairment and neurologic deficits. Older adults are at risk for the development of subdural hematomas caused by brain atrophy and corresponding vascular changes that occur with normal aging and are also at risk for falls and subsequent head injuries.
The two types of subdural hematomas are acute subdural hematoma and chronic subdural hematoma. Symptoms of acute subdural hematomas develop within 48 to 72 hours after a head injury but are not seen with the typical signs of increased intracranial pressure (ICP). Instead, the presentation includes insidious changes in mentation and focal neurologic signs. Chronic subdural hematomas may be caused by trauma but often are not noticed until 3 or more weeks after the initial injury because of slow bleeding into the intracranial space.
Treatments for both acute and chronic subdural hematomas include the evacuation of the hematoma, usually with the use of burr holes and a closed drainage system. Unfortunately, recurrence is not uncommon.
Intracranial Tumors
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Intracranial tumors occur more frequently in older adults than in younger adults and may be either benign (meningiomas) or malignant (gliomas). Intracranial tumors in older adults rarely are seen with the typical signs of increased ICP (e.g., headaches, vomiting, and papilledema); rather, they are seen with subtly progressive changes such as withdrawal, isolation, personality changes, and slowly progressive hemiparesis. Because the symptoms are insidious and include cognitive dysfunction and withdrawal, older adults with intracranial tumors are often misdiagnosed with depression or dementia; later, when focal neurologic signs appear, brain tumors are considered.
The diagnosis of an intracranial tumor is made after cranial CT or MRI. The pathologic condition is determined through biopsy, either by tumor extraction or stereotactic needle biopsy under CT or MRI guidance. Treatment is based on the results of the biopsy and may include surgical extraction followed by radiation if the tumor recurs (meningioma) or surgical extraction followed by radiation and concomitant chemotherapy (malignant glioma). The prognosis is generally poor: the 1-year survival rate for malignant gliomas is 23%.
The decision of whether and how to treat intracranial tumors in older adults is complex, in part because of preexisting illnesses that may complicate neurosurgery, as well as potential complications or side effects after surgery, chemotherapy, and radiation. Treatment in older patients may lead to deficits that are as serious as those resulting from no treatment or limited treatment. All treatment decisions should be made in conjunction with individuals and their families.
Amnesic Disorders Amnesic disorders are characterized by memory impairment that is the result of a general medical condition or the persisting effects of a drug, medication, or toxin. Duration of the disturbance is a qualifier for the diagnosis. Transient disorders are those lasting less than 1 month; chronic disorders last more than 1 month.
Cognitive Disorders Not Otherwise Specified
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This category of diagnosis describes those disorders characterized by cognitive dysfunction presumed to be a result of the physiologic effect of a medical condition but that do not meet other criteria.
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Diagnostic assessment of altered thought processes Examination History taking, physical examination, behavioral observation, and functional and mental status examinations form the basis for a diagnosis of depression, delirium, and dementia. Medical screening alone is not sufficient for the evaluation of intellectual decline in older adults, but it does provide valuable information for ruling out treatable disorders. The only positive diagnosis for dementia- related disorders is brain tissue biopsy or autopsy of the brain. Screening for treatable, reversible causes is essential in identifying and implementing appropriate treatment for the underlying cause of cognitive dysfunction associated with altered thought processes.
Diagnostic Studies Laboratory tests are used to assess the nervous system or rule out medical problems causing the disorder. CT, MRI, and electroencephalography (EEG) have been used for diagnosis of delirium or dementia. CT is useful in detecting pathologic conditions such as space-occupying lesions (e.g., intracranial tumors, subdural hematomas, and hydrocephalus) that may lead to dementia. The pathologic changes seen in dementia, including ventricular enlargement, narrowing of the gyri, widening of the sulci, and brain atrophy, may be identified on CT. Images obtained by MRI have a high resolution and may be useful in detecting multiple subcortical brain attacks and white matter disease. MRI is useful in the diagnosis of VaD. The disadvantage of MRI is that the test requires the older person to lie motionless for a long time. This may be impossible for older persons with cognitive disorders. EEG may provide important information about the mental status. The background frequency of the waking EEG can be correlated with a patient’s mental state. Normal EEG results in a severely impaired patient support the diagnosis of pseudodementia. In early dementia, EEG results may demonstrate an abnormally slow
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response which indicates a treatable diagnosis. PET is a noninvasive technique that allows assessment of regional glucose use, oxygen consumption, and regional cerebral blood flow. This technique may be useful in the differential diagnosis of the hippocampal atrophy seen in AD and the changes associated with FTD.
Laboratory Studies CSF studies are useful for identifying reversible causes of dementia. Laboratory screening tests to rule out treatable medical diagnoses may include a complete blood cell count (CBC); electrolytes; chest radiography; urinalysis; liver, kidney, and thyroid function tests; serum B12 levels; folate; syphilis serology (with high index of suspicion of syphilis); and drug studies. Genetic testing remains controversial; however, testing for the APOE epsilon-4 allele has been considered in AD. Routine use of this test may, however, lead to overdiagnosis of AD.
Postmortem biopsy is considered the only definitive means of differentiating the type of dementia causing the symptoms. The clinical profile, obtained through history taking, physical examination, mental status examination, laboratory tests, and behavioral observations, has improved the classification of dementia.
DSM-5 Criteria The DSM-5 classification (APA, 2013) is the most widely accepted system of classifying abnormal behaviors and is consistent in most respects with the systems used by the WHO and the International Classification of Diseases. The DSM-5 classification categorizes each disorder as a clinically significant behavioral or psychological syndrome or pattern that may occur in a person and is associated with present distress and disability; loss of an important freedom; or an increased risk of suffering, death, pain, or disability. It cannot be assumed that each mental disorder is a discrete entity, with sharp boundaries separating it from other disorders. The classification includes all age groups and is not specific to older
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adults.
The DSM-5 disorders of delirium, dementia, and other cognitive disorders are discussed under the heading of “Neurocognitive Disorders.” These disorders are further subdivided on the basis of cause:
Delirium • Delirium resulting from a general medical condition
• Substance-induced delirium (as a result of a drug or medication or toxin exposure)
• Delirium resulting from multiple causes
• Delirium not otherwise specified (if the cause is indeterminate)
Dementia • AD
• VaD
• Dementia resulting from other general medical conditions (e.g., HIV, head trauma, PD, and Huntington disease)
• Substance-induced persisting dementia (resulting from drug abuse, medications, or toxin exposure)
• Dementia resulting from multiple causes
• Dementia not otherwise specified (if the cause is indeterminate)
Cognitive Disorder Not Otherwise Specified • Does not meet criteria for other disorders
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Treatment of altered thought processes Pharmacotherapy Disease Management Medication management of each of the disorders described has been listed previously. In summary, medication management of depression requires the use of antidepressant medications. These are described in greater detail in Chapter 20. Medication management for the treatment of delirium may include the discontinuation of medications contributing to the older person’s recent mental status changes or the addition of medications to treat underlying conditions. The advent of cholinesterase inhibitors has revolutionized the treatment of early AD, and cholinesterase inhibitors have shown some promise in the treatment of both VaD and DLB. These medications work to slow disease progression and decrease agitated behaviors. Pharmacotherapy for altered thought processes in older adults is summarized in Table 27-4.
Table 27-4 Pharmacotherapy for altered thought processes in older adults
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(From Sutor, B., Rummans, T.A., & Smith, G.E. (2001). Assessment and management of behavioral disturbances in nursing home patients with dementia. Mayo Clinic Proceedings, 76(5), 540.)
bid, Twice daily; ECG, electrocardiography; GI, gastrointestinal; qhs, at bedtime.
Behavior Management Several classes of medications are available to aid in the behavior management of older persons with dementia. These medications include antipsychotics, antidepressants, benzodiazepines, buspirone (BuSpar), and antiepileptics.
Antipsychotics are useful for the treatment of the behavioral response to psychotic symptoms such as delusions or hallucinations. They are also used to decrease aggression in older adults who may be endangering themselves or others. This is particularly helpful when acute confusion or delirium is thought to be the cause and when the agitation does not allow the nurse or primary caregiver to assess the patient. Haloperidol in daily doses of 0.25 to 2 milligrams (mg) orally or intramuscularly has been supported for acute control of agitation symptoms (Flaherty et al., 2011).
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Depression Management Antidepressants may be helpful in the management of troubling behaviors and for the treatment of depression with dementia. Trazodone, a sedating antidepressant, may be useful in managing wandering at night or in reversing the sleep–wake cycle. Trazodone is often also used as a first-line medication when an older adult has mild to moderate agitation during the day. Small doses of 25 to 50 mg a few times during the day, followed by a larger dose at bedtime, are often useful. Patients should be monitored for orthostatic hypotension while taking this medication. Sedation may limit the use of this medication in some older adults. When depression is a concern in a patient who is agitated, SSRIs such as paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac) have been helpful in managing agitation. Unfortunately, SSRIs tend to cause transient appetite suppression, especially on initiation of therapy. Fluoxetine, an SSRI, is often avoided in older adults because of its long half-life (Box 27-3).
Box 27-3
Side effects associated with antidepressants • Drowsiness
• Dry mouth
• Urinary retention
• Nasal congestion
• Delirium
• Increased appetite for sweets
• Increased heart rate
• Blurred vision • Dizziness or fainting
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• Constipation
• Hypotension
• Arrhythmias
• Weight gain
Benzodiazepines Benzodiazepines should be reserved for acute situations and not used for the long-term management of troubling behaviors. The 1987 Omnibus Budget Reconciliation Act (OBRA) discouraged the overuse of benzodiazepines in long-term care settings. Significant risk factors are associated with the use of benzodiazepines among older adults. These include increased risk for falls, impaired cognition, and addiction with acute withdrawal symptoms between doses or on abrupt cessation of the medication. For short-term use or one-time dosing for acute agitation or combativeness, lorazepam (Ativan), 0.25 to 1 mg orally or intramuscularly, or oxazepam (Serax), 5 to 10 mg orally, may be helpful (Duffy, 2010).
Buspirone Buspirone has been found to be useful in the treatment of anxiety- triggered agitation. It is important to educate caregivers that it may take 2 to 6 weeks before the results of this medication are appreciated; therefore, it is not useful for acute episodes of agitation. Buspirone is also useful in older adults who have mild to moderate levels of agitation. It has a low side effect profile and a low risk for drug–drug interactions (Duffy, 2010).
Antiepileptic or Anticonvulsant Medications Antiepileptic medications are useful when frequent mood fluctuations or sudden outbursts of agitation are problematic. Two medications used most frequently as mood stabilizers are carbamazepine (Tegretol) and divalproex, which is also known as valproic acid. Both these medications are indicated for moderate to severe agitation with aggressive outbursts in older adults who require long-term management. An advantage of both medications
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includes the ability to monitor serum levels. Carbamazepine has an antikindling effect on CNS electrical activity at serum levels between 4 and 8 micrograms per milliliter (mcg/mL) (Duffy, 2010). Unfortunately, multiple drug interactions and potentially serious side effects such as agranulocytosis, ataxia, and hyponatremia limit the use of carbamazepine. Divalproex has fewer side effects and drug interactions, making it more likely to be the first-line agent for the treatment of moderate to severe agitation and combativeness among older adults. Titration of the dose to serum levels of 40 to 100 grams per milliliter (g/mL) is considered a therapeutic level.
Individualized Care When initially considering the use of medications in the treatment of altered thought processes, health care providers must remember that individual responses to medications vary considerably. All medications require close monitoring by health care workers and family members for action and side effects. The recommendation for pharmacotherapy in the older adult is to “start low, go slow, and titrate upward until benefits or side effects are seen” (Zwicker & Fulmer, 2012). Patient and family education is essential when a new medication is started. Education helps create realistic expectations of the medication’s benefits and potential side effects. Every patient may respond differently to medication management; therefore, individualized care is essential.
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Nursing management Nurses caring for older adults who have symptoms of an acute cognitive disorder need to support existing sensory perception until the cognitive state returns to the previous level of function. The goal of caring for older persons with dementias should be the maintenance of good health, gross and fine motor skills, and functional behaviors to maximize self-care abilities. The care provided to older adults with dementia is similar in the beginning stages, but it becomes complex and individually focused as the disease progresses. The philosophy of the care of older adults with cognitive and behavioral impairment has changed over the years. Public policy has shifted to encourage family members to care for older adults in their homes, thus decreasing health care costs and individualizing care to meet patient needs. The nurse’s role has shifted from that of caregiver to one of care coordinator; that is, the nurse teaches and assists family members with home care, provides supportive care, and serves as a patient advocate.
Assessment Performing a complete baseline physical examination, along with a neurologic examination and mental status assessment, is essential for ruling out an atypical presentation of a medical illness in an older adult. Deficits and impairments may be wrongly attributed to age or disease if accurate and complete baseline information is not available. Verbal and nonverbal responses from the patient, family members, and significant others should be used to validate assessment data. The assessment process is ongoing to ensure the accurate collection of information. The purpose of a comprehensive assessment is to determine problem areas, as well as areas of strength on which to base a care plan, including education of families and caregivers.
Assessment data gathered at the time of an acute crisis, as in a hospital setting, are critical for initial treatment. The special needs of an older adult with a cognitive disorder may require completing
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the assessment after treatment of the crisis to ensure discrete symptoms are not overlooked and treatment is appropriate for the disorder.
Assessment of Depression Depression in older adults can be assessed with standardized rating scales or with a comprehensive nursing assessment that includes an evaluation of several key components of depression. A number of instruments have been developed to screen older adults for depression, and other instruments provide a standardized approach to rating its severity. One of the most commonly used scales in assessing the presence or absence of depression in older adults is the Geriatric Depression Scale (GDS) (see Chapter 4). Because the GDS minimizes the number of somatic depressive items, it is not necessary to upwardly adjust the cutoff score (Yesavage, 1983; Yohannes & Baldwin, 2008).
When the nursing assessment indicates the possibility of depression, the nurse may further assess the symptoms of depression previously mentioned. The comprehensive assessment includes obtaining health, nutritional, and medication histories; physical examination; mental status examination; family assessment; and assessment of performance of ADLs. Diagnostic tests that may be useful in ascertaining the presence of depression instead of another illness include certain laboratory tests (CBC, thyroid function studies, urinalysis, and dexamethasone suppression test), electrocardiography (ECG), EEG, MRI, and CT.
Level of Consciousness Assessment of the level of consciousness provides an indication of the pathologic processes. Consciousness is defined as the state of awareness of the self and the environment. The most widely used and accepted tool for measuring consciousness is the Glasgow Coma Scale (GCS). The GCS measures eye opening, verbal response, and motor response. This may be the appropriate tool to use for assessment of an older person in a critical state, when the neurologic status is undetermined or rapidly changing.
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Mental Status Examination Mental status examinations for assessment of mental and cognitive function are necessary to identify impairments that may have significant and permanent effects. The choice of cognitive assessment tool varies, depending on the setting and results of the physical examination. An objective assessment may require more than obtaining orientation to person, place, and time and should be considered before labeling a person “disoriented.” It is important to thoroughly assess visual and hearing deficits and alter the environment to enhance the validity of the patient’s response.
Pupil Assessment Pupil assessment provides neurologic information and assists in the identification of the cause, responses, and location of the pathologic condition. Evaluation of an older adult’s pupil size and reaction to light may be difficult because his or her pupils may appear smaller than normal and the light reflex may be sluggish. Pupil response may also be altered by the presence of cataracts, retinal detachment, glaucoma, and sclerotic changes in the iris.
Neurologic Assessment Neurologic disorders may cause a wide range of motor abnormalities. The extremities should be assessed for muscle strength and tone and compared for symmetry. Many older persons have normal age-related symmetric weakness and muscular fatigue. A decreased vibratory sense in the feet, a decreased Achilles tendon reflex, and decreased sensory perception may be caused by the normal loss of neurotransmitters or sensory receptors.
In the event of traumatic injury resulting in increased ICP, the classic symptoms of headache, vomiting, and papilledema may not appear in older persons or may be more subtle because of normal, age-related changes caused by cerebral atrophy. These changes, including alterations in consciousness, cranial nerve deficits, and motor changes, may mimic cognitive disorders.
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Behavioral Assessment Persons with cognitive disorders commonly demonstrate problematic behaviors. These new behaviors should not be overlooked but should be viewed as symptoms requiring assessment. The type and intensity of the behavior vary, depending on the stage of disease, but each behavior exhibited requires a comprehensive, individualized assessment. Identifying the behavior and extenuating circumstances assists in ruling out treatment causes and determining the personal meaning associated with the behavior.
Diagnosis The selection of nursing diagnoses should be based on the assessment findings. The most commonly used nursing diagnoses for an older adult with cognitive impairment include the following:
• Activity Intolerance, related to physical illness
• Dysfunctional Family Processes, related to cognitive impairment
• Imbalanced Nutrition: Less Than Body Requirements, related to poor oral intake
• Ineffective Role Performance, related to cognitive impairment
• Anxiety, related to misinterpretation of environmental cues
• Bathing Self-Care Deficit, related to cognitive impairment
• Bowel Incontinence, related to cognitive decline and misinterpretation of physiologic needs
• Caregiver Role Strain, related to older adult’s cognitive decline and behavioral problems
• Confusion (acute or chronic), related to physiologic, emotional, or environmental processes
• Dressing Self-Care Deficit, related to cognitive impairment
• Fatigue, related to increased physical, emotional, and environmental demands
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• Fear, related to cognitive impairment
• Feeding Self-Care Deficit, related to increased cognitive impairment
• Functional Urinary Incontinence, related to inability to interpret physiologic and environmental cues
• Risk for Injury, related to altered ability to interpret the environment
• Impaired Physical Mobility, related to neurologic deficits
• Impaired Social Interaction, related to cognitive impairment
• Compromised Family Coping, compromised because of the needs of the older adult with cognitive impairment
• Compromised Family Coping, disabling related to lack of social supports
• Deficient Knowledge, related to lack of previous exposure to disease process
• Situational Low Self-Esteem, related to awareness of cognitive deficits
• Spiritual Distress, related to the impact of cognitive impairment on individual and family
Planning and Expected Outcomes Expected outcomes for older adults with cognitive changes are adapted for each diagnosis. Expected outcomes include the following:
1. The patient will exhibit no episodes of acute confusion, as evidenced by adequate hydration, nutrition, and socialization.
2. The patient will maintain continence through the use of visual and verbal cues and regular fecal and urinary elimination routines.
3. The patient and family will demonstrate the ability to cope by accessing community agencies for support groups, Internet pages, and home health agencies for respite and support services.
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4. The patient will exhibit reduced fear and anxiety by establishing a routine, keeping familiar objects, and participating individually in activities for calming down (e.g., listening to favorite music, sitting in the sun, and retreating to his or her room).
5. The patient will demonstrate fewer inappropriate behaviors such as agitation, combative behavior, and mood changes, as evidenced by identifying the triggers that cause them and decreasing or eliminating these triggers.
6. The patient will demonstrate increased socialization by voluntarily participating in activities.
7. The patient will maintain physical health.
8. Family members will participate in activities and care.
9. The spiritual health of the older adult and his or her family will be maintained, as evidenced by participation in religious services, communication with their religious organization, and participation in formal and informal spiritual practices.
Intervention Each older adult will have a different presentation, triggers, and responses to illness; therefore, the most effective interventions are based on the assessment and are individualized for each patient. When interventions are planned, it is important to consider environmental and cultural influences that affect the person’s response patterns. Remaining attentive to needs as they are communicated, as well as to changes and responses in behavior, and using creativity in each situation may accomplish this. The best interventions are learned through trial and error, requiring commitment and communication with the family and the caregiver.
The efforts of health care personnel and caregivers will result in implementation of the best strategies for managing care of the patient with dementia. Identifying the stage of disease provides a baseline for management of care, but because each person’s behavioral responses are based on an individual personal history and experiences, it requires persistence to determine approaches
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that result in desired responses. Positive responses to selected interventions may continue for a time but may decline as the disease progresses, which results in the need to reevaluate strategies. General principles of care should be individualized when caring for people with dementia (Box 27-4).
Box 27-4
Principles for implementation of care for older adults with cognitive impairment • Monitor and maintain physical health.
• Recognize the meaning of behaviors.
• Adapt the environment (e.g., routines, setting).
• Communicate in a simple, direct manner.
• Provide cues for reality orientation.
• Maintain social interaction and self-esteem.
Communication Relaying trust, security, care, and support through simple and direct therapeutic verbal and nonverbal communication is essential when caring for older persons with dementia. In some situations, older persons are more inclined to respond to the nonverbal messages. The tone of communication should be calm and relaxed. Using eye contact and therapeutic touch when delivering a message helps the patient focus on meaning. It is important to use simple words and short sentences, along with simple gestures to demonstrate meaning. At times, distraction as a form of communication may be necessary to dissuade a person with memory impairments from engaging in undesirable activities. Verbal communication may become less meaningful for the older
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person with altered thought processes resulting from memory loss, aphasia, apraxia, agnosia, and disorientation. Nevertheless, verbal communication on the part of the caregiver remains essential. Sounds and voices may elicit a response and provide a calming effect and an orientation to reality in these individuals.
Physical Interventions Assessing the physical health and the ability of individuals with altered thought processes to meet their basic needs is the foundation of nursing care. Independence should be encouraged and self-esteem promoted by maintaining daily hygiene and grooming. Because a limited ability to verbally communicate may prevent an older adult from relaying a problem or symptom, nonverbal cues should be observed and considered indicative of a potential symptom requiring attention.
Nutritional Interventions It is important to support the ongoing nutrition of individuals with dementia because they may experience decreased hunger and ability to taste food. Problems that occur during feeding may include patients’ refusing to open the mouth, pocketing food in the cheeks, refusing to swallow, and coughing or choking while swallowing.
People who demonstrate symptoms of moderate to severe cognitive impairment may benefit from having meals in the same place at the same time each day. Small, frequent, nutritionally dense meals and snacks should be provided. It is important to assess the condition of the individual’s teeth and ensure dentures fit well. During the later stages of dementia, the individual may need to be reminded to open the mouth and chew. Food should be soft and cut into small pieces. Thin liquids may become difficult to swallow, so serving gelatins, pudding, or ice cream may decrease problems with liquid intake. Coughing during meals is a sign of swallowing difficulties; referral to a speech therapist is recommended.
Mental Interventions
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Reality orientation supports failing memory in early stages of dementia and preserves independent functioning for a longer duration. Although written messages and signs may become meaningless to individuals with advancing dementia, pictures often evoke a response. Persons in all stages of dementia benefit from the use of clocks, calendars, and mementos placed in their environment. As the disease progresses, daily orientation to caregivers and daily tasks improves the productivity and responses of older adults with altered thought processes.
Behavioral Interventions Behaviors are a form of communication and may be the cognitively impaired patient’s primary method of communicating needs; therefore, recognizing behaviors may be the first step in ensuring that appropriate care is provided. Disruptive behaviors are a result of the disease, not deliberate actions on the part of the older person. The caregiver must realize that the patient cannot control the behaviors and cannot be taught to change. The person displaying the symptoms may be unaware of their effect on others, whereas the family or other people involved may be more sensitive to the behaviors. It is important for care providers to learn what to expect as the older person’s disease progresses. The effective management of problem behaviors should not focus on trying to change the older person but on modifying factors that may contribute to these behaviors. Careful and creative observation may identify the message in the behavior and provide opportunities for behavioral intervention (Smith, Russell, & White, 2013). Various behavior problems, possible antecedents, and strategies specific to these antecedents are listed in Table 27-5.
Table 27-5 Behavioral management techniques
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(From Carlson, D.L., Fleming, K.C., Smith, G.E., & Evans, J.M. (1995). Management of dementia-related behavioral disturbances: A nonpharmacologic approach. Mayo Clinic Proceedings, 70, 1108.)
Because of the potential side effects of pharmacologic interventions, behavioral techniques should be the first line of treatment for older adults with altered thought processes. The use of physical or chemical restraints has demonstrated no benefit in controlling disruptive behaviors or managing disease. Unless the behaviors are upsetting or dangerous, learning how to adjust when these occur will probably result in a less stressful environment.
Social Interventions Maintaining social interaction and human contact in a variety of ways is beneficial for older persons with cognitive decline. It provides the much needed opportunity for participation in activities that prevent boredom and restlessness. The response from an older adult will be positive if he or she is provided the opportunity to experience success and contribute in a positive way.
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Family Interventions Caregivers have been described as the “hidden victims” of severe dementia. It is important to provide social and emotional support to the family members caring for the individual with cognitive disorders. Day-to-day problems such as finances, legal obligations, household chores, self-care needs, troublesome behaviors, and interpersonal conflicts are just a few difficulties that must be managed by caregivers. Involving the family in care planning for a family member with dementia assists with adjustment and support.
Family members do not always understand role changes and expectations associated with caring for a loved one with a cognitive disorder. One of the most important issues faced is the loss of autonomy, not only for the older person but also for the caregiver. The encouragement and support of family members are critical to the motivation of an older person with the disability. Adjusting to the fact that dementia is an irreversible and prolonged problem places families in situations of dealing with grief over a long period. Nurses need to assist family members in understanding and accepting that each person deals with feelings differently. With this understanding, family members can serve as a strong support for the caregiver through the adjustment process.
In addition to patient assessment, the nurse must also assess the caregiver’s physical health, functional status, medication regimen, nutritional status, and exercise patterns, although these may be assessed informally. The information obtained from this assessment may identify factors contributing to the caregiver’s general well- being. Nurses need to encourage caregivers to take time out from their task and participate in self-care and health promotion activities. Referrals to social support groups such as dementia and AD support groups may also be beneficial for caregivers and family members.
Environmental Interventions Individuals with dementia often have difficulty processing information, and the overloading of senses may cause confusion and anxiety. It is essential to consider the visual, auditory, olfactory,
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and tactile characteristics of the environment to make it more pleasant to the patient. Changes in the environment, routines, or setting may exacerbate negative behaviors in individuals with cognitive disorders. Mealtime, bath time, and activities should have a predictable pattern. Consistency is essential when the nurse identifies strategies for environmental modification. It is essential to create a feeling of security for the older adult with altered thought processes, but routines should not become so rigid that changes will not be accepted (Smith et al., 2013).
Certain routines such as sitting next to the same person during mealtime or having the same caregiver are comforting to the older adult. Changes in the routine should be introduced slowly, and a stimulus should be provided to ensure that feelings of comfort and security are not lost. Environmental modifications may be required to provide security and safety as the disease progresses. Examples of environmental modifications include decreasing stimuli by using soft colors and by limiting obstacles. Eliminating access to unsafe locations and unnecessary noises in the environment also may help with managing disruptive behaviors.
Safety and Self-Esteem Interventions The impaired judgment, unpredictable behavior, and decreased cognitive ability in individuals diagnosed with dementia usually lead to job loss if they had been working, sometimes even before the diagnosis is made and they understand what is causing their problems. This will have a negative effect on financial status and self-esteem and may psychologically inhibit the person from using preserved abilities. Self-esteem, independence, and autonomy are also affected when the individual with dementia must give up driving for reasons of safety. Wandering can sometimes be managed through environmental changes such as establishing fences or alarm systems and close supervision (Song & Algase, 2008).
Evaluation Evaluation is a continual process when caring for individuals with
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altered thought processes related to cognitive decline. Behaviors and activities require ongoing assessment to determine variances from the baseline. Careful observation and recording of moods, behaviors, and memory provide clues to minor changes in the individual’s condition. Interventions should be evaluated on an ongoing basis for efficacy. Successful and unsuccessful interventions should be communicated to other caregivers and family members to aid in the continuity of care.
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Challenges in the care of older adults with cognitive disorders Individuals with cognitive disorders react differently to those disorders. Because it is difficult to predict these reactions, nurses must be aware of the possible emotional, behavioral, and physical challenges they may face when caring for older persons with cognitive disorders. As a case manager and educator, the nurse also must teach family members and caregivers about potential challenges and introduce a variety of methods for facing these challenges.
Sundown Syndrome Sundown syndrome is a commonly observed tendency in people with dementia to become more confused and agitated around late afternoon to nightfall. Sundown syndrome may resemble delirium. Along with depleted cognition, other symptoms such as reduced attention, altered sleeping and waking patterns, and disturbed psychomotor behavior are present, and these symptoms tend to be more evident in the evening. No specific cause for the occurrence of sundown syndrome has been established; however, some have hypothesized that sundowning may be the result of neurologic damage, which makes it impossible for the individual with dementia to clearly interpret environmental stimuli. Specific pathophysiologic findings that relate to sundown syndrome behaviors include disturbance in REM sleep, episodes of sleep apnea, and deterioration of the suprachiasmatic nucleus of the hypothalamus.
Sundown syndrome may also be modified through behavioral interventions, including redirection, the provision of companionship and empathy, environmental modifications in lighting, and noise reduction. Because the cause of sundowning may be different for each patient, individualized care is essential. The first step in the management of sundowning behavior includes the identification and treatment of any physiologic factors that may
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be contributing to those behaviors. These may include hunger, thirst, pain, and elimination needs. Nonpharmacologic management strategies for sundown syndrome include the following:
• Scheduling appointments and activities earlier in the day when the individual is rested
• Reducing environmental stimulation as the day progresses
• Providing activities that are calming in the evening, for example, playing soft music
• Increasing lighting levels: turning on room lights before dusk and providing a nightlight at bedtime
• Offering companionship and reassurance during the evening hours
• Providing 1-hour rest periods in either the late morning or the early afternoon
Medication management of these behaviors should be avoided unless the older person is a danger to self or others. If nonpharmacologic interventions are unsuccessful, low doses of specific neuroleptic agents may be indicated.
Wandering Wandering behaviors have been described as one of the most challenging behaviors to manage in older persons with cognitive impairments. Wanderers might have experienced sleep problems, had a more active lifestyle in their younger years, and used more psychotropic medications within their lifetime. They may wander in response to a need to use the bathroom or to combat boredom (Smith et al., 2013; Song & Algase, 2008).
Some nonpharmacologic interventions for wandering behaviors include the following:
• Ensuring an environment safe for wandering
• Informing neighbors and police of this potential problem
• Having the person wear a medical alert bracelet
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• Observing potential wandering trigger behaviors
• Maintaining a regular activity and exercise program for individuals prone to wandering behavior
Paranoia or Suspiciousness Paranoid or suspicious behaviors may reflect an individual’s basic insecurity about his or her progressive memory and sensory losses. Individuals with dementia may forget where they placed certain items and then become suspicious of others and accuse them of stealing those items. Paranoia may result as a response to sensory deficits. As individuals observe others talking but are unable to hear what is being said, they may fear that others are talking about them and cling to or hoard objects, fearing they will be stolen. Nonpharmacologic interventions for suspicious or paranoid behavior include the following:
• Securing valuables in locked locations
• Avoiding the use of confrontation and the application of logic
• Looking in wastebaskets before emptying
• Not whispering or behaving in a secretive manner
• Marking all personal items with that individual’s name
Hallucinations and Delusions Hallucinations experienced by individuals with dementia are most often visual but may be auditory. Medical causes of hallucinations should be evaluated because issues such as overmedication, toxicity, fever, infection, or a combination of causes may trigger this response. If the hallucination is disturbing to the older person, offering protection and security may help calm him or her. Reasoning or logic is ineffective. Delusions occur when an individual believes something to be true when it is illogical or wrong. Depending on the stage of the disease, orientation to reality may be appropriate. If the disease has progressed, it may be best to go along with the individual’s reality but attempt to change disturbing behaviors in relation to the situation. Behavior
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modification is the treatment of choice in the management of both hallucinations and delusions; however, if these symptoms place an individual at risk, a short course of an antipsychotic medication may be necessary.
Catastrophic Reactions Catastrophic reactions are emotional outbursts or exaggerated reactions to minor stresses. These may be precipitated by emotional and sensory overload and aggravated by fatigue, overstimulation, inability to meet expectations, or misinterpretation of actions or words. Signs of impending reaction might include restlessness or refusals to carry out tasks. Nurses and caregivers must assess the environment for potential triggers and remove these triggers. Nonpharmacologic interventions useful in dealing with catastrophic reactions include the following:
• Removing the individual from the environment in which the reaction is occurring
• Providing a calming atmosphere to distract the individual
• Using a calm tone of voice, touch, and reassurance
• Temporarily separating the individual from the causative source
Resources Physical and mental strain placed on caregivers can be significantly reduced if available resources are identified and used. Community resources become increasingly important as the primary caregiver grows more isolated and overextended. The nurse should identify appropriate community resources available to the patient and family and encourage family members to participate as the need becomes critical. These resources may include community mental health centers, adult day care centers, respite services, local Alzheimer’s Associations and support groups, medical information and referral programs, and other family support groups specific to the disease type.
Family Support Groups
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A significant increase in family support groups has created a network to help families faced with caring for a loved one with dementia. These support groups offer a variety of services ranging from assisting family members in coping with the inevitable losses faced by patients with dementia to emotional support and respite.
Respite Services Respite service is provided to family members requiring occasional relief from the pressures of continuous caregiving. These services may prevent premature institutionalization of individuals with dementia because of caregiver stress. Respite programs offer relief services ranging from several hours to several weeks. Shared respite care is a form of respite care available in some communities, where a number of families join together to provide care on a rotating basis. In this setting, group members watch over a number of patients which allows free time for other caregivers. Caring for loved ones in the company of others may reduce the social isolation experienced by caregivers.
Adult Day Care Adult day care centers help keep people with dementia in the community by providing family respite, promoting activity, and encouraging the retention of previously learned skills. Some centers provide specialized social work, nursing, or physical and occupational therapy services. Adult day care centers allow family members to work during the day, do errands, rest, and yet be involved in important areas of their loved ones’ lives.
Home Health Care Home health care may provide nursing, physical and occupational therapies, services of social workers, and personal care services to patients in their homes in the later stages of dementia. Home health personnel may help with direct care needs, including meals and shopping, medications, cleaning, laundry, transportation, appraisal of a person’s condition, and companionship. However, unless the individual has an established need for skilled nursing or therapy, these services are not covered by Medicare.
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Legal Services Legal services are necessary when family members must consider questions related to the person’s ability to handle finances and make decisions. It is important to set up a durable power of attorney for financial matters and a health care proxy for medical matters early in the disease process while the individual can still participate in decision making. Legal guardianship is granted when the individual is no longer capable of making decisions for himself or herself. This requires that a physician or mental health professional document that the patient does not understand the ramifications of decisions or behaviors.
Community Mental Health Centers Community mental health centers may have specialized geriatric programs, which provide a wide range of services. These services may include comprehensive assessment; psychiatric evaluations; and individual, group, and family counseling. In addition, case management services available in community mental health centers may assist in the identification of other community resources to maintain individuals in the home.
Psychiatric Hospitals Psychiatric hospitals offer assessment and behavior stabilization. In addition, an increasing number of geriatric psychiatric units can meet the multidimensional physiologic and mental health needs of older adults with cognitive disorders. Psychiatric hospital placement usually occurs when an individual cannot be managed in the community setting and more advanced assessment and behavior management techniques are required. Outcomes of geriatric psychiatric hospital placement may include medication management and behavior modification therapies for the individual’s return to the community or may result in placement in long-term care facilities.
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Other common problems and conditions Suicide The Elderly Suicide Fact Sheet from the American Association of Suicidology (AAS) provides the following statistics (AAS, 2008). Older adults made up 12.4% of the population in 2004, and they accounted for almost 16.6% of all suicides. The rate of suicide among older adults in 2005 was 14.7 per 100,000. One suicide occurred every 100 minutes among older adults; 14.5 suicides occurred each day, resulting in 5404 suicides among those 65 or older. Older white men were at the highest risk, with a rate of approximately 33 suicides per 100,000 each year. White men older than age 85, the “old-old,” were at the greatest risk among all age– gender–race groups. In 2005, the suicide rate for these men was 45.23 per 100,000. That was 2.5 times the current rate for men of all ages (17.7 per 100,000). Of suicides among older adults, 84.19% were committed by males, and the rate in late life was 5.2 times greater than that of suicide among females. The rate of suicide among women typically declines after age 60 (after peaking in middle adulthood, ages 45 to 49).
The suicide rate among older adults reached a peak in 1987, at 21.8 per 100,000 people. Since 1987, the rate of suicides has declined 28% (down to 14.7 in 2005). This is the largest decline in suicide rates among older adults since the 1930s.
Although older adults attempt suicide less often than those in other age groups, they have a higher completion rate. For all ages combined, it is estimated that 1 in 25 attempted suicides is completed. Among the young (15 to 24 years), the rate is 1 completed suicide in 100 to 200 attempts. For those older than age 65, 1 in 4 attempted suicides is completed.
In 2005, suicide rates were 12.64 per 100,000 among persons aged 65 to 74, 17.08 per 100,000 persons aged 75 to 84, and 16.94 per 100,000 persons aged 85 or older. Firearms were the most common
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means (72%) used for completing suicide among older adults. Men (92%) used firearms 11.5 times more often compared with women (8%). Alcohol or substance abuse plays a diminishing role in suicides in later life compared with suicides in younger years. One of the leading causes of suicide among older adults is depression, often undiagnosed and untreated. The act of suicide is rarely preceded by only one cause or one reason. In older adults, common risk factors include the following:
• Recent death of a loved one
• Physical illness, uncontrollable pain, or fear of a prolonged illness
• Perceived poor health
• Social isolation and loneliness
• Major changes in social roles (e.g., retirement)
Despite these sobering statistics, American society continues to ignore the problem of suicide in older adults. Older adults are less likely to communicate their intent to commit suicide; as a result, many health care professionals have assumed erroneously that suicide is not a significant issue among older adults. Some older adults attempt suicide to retain control by deciding on the appropriate time to die. Such acts are sometimes called benign suicides or rational suicides. These terms refer to suicides planned by individuals because they perceive their life to have no value. These types of suicide pose an ethical dilemma for nurses with regard to patient autonomy versus the value of life and often also pose a legal issue, as evidenced by the recent publicity resulting from reexamination of laws in several states. Despite the inherent uncertainty in these cases, nursing scholars have supported a nursing perspective that affirms life by enhancing the individual’s quality of life rather than assuring them of their right to die (Baldessarini, 2003; Fontaine, 2008; Montross, Mohamed, Kasckow et al., 2003; Vance, Moneyham, & Farr, 2008).
Another issue that nurses deal with in caring for older adults is passive suicide, or subintentioned suicide. It is a passive attempt to hasten one’s death. This type of self-destructive behavior often goes unrecognized and may include noncompliance with the health care
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regimen (e.g., refusing safe and appropriate use of needed medication), behaviors that harm the individual in a more active manner (e.g., continued smoking, alcohol abuse, or an eating disorder), and participating in dangerous situations (e.g., reckless driving).
Risk Factors The risk factors for suicide in older adults are presented in Box 27-5. Evidence suggests that Protestant white men living alone in their homes are at the highest risk for suicide. They often display a neat appearance and calm behavior and take either antianxiety or antipsychotic medications. Many of the steps outlined in the nursing process of older adults with depression are also appropriate for older adults at risk for suicide.
Box 27-5
Risk factors for suicide in older adults • Age (especially those between ages 75 and 85)
• Low socioeconomic status
• Male gender
• White race
• Living alone
• Chronic illness
• Chronic pain
• Alcoholism
• Recent personal loss (especially spouse’s death within past year)
• Other losses (such as economic, social, or prestige) or cumulative losses
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• Substance abuse (e.g., alcohol, prescription medication, over- the-counter medication, or illegal substances)
• Family history of suicide
• Prior suicide attempts or threats
• Fear of institutionalization or increasing dependence
• Recent retirement
• Social isolation
• Chronic sleep problems
• Symptoms of depression (related to 50% to 70% of suicides by older adults)
• Impulsivity
• Unemployment
• Widowed or never married (Compiled from Browning, M.A. (1995). Depression, suicide and bereavement. In M.O. Hogstel (Ed.), Geropsychiatric nursing (2nd ed.). St. Louis, MO: Mosby; Courage, M., Gobbey, K., Ingram, D.A., et al, (1993). Suicide in the elderly: Staying in control. Journal of Psychosocial Nursing and Mental Health Service, 31(7), 25; Holzapfel, S.K. (1994). The elderly. In E.M. Varcarolis (Ed.), Foundations of psychiatric mental health nursing (2nd ed.). Philadelphia: Saunders; Varcarolis, E.M. People who contemplate suicide: Aggression toward self. In E.M. Varcarolis (Ed.), Foundations of psychiatric mental health nursing (2nd ed.). Philadelphia: Saunders; and Kelsey, J.E. (1998). The use of antidepressants in long- term care and the geriatric patient: Primary care issues. Geriatrics, 53(Suppl 4), 512.)
The following steps are more specific to patients who are suicidal.
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Nursing management Assessment
In assessing patients at risk for suicide, it is helpful to have on hand a series of interview questions (Box 27-6). Although not all questions are needed or appropriate for all patients, it is helpful to have a progressive series of assessment items in mind that can be adapted to the situation. The basic components of suicide risk assessment include evaluating suicidal ideation (thoughts), any prior attempts, a patient’s suicide plan, the plan’s lethality, the availability of the implements of the plan, coexisting substance abuse, and the pervasiveness of the despair the patient is experiencing.
Box 27-6
Questions for assessing the risk for suicide • What has been the most difficult moment for you in the recent
past?
• Have things been so bad that you have thought about escaping? If so, how?
• Are there times when death seems like an attractive option to you?
• Have you thought of harming yourself?
• Have you thought about killing yourself?
• If you were to harm yourself, how would you do it?
• Do you have access to the items you would need to carry out your plan (e.g., gun, quantities of medication, rope, enclosed
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garage)?
• Have you thought about harming yourself or attempted to harm yourself in the past?
• What has kept you from harming yourself thus far?
• What might keep you from harming yourself in the future?
Diagnosis Nursing diagnoses for older adults at risk for suicide include the following:
• Ineffective Coping, related to multiple perceived losses
• Complicated Grieving, related to multiple perceived losses
• Hopelessness, related to deteriorating health
• Risk for Self-Directed Violence, related to perceived loss of control
• Spiritual Distress, related to hopelessness
Planning and Expected Outcomes Planning care for an older adult patient who is suicidal requires a strong interpersonal connection with the patient. Expected outcomes include the following: 1. The patient identifies and verbalizes thoughts and feelings related to his or her emotional state.
2. The patient reports absence of suicidal ideation.
3. The patient demonstrates effective coping skills for managing stress and frustration, as evidenced by reported use of two coping strategies.
4. The patient experiences behavior control with assistance of others, as evidenced by absence of suicidal ideation.
5. The patient expresses satisfaction with spiritual well-being, as evidenced by verbalization of positive statements about self and
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life, including a sense of purpose in life.
Intervention When risk of suicide is identified in an older adult patient, appropriate safety measures must be taken. These safety measures may be tailored on the basis of the patient’s suicide plans, the setting in which the nurse is intervening (e.g., the patient’s home, an inpatient setting), and the extent of human connection the patient has. It may be necessary for the nurse to arrange with the local mental health authorities for inpatient hospitalization (voluntary or involuntary) if patient safety cannot be ensured in an outpatient setting. The patient’s significant other can often help in developing a plan for safety. It is essential for nurses to remember that no extent of environmental precautions can take the place of a strong interpersonal connection with the patient. Patients who are suicidal may be creative and adaptive in finding alternative methods of suicide. Without a strong therapeutic relationship to assist the patient, the nurse’s best efforts to keep him or her safe may prove fruitless.
Asking patients about their suicidal thoughts does not plant the idea in their minds. If the nurse has reason to believe a patient may be suicidal, it is quite likely that he or she has already considered this option. A useful tool in working with individuals who are suicidal is a “no-suicide contract.” This is an agreement (ideally written and signed) between the patient and the health care provider that the patient will not harm himself or herself. The specific wording of the agreement may differ, depending on the patient’s risk factors and the setting in which the care is being provided. For example, on an inpatient unit, an agreement might state, “I commit that I will not harm myself while in the hospital, and if I have thoughts of harming myself, I will immediately inform a staff member.”
Once a patient is past the immediate danger of suicidal behavior, the next step is to help him or her develop suicide prevention plans. Such plans may include alternatives other than suicide and may also include specific steps that the patient can take if he or she again
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experiences suicidal thoughts. These plans encourage patients to take a problem-solving (active) approach in dealing with the potential for self-harm; therefore, their planning increases their sense of control. Nurses can play a significant role in the prevention of suicide among older adults. Essential components in such preventive intervention include assessing all older adults for potential self-harm issues, proactively identifying and treating depression in older adults, developing community programs focused on prevention of suicide among older adults, and informing health care professionals who work with older adults in different settings about the risk for suicide.
Evaluation Unfortunately, despite excellent nursing assessment and intervention, older adults do continue to commit suicide at a distressingly high rate. When an older adult has committed suicide, the nurse’s focus may be to assist the family and friends in coping with the resulting grief and trauma. A psychological autopsy, or the processing of events and behaviors surrounding the patient’s suicide, may be useful to both the health care professionals and the patient’s family and friends. Family and friends may also be encouraged to obtain assistance from support groups.
Parkinson Disease PD is the most common form of parkinsonism (parkinsonian syndrome). PD is a common, progressive degenerative disorder of the basal ganglia involving the dopaminergic nigrostriatal pathway (Duffy, 2010). PD is characterized by slowing in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremors at rest, and impaired postural reflexes (Duffy, 2010).
Approximately 50,000 people per year are diagnosed with PD, and it affects 50% more men than women. The risk of PD increases with age, and the peak onset is in the sixth decade. Of those with PD, 5% to 50% have early onset, before age 50. In rare cases,
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parkinsonian symptoms occur before age 20. Although some cases have a hereditary component and others may be traced to gene mutations, most are of a sporadic nature. In fact, most researchers believe that most cases of PD result from a genetic susceptibility and that environmental factors may trigger the disease (Buter, van den Hout, Matthews, Larsen et al., 2008; NINDS, 2013).
Motor activity occurs as a result of the integrated actions originating from the cerebral cortex, basal ganglia, and cerebellum. The main area in the brain affected by PD is the basal ganglia. The basal ganglia are a group of neurons located deep within the cerebrum near the lateral ventricles. The basal ganglia control both muscle tone and the process of voluntary movement. This is accomplished through the secretion of the excitatory neurotransmitter acetylcholine (ACh) and the inhibitory neurotransmitter dopamine. Dopamine is a neurotransmitter produced in the substantia nigra and in the adrenal glands. It is then transmitted to the basal ganglia, when needed. ACh is produced in the basal ganglia and transmits excitatory messages throughout this area. Dopamine inhibits the function of ACh in the basal ganglia to control fine and voluntary movements. Therefore, it is the dopamine–ACh balance that produces normal motor function (Figure 27-6).
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FIGURE 27-6 Nigrostriatal disorders producing parkinsonism. (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R., & O’Brien, B. (2007). Medical surgical nursing: Assessment and management of clinical problems (7th ed.). St.
Louis, MO: Mosby.)
In PD, degeneration of the dopaminergic nigrostriatal pathway causes dopamine depletion in the basal ganglia, while the ACh- secreting neurons remain active. This creates an imbalance between excitatory and inhibitory neural activity in neurotransmitters and is the cause of symptoms such as hypertonia (tremors and rigidity) and akinesia in PD.
Risk Factors PD is an idiopathic syndrome. An autosomal-dominant form of parkinsonian syndrome is associated with a genetic defect of chromosome 4. Environmental factors contributing to PD include postencephalitic parkinsonism, drug-induced or toxin-induced parkinsonian syndrome, exposure to agriculture pesticides and herbicides, and trauma to the midbrain. Other related causes include hydrocephalus, hypoxia, infections, stroke, tumor, and traumas (Duffy, 2010).
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Clinical Manifestations Signs and symptoms begin subtly and include manifestations such as fatigue and a slight resting tremor. These may be the only initial symptoms. In a small portion of individuals, dementia may be the presenting symptom. The classic manifestations of PD are tremors at rest, muscle rigidity, bradykinesia, and postural abnormalities.
Balance in PD is affected by postural changes. Individuals with PD may have difficulty getting out of a chair, walking backward, or maneuvering in tight spaces. Fear of falling is a common complaint. Gait changes are caused by postural changes and a decrease in autonomic balancing reflexes. Common problems with postural and gait changes include festinating gait, freezing, propulsive gait, and retropulsion (Box 27-7).
Box 27-7
Postural and gait terms for parkinson disease • Festinating gait: occurs when the individual can only take small
short steps
• Freezing: a phenomenon in which the individual appears to be glued to the floor, unable to move
• Propulsive gait: occurs when an individual begins walking, then starts running forward, unable to stop until he or she falls or runs into something
• Retropulsion: similar to propulsive gait, but the individual is walking and falling backward instead of forward
Muscle rigidity also affects the eyes, mouth, and voice and contributes to the staring gaze. These manifestations may develop alone or in combination. As the disorder progresses, more manifestations become apparent, including uncoordinated movements; short stepped, shuffling, and propulsive gait, which
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leads to increased risk of falls; postural disturbance; and trunk tilting forward.
Autonomic–neuroendocrine symptoms become noticeable and include seborrhea and excessive perspiration in the face and neck areas and absence of perspiration on the trunk and extremities. Heat intolerance, constipation, anxiety, depression, sleep disturbances, and dysphagia (difficulty swallowing) are also neuroendocrine manifestations of PD. The course of the disorder is slowly progressive. The person becomes more rigid and more disabled, eventually requiring full assistance with ADLs.
Diagnostic Studies No specific studies can be used to diagnose PD. The diagnosis is based primarily on the clinical features of the disorder. Some of the diagnostic and laboratory studies used to assist in the identification of PD include CBC, which may reveal anemia. Blood chemistry profile may show low albumin and protein levels. Drug screens may be done to rule out toxic causes of the symptoms. EEG may reveal a slow pattern and disorganization of electrical activity in the brain. Upper gastrointestinal series may show delayed emptying, distention, and megacolon. Video fluoroscopy may demonstrate a slowed response of the cricopharyngeal muscles when swallowing. A diagnosis of PD is confirmed when the individual’s symptoms improve with antiparkinsonian drugs (Duffy, 2010).
Management Treatment is aimed at relieving clinical manifestations, increasing the individual’s ability to perform ADLs, and decreasing the risk for injury. This is accomplished through the use of medications, surgery, and rehabilitation aimed at optimizing the patient’s functional level. A team approach is essential for high-quality care of PD patients.
Medication Medications are used primarily to relieve the symptoms associated with PD. Medications used include monoamine oxidase inhibitors
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(MAOIs), which are used as adjunct therapy; dopaminergics, used to provide dopamine to the basal ganglia; dopamine agonists, used to activate dopamine in the CNS; and anticholinergics, used to block the release of ACh. A new class of drug called catechol-O- methyltransferase inhibitors may be given with dopaminergics to increase the availability of dopamine in the brain (Black et al., 2005). Table 27-6 lists drugs used to treat PD. Unfortunately, the effectiveness of these drugs decreases eventually. The fluctuating response of individuals to antiparkinsonian drugs is called the on– off response. Antidepressants, especially amitriptyline, are used to treat depression often associated with PD. Propranolol may be used to treat tremors.
Table 27-6 Drugs used to treat parkinson disease
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(From Black, J.M., Hawks, J.H., & Hogan, M.A. (2005). Medical-surgical nursing: Clinical management for positive outcome (7th ed.). Philadelphia: Saunders.)
COMT, Catechol-O-methyltransferase; MAOI, monoamine oxidase inhibitor. * One study showed that levodopa in combination with selegiline provided no clinical benefit over levodopa alone in treating early, mild Parkinson disease. Moreover, the mortality rate was significantly higher when these two drugs were used together.
Surgical Therapy Surgical procedures to alleviate symptoms of PD are used in patients who have not responded to medication therapy. The surgical procedures fall into three categories: (1) ablation (destruction), (2) deep brain stimulation (DBS), and (3) transplantation. Ablation and DBS work by reducing the increased neural activity produced by dopamine depletion. Transplantation of fetal neural tissue is designed to provide dopamine-producing
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cells in the brains of individuals with PD. This procedure is still in its experimental phase (Duffy, 2010).
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Nursing management Diagnosis
Priority nursing diagnoses for a patient with PD include the following:
• Impaired Physical Mobility
• Impaired Verbal Communication
• Imbalanced Nutrition: Less Than Body Requirements
• Risk for Injury
Planning and Expected Outcomes Expected outcomes for a patient with PD include the following:
1. The patient will maintain an effective communication pattern.
2. The patient will maintain physical functioning and mobility and will not sustain injury.
3. The patient will maintain effective coping by demonstrating the use of coping strategies that enhance individual and family functioning.
4. The patient will maintain socialization by participation in activities.
5. The patient will verbalize satisfactory effects from medications and safely manage the medication schedule.
The care planning and expected outcomes for a patient with PD frequently need revision because of changes in the patient’s status.
Intervention Nursing care includes teaching patients the importance of performing active range-of-motion exercises twice a day, walking at least four times a day, and using assistive device when
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recommended to prevent injury associated with falls. Because PD leads to rigidity of the facial muscles, mouth, and general functioning of individuals, assessment of communication skills, speech, and writing is needed.
Consultation with a speech pathologist may be necessary if the patient develops dysphagia. Assessment of nutritional status and self-feeding abilities is crucial for preventing aspiration, respiratory complication, and nutritional imbalance. Nurses are also responsible for monitoring the intake of foods high in bulk and fluids.
Patient education includes the following:
• Teaching preventive measures for malnutrition, falls and other environmental hazards, constipation, skin breakdown from incontinence, and joint contractures
• Teaching gait training and exercises for improving ambulation, swallowing, speech, and self-care
Referral to community agencies and resources is also helpful. Some of the resources specifically available to individuals and families affected by PD include the American Parkinson Association (see listings in Appendix 27A, at the end of this chapter). Recommendations of appropriate Internet sites for further information is also helpful. The nurse should encourage families and patients to communicate with their primary care provider when they have questions about PD and encourage them to keep a diary to track the symptoms, as well as the effects and side effects of medications.
Evaluation PD is a progressive terminal disease that has no cure at this time. Therefore, the evaluation of nursing interventions should focus on maintenance of function and engagement in activities for as long as possible. Evaluation is based on documentation of achievement of expected outcomes, as evidenced by an older adult patient exhibiting intact skin, appropriate body weight, effective communication, effective coping, and knowledge of appropriate
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self-care practices. Participation of family members in continued care and rehabilitation is also noted. Specific problems are documented, as is any teaching.
Cerebrovascular Accident (Brain Attack) A disruption in the normal blood supply to the brain tissue causes a CVA (stroke, or brain attack). CVAs occur suddenly and produce focal neurologic deficits lasting more than 24 hours. They are medical emergencies that should be treated immediately to prevent permanent neurologic deficits and disability. A TIA consists of the same symptoms but lasts less than 24 hours. However, about a third of those experiencing a TIA will suffer a CVA in the future.
The warning signs of a stroke are sudden numbness of face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking or dizziness, loss of coordination or balance; sudden severe headache with no known cause (CDC, 2013; NINDS, 2013). Recurrence of stroke is unfortunately frequent; approximately 25% will have a recurrence within 5 years (NINDS, 2013).
Strokes are the fourth leading cause of death and the most common cause of disability in the United States; each year, they kill nearly 130,000 of the almost 800,000 who have one (American Stroke Association [ASA], 2013). The CDC reports that 60% to 75% of strokes occur in individuals older than age 65, and the risk doubles each decade after age 55. However, in 2009, 34% of those hospitalized for a stroke were under age 65 (CDC, 2013).
Approximately 30% to 50% of those who survive a CVA are left with moderate to severe disability. Blacks are more likely than whites to have a stroke, perhaps because this population has a higher incidence of hypertension and diabetes. The risk of having a stroke in their lifetime is higher among women than among men (1:5 to 1:6) (WHO, 2012). The incidence rate of stroke for Hispanic Americans is somewhere between those for African Americans and whites. American Indians and Alaska Natives are more likely to have strokes compared with other ethnic groups (not listed). Of all
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the groups, African Americans are more likely to die following a stroke (CDC, 2013).
In 1996, a national campaign was initiated to increase public awareness of CVA (Black et al., 2005). The NINDS conducted a study (published in 1996) that revolutionized the way we approach and treat acute ischemic stroke (AIS). The major change was the use of thrombolytic agents (recombinant tissue plasminogen activators [r-TPA]) within a 3-hour window of the onset of signs or symptoms of AIS. Findings from this study demonstrating decreased mortality and morbidity rates ignited the campaign to make the public aware of the common signs and symptoms associated with “brain attack” and to activate the emergency system for prompt diagnosis and early treatment of stroke (NINDS, 2013). Since 2004, the MERCI Retrieval System has been used for those patients beyond the 3- hour window for IV-tPA or with a response failure. It is a corkscrew-shaped device that wraps itself around the clot, which then can be removed. In 2008, the Penumbra system, which uses suction to grab clots, has been used successfully as well (National Stroke Association [NSA], 2012). The NINDS continues to research and investigate new therapies to aid in the treatment and even removal of clots caused by hemorrhagic CVAs (NINDS, 2013).
Cerebral infarctions are ischemic or hemorrhagic in origin. The brain is very sensitive to any decrease in blood supply. As a result, when cerebral blood flow is reduced to a level insufficient to maintain neuronal viability, it causes a state of hypoxia. This hypoxic state leads to tissue ischemia and injury. Short-term ischemias result in TIAs. Long-term ischemia leads to permanent infarction (death of cerebral cells). Cellular events that ensue as a result of the ischemia alter the cell membrane. As a result, the polarization of the cell membrane changes, allowing an influx of calcium into the cell and altering cellular metabolism. Glutamate is then released, altering the cell’s permeability to electrolytes. Electrolytes change the metabolic rate of the cell, leading to cellular acidosis, lactic acid production, vasodilation, and cellular hypoxia. Sustained anoxic events lead to infarct of brain tissue and irreversible neuronal injury. If an infarct occurs, the affected brain softens and liquefies.
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The extent of brain infarction depends on factors such as location and size of an occluded vessel and the adequacy of the collateral circulation to the area supplied by the occluded vessel. Cell death and permanent changes may occur within 3 to 10 minutes of anoxia. The most common vessels for ischemic stroke are the middle cerebral artery and the vertebrobasilar artery. A mean arterial pressure of 50 mm Hg or less may affect brain perfusion (NINDS, 2013).
Symptoms of thrombotic stroke may be sudden but typically progress gradually over minutes to hours. The development of thrombotic strokes causes a syndrome known as stroke-in-evolution. The completed stroke is a CVA that has caused maximum damage with regard to neurologic deficits.
Risk Factors The risk factors for CVAs, both genetic and lifestyle, are many. A genetic factor includes the sickle cell disease. The NINDS continues to research both the genome and biomarkers for those indicators that predispose persons to strokes over their lifetime. Lifestyle factors are high blood pressure, diabetes, cigarette smoking, and heart disease caused by atherosclerosis, obesity, and physical inactivity. Another risk factor is atrial fibrillation (NINDS, 2013).
CVAs are caused by two major pathologic events: ischemic stroke and hemorrhagic stroke. An ischemic stroke is further categorized as thrombotic, cardioembolic, and lacunar strokes. The most common cause for ischemic strokes are atherosclerosis, inflammatory disease processes, and a thrombus breaking away outside the brain or in the cardiovascular system. Hemorrhagic strokes are divided into subarachnoid and intracerebral hemorrhages, according to the site of the hemorrhage. The most common causes for hemorrhagic strokes are hypertension, a ruptured aneurysm, vascular malformations, bleeding into a tumor, hemorrhages associated with bleeding disorders or anticoagulation, head trauma, and illicit drug use (Duffy, 2010).
The incidence of deaths from stroke has gradually declined in many industrialized countries over the past 20 years. The
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aggressive campaign started by the NINDS in 1996 to educate the general population about the risk factors and forms of prevention has played a pivotal role in decreasing the mortality rate.
Both nonmodifiable and modifiable risk factors are associated with CVA. The nonmodifiable risk factors for CVA include gender, age, race, and heredity. Although changes cannot be made in these areas, awareness of the association of stroke could increase patients’ involvement in the process of secondary prevention. Advanced age is one of the most significant risk factors for stroke. Modifiable risk factors include hypertension, diabetes mellitus, cardiovascular disease, nonvalvular atrial fibrillation, blood lipid abnormalities, smoking, substance abuse (particularly cocaine), obesity, a sedentary lifestyle, high stress levels, previous CVA or TIA, heavy alcohol use, and sudden discontinuation of antihypertensive medications (causes hemorrhagic stroke). Modifiable risk factors may be reduced or eliminated through lifestyle changes. Hypertension is the most important modifiable risk factor for both ischemic and hemorrhagic strokes. Table 27-7 summarizes the levels of prevention for stroke.
Table 27-7 Levels of prevention for stroke
Level Preventive Steps Primary prevention Maintain ideal body weight.
Manage cholesterol levels. Stop smoking. Reduce alcohol consumption. Eliminate illicit drugs.
Secondary prevention Tightly manage blood pressure. Effectively manage diabetes mellitus. Promptly treat cardiovascular disease, transient ischemic attack, and atrial fibrillation.
Tertiary prevention Initiate rehabilitation program early.
Clinical Manifestations Specific clinical manifestations of a TIA vary, depending on the vessel involved, the degree of obstruction of the vessel, and collateral blood supply. If the carotid system is involved, the individual may experience blurred vision, gradual visual obstruction, flashes of light, and headaches. If the posterior system is involved, symptoms may include tinnitus, vertigo (dizziness),
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bilateral sensory and motor symptoms, diplopia, facial weakness, and ataxia.
Early warning signs for thrombotic stroke include transient hemiparesis, loss of speech, and paresthesias (abnormal sensations) involving one side of the body and lasting a few minutes to less than 24 hours. These are considered TIAs. Common signs and symptoms that may precede cerebral hemorrhage in patients with hypertension include severe occipital or nuchal (back of the neck) headache, vertigo or syncope (fainting), paresthesias, transient paralysis, epistaxis (nose bleed), and retinal hemorrhages.
Common findings that are seen with strokes include headaches, vomiting, seizures, mental status changes (including coma), fevers, and ECG changes (e.g., T-wave changes, shortened P–R interval, prolonged Q–T interval, premature ventricular contractions, sinus bradycardia, ventricular tachycardia, and supraventricular tachycardia).
Clinical manifestations vary according to the cerebral vessel involved:
• Internal carotid: contralateral motor and sensory deficits of the arm, leg, and face. In dominant hemispheric CVA, aphasia occurs. In nondominant hemispheric CVA, apraxia, agnosia, and unilateral neglect occur, as well as homonymous hemianopia (loss of one half of the visual field in each eye).
• Middle cerebral artery: drowsiness, stupor, coma, contralateral hemiplegia and sensory deficits of arm and face, aphasia, and homonymous hemianopia may be seen.
• Anterior cerebral artery: contralateral weakness or paralysis and sensory loss of the foot and leg, loss of ability in decision making and voluntary actions, and urinary incontinence
• Vertebral artery: pain in the face, nose, or eye; numbness or weakness of the face on the ipsilateral side; problems with gait; dysphagia; and dysarthria (difficulty speaking)
Diagnostic Tests The characteristic feature of ischemic CVA is persistent clinical
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manifestations that last longer than 24 hours. Therefore, prompt diagnosis and treatment play a pivotal role in decreasing the progression of the injury and complications or disabilities that ensue. With the advent of improved imaging technologies, an individual experiencing any significant manifestation will receive a noncontrast CT of the head, standard MRI or diffuse-weighted MRI, or diffuse-weighted imaging (DWI). The last procedure provides signs of the earliest changes associated with ischemia, even before injury or infarction occurs. This makes DWI a valuable tool in the early detection and treatment of CVAs. DWI performed with perfusion imaging helps improve the accuracy of the diagnosis.
Establishing an accurate diagnosis between hemorrhagic and ischemic stroke is vital. Performance of CT without contrast is the first step in trying to determine the stroke type. Because of the strong correlation between cardiovascular disease and stroke, ECG is also essential. A chest radiography and cardiac monitoring are recommended to rule out cardioembolism or any coexisting conditions such as cardiomegaly associated with valvular disease. Additional studies that may be recommended include a hematologic function laboratory test, electrolyte and glucose levels, and liver and kidney function tests. EEG is performed if the patient has seizures and a lumbar puncture if a subarachnoid hemorrhage is suspected but not seen on CT.
Management Medical and Pharmacologic Therapy As a result of advancements in pharmacologic therapy, patients with ischemic strokes receive thrombolytic agents within 3 hours of the onset of the CVA (ASA, 2013). Confirmation of an ischemic stroke with CT without contrast is essential before r-TPA can be used. The NINDS has established exclusion criteria for r-TPA therapy for acute ischemic strokes (Box 27-8). The NINDS is also working with hospitals to help them establish stroke teams to work with patients in a coordinated manner on arrival. The desired effect of this therapy is to dissolve the clot and reperfuse the
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compromised brain tissue. Patients receiving r-TPA should not receive anticoagulants, antiplatelets, or any type of antithrombotic drug for at least 24 hours after treatment.
Box 27-8
Exclusion criteria for intravenous r-tpa therapy for acute ischemic stroke • Current use of oral anticoagulant or prothrombin time
> 15 seconds
• Use of heparin in previous 48 hours and a prolonged partial thromboplastin time
• Platelet count < 100,000/mm3 (cubic millimeters)
• Previous stroke or head injury within the past 3 months
• Major surgery within past 14 days
• Pretreatment systolic blood pressure > 185 mm Hg or diastolic blood pressure > 110 mm Hg
• Rapid decrease in neurologic signs
• Isolated, mild neurologic deficits such as ataxia alone, sensory loss alone, dysarthria alone, or minimum weakness
• Prior intracranial hemorrhage • History of urinary bleeding within past 21 days
• Recent myocardial infarction
Drugs used to treat CVA patients include the following:
• Atorvastatin calcium, for high cholesterol
• Baclofen, for spasticity
• Onabotulinumtoxin A, for upper limb spasticity and incontinence
• Dextromethorphan hydrobromide and quinidine sulfate, for
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pseudobulbar affect
• Anticoagulants, to reduce the risk of blood clots
• Antiplatelets, to prevent platelets from sticking together
• Angiotensin II receptor antagonists, to reduce blood pressure
Surgical management includes the following:
• Endarterectomy
• Extracranial–intracranial bypass
• Management of arteriovenous malformation
• Management of cerebral aneurysms
• Management of intracranial bleeding and evacuation of hematomas
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Nursing management Diagnosis
Nursing diagnoses for an older adult with a CVA include the following:
• Risk for Ineffective Cerebral Tissue Perfusion, related to hemorrhage, increased intracranial pressure, or both
• Ineffective Breathing Pattern, related to changes in mental status
• Risk for Aspiration, related to loss of muscle tone, airway protection, and dysphagia
• Impaired Physical Mobility, related to arm and leg weakness or paralysis (hemiparesis or hemiplegia)
• Impaired Verbal Communication, related to aphasia and dysarthria related to alteration in the speech center
• Risk for Injury, related to seizures or hemiplegia
• Risk for Impaired Skin Integrity, related to prolonged immobility
• Impaired Urinary Elimination, related to immobility
• Feeding/Bathing/Dressing/Toileting Self-Care Deficit, related to impairments secondary to CVA
• Deficient Knowledge related to lack of exposure to medication use, rehabilitation, and long-term care for CVA
Planning and Expected Outcomes Outcomes for an older adult with a CVA include the following:
1. The patient will not die.
2. The patient will have minimum residual deficits and complications.
3. The patient’s increased ICP will be reduced.
4. The patient will not suffer evolution, extension, or completion of
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the stroke.
Intervention Initial nursing interventions include positioning the patient at a 30- to 45-degree angle to prevent further elevation of ICP. This position also helps manage or protect the airway of the patient with a neurologic deficit. Monitoring of vital signs assists the nurse in detecting signs of increased ICP and in effectively managing blood pressure. The nurse is responsible for continuous monitoring for signs of complications such as hydrocephalus, vasospasm, and increased neurologic changes.
Additional nursing interventions include the following:
• Encourage active range of motion on the unaffected side and passive range of motion on the affected side.
• Turn the patient every 2 hours.
• Monitor lower extremities for thrombophlebitis resulting from immobilization.
• Encourage the use of the unaffected arm for ADLs.
• Teach the patient to put clothing on the affected side first.
• Have the patient resume an oral diet only after he or she has successfully completed a swallowing evaluation. The patient may need thickened liquids or foods the consistency of oatmeal and may need to chew on the unaffected side of the mouth. This is sometimes referred to as a dysphagia diet.
• Collaborate with occupational and physical therapists for rehabilitation.
• Try alternative methods of communication with the patient who has aphasia.
• Teach the patient with homonymous hemianopia to adapt to the deficit by turning the head side to side to fully scan the visual field.
• The nurse also needs to educate the patient and family about:
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• CVA and CVA prevention
• Community resources
• Physical care and the need for psychosocial support
• Medications
Evaluation Patient progress occurs in small increments, and interventions are modified to assist patients in meeting their goals. Evaluation criteria include the following:
• Maintenance and improvement of cerebral tissue perfusion
• Avoidance of respiratory complications
• Prevention of aspiration from food, fluids, and secretions
• Prevention of contractures
• Prevention of edema in the affected extremity
• Maintenance of skin integrity
• Achievement of independence
• Pain management
• Increased ability to communicate, express feelings, and understand others
• Prevention of fecal and urinary incontinence
• Establishment of a normal voiding pattern
• Compensation for sensory deficits and physical and intellectual losses
• Participation by family members in the rehabilitation process
Home care
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1. Assess sensorimotor function. A decline in this function is the most notable change in older adults and may be the cause of other changes such as slowed reaction time.
2. Memory impairment may compromise the teaching of homebound patients, so the nurse may have to use alternative approaches and rely on family and significant others involved in caregiving.
3. Assess for signs of impaired emotional control, diminished initiative, withdrawal, or other changes, which may be initial signs of brain dysfunction.
4. Altered thought processes occur with cognitive decline or disturbances in cognitive function, both of which occur in homebound patients with dementia, depression, delirium, or amnesic disorders.
5. The effects of aging must be considered when interpreting laboratory tests and alerting physicians about abnormal results.
6. Instruct caregivers about dosages and side effects of medications, especially tranquilizers and antidepressants that are used in managing symptoms caused by dementia.
7. Instruct caregivers on methods to manage behavioral problems and caregiver stress.
8. Use social workers to assess community resources for caregivers and patients with dementia.
9. Assess the home environment of the older person with cognitive impairment for safety hazards, and provide caregivers with tips and strategies for reducing and eliminating the identified hazards.
Anxiety Anxiety is one of the most common symptoms seen in older adults; the most common anxiety disorder seen in older persons is obsessive-compulsive disorder (OCD) (Berlin & Hollander, 2008; Calleo & Stanley, 2008). OCD comprises obsessive symptoms (e.g., persistent intrusive thoughts) and compulsive symptoms (e.g.,
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repetitive behavior performed in an attempt to reduce anxiety). For example, older adults may manifest OCD in morning routines so ritualistic that they miss both breakfast and lunch. Other anxiety disorders seen in older adults may be generalized anxiety disorder (GAD) and phobic disorders. GAD is excessive worry that is beyond the individual’s control (APA, 2013) and may be evidenced by symptoms such as restlessness, fatigue, decreased concentration, irritability, muscle tension, or disturbed sleep. A phobic disorder is manifested by a persistent, irrational fear provoked by the feared object or situation.
Anxiety disorders in older adults may develop as a result of a specific event or a general pattern of change seen by patients as threatening. Such changes may include declines in health, illness, financial strain, an actual or potential change in living situation, the death of a significant other, or a loss of independence. Retirement is a change that often is associated with the development of an anxiety disorder in older adults.
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Nursing management Assessment
Older adult patients with anxiety disorders are usually able to describe their anxiety without the nurse needing to probe extensively. They may also exhibit behavioral clues such as pacing, irritability, and fidgeting. When patients lack insight into their anxiety, the nurse may find it helpful to describe the symptoms observed as indicating anxiety. The nurse should also assess associated changes such as sleeping habits and appetite, the presence or absence of depression, and any complaints of physical pain, which may accompany the anxiety. Box 27-9 lists factors that should be assessed in older adults with an anxiety disorder.
Box 27-9
Factors to assess in older adults with anxiety disorder • Recent changes in the patient’s life
• Degree of anxiety
• Interference of the anxiety with performance of activities of daily living
• Physical symptoms (e.g., vital signs, gastrointestinal function, headaches, and tremor)
Somatic complaints are often seen in older adult patients experiencing anxiety. This may be attributed to the physical toll that anxiety takes on the physical systems or to a patient being more comfortable reporting a physical health concern rather than a mental health one. If the nurse believes the somatic concerns may be related to anxiety, a thorough anxiety assessment should be
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conducted.
Diagnosis The nursing diagnoses for older adults with an anxiety disorder usually include the following:
• Anxiety, related to a situational crisis
• Ineffective Coping, related to perceived vulnerability
Planning and Expected Outcomes Expected outcomes include the following:
1. The patient identifies his or her own anxiety and coping patterns.
2. The patient reports an increase in psychological and physiologic comfort.
3. The patient demonstrates effective coping skills, as evidenced by his or her ability to solve problems and meet self-care needs.
4. The patient demonstrates the use of appropriate relaxation techniques.
Intervention The nurse may intervene with older adults experiencing anxiety in a number of ways. It may be helpful to assist patients in examining their own “worst case scenario.” By developing strategies that could be used to cope with the worst possible situation, patients may feel an increased ability to cope with their current situation. Relaxation strategies such as progressive muscle relaxation, breathing techniques, therapeutic use of music, and exercise are useful in helping patients alleviate the acute anxiety states that are most distressing to them. The nurse should help patients learn to identify increasing anxiety early in the anxiety cycle so that they can take steps to reduce it to a lower level. Family education may also be beneficial to obtain support systems for patients. Patients experiencing moderate to panic-level anxiety may need a referral
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for antianxiety medications. Patients who continue to experience distress as a result of anxiety may benefit from psychotherapy. Behavior modification techniques are especially effective with phobic disorders.
Evaluation The nurse may evaluate the care that has been provided to patients experiencing anxiety by monitoring their progress toward achievement of the expected outcomes and documenting the results. Effectiveness of any health teaching is evident in a patient’s ability to use relaxation techniques and constructive problem solving.
Schizophrenia Schizophrenia is a thought disorder characterized by altered perceptions of reality, alterations in thought processes (both form and content), and declines in patients’ ADLs and occupational and social functioning. The onset of schizophrenia usually occurs between the late teens and the mid-30s. However, in rare cases schizophrenia has an onset after age 45 (APA, 2013).
Typically, older adult patients with schizophrenia have been dealing with the disorder for a long time but may experience exacerbations of the schizophrenic symptoms with the stress of the aging process. The presentation is more likely to include delusions and hallucinations and less likely to include disorganized and negative symptoms (Cohen, Vahia, Reyes et al., 2008; McNamara, 2006a).
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Nursing management Assessment
The reader is referred to a general psychiatric nursing textbook for a complete review of the assessment process in individuals with a diagnosis of schizophrenia.
Diagnosis Nursing diagnoses appropriate to the older adult with schizophrenia include the following:
• Social Isolation, related to altered mental status
• Anxiety, related to unconscious conflict with reality
• Ineffective Coping, related to unrealistic perceptions
• Disturbed Sleep Pattern, related to psychological status
Planning and Expected Outcomes Schizophrenia is an illness that shows periods of exacerbation and remission. The goal of nursing intervention in individuals with schizophrenia is safe, effective treatment, rather than a cure. The goals for the patient that the nurse should work toward are reduction in symptoms and an improved quality of life. Other goals include reducing patient anxiety (anxiety usually exacerbates the schizophrenic symptoms), building a therapeutic relationship with the patient, providing continuity of care, and eliciting the support of family and friends to enhance the patient’s function and experience. Expected outcomes include the following:
1. The patient develops a trusting relationship, as evidenced by the presence of supportive significant others.
2. The patient maintains contact with mental health caregivers, as evidenced by weekly meetings with a counselor.
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3. The patient experiences a decrease in hallucinations and distress, as evidenced by verbalized reports of fewer hallucinations and feelings of distress, as well as demonstration of methods to handle hallucinations.
4. The patient gets adequate sleep, as evidenced by reports of sleeping through the night or verbalization of feeling rested after a night’s sleep.
Intervention Nursing interventions for older adults with schizophrenia should provide a comprehensive approach to the maintenance of ADLs, nutrition, hygiene, health promotion, and reality orientation. The reader is referred to a general psychiatric nursing text for a thorough review of nursing interventions for patients with schizophrenia. Interventions that may be most essential in dealing with older adults with schizophrenia include providing adequate family or social support, responding to patient symptoms, using touch appropriately, and dealing with aggressive behavior.
If patients give evidence (verbal or nonverbal) of hallucinations or delusions, the nurse should focus on responding to the feelings without arguing about the reality of their perceptual experiences. For example, if a patient states that the television is broadcasting his or her thoughts, the nurse could respond by saying, “That must be frightening,” rather than saying, “Now Mr. D, you know that the television can’t do that!” Attempting to argue perception with patients only escalates their anxiety. It may, however, be helpful to reorient patients without being confrontational.
Patients with schizophrenia may easily misinterpret touch by the nurse as being harmful or threatening to them. Therefore, the nurse should only touch the patient for a specific purpose and only with permission from the patient.
Older adults with schizophrenia may at times present a danger to themselves or others. The nurse should assess the level of danger that each patient presents. If the assessment shows that a patient has a potential for aggression, the nurse should take steps to
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deescalate the patient’s anger and to provide safety for the patient and others.
Evaluation Evaluation is based on achievement of the identified expected outcomes. The nature of the disorder may make it difficult for the nurse to establish a relationship with a patient; the nurse may therefore feel hopeless, frustrated, and inadequate while attempting to provide care. It is often helpful to establish short-term goals for patients with schizophrenia that are easily achievable and specific. The nurse is responsible for documenting progress toward achievement of the objectives, as well as the level of safety achieved.
Delusional Disorders Delusional disorders involve nonbizarre delusions. (An example of a nonbizarre delusion would be a person with the false belief that he or she is under surveillance by the police. An example of a bizarre delusion would be that one’s bodily organs have been removed and replaced by someone else’s organs.) Except for the delusion, the patient’s thinking is otherwise normal. Hallucinations rarely occur. These patients usually do not respond well to antipsychotic medications (Calandra, 2003).
The following types are designated on the basis of the predominant delusional theme (APA, 2013):
• Erotomanic type: delusions that another person, usually of higher status, is in love with the individual
• Grandiose type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
• Jealous type: delusions that the individual’s sexual partner is unfaithful
• Persecutory type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way
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• Somatic type: delusions that the person has some physical defect or general medical condition
• Mixed type: delusions characteristic of more than one of the above but with no one theme predominant
• Unspecified type
Mental Retardation Mental retardation is characterized by below-average intellectual functioning. The onset occurs before age 18 and is accompanied by an alteration in an individual’s ability to cope with life’s demands and to function independently (APA, 2013). The individual’s functioning, including such things as communication, self-care ability, performance of ADLs, interpersonal relationships, occupational functioning, and health and safety behaviors, may all be affected by the mental retardation. Multiple causes of mental retardation exist. The functioning of patients with mental retardation is affected throughout the life span, including the later years. These individuals are also more susceptible to alterations in emotional states.
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Nursing management Assessment
Variables that may determine a patient’s level of functioning should be assessed to determine the extent to which they enhance or detract from patient well-being (Box 27-10).
Box 27-10
Factors to assess in older adults with mental retardation • Sociocultural factors (e.g., financial resources)
• Community setting (e.g., availability of needed services)
• Family support (e.g., their level of acceptance)
• Functional status (e.g., living independently)
• Education (e.g., highest grade level completed)
• Personal characteristics (e.g., level of happiness)
• Occupational opportunities (e.g., employment status)
• Social setting (e.g., peer group)
Diagnosis The most common nursing diagnosis seen in older adults with mental retardation is Delayed Growth and Development. This may be evidenced by delusions, a decreased attention span, or impaired problem solving. This diagnosis represents the ongoing challenge that older adults with mental retardation are living with. Other common nursing diagnoses for older adults with mental retardation include Self-Care Deficit and a Risk for Self-Directed or
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Other-Directed Violence.
Planning and Expected Outcomes In planning short-term and long-term goals, the nurse should customize the care plan to a patient’s intellectual abilities. Adaptations to routine interventions may be needed to assist patients in comprehending their care, thereby allowing them to participate in the care. It may be useful to know a patient’s intellectual functioning in terms of age level so that interventions can be adapted accordingly. Expected outcomes include the following:
1. The patient demonstrates the ability to maintain personal safety, as evidenced by the ability to communicate anger and frustration, appropriately use methods for coping with feelings, and exhibit appropriate self-control.
2. The patient demonstrates the ability to care for self independently within limitations, as evidenced by demonstration of appropriate self-care activities on a regular, consistent basis with minimum supervision.
Intervention Nursing interventions that are specifically useful in dealing with older adults with mental retardation primarily involve customizing the care routines to their level of intellectual functioning. When communicating with a patient, the nurse should use clear, simple instructions. Caregivers may be assigned a parental role by patients with mental retardation. This role may represent a challenge for these patients because of their continued dependence throughout their life span; this is especially true if parents or other family members who have cared for patients throughout their life have become disabled or are now deceased. Therefore, many older adults with mental retardation as well as physical problems are admitted to nursing facilities for care.
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Evaluation In evaluating the care provided to older adult patients with mental retardation, the nurse should also be aware of the need for an expanded nursing focus in this population. The opportunities for nursing research and service, especially in community settings, are varied and abundant. Documentation focuses on achievement of the expected outcomes and on the adaptations that are required as a result of age-related changes superimposed on the mental retardation.
Conditions Associated with Physical Problems This category includes mental illness symptoms that result from a physiologic process or a general medical condition, as well as the somatoform disorders. An example of a mental illness symptom that may be a result of a physiologic process would be a cognitive disorder resulting from head trauma. Personality changes caused by hypothyroidism are an example of a mental illness symptom that may be a result of a general medical condition (APA, 2013). Somatoform disorders are seen in a higher incidence among older adults. They are described as complaints of physical symptoms without the medical conditions that would explain the existence of the symptom. Table 27-8 outlines the various types of somatoform disorders.
Table 27-8 Types of somatoform disorders
Type Characteristics Somatization Multiple symptoms, usually a combination of symptoms and pain, often including gastrointestinal or
sexual symptoms Conversion Unexplained neurologic motor disorders or sensory deficits Pain disorder Pain with unexplained onset, severity, or duration Hypochondriasis Preoccupation with or fear of serious disease that leads to inordinate focus on body functions or
symptoms; the most common somatoform disorder seen in older adults Body dysmorphic disorder
Preoccupation with an exaggerated or imagined physical appearance deficit
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Nursing management Assessment
The initial priority when assessing these patients is their physical status, which determines the interplay between their physical and mental status. Therefore, a thorough health history, medication history, physical assessment, and mental status examination should be completed. Physical symptoms should not be ignored. Their presence should be explained by a physical illness, or their possible causes should be ruled out.
Health care professionals often minimize the physical complaints exhibited by older adults with somatoform disorders, but this may be a fatal mistake. Diagnoses may be missed, and patients who have true somatoform disorders may develop physical illnesses unrelated to their disorder. Failure to diagnose and appropriately treat such illnesses may be disastrous. In addition to assessing the physical and mental status of patients, the nurse should attempt to understand the secondary gain that patients may receive from the somatoform disorder. Often, this information is best elicited by assessing the impact of the somatoform disorder on a patient’s family members and friends.
Diagnosis, Planning, and Expected Outcomes The care of older adults with somatoform disorders is often planned around the nursing diagnosis of Ineffective coping. The short-term and long-term goals are then centered around enhancing patient coping skills.
Intervention The nurse should reinforce positive, healthy, well-role behaviors and attitudes that patients may demonstrate. At the same time, the
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nurse should encourage and reward patient discussion of non– symptom-related topics. When patients attempt to focus on their physical symptoms, the nurse should respond with a caring but neutral attitude that does not encourage this focus. The nurse should not try to convince patients they are not ill or are not really experiencing the physical symptoms. Such efforts may be futile and frustrating for the patients and the nurse. The nurse should respond to patients’ emotional feelings rather than focusing on the symptom. The nurse should be alert to the possibility of patients using multiple physicians who are unaware of this fact, as well as the possibility of patients overusing both prescription and OTC medications.
Evaluation The nurse may become easily frustrated if all evaluation criteria center around a patient’s somatoform symptoms. These symptoms are not easily treated or readily relinquished. It may be helpful to use markers such as the consistency of the care a patient received, any observed decrease in the patient’s levels of anxiety, or the patient’s improved awareness of his or her emotions and then document based on these markers.
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Medication management Psychotropic Medications The second most common type of medication used by older adults is psychotropic agents. These drugs affect patient brain function, behavior, or experience (Reeves & Brister, 2008; Vahia, Diwan, Bankole et al., 2008). Older adults exhibit changes in the absorption, distribution, metabolism, and excretion of medications, as well as changes in the CNS neurotransmitters and receptor sites that these drugs affect. Therefore, a corresponding change occurs in the indications and contraindications for appropriate use of these medications (see Chapter 20).
In the past, psychotropics were commonly used for residents of long-term care facilities. This use was often inappropriate or excessive. In 1987, federal regulations were developed (the Omnibus Budget Reconciliation Act) to decrease the inappropriate use of antipsychotic medications. A corresponding decline has been seen in the frequency of use of antipsychotic agents in residents of long-term care facilities. Psychotropic medications are appropriate when used in long-term care settings for what Drinka (1993) terms the three Ds: “danger to the resident or others; distress for the resident; dysfunction of the resident including interference with basic nursing care.”
A primary goal in medication management for older adult patients is to find the lowest effective dose with the least adverse effects. When psychotropic medications are used in older adults, it is also essential to remain aware of drug–drug interactions, drug– food interactions, nonadherence issues, and substance abuse and dependency issues. The nursing implications of antianxiety medications, antidepressants, antimanic agents, antipsychotics, and other psychoactive medications used in older adults are discussed in this section (Zagaria, 2009).
Antianxiety Agents Antianxiety medications are also called anxiolytics. In the past,
1973
barbiturates were the main types of drugs used for anxiety; however, benzodiazepines (BZs) are now used because of their improved safety compared with barbiturates. Long-term use of BZs (usually defined as longer than 1 to 2 months) puts patients at risk for the development of dependence, and benzodiazepines do have potential adverse interactions, especially with sedative agents and alcohol. The two broad categories of BZs are short-acting BZs (e.g., alprazolam [Xanax], lorazepam [Ativan], and oxazepam [Serax]) and long-acting BZs (e.g., diazepam [Valium], chlordiazepoxide [Librium], and clonazepam [Klonopin]). The short-acting agents are preferred for older adults because of their lower potential for buildup leading to sedation and depression.
When used for anxiety, BZs should be given in the lowest possible dose for the shortest possible time. Therefore, the precipitating cause of the anxiety needs to be evaluated and addressed while the BZ is being used. Although alprazolam may be used on a long-term basis for panic in older adults, most BZs should be used for less than 30 days. When BZs are used for longer periods, patients may experience withdrawal symptoms that can be as severe as seizures. When a drug is discontinued, it should be tapered slowly to prevent withdrawal symptoms or rebound anxiety symptoms. Of particular concern in older adults is the potential for BZs to exacerbate sleep apnea. Therefore, older adults should be assessed for alterations in sleep patterns (especially snoring) before using a BZ.
Other options besides BZs are available for older adults who need an anxiolytic. Buspirone (BuSpar) is a chemically unique antianxiety agent that does not produce dependence or interaction with BZs or alcohol. Its drawback lies in its slow onset of action (often up to 2 weeks), which tends to limit patient compliance. Nurses play an important role in educating patients about the slow onset of buspirone, thereby improving the patients’ adherence to their medication regimens and giving older adults a safer option for reducing anxiety. Other medications used to manage anxiety in older adults include antidepressants and beta-blockers such as propranolol (Inderal).
1974
Antidepressants Antidepressant medications include MAOIs, tricyclic antidepressants (TCAs), and SSRIs. MAOIs (e.g., phenelzine [Nardil] and tranylcypromine [Parnate]) affect the monoamine neurotransmitter system but are rarely used because of their potential drug–food interaction with tyramine, which may precipitate a hypertensive crisis. They are used in older adults with refractory depression or cardiac arrhythmias because they do not produce the cardiovascular side effects of other antidepressants (McNamara, 2006b). Patients taking MAOIs must adhere to a tyramine-free diet and must be warned of the potential for a hypertensive crisis from drug–drug interactions with a number of other medications. Their physicians and pharmacists should monitor any new prescription or OTC medications. Selegiline (Emsam) is the first and only transdermal MAOI currently available (no dietary modifications are necessary at the starting and target dose of 6 mg/24 hours).
TCAs such as amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin), and nortriptyline (Pamelor) block the reuptake of norepinephrine and serotonin. The side effects include anticholinergic effects, sedation, hypotension, dry mouth, tachycardia, blurred vision, constipation, and urinary retention. These medications are contraindicated in patients with recent myocardial infarction or cardiac arrhythmias. They are rarely used since the development of the new SSRIs.
The most recent additions to the antidepressant category are SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). All are selective and potent inhibitors of serotonin reuptake, but each differs slightly in its effect on other neurotransmitter receptors and enzymes, which may make a difference in the tolerability and efficacy of individual agents. When using SSRIs with the older population, the recommendation is to start with a low dose and go slow. Antidepressants should be withdrawn over 2 to 6 weeks to avoid withdrawal symptoms. SSRIs are considered safe in older adults because of the low risk of CNS, anticholinergic, and cardiovascular effects. However, the older
1975
population is at increased risk for impaired balance and falls with any antidepressant, especially at a higher dose. Older patients may need up to 12 weeks of these medications for evaluation of a full response. It is important to monitor for drug–drug interactions and for excessive weight loss, especially in those who are debilitated. Improved cognitive function has been noted in the older patient with depression who is treated with antidepressants.
Bupropion (Wellbutrin, Wellbutrin SR, and Wellbutrin XL) is a norepinephrine dopamine reuptake inhibitor. The main consideration in its use is identifying patients with a history of seizures, organic brain disorder, or alcohol withdrawal. Older adults are at risk for increased accumulation of bupropion because of decreased clearance of the drug and its metabolites.
Venlafaxine (Effexor and Effexor SR) and duloxetine (Cymbalta), selective serotonin norepinephrine reuptake inhibitors (SNRIs), are considered three drugs in one. At the lower dose, an SNRI is a potent inhibitor of serotonin; at moderate doses, both serotonin and norepinephrine reuptake occurs; and at the higher doses, neuronal uptake pumps for serotonin, norepinephrine, and dopamine are inhibited. SNRIs are an excellent choice for GAD and for anxiety with comorbid depression. Desvenlafaxine (Pristiq) and milnacipran (Savella) are two of the latest SNRIs.
Mirtazapine (Remeron) is a nonadrenergic-specific serotonergic antidepressant and is very sedating at 15 mg or less and less sedating at doses greater than 15 mg. It may increase appetite and cause weight gain because of its strong antihistaminic properties, but the side effects sometimes diminish over time. The nurse should monitor for sedation, hypotension, and anticholinergic effects and taper this medication gradually, as with all antidepressants, to avoid withdrawal symptoms. Clearance of the medication is reduced in older men by up to 40% and in older women by up to 10% (Zagaria, 2009).
Additional helpful information about antidepressants includes the course of treatment. Antidepressants are commonly used until patients have been free of the symptoms of depression for 6 months to 2 years. Patients then gradually stop taking the medication to prevent the development of rebound depression. Some patients
1976
with recurrent major depression may continue to use antidepressants indefinitely. Compliance problems may be more common in older adults because of the side effects of the medication. However, because of concerns about side effects, the recommendation for prescribing this medication in this age group has been to “start low, go slow, and never go high,” often resulting in doses that do not achieve “a full response.” Careful monitoring of drug dosage and drug interactions will aid in patient adherence, safety, and recovery. Electroconvulsive therapy (ECT) may be used in patients with life-threatening depression if antidepressants have not been effective. The usual course of ECT would be 10 to 14 treatments every other day. ECT is now considered a humane and effective treatment for depression because of the use of anesthesia and muscle relaxants during the procedure.
Mood Stabilizers In the older population with bipolar disorder, lithium and anticonvulsants are used as mood stabilizers. The older adult is more sensitive to lithium and is at a higher risk for neurotoxicity and cognitive impairment, even at therapeutic plasma levels. Before beginning lithium use, patients should have baseline ECG, CBC, and renal, thyroid, and liver function studies. In the older adult, lithium is started at a low dosage (e.g., 300 mg/day), and blood level is obtained in 3 or 4 days. Blood should be drawn 12 hours after the last dose of lithium. The dose is then titrated until a therapeutic blood level is reached (usually 0.4 to 1.5 milliequivalents per liter [mEq/L]). Blood levels are determined every 3 or 4 days until the therapeutic level is attained. The frequency of obtaining blood for the study may then be decreased to once a month for the first 6 months and every 2 to 3 months for an indefinite period. Renal, liver, and thyroid studies should be performed every 6 months because of the drug’s potential toxicity.
Side effects seen in older adults who are taking lithium include gastrointestinal distress, hand tremors, ataxia, and weight gain. Cardiovascular side effects may also occur; therefore, periodic ECG may be performed, as needed. Lithium toxicity may occur if blood levels are greater than 1.5 mEq/L; moderate to severe toxicity may
1977
be seen if levels are greater than 2 mEq/L; and death may occur if blood levels are greater than 2.5 mEq/L. Patients should inform all physicians and pharmacists involved in their care of any lithium use because of the potential for drug–drug interactions.
Anticonvulsants are also considered a good option for treating bipolar mood disorders, but, again, dosing should be graduated in the older population and in those with liver impairment (Lavretsky, 2008). These drugs may cause confusion, cognitive impairments, or ataxia that may lead to falls. Additional caution is warranted if anticonvulsants are combined with other drugs that affect the CNS or have anticholinergic properties. Valproate, one of the anticonvulsants, causes an increased risk for thrombocytopenia in the older population. Symbyax (fluoxetine and olanzapine) is a new combination drug for bipolar disorder with depressive episodes.
Antipsychotic Medications Antipsychotic medications are also called neuroleptics. They work by blocking the action of dopamine. Neuroleptics are used in the treatment of schizophrenia, acute psychosis, and delirium; they may be used to treat the agitation and aggression sometimes seen in dementia. The specific choice of a neuroleptic agent is made by both considering patients’ clinical symptoms and examining the side effect profiles of the various neuroleptic agents. Older adults usually are started on lower doses (one half to one third of the normal dose) of high-potency neuroleptics such as haloperidol (Haldol), thiothixene (Navane), or trifluoperazine (Stelazine). The high-potency neuroleptics have a lower frequency of anticholinergic, cardiovascular, and sedative side effects compared with low-potency neuroleptics such as chlorpromazine (Thorazine) and thioridazine (Mellaril). However, high-potency neuroleptics cause an increased rate of extrapyramidal symptoms (EPSs) in comparison with low-potency neuroleptics. Therefore, it is essential to monitor all patients who are taking neuroleptics for EPSs, which are discussed later in this chapter. Haloperidol and fluphenazine (Prolixin) are neuroleptics that are available in long-acting decanoate forms for nonadherent patients and may be administered weekly to monthly (Howland, 2008). However, the decanoates are
1978
rarely used in older adults because of their long half-life of 1 to 4 weeks. This treatment could be dangerous should side effects become problematic (Driver, Kurth, Buring et al., 2008).
Clozapine (Clozaril), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), and paliperidone (Invega) are the latest of the atypical antipsychotics with a decreased incidence of side effects and EPSs. Unfortunately, clozapine carries with it the potentially dangerous side effect of agranulocytosis; therefore, weekly CBCs must be obtained for all patients receiving clozapine. The safety of the newer, atypical antipsychotics for older adult patients is uncertain because of limited data.
Side Effects Extrapyramidal Symptoms Nurses play a vital role in the monitoring, education, and evaluation of EPSs in patients who are receiving neuroleptic medications. EPSs are described in Table 27-9.
Table 27-9 Extrapyramidal symptoms
Symptom Characteristics Acute dystonic reaction
Muscle rigidity; eyes fixed in deviated position; arched posture; should be treated with an anticholinergic agent such as diphenhydramine
Akathisia Inability to sit still Akinesia Decreased psychomotor movements; shuffling gait Pseudoparkinsonism Tremor in the extremities that resembles Parkinson disease Perioral tremor (rabbit syndrome)
Fine, rapid lip movements
EPSs are treated with anticholinergic or antiparkinsonian agents such as diphenhydramine (Benadryl), benztropine (Cogentin), or trihexyphenidyl (Artane). Amantadine (Symmetrel), a dopamine agonist, may be used, especially in older patients and in those with cardiovascular dysfunction because of its reduced anticholinergic effects.
Tardive Dyskinesia Tardive dyskinesia (TD) is a potentially permanent neurologic side
1979
effect of neuroleptic medications. Patients and their families must be informed of the risk of TD before initiating neuroleptic therapy. TD is characterized by involuntary movements, especially in the face, lips, and tongue. The trunk and extremities may also be involved. TD is most likely to develop in patients who have used neuroleptics longer than 2 years. Patients should be evaluated for TD at each appointment. Unfortunately, no effective treatment for TD exists. The best prevention is using the lowest possible dose of a neuroleptic for the shortest time necessary.
Neuroleptic Malignant Syndrome Neuroleptic malignant syndrome (NMS) is a rare but serious side effect that may lead to death. Its frequency increases with the use of high-potency antipsychotics. The initial symptoms include a decreased temperature, the development of EPSs, and delirium. If untreated, it then progresses to hyperthermia, stupor, severe EPSs, and coma. It is treated by immediately discontinuing any neuroleptic medication. In addition, dantrolene sodium, which may cause liver toxicity, or bromocriptine may also be used. Because of the potential for death from NMS, all patients receiving neuroleptic medications in an inpatient or long-term care setting should have their vital signs assessed daily. Patients who take neuroleptics on an outpatient basis should be educated on the signs of NMS, particularly the cardinal sign of a temperature change.
EPSs, TD, and NMS all present significant risks for patients taking neuroleptic medications. It is therefore essential that nurses educate patients and their caregivers of the need for routine monitoring for the development of these side effects.
Other Psychoactive Medications Used in Older Adults Anafranil Clomipramine (Anafranil) is a TCA that is specifically helpful for OCD. Its side effect profile is consistent with that of other TCAs.
1980
Antiparkinsonian Agents As discussed earlier, antiparkinsonian agents such as benztropine and trihexyphenidyl are used to treat the side effects of antipsychotic medications.
Sedative-Hypnotic Agents Sleep patterns change with age, and older adults may experience decrease in both the quantity and quality of sleep. Delayed onset of sleep and nighttime awakenings are not uncommon in older adults. Sedative–hypnotic agents may be dangerous when used in older adults; therefore, they are used only if patients are unable to function on a daily basis as a result of insomnia. Long-term use of sedative–hypnotics may produce a disturbed sleep–wake cycle and may lead to dependence and a decrease in the sense of being rested, even after an adequate amount of sleep. In older adults whose symptoms include insomnia, other causes should be ruled out first. Early-night insomnia may be indicative of anxiety or pain (e.g., arthritis), and middle-of-the-night to late-night insomnia may be seen with depression. Additional information on the nursing management of sleep disorders in older adults is provided in Chapter 11.
1981
Mental health care resources The number and quality of resources for the care of mental illness in older adults are minimal because geropsychiatric care is a relatively new specialty within gerontology. These resources include human resources (e.g., mental health professionals [physicians and nurses]), physical resources (e.g., hospitals, clinics, nursing facilities, and dementia units), and financial resources needed to pay for mental health care (e.g., Medicare, Medicaid, and health insurance coverage).
Human Resources Geropsychiatric nurses and geriatric mental health nurses are trained at the master’s level, usually in programs that offer some combination of psychiatric or mental health nursing and gerontologic nursing course work (Hoeffer, 1994). The primary major is usually psychiatric or mental health nursing with some courses in gerontologic nursing. These nurses may be certified by the American Nurses Credentialing Center as clinical nurse specialists in adult psychiatric and mental health nursing, as gerontologic nurses, or as both, if they have master’s degree preparation in one or both specialties. These specialists should be prepared to assess and care for individuals who often have multiple, complex physical and mental or emotional problems. No national certification is currently offered in geropsychiatric nursing.
More geropsychiatric nurses are needed to work as staff or consultants in hospitals, nursing facilities, outpatient clinics, day treatment centers, adult day services programs, and home health agencies. Geropsychiatric advanced practice nurses, often working with geriatric psychiatrists, provide much needed care in nursing facilities. They perform assessments, manage medications, participate in individual and group therapy on a regular schedule, and provide in-service education for the nursing staff. As previously mentioned, many older adults are never adequately diagnosed or treated for underlying psychopathologic problems.
1982
Nurses in these settings can help resolve this problem. These nurses are also greatly needed to teach technical nursing staff members, who have close contact with patients, how to communicate with and relate to older adults with mental and emotional disturbances. Patient abuse may occur when nonprofessional staff members do not know how to respond to aggressive, hostile, and combative behavior.
Because an interdisciplinary approach is important in the health care of older adults, psychiatrists, social workers, dietitians, clergy, speech pathologists, and physical and occupational therapists with some formal preparation in geriatrics and gerontology are also essential in providing high-quality care for geropsychiatric patients.
Physical Resources Older patients with mental and emotional problems are increasingly being treated on an outpatient basis, primarily because of available methods of payment. Some of these outpatient choices are as follows:
• Community mental health centers (which may include emergency psychiatric services during the evening or night)
• The clinic or offices of a geriatric psychiatrist, geriatric mental health nurse, or advanced practice nurse specializing in geriatric mental health
• Senior partial-hospitalization programs where patients receive assessment, diagnosis, and treatment (including various types of medications and other therapy) and return home in the late afternoon
• In-home assessments, diagnosis, treatment, care, and follow-up in patients’ own residences
On the one hand, these types of programs may be more effective for older patients than residential treatment in hospitals, which may cause relocation confusion, loss of familiar environmental and sensory stimulation, and functional decline associated with the hospitalization. On the other hand, individuals without family members or an adequate support system may have problems
1983
managing difficult medication regimens alone at home. Those with major depression are at greater risk for potential suicide.
Some general hospitals have geropsychiatric units staffed and equipped to care for the mental and physical needs of older patients. These units provide thorough assessments and an interdisciplinary approach to total care and rehabilitation on a relatively short-term basis for older patients with primarily mental and emotional problems. Unless the general psychiatric hospital has a specific unit planned for older patients, such a facility may have difficulty meeting their needs. In fact, many general psychiatric hospitals do not even admit patients who also have physical problems and needs. Most geropsychiatric units are located in psychiatric facilities associated with medical schools, where fellowships are available to psychiatrists specializing in this area. Some psychiatric hospitals have well-developed day hospitalization programs that provide treatment, care, and supervision on a daily basis. However, adequate transportation to and from the hospital each day may be a problem for older persons. Some hospitals and community agencies provide this type of medical transportation when individuals or their families cannot provide it. However, escort services from the van to the area of treatment may not be available, so the older person cannot make the trip alone for safety reasons.
The large majority of older persons who have some type of chronic mental illness or disorder are found in long-term care nursing facilities with some type of dementia or depression related to physical or environmental factors. In fact, Brower (1993) has stated that nursing facilities “are, in reality, mini-geropsychiatric facilities, but without the trained psychiatric staff.” Many of the residents in these facilities have not had the benefit of a thorough mental status assessment and diagnosis and therefore lack proper treatment and care. In addition to ageism, a reason for this problem is the lack of adequate financial resources for the necessary assessment and treatment.
Financial Resources
1984
One of the greatest issues in the care of mental illnesses or disorders in older adults is the lack of adequate financial resources to provide for needed care. For adults ages 65 or older, Medicare coverage is limited. An annual review of Medicare coverage for mental illness or disorders is needed to keep current with governmental changes. For in-depth current information, go online to www.cms.hhs.gov.
Inequality in the provision of health insurance coverage exposes a person with mental or emotional distress to disproportionately high co-payments and out-of-pocket expenses. Compared with general medical coverage, many health plans provide fewer “covered days” for psychiatric hospitalization and limited visits to mental health specialists. This practice is especially hurtful to Medicare beneficiaries, who are required to pay a 20% co-payment for medical and surgical services but are held responsible for 50% of the cost of mental health services. The General Accounting Office (GAO) reported that approximately 90% of all insurance plans impose some restrictions on mental health benefits that are not placed on general medical care (Hogan, 2008; Novosel, 2004;).
Medicaid is a federal–state program that differs somewhat from state to state. Services for mental health care for both inpatient and outpatient care are limited for Medicaid recipients (Hogstel & Weeks, 1998). A current trend in many states is to place people receiving Medicaid in coordinated (managed) care plans to save money. States must receive a waiver from the federal government for this plan because partial federal funds are used. How this proposal works will be of interest, especially as it affects those with dementia who reside in nursing facilities. The concern is that if nursing facilities bid on Medicaid-coordinated (managed) care contracts for their residents receiving Medicaid, less money will be available for total care and even less for mental health care. Managed care plans have generally not “established systemic policies for how mental health is to be delivered” (Colenda, Banazak, & Mickus, 1998; Ruiz, 2008).
1985
Trends and needs The need to focus more on the mental and emotional health care needs of older adults will continue to increase (Box 27-11). Nurses and family members must advocate for older persons with mental illnesses or disorders, who are not being adequately diagnosed and treated. State and local ombudsman programs are expanding, with plans to have at least one or two certified trained volunteer ombudsmen in all long-term care facilities, including nursing facilities, hospital skilled nursing units, and assisted living facilities (sometimes called personal care homes).
Box 27-11
Trends and needs in mental health care of older adults • Strong advocacy
• Increased outpatient care
• Expanded community resources
• Improved quality of long-term care
• Additional legislation and regulations related to psychosocial training for staff in long-term care facilities
• More emphasis on gerontologic, geriatric, and geropsychiatric education for health care providers
• More educational programs for family members
• Short-term respite care for family members
Long periods of hospitalization in a psychiatric hospital are rare. More people are treated in the home setting and in partial hospitalization and outpatient settings. Other community organizations such as churches and congregations, senior citizens’
1986
groups, and other social organizations are developing programs to help older persons maintain their mental health by preventing loneliness and depression. Increased emphasis will be placed on improving the quality of care in long-term care facilities. The primary need is to focus more on mental illnesses or disorders, psychosocial issues, and communication skills (e.g., in-service training for all personnel). This goal may be accomplished through state legislation or the efforts of regulatory agencies. Emphasis will also be placed on increasing gerontologic, geriatric, and geropsychiatric content in the curricula of medical, nursing, and social work educational programs. Advocacy groups should work toward including more of such content in state licensing examinations.
Family members also need to learn more about the aging process, especially the normal, common changes as well as abnormal changes in behavior with aging so that they will be better able to relate to and care for their older family members in the home, if needed. Although respite care (e.g., adult day programs and nursing facilities) is available to some extent for those family members who care for older persons with mental and behavioral problems, additional short-term respite care is greatly needed. Family members caring for older persons in the home need a couple of hours of relief now and then, perhaps by a volunteer from a church, so that they may take a walk, go to a movie, or go shopping. Trained volunteers can easily provide this kind of short- term respite care to assist the caregiver and, ultimately, the older family member (Bharani & Lantz, 2009).
1987
Summary Nurses caring for older adults face many challenges, especially because this population group continues to increase in the United States and in other countries of the Western world. It has been found that a significant percentage of older adults suffer from some form of cognitive impairment, all of whom could benefit from nursing care focusing on the special needs of these people. Without radical changes in the way health care is allocated and delivered in this country, the issues of shrinking health care dollars, accessibility to care, and increasing commercially managed care could threaten the care of older adults. Those with cognitive impairment continue to be at high risk for limited access to appropriate and cost-effective care. This will become especially critical as more state mental health hospitals are closed without the establishment of adequate community-based treatment facilities to replace them (Elliott, Horgas, Marsiske, 2008).
Cost-effective models for care should be developed and tested along the continuum of care, from prevention of illness to management of acute illness to restoration of function and, finally, to staying in the community or home environment. In addition, most older adults are less active participants in their own care. They trust and accept physician decisions and recommendations without question. This group needs extensive teaching to become informed consumers and partners in health care.
The practice of gerontologic nursing is collaborative and interdisciplinary in scope. This is necessitated by the vast complexity, diversity, and dissimilarity of older adults in terms of their physical and mental conditions, health care needs, past life experiences, current lifestyles, culture, ethnicity, and resources. The family is an extremely important aspect of gerontologic practice, not only because the majority of older adults live within a family setting but also because the family is becoming a primary provider of care.
The most serious health problems occur in those older than 80 years old, and this group is likely to be cared for by relatives who
1988
are older than 65 years of age. The blend of medical–surgical, psychiatric, and community health nursing skills and the expertise required to care for older adults with cognitive impairments provides unique and unlimited opportunities and challenges in practice.
1989
Key points • The nervous system is a network of complex structures that
change as an individual ages.
• The loss of neurons is not as excessive in the process of aging as previously believed. In fact, large neurons appear to shrink, and few are lost.
• Normal aging is associated with changes in the ability to consciously learn and retain new information easily.
• The age-related neurodegenerative and neurochemical changes in the cerebellum are believed to be the underlying cause of decline in motor and cognitive function.
• Sleep disorders are common in aging individuals. Excessive daytime somnolence is not part of normal aging.
• Vision changes that occur with aging are significant. The lens of the eye thickens, becoming yellow, cloudy, and less elastic.
• Presbycusis is hearing loss associated with the aging process.
• The loss of taste and smell receptors means that food is not as appetizing to the older adult.
• It is important to include functional assessment as part of the assessment of older adults.
• A decline in cognitive function is an effect of disease, not an effect of the normal aging process.
• Depression may manifest itself through signs such as fatigue; constipation; psychomotor retardation; depressed mood; loss of interest, energy, libido, or pleasure; changes in appetite, weight, and sleep patterns; and agitation; anxiety; or crying.
• The risk factors for delirium include advanced age, CNS diseases, infection, polypharmacy, hypoalbuminemia, electrolyte imbalances, trauma history, gastrointestinal or genitourinary disorders, cardiopulmonary disorders, and sensory changes.
• The treatment of delirium is focused on the identification and
1990
treatment of the underlying cause.
• Nonpharmacologic approaches for delirium may include removing bladder catheters, improving nutritional intake, using reality orientation, decreasing sensory overstimulation or deprivation, and reassuring the older adult and their family members.
• Dementia is a syndrome of gradual and progressive cognitive decline.
• Although dementia is more common in old age, it is not part of the normal aging process.
• From the time of diagnosis, individuals with AD survive about half as long as those of similar age without dementia.
• Ginkgo biloba, a herbal plant extract, has shown promise in stabilizing and occasionally improving cognitive performance and function in demented older adults for 6 months to a year.
• Management of AD focuses on maintaining cognitive and global function early on in the disease process to postpone the need for institutional care.
• Individuals who have experienced a CVA have an even greater risk of VaD.
• Older adults are at risk for the development of subdural hematomas because of brain atrophy and corresponding vascular changes that occur with normal aging and are also at risk for falls and subsequent head injuries.
• The only positive way to diagnose dementia-related disorders is brain tissue biopsy or autopsy of the brain.
• Antipsychotics are useful for the treatment of psychotic symptoms such as delusions or hallucinations.
• When depression is a concern in a patient who is agitated, SSRIs have been helpful in managing agitation.
• Nurses caring for older adults who have symptoms of an acute cognitive disorder need to support existing sensory perception until the cognitive state returns to the previous level of function.
1991
• Public policy has shifted to encourage family members to care for older adults in their homes, thus decreasing health care costs and individualizing care to meet patient needs.
• The nurse’s role has shifted from caregiver to care coordinator; that is, the nurse teaches and assists the family members with home care, provides supportive care, and serves as a patient advocate.
• The purpose of a comprehensive assessment is to determine problem areas, as well as areas of strength on which to base a care plan, including education of families and caregivers.
• Persons with cognitive disorders commonly demonstrate problematic behaviors.
• People who demonstrate symptoms of moderate to severe cognitive impairment may benefit from having meals in the same place at the same time each day.
• Persons in all stages of dementia benefit from the use of clocks, calendars, and mementos within the environment.
• The effective management of problem behaviors should not focus on trying to change the older person but on modifying factors that may be contributing to these behaviors.
• The use of physical or chemical restraints has demonstrated no benefit in controlling disruptive behaviors or managing disease.
• Maintaining social interaction and human contact in a variety of ways is beneficial for older persons with cognitive decline.
• Changes in the routine should be introduced slowly, and a stimulus should be provided to ensure that feelings of comfort and security are not lost.
• Wandering can sometimes be managed through environmental changes such as fences or alarm systems and close supervision.
• Sundown syndrome may also be modified through behavioral interventions, including redirection, the provision of companionship and empathy, and environmental modifications in lighting and noise reduction.
1992
• PD, the most common form of parkinsonism, is a common progressive degenerative disorder of the basal ganglia involving the dopaminergic nigrostriatal pathway.
• A CVA is caused by a disruption in normal blood supply to the brain tissue.
• Strokes are the third leading cause of death and the most common cause of disability in the United States.
• A major change in the treatment of strokes is the use of thrombolytic agents (r-TPA) within a 3-hour window of the onset of signs or symptoms of AIS.
• Advanced age is one of the most significant risk factors for strokes.
• Modifiable risk factors for strokes include hypertension, diabetes mellitus, cardiovascular disease, nonvalvular atrial fibrillation, blood lipid abnormalities, smoking, substance abuse (particularly cocaine), obesity, a sedentary lifestyle, high stress levels, previous CVA or TIA, heavy alcohol use, and sudden discontinuation of antihypertensive medications.
• Hypertension is the most important modifiable risk factor for both ischemic and hemorrhagic strokes.
Case study Mr. J is 78-year-old black man who arrived in the emergency department lethargic, vomiting, unable to speak clearly and with weakness on the right side of his body. Mr. J has a medical history of hypertension and diabetes mellitus – type 2. His family (wife and daughter) reported that for the past 3 months he has been having right-sided weakness and slurred speech that resolved within an hour of onset. Mr. J also has glaucoma, gout, and a history of atrial fibrillation (managed with medications). Mr. J’s family reported that he was taking the following medications at home: digoxin, allopurinol, furosemide (Lasix), NPH (neutral protamine Hagedorn) insulin twice a day,
1993
lisinopril, baby acetylsalicylic acid, potassium chloride, and eye drops.
Mr. J’s wife, 77 years old, reported that approximately 3 days ago, Mr. J stopped taking his blood pressure medications (lisinopril and furosemide) because he had spent the money on a horse race. Two nights ago, he started to experience more frequent numbness of the right arm and slurred speech, but she did not think it was important because it disappeared after several hours. Today, she had difficulty waking him up, and her daughter told her to call the ambulance.
Mr. J’s blood pressure on admission was 220/120 mm Hg; his heart rate was 126 beats/min; respiratory rate was 28 breaths/min; and temperature was 98.9 ° F (37 ° C). He had right-sided hemiparesis and hemiplegia. His speech was slurred and at times incomprehensible. Mr. J was able to maintain his airway at this time.
Oxygen via nasal cannula is started at 2 liters per minute (L/min), and a peripheral intravenous line is started with normal saline intravenous fluid therapy at 80 milliliters per hour (mL/hr). A 12-lead electrocardiography (ECG) is performed, and Mr. J is sent for computed tomography (CT) of the head.
1994
Critical thinking questions 1. Which one of Mr. J’s symptoms supports a diagnosis of stroke?
2. What are the risk factors that Mr. J presents for the development of stroke?
3. Indicate the type of stroke Mr. J most likely had, and support your answer.
4. What evidence is presented to support that Mr. J had experienced previous TIAs?
5. Why is atrial fibrillation a risk factor for embolic stroke?
6. Identify a nursing diagnoses based on Mr. J’s assessment, and develop an appropriate nursing care plan.
1995
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2004
Appendix 27A Resources Dementia and Alzheimer disease Alzheimer’s Association
225 North Michigan Avenue, Floor 17
Chicago, IL 60601–7633
(800) 272–3900 or (312) 335–8700
Fax: (312) 335–1110
www.alz.org
Alzheimer’s Disease Education & Referral Center P.O. Box 8250
Silver Spring, MD 20907–8250
(800) 438–4380
www.alzheimers.org
American Association for Geriatric Psychiatry
7910 Woodmont Avenue, Suite 1050
Bethesda, MD 20814–3004
(301) 654–7850
Fax: (301) 654–4137
www.aagponline.org
National Family Caregivers Association
10400 Connecticut Avenue, Suite 500
Kensington, MD 20895–3944
(800) 896–3650
Fax: (301) 942–2302
2005
www.nfcacares.org
Chronic neurologic disorders and Parkinson disease American Association of Neuroscience Nurses
4700 West Lake Avenue
Glenview, IL 60025-1485
(888) 557–2266 or (847) 375–1733
Fax: (847) 734–8677
www.aann.org
American Parkinson Disease Association
1250 Hylan Boulevard, Suite 4B
Staten Island, NY 10305–1946
(800) 223–2732
Fax: (781) 981–4399
www.apdaparkinson.com
Association of Rehabilitation Nurses (ARN)
4700 West Lake Avenue
Glenview, IL 60025–1485
(800) 229–7530 or (847) 375–4710
Fax: (877) 734–9384
www.rehabnurse.org
Stroke American Stroke Association
American Heart Association National Center
7272 Greenville Avenue
Dallas, TX 75231
2006
(888) 4-STROKE or (888) 478–7653
www.strokeassociation.org
National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD 20824
(800) 352–9424 or (301) 496–5751
http://www.ninds.nih.gov/
National Stroke Association
9707 East Easter Lane
Englewood, CO 80112
800-STROKES or 303–649–9299
Fax: 303–649–1328
http://www.stroke.org/site/PageNavigator/HOME
Other resources Parkinson’s Disease Association
(800) 223-2732
The National Parkinson Foundation
(800) 327-4545
The Parkinson’s Disease Foundation
(800) 457-6676
The United Parkinson Foundation
(800) 733-1893
Stroke Clubs International
805 12th Street
Galveston, TX 77550
(409) 762–1022
2007
www.medhelp.org
* Previous authors: Brenda Gregory Dawes, MSN, RN, CNOR; Pam Cacchione, PhD, MSN, RN, CSGNP; Revisions: Kristal Imperio, PhD, RN, CS, ANP, GNP; Eleanor Pusey-Reid, MS, Med, RN, CCRN; and Meredith Wallace Kazer, PhD, APRN, ANP, GNP-BC.
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C H A P T E R 2 8
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Integumentary Function Sabrina Friedman, EdD, DNP, FNP-C, PMHCNS-BC
Learning objectives
On completion of this chapter, the reader will be able to: 1. Discuss the primary functions of the integumentary system.
2. Identify normal age-related skin changes.
3. Discuss common skin problems and conditions experienced by older adults and their associated nursing implications.
4. Describe common skin cancers that affect older adults.
5. Differentiate between the three types of lower leg ulcers.
6. Describe the risk factors for pressure ulcer development.
7. Identify five pressure ulcer preventive strategies endorsed by the Agency for Healthcare Research and Quality (AHRQ) clinical guidelines.
8. State three principles necessary for successful wound healing.
9. Conduct an assessment for a patient with impaired skin integrity.
10. Determine when to appropriately use antiseptics.
11. Discuss six types of dressings, including indications, contraindications, advantages, and drawbacks.
http://evolve.elsevier.com/Meiner/gerontologic
The skin is the protective outer covering of the body. The skin, hair, nails, and glands make up what is called the integumentary system. The integumentary system is the largest organ of the body. The primary function of the skin is to serve as a barrier against harmful bacteria and other threatening agents, which makes the skin the first line of defense for the immune system. Other major
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functions of the integumentary system include (1) preventing fluid loss or dehydration, (2) protecting the body from ultraviolet (UV) rays and other external environmental hazards, and (3) protecting underlying organs from injury. In addition, the skin provides thermal regulation of body temperature. Radiation, conduction, convection, and evaporation are facilitated by sensory perceptions that occur in the skin’s nerve endings. Blood vessels in the skin assist in regulating blood pressure because of the amount of blood that can be stored within the system. The integumentary system also reveals emotions such as anger, fear, or embarrassment through vasodilatation, which reddens the skin tissue. In the presence of the sun’s ultraviolet (UV) rays, the skin synthesizes vitamin D, which is then used by other parts of the body. Subcutaneous fat, the deepest layer of the integumentary system, provides insulation and acts as a caloric reservoir. Hair serves as body insulation and provides unique physical characteristics by virtue of its varying textures, shades, patterns, and colors.
A careful and thorough assessment of the integumentary system is essential when a physical assessment is performed on a patient. Skin assessment helps determine hydration status, potential for or actual infection, and other information about the individual (e.g., sun exposure, attention to personal appearance, and scars). Palpation of the skin identifies tender areas, nodules, and masses (see Assessments in Chapter 4).
The value of the integumentary system is demonstrated by the high morbidity and mortality rates associated with extensive burns when all functions of the skin are greatly compromised. The overall state of health is affected by physical or emotional insults to this system, for example, loss of thermal regulation or fluid, impaired barrier protection, and other catastrophic changes in physical appearance and functioning. The integumentary system provides valuable information for comprehending its complexities.
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Age-related changes in skin structure and function The integumentary system reflects the normal aging process, which includes graying hair, increased number and depth of wrinkles, loss of elasticity, and discoloration and thickening of the nails. Box 28-1 describes basic age-related skin changes.
Box 28-1
Age-related Skin changes • Loss of thickness, elasticity, vascularity, and strength that may
delay the healing process and increase the risk of skin tears and bruising
• Increased lentigines (brown-pigmented spots, or age spots)
• Loss of subcutaneous tissue causing wrinkling and sagging of the skin, which may affect self-esteem, temperature control, and drug efficacy
• Loss of hair follicles along with thinning and graying
• Increased hair density in the nose and the ears, particularly in men, which may clog external ear canals and impair hearing
• Thicker nails with longitudinal lines
• Decreased sebaceous and sweat gland activity, which affects thermoregulation and decreases sweating
• Higher incidence of benign and malignant skin growths
Epidermis The epidermis is the outermost layer of the skin. The replacement rate of the stratum corneum, the first layer of epidermis, declines by
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50% as a person ages. This decline results in slower healing, reduced barrier protection, and delayed absorption of medications and chemicals placed on the skin. The area of contact between the epidermis and dermis decreases with age, which results in easy separation of these layers. Therefore, skin tears occur from harmless activities such as removing a bandage or pulling an older patient up in the bed. Bruising occurs more easily as a result of these age- related skin changes. A thinner epidermis allows more moisture to escape and may compound previously existing skin problems. The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from UV rays, paler skin, and graying hair. Melanocytes also produce uneven pigmentation, causing the development of lentigines, also known as “age spots” or “liver spots.”
Dermis The dermis decreases in thickness by approximately 20% with aging. It consists of strong connective tissue that contains the sweat glands, blood vessels, and nerve endings. With aging, sweat glands, blood vessels, and nerve endings also decrease in number. These changes lead to diminished thermoregulatory function and inflammatory responses, decreased tactile sensation, reduced pain perception, and development of wrinkles and sagging skin as a result of loss of underlying tissue. Collagen, a fibrous protein that provides tensile strength within the dermis, stiffens and becomes less soluble.
Subcutaneous Fat Aging results in a decreased amount of subcutaneous tissue and a redistribution of fat to the abdomen and thighs. Breast tissue also changes and becomes more granular and atrophic. As a result of a loss of padding supplied by subcutaneous tissues, the risk for hypothermia, skin shearing (see Pressure Ulcers, later in this chapter, for the definition and adverse effects of shearing), and blunt trauma injury is greater. The loss of this protective padding increases vulnerability of pressure points. Topical medication and
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dermal medication patch absorption may increase because of the changes in the subcutaneous tissue.
Appendages With aging, fewer eccrine glands (sweat glands of the palms, feet, and forehead) and apocrine sweat glands (sweat glands of the axilla, scalp, face, and genital areas) exist, resulting in decreased body odor and reduced evaporative heat loss because of decreased sweating. The need for antiperspirants and deodorants is reduced. However, older adults are at greater risk of heat stroke as a result of a compromised cooling mechanism. Older adults should avoid heat exposure over long periods and in areas of high humidity. Hats with wide brims and cool, light, breezy clothing should be worn when outdoors. It is important that older adults drink extra fluid (minimum of 2000 milliliters per day [mL/day], unless contraindicated by a medical condition such as renal failure or congestive heart failure [CHF]) to maintain adequate hydration (Touhy & Jett, 2012).
Sebum oils the skin and provides an antimicrobial property. The sebaceous glands and pores become larger with aging. Nevertheless, many older adults experience dry skin, which places them at a greater risk of infection as a result of an impaired immune response.
Hair thins, and its growth declines. A progressive loss of melanin occurs, resulting in graying of the hair. Heredity influences the onset of the graying process. Older women may have increased lip and chin hair while experiencing thinning of hair on the head, axilla, and perineal area. Men lose scalp and beard hair and experience increased growth over the eyebrows and in the ears and nostrils. The increased hair in ears predisposes men to cerumen impaction, which leads to impaired hearing (see Chapter 29). Changes in the patterns of hair growth and distribution as a person ages are thought to be hormone related. Nails grow more slowly with age and become thicker, brittle, and dull and also develop longitudinal striation with ridges (Touhy & Jett, 2012). These changes may affect a person’s body image and self-concept (see
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Cultural Awareness Box).
Cultural Awareness
Biocultural Variations in Integumentary System during Health and Illness Normal skin color ranges vary, and health care practitioners have attempted to describe the variations seen by labeling observations with some of the following adjectives: copper, olive, tan, and various shades of brown (light, medium, dark). The term ashen is sometimes used to describe pallor.
Normal Biocultural Variations Mongolian spots, irregular areas of deep blue pigmentation, are usually located in the sacral and gluteal areas but sometimes occur on the abdomen, thighs, shoulders, or arms. Mongolian spots are present in 90% of African Americans, 80% of Asian Americans and Native Americans, and 9% of whites.
Vitiligo, a condition in which the melanocytes become nonfunctional in some areas of the skin, is characterized by unpigmented skin patches. Vitiligo affects millions of Americans, primarily dark-skinned individuals. Older adults with vitiligo also have a statistically higher-than-normal chance of developing pernicious anemia, diabetes mellitus, and hyperthyroidism.
Cyanosis Cyanosis is the most difficult clinical sign to observe in people with dark pigmentation. Because peripheral vasoconstriction may prevent cyanosis, environmental conditions such as air conditioning, mist tents, and other factors that may lower the room temperature should be noted. For an older adult to manifest clinical evidence of cyanosis, the blood must contain 5 grams (g) of reduced hemoglobin in 1.5 g of methemoglobin per 1 deciliter (dL) of blood.
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Given that most conditions causing cyanosis also cause decreased oxygenation of the brain, other clinical symptoms such as changes in level of consciousness are evident. Cyanosis usually is accompanied by an increased respiratory rate, the use of accessory muscles of respiration, nasal flaring, and other manifestations of respiratory distress. When assessing people of Mediterranean descent, the nurse should be aware that the circumoral region is normally dark blue.
Jaundice In both light-skinned and dark-skinned patients, jaundice is best observed in the sclera. Many people with dark pigmentation have heavy deposits of subconjunctival fat that contain high levels of carotene in sufficient quantities to mimic jaundice. The fatty deposits become denser as the distance from the cornea increases. The portion of the sclera that is revealed naturally by the palpebral fissure is the best place to assess color accurately. If the palate does not have heavy melanin pigmentation, jaundice can be detected there in the early stages (i.e., when serum bilirubin is 2 to 4 milligrams per deciliter [mg/dL]). The absence of a yellowish tint of the palate when the sclera are yellow indicates carotene pigmentation of the sclera rather than jaundice. Light or clay-colored stools and dark golden urine often accompany jaundice in both light-and dark-skinned patients.
Pallor When assessing for pallor in darkly pigmented older adults, the nurse may experience difficulty because the underlying red tones that give brown or black skin its luster are absent. The brown- skinned individual manifests pallor with a more yellowish brown color and the black-skinned person appears ashen or gray. Generalized pallor may be observed in the mucous membranes, lips, and nail beds. The palpebral conjunctiva and nail beds are preferred sites for assessing the pallor of anemia. When inspecting the conjunctiva, the nurse should lower the patient’s eyelid sufficiently to visualize the conjunctiva near both the outer canthus and the inner canthus. The coloration is often lighter near the inner canthus.
2016
In addition to changes in skin color, the pallor of impending shock is accompanied by other clinical manifestations such as increasing pulse rate, oliguria, apprehension, and restlessness. Anemia, particularly chronic iron deficiency anemia, may be apparent by the characteristic “spoon” nails, which have a concave shape. A lemon-yellow tint of the face and slightly yellow sclera accompany pernicious anemia, which is also manifested by neurologic deficits and a red, painful tongue. The nurse will also note the following symptoms in the presence of most severe anemia: fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental function.
Erythema Erythema (redness) is commonly associated with localized inflammation and is characterized by increased skin temperature. When assessing inflammation in dark-skinned patients, it is often necessary to palpate the skin for increased warmth, tautness, or tightly pulled surfaces that may indicate edema and hardening of deep tissues or blood vessels.
The erythema associated with rashes is not always accompanied by noticeable increases in skin temperature. Macular, papular, and vesicular skin lesions are identified by a combination of palpation and inspection, combined with the patient’s description of symptoms. For example, people with macular rashes usually complain of itching, and evidence of scratching will be apparent. When the skin is only moderately pigmented, a macular rash may become recognizable if the skin is gently stretched. Stretching the skin decreases the normal red tone, thus providing more contrast and making the macules appear brighter. In some skin disorders with generalized rash, the hard and soft palates are the locations where the rash is most readily visible.
The increased redness that accompanies carbon monoxide poisoning and the blood disorders collectively known as the polycythemias may be observed in the lips of dark-skinned patients. Because lipstick masks the actual color of the lips, older adult women should be asked to remove it with a tissue.
2017
Petechiae In dark-skinned patients, petechiae are best visualized in the areas of lighter melanization such as the abdomen, buttocks, and volar surface of the forearm. When the skin is black or very dark brown, petechiae cannot be seen. Most of the diseases that cause bleeding and microembolus formation such as thrombocytopenia, subacute bacterial endocarditis, and other septicemias are characterized by the presence of petechiae in the mucous membranes and skin. Petechiae are most easily visualized in the mouth, particularly the buccal mucosa, and in the conjunctiva of the eye.
Ecchymotic lesions caused by systemic disorders are found in the same locations as petechiae, although their larger size makes them more apparent on dark-skinned individuals. When differentiating petechiae and ecchymosis from erythema in the mucous membrane, the nurse should note that pressure on the tissue momentarily blanches erythema but not petechiae or ecchymosis.
2018
Common problems and conditions Benign Skin Growths Cherry Angiomas Cherry angiomas are common, bright red, 1- to 5-millimeter (mm) superficial vascular lesions that begin around age 30 and increase in number with age. The cause of these lesions is unknown. They are red or deep purple dome-shaped papules. Although they are most commonly found on the trunk, they may be located anywhere on the body and vary in number. Because cherry angiomas are new growths, patients are often concerned that they are malignant or indicate a serious health problem. Patients need to be reassured that cherry angiomas are benign growths resulting from increased vascularity in the dermis and occur in most people.
Seborrheic Keratoses Seborrheic keratoses are benign lesions more commonly seen in the older adult. These are scaly growths that have a “stuck-on,” crumbly appearance that varies in color from tan to brown to black. The lesions may be elevated and range in diameter from 2 to 3 mm. Characterized by slow growth, these lesions begin to appear later in life. The borders may be round and smooth or irregular and notched. To the untrained eye, these lesions may resemble a malignant melanoma, particularly when dark brown or black. They have a greasy feeling and often occur in sun-exposed areas (face, neck, or trunk) but may appear anywhere on the body. In an Australian study of the relationship between sun exposure and the prevalence of seborrheic keratoses, the median number of lesions in those who had them increased with age from 6 per person among 15- to 25-year-olds to 69 per person in those older than 75 years of age. The growths are usually removed for cosmetic reasons (often related to self-esteem) or if irritated. If the lesion is “picked off,” it will recur. Therefore, it is best to have a physician remove the growth if it is bothersome to a patient. Cryotherapy is effective, and the lesion usually sloughs off in a few weeks. Patients should be
2019
reassured that the growths are benign and are a commonly occurring skin manifestation.
Skin Tags (Acrochordons) Skin tags are common stalklike, benign tumors often found on the neck, axilla, eyelids, and groin, although they may occur anywhere on the body. Beginning as early as age 20, these are tiny, flesh- colored or brown excrescences that develop into a long, narrow stalk (up to 1 centimeter [cm]). As they mature, they can be easily removed with scissors, electrocautery, or liquid nitrogen. Skin tags are usually excised only on the request of the patient, usually for cosmetic reasons.
Inflammatory Dermatoses Seborrheic Dermatitis Seborrheic dermatitis is a common, chronic inflammation of the skin. The scalp, ear canals, eyebrows, eyelashes, nasolabial folds, axilla, breasts, chest, and groin are common sites. It is more common in patients who have Parkinson disease or who have suffered a stroke.
In differentiating between dandruff and seborrheic dermatitis, it should be noted that dandruff is scaling without inflammation, and seborrheic dermatitis is an inflammatory response sometimes associated with scaling. With inadequate management, dandruff may evolve into seborrheic dermatitis. Seborrheic dermatitis appears as a white or yellow scale with a plaquelike appearance. An erythematous red base, indicating an inflammatory process, is always present. Mild itching is not uncommon. The usual pattern of distribution begins with the scalp and moves down toward the eyebrows, progressing to the chest with a bilateral, symmetric presentation.
Intertrigo Intertrigo is a form of seborrheic dermatitis. It results from the friction of opposing skin surfaces and the irritation this causes. It is
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usually found in the armpits, inner aspects of the thighs, skin folds of the breasts, and abdominal folds. The area is erythematous and may itch. Intertrigo occurs more often in aging patients who are obese or have diabetes. Medical management usually includes losing weight, applying topical hydrocortisone cream, and keeping the skin clean and dry.
Psoriasis Psoriasis is an autoimmune condition that affects 2% to 5% of the world’s population and approximately 2.6% of the United States population (Aldredge, 2009). The condition may affect persons of any age, although it often begins during early adulthood. Psoriasis is sometimes associated with other diseases such as arthritis, myopathy, enteropathy, spondylitic heart disease, and acquired immunodeficiency syndrome (AIDS). Approximately one third of patients with psoriasis have a first-degree relative affected by the disease; those developing the disease before age 40 have a stronger genetic component (Aldredge, 2009). Once psoriasis begins, there are periods of remission and relapse with varying degrees of intensity. Currently, no known cure exists.
Clinically, psoriatic lesions are typically seen as well circumscribed, pink plaques covered with silver-white, loosely adherent scales. These scaly plaques result from the accelerated replication of the dermis and epidermis over certain parts of the body. Psoriasis frequently affects the skin of the elbows, knees, scalp, lumbosacral areas, intergluteal cleft, and glans penis. Changes in the nails occur in approximately 30% of patients and consist of yellow-brown discoloration with pitting, dimpling, separation of the nail plate from the underlying bed (oncolysis), thickening, and crumbling. Psoriasis is a reactive disorder. Triggers such as infection, smoking, climate, and hormonal factors may exacerbate an attack; other factors such as sunlight may decrease the severity of an attack.
Psoriasis may be a cause of a total body erythema and scaling termed erythroderma. Another variant of psoriasis is the pustular type, which manifests as multiple small pustules forming the
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erythematous plaques. Pustular psoriasis may be benign and localized or life threatening and generalized. In the more generalized form, the patient will also have fever, leukocytosis, arthralgias, diffuse cutaneous and mucosal pustules, secondary infection, and electrolyte disturbances.
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Nursing management Assessment
Nursing assessment consists of recognizing the inflammatory dermatitis and noting its location, degree of erythema, itching, and scaling. The dermatitis should be examined for an erythematous base with yellow, white, or silvery scales or plaques. The nurse should inquire about itching, usual hygienic habits, and steps the patient has taken to control the scaly, erythematous dermatitis. Bedbound individuals are more prone to develop seborrheic dermatitis; therefore, targeting these patients for assessment, in addition to thorough cleansing of scalp, hair, and skin, is a preventive strategy.
Diagnosis Nursing diagnoses for a patient with inflammatory dermatitis include the following:
• Impaired Skin Integrity, related to immunologic deficit (psoriasis)
• Impaired Skin Integrity, related to bedbound state (seborrheic dermatitis)
• Impaired Skin Integrity, related to the physiologic disease process (intertrigo)
• Disturbed Body Image, related to the psoriatic lesions
Planning and Expected Outcomes The goal of nursing management is control of the inflammatory process with maintenance therapy using topical agents and shampoo, as prescribed. Patient comfort is evidenced when medical treatment is done according to advice. Expected outcomes include the following:
1. Skin lesions will remain free from infection.
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2. The patient will experience resolution of the inflammatory process.
3. The patient will demonstrate increased knowledge of the condition, as evidenced by:
• Verbalizing the rationale for regular and consistent skin care.
• Verbalizing knowledge of maintenance therapy.
• Verbalizing triggers to inflammatory dermatitis.
• Demonstrating accurate application of topical medications.
Intervention One crucial aspect of nursing management is to ensure proper use of an antiseborrheic shampoo containing zinc pyrithione, selenium sulfide, or ketoconazole. One successful strategy is to wet the hair, chest, axilla, and affected areas, apply selenium shampoo, and then proceed with the rest of the bath or shower. After cleansing the affected areas, the patient should apply hydrocortisone 1% cream or another prescribed steroid cream, which decreases the inflammation and irritated red appearance of the skin. Low-dose steroid creams or newer nonsteroidal creams such as pimecrolimus cream (Elidel) must be applied on the face to prevent scarring, atrophy, or acne. After inflammation and scaling have resolved, the patient should continue using selenium shampoo on the scalp twice weekly as preventive maintenance therapy.
Nursing interventions for a patient with psoriasis consist of reinforcing the directions of the physician or advanced practice registered nurse (APRN) to optimize treatment and identify patient-specific triggers that may be avoided to decrease the severity of flare episodes. Because psoriasis varies in type and severity, treatment plans may use both prescription and over-the- counter (OTC) topical ointments. As with seborrheic dermatitis, a common therapy used to treat psoriasis is a topical steroid. Topical steroids, which may be OTC or prescription-strength creams, are not recommended for use on the face. Coal tar has been used topically for many years to relieve the itching and scaling in minor
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cases of psoriasis. These compounds are messy and may make the skin more sensitive to UV rays and sunlight. A topical vitamin D3 ointment, calcipotriene skin ointment (Dovonex), is used to treat moderate cases of psoriasis. It is available by prescription only and has few known side effects. Calcipotriene ointment should not be used on the face, as photosensitivity is likely. Tazarotene (Tazorac) is a retinoid, a group of drugs related to vitamin A. It should be applied only to the affected areas, and contact with the eyes, eyelids, and mouth should be avoided. Because the medication may result in photosensitivity, exposure to sunlight should be avoided.
Light therapy using ultraviolet B (UVB) rays has been shown to be beneficial when used in prescription light boxes. It is currently thought that ultraviolet A (UVA) light therapy used in combination with psoralen (an oral or topical medication) is the preferred method (called PUVA). The UV dosage is carefully monitored for the amount of exposure because the total exposure time has a set limit. With UVA light therapy, it is important to be aware of the potential risk of developing skin cancer. A number of reports suggest that foods may trigger psoriasis attacks; therefore, approaches to diet modification and other homeopathic remedies abound in patient resource literature. Patients should be encouraged to discuss with their health care team any and all remedies used. The nurse should teach the older adult patient, family members, and staff the causes of inflammatory dermatitis to alleviate anxiety and misconceptions. An explanation of treatment measures and the importance of follow-through will increase compliance and involvement in care. Symptom management is an area where nurses can have a positive effect on an older adult’s quality of life.
Evaluation Nursing accountability and evaluation are supported through accurate, comprehensive charting that describes physical assessment and maintenance interventions. A weekly assessment of the lesions with a description of the response to treatment, including maintenance therapy, is recorded. In addition, the nurse
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should address the response to teaching (e.g., verbalized understanding) as measured by patient, family, or staff compliance with treatment.
Pruritus Pruritus is another term for itching that is so intense that it causes the patient to scratch the offending area. The most common cause of itching is dry skin, or xerosis. Atopic eczemia, contact or other forms of dermatitis, urticaria, psoriasis, or bullous pemphigoid are other suspects of pruritus. Infections and drug reactions can also be causative agents.
The mechanism of itching is not fully understood, but histamine is a known mediator of pruritus. Itching may be precipitated by heat, sudden temperature changes, sweating, clothing, cleaning products such as soap, fatigue, and emotional stress, and it may be more severe in the winter (Touhy & Jett, 2012). Pruritus may be related either to a skin disorder or systemic disease; therefore, the complaint should not be dismissed and warrants a complete assessment. Pruritus may occur with other dermatologic conditions and with systemic disorders such as liver, renal, hematologic, diabetes, and thyroid conditions (Cassano, 2010).
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Nursing management Assessment
A full skin assessment is warranted when a patient complains of pruritus. The patient is interviewed to determine the location, intensity, and onset of itching. The nurse should inquire about any patterns of behavior that precipitate itching (e.g., anxiety, environmental exposures, friction [rubbing the skin with a towel]) and obtain information about bathing practices and kinds of soaps, detergents, and skin products used (Feramisco, Berger, & Steinhoff, 2010). The nurse should also look for rashes, vesicles, scaling, and erythema; any of these suggests a skin disorder.
Diagnosis Nursing diagnoses for a patient with pruritus include the following:
• Risk for Impaired Skin Integrity, related to scratching
• Pain, related to persistent burning and itching
• Anxiety, related to role strain, family crisis, or other sources of patient’s anxiety
• Risk for Infection, related to impaired skin integrity
Planning and Expected Outcomes The goal of nursing management is resolution of pruritus without injury from scratching. Time should be planned to teach the patient and family about etiologic factors and the importance of not scratching. Expected outcomes include the following:
1. The skin will remain intact.
2. The patient will experience adequate periods of rest without symptoms of scratching.
3. The patient will obtain adequate pain relief, as evidenced by
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verbalization of comfort and pain relief.
Intervention Nursing interventions are influenced by the cause of the pruritus. If dry, scaly skin (xerosis) is present with no lesions or erythema, the nurse should suggest that the patient apply emollients (e.g., Lubriderm, Moisturel, or Eucerin lotion or cream), which have more lanolin or oily substances than many commercial lotions. Emollients should be applied at least twice daily and immediately after bathing to trap moisture. The patient should gently pat the skin dry and avoid brisk drying with a towel. If the patient is unable to apply lotion, the nurse should instruct the caregiver in its use. The patient should decrease the frequency of baths to a maximum of every other day (see Patient/Family Teaching Box). Antihistamines may be needed to relieve itching and to prevent tissue breakdown from scratching but are to be used with caution because of adverse effects in older adults.
Patient/Family Teaching
Prevention and Treatment of Dry Skin (Xerosis) Bathing or showering with warm water should not exceed a
frequency of every other day. Pat skin dry to avoid irritation. In the winter, when the air is drier, one bath or shower a week is sufficient, with a daily sponge bath to underarms, perineal area, and skin folds.
Bath oil may be used in a basin when sponge bathing but not in the tub or shower. To avoid risk of slipping in the tub or shower, apply oil after bathing.
Avoid the use of harsh soaps (e.g., Zest, Ivory, Dial); instead use a superfatted soap (e.g., Dove, Basis, Tone, Cetaphil) in limited quantities with only one lathering.
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Use heavy emollient lotions or creams containing urea or lactic acid (e.g., Lubriderm, Nivea, Eucerin, Aveeno, Cetaphil) after bathing when skin is moist. Mineral oil, petroleum jelly, and shortening are less expensive alternatives.
Never use alcohol or other drying rubs on skin because these deplete natural skin oils.
Drink at least 1500 to 2500 milliliters (mL) of water a day to ensure adequate hydration, if not contraindicated by other medical conditions (e.g., congestive heart failure [CHF]). Avoid tight-fitting clothes that rub against the skin.
(Modified from Davis, C. (1993). In D.L. Carnevali & M. Patrick (Eds.), Nursing management for the elderly (3rd ed.). Philadelphia: JB Lippincott; Touhy, T. & Jett, K. (2012). Toward healthy aging: Human needs and nursing response (8th ed.). St. Louis, MO: Mosby.)
A diagnostic workup may be conducted to identify any systemic cause for persistent pruritus (e.g., cancer or diabetes). Anxiety or stress may be the source of itching. If so, the nurse should assess the patient’s self-esteem and coping strategies and identify any family or role strain or other factors that may lead to anxiety. He or she should also discuss stress management strategies and assist the patient in determining effective ones. A referral to a community agency or professional such as an APRN, a psychologist, or a psychiatrist may be needed for continued support and guidance.
The older patient, family members, and staff need to be taught the management of pruritus and the need to prevent skin trauma from scratching. Treatment measures should also be explained to increase compliance and involvement in care. The causes of pruritus may be difficult to determine, and the expected effects of topical agents may be diminished as a result of the delayed absorption of medications placed on aging skin.
Evaluation Evaluation of interventions focuses on symptom relief, prevention of secondary complications, and, when possible, identification of the source of the pruritus. Nursing accountability is demonstrated through documentation of physical presentation such as erythema
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and intact skin with no lesions, hives, or rash; response to treatment measures; patient comprehension of teaching; and other nursing interventions.
Candidiasis Candidiasis is an inflammatory process of the epidermis caused by the yeastlike fungus Candida albicans. C. albicans is a normally occurring flora in the mouth, vagina, and gut (moist habitats). Pregnancy, oral contraception, antibiotics, diabetes, topical and inhalant steroids, skin maceration, and immunocompromised conditions create an environment that fosters the development of yeast infections such as candidiasis. Candidiasis is most commonly seen in diaper-clad infants, patients with incontinence, and bedbound individuals and in the moisture-prone areas of the body (e.g., skin folds and axillae).
Candidiasis is characterized by erythematous, denuded, or raw skin usually surrounded by satellite papules or pustules. Satellite lesions are a helpful diagnostic clue. Red, erythematous areas on the buttocks, perineum, or intertriginous areas of incontinent patients also have diagnostic significance. Scaling may also be present, usually at the borders (Playford, Lipman, & Sorrell, 2010).
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Nursing management Assessment
Nursing assessment includes inspection of the skin, particularly under any fat folds, where moisture will accumulate. A hallmark of candidiasis is a bright red erythema with satellite papules or pustules. Any breaks in the skin, which place the patient at greater risk for infection or further breakdown, should be noted. The patient may be the one to alert the nurse to the infection. The nurse should conduct a medication assessment to identify any medications that may have precipitated this fungal infection, for example, antibiotics or steroids. If the patient has diabetes, hyperglycemia may be present; therefore, the nurse should conduct a diet assessment to evaluate compliance and should check the blood sugar level. In some individuals with diabetes mellitus – type 2, candidiasis infection may be the first clinical manifestation of hyperglycemia. Therefore, a thorough health history is warranted when a candidiasis infection is present.
Diagnosis Nursing diagnoses for a patient with candidiasis include the following:
• Impaired Skin Integrity, related to poor control of moisture
• Toileting Self-Care Deficit
• Impaired Urinary Elimination
Planning and Expected Outcomes The goals of nursing management are prevention and resolution of candidiasis and, consequently, increased patient comfort. Expected outcomes include the following:
1. Skin lesions will be without evidence of infection and will be
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healing.
2. The patient will perform self-care practices (within limitations) for keeping the skin dry and clean.
3. The skin will regain its usual appearance without evidence of candidiasis.
Intervention The main nursing intervention is keeping the skin dry, especially the intertriginous areas. A patient’s discomfort, costs, and nursing time is minimized through use of preventive strategies such as drying the skin well (particularly the skin folds) after bathing or sweating episodes and changing the sheets as soon as possible after an episode of incontinence. After changing linens, the nurse should cleanse and dry the skin well and apply a zinc-based cream (such as Desitin or Calmaseptine) to the buttocks and perineal area. Cornstarch or powder, whether medicated or scented, is not recommended because of clumping and hence limited long-term skin protection. Creams are much more effective and efficient.
The nurse should teach the older adult patient, family members, and support staff to pat the skin dry; the nurse should also educate the staff and provide the scientific rationale for changing linen, cleansing the affected area, and using a moisture barrier such as zinc oxide or Desitin. The importance of prompt delivery of care after an incontinent event must be stressed. It is important to keep topical antifungal agents on the infected area until healing is complete, which may take 2 to 3 weeks. If the yeast infection does not improve, a physician or an APRN should be informed so that an alternative agent can be considered.
Management protocols may be developed and approved by the employee’s institution and medical and nursing staff with the intent of empowering the professional nurse to act immediately when candidiasis is present. This promotes high-quality care, patient comfort, a sense of professional pride, and a team approach. Nursing management is key in resolving a candidiasis infection.
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Evaluation Evaluation of nursing management focuses on treatment efficacy and the rate of recurrence. The nurse must document how the infection responds to medical treatment and the maintenance therapy of keeping the skin dry and applying a moisture barrier. The effectiveness of patient care is supported with positive outcomes, compliance with preventive actions, and verbalized comprehension. If little improvement is seen in 2 weeks, the nurse should ensure that moisture control and application of antifungal cream are being maintained. Consultation with the physician or the APRN is needed when response to therapy is poor; another agent may need to be ordered.
Herpes Zoster (Shingles) Herpes zoster, also known as shingles, is caused by the reactivation of latent varicella zoster (chickenpox) virus. The virus remains in the dorsal nerve endings after an episode of chickenpox, which is usually experienced in childhood. The main reason for recurrence is an immune system deficiency. Conditions that may impair the immune system are advanced age, stress or emotional upset, fatigue, or radiotherapy. An immunocompromised state caused by disease (e.g., human immunodeficiency virus, lymphoma, leukemia, and other malignancies) or drugs (e.g., chemotherapy and steroids) may also activate the latent virus. Chickenpox is highly contagious because it is an airborne virus. Herpes zoster is not as infectious because it is related to reactivation of latent varicella zoster. Therefore, it is not necessary to isolate a patient with herpes zoster. Cases of contracting shingles after personal exposure have been reported, but these have been in individuals who have not had chickenpox. Consequently, patients with herpes zoster should be cared for only by health care personnel who have had chickenpox or have positive serum varicella titers (Habif, 2004; Johnson, 2010). As always, universal precautions should be followed.
Approximately 50% of herpes zoster cases involve the thoracic region, 15% involve the cranial dermatomes, and 10% affect the
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cervical and lumbar regions. Ophthalmic herpes zoster is referred to an ophthalmologist for evaluation and treatment because blindness could result from corneal scarring.
Herpes zoster often has prodromal symptoms of tingling, hyperesthesia, tenderness, and burning or itching pain along the affected dermatome. The prodromal symptoms are followed by vesicles with an erythematous base occurring within 3 to 5 days. A unilateral, bandlike, erythematous, maculopapular rash first occurs along the involved dermatome and rarely crosses the midline of the body. The rash develops into clustered vesicles (usually on an erythematous base) that become purulent, rupture, and crust. Debilitated older adults may have a prolonged and difficult course. For them, the eruption is typically more extensive and inflammatory, occasionally resulting in hemorrhagic blisters, skin necrosis, secondary bacterial infection, or extensive scarring, which is sometimes hypertrophic or keloidal (Habif, 2009). These vesicles are prone to secondary bacterial infections. This occurs more often in older adults. It may take up to 1 month for the crusting lesions to heal; mild cases resolve in 7 to 10 days. The average duration for herpes zoster is 3 weeks. Scarring and permanent or temporary pigment discoloration may occur, especially in severe cases. Lymphadenopathy and occasional temperature elevation are not uncommon. Postinfection paresthesia and meningoencephalitis may occur for 2 to 4 weeks when motor neurons and the central nervous system (CNS) are involved (Habif, 2004; Willison, 2010).
The incidence of herpes zoster increases with age, most likely as a consequence of diminishing immune function. The older adult is also at a greater risk of developing postherpetic segmental pain. Dissemination is often seen in older adults or immunosuppressed patients. Disseminated herpes zoster, which is rare and occurs in only 2% to 5% of patients, is more serious because of its systemic nature. In disseminated herpes zoster, satellite lesions appear outside the affected dermatome within 4 to 6 days after the initial eruption. Dissemination may be associated with fever, lymphadenopathy, headache, neck rigidity, and increased risk of serious complications such as encephalitis, hepatitis, and pneumonitis. Disseminated herpes zoster may occur in as many as
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15% to 50% of patients with active Hodgkin disease, and 10% to 25% of these patients die (Habif, 2004).
One of the major complications from this acute viral infection is postherpetic neuralgia, which is pain that persists along the affected dermatome after resolution of vesicular lesions. Postherpetic neuralgia may last less than 1 year, but it may last a lifetime with little pain relief. It affects approximately 33% of patients age 40 or older, and by age 70 the risk increases to 74%. Postherpetic neuralgia is more common in persons with trigeminal nerve involvement (Habif, 2009).
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Nursing management Assessment
Nursing assessment begins with interviewing the patient to identify prodromal symptoms such as burning, itching, or tingling along a dermatome before rash development. The nurse should obtain a pertinent health history that addresses chickenpox history, medications, diabetes, malignancy with recent chemotherapy or radiotherapy, and AIDS and other immunocompromised states. The nurse should also identify persons with whom the patient has had close physical contact who have not had chickenpox or the chickenpox vaccine because they may be at risk of infection. He or she should inspect the area of discomfort for the characteristic unilateral, bandlike, erythematous, maculopapular rash that may have clustered vesicles. Initially, the area may be a raised, erythematous rash before the vesicles appear. Intense pain is often associated with the rash, particularly in older adults. On the basis of the lesions and prescribed treatments, the nurse must determine the effect on the patient’s mobility and capacity for activities of daily living (ADLs). Recommended treatment measures may require the assistance of another person.
Diagnosis Nursing diagnoses for a patient with herpes zoster include the following:
• Impaired Skin Integrity, related to immunologic deficit
• Risk for Infection, related to impaired skin integrity
• Disturbed Sleep Pattern, related to impaired skin integrity or pain
• Pain, related to inadequate pain relief from analgesia
• Deficient Knowledge, related to lack of previous exposure to disease process and treatment
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Planning and Expected Outcomes The goals of nursing management are pain relief and the prevention of secondary infection and scarring. Local skin care treatments may need to be taught to the patient or caregiver. The nurse must be alert to the possibility of long-term pain (postherpetic neuralgia) and the resulting depression. Expected outcomes include the following:
1. Skin lesions will remain free from necrotic tissue and infection.
2. The patient will experience adequate periods of restful sleep, as evidenced by:
• No requests for pain medication during the night
• Reports of uninterrupted sleep during the night and feeling well rested on arising
3. The patient will obtain adequate pain relief, as evidenced by:
• Verbalizing comfort and pain relief after taking an analgesic
• Augmenting analgesic pain relief with the use of relaxation exercises, music diversion tapes, or guided imagery
4. The patient will demonstrate increased knowledge of his or her condition, as evidenced by:
• Verbalizing significant and reportable signs and symptoms of infection
• Verbalizing the rationale for regular, consistent use of analgesics
• Correctly performing a return demonstration of lesion care and dressing change procedure
Intervention Nursing interventions consist of notifying the physician or the APRN as soon as the characteristic rash and vesicles are identified, especially if they follow a dermatomal pattern. After a diagnosis is made, follow-through with medical and nursing management is paramount to patient comfort. Lesions should be monitored closely
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for the development of secondary bacterial infections, as evidenced by erythema, tenderness, or a purulent discharge. If satellite lesions develop outside the dermatome, especially if the patient is also experiencing headaches, neck rigidity, or pulmonary congestion, the physician or APRN must be notified immediately because this is indicative of disseminated herpes zoster (Dasgupta, 2009).
The nurse should teach the older adult patient, family members, and staff the cause of shingles so that anxiety and misconceptions may be alleviated, and he or she should explain the treatment measures to increase compliance and involvement in care. Herpes zoster may be very painful, so prompt administration of pain medications is crucial for patient comfort. For optimal pain control, patients should be instructed to inform the nurse when they experience the initial onset of pain, before the pain becomes well entrenched. Effective pain management is one area in which nurses may have a positive effect on a patient’s quality of life (see Chapter 14). If postherpetic neuralgia occurs, antidepressants are used as adjuncts to analgesics for control of pain.
Evaluation Evaluation of interventions focuses on pain control, with documented results of analgesics and adjunct therapies, and on prevention of secondary infection by frequent monitoring of the site. Many barriers to effective pain management in older adults exist, leading to frequent underrecognition and undertreatment of pain. If pain is not relieved, the physician or the APRN should be consulted to obtain an alternative analgesic agent or adjunct drug therapy. The inflammatory response in an older adult may be diminished, even in the presence of severe infection, so the nurse should be alert to even slight symptoms of a secondary bacterial infection. If evidence of cellulitis is noted, the physician or the APRN should be informed to implement topical or oral antibiotic therapy. Documentation of assessment, the response to treatment measures, patient comprehension of teaching, and other nursing interventions demonstrates nursing accountability (see the Nursing Care Plan: Herpes Zoster).
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Nursing Care Plan
Herpes Zoster
Clinical Situation Mr. F. is a 72-year-old man who lives with his daughter and her husband. He has severe rheumatoid arthritis and hypertension. He takes ibuprofen, amiodipine, and atorvastatin. He has had both knees replaced in the past 5 years.
Mr. F. began to experience a burning with pain 2 days ago and this morning awoke with clustered vesicles on the left side of his torso extending from the midback around to the midline of the anterior aspect of his chest. He went in to see his primary care physician. The physician ordered acyclovir, analgesics as needed for pain and a topical antibiotic to prevent secondary infection.
Nursing diagnosis Risk for Infection, related to herpes zoster and open lesions
Outcome The patient will experience no secondary infection, as evidenced
by no fever and other vital signs within normal limits, and will practice habits that decrease the risk of infection.
Interventions Instruct the patient not to scratch or rub the affected area so as not
to break vesicles, which would increase the risk of secondary infection.
Assess vital signs, mental status, and skin lesions every shift to identify signs of infection (e.g., fever, tachycardia, erythema, tenderness, purulent discharge, and confusion).
If the patient is febrile, ensure adequate hydration because a fever increases hydration needs.
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Tachycardia could precipitate congestive heart failure (CHF) from decreased cardiac output; monitor for shortness of breath, rales, edema, and other signs of cardiovascular compromise.
If vesicle lesions rupture, implement topical treatment, noting the response.
Ensure adequate nutrition to foster healing.
Monitor food intake, and ensure food preferences are being met.
Teach the patient the need to eat at least 2000 calories and drink a minimum of 1500 milliliters (mL) of liquid per day.
Be alert for vesicles outside of the involved dermatome, which could indicate disseminated herpes zoster; if vesicles appear, contact the physician or nurse practitioner immediately.
Teach the patient, staff, and visitors the value of hand washing and proper disposal of dressing and treatment material as an infection control standard.
Identify staff and visitors who have no known history of chickenpox or vaccine, and inform them that they are not able to provide care for the patient because they may not have immunity to the varicella virus; isolation is not required; the infection control strategy is to take universal precautions.
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Premalignant skin growths: actinic keratosis Actinic keratosis is a premalignant lesion of the epidermis that is caused by long-term exposure to UV rays. This precancerous lesion is more common in individuals with light complexions and occurs most commonly on the dorsum of the hands, scalp, outer ears, face, and lower arms. No definitive way exists to distinguish actinic keratosis from squamous cell carcinoma (SCC); therefore treatment should be aggressive and patients monitored closely to prevent progression (Habif, 2009).
Actinic keratosis begins in vascular areas as a reddish macule or papule that has a rough, yellowish brown scale that may itch or cause discomfort. During assessment, the nurse should be attuned to the rough surface of the lesion and its location and be particularly alert if a suspicious lesion occurs on a sun-exposed area. Accumulation of keratin may also lead to the formation of a cutaneous horn that tends to develop on the outer ear. Because of abundant vascular supply to this area, removal of the crust may cause bleeding. Induration, inflammation, or oozing may be indicative of malignancy and merit prompt referral (Habif, 2004; Shoimer, Rosen, & Muhn, 2010).
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Nursing management Assessment
Nursing assessment begins with the patient interview to determine risk factors such as the frequency of activities with sun exposure and the use of preventive practices (e.g., wearing a hat and long sleeves while outside). The skin should be inspected and any rough lesions palpated and noted for location and texture. If hand lotion is used frequently, roughness will not be present; therefore, the nurse should look for an erythematous macule or papule. The nurse should refer patients to their primary care provider whenever a suspicious lesion is found. The nurse should also explain the value of treating skin cancer early, which may minimize scarring and disfigurement.
Diagnosis Nursing diagnoses for a patient with actinic keratosis include the following:
• Impaired Skin Integrity, related to removal of a lesion
• Risk for Infection, related to a break in skin integrity
• Disturbed Body Image, related to disfigurement and scarring resulting from removal of lesion
Planning and Expected Outcomes The goals of nursing management after the removal of premalignant lesions are the prevention of secondary infection and assistance in coping with any body image disturbance. Expected outcomes include the following:
1. The site of lesion removal will heal without evidence of secondary infection.
2. The patient will demonstrate no changes in body image
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perception.
3. The patient will demonstrate behavior change through adoption of preventive skin care practices.
Intervention Nursing intervention consists of reinforcing the treatment regimen with the patient and family, monitoring the treated site to prevent secondary infection, providing support, and teaching preventive strategies. To lower a patient’s anxiety and assist with body image changes, the nurse should explain the treatment, stressing that erythema and crusting are temporary. The resulting body image trauma from treatment of many facial lesions may isolate an individual. The nurse should identify the patient’s fears and discuss them in an open, reassuring manner.
Wounds should be assessed for development of a bacterial infection, as evidenced by increased tenderness, increasing erythema around the treated site, purulent discharge, and possibly fever. Topical management with an antibiotic ointment may be implemented prophylactically.
The nurse should teach older adult patients and family members the strategies necessary to prevent recurrence and stress the need to wear hats with wide brims and long-sleeved shirts to protect the skin from sun exposure. If an individual is going to be exposed to the sun, a sunscreen with a sun protection factor (SPF) of at least 15 should be applied (Habif, 2004).
Evaluation Evaluation of nursing management is supported with documentation addressing treatment progress, which includes a physical description, patient comprehension of educational information, and identification of and coping with any body image disturbances.
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Malignant skin growths Basal Cell Carcinoma Basal cell carcinoma (BCC) is the most common skin cancer and is more prevalent in fair-skinned, blond, or red-headed individuals with extensive previous sun exposure. BCC rarely occurs in black persons because the darker skin pigmentation plays a protective role against UVB radiation, the spectrum thought to be causative in the development of skin cancer (Johnson, Moy, & White, 1998). It occurs more often in men than in women; however, this gender difference has decreased in recent years. BCC is most commonly found on the face and scalp, less often on the trunk, and rarely on the hands. It may also arise from scars or burns, particularly in older adults who have experienced chronic sun damage. BCC usually does not metastasize, but if left untreated, it may metastasize to the bone, lungs, and brain (Dessinioti, 2010; Habif, 2004).
Typically, BCC appears as a pearly papule with a depression in the center, giving the lesion a doughnut-shaped appearance with telangiectasia on or around the lesion. BCC may also appear as a blue-black pearly nodule (pigmented basal cell) or a red, scaly, or eczematous-appearing macule that is usually on the thoracic area (superficial spreading BCC).
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Nursing management Assessment
Nursing assessment begins with an interview focusing on the length of time the lesion has been present, the presence of risk factors such as chronic sun exposure, and a history of previous skin lesions. The nurse should conduct a skin assessment and be alert for pearly, doughnut-shaped lesions with telangiectasia. A magnifying glass may be useful for closely examining any lesion. The nurse should inspect and palpate the lesion, surrounding tissue, and lymph nodes (to identify possible metastasis). When a suspicious lesion is identified, the patient is referred to the primary care provider for prompt treatment. The nurse should explain to the patient that early treatment lessens the extent of scarring and lowers the risk of metastasis.
Diagnosis Nursing diagnoses for a patient with BCC include the following:
• Impaired Skin Integrity, related to removal of a cancerous lesion
• Risk for Infection, related to a break in skin integrity and a surgical wound
• Disturbed Body Image, related to disfigurement and scarring resulting from removal of a cancerous lesion
• Fear, of cancer, pain, or death, related to having a cancerous skin lesion
Planning and Expected Outcomes The goals of nursing management are to facilitate the referral of patients for treatment and removal of suspicious lesions and to prevent secondary infections. Time should be scheduled to discuss the patient’s and family’s feelings about having a cancerous lesion
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so that any need for a community referral or educational material can be identified. In addition, patient education regarding preventive strategies should be included in the plan. Expected outcomes include the following:
1. The site of BCC will heal without evidence of infection.
2. The patient will demonstrate no disturbance in body image.
3. The patient will verbalize concerns regarding the diagnosis and will be able to articulate feelings and concerns related to the diagnosis.
4. The patient will adopt preventive strategies into his or her lifestyle.
5. The patient will demonstrate increased knowledge of his or her condition.
Intervention Nursing interventions include reinforcement of the treatment regimen and monitoring the wound for secondary infection (e.g., erythema, tenderness, and purulent discharge). The nurse should explain procedures, emphasizing that a wound or erosion may occur and may require a dressing. He or she should teach the patient or family about dressing care and signs of infection. Removal may result in scarring, especially if the lesion is large; consequently, reassurance should be provided and feelings addressed regarding having a cancerous lesion and the associated body image changes. Focus is placed on comfort, education, and emotional support.
The nurse must identify and discuss the patient’s feelings about having a cancerous lesion and should refer the patient to appropriate community resources if he or she is having difficulty coping or has a high anxiety level. The nurse should explain that the risk of metastasis is low and refer the patient to the American Cancer Society (ACS), the local library, or Internet sources for information. Preventive strategies such as wearing long sleeves and hats with wide brims and using sunscreens should also be taught.
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Evaluation Evaluation of interventions focuses on monitoring for infection, pain control measures, comprehension of patient education, and discussions related to body image changes and fear of cancer. In case of poor pain control or infection, the physician or the APRN should be contacted for an alternative strategy. Documentation of assessment, the response to treatment measures, patient comprehension of teaching, and other nursing interventions demonstrates nursing accountability.
Squamous Cell Carcinoma SCC is skin cancer arising from the epidermis and is found most often on the scalp, outer ears, lower lip, and dorsum of the hands. SCC may also develop in chronic leg ulcers or open fractures and has a 20% incidence of metastasis, generally to regional lymph nodes (Helm & Marks, 1998). SCC accounts for 90% of lip lesions. The etiologic factors of SCC may be UV rays, chemical carcinogens, and x-rays. SCC is more common in men and older adults, and the incidence increases with geographic proximity to the equator. SCC is the most common skin cancer in blacks, in whom the majority of SCCs are found in areas that have not been exposed to the sun (Rodust, 2009).
Symptoms of SCC usually include a thick, adherent scale with a soft, movable tumor that has well-defined borders. The center is often ulcerated or crusted. At first glance, SCC may even look like a wart. The base may be inflamed and red and usually bleeds easily. SCC may arise from actinic keratosis, which supports early detection and removal of such lesions. If tumors are ignored or left unattended, they may enlarge, creating significant disfigurement after surgical excision.
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Nursing management Assessment
Nursing assessment begins with interviewing the patient with a focus on the length of time the lesion has been present, risk factors such as chronic sun exposure, and a history of previous skin lesions. The nurse should inspect and palpate the lesion, surrounding tissue, and lymph nodes (to identify possible metastasis). A magnifying glass may be useful for close examination of any lesion. When a suspicious lesion is identified, especially if the lip is involved, the nurse should refer the patient to the primary care provider for prompt treatment; he or she should also explain to the patient that early treatment lessens the extent of scarring and, in the event of a cancerous lesion, lowers the risk of metastasis.
Diagnosis Nursing diagnoses for a patient with SCC include the following:
• Impaired Skin Integrity, related to removal of a lesion
• Risk for Infection, related to a break in skin integrity and a surgical wound
• Disturbed Body Image, related to disfigurement and scarring resulting from removal of a cancerous lesion
• Fear, related to cancer, pain, or death
Planning and Expected Outcomes The goals of nursing management are to facilitate the referral of patient for treatment and removal of suspicious lesions and to prevent secondary infections. Time should be scheduled to discuss the patient’s and family’s feelings about having a cancerous lesion so that any need for a community referral or educational material
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can be identified. In addition, preventive strategies should be included in patient education. Expected outcomes include the following:
1. Skin lesions will remain free from necrotic tissue and infection.
2. Skin lesions will heal with minimum scarring.
3. The patient will demonstrate positive adaptation to body image changes, as evidenced by verbalization of feelings of acceptance.
4. The patient will verbalize acceptance of the diagnosis and seek appropriate care.
Intervention Nursing intervention is the same as with BCC; however, more disfigurement may be present after removal. If the lesion is large and extensive, more intense emotional and social support may be needed. The nurse should identify and discuss the patient’s feelings about having a cancerous lesion and should refer the patient to appropriate community resources (e.g., therapist or support group) if he or she is having difficulty coping or is experiencing high levels of anxiety. The nurse should explain that the risk of metastasis is low and refer the patient to the ACS, Internet sources, or the local library for additional information and literature. The patient may experience greater anxiety about long-term quality-of-life issues if metastasis has occurred.
The nurse should teach the older adult patient and family methods to care for the wound after removal of the lesion, signs of infection, preventive strategies, and the appearance of questionable skin lesions that warrant examination by the primary care provider.
Evaluation Evaluation, supported by documentation, focuses on the appearance of wound infection, the patient’s coping response to changes in body image, and comprehension of teaching. If assessment reveals the development of an infection, the physician
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or the APRN should be contacted so that therapy can be implemented. Return demonstrations of dressing changes assist in evaluating the patient’s comprehension and technique. In addition, the nurse should obtain verbal confirmation of teaching by asking the patient to repeat or list preventive activities (e.g., ways of protecting the skin from UV rays).
Melanoma Melanoma is a malignant neoplasm of pigment-forming cells that is capable of metastasizing to any organ of the body, even before the lesion is noted; therefore, early detection is crucial. Melanoma accounts for 5% of skin cancer diagnoses and accounts for approximately 75% of the mortality from the disease. Melanoma represents 2% of all cancers and 1% of cancer-related deaths, and it is the second most common cause of death in men ages 30 to 49. After excision, primary, “thin” (less than 76 mm thick) melanoma has a 5-year survival rate of approximately 98%. The survival rate for other stages is 83%.
Melanoma incidence is rising. This is most likely a result of thinning of the ozone layer, combined with increased recreational sun exposure. A genetic predisposition to melanoma also exists: 10% of patients have a parent or sibling with a history of melanoma. Individuals with a family history of melanoma should perform monthly skin self-examinations and have a professional skin evaluation at regular intervals (Gasent Blesa, 2011; Habif, 2009).
Individuals at high risk are fair skinned and their skin has a tendency to burn rather than tan; have red or blond hair; have multiple nevi; and have a tendency to freckle. African Americans, Asians, and dark-skinned whites are at less risk of developing melanoma; however, the majority of melanomas found in these populations occur in skin areas not exposed to the sun, especially the periungual, palmar, and plantar surfaces (Johnson et al., 1998). An individual with one melanoma is at risk for having another (Habif, 2004; Psaty, 2010).
Melanoma’s clinical hallmark is an irregularly shaped nevus
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(mole), papule, or plaque that has undergone a change, particularly in color. The characteristic signs of a majority of malignant melanomas are referred to as the ABCDs: Asymmetry, Border irregularity, Color variation (red, white, blue), Diameter greater than 6 mm; some clinicians now include E: Evolution, Elevation, or Enlargement of a lesion (Gordon, 2009; Rigel, Russak, & Friedman, 2010). The lesion may itch or bleed; however, this is usually a later sign. Any mole or lesion that has irregularly shaped borders and that has had a color change, usually to a darker color, should be examined by a dermatologist or family physician.
All melanomas grow both vertically and radially. During the radial (lateral) growth phase, metastasis occurs infrequently, which reinforces the need for early detection and professional examination (Habif, 2004).
Of the four types of melanoma, the most common is the superficial spreading melanoma, which is slower growing. Superficial spreading melanoma accounts for 70% of all melanomas, occurring most commonly on the back in males and the extremities in females. The mean age of diagnosis is the mid-40s. Superficial melanoma is a slow-growing, flat, slightly elevated, pigmented papule or patch that has irregular borders and varied colors within the lesion (Psaty, 2010).
Nodular melanoma occurs in 15% to 30% of patients with melanoma and has the worst prognosis because it grows vertically at an early stage. Nodular melanoma is not often found on the head, neck, and trunk, and it is more common in black and dark- skinned individuals. The mean age at diagnosis is the fifth or sixth decade of life. Nodular melanoma is a hard, usually dark nodule arising from a preexisting mole (Habif, 2004).
Lentigo melanoma occurs in 5% to 10% of all patients with melanoma and is more prevalent in women. Of these lesions, 30% to 50% arise in individuals with lentigo maligna. Therefore, thorough skin assessment and instruction in self-examination is important in people with lentigo maligna. The mean age of occurrence is 70. Lentigo maligna melanoma is a brown-tan macular lesion with varied pigmentation and highly irregular borders (Habif, 2004).
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Acral-lentiginous melanoma (10% of all melanomas) usually occurs on the palms, soles, fingers, and toes. It is more common in older adults, and the mean age is 60 at the time of diagnosis. It is the most common melanoma found in blacks and Asians; therefore, inspection of the foot soles, palms, and hands is warranted when caring for black and Asian American patients. Acral-lentiginous melanoma resembles lentigo melanoma with its flat, irregular, discolored borders (Habif, 2004; Rigel, Russak, & Friedman, 2010).
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Nursing management Assessment
Nursing assessment begins with interviewing the patient to determine how long the lesion has been present and to identify risk factors such as chronic sun exposure and family history. The nurse should inspect and palpate the suspicious lesion, surrounding tissue, and lymph nodes (to identify possible metastasis). A magnifying glass may be useful for closely examining any lesion. When a suspicious lesion is identified, the nurse should promptly refer the patient to the primary care provider. He or she should also explain that early treatment lessens the extent of scarring and possibly intervenes before metastasis. Because this is an aggressive cancerous lesion, the nurse should discuss the patient’s feelings and fears about cancer.
Diagnosis Nursing diagnoses for a patient with melanoma include the following:
• Impaired Skin Integrity, related to removal of a cancerous lesion
• Fear, of cancer, pain, or death, related to having a cancerous skin lesion
• Risk for Infection, related to a break in skin integrity and a surgical wound
• Disturbed Body Image, related to disfigurement and scarring resulting from removal of a cancerous lesion
Planning and Expected Outcomes The goals of nursing management are to facilitate the referral of patients for treatment and removal of suspicious lesions, prevent secondary infections and metastasis, and address fears and feelings
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related to cancer; referrals to community resources should be made as indicated. The nurse must discuss the patient’s and family’s feelings about having a cancerous lesion so that any need for a community referral or educational material can be identified. Expected outcomes include the following:
1. The site of excision will heal without evidence of infection.
2. The patient will verbalize fears related to the diagnosis and actively seek information and clarification.
3. The patient will identify community resources for support and additional information.
4. The patient will verbalize understanding of the treatment plan.
5. The patient will demonstrate increased knowledge of condition, as evidenced by adoption of preventive strategies.
Intervention Nursing management includes reinforcement of the treatment regimen by monitoring the wound for secondary infection (e.g., erythema, tenderness, and purulent discharge) and reinforcement of the caring component of nursing by discussing the patient’s and family’s feelings related to cancer. The nurse should identify and discuss the patient’s and family’s feelings about having a cancerous lesion and refer the patient to appropriate community resources if he or she is having difficulty coping or has a high level of anxiety. The nurse should also explain that a risk of metastasis exists and refer the patient to the ACS, Internet sources, or the local library for additional information.
The nurse should teach the patient or family dressing care and signs of infection. Removal may result in scarring, especially if the lesion was large. Consequently, reassurance must be provided, and feelings related to body image changes should be addressed; the focus is on comfort, education, and emotional support. Preventive strategies such as wearing hats with wide brims, wearing long sleeves, and using sunscreen should also be taught to both the patient and family. In addition, the patient and family members
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should have annual skin assessments because a hereditary tendency for occurrence exists.
Evaluation Evaluation of nursing interventions focuses on monitoring for infection, the effectiveness of pain control measures, comprehension of patient education, and discussions related to body image changes and fears about cancer. If there is poor pain control or development of an infection, the physician or the APRN should be contacted for an alternative strategy. Documentation of assessment, the response to treatment measures, patient comprehension of teaching, and other nursing interventions demonstrates nursing accountability.
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Lower extremity ulcers Chronic leg ulcers are a common problem in older adults, occurring primarily from three causes: arterial insufficiency, diabetic neuropathy, and venous hypertension (Table 28-1). A brief overview of each etiologic factor and treatment follows. Greater emphasis is placed on venous ulcers because these are more prevalent in older adults and more challenging as a result of their chronicity.
Table 28-1 Leg Ulcer Differentiation
TypE Primary Cause
Characteristics
Arterial Arterial insufficiency; PVD
Located on toes, feet, or lower third of leg; irregularly shaped wound; thin, shiny, cool skin with cyanotic hue, loss of hair, thickened toenails; pain with activity, rest, or at night
Diabetic neuropathy
Neuropathy Located on plantar surface of foot; circular, often deep wounds; decreased or absent vibratory sensation; painful; paresthesia
Venous Venous hypertension
Located on medial aspect of lower third of leg; irregularly shaped wound; either flat or shallow crater; discoloration, varicosities, edema, and exudate; pain relieved with activity
PVD, Peripheral vascular disease.
Arterial Ulcers Arterial or ischemic ulcers result from arterial insufficiency and are not as prevalent as venous ulcers. Arterial insufficiency is also referred to as peripheral vascular disease (PVD). Arteriosclerosis— thickening and hardening of the arterial wall—is the primary cause for the decreased blood flow that results in ischemia and eventually tissue death. The term arteriosclerosis obliterans is used when atheromatous lesions develop in the lower extremities below the abdominal aorta. Several risk factors, including smoking, diabetes, hyperlipoproteinemia, and hypertension, may lead to arteriosclerosis obliterans.
Pain with exercise, at night, or while resting is the most common sign of arterial insufficiency. Pain at rest indicates severely restricted arterial blood flow. The area proximal to (above) the painful area is usually the site of restricted blood flow. Pulses distal
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to the restriction may be present as a result of collateral circulation. The patient may also complain of cramping, burning, or aching. As the disease advances, the extremity develops a cyanotic hue and becomes cool. The skin becomes thin, shiny, and dry and has an associated loss of hair and thickened nails, all of which results from the diminished blood supply. Tissue anoxia leads to necrosis and poor healing. Arterial ulcers are usually located on the feet and toes. The causes must be corrected so that oxygen and other nutrients are available to promote healing of necrotic wounds. Treatment is usually surgical intervention with revascularization; if the disease is too advanced, amputation may be necessary.
Diabetic Neuropathic Ulcers Risk factors for developing a diabetic foot ulcer are smoking, hypertension, lipoprotein abnormalities (particularly elevated low- density lipoprotein), chronic hyperglycemia, absent vibratory sensation in the lower extremities, PVD, and poor outpatient diabetes education (Levin, 1997). Older adults who live alone or who have mental confusion are at an increased risk for foot ulcers because they may not have the means to recognize an ulcer or to follow up with appropriate treatment. A risk factor for lower extremity amputation is neuropathy, which is implicated in approximately 90% of diabetic foot ulcers. This sensory loss is associated with a 15.5% relative risk of amputation. Therefore, individuals with diabetes and neuropathy are at risk of developing lower leg ulcers, which may lead to an amputation.
Pain and temperature are usually the first sensations affected by neuropathy. The loss of the peripheral sensory feedback system impairs the patients’ ability to feel tissue damage, inflammation, or injury. Ulcers resulting from diabetic peripheral neuropathy tend to be bilateral, symmetric, and located on the plantar surface of the foot. Patients usually complain of pain and paresthesias; however, they also have diminished or absent vibratory and temperature sensation of the affected extremities. Pain relieved by walking is one diagnostic sign of neuropathy. Neuropathic ulcers are usually well perfused, yet a patient with diabetes may have arterial insufficiency, which compromises healing abilities.
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Treatment varies, depending on the etiologic factors and wound condition. Patient education regarding how to minimize the risk of chemical, thermal, and mechanical trauma is the first line of defense against diabetic foot ulcers. Physical examination of the foot should include testing for neuropathy and the identification of high foot pressures. An easy and inexpensive device for establishing neuropathy is the Semmes-Weinstein monofilament. Inability to feel the 5.07 monofilament indicates the patient is at risk for ulceration and needs orthotics (specially fitted shoes designed to prevent ulcers and to decrease callous formation by redistributing weight) to offload pressure (Birke & Rolfsen, 1998). The nurse should stress to patients with diabetes, particularly if they have peripheral vascular disease (PVD), that any trauma to the lower leg, ankles, or feet may lead to an ulcer and possible amputation. They must protect their feet and lower legs with proper shoes and foot care. Orthotics may be helpful in preventing mechanical trauma. When an ulcer is present, a total contact cast may be applied to redistribute weight and minimize trauma but is contraindicated with cellulitis, or excessive drainage. Some physicians use hyperbaric oxygenation in hopes of increasing oxygenation to the affected area; however, this treatment is controversial because of its questionable effectiveness in wounds with compromised circulation, for example, diabetic ulcers. The success of this strategy depends on the amount of circulation present in the affected area.
Venous Ulcers Venous ulcers, or venous dermatitis, have been recognized for more than 2000 years. The cause of this chronic, costly condition is not completely known, but it has been attributed to chronic venous insufficiency. Venous ulcers affect 1% to 1.3% of the general population, and a higher incidence (3.5%) is seen in older adults. Chronic venous leg ulcers usually have an onset in early adulthood; however, peak prevalence is seen in people ages 70 or older. Venous ulcers occur more often in women (3:1) than in men. Epidemiologic studies have revealed that 57% to 80% of all lower leg ulcers are related to venous insufficiency, and 10% to 25% have a combination of venous and arterial insufficiency.
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Homans stated in 1917 that venous ulcers were related to venous stagnation, which led to anoxia and ulceration. Consequently, the term venous stasis ulcer or dermatitis was established. The concept of stasis was challenged in 1929 when research revealed higher oxygenation in limbs with venous ulcers. The correct term now is venous ulcer because the cause is not related to stasis. Browse and Burnand (1982) revealed the most current etiologic factor: an enlarged capillary bed from venous hypertension that causes leakage of fibrinogen into interstitial tissue, creating a fibrin cuff (Burton, 1994). Falanga and Eaglstein (1993) proposed that the fibrin cuff facilitates the trapping of growth factors, which impedes healing.
Venous hypertension is the primary cause of venous ulcers. Valvular incompetence of the deep or perforating veins of the lower leg is present in the majority of venous ulcer cases. Venous hypertension leads to a tortuous capillary system, which causes an accumulation of fibrinogen, leukocytes, and erythrocytes. The accumulation of erythrocytes in the tissue produces a brownish skin discoloration caused by the release of hemoglobin. Often, the discoloration and thickening of the skin (liposclerosis) is the first indication of venous hypertension. Capillary occlusion caused by trapping of white blood cells (WBCs) results in the release of proteolytic enzymes, which foster fibrinogen leakage. The fibrin cuff creates a barrier that prevents or delays exchange of oxygen and other nutrients, resulting in cell death. Anoxia and trapping of growth factors are the primary causes of ulceration and poor healing. The fibrin cuff is irreversible, which sets the stage for frequent recurrence and makes venous ulcers a chronic disorder.
The diagnosis of venous ulcer is commonly based on clinical presentation. Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and irregular borders, accompanied by varicosities, liposclerosis (brown-ruddy color and thickened skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded by erythema and edema. Although it may be difficult, it is important to differentiate between venous ulcers and cellulitis.
It is well recognized that venous ulcers heal with prolonged
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elevation of the affected extremity; however, compliance is difficult. Research has demonstrated that compression therapy of at least 20 to 30 mm Hg at the ankle and distal lower leg decreases edema by compressing fluid through the fibrin cuff (Fletcher, Sheldon, & Cullum, 1997). The most common cause of recurrence is noncompliance with compression therapy. It is important to remember that compression therapy is intended for ambulatory patients. The older adult with dependent edema, not primary venous disease, does not tolerate compression well. Compression therapy is not a management option for arterial insufficiency; pain and cyanosis will occur from further impaired circulation.
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Nursing management Assessment
Nursing assessment begins with the determination of the location and characteristics of lower leg ulcers. The nurse should determine ulcer dimensions, depth, and amount of exudate; palpate popliteal pulses at least every day if the patient is in acute care and at every visit if he or she is in an ambulatory or home setting; and note any discoloration and edema. The nurse should also ascertain if the patient experiences any pain or itching and how it has been managed. A nutritional assessment should be conducted, which includes the patient’s weight, 24-hour diet recall, chewing abilities, and food preparation abilities. The nurse should determine whether shopping assistance is needed.
Diagnosis Nursing diagnoses for a patient with lower extremity ulcers include the following:
• Impaired Skin Integrity, related to altered circulation
• Risk for Infection, related to open, chronic wounds
Planning and Expected Outcomes The goal of nursing management is to facilitate healing without infection by promotion of treatment compliance and by provision of patient education regarding the disease process and treatment; the nurse should stress that venous ulcers are a chronic process. Time for patient education will be needed. Expected outcomes include the following:
1. Skin lesions will remain free from necrotic tissue and infection.
2. Edema in lower extremities will be controlled.
3. Skin lesions will heal with minimum scarring.
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4. The patient will be able to maintain a healed state for at least 6 months.
Intervention Nursing interventions consist of keeping the legs elevated above the heart; implementing compression therapy; administering wound care; and educating the patient about the causes of a venous ulcer and its chronic nature, the strategy of compression therapy, and specific wound care. The nurse must stress the need to maintain compression therapy to facilitate healing of ulcers and avoid further breakdown. Infection is difficult to determine because venous ulcers often have erythematous bases with induration; however, if the patient develops a fever and tenderness surrounding the ulcer, the physician or the APRN should be contacted. The nurse should determine whether any community services such as home-delivered meals, grocery shopping assistance, and other support services are needed. He or she should also identify and discuss the patient’s feelings regarding chronicity and body image changes; teach the patient that venous ulcers generate a large amount of exudate; and instruct on dressing changes and how to place 15- to 20-cm blocks at the foot of the bed at home for long-term edema management.
Evaluation Evaluation of nursing interventions focuses on prevention of further ulcer deterioration and infection, as well as the effectiveness of patient education. A return demonstration of compression therapy application and wound care is a concrete evaluation and ensures patient comprehension. Nursing accountability is demonstrated by documentation of assessment, the response to treatment measures, patient comprehension of teaching, and other nursing interventions.
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Pressure ulcers Pressure ulcers (also known as bedsores, decubitus, or pressure sores) have plagued humans for centuries. Hippocrates devised a débridement treatment with healing by secondary closure. Ambroise Paré, a sixteenth-century surgeon, published strategies for healing skin ulcers that challenged the existing practice of pouring hot oil on the wound. These included increased nutrition and mobility, débridement, and application of dressings (Levine, 1992).
It was not until the twentieth century that scientific research began to determine the cause and appropriate management of pressure ulcers. In 1930, Landis determined that the average capillary pressure before which ischemia occurs is below 32 mm Hg. In the 1950s, Kosiak (1958) found that pressure applied to rabbits’ ears over 2 hours would result in ulceration. Thus, the universal recommendation of turning every 2 hours was established. The first pressure ulcer risk assessment tool was designed and tested by Doreen Norton (1989) in the late 1950s but not disseminated until 1962 when she presented study findings at a conference.
In 1962, researchers first demonstrated that moisture, applied with occlusive dressings, increases epithelialization (the healing process) (Krasner, 1991). In 1972, a plastic occlusive dressing was shown to cut epithelialization time in half, which led to film dressings, followed by hydrocolloidal dressings.
This information explosion has resulted in varied terminology and beliefs. As a result, leading experts in pressure ulcer management and research formed the National Pressure Ulcer Advisory Panel (NPUAP) in 1987, with the intent of improving prevention and management through education, legislation, standardization of staging criteria, and identification of research needs. The NPUAP held consensus conferences beginning in May 1988, the outcome of which included standardized staging criteria that are endorsed by the International Association for Enterostomal Therapists and the AHRQ (formerly the Agency for Health Care
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Policy and Research [AHCPR]). Also, to standardize terms and to more accurately reflect the cause of pressure damage, NPUAP decreed that pressure ulcer is a more appropriate term than pressure sore or decubitus. Therefore, the term pressure ulcer is used throughout this discussion.
In December 1989, the Omnibus Budget Reconciliation Act (OBRA) established the AHCPR. On the basis of reviews of current research and practice, this agency was charged with developing clinical practice guidelines that appropriately and effectively prevent, diagnose, treat, and manage clinically relevant disorders and diseases (AHCPR, 1992). Pressure ulcer prevention and management was one of the first three areas reviewed by the AHCPR. Pressure Ulcers in Adults: Prediction and Prevention was published in May 1992, and Treatment of Pressure Ulcers was published in February 1994. Most recently the NPUAP in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP) developed evidence-based guidelines on prevention and treatment that were published in 2009. These comprehensive references continue to be the recommended guides for pressure ulcers. They are used for the discussion that follows.
Epidemiology of Pressure Ulcers The epidemiology of pressure ulcers has been difficult to quantify and varies, depending on sample size, definition of terms, and type of facility. Despite methodologic limitations, incidence (new cases) and prevalence (over a specific period) rates of pressure ulcers are sufficiently high to generate concern.
The incidence of pressure ulcers in hospitals ranges from 2.7% to as high as 60%. The prevalence rate in hospitals ranges from 3.5% to 29.5%. Several studies have identified high-risk groups of hospitalized patients: quadriplegic patients, older patients with hip fractures, orthopedic patients who are immobile, and critical care patients (AHCPR, 1992).
The prevalence rate of pressure ulcers in long-term care facilities ranges from 2.4% to 23%. Incidence rates vary among nursing care facilities because of the heterogeneous case-mix and staffing
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patterns. Better data are needed to determine the degree of the problem in long-term care (AHCPR, 1992). It is believed that OBRA regulations have been instrumental in decreasing the incidence of pressure ulcers in nursing facilities.
Etiology of Pressure Ulcers Pressure on soft tissue over bony prominences or other hard surfaces is the primary causative factor in pressure ulcer formation. However, other contributing factors exist and explain why the tissue of some individuals breaks down within 30 minutes of lying in the same position, whereas that of others does not break down for hours.
Pressure ulcers begin at the point of contact between soft tissue and a hard surface (e.g., bone). Consequently, an inverted-cone– shaped wound develops, with the largest area of breakdown being near the bone. Common bony prominences susceptible to pressure ulcer development are the sacrum, ischial tuberosity (especially in an upright sitting position in a chair or bed), lateral malleolus, trochanter, and heels (Figure 28-1).
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FIGURE 28-1 Common sites for pressure ulcers and frequency of ulceration per site. (Artwork by John A. Craig, MD, from Clinical Symposia, vol
31, No 5. Used as a reference with permission from Icon Learning Systems, a division of MediMedia USA, Inc. All rights reserved.)
The intensity of pressure that leads to capillary closure, compounded by the duration of pressure and tissue tolerance, results in tissue anoxia, ischemia, edema, and eventually tissue necrosis. Immobility, decreased activity, and decreased sensory perception place individuals at risk for unrelieved pressure that generates tissue ischemia and death. Tissue tolerance is influenced by extrinsic factors—moisture, friction, and shearing—and intrinsic factors—poor nutrition, advanced age, hypotension, emotional stress, smoking, and skin temperature (Cox, Laird, & Brown, 1998).
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The development of pressure ulcers is a complex, synergistic phenomenon that makes prevention a challenge (Figure 28-2).
FIGURE 28-2 Factors contributing to the development of pressure ulcers. (Reprinted with permission from Braden, B. & Bergstrom, N. (1987a). A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing, 12(1), 8. Copyright 1987 by the Association of Rehabilitation Nurses.)
Capillary pressure ensures the movement of blood through the capillary membrane, maintaining oxygenation and tissue nutrition. Exact capillary pressure is not known. Various studies have identified ranges from 10 to 14 mm Hg in the venous limb system to 32 to 40 mm Hg in the arteriolar limb system (Landis, 1930).
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Capillary collapse may result from intense and prolonged pressure, which leads to tissue anoxia, ischemia, reactive hyperemia (erythema), leakage of plasma into interstitial tissue, and microvascular hemorrhaging observable by nonblanchable erythema. If the pressure persists, tissue death will result. It is assumed that capillary pressure ranging from 10 to 40 mm Hg, which varies according to the location and individual, must be exceeded to impair circulation.
People with sensory impairment (paralysis or sedation) do not have a normal protective reflex, which is shifting weight in response to discomfort from capillary closure and tissue anoxia. This inability may explain the higher incidence of pressure ulcers among individuals with paralysis or those undergoing long surgical procedures. Patients with altered mental status as a consequence of disease (e.g., dementia) or medication may have decreased pain or tissue anoxia perception. These individuals are at risk for pressure ulcer development.
Tissue tolerance, another major contributing factor in the development of a pressure ulcer, is defined as the ability of the skin and supporting structures to endure the effects of pressure. It is apparent, then, that poor tissue tolerance makes one more vulnerable to pressure intensity and duration, thus increasing the response to pressure. Shearing, friction, age-related changes in the integumentary system, low blood pressure, and nutritional status all influence tissue tolerance.
Shearing, which is the sliding of parallel surfaces, causes stretching and occlusion of the arterial supply, usually of the fascia and muscle. Shearing forces may decrease the blood supply, leading to tissue ischemia and necrosis. The most common position for shearing is when the head of the bed is elevated, causing the body to slide downward (Figure 28-3). Resistance keeps the skin in place while gravity pulls the body toward the foot of the bed. It is believed that shearing forces cause more damage than is recognized: as many as 40% of pressure ulcers result from shearing rather than pressure (Bryant, Shannon, Pieper et al., 1992).
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FIGURE 28-3 Shearing force. (From Loeper, J.M., Flinn, N.A., Irrgang, S.J., et al. (1986). Therapeutic positioning and skin care. Minneapolis, MN: Sister Kenny
Institute.)
Friction, the rubbing of skin against another surface, primarily affects the epidermal and dermal layers, causing a superficial abrasion (e.g., sheet burn) (Maklebust, 1997). Restless patients or those with persistent movements are at risk for friction injuries. However, when friction occurs concurrently with gravitational forces, shearing is the outcome.
Moisture from incontinence or profuse sweating may decrease tensile strength, alter skin resiliency to external forces, and exacerbate friction and shearing forces (Cox et al., 1998). Some experts believe that friction and shearing forces are increased in the presence of mild to moderate moisture and decreased in the presence of profuse moisture (Bryant et al., 1992). Therefore, urinary incontinence may not be as significant in pressure ulcer development as was once thought. Regardless, efforts should be made to keep the skin dry.
As many studies have revealed, nutritional status greatly influences the development of pressure ulcers. Protein deficiency weakens tissue tolerance (i.e., the spring between the skin surface and bony prominences), making soft tissue more susceptible to breakdown when pressure intensity is prolonged. Hypoproteinemia changes osmotic equilibrium, which leads to
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edema. Consequently, sluggish oxygenation and transportation create an environment for tissue breakdown and poor healing. Serum albumin levels below 3.5 grams per deciliter (g/dL) have a correlation with pressure ulcer development and poor wound healing (Thomas, 1997). Proteins are also needed for collagen formation, granulation tissue formation, and immunologic response.
The incidence of pressure ulcers is increased in older adults, particularly in those older than age 70. With aging, the epidermis thins, elasticity decreases, and vessels degenerate, resulting in reduced blood flow. These age-related changes impair the early warning sign of erythema, delay crucial early immunologic responses, and impede the healing process, thereby making older adults at risk for pressure ulcer development.
Low blood pressure and dehydration may reduce circulation, especially in the microvasculature, which eventually leads to tissue ischemia. Diastolic blood pressure below 60 mm Hg has been found to be a risk factor for pressure ulcer formation, presumably because of decreased peripheral circulation and subsequent ischemia (Braden & Bryant, 1990).
Other intrinsic factors are stress, smoking, and elevated body temperature. Emotional stress with reduction in effective coping mechanisms leads to release of cortisol from the adrenal glands. The effects of cortisol are not completely understood but are believed to alter the skin’s ability to absorb mechanical loads such as pressure. In addition, cortisone may affect cellular metabolism between capillary beds and cells, making the skin vulnerable to breakdown and poor healing. A relationship between cigarette smoking and pressure ulcer development is becoming evident, especially in patients with spinal cord injury. The reason is not clear but is thought to be related to vasoconstriction. Elevated temperature, especially in older adults, is associated with pressure ulcer formation, possibly caused by increased oxygen demands in anoxic tissue (Bryant et al., 1992).
The formation of a pressure ulcer is a complex process involving many variables within the nurse’s control (e.g., pressure, shearing, and moisture), as well as variables out of the nurse’s control (e.g.,
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smoking, malnutrition, low blood pressure, and paralysis). The principal mechanisms of injury are loss of microcirculation through pressure compressing the microvessels or intrinsic factors causing soft tissue to become more vulnerable to lost blood supply.
Risk Assessment Tools The success of pressure ulcer prevention depends on early identification of at-risk patients. As recommended by the AHCPR clinical guidelines, a valid, research-based assessment tool should be used. For consistency and accuracy to be established, there should be written protocols specifying how to use the risk assessment tool, when to use it, and which health care team members should use it. A risk assessment should be conducted on all individuals who are bed bound, chair bound, incontinent, frail, disabled, or nutritionally compromised or who have demonstrated altered mental status (AHCPR, 1992). An assessment should be conducted on patients admitted to an acute care facility, rehabilitation hospital, nursing facility, home care agency, or other health care facility. Identified high-risk individuals should be reassessed at regular intervals if mobility or activity is impaired. The risk assessment should be repeated and the care plan modified accordingly whenever a patient’s condition changes. Examples of these changes include decreased mobility, eating less, a change in the serum albumin level or other abnormal laboratory findings, and mentation changes.
Numerous instruments have been designed to identify patients at risk for pressure ulcer formation. However, many tools have not been subjected to vigorous evaluation of reliability and validity testing. The Braden and Norton risk assessment tools, according to AHCPR clinical guidelines, have undergone the most extensive evaluations.
The Norton Risk Assessment Scale was the first such tool designed for use in a study investigating geriatric nursing problems in hospitals. Consequently, it has set the stage for more comprehensive assessment tools. The study began in the late 1950s, but results were not disseminated until a conference in 1962. At that
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time, it was believed that pressure ulcers were the result of poor nursing care; however, additional research has revealed the problem to be much more complex. The Norton scale is simple to use and has only five assessment categories. Although the original research assessed nutritional status, it was not included in the scale because it was believed that the patient’s general health was a reflection of nutritional status. Norton (1989) indicates that nutritional status, including eating behaviors, would have been an important parameter to include. Patients with a score of 16 or lower on the Norton scale are considered to be at risk for pressure ulcer development (Figure 28-4).
FIGURE 28-4 Norton risk assessment scale. (Reprinted with permission from Norton, D., McLaren, R., & Exton-Smith, A.N. (1975). An investigation of
geriatric nursing problems in hospital. Edinburgh, Scotland: Churchill Livingstone.)
The Braden Scale for Predicting Pressure Sore Risk has been shown to be highly reliable when used by registered nurses and is the most rigorously tested risk assessment tool (AHCPR, 1992; Bergstrom et al., 1987). The Braden scale assesses sensory perception rather than mental status. Assessing sensory perception is thought to be a more precise risk indicator because impaired sensation prevents an individual from sensing the need to change positions, which, in turn, would decrease pressure intensity (Braden & Bergstrom, 1987b). As a rule, a patient scoring below 18 on the Braden scale is considered to be at high risk for skin breakdown (Figure 28-5) (see Evidence-Based Practice Box).
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FIGURE 28-5 Braden scale for predicting pressure sore risk. IVs, Intravenous feedings; NPO, nothing by mouth; TPN, total parenteral
nutrition. (Copyright by Barbara Braden and Nancy Bergstrom, 1998. All rights reserved. Reprinted with permission.)
Evidence-based Practice Pressure Ulcer Preventive Devices Use Sample/Setting Two large urban hospitals were the setting. The researcher enrolled 792 inpatients age 65 or older in the study. The average patient was 77 years old, black, female and was hospitalized for 5 days. The study data were collected between the years 1998 and 2001.
Methods Patients or their proxy were contacted on day 3 of the hospitalization for consent to participate in this study. If consent was given, data were collected on the presence of pressure wounds, characteristics of the pressure wounds, use of
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preventive devices, Norton Scale score, nutritional status, comorbidities, incontinence, mental status, and functional status. Charts were also reviewed for accuracy of documentation regarding the existence of pressure wounds.
Findings Findings of interest were as follows: 88.3% (n = 561) of patients had no pressure wounds. Of those patients with pressure wounds, 146 had only 1 pressure wound, 40 had 2 pressure wounds, and 45 patients had 3 pressure wounds. For patients with pressure wounds, documentation of the wound was located in 67.5% of the medical records. Of all the patients, 17% were at risk for skin breakdown according to their Norton Scale score (< 14). Of those at risk, 51% had preventive devices in place. Preventive device use included replacement mattresses (0.4%), overlay mattresses (3.6%), heel protectors (2.9%), chair cushioning (1.1%), positioning pillows (11.4%), and other (0.6%).
Implications This study may not represent the current state of nursing knowledge and vigilance in prevention of pressure wounds at this date, although the findings highlight areas of concern. The most concerning issues are implementation of preventive devices for patients at risk and actual documentation of skin changes. Nurses should be vigilant in the use of preventive measures to avoid skin breakdown. Interventions such as screening patients with the Norton or Braden scale, turning, and the use of overlay mattresses are easy to implement. Not doing so is likely to result in skin breakdown, which is costly to patients both financially and from a morbidity perspective. When the use of a screening tool indicates the risk of skin breakdown, the nurse should implement preventive measures as available in his or her facility. Hospitals must offer options for preventive devices that are easy to use and must educate nurses regarding the importance of these devices.
Once a pressure wound occurs, be it preexisting or hospital acquired, documentation of the wound and its characteristics is necessary for appropriate follow-up care and reimbursement by
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Centers for Medicare and Medicaid Services (CMS).
Prevalence studies such as this are an important start to benchmarking data. Many hospitals across the United States participate in the National Database of Nursing Quality Indicators (NDNQI) that includes wound prevalence. These data allow hospitals to compare their findings with those of other facilities and then determine whether current nursing care practices are reducing the number of wounds. Many facilities in the United States have instituted detailed policies and protocols for wound prevention in response to the CMS announcement that hospitals would not be reimbursed financially for treatment of wounds that develop during hospitalization. It would be important for hospitals to know whether these interventions have any positive effect on the prevalence of wounds and whether they are truly being implemented as expected. (From Rich, S.E., Shardell, M., Margolis, D., & Baumgarten, M. (2009). Pressure ulcer preventive device use among elderly patients early in the hospital stay. Nursing Research, 58(2), 95-104.)
Another tool discussed in the literature is Gosnell’s scale, designed in the mid-1980s. Gosnell’s scale paralleled Norton’s; however, it added nutritional and other medical variables such as medications, vital signs, and hydration status. Risk scoring has been revised from the original work, and higher scores reflect greater risk (Gosnell, 1989). The tool requires more data collection but includes more in-depth assessment of intrinsic factors such as blood pressure and hydration. Although this tool has undergone some reliability and validity testing, AHCPR still endorsed the Braden and Norton scales because these tools have been more extensively tested.
Preventive Strategies Prevention is the first line of defense against pressure ulcers, which are costly health care problems that adversely affect a patient’s quality of life. The professional nurse has a responsibility to identify patients at risk for pressure ulcers and to implement research-based preventive strategies. Nurses as front-line providers and managers
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of care are key health care team members who can influence the prevalence of pressure ulcers and enhance the patient’s quality of life. Nurses should mobilize the health care team when needs are identified by seeking a dietary consultation and alerting the physician or the APRN when a patient is not eating sufficiently or when a patient develops nonblanchable erythema. Written preventive protocols endorsed (and embraced) by the health care team and institution empower the professional nurse to act independently and immediately when vulnerable patients are identified.
All at-risk individuals identified through use of a risk assessment tool should have a daily skin inspection with close attention to bony prominences as recommended by AHCPR clinical guidelines. The EPUAP and NPUAP guidelines also recommend assessment for localized heat, edema, or induration. These signs are recommended as warning signs of pressure ulcer development on darkly pigmented skin because redness is not always possible to see. This routine assessment should be documented to demonstrate professional accountability and so that preventive strategy outcomes can be evaluated. Another skin-related activity recommended by AHCPR clinical guidelines is to cleanse the skin of a patient with incontinence with a mild, nonirritating cleanser using warm—not hot—water at the time of soiling to minimize skin irritation and dryness. Moisturizers such as emollient lotions, should be used to keep the skin from drying and cracking. It is best to apply the lotion immediately after bathing to increase the moisture absorbed by the skin. Skin should not be rubbed or massaged over bony prominences because it may cause further deep tissue damage, especially if erythema is present (which already indicates injury) (AHCPR, 1992; EPUAP & NPUAP, 2009).
Proper turning and placement reduce the effects of pressure but not the intensity. It has been standard practice to turn patients a minimum of every 2 hours, which was endorsed in the AHCPR clinical guidelines. However, capillary closing pressure varies with each individual; therefore, the ideal strategy is to determine the turning schedule based on development of erythema, which may precede ischemia (Bergstrom et al., 1987). For many reasons, this
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ideal strategy may not be possible, but it should be done when staffing and the patient’s condition allow a turning schedule based on the clinical presentation of erythema, particularly in frail, vulnerable patients.
Patients should be turned only at a 30-degree oblique angle rather than a lateral, side-lying 90-degree angle to decrease pressure intensity over the trochanter and lateral malleolus prominences. It is also easier to turn a person at a 30-degree angle (Colin, Abraham, Preault et al., 1996) (Figure 28-6). To decrease pressure intensity on the heels, a patient should have a pillow or pillows under the calves to lift the feet and heels off the bed. Commercial devices also exist to suspend the heel, maintain or correct foot-ankle position, and protect the patient from neurosensory damage.
FIGURE 28-6 Repositioning schedule. Begin with the person on his or her back. Reposition by placing pillows underneath the
person’s shoulder blades, buttocks, and thighs. Adjust the pillows so that the person is at a 30-degree angle to the mattress. Alternate
the position from right to left. Elevating the head of the bed increases the risk for ulcer development and should be avoided.
Avoid placing persons at high risk for ulcer development flat on their backs. (Modified from Colin D., Abraham P., Preault L., Bregeon C., & Saumet, J.L. (1996). Comparison of 90 degrees and 30 degrees laterally inclined positions in the
prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures. Adv Wound Care, 9(3):35-8. Reprinted with permission from Family Pract
Recertification, 12,104 1990.)
At-risk individuals should be placed on a pressure-reducing device in hopes of preventing the development of a pressure ulcer by decreasing pressure intensity. Pressure-reducing support surfaces such as mattress overlays, chair cushions or overlays, and specialized beds, redistribute weight over a larger area and reduce tissue-interface pressure. Tissue-interface pressure is the amount of
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pressure between the skin and resting surface (e.g., mattress). It has been thought that if the tissue-interface pressure is 32 mm Hg or lower, capillary closure will not occur. However, this logic may be questioned because capillary closing pressures vary from one individual to another.
Mattress overlays reduce pressure, are usually economical with only a one-time charge, and are accessible in most environments. Overlays may be static (e.g., foam, gel, water, air, and low air loss) or dynamic (e.g., alternating air). Because the overlays are placed on top of a mattress, the height of the bed is increased, making it more difficult for patients to get in and out of the bed, which is a common patient and nurse complaint. The overlay may also decrease the protective height of bed side rails because the effective mattress height has increased. Some mattress overlays trap moisture and heat, which may be uncomfortable. Foam overlays should have a base height of at least 4 inches from the bottom to the beginning of the convolutions, not to the peak, and a stiffness of 25% of indentation load deflection (AHCPR, 1992). Foam overlays must also be examined regularly to assess for continued effectiveness (i.e., no obvious sagging) because their use is limited. Static air and water overlays must be checked regularly for proper inflation and must be cleaned periodically.
Specialty beds such as air-fluidized beds (Clinitron) or low-air loss beds (KinAir or Flexicair) are generally used for individuals who have multiple stage III and IV pressure ulcers or who are at high risk, after posterior grafts or flap procedures. These beds may, in fact, overheat a patient and may elevate the body temperature if not adequately controlled. Multiple hybrids of the air-fluidized and low–air loss beds exist, which enables the nurse to better match beds with patient needs. Specialty beds do not eliminate the need for meticulous nursing care. Patients must still be repositioned, assessed, and kept clean and dry.
The presence of skin moisture (whether the result of incontinence of urine or feces, perspiration, or wound exudate) should be minimized. If necessary, absorbent underpads or diapers may be used to maintain a dryer skin surface. However, it is important to check these absorbent pads or diapers frequently to determine
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whether new products are needed after significant wetting or any soiling. Topical barriers such as zinc oxide may be applied after cleansing and gently drying the skin (AHCPR, 1992). Indwelling Foley catheters should be used only on a short-term basis or avoided, if at all possible, because of the risk of urinary tract infections. Thought must be given to the reason for a catheter and whether the benefit of placement outweighs the risk of infection. Although most orders are for turning and repositioning every 2 hours, the primary care provider may need to be contacted to implement consistent scheduled checks before the 2-hour intervals. With implementation of regular checks to keep skin clean and dry and the use of absorbent pads and topical barriers, catheter placement can be avoided, thus reducing patient risk.
Skin injury from friction or shearing forces can be avoided by using proper turning techniques and proper placement. Friction injuries can be prevented by using proper transfer techniques and a draw sheet. Lubricants, topical barrier creams, film or hydrocolloid dressings, or protective padding may be used to reduce damage when skin moves across a coarse or hard surface. Shearing results when the body shifts and slides downward; therefore, most shearing injuries can be eliminated with proper placement. For example, not elevating the head of the bed greater than 30 degrees and elevating the knees slightly when the head is elevated prevent slipping down in bed. When the patient is sitting in a chair, placing the feet on a stool prevents sliding downward (AHCPR, 1992).
Nutritional status must be closely monitored by assessing caloric intake, weight, levels of serum albumin and cholesterol, and total lymphocyte count (TLC). Accurate food intake should be monitored routinely to identify both the need for changes before a compromised state develops and nutritionally at-risk patients. Hydration status is another important nutritional component because dehydration may contribute to development of a pressure ulcer. An older adult requires a minimum of 2000 to 2500 mL of water a day, unless contraindicated such as in CHF or renal failure. The use of an air-fluidized or low–air-loss bed increases daily fluid needs because insensible loss is increased. When the professional nurse recognizes a pattern of decreased food or water intake, a full
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assessment addressing food preferences, dentition, and swallowing difficulties is warranted. The patient should also be evaluated for constipation or fecal impaction, which decreases appetite. A more comprehensive nutritional assessment may be necessary, which may include a registered dietician consultation, occupational therapy, and a dental appointment; nutritional supplements may be needed. A person’s weight changes slowly; therefore, weighing the patient monthly is sufficient and is needed more frequently only when assessing cardiovascular status. A weight loss of 5% to 10% is significant, and a weight loss of one third of the ideal body weight is an ominous sign (Stotts & Wipke-Tevis, 1996).
A serum albumin level of 3 g/dL or lower is associated with protein malnutrition and increased morbidity and mortality (Stotts & Wipke-Tevis, 1996). Malnutrition is also correlated with a low TLC. A TLC of 800 to 1200/mm3 (cubic millimeter) is indicative of moderate malnutrition, and a count below 800/mm3 is classified as severe malnutrition (Pinchcofsky-Devin & Kaminski, 1986). Pinchcofsky-Devin and Kaminski (1986) demonstrated a relationship between pressure ulcers and a TLC below 1200/mm3. The level of serum protein and TLC are valid nutritional indicators for pressure ulcer development. Serum cholesterol level is another nutritional variable to monitor. Several studies have demonstrated a positive correlation between nursing facility residents’ and hospitalized patients’ mortality rates and serum cholesterol levels below 120 to 150 milligrams per deciliter (mg/dL) (Strauss & Margolis, 1996). Therefore, a serum cholesterol level below 150 mg/dL warrants aggressive nutritional support.
Because of multiple risk factors and their synergistic effect on pressure ulcer development, prevention is a nursing challenge, offering an opportunity to demonstrate the impact of nursing by recognizing at-risk patients, immediately implementing preventive strategies, and preventing a costly health care problem. Most of all, preventive measures promote high-quality patient care, which is the primary goal of nursing (Box 28-2).
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Box 28-2
Pressure Ulcer Prevention Points Risk assessment 1. Consider all bedbound or chairbound persons, or those whose
ability to reposition is impaired, to be at risk for pressure ulcers.
2. Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors.
3. Assess all at-risk patients at the time of admission to health care facilities and at regular intervals thereafter.
4. Identify all individual risk factors (e.g., decreased mental status, moisture, incontinence, nutritional deficits, altered perfusion and oxygenation, and advanced age) to direct specific preventive treatments. Modify care according to the individual factors.
5. Develop and implement a prevention plan when individuals are identified as being at risk.
Skin care and early treatment 1. Inspect the skin at least daily, and document assessment
results.
2. Consider signs other than redness for darkly pigmented skin (e.g. localized heat, edema, and induration).
3. Individualize bathing frequency. Use a mild cleansing agent. Avoid hot water and excessive friction.
4. Assess and treat incontinence. When incontinence cannot be controlled, cleanse skin at the time of soiling, use a topical moisture barrier, and select underpads or briefs that are absorbent and provide a quick-drying surface to the skin.
5. Use moisturizers for dry skin. Minimize environmental factors leading to dry skin such as low humidity and cold air.
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6. Avoid massaging over bony prominences.
7. Use proper positioning, transferring, and turning techniques to minimize skin injury from friction and shear forces.
8. Use dry lubricants (cornstarch) or protective coverings to reduce friction injury.
9. Identify and correct factors compromising protein and calorie intake and consider nutritional supplementation or support for nutritionally compromised persons. Refer to a registered dietician for a nutritional consultation.
10. Institute a rehabilitation program to maintain or improve mobility and activity status.
11. Monitor and document interventions and outcomes.
Mechanical loading and support surfaces 1. Reposition bedbound persons at least every 2 hours and
chairbound persons every hour.
2. Use a written repositioning schedule.
3. Place at-risk persons on a pressure redistributing mattress or chair cushion. Do not use doughnut-type devices, synthetic sheepskin pads, or water-filled devices.
4. Consider postural alignment, distribution of weight, balance and stability, and pressure relief when positioning persons in chairs or wheelchairs.
5. Teach chairbound persons to shift their weight every 15 minutes, if they are able.
6. Use lifting devices (e.g., trapeze, mechanical, or bed linen) to move rather than drag persons during transfers and position changes.
7. Use pillows or foam wedges to keep bony prominences such as knees and ankles from making direct contact with each other.
8. Use devices that totally relieve pressure on the heels (e.g., place pillows under the calf to raise the heels off the bed).
9. Avoid positioning the patient directly on the trochanter when
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the patient is in the side-lying position (use the 30-degree lateral inclined position).
10. Elevate the head of the bed as little (maximum 30-degree angle) and for as short a time as possible.
Education 1. Implement educational programs for the prevention of pressure
ulcers that are structured; organized; comprehensive; and directed at all levels of health care providers, patients, family, and caregivers.
2. Include information on the following:
• Etiology of and risk factors for pressure ulcers
• Risk assessment tools and their application
• Skin assessment
• Selection and use of support surfaces
• Development and implementation of individualized programs of skin care
• Demonstration of positioning to decrease risk of tissue breakdown
• Accurate documentation of pertinent data
3. Include built-in mechanisms to evaluate program effectiveness in preventing pressure ulcers.
(From Agency for Health Care Policy and Research (AHCPR). (May 1992). National Pressure Ulcer Advisory Panel’s Summary of the AHCPR Clinical Practice Guideline: Pressure ulcers in adults: Prediction and prevention, AHCPR Pub No 92–0047, Rockville, MD: USDHHS; European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009). Treatment of pressure ulcers: Quick reference guide. Washington, D.C.: National Pressure Ulcer Advisory Panel.)
Pressure Ulcer Management Nurses play a key role in pressure ulcer management because they are the professionals responsible for wound care and often the first team members to identify wound changes. In addition, the professional nurse, especially in long-term care, is perceived by
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physicians as an expert in pressure ulcer management. It is not uncommon for physicians to say, “Do whatever treatment you think is best.” Often, the physician or the APRN, when assessing medical management, asks the nurse to describe and evaluate the treatment. Therefore, it is important for the professional nurse to comprehend the healing process, to understand treatment strategies, and to maintain a current knowledge base. The following discussion reviews the healing trajectory and treatment options, which include nutritional management. It is hoped that the professional nurse will become empowered, promote a positive image for nursing, and, most important, be able to deliver more successful patient care by comprehending the physiology of the healing process and the logic for treatment strategies.
Physiology of Wound Healing An understanding of the healing process is necessary for critically analyzing pressure ulcer care and determining the best management strategy. Pressure ulcer research has expanded our understanding of the etiology of pressure ulcers and the healing process. The three major stages of wound healing are (1) the inflammatory stage; (2) the proliferative, or granulation, stage; and (3) the maturation, or matrix formation, stage.
The inflammatory stage, characterized by redness, heat, pain, and swelling, lasts approximately 4 to 5 days. The inflammatory stage initiates the healing process by stabilizing the wound through platelet activity that stops bleeding and triggers the immune system. Neutrophils, monocytes, and macrophages arrive within 24 hours of the insult to control bacteria, remove dead tissue, and secrete angiogenesis factor (AGF) and other growth factors, which stimulate the development of granulation tissue. Bradykinin and histamine, released from injured cells, cause vasodilation, which leads to swelling. This creates the red, swollen, tender, clinical presentation often seen in wounds (Schaffer & Barbul, 1998). The inflammatory stage is crucial for successful healing, and a delayed or altered response may possibly contribute to the development of chronic, stagnant wounds if appropriate growth factors and responses were not mobilized when the patient was first injured.
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Medications (e.g., steroids), decreased tissue oxygenation, poor nutritional status, and age-related changes (e.g., decreased response of the immune system) may impede this stage.
The proliferative, or granulation, stage begins 24 hours after injury and continues for up to 22 days. Three significant events occur: (1) epithelialization, (2) granulation, and (3) collagen synthesis. Epithelialization, via a microscopic epithelial layer, seals and protects the wound from bacteria and fluid loss. This microscopic layer, which is fostered by a moist environment, is extremely fragile and may easily be washed away with aggressive wound irrigation or harsh wiping of the involved area. Granulation, also known as neovascularization, is the formation of new capillaries that generate and feed new tissue, creating a beefy-red tissue bed that bleeds easily. Collagen synthesis creates a support matrix that provides strength to the new tissue. Oxygen, iron, vitamin C, zinc, magnesium, and amino acids are necessary for collagen synthesis. Fibroblasts, stimulated in the first phase by AGF, are necessary for collagen production. This phase rebuilds the injured area and can easily be influenced by the effectiveness of the inflammation stage and wound environment.
The maturation stage, also known as the differentiation or remodeling phase, is the final stage. It does not begin until 21 days after injury and may take years. During this stage, maximum tensile strength is generated through collagen deposits that make the wound thicker and more compact. These collagen deposits contract until closure is attained. Initially, the scarred area is a dark, scarlet red that fades over time to a silvery white. Tensile strength reaches only 80% of preinjury capacity; therefore the “scarred” area is more vulnerable to breakdown or injury (Hunt, 1988).
Definition of Terms and Staging Criteria A pressure ulcer is “any lesion caused by unrelieved pressure resulting in damage of underlying tissue” and is usually over bony prominences (AHCPR, 1992).
A pressure ulcer is localized injury to the skin, underlying tissue, or both, usually over a bony prominence, as a result of pressure, or
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as a result of pressure in combination with a shear (EPUAP & NPUAP, 2009).
The recommended staging criteria established by the NPUAP in 1989 were adopted by AHCPR clinical practice guidelines, and the 2009 EPUAP–NPUAP guidelines did not change these criteria but added the term category to each stage I-IV(Box 28-3). If an ulcer is covered with eschar, a stage cannot be determined until the eschar is removed. Box 28-4 provides the definitions of relevant terms.
Box 28-3
Staging Criteria Suspected deep tissue injury
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Purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure, shear, or both. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler, as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with treatment.
Stage/category I: Nonblanchable erythema
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An area of red, deep pink, or mottled skin that does not blanch with fingertip pressure. In people with darker skin, discoloration of the skin, warmth, edema, or induration (area feels hard) may be signs of a stage I pressure ulcer. May indicate “at risk” persons.
Stage/category II: partial thickness
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Partial-thickness skin loss involving epidermis, dermis, or both. It may look like an abrasion, blister, or shallow crater. The area surrounding the damaged skin may feel warmer. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.
Stage/category III: full-thickness skin loss
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Full-thickness skin loss that looks like a deep crater and may extend to the fascia. Subcutaneous tissue is damaged or necrotic. Bacterial infection of the ulcer is common and causes drainage from the ulcer. There may be damage to the surrounding tissue.
Stage/Category IV: Full-Thickness Tissue Loss
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Full-thickness tissue loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures; sinus tracts may be present. Infection is usually widespread. The ulcer may appear dry and black, with a buildup of tough, necrotic tissue (eschar), or it may appear wet and oozing.
Unstageable/unclassified: full-thickness skin or tissue loss
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Loss of full thickness of tissue. The base of the ulcer is covered by eschar (tan, brown or black in color) in the wound bed, or the base of the ulcer contains slough (yellow, tan, gray, green, or brown in color). Stable eschar on the heels serves as “the body’s natural cover” and should not be removed.
From the AHCPR, National Pressure Ulcer Advisory Panel, 2007. Reprinted with permission. Reproduction of the National Pressure Ulcer Advisory Panel (NPUAP) materials in this document does not imply endorsement by the NPUAP of any products, organizations, companies, or any statements made by any organization or company.
From European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick reference guide. (2009). Washington, D.C.: National Pressure Ulcer Advisory Panel.
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Box 28-4
Definitions of Terms Autolysis: Self-débridement of necrotic tissue by white blood
cells, which is fostered by a dressing that retains moisture (e.g., transparent film); a yellowish brown fluid is generated from the white blood cells and breakdown of tissue
Débridement: Removal of dead, damaged tissue
Epithelialization: Growth of a microscopic layer that covers an open wound, which creates a barrier that protects from fluid loss and bacterial assault and that is highly fragile and easily destroyed
Eschar: Thick, necrotic, devitalized tissue; often black but may be yellowish
Exudate: Wound discharge that may be serosanguinous, serous, or purulent
Friction: Rubbing of skin against another surface (e.g., sheets, bed, or chair)
Granulation tissue: New capillary growth that creates a beefy-red color and tissue that bleeds easily (friable)
Interface pressure: Force exerted between body and support surface (e.g., mattress)
Pressure ulcer: Lesion caused by unrelieved pressure that causes tissue damage and death; usually occurs over bony prominences or other pressure points (e.g., tubing, foreign material in bed)
Reactive hyperemia: Transient, blanching erythema from tissue anoxia, which generates a compensatory mechanism resulting in dilated vessels
Shearing force: Sliding of parallel surfaces when skeletal frame
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and deep fascia slide downward; the superficial fascia remains attached to the dermis, thus stretching or occluding the arterial supply to fascia and muscle, which may lead to tissue anoxia and damage; most common position for this occurrence is when the head of the bed is elevated and the body slides downward
Sinus tract: Vertical tunnel connecting one anatomic compartment with another
Tissue tolerance: The skin’s (i.e., blood vessels, interstitial fluid, collagen, and other structures) ability to endure the effects of pressure without adverse consequences
Undermining: Separation of tissue under the dermis creating a horizontal tunnel; length can be measured by inserting a cotton- tipped applicator into the tunnel, marking length on applicator, and then placing next to a tape measure
(Modified from Bryant, R.A., Shannon, M.L., Pieper, B., et al. (1992). Pressure ulcers. In R.A. Bryant (Ed.), Acute and chronic wounds: Nursing management. St. Louis, MO: Mosby; Agency for Health Care Policy and Research. (1992). Pressure ulcers in adults: Prediction and prevention, Clinical Practice Guideline No 3, Rockville, MD: US Department of Health and Human Services; Sanders, S.L. 1992). Pressure ulcers, part II: Management strategies. Journal of the American Academy of Nurse Practitioners, 4(3), 101.)
Basic Principles of Pressure Ulcer Management Three basic principles guide successful pressure ulcer management:
1. Eliminate or minimize precipitating factors such as pressure, friction, shearing, and poor nutrition.
2. Provide nutritional support and monitor nutritional status.
3. Create and maintain a clean, moist wound environment with adequate circulation and oxygenation.
Pressure ulcer preventive strategies must be implemented, or wound care efforts are futile (review Box 28-2). Through institutional policy and protocol, the professional nurse applies an appropriate mattress overlay without waiting for a physician’s order. The professional nurse ensures that proper technique is used by all staff members when repositioning a patient to minimize shearing and friction forces. As leader of the nursing team, the professional nurse is responsible for observing nursing aides or
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other support team members who deliver hands-on care to identify specific learning needs so that pressure, shearing, and friction are minimized. Teaching the logic for such techniques may motivate staff members to exercise more diligence in performing proper preventive actions. The nurse must rely on teaching principles such as repetition of key information in a nonthreatening manner. He or she should reinforce appropriate activity with positive feedback.
Nutritional status should be monitored; specifically, the physician or the APRN should monitor serum albumin levels, prealbumin levels, weight, and food consumption so that needs can be identified immediately. This also promotes a collaborative effort among health care providers. When food intake is first noted to decrease, the professional nurse should identify reasons, such as not meeting food preferences, sore mouth, the patient’s being rushed to eat, conflict with staff, depression, or pain.
For closure of the wound or ulcer, a clean, moist environment must be created and maintained. This principle, which has been scientifically established, is the key to successful healing and should guide the professional nurse and practitioner. Consequently, necrotic tissue must be removed and any infectious process (as evidenced by erythema, induration, and tenderness in the periwound skin; pus; or a pale wound bed) resolved to implement a dressing strategy that fosters rapid epithelialization and granulation.
It is important to know when to culture a wound because of the expense to the patient and the health care system. Also, inappropriate antibiotic use is decreased when wounds are cultured appropriately. All wounds are contaminated; therefore, all cultures grow surface bacteria, and the true pathogen may not be identified. A culture is warranted only when cellulitis (e.g., erythema, induration, and tenderness) or a wound infection (evidenced by a pale wound bed, pus, increased tenderness, persistent exudate, or no new growth) exists. An accurate culture includes both anaerobic and aerobic species. To obtain the culture, the nurse should use the most accurate method, considered the gold standard for pressure ulcer cultures, which is a tissue or needle aspiration biopsy (Robson, 1997). According to the AHCPR treatment guidelines, an
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ulcer is not to be cultured with the use of a culturette because colonized bacteria may be obtained instead of the offending pathogen.
The EPUAP–NPUAP treatment guidelines recommend obtaining a tissue biopsy or quantitative swab technique. An infected wound is managed topically with antiseptics, or systemically, depending on the severity and risk of osteomyelitis.
Great controversy has existed in recent years regarding the use of antiseptic solutions such as povidone-iodine (Betadine) or acetic acid because of their cytotoxic effects. Antiseptic solutions should be used only when the wound is obviously infected, never on a healthy, granulating ulcer. Infection and associated stress on the wound are as destructive as—maybe more destructive than—any antiseptic. The proper dilution of the solution is also important for minimizing tissue damage. The management goal must be kept in mind: to obtain a clean wound bed. If an antiseptic can facilitate the achievement of this wound environment, it should be tried, especially if it means a patient does not have to be admitted to a hospital or receive intravenous antibiotic therapy. The key to successful use of any antiseptic agent is discontinuing it when purulent discharge or signs of infection have resolved so that tissue destruction is minimal.
Antiseptic solutions are used with wet-to-dry dressings, which also provide some mechanical débridement. At times, a wound may be irrigated with the antiseptic; however, a rinse with normal saline should follow. The most common antiseptics are povidone- iodine, acetic acid, hydrogen peroxide, and sodium hypochlorite (also known as Dakin solution [Clorpactin]). All four solutions are cytotoxic and destroy fragile epithelial tissue and fibroblasts. Povidone-iodine, when used long term or undiluted, may cause systemic iodine toxicity, which is evidenced by an unpleasant brassy taste, burning in the mouth or throat, sore gums and teeth, increased salivation, head and cold symptoms (rhinitis), gastric irritation, diarrhea, and occasional fever; it has been known to lead to death (Goodman, Thomas, & Rappaport, 1990). The keys to successful use of povidone-iodine are dilution, short-term use (3 to 5 days), and avoiding use on a healthy, granulating wound bed.
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Acetic acid is recommended for wounds infected with Pseudomonas organisms, evidenced by a malodorous, green discharge or positive culture. Hydrogen peroxide provides some débridement by effervescent action. It would be prudent not to use hydrogen peroxide in a sinus tract or deep, cavernous wound. Sodium hypochlorite, which is essentially diluted bleach, may affect clotting abilities and may also burn intact healthy tissue not protected by zinc oxide. Second-degree burns have been witnessed from Dakin solution that was inadvertently splashed on the skin surrounding a wound. Regardless of the solution, it should be used only during times of infection and wound stress. If the professional nurse notices that antiseptic use has continued for longer than 1 week, a reminder or question should be posed to the physician or the APRN.
The first step in pressure ulcer wound care is to thoroughly assess the wound to determine the most effective strategy and dressing. The professional nurse is usually the first person to identify a need for change; therefore, this assessment should be an ongoing process. The nurse should examine the wound, noting its color; any discharge, bleeding, or odor; degree of undermining or presence of a sinus tract (may be measured using a cotton-tipped applicator); any necrotic tissue; pain or tenderness; and amount of erythema surrounding the wound edges. Limited erythema around the wound is a normal phenomenon that signifies increased circulation to provide nutrients; however, if the erythema extends, infection or candidiasis should be suspected and the wound closely monitored. Ideally, the wound base should be a beefy-red color, which is indicative of granulation. However, some hydrogel and hydrocolloid dressings generate a pale pink wound bed, which ordinarily would mean an “ill” wound bed. If the bed is pale pink and not associated with a purulent discharge or cellulitis, the wound environment is most likely clean and should just be observed. Note that granulation tissue has a rich capillary supply and bleeds easily and profusely when disturbed (e.g., when it is irrigated or during a dressing change). Thus, if a tunneling wound bleeds, it can be deduced that granulation tissue exists, although it is not visible as a result of the tunneling.
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The wound assessment should be ongoing and supported with documentation. All new wounds should be described, including location, color, discharge, tenderness, amount of necrotic tissue or undermining, dimensions, and stage. The wound measurements should include length, width, and depth. When measuring undermining, the nurse should use a cotton-tipped applicator, marking depth on the applicator and placing it next to a tape measure to obtain dimension and to note position (e.g., 4 cm at 2 o’clock). It is not imperative that all dimensions or locations of undermining be documented. The nurse should record only the greatest length because the wound cannot be deemed healed until closed. It is recommended that facilities develop a written procedure stating how dimensions should be obtained and documented (e.g., length by width by depth and undermining) to establish continuity and minimize confusion regarding the procedure.
Débridement Necrotic tissue provides the ideal environment for bacteria growth, which may cause inflammation and impair the body’s ability to fight infection. Therefore, necrotic tissue must be débrided as soon as possible, and measures (such as wet-to-dry dressings or topical antimicrobials) should be taken to resolve bacterial insults until purulent discharge has dissipated. If necrotic tissue is not débrided, the nurse’s efforts are futile and the patient’s comfort and quality of life are affected.
The removal of dry, hard eschar should be considered because its presence slows the migration of epithelial cells and delays healing, except for stable heel ulcers, in which case dry eschar should be left intact (AHCPR, 1994). At times, this dry eschar may serve as an efficient and comfortable dressing, but the area must be watched for development of infection. If the patient has diabetes or has an ischemic wound with a dry, hard, intact eschar, it may be more prudent to leave the eschar in place. It serves as a barrier and does not place the patient at risk for any possible problems from frequent dressing changes (e.g., infection, skin tears, and candidiasis). However, the eschar and periwound skin must be monitored. If the
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eschar becomes soft and mushy, tissue liquefaction is most likely accumulating and must be removed. This is especially true if the wound is tender or has periwound erythema indicating infection.
Four methods of débridement are mechanical, autolytic, chemical, and surgical. Mechanical débridement (wet-to-dry dressings or whirlpool) is effective for removing slimy or stringy exudate that cannot be removed surgically or chemically (because of damage to viable tissue). If mechanical débridement using wet- to-dry dressings is employed, the nurse should protect wound borders from maceration with zinc oxide or stoma adhesive. Using a whirlpool or a handheld pulsed irrigation system once or twice daily may mechanically débride and should be reserved for large, exuding wounds; this should be discontinued after the wound is clean or demonstrates stability. Mechanical débridement requires more nursing time, is more uncomfortable for the patient, and may destroy fragile epithelial cells. For these reasons, a more efficient method should be sought first.
Autolytic débridement is effective for removing stringy slough when less than 50% of the wound bed is involved and no evidence of infection exists in the periwound skin. Autolytic débridement involves using the body’s own enzymes to provide additional débriding and cleansing. Hydrocolloid or hydrogel dressings may soften and facilitate removal of eschar if the wound is not infected. It should be noted that autolysis creates a larger appearing wound because debris is being removed. Autolysis generates a brownish yellow fluid that may have some pus in it as a result of dead cells and neutrophils. The nurse should not become alarmed unless clinical evidence of infection exists (e.g., erythema, tenderness, heat, and swelling). Autolytic débridement may be used in conjunction with mechanical methods to further shorten the time to wound cleansing.
Chemical débridement is costly and time consuming; however, it may be effective on small, necrotic areas or for removing yellow, tender eschar that is difficult to remove surgically. Chemical débridement is primarily used in the home setting or nursing facility where appropriately educated or certified professionals are not readily accessible to surgically débride at the bedside. Chemical
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débridement may save the patient from hospital admission. If used, the chemical enzyme must not be applied on healthy, viable tissue because the enzyme will destroy granulation tissue and epithelial cells. Patients should be certain to read storage instructions for débriding enzymatics; some have to be refrigerated.
If the wound has a dry, rubbery eschar, surgical débridement is recommended over chemical débridement because chemical débridement takes much longer. The main principle that guides surgical débridement is to stop when bleeding occurs, which indicates that viable, healthy tissue has been reached. Because the wound is dirty, aseptic technique is appropriate. To prevent “showering” of bacteria from surgical débridement and to assist in cleaning up the wound, nurses should apply wet-to-dry dressings moistened with an antiseptic such as povidone-iodine every shift for 1 to 3 days, depending on the wound condition.
Wound Care Principles and Dressing Types The wound care market is a multibillion dollar business and has created many dressing options. Therefore, the professional nurse must understand the healing trajectory to select the best treatment option. The major goal is to create an environment that supports healing—a clean, moist (hydrated, not wet) ulcer bed. If no growth is evident in weekly measurements after 2 to 4 weeks, consideration should be given to changing the dressing strategy. Table 28-2 provides a brief overview of commonly used dressing types and general treatment principles.
Table 28-2 Commonly Used Types of Dressings
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With each dressing change, all open wounds should be gently irrigated with approximately 20 to 50 mL of normal saline with the use of either a catheter-tip syringe, butterfly tubing with the needle cut off and connected to a Luer-Lok syringe, or a syringe with a 19- gauge needle. After irrigation, the wound can be assessed.
It is prudent to always write the date and time of the dressing change on the outside of the dressing itself. This practice reflects professional accountability and assists in problem solving. For example, a wound may have more discharge or a significant change
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because the dressing was not changed soon enough or, inadvertently, not changed at all.
If the wound border has candidiasis, evidenced by a fire red erythema usually with satellite lesions and denuded skin, a zinc oxide–nystatin (50/50) mixture may be applied on affected areas and then the dressing applied. Because candidiasis flourishes in a moist environment, a thoughtful assessment should be done to identify the reason for excess moisture. Is a moist dressing such as gauze overlapping the wound edges? Is the film dressing generating so much fluid retention and maceration that candidiasis is occurring? If so, the zinc oxide–nystatin cream could be applied and the wound monitored. It may be that the dressing type must be changed. After the candidiasis has resolved, a stoma adhesive wafer may be placed around the wound to protect the skin from future problems. Stoma adhesive is recommended over a hydrocolloid dressing because tape and film dressings do not stick to the stoma adhesive barrier as they do to a hydrocolloid wafer. If no infection exists, another alternative that decreases maceration is to apply petroleum jelly (Vaseline) or zinc oxide around the wound borders and then to apply the dressing.
Gauze dressings have been used for many years with success; however, a huge amount of scientific information regarding pressure ulcers and wound care has been accumulating since 1962, when moisture was first identified as a facilitator of healing. This discovery has generated many other effective, efficient, and comfortable options. Thus, gauze is primarily used for débriding and cleaning up the wound bed, except when used for protecting closed surgical wounds or when the newer expensive dressings are not on the formulary. However, when a wound has tunneling or undermining, saline-moistened gauze, loosely packed into the wound, may maintain a moist environment. Caution should be exercised not to pack tightly or have the moistened gauze touching the healing surface surrounding the ulcer to avoid additional damage and maceration. If gauze is being used on a clean wound, the strategy should be wet-to-moist dressing to prevent drying of epithelial cells. The nurse should slightly moisten the gauze touching the wound bed with normal saline and place dry gauze or
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an abdominal pad over the moist gauze and secure with tape; this should keep the wound moist at all times.
Some gauze is impregnated with material such as saline, povidone-iodine, or petroleum jelly. The hypertonic saline gauze (Mesalt) is an exudate absorber and assists in cleaning wounds. After the exudate has diminished, a less harsh wound care product should be employed (e.g., a hydrogel). Gauze ribbons impregnated with povidone-iodine (iodoform gauze) are effective for cleaning up a tunneling wound that has purulent or foul exudate. However, the povidone-iodine gauze should be stopped when the purulent, foul exudate has resolved so that healthy tissue is not destroyed. Petroleum jelly gauze is a good, inexpensive method for keeping a wound from drying out and protecting the wound and surrounding tissue. Petroleum jelly gauze secured with Kerlix wrapped around the extremity, changed every 2 to 4 days and as needed, is an effective strategy for healing skin tears. The petroleum jelly keeps the wound moist and protects from further insults.
Nonadherent dressings such as Telfa are used when the wound bed must be protected and epithelial cells left undisturbed. Nonadherent dressings are suitable for skin tears, skin grafts, or other wounds that require minimum insult. Often, an antibiotic ointment is applied to the wound bed (which keeps it moist), and then the bed is covered with a nonadherent dressing, which is changed once or twice a day.
Foam dressings, which are nonadherent, absorbent dressings, protect an ulcer and assist in minimizing maceration of ulcer edges. Consider use of foam dressings for stage/category II and shallow stage or category III pressure ulcers, exudating cavity ulcers, painful ulcers, and on body areas and pressure ulcers at risk for shear injury (EPUAP & NPUAP, 2009). Foam dressings have also been used around tracheal tubes; they are beneficial when candidiasis exists around tracheal stomas, acting to absorb moisture. Foam dressings are secured with tape or film and may be used in combination with other topical agents or primary dressings.
Transparent films are used for stage I or II pressure ulcers (superficial wounds) to secure dressings, to protect vulnerable areas
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(e.g., elbows) from friction, and to facilitate autolysis. Transparent films such as Opsite or Tegaderm are semipermeable, thus allowing exchange of air. However, they should not be used to cover enzymatic débriding agents, gels, or ointments. Film dressings may be left on for 3 to 7 days but should be checked a minimum of once a day. Film dressings facilitate autolysis, which causes fluid buildup and may consequently lead to maceration of good tissue and dressing leakage. Petroleum jelly or zinc oxide applied around the ulcer edges before placement of the film may prevent maceration. A nonadherent dressing or alginate may also be used under the film to assist with exudate management.
Hydrocolloids such as DuoDERM are sticky, nonpermeable wafers containing a hydrocolloid material that eventually melts, combines with natural body fluids, and keeps the wound bed moist. The nonpermeable wafer also serves as a barrier and creates a hypoxic wound environment that stimulates granulation, as long as peripheral circulation provides enough oxygen. Consider the use of hydrocolloid dressings on noninfected, shallow stage/category III pressure ulcers and to protect body areas at risk for friction injuries or at risk of injury from tape (EPUAP & NPUAP, 2009). Hydrocolloid dressings should not be used if candidiasis exists. Hydrocolloid wafers are usually changed every 3 to 7 days. It should be noted that the foul, sour odor generated by hydrocolloid dressings is considered normal. Infection is present when erythema, warmth, tenderness, or purulent discharge exists. Hydrocolloid dressings should never be applied to ulcers that are infected, have purulent discharge, or have a suspected infection. The occlusive, moist environment provides a perfect medium for bacterial growth and may worsen the infection.
Hydrogels consist primarily of water and are effective in maintaining a moist ulcer bed, which fosters healing. Hydrogel dressings may be obtained in a sheet form suitable for superficial wounds or as an amorphous gel that can be applied and spread into deep, cavity wounds. Hydrogel dressings should not be used on infected wounds because they retain humidity, thus facilitating autolytic débridement. The cover dressing should be chosen on the basis of the health of the surrounding skin and the degree of wound
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exudate. Examples of cover dressings include gauze, foam, and transparent films. Dressings using a hydrogel may be left in place for 1 day or up to 5 to 7 days, depending on the setting, product, and ulcer state (see Table 28-3 and Nursing Care Plan: Pressure Ulcer).
Table 28-3 General Pressure Ulcer Care Guidelines
Stage Actions Dressing Options I Implement preventive strategies (e.g.,
mattress overlay; nutritional assessment; reinforcement of value of turning, keeping dry, and minimizing friction)
May protect with film or hydrocolloid
II and III
Implement preventive strategies, assess for infection, débride necrotic tissue, conduct nutritional assessment, and provide appropriate nutritional support
May use film, if clean, depending on depth; hydrocolloid; hydrogel, foam, honey-impregnated, collagen matrix, wet-to-moist dressing; if infected, manage topically with antiseptic and wet-to-dry dressing until infection is resolved
IV Same as above; specialized bed may be considered
If clean, hydrogel, hydrocolloid paste and wafer, collagen matrix or wet-to-moist dressing; if infected, manage topically with antiseptic and wet-to-dry dressing until infection is resolved (but no longer than 5 days)
Nursing Care Plan
Pressure Ulcer Clinical Situation Mrs. M. is an 80-year-old female who developed stage IV pressure ulcers on her sacral area and right ischium while recently hospitalized for pneumonia. Her decreased appetite and poor food intake, a 10-pound weight loss, and her not being initially placed on an egg-crate mattress led to the development of the pressure ulcers. Mrs. M. was discharged home with home health care.
The sacral and ischial pressure ulcers are clean, beginning to granulate, managed with a hydrogel, covered with a foam dressing to lessen maceration, and sealed with a transparent dressing that is changed every other day. It is estimated that complete healing will take 6 to 8 months as long as nutritional
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status and other preventive strategies are maintained.
Nursing diagnosis Impaired Skin Integrity, related to altered nutrition, altered
circulation, and immobilization.
Outcome The patient will have intact skin, as evidenced by clean, healing
wounds; maintenance of circulation to skin; and laboratory values within normal limits.
Interventions Implement pressure ulcer preventive strategies to create an
environment that will foster healing and prevent further development of ulcers.
Place the mattress overlay on the bed and obtain an appropriate pressure-relieving chair cushion to decrease ischial pressure.
Teach the patient and family to position the patient at a 30-degree angle and support extremities with pillows when lying in bed to lessen trochanter pressure.
Teach the patient, family, and nurse’s aide to avoid the use of hot baths and harsh soaps, to use moisturizers for dry skin, and not to massage over bony prominences.
Teach the patient not to sit at a 45- to 90-degree angle when in bed or on the couch to minimize shearing forces.
Assess and treat incontinence by cleansing the skin at the time of soiling; use a topical moisture barrier and (if necessary) absorbent undergarments or briefs to maintain a dry surface and decrease the risk of additional skin breakdown.
Inspect the skin during home visits, observing for any pressure points, as seen by erythema or skin breakdown. If a stage I or II ulcer is present but the site is not infected, apply the film or hydrocolloidal dressing to protect from further breakdown.
Assess the pressure ulcer when changing the dressing, noting the wound bed and border color, discharge, and general condition.
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Document each assessment and measure weekly. If the wound bed is infected or cellulitic, as seen by erythema, tenderness, pale granulation tissue, or purulent discharge, change the dressing to wet-to-dry with an antiseptic but only until the wound is improved and no longer than 5 to 7 days to minimize damage to viable tissue.
If the wound is stagnant, as documented by serial dimensions over 3 to 6 weeks, consider changing to another dressing strategy.
Monitor nutritional status because it may influence skin integrity and the healing process.
Monitor weight gains or losses monthly.
Take a 24-hour diet recall with each visit to assess eating habits and nutritional intake.
Teach the patient and family the role nutrition plays in healing and general health status.
If weight loss is experienced, interview the patient to determine the reason (e.g., food preferences are not met or food is cold or aesthetically unappealing).
Examine the oral cavity and, if appropriate, fit for dentures.
Maintain a clean, moist wound environment to foster healing.
If necrotic tissue is present, facilitate débridement by arranging for a physician, nurse practitioner, or certified enterostomal therapist to perform bedside débridement.
If only a small amount of necrotic tissue is present, attempt chemical or mechanical débridement.
Select the most comfortable and efficient dressing, such as a hydrogel or hydrocolloidal dressing, with the intent of maintaining a moist wound environment, which fosters granulation and thus healing.
Use clean technique for dressing care; sterile technique is not necessary because the wound is dirty.
Gently irrigate the wound with normal saline to clean wound,
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make an appropriate assessment, and measure the wound dimensions weekly.
Teach the patient and family dressing care and changing technique to involve them in the care and to promote self-care.
Alginates are a category of exudate management dressings. The alginate dressings are manufactured from seaweed and are applied to wounds that are moderately to heavily exudative. In most cases, the alginates are safe to use on infected wounds. These dressings have excellent exudate handling properties and are useful in wounds and around drainage tubes when the wound fluid is causing periwound skin maceration.
In addition, some types of dressings are impregnated with various substances, for example, silver-impregnated dressings, which are used for infected or heavily colonized ulcers; honey- impregnated dressings, which are impregnated with medical grade honey and are used for stage II and III ulcers; and cadexomer iodine dressings, which are used for highly exudating ulcers.
Additional pressure ulcer dressings include silver-impregnated dressings for stage/category II and shallow stage/category III pressure ulcers, honey-impregnated dressings for stage/category II and III pressure ulcers, cadexomer iodine dressings for moderately to highly exudating ulcers that do not require frequent changes, silicone dressings, and collagen matrix dressings.
Biophysical Agents in Pressure Ulcer Management Research has been conducted in the use of different energy forms in the management of pressure ulcers. These include acoustic (ultrasound), mechanical, and kinetic energy, as well as energy from the electromagnetic spectrum (EMS). Infrared (thermal) radiation, ultraviolet light (invisible light), and laser are all part of the EMS, as electrical or electromagnetic stimulation (EPUAP & NPUAP, 2009). Negative-pressure wound therapy may be considered as an early adjuvant for deep stage/category III and IV pressure ulcers. Last, hydrotherapy is used as an adjunct for wound cleaning and to facilitate healing (EPUAP & NPUAP, 2009).
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Summary Pressure ulcers are a costly health care problem, not only in terms of dollars but also in terms of nursing time and human lives. Prevention is the first line of defense against pressure ulcer development. Nurses have an opportunity to demonstrate the profession’s power and accountability by implementing preventive strategies, thereby having a positive effect on a patient’s quality of life while preventing a costly health care problem. It is imperative that the nurse conduct pressure ulcer risk assessments, use mattress overlays, teach support staff prevention and management techniques, monitor the patient’s nutritional status, and serve as a role model by focusing on prevention. With expanded pressure ulcer knowledge and the publication of the AHCPR and EPUAP/NPUAP clinical guidelines, preventive measures are a nurse’s responsibility.
Home Care
1. Regularly assess for signs and symptoms of skin breakdown in homebound older adults who are at high risk for the development of a pressure ulcer.
2. Assess for and instruct caregivers and homebound older adults on factors that predispose patients to the development of a pressure ulcer.
3. Use the services of a wound care clinical nurse specialist in assessing, planning, and recommending appropriate wound care management techniques.
4. Prevention is the first-line strategy for pressure ulcer care. Teach caregivers of at-risk homebound older adults the techniques for preventing a pressure ulcer—focusing on preventing moisture, avoiding friction and shearing, changing position frequently, and ensuring excellent nutritional intake.
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The collaborative relationship that the nurse establishes with the physician and the APRN to utilize the most efficient and effective strategies is vital to successful healing. Collaboration develops trust and professional maturity and is necessary for growth in our strained health care system.
Successful pressure ulcer management requires the application of the principles of healing, which should guide selection of treatment strategies. Frequent review of the healing trajectory, when reinforced with clinical examples, facilitates comprehension of this complex process. Pressure ulcer management is a science and an art that requires experience.
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Key points • As a result of normal, age-related changes in the skin, older adults
are more susceptible to skin tears and bruising caused by thinning of the skin.
• Older adults are at greater risk for hypothermia, shearing, pressure damage, and blunt trauma as a result of decreased subcutaneous tissue.
• Older adults may experience altered medication absorption as a result of an age-related decrease in fatty tissue and dermis blood supply.
• Older adults are at increased risk of heatstroke as a result of the compromised cooling mechanism from decreased sweating.
• The typical pattern of spreading for seborrheic dermatitis starts at the scalp margins, progresses downward to the eyebrows, the base of the eyelashes, and around the nose in a butterfly pattern, and continues to the ears and sternum.
• Psoriasis is a common disorder affecting the epidermis and the dermis. It is recognized by the presence of erythematous, scaly, and itchy patches on various parts of the body. A number of triggers exacerbate the condition.
• Pruritus warrants a full skin assessment because it may be indicative of many diseases, drug reactions, and possibly cancer. The nurse should determine the location, intensity, alleviating and aggravating events, onset, and what the patient is doing to control it.
• Candidiasis, recognized by fire-red, denuded skin with satellite macules or pustules, develops in moist intertriginous areas.
• Herpes zoster is characterized by prodromal symptoms of itching or burning along a dermatome, followed by a unilateral, bandlike maculopapular rash and vesicles, which rarely cross the midline.
• The nurse should notify the physician or the APRN if the following suspected lesions are found on assessment of actinic
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keratosis: BCC, SCC, or melanoma.
• Venous hypertension leads to the formation of a capillary fibrin cuff, which causes chronic edema, decreased circulation, and recurring medial lower leg ulcers.
• Arterial ulcers are usually located on toes or feet and are associated with pain during activity, nighttime, and rest. The cause of decreased arterial blood flow must be corrected for ulcers to heal.
• Diabetic neuropathic ulcers are usually located on the plantar foot and result from loss of protective sensation in the foot, which leads to abnormal gait and increased pressure on the foot. Bony deformities may develop and further change foot pressures, increasing the likelihood of trauma and subsequent ulceration.
• Pressure ulcers are a costly health care problem, not only in terms of dollars but also in nursing time and human lives. Prevention is the first-line strategy for pressure ulcer care.
• The nurse should assess the nutritional status of patients with pressure ulcers with a determination of monthly weight and laboratory variables.
• To minimize friction, the nurse should use sheets to lift and pull the patient up in bed and apply a film dressing or lotion to vulnerable areas such as elbows, coccyx, and heels.
• To minimize shearing forces, the nurse should not elevate the head of the bed greater than 30 to 45 degrees.
• Antiseptic solutions should be used only when the wound is infected; they should never be used on a clean, healthy wound because they are cytotoxic and destructive to tissue.
• Surface cultures have been shown to grow different organisms than what is in underlying tissues and blood cultures; thus routine wound cultures are not appropriate.
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Critical thinking exercises 1. Outline major teaching points that would be beneficial to maintaining the integumentary health of older individuals.
2. A 78-year-old Hispanic man has a history of SCC. After having a lesion removed from his upper back 3 years ago, he has been extremely anxious about other skin lesions and skin changes. What approach would you take to help your patient reduce his anxiety and yet remain active in the prevention and early recognition of skin cancer?
3. Your 79-year-old female patient suffered a stroke 6 months ago and is cared for in her sister’s home. The patient is dependent for position changes, is unable to communicate the need to be turned, must be fed, and has a stage II pressure ulcer on her sacral area. Develop a teaching plan for the family to ensure that the patient’s needs are met.
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Agency for Health Care Policy and Research. Treatment of pressure ulcers. Clinical Practice Guideline No 15. Rockville, Md: US Department of Health and Human Services; 1994.
Aldredge LM. Beneath the surface. Psoriasis is more than skin deep. Advance for Nurse Practitioners. 2009;17(4):27–31.
Bergstrom N, Braden BJ, Laquzza A, et al. The Braden Scale for predicting pressure sore risk. Nursing Research. 1987;36(4):205–210.
Birke JA, Rolfsen RJ. Evaluation of self-administered sensory testing tool to identify patients at risk of diabetes-related foot problems. Diabetes Care. 1998;21:23.
Braden B, Bergstrom N. A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing. 1987a;12(1):8.
Braden BJ, Bergstrom N. Clinical utility of the Braden scale for predicting pressure sore risk. Decubitus. 1987b;2(3):44.
Braden BJ, Bryant R. Innovations to prevent and treat pressure ulcers. Geriatric Nursing. 1990;11(4):182–186.
Browse RA, Burnand KG. The cause of venous ulceration. Lancet. 1982;2(8292):243–245.
Bryant RA, Shannon ML, Pieper B, et al. Pressure ulcers. In: Bryant RA, ed. Acute and chronic wounds: nursing management. St Louis: Mosby; 1992.
Burton CS. Venous ulcers. The American Journal of Surgery. 1994;167(1A):375–405.
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Cassano N. Chronic pruritus in the absence of specific skin disease: an update on pathophysiology, diagnosis, and therapy. American Journal of Clinical Dermatology. 2010;11(6):399–411.
Colin D, Abraham BJ, Preault L, Bregeon C, et al. Comparison of 90 degrees and 30 degrees laterally inclined positions in the prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures. Advances in Wound Care. 1996;9(3):35.
Cox KR, Laird M, Brown JM. Predicting and preventing pressure ulcers in adults. Nursing management. 1998;29(7):41.
Dasgupta G. New concepts in herpes simplex virus complex vaccine development: notes from the battlefield. Expert Review of Vaccines. 2009;8(8):1023–1035.
Davis C. In: Carnevali DL, Patrick M, eds. Nursing management for the elderly. ed 3 Philadelphia: JB Lippincott; 1993.
Dessinioti C. Basal cell carcinoma: what’s new under the sun. Photochemistry and Photobiology. 2010;86(3):481–491.
European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP). Prevention of pressure ulcers: quick reference guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
Falanga V, Eaglstein WH. The “trap” hypothesis of venous ulceration. Lancet. 1993;34(8851):1006–1007.
Feramisco JD, Berger TG, Steinhoff M. Innovative management of pruritus. Dermatologic Clinics. 2010;28(3):467–478.
Fletcher A, Sheldon TA, Cullum N. A systematic review of compression treatment for venous leg ulcers. BMJ. 1997;315:576.
Gasent Blesa JM. Melanoma: from darkness to promise. American Journal of Clinical Oncology. 2011;34(2):179–187.
Goodman T, Thomas C, Rappaport N. Skin ulcers: overview
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of nursing implications. AORN Journal. 1990;52(1):24–28 30– 31, 33–37.
Gordon RM. Common, yet preventable, skin cancer presents in several forms, meaning NPs must be aware of its clinical features and various treatments. The Nurse Practitioner. 2009;34(4):21–27.
Gosnell DJ. Pressure sore risk assessment: a critique, part I, the Gosnell scale. Decubitus. 1989;2(3):32.
Habif TP. Clinical dermatology. ed 4 St Louis: Mosby; 2004.
Habif TP. Clinical dermatology. ed 5 St Louis: Mosby; 2009.
Helm KF, Marks JG. Atlas of differential diagnosis in dermatology. New York: Churchill Livingstone; 1998.
Hunt TK. The physiology of wound healing. Annals of Emergency Medicine. 1988;17:1265–1273.
Johnson RW. Herpes zoster and postherpetic neuralgia. Expert Review of Vaccines. 2010;9(supplement 3):21–26.
Johnson BL, Moy RL, White GM. Ethnic skin. St Louis: Mosby; 1998.
Kosiak M. Etiology and pathology of ischemic ulcers. Archives of Physical Medicine and Rehabilitation. 1958;40(2):62.
Krasner D. Resolving the dressing dilemma: selecting wound dressings by category. Ostomy/Wound Management. 1991;35(4):62.
Landis EM. Micro-injection studies of capillary blood pressure in human skin. Heart. 1930;15(209).
Levin M. Diabetic foot wounds: pathogenesis and management. Advances in Wound Care. 1997;10(2):24.
Levine JM. Historical notes on pressure ulcers: the cure of Ambrose Pare. Decubitus. 1992;5(2):23–26.
Loeper JM, Flinn NA, Irrgang SJ, et al. Therapeutic positioning and skin care. Minneapolis: Sister Kenny Institute; 1986.
Maklebust J. Pressure ulcers decreasing the risk for older
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adults. Geriatric Nursing. 1997;18:250.
Norton D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in hospital. Edinburgh: Churchill Livingstone; 1975.
Norton D. Calculation of the risk: reflections on the Norton scale. Decubitus. 1989;2(3):24.
Playford EG, Lipman J, Sorrell TC. Prophylaxis, empirical and preemptive treatment of invasive candidiasis. Current Opinion in Critical Care. 2010;16(5):470–474.
Pinchcofsky-Devin G, Kaminski M. Correlation of pressure sores and nutritional status. Journal of the American Geriatrics Society. 1986;34:435.
Psaty EL. Defining the patient at risk for melanoma. Int J Dermotol. 2010;49(4):362–376.
Rich SE, Shardell M, Margolis D, Baumgarten M. Pressure ulcer preventive device use among elderly patients early in the hospital stay. Nursing Research. 2009;58(2):95–104.
Rigel DS, Russak J, Friedman R. The evolution of melanoma cells: a 25-years beyond the ABCDs. Cancer Journal for Clinicians. 2010;60(5):301–316.
Robson MC. Wound infection: a failure of wound healing caused by an imbalance of bacteria. The Surgical Clinics of North America. 1997;77:637–650.
Rodust PM. UV-induced squamous cell carcinoma – a role for antiapoptotic signaling pathways. The British Journal of Dermatology. 2009;161(suppl.3):107–115.
Sanders SL. Pressure ulcers, part II, management strategies. Journal of the American Academy of Nurse Practitioners. 1992;4(3):101.
Schaffer M, Barbul A. Lymphocyte function in wound healing and following injury. The British Journal of Surgery. 1998;85:444.
Shoimer I, Rosen N, Muhn C. Current management of actinic
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keratoses. Skin Therapy Lett. 2010;15(5):5–7.
Stotts NA, Wipke-Tevis D. Nutrition, perfusion, and wound healing: an inseparable triad. Nutrition. 1996;12:733–734.
Strauss EA, Margolis DJ. Malnutrition in patients with pressure ulcers: morbidity, mortality, and clinically practical assessments. Advances in Wound Care. 1996;9(5):37– 40.
Thomas DR. Specific nutritional factors in wound healing. Advances in Wound Care. 1997;10:40–43.
Touhy T, Jett K. Ebersole and Hess’ Toward healthy aging: human needs and nursing response. ed 8 St Louis: Mosby; 2012.
Willison CB. Shingles vaccine. Expert Opinion on Biological Therapy. 2010;10(4):631–638.
* Original authors: Susan L. Sanders, MSN, RN-C, GNP and Laurel Wiersema-Bryant, MSN, RN, CS; Revised: Sabrina Friedman, EdD, DNP, FNP-C, PMHCNS-BC.
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C H A P T E R 2 9
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Sensory Function Cindy R. Morgan, RN, MSN, CHC, CHPN and; Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C
Learning objectives
On completion of this chapter, the reader will be able to: 1. Describe age-related changes in the senses.
2. Compare and contrast cataracts and glaucoma and the associated nursing interventions.
3. Compare and contrast retinal disorders and the medical and nursing management of each disorder.
4. Identify nursing interventions for older adults with low vision.
5. Describe the proper method for instilling eye medications.
6. Describe the proper method for removing impacted cerumen.
7. Identify safety measures for older patients with vertigo.
8. Identify nursing interventions for older patients with xerostomia.
9. Describe potential hazards for older adults with diminished senses of vision, hearing, and touch.
10. Conduct a sensory system assessment and describe the normal findings.
11. Describe aural rehabilitation methods to use with older adults who have hearing impairment.
12. Identify how activities of daily living are affected by sensory changes.
http://evolve.elsevier.com/Meiner/gerontologic
The senses connect the human body to the environment. They
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allow individuals to be aware of and interpret various stimuli, thus enabling interaction with the environment. Sensory changes may have a dramatic effect on the quality of life of older adults. Visual and hearing impairments may interfere with communication, social interactions, and mobility, leading to social isolation. Olfactory, gustatory, and tactile deprivations may lead to nutritional problems and safety hazards. It is important to understand the sensory changes associated with aging to help older adults adapt and function as independently as possible.
In the past, five senses were recognized: sight, hearing, taste, smell, and touch. Today, additional senses are recognized and categorized into two major groups: general and special. General senses include the senses of touch, pressure, pain, temperature, vibration, and proprioception (position sense). These have relatively simple receptors, which are located all over the body. These senses are further classified as somatic (those providing sensory information about the body and the environment) or visceral (those supplying information about the internal organs). Special senses are produced by highly localized organs and specialized sensory cells. These include the senses of sight, hearing, taste, smell, and balance.
Sensation is a conscious or unconscious awareness of external and internal stimuli. Perception is the interpretation of conscious sensations. The brain receives stimuli from both inside and outside the body. Conscious sensation occurs via action potentials generated by receptors that reach the cerebral cortex.
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Vision Vision plays an integral part in a person’s ability to function in the environment. Visual acuity (the ability to see clearly) is an important part of performing activities of daily living (ADLs); dressing, grooming, cooking, sewing, driving, and reading are all tasks that involve the use of eyesight (Figure 29-1).
FIGURE 29-1 Anatomy of the eye. (From Black, J.M. (2008). Medical- surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO:
Saunders.)
Age-Related Changes in Structure and Function Normal age-related changes in the external and internal eye have been well documented. The eyelids lose tone and become lax, which may result in ptosis of the eyelids, redundancy of the skin of the eyelids, and malposition of the eyelids. Eyebrows may turn
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gray and become coarser in men, with outer thinning in both men and women. The conjunctiva thins and yellows in appearance. In addition, this membrane may become dry because of diminished quantity and quality of tear production. The sclera may develop brown spots. The cornea yellows and develops a noticeable surrounding ring, made up of fat deposits, called the arcus senilis. The pupil decreases in size and loses some of its ability to constrict. Changes related to aging that decrease the size of the pupil and limit the amount of light entering the eye also occur in the iris. The lens increases in density and rigidity, affecting the eye’s ability to transmit and focus light. Peripheral vision decreases, night vision diminishes, and sensitivity to glare increases (Brodie, 2010; Roach, 2005). The yellowing of the lens results in difficulty identifying certain colors, especially cool colors such as blue, green, and violet (Lueckenotte, 1998).
Ophthalmoscopic examination of the retina may reveal the following changes: blood vessels have narrowed and straightened; arteries seem opaque and gray; and drusen, localized areas of hyaline degeneration, may be noted as gray or yellow spots near the macula (Lueckenotte, 1998). Two common complaints of older adults, floaters and dry eyes, are discussed in the following section.
Common Complaints Floaters and Flashers Floaters appear as dots, wiggly lines, or clouds that a person may see moving in the field of vision. They become more pronounced when a person is looking at a plain background. Floaters occur more often after age 50 as tiny clumps of gel or cellular debris float in the vitreous humor in front of the retina. They are caused by degeneration of the vitreous gel and are more common in older adults who have undergone cataract operations or yttrium– aluminum–garnet (YAG) laser surgery.
In general, floaters are normal and harmless, but they may be a warning sign of a more serious condition, especially if they increase in number and if changes in the type of floater, light flashes, or visual hallucinations are noted. These symptoms may indicate a
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vitreous or retinal tear, which could lead to detachment. In addition, visual hallucinations have been associated with a brain tumor or cortical ischemia. Therefore, any of these symptoms warrants a complete eye examination by an ophthalmologist.
Flashers occur when the vitreous fluid inside the eye rubs or pulls on the retina and produces the illusion of flashing lights or lightning streaks. Flashers that appear as jagged lines, last 10 to 20 minutes, and are present in both eyes are likely to be caused by a spasm of blood vessels in the brain called a migraine. These flashers commonly occur with advancing age, but they warrant prompt medical attention if they increase in number, if a large number of new flashers appears, or if partial loss of side vision is noted (Kollarits, 2007).
The nurse should refer a patient who experiences any of the above symptoms to an ophthalmologist for a comprehensive eye examination. If no cause is found for floaters and flashers, the nurse should teach the patient about the condition and how to live with it. Patients should be taught to look up and down to get the floaters out of the field of vision. In addition, the nurse should provide the patient with the printed information instruction sheet titled “Aging and Your Eyes” so that he or she may learn more about floaters and flashers (Kollarits, 2007) (Box 29-1).
Box 29-1
Aging and your Eyes 1. Use bright light when performing tasks such as sewing,
reading, and cooking; avoid fluorescent light.
2. Use a magnifying glass, if necessary, for close work.
3. See your health care provider regularly to detect health problems (e.g., diabetes, hypertension) that might affect your eyes.
4. Have your eyes examined and a glaucoma test performed by a
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qualified specialist every 1 to 2 years. Have your eyes examined more frequently if you have a disease or condition that is known to affect your vision.
5. Symptoms that require an immediate call to your health care provider or eye care specialist include pain, discharge, redness or swelling, and loss of vision (no matter how slight).
6. The use of a humidifier in the home or artificial tears may relieve dry eyes, which is a common condition. Check with your health care provider or eye care specialist before using any over-the-counter preparations.
7. Excessive tearing can be a benign condition, or it may reflect a more serious problem. See your health care provider or eye care specialist if you are troubled by this problem.
8. Floaters, a common occurrence in older persons, are just spots or flecks that literally “float” across your field of vision. They usually occur gradually and are most noticeable in a brightly lit environment. If they occur in association with light flashes in your visual field, call your health care provider or eye care specialist.
9. Cataracts are a normal part of the aging process. They develop gradually and without pain. However, when tasks become increasingly difficult and fatiguing because of the vision changes that cataracts produce, see your health care provider or eye care specialist to discuss treatment options.
Data from U.S. Department of Health and Human Services. (2009b). Aging and your eyes. Bethesda, MD: National Institute on Aging.
Dry Eyes Dry eyes result as the quantity and quality of tear production diminish with aging. Stinging, burning, scratchiness, and stringy mucus are some of the symptoms. Although this may seem surprising, increased tearing may be a symptom of dry eyes. If tear secretion is below normal, excess tears are produced by the lacrimal gland in response to irritation. If no foreign body is found, the condition is called dry eye syndrome. Tear production decreases with age, and menopausal women are most often afflicted. Also, dry
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eyes may be associated with arthritis and the use of certain medications.
Treatment consists of tear replacement or conservation. Tears may be replaced by instilling an over-the-counter (OTC) artificial tear preparation to lubricate the eye and replace missing moisture. This type of preparation may be used as often as necessary, especially before activities that require significant eye movement. Solid inserts that gradually release lubricants throughout the day are also available. An ophthalmologist can help conserve the naturally produced tears by temporarily or permanently closing the lacrimal drainage system. Other methods of conservation include use of a humidifier when the heat is on, wraparound glasses to reduce evaporation of eye moisture caused by wind, and avoidance of smoke (Kollarits, 2007).
Common Problems and Conditions Common problems related to the aging eye include presbyopia, ectropion and entropion, blepharitis, glaucoma, cataracts, retinal disorders, eye injuries, and visual impairment. Presbyopia is a normal change that occurs with aging. The other problems are eye diseases that are more prominent in older adults.
Presbyopia The most common complaint of adults older than age 40 is a diminished ability to focus clearly on close objects (arm’s length) such as a newspaper. In presbyopia, the lens loses its ability to focus on close objects. Accommodation is impaired as the lens thickens and loses its elasticity. The ciliary muscles weaken the lens’s ability to contract. Treatment involves wearing reading glasses or bifocals (two-part lenses that correct near and distant vision); the prognosis for corrected vision is excellent.
Nursing care is aimed at encouraging the patient to adjust to the glasses by wearing them and following up with a visit to the ophthalmologist every 2 years. Patients may be provided with an “Aging and Your Eyes” pamphlet (see Box 29-1) for information about presbyopia. Also, patients and their families can be taught
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eye health promotion and prevention techniques (see Health Promotion/Illness Prevention: The Eye).
Health Promotion/Illness Prevention The Eye
Health Promotion • Notify health care provider of any pain, discharge, redness,
swelling, or loss of vision.
• Take measures for detection and appropriate treatment of vision difficulties and eye disease (e.g., cataracts, glaucoma, diabetic retinopathy, and macular degeneration).
• Maintain prescribed corrective lenses, low-vision aids, and medications.
Prevention of Disease • Have a yearly eye examination and screening (including a
glaucoma test) for eye disease and vision problems.
• Use a bright light when sewing, reading, and cooking; avoid fluorescent light.
• Have an ultraviolet filter coating on spectacle lenses and sunglasses for outdoor activities.
Ectropion and Entropion Ectropion and entropion are external eye conditions; specifically, they are malpositions of the lower lid, which irritate the eye. Both conditions are caused by tissue laxity and scarring of the eyelids from infection. Ectropion (turning outward) prevents normal closure, affects tear drainage and production, and causes redness and tearing of the eyeball. Entropion (turning inward) results in the eyelashes rubbing against the eye, causing corneal abrasion. The lower lashes may not be visible and may cause watering and redness of the eye. Both can be treated with minor, same-day
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outpatient surgery performed by an ophthalmologist. The prognosis for complete recovery and cessation of symptoms is excellent (Brodie, 2010).
Blepharitis Blepharitis is chronic inflammation of the eyelid margins that is commonly found in older adults. It may be caused by seborrheic dermatitis or infection. The use of antihistamines, anticholinergics, antidepressants, and diuretics may exacerbate this condition because of the drying effects of these medications. In addition, the deficiency in tear production with aging may lead to infection. The symptoms include red, swollen eyelids; matting and crusting along the base of the eyelash at the margins; small ulcerations along the lid margins; and complaints of irritation, itching, burning, tearing, and photophobia. Treatment is aimed at removing the causative bacteria and healing the affected areas. Physicians may prescribe topical antibiotics or steroids. However, the nurse can play a significant role in the treatment of this condition by teaching a patient certain interventions described later.
The patient must be taught scrupulous eye hygiene, including good hand washing habits. Mild soap (e.g., Ivory, Neutrogena) should be used. Contact lens wearers must be taught proper cleaning and storage techniques to prevent contamination of the eye, lens, lens solution, and lens case. Because cosmetics are a common source of bacterial contamination, eye makeup products should be replaced every 3 to 6 months to avoid bacterial growth. It is also important that patients know how to apply makeup with cotton balls and cotton-tipped applicators and understand the importance of discarding the applicators after each use. Mascara should be water resistant, free of lash-extending fibers, and not applied to the base of the lashes. Eyeliner should be a medium-hard pencil and not be applied to the inner margin of the eyelid. Patients should avoid the use of aerosol hairsprays because these may irritate the eyes. Inflammation caused by blepharitis will be resolved and the patient’s comfort level will improve after a week of these hygiene measures.
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Glaucoma Glaucoma is the second leading cause of blindness in the United States and the first cause of blindness among blacks. Although glaucoma may occur at any age, those most at risk are adults older than age 60 (Gohdes, Balamurugan, Larsen, & Maylahn, 2005; Roach, 2005). The most common form has few, if any, symptoms and may cause partial vision loss before it is detected. This major public health problem affects approximately three million older Americans and is associated with over 120,000 blind older adults (Touhy & Jett, 2012).
Glaucoma results from a blockage in the drainage of the fluid (the aqueous humor) in the anterior chamber of the eye. Normally, this fluid drains through the Schlemm canal and is transported to the venous circulation system. If the fluid is formed in the eye faster than it can be eliminated, intraocular pressure (IOP) increases. Pressure is then transferred to the optic nerve, where irreparable damage, possibly even total blindness, may result. Three types of glaucoma are found in older adults: chronic open-angle glaucoma, closed-angle glaucoma, and secondary glaucoma.
Chronic Open-Angle Glaucoma Chronic open-angle glaucoma, the most common type (making up 90% of all primary glaucoma), develops slowly. Degenerative changes in the Schlemm canal obstruct the escape of aqueous humor, resulting in increased IOP. This type of glaucoma may damage vision so gradually and painlessly that a person is unaware of a problem until the optic nerve is badly damaged. Visual loss begins with deteriorating peripheral vision (O’Neil, 2002).
Closed-Angle Glaucoma This is acute glaucoma that occurs suddenly as a result of complete blockage. It requires prompt medical attention to avoid severe vision loss or blindness. The following symptoms of closed-angle glaucoma occur rapidly:
• Severe eye pain
• Redness in the eye
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• Clouded or blurred vision
• Nausea and vomiting
• Bradycardia
• Rainbow halos surrounding lights
• Pupil dilation
• Steamy appearance of cornea
Secondary Glaucoma Secondary glaucoma occurs when the drainage angle is damaged by eye injury or other specific conditions such as medication use (e.g., use of steroids), tumors, inflammation, or abnormal blood vessels.
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Nursing management Assessment
Patients with glaucoma may complain of dull eye pain, or they may experience no early symptoms. Visual field testing reveals a loss of peripheral vision (tunnel vision), and increased IOP is seen on ophthalmologic examination.
Diagnosis Potential nursing diagnoses for the patient with glaucoma include the following:
• Deficient Knowledge, related to lack of exposure and inexperience with regard to glaucoma causes and treatments
• Pain, related to increased IOP
• Risk for Infection, related to eye drop instillation
• Dressing Self-Care Deficit, related to visual impairment
Planning and Expected Outcomes Expected outcomes for the patient with glaucoma include the following:
1. The patient will have no further loss of vision.
2. The patient will follow prescribed glaucoma care guidelines daily.
3. The patient will state that eye pain is decreased.
4. The patient will be free from eye infection.
5. The patient will be able to perform activities of daily living (ADLs) safely and independently.
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Intervention Nursing management is aimed at teaching the patient that glaucoma is a chronic condition requiring lifelong medical treatment. Any current visual loss is permanent, but further loss may be prevented by following the care guidelines outlined in Box 29-2. If medication fails to control rising IOP, surgical intervention may be necessary.
Box 29-2
The Patient with Glaucoma 1. Medical follow-up and eye medication will be required for the
rest of your life.
2. Eye drops must be continued as long as prescribed, even in the absence of symptoms.
a. Blurred vision decreases with prolonged use.
b. Avoid driving for 1 to 2 hours after administration of miotics.
3. To prevent complications:
a. Press lacrimal duct for 1 minute after eye drop insertion to prevent rapid systemic absorption.
b. Have a reserve bottle of eye drops at home.
c. Carry eye drops on person (not in luggage) when traveling. d. Carry card or wear Medic-Alert bracelet identifying
glaucoma and the eye drops solution prescribed.
4. Bright lights and darkness are not harmful.
5. No apparent relationship exists between vascular hypertension and ocular hypertension.
6. Report any reappearance of symptoms immediately to the ophthalmologist.
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7. If admitted to the hospital for a different medical condition, alert staff of continued need to use prescribed eye drops.
8. Avoid the use of mydriatic or cycloplegic drugs (e.g., atropine) that dilate the pupils.
Modified from Monahan, F., Sands, J., Neighbors, M., et al. (2006). Phipps medical-surgical nursing: Health & illness perspectives (8th ed.). St. Louis, MO: Mosby.
Trabeculoplasty is usually performed on an outpatient basis. It requires an IOP check 3 to 4 hours after surgery. A sudden rise in IOP may occur immediately after surgery. A 4- to 8-week wait is necessary to determine whether the procedure was effective. However, continual use of glaucoma medications is necessary.
Trabeculectomy requires overnight hospitalization. Postoperative nursing care for the patient who has had a trabeculectomy includes (1) routine postanesthesia care, (2) protection of the operated eye with an eye patch or a shield, proper positioning of the patient on the back or on the side of the nonoperated eye, and the use of a call light and side rails, (3) administration of pain medications and cold eye compresses to maintain comfort, (4) monitoring of the eye for increased IOP, bleeding, or infection, and (5) assistance and teaching of safe, independent performance of ADLs (Monahan, 2006).
Evaluation Evaluation includes documentation of the achievement of the expected outcomes, no further vision loss, and the independent performance of ADLs. It is imperative that the patient and family understand the chronic nature of this disease and its treatment. The patient must be able to state the name and dosage of the prescribed eye medications and describe their daily use, even during periods of travel or hospitalization. The patient must also be able to identify significant signs and symptoms so that they can be reported to the ophthalmologist.
Cataracts Cataracts are the most common disorder found in the aging adult.
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The highest incidence is found in adults older than age 55; cataracts are found in virtually all adults older than age 80.
A cataract is a clouding of the normally clear and transparent lens of the eye. The lens focuses light on the retina to produce a sharp image. When a cataract forms, the lens may become so opaque that light cannot be transmitted to the retina. Cataracts result from changes in the chemical composition of the lens; these changes may be caused by aging, eye injuries, certain diseases, and heredity. In addition, different types of cataracts exist. The normal aging process may cause the lens to harden and turn cloudy. These cataracts are called senile cataracts and may occur as early as age 40. Eye injuries such as a hard blow, puncture, cut, or burn may damage the lens and result in a traumatic cataract. Secondary cataracts may be caused by certain infections, drugs, or diseases (Brodie, 2010).
The size and location of a cataract determine the amount of interference with clear sight. A cataract located near the center of the lens produces more noticeable symptoms such as the following:
• Dimmed, blurred, or misty vision
• The need for brighter light to read
• Glare and light sensitivity
• Loss of color perception
• Recurrent eyeglass prescription changes
These symptoms develop slowly and at different rates in each eye.
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Nursing management Assessment
Subjective complaints include having trouble reading and the necessity for constantly cleaning the glasses (the vision difficulties are thought to be caused by dirty glasses). Lens opacity may be visible on external or internal eye examination.
Diagnosis Nursing diagnoses for the patient with cataracts include the following:
• Anxiety, related to uncertain surgical outcome
• Deficient Knowledge, cataracts related to lack of exposure
• Risk for Injury, related to changes in visual acuity
• Dressing Self-Care Deficit, related to inability to see body and face clearly enough to maintain appearance of clothes and cosmetics
Planning and Expected Outcomes Expected outcomes for a patient with cataracts include the following:
1. The patient will have cataract surgery when it is recommended by an ophthalmologist.
2. The patient will ask questions about preoperative and postoperative care and report satisfaction with information.
3. The patient’s affected eye will be free from increased IOP, stress on the suture line, hemorrhaging, and infection.
4. The patient will verbalize appropriate home care activities to avoid and activities to do after cataract surgery.
5. The patient will demonstrate correct administration of eye drops.
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6. The patient will avoid falling, bumping into objects, and having automobile accidents before and after surgery.
7. The patient will dress and groom himself or herself when vision returns.
Intervention Nursing management for a patient with cataracts focuses mainly on preoperative and postoperative surgical care because surgery is the only method for treating cataracts. However, asymptomatic patients do not require referral. Most cataract surgery is performed as outpatient surgery with the administration of a local anesthetic; this makes preoperative teaching difficult because patients arrive just hours before surgery. Many ambulatory centers conduct preoperative assessment and teaching via phone calls a week before surgery. Preoperative care involves administering eye drops and a sedative, as ordered. Postoperative care requires teaching the patient and family home care procedures for the period after cataract surgery (see Patient/Family Teaching box: Home Care after Cataract Surgery), including the correct method for instilling eye drops. The home care instructions need to include special precautions recommended by the ophthalmologist based on the type of surgery performed. If a lens implant has not been inserted, patients need to wear contact lenses or cataract glasses. Patients wearing cataract glasses experience loss of depth perception and distorted peripheral and color vision. They need to be taught that objects are magnified by 25% and appear larger and closer than they really are; this requires home safety measures and the modification of dressing and cosmetic application after surgery (see Nursing Care Plan).
Patient/Family Teaching
Home Care after Cataract Surgery
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Activities Not to Do • Avoid rubbing or pressing on the eye.
• Avoid bending at the waist or lifting heavy objects for at least 1 month:
• To pick objects up from the floor, kneel while keeping the head erect.
• To put on stockings or tie shoes, sit and raise the foot to reach the hand while keeping head erect.
• Use long pick-up “reachers” to pick up small objects from the floor.
• Avoid straining with bowel movements (stool softener may be necessary).
• Avoid taking showers and shampooing hair (soap may irritate eye) for the specified time as instructed.
• Limit reading (back and forth movement may loosen stitches).
Activities to Do • Sleep on back or unaffected side for the prescribed time (3 to 4
weeks).
• Apply metal eye shield at night or when napping to protect eye.
• Wear glasses indoors (all day) and sunglasses with side shields outdoors.
• Wash hands before instilling eye drops, and follow the correct procedure for eye drop instillation.
• Follow the steps for an eye pad:
• Wash hands before changing the eye pad.
• Use two oval eye pads.
• Tape the pad snugly and diagonally from above the nose to the lower cheek.
Modified from Monahan, F., Sands, J., Neighbors, M., et al. (2006). Phipps medical-surgical nursing: Health & illness perspectives (8th ed.). St. Louis, MO: Mosby.
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Nursing Care Plan
Cataracts
Clinical Situation Mrs. D, a 78-year-old retired nurse, has been admitted to the skilled nursing unit of a local hospital for rehabilitation therapy after repair of a right hip fracture. She is accompanied by her daughter. Mrs. D has no significant medical history, but a fall in her home resulted in the break in her hip. She states that she has been having trouble with her eyes, and she tripped on the stairs. Since her admission to the hospital, a vision screening detected cataracts in both eyes and surgery was recommended once she recovers. Mrs. D requires assistance with all activities of daily living (ADLs) except eating. She is unable to bear weight on her right leg, so assistance is needed to transfer to the toilet, chair, or bed. She also needs help bathing and dressing the lower half of her body because she cannot reach her legs or feet. Mrs. D states that her biggest concern is fear of falling again.
Nursing diagnoses Risk for Injury, related to altered visual acuity
Bathing Self-Care Deficit, related to immobility
Dressing Self-Care Deficit, related to immobility
Toileting Self-Care Deficit, related to immobility
Anxiety, related to fear of falling
Outcomes The patient will verbalize questions and concerns regarding
cataracts and the recommended surgical treatment.
The patient will have cataract surgery, when appropriate.
The patient will not fall.
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The patient will assist with self-care to the fullest extent possible, as evidenced by fulfilling needs for cleanliness, grooming, and toileting.
The patient will report reduced anxiety, as evidenced by a relaxed state and learning about cataract surgery.
Interventions Provide the patient with the printed information sheet, “Aging
and Your Eyes” (review Box 29-1) and the patient education sheet “Home Care after Cataract Surgery” (see Patient/Family Teaching box).
Encourage the patient and family member to speak with an ophthalmologist about the recommended surgery.
Explain preoperative and postoperative procedures related to the recommended surgery.
Provide a safe environment (e.g., bed in low position, side rails as needed, and call light and personal items in reach).
Assist with transfers until the patient demonstrates safe transfer while unassisted.
Assess the patient’s home for factors that hinder or support vision changes.
Administer pain medication as needed before helping the patient to perform self-care.
Encourage the patient to perform as much of her own care as possible to help restore independence.
Provide assistance, supervision, and teaching with the use of assistive devices, as needed, to perform self-care. Assess factors in the patient’s home that support or hinder self-care.
Encourage expression of fears of falling.
Use therapeutic communication to gain insight into the patient’s fears and give realistic feedback.
Increase attention to the patient when she is feeling anxious. Modified from Gulanick, M. & Myers, J.L. (2013). Nursing diagnosis and intervention:
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Planning for patient care (8th ed.). St. Louis, MO: Mosby; Ackley, B.J. & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care. (10th ed.) St. Louis: Elsevier
Evaluation Evaluation includes documentation of the achievement of the expected outcomes. Patients who have had successful cataract surgery will be free from complications and will have improved vision. Additionally, they will report performance of their usual daily activities with the use of lens implants, contact lenses, or corrective glasses. The patient and family will arrange assistance with ADLs for the first 24 to 48 hours after surgery, or they will notify the home health agency.
Retinal Disorders Three common disorders that affect the retina of an older adult are macular degeneration, diabetic retinopathy, and retinal detachment.
Age-Related Macular Degeneration Age-related macular degeneration (AMD) is the leading cause of blindness among older adults in the United States. It does not cause total blindness but results in loss of close vision. AMD is a poorly understood disease that causes damage to the macula, the key focusing area of the retina. The cells within the macula diminish in functional ability with age, and replacement of the damaged cells is decreased, causing irreversible damage to the macula (Roach, 2005). As a result, central visual acuity declines, which makes performance of daily tasks requiring close vision nearly impossible. Peripheral vision is retained. AMD is viewed as a disease that is becoming an epidemic among older adults (Bressler, 2004).
Types of AMD include the following:
• Dry macular degeneration. Also known as involutional macular degeneration, this condition is caused by breakdown or thinning of macular tissue related to the aging process. Vision loss is gradual.
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• Wet macular degeneration. Also known as exudative macular degeneration, this type of AMD results when abnormal blood vessels form and hemorrhage on the retina. Vision loss may be rapid and severe.
AMD is almost exclusively a disorder of whites and is more common in women than in men. Cases tend to cluster in families. Smoking, low dietary intake of antioxidant vitamins and zinc, and sun exposure are some modifiable risk factors (Taylor, 2002).
Symptoms of macular degeneration include the following:
• Difficulty performing tasks that require close central vision, such as reading and sewing
• Decreased color vision (i.e., colors look dim)
• Dark or empty area in the center of vision
• Straight lines appearing wavy or crooked
• Words on a page looking blurred
Diabetic Retinopathy Loss of visual function is one of the most common complications of diabetes. Altered circulation to the eye may result in retinal edema, degeneration, or detachment. This condition is a complication of diabetes that affects the retinal capillary circulation. Ballooning of these tiny vessels leads to hemorrhaging, scarring, and blindness. These vascular changes, in and around the retina, lead to macular edema which causes the retina to swell. No symptoms of early retinal changes exist, and no symptoms may be apparent even when the retinopathy is advanced. Early detection requires a complete ophthalmoscopic examination; therefore, patients with diabetes should have yearly examinations by an ophthalmologist.
Retinal Detachment Retinal detachment occurs when the sensory layer of the retina separates from the pigmented layer. Tears or holes occur in the retina as a result of trauma, aging (degeneration), hemorrhaging, or the presence of a tumor. When a tear occurs, fluid seeps between
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the layers which causes detachment. The usual symptoms include the following:
• Light flashes
• A shower of floaters that resembles spots, bugs, or spider webs
• Loss of vision
• Veil or curtain obstructing vision
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Nursing management Assessment
No early symptoms of diabetic retinopathy exist, and sometimes no symptoms are observed even with advanced retinopathy. Patients with macular degeneration may complain that they are unable to thread a needle or that the words on a page look blurred, making reading difficult. Patients with retinal detachment notice flashes of light followed by floating spots before the eye with progressive loss of vision. The specific area of vision loss depends on where the detachment is located. When detachment occurs quickly and is extensive, the patient may feel that a curtain has been drawn before the eyes.
Ongoing nursing assessment involves monitoring the patient’s subjective statements about changes in vision and observing for signs of anxiety. All three retinal disorders are diagnosed with ophthalmoscopy.
Diagnosis Nursing diagnoses are determined by analysis of the patient assessment. Possible nursing diagnoses for a patient with a retinal disorder include the following:
• Deficient Knowledge, related to lack of exposure to accurate information about the effect of diabetes on eyes
• Deficient Knowledge, related to retinal detachment condition, surgery, preoperative and postoperative care, and home care after surgery
• Anxiety, related to fear of blindness
Planning and Expected Outcomes Expected outcomes for an older person with a retinal disorder
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include the following:
1. The patient will adjust successfully to vision loss by using low- vision aids.
2. The patient will state in his or her own words the effect of diabetes on the eyes.
3. The patient will see an ophthalmologist yearly.
4. The patient will ask questions about preoperative and postoperative retinal surgery care and report satisfaction with the information.
5. The patient’s affected eye will be free from further retinal detachment, infection, or hemorrhaging.
6. The patient will verbalize appropriate home care activities to participate in after retinal surgery.
7. The patient will demonstrate correct administration of eye drops.
8. The patient will report reduced anxiety.
Intervention Patients with macular degeneration and diabetic retinopathy must learn to cope with chronic, gradual vision loss. Patients with macular degeneration are often taught to self-monitor their central vision using an Amsler chart, which is a small printed grid. The appearance of an increase in waves or curves on the grid may indicate worsening disease. Patients must be taught how to obtain and use low-vision aids (Box 29-3). Teaching about the condition and encouraging yearly follow-up visits with an ophthalmologist help patients understand the disease and how it affects their eyes.
Box 29-3
Low-Vision Aids
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• Prisms, mirrors
• Magnifying devices
• Glasses
• Magnifying television screen
• Large-print books, magazines, telephone pads, clocks, watches, and playing cards
• Computers
• Reading machines
• Talking books, clocks, and wristwatches
• Closed-circuit television, video units, and computers
• Special lighting, including high-intensity reading lamps
• Special lenses
• Telescopic for distance vision
• Microscopic for close vision
• Reading aids
• Angled book stands and book racks
• Prismatic glasses Modified from Redford, J.B. (2007). Assistive devices. In E.H. Duthie & P.R. Katz (Eds.), Practice of geriatrics (4th ed.). Philadelphia: Saunders.
Patients with retinal detachment require the immediate care of bed rest in the proper position (i.e., retinal hole in most dependent position) and eye patches (may be prescribed for one or both eyes) until surgery is performed. Safety precautions and means of communicating are essential for the patient at this point. Postoperative care includes administration of eye medication, pain medication, antiemetics (as needed), and cough medication (as needed). Cold compresses are applied to reduce swelling and promote comfort. Patients must be instructed to avoid jerking movements of the head, as with coughing, sneezing, and vomiting. If the eyes are patched, safety precautions such as keeping call lights, side rails, and necessary items within reach must be
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instituted. Finally, assistance must be provided with ADLs and walking, as needed, to promote comfort and safety. Home care instructions to teach the patient and family include the following: (1) report increases in floaters or flashes of light, decreased vision, drainage, or increased pain to an ophthalmologist, (2) administer eye drops, (3) limit physical activity for 1 to 2 weeks, and resume active sports and heavy lifting as indicated by a physician, and (4) make follow-up appointments with the ophthalmologist.
Patients with any retinal disorder may experience anxiety about the loss of vision and possible blindness. The opportunity for patients to discuss their concerns needs to be provided. Nurses must also be knowledgeable about available resources.
Evaluation Evaluation includes documentation of the achievement of the expected outcomes. Patients with macular degeneration and diabetic retinopathy will describe the condition and report use of low-vision aids. These patients will also follow up with annual visits to the ophthalmologist. Patients who have had surgery for retinal detachment will experience no complications and gradual improvement in vision. Patients will limit their physical activity for 1 to 2 weeks with the help of significant others or home health care. Patients with macular degeneration will monitor their central vision with an Amsler chart and report changes to the ophthalmologist. Patients with any retinal disorder will report reduced anxiety, as evidenced by their ability to learn about and cope with their disease.
Visual Impairment Visual impairment is the most common sensory problem faced by older adults. The visually impaired population includes those with low vision (20/50 to 20/200) and those who are legally blind (visual acuity of 20/200 or worse in the better eye with the aid of the best possible correction with the use of spectacles or contact lens) (Kollarits, 2007). Blindness in older adults results from diabetic retinopathy, glaucoma, cataracts, and macular degeneration, and its
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incidence has increased as the number of adults age 65 or older grows.
Emergency Treatment
Eye Injuries
Burns (chemical or flame) • Flush eye immediately with cool water or any available
nontoxic liquid.
• Seek medical assistance.
Foreign Body (loose substance on conjunctiva such as dirt or an insect) • Pull upper lid down over lower lid to produce tearing and
dislodge substance.
• Irrigate eye with water, if needed.
• Do not rub eye.
• Seek medical assistance if above interventions are unsuccessful.
Contact Injury (e.g., hematoma, ecchymosis, laceration) • If no laceration is present, apply cold compresses.
• If laceration is present, cover eye and seek medical assistance.
Penetrating Objects • Do not remove object.
• Place protective shield (e.g., paper cup) over eye and cover.
• Seek medical assistance. Modified from Monahan, F., Sands, J., Neighbors, M., et al. (2006). Phipps medical-surgical nursing: Health & illness perspectives (8th ed.). St. Louis, MO: Mosby.
Sudden vision loss is considered a medical emergency and
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should be evaluated immediately. It may be caused by retinal detachment or an eye injury (see Emergency Treatment box). The medical management of vision loss depends on the type, cause, and amount experienced. Any patient with a visual disability that cannot be improved by corrective lenses or surgery should be referred to a low-vision specialist or center. Assistive devices for low vision, including glucose monitoring instruments, large-print books, talking clocks, and computer accessories, are available and are continuing to be developed for many health issues (Goldzweig, Rowe, Wenger et al., 2004).
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Nursing management Assessment
Nursing assessment of the patient with impaired vision requires an understanding of the patient’s response to the vision loss. The older adult who becomes blind suddenly usually has a harder time adjusting to the disability than a person who was born blind. Loss of vision may result in a self-esteem disturbance, leading to social isolation. A self-esteem disturbance leads to decreased self- confidence, which may affect interactions with others, the ability to carry out normal daily activities, job performance, and the desire to engage in familiar hobbies. Grief and mourning occur over the loss of vision and result in reactions similar to those experienced with death, for example, denial, anger, guilt, hopelessness, and depression. The patient’s ability to cope with the loss depends on the type, amount, and duration of the vision loss as well as the patient’s support system and coping style. Over time, persons with vision loss are able to compensate by increasing sensitivity in other senses such as hearing, taste, touch, and balance.
Diagnosis Potential nursing diagnoses for the patient with visual impairment include the following:
• Situational Low Self-Esteem, related to sudden loss of vision
• Social Isolation, related to impaired communication
• Ineffective Coping, related to sudden loss of vision
• Feeding/Bathing/Dressing/Toileting Self-Care Deficits, related to visual impairment
• Impaired Physical Mobility, related to visual impairment
• Risk for Injury, related to impaired vision
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Planning and Expected Outcomes Expected outcomes for a patient with visual impairment include the following:
1. The patient will perceive himself or herself positively by making positive statements about self.
2. The patient will participate successfully in activities with others.
3. The patient will demonstrate increased objectivity and ability to solve problems, make decisions, and communicate needs.
4. The patient will safely provide self-care by using low-vision aids and environmental strategies.
5. The patient will demonstrate the safe and correct use of adaptive devices.
Intervention Counseling provides an opportunity for persons who have become visually impaired to talk about their feelings, concerns, and anxieties. Once these emotions have been identified, patients may be given assistance in identifying their strengths and resources. Problem solving may lead to alternative ways to complete the tasks of everyday living and participate in recreational activities.
The nurse who is interacting with a visually impaired patient must rely heavily on various techniques and methods when communicating with that person. See Boxes 29-4 and 29-5 for tips and aids that facilitate communicating and caring for the visually impaired. Keep in mind that these tips can be used in any setting— home care, acute care, or long-term care.
Box 29-4
Signs and Behaviors that May Indicate
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Vision Problems Patient may report • Pain in eyes
• Difficulty seeing in darkened area
• Double or distorted vision
• Migraine headaches coupled with blurred vision
• Flashes of light
• Halos surrounding lights
Staff may notice the patient • Getting lost
• Bumping into objects
• Straining to read or not reading
• Spilling food on clothing
• Withdrawing socially
• Making less eye contact
• Displaying placid facial expressions
• Viewing the television at close range
• Suffering from a decreased sense of balance
• Mismatching clothes Modified from McNeely, E., Griffin-Shirley, M., & Hubbard, A. (1992). Teaching caregivers to recognize diminished vision among nursing home residents. Geriatric Nursing, 13(6), 332.
Box 29-5
Communicating with and Caring for Visually Impaired Nursing Facility
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Residents • Always identify yourself clearly.
• Always make it clear when you are leaving the room.
• Make sure you have the resident’s attention before you start to talk.
• Try to minimize the number of distractions.
• Whenever possible, choose bright clothes with bold contrasts.
• Check to see that the best possible lighting is available.
• Assess your position in relation to the resident. One eye or ear of the resident may be better than the other.
• Try not to move items in the resident’s room. Narrate your actions.
• Try to keep the resident between you and the window or you will appear as a dark shadow.
• Use some means to identify residents who are known to be visually impaired.
• Use the analogy of clock hands to help the resident locate objects.
• Keep color and texture in mind when buying clothes.
• Be careful about labeling residents as confused! They may be making mistakes because of poor vision.
• Obtain and encourage the use of low-vision aids. Modified from McNeely, E., Griffin-Shirley, M., & Hubbard, A. (1992). Teaching caregivers to recognize diminished vision among nursing home residents. Geriatric Nursing, 13(6), 332.
Strategies to increase adaptation to daily living include (1) organizing the environment, (2) encouraging the use of the clock method of eating, and (3) using a sighted guide to assist in ambulation (Box 29-6). Organizing the environment means placing items of clothing in specific drawers or closets to facilitate selection and placing furniture in specific locations to facilitate mobility.
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Additionally, the use of color-contrast and color-coding schemes helps the patient locate items; bright, sharply contrasting colors make furniture and personal items visually distinct. For example, a bright red toothbrush shows up well against a white sink. Coding schemes that facilitate independent living include applying fluorescent tape around light switches, thermostats, and keyholes. Coding with colored paper, textured paper such as sandpaper, or rubber bands may help the patient differentiate among medication containers. The clock method assists the patient at meals because the location of food on the plate is described in terms of a clock face (e.g., beans at the top of the plate are at the 12 o’clock position; potatoes at the bottom of the plate are at the 6 o’clock position). In addition, the patient may use a piece of bread or roll to push food onto the fork. Sighted guides, who lead persons with visual impairments from place to place can help a patient walk confidently (see Box 29-6). The use of a cane or a seeing-eye dog also help promote independence in mobility, especially when the patient is in an unfamiliar environment.
Box 29-6
The Sighted Guide 1. Ask the Older Adult if he or She Would Like to Walk with a
Sighted Guide.
2. If assistance is accepted, offer your elbow or arm. The older adult should grasp your arm just above the elbow. If necessary, physically assist the older adult by guiding his or her hand to your arm or elbow.
3. You will then go a half-step ahead and slightly to the side of the older adult. The older adult’s shoulder should be directly behind your shoulder (Note: If the older adult is frail, locate the hand on your forearm. When this modified grasp is used, the older adult will be positioned laterally to your body.)
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4. You and the older adult should be relaxed and walk at a comfortable pace. When approaching doorways or a narrow space, tell the older adult. The older adult should then go directly behind you. Some modifications may be needed for frail older adults; be sure the modifications are safe and comfortable.
5. Describe the surroundings to the older adult as you walk to augment mobility and enrich the experience.
Modified from McNeely, E., Griffin-Shirley, M., & Hubbard, A. (1992). Teaching caregivers to recognize diminished vision among nursing home residents. Geriatric Nursing, 13(6), 332.
The home health or community health nurse can assist with referral to a social worker who has information on local, state, and federal services available. Services for persons with visual impairments include counseling, mobility training, vocational rehabilitation, self-care skills training, special education, and financial assistance. Low-vision aids such as “talking books,” tapes, and tape players are available from public libraries, the National Federation of the Blind, the American Foundation for the Blind, the National Association for Visually Handicapped, the National Braille Association, and the U.S. Library of Congress. Legal blindness entitles a person to some federal assistance, based on need. Blind persons can claim an additional tax deduction on their federal income tax returns. The American Council of the Blind (ACB) also has resources for the blind and visually impaired such as a directory of banks with talking ATMs, voting access guide for blind voters, and music resources (ACB, 2013).
Evaluation Evaluation includes documentation of the achievement of the expected outcomes, demonstrated by the patient actively participating in self-care and social activities. Patients who display signs and symptoms of depression or social isolation require further counseling to talk about their feelings, strengths, and resources. In addition, alternative visual aids and strategies will need to be identified to increase communication and promote self-
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care.
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Hearing and balance The organs of hearing and balance can be divided into three parts: the external ear, the middle ear, and the inner ear. The external ear and middle ear are involved only in hearing; the inner ear is involved in both hearing and balance. The external ear consists of the auricle and the external auditory canal, a passageway from the outside to the eardrum. The middle ear is an air-filled space that contains the tympanic membrane, the eardrum, and the auditory ossicles. The inner ear contains the sensory organs for hearing and balance. It is made up of interconnecting, fluid-filled tunnels and chambers in the petrous portion of the temporal bone (Figure 29-2).
FIGURE 29-2 Anatomy of the ear. (From Black, J.M. (2008). Medical- surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis, MO:
Saunders.)
The organs of balance are located within the inner ear and is divided into two parts. The vestibule contains the membranous labyrinth, which consists of the utricle and saccule. This portion
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evaluates the position of the head relative to gravity or linear acceleration and deceleration. The second part is located in the semicircular canals and is called the kinetic labyrinth. This labyrinth evaluates the movements of the head.
Age-Related Changes in Structure and Function Age-related changes in the external ear may be seen in the auricle, which appears larger because of continued cartilage formation and loss of skin elasticity. The lobule of the auricle becomes elongated, with a wrinkled appearance. The periphery of the auricle becomes covered with coarse, wirelike hairs. Compared with women, men have larger tragi, which are laterally situated in the external canal. These tragi become larger and coarser with age. The auditory canal narrows as a result of inward collapsing. The hairs lining the canal become coarser and stiffer. In addition, cerumen glands atrophy, causing the cerumen to be much drier. In the middle ear, age- related changes in the tympanic membrane cause a dull, retracted, and gray appearance. Degeneration of ossicular joints in the middle ear has also been noted. Finally, changes within the inner ear result in decreased vestibular sensitivity.
Age-related balance decline is caused by a combination of decreased sensory input, slowing of motor responses, and musculoskeletal limitations. Numerous studies comparing healthy younger and older adults have reported an increase in postural sway in older adults. Despite this increase, most healthy older adults have enough sensory function reserve to maintain postural control. However, deprivation in more than one system is likely to lower the balance threshold. In addition, under conditions in which balance is maximally stressed, for example, climbing up or down steps or curbs and getting in and out of a bathtub, maintaining balance becomes more difficult.
Common Problems and Conditions Pruritus
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Pruritus, itching within the external auditory canal, is related to age-related atrophic changes in the skin. Atrophy of the epithelium and epidermal sebaceous glands results in dryness. Often, chronic pruritus of the ear canal results from an itch–scratch–itch cycle initiated by dry skin. The problem may be exacerbated by efforts to retard and remove dry earwax buildup. Several drops of glycerin or mineral oil instilled in the ear canal daily will add moisture to the external ear. More resistant conditions may be treated by instilling steroid-containing medications in the external canal.
Cerumen Impaction Cerumen impaction is a reversible, often overlooked, cause of conductive hearing loss. With increasing age, atrophic changes in the sebaceous and apocrine glands lead to drier cerumen. These changes in the cerumen coupled with a narrowed auditory canal and stiffer, coarser hairs lining the canal lead to cerumen impaction. The cerumen blockage may interfere with the passage of sound vibrations through the external auditory canal to the middle and inner ear, affecting a person’s ability to hear and communicate. This impaired communication may then lead to social isolation and depression.
Common symptoms of cerumen impaction include hearing loss, a feeling of fullness in the ear, itching, and tinnitus (ringing in the ears). Identification and removal of the impaction may restore hearing acuity and relieve symptoms associated with impaction. Older adults often have less cerumen but dryer cerumen because of a larger amount of keratin in the canal (Maas, Buckwalter, Hardy et al., 2001).
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Nursing management Assessment
Patients with cerumen buildup may complain of ear fullness, itching, and difficulty hearing. An otoscopic examination will show whether the external ear canal is obstructed by cerumen and whether the tympanic membrane is visible.
Diagnosis Potential nursing diagnoses for a patient with the aforementioned assessment findings include the following:
• Social Isolation, related to difficulty communicating with family and friends
Planning and Expected Outcomes Expected outcomes for a patient with cerumen impaction include the following:
1. The patient will be free from cerumen impaction.
2. The patient will follow proper instillation of softening agents.
3. The patient will report a satisfactory level of involvement with family and friends.
Intervention The nurse must assess patients for signs of hearing impairment that may indicate cerumen impaction, including (1) difficulty understanding the spoken word (patients may ask why others are mumbling or deliberately excluding them from conversation), (2) loud radio and television volume, (3) withdrawal from social activities and accompanying depression, and (4) possible confusion and paranoia. Once an otoscopic examination reveals an impaction,
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the nurse should follow the protocol for cerumen removal. For patients living in the community, both patients and their families should be taught how to instill the softening agent. In addition, patients should be instructed to notify their health care provider if they experience decrease in hearing, any pain, or a ringing or a crackling in their ear.
The protocol for cerumen removal includes the following steps (Meador, 1995):
1. Clip and remove hairs in the ear canal.
2. Instill a softening agent, mineral oil, or a carbamide peroxide and glycerin solution (Debrox, a nonprescription otic solution) twice daily for several days until the wax softens.
3. Irrigate the ear by using a bulb syringe, a plastic syringe (2 to 4 ounces [oz]), or a WaterPik device (on its low setting).
4. Use a solution of 3% hydrogen peroxide (3 oz) in 1 quart (qt) of water warmed to 98 ° F to 100 ° F. If the patient is sensitive to hydrogen peroxide, use sterile, normal saline solution.
5. Place a towel around the patient’s neck and tip his or her head to the side being drained, with the emesis basin kept under the ear to catch drainage.
6. Tip the patient’s head to the side that is being irrigated.
7. Place the tip of the irrigating device just inside the external meatus; the tip should still be visible.
8. Straighten the auditory meatus by gently drawing the pinna up and back.
9. The flow of irrigating fluid should be steady; as fluid passes the plug, small to large pieces of cerumen will be forced out of the canal. Lavage continues until the cerumen is removed.
10. Drain excessive fluid from the ear by tilting the head toward the affected side. Wipe with a cotton-tipped applicator and alcohol (70% isopropyl).
11. Firmly impacted cerumen must be manually extracted by a physician or advanced practice nurse with an otoscope and a
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curette.
Evaluation The patient will be free from cerumen impaction and verbalize a decrease in ear fullness and an increase in the ability to hear. The cerumen removal should be documented, noting the method of irrigation, the amount and type of debris removed, and the patient’s response. The patient will demonstrate the proper method to instill the softening agent. The patient will also state the ear symptoms to report to his or her health care provider.
Tinnitus Tinnitus is a chronic combination of both conductive and sensorineural hearing loss. It is a subjective sensation of noise in the ear, defined as a ringing, buzzing, or hissing. Tinnitus occurs more frequently in whites and the prevalence of tinnitus is almost twice as frequent in the South as in the Northeast. Individuals at any age may experience tinnitus, but its prevalence increases with advancing age. About 12.3% of men and almost 14% of women age 65 and older are affected by tinnitus. For most, it is an annoying and bothersome condition, and for others, it is an indication of permanent hearing loss or a tumor (National Institutes of Health [NIH], 2013).
The most common causes of tinnitus are noise or toxin damage to the hair receptors of the cochlear nerve and age-related changes in the organs of hearing and balance. Tinnitus is not a disease but a symptom associated with many diseases, conditions, and medical treatments. Tinnitus is classified as subjective or objective. Subjective tinnitus is audible only to the patient. It is characterized as ringing, buzzing, or humming. Objective tinnitus, although rare, is audible to both the patient and the examiner. It is more likely to be low pitched and is often associated with an identifiable cause such as muscle spasms or vascular and musculoskeletal cranial disorders. An additional important classification of tinnitus is whether it is bilateral or unilateral. Unilateral tinnitus is associated with more serious diseases such as Meniere disease, tumors, or
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vascular problems and requires an extensive workup (NIH, 2013).
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Nursing management Assessment
The Tinnitus Questionnaire should be used to gather necessary subjective data (Box 29-7). Objectively, the patient will have signs of subjective or objective unilateral or bilateral ringing in the ear.
Box 29-7
Tinnitus Questionnaire 1. How long have you had ringing (or other sounds) in your ears?
2. Describe as nearly as possible the sound you hear.
3. Is the sound in the left, right, or both ears? Is it constant or occasional?
4. Does the sound change with exercise, climbing stairs, or fast walking?
5. Do you have a hearing problem?
6. Do you have ear pain, discharge, or an infection?
7. When is the sound in your ears worse: daytime, evening, or night?
8. Does this sound interfere with sleep, television, radio, crowds, or conversation?
9. Do you grind your teeth or clench your jaws at times?
10. Have you recently had dental problems or treatments? Ear pain? Excessive ear wax? Ear discharge or infection? Cold or flu? Recent head or neck injury? Headaches? Dizziness? Balance difficulty? Visual problems? Swallowing problems? Speaking problems? Numbness or weakness anywhere?
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11. Do you smoke? Drink coffee, tea, chocolate, cola, or other carbonated drinks with caffeine, or alcoholic or quinine water drinks?
12. What prescription medications do you take? What other medications do you take: aspirin, aspirin-containing medications, or ibuprofen (Advil) for headaches, joint pain, or congestion; sleeping aids; or diet pills?
13. Do you experience considerable sudden or intense noise at work, home, or recreation that involves the use of motors or firearms?
14. Have you or any family member had allergies? Arthritis? Anemia? Diabetes? High blood pressure? Thyroid problems?
From Ross, V., Echevarria, K.H., & Robinson, B. (1991). Geriatric tinnitus: Causes, clinical treatment and prevention. Gerontological Nursing, 17(10), 6.
Diagnosis Potential nursing diagnoses for the patient with tinnitus include the following:
• Ineffective Health Maintenance, related to a lack of knowledge about tinnitus prevention practices
• Anxiety, related to coping with the chronic condition of ringing in the ears
Planning and Expected Outcomes Expected outcomes for the patient with tinnitus include the following:
1. The patient will follow tinnitus prevention practices.
2. The patient will use home masking measures and a hearing aid or tinnitus masker to relieve tinnitus. 3. The patient will cope with anxiety independently by using relaxation techniques.
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Intervention Nursing interventions are outlined in Box 29-8. Patients should be taught prevention practices, including (1) treating correctable problems (e.g., cerumen impaction and ear infections) that cause tinnitus, (2) softening loud sounds through improved acoustics, (3) using protective ear plugs, and (4) avoiding foods, drinks, and drugs that contain ototoxic substances. Teach patients about the following home masking measures that produce a variety of distracting sounds:
Box 29-8
Chronic Tinnitus Interventions Mild tinnitus (does not affect ADLs) • Reassure the older adult that tinnitus is not life threatening.
• Instruct the patient to avoid ototoxic substances in foods, drinks, and drugs.
• Avoid quinine, aspirin, and antiinflammatory drug compounds.
• Avoid caffeine, sodium, chocolate, tea, and alcohol.
Moderate tinnitus (interferes with sleep and ADLs) • Teach simple home masking measures to relieve tinnitus:
• Radio tuned between stations
• Clocks that tick loudly
• Soft, pleasant, distracting music
• Semielevated head position to sleep
• Recommend evaluation for properly fitted hearing aid; may relieve tinnitus even if hearing loss is mild.
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• More sophisticated, commercial tinnitus maskers and instruments may be matched to the individualized pitch of one’s tinnitus.
• Use habituation therapy (exposing patients to low-level broad- band noise produced by wearable noise generators).
• Medications (e.g., amitriptyline [Elavil], zolpidem [Ambien], alprazolam [Xanax], lorazepam [Ativan], and histamines) may be used, but with caution because they may cause drowsiness and mental confusion.
severe tinnitus • Refer patient for extensive counseling and education.
• Apply all moderate tinnitus interventions.
• Teach relaxation methods to cope with stress and promote sleep; combined with biofeedback, this has proved to be beneficial for long-term sufferers of tinnitus.
• Perform electrical stimulation.
• Perform acupuncture.
• Perform surgery (rare; for those patients with objective tinnitus or those who have no auditory function and perceive tinnitus as originating from the nonfunctioning ear).
• Contact local self-help tinnitus support groups (for information, contact the American Tinnitus Association, www.ata.org/for- patients/about-tinnitus [2010])
Compiled from Ross, V., Echevarria, K.H., & Robinson, B. (1991). Geriatric tinnitus: Causes, clinical treatment and prevention. Gerontological Nursing, 17(10), 6; Seidman, M.D. & Jacobson, G.P. (1996). Update on tinnitus. Otolaryngological Clinics of North America, 29(3), 455.
• Portable radio tuned between stations
• Loud ticking clock • Soft, pleasant music
• Electric fan
• Sleeping with head elevated on two pillows
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Recommend that patients get evaluated for aids or a specially designed masker to lessen tinnitus. Coping strategies to relieve anxiety and stress, for example, relaxation training, biofeedback, and counseling, should also be taught.
Evaluation Achievement of the expected outcomes is evidenced by patients following recommended tinnitus interventions and strategies to cope with the chronic ringing in their ears. The Tinnitus Handicap Inventory was published in 1996 to identify the problems that individuals have with tinnitus. The 25-question inventory delves into feelings and interference with living issues (McCombe, Bagueley, Coles et al., 2001; Newman, Jacobson, & Spitzer, 1996). Some areas of interference in daily living include the ability to concentrate, frustration, stress, and problems with sleep, among others. Patients noting no improvement or increase in symptoms should be referred to a multidisciplinary team (specializing in tinnitus) composed of an otolaryngologist, audiologist, and psychiatrist for evaluation and counseling. Patients taking medications should be free from side effects. Those displaying adverse side effects should report to their health care provider for dosage modification, alternative drug therapy, or discontinuation of the medication.
Hearing Loss Approximately 17% (36 million) of American adults report some degree of hearing loss. A strong correlation exists between age and hearing loss; however, hearing loss is not a normal part of the aging process and should be further evaluated for proper treatment. Over 30% of adults age 65 or older in the United States have some type of hearing impairment, and only 1 out of 5 people who could benefit from a hearing aid actually wears one (NIH, 2013).
Hearing impairment is classified as conductive, sensorineural, or mixed. Conductive hearing loss results from interruption of the transmission of sound through the external auditory canal and
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middle ear. Conditions that may result in conductive hearing loss are cerumen impaction, otitis media, and otosclerosis (fixation of auditory ossicles).
Sensorineural hearing loss results when the inner ear, auditory nerve, brainstem, or cortical auditory pathways do not function properly so that sound waves are not interpreted correctly. Mixed hearing loss is a conductive hearing loss superimposed on a sensorineural hearing loss.
Cochlear implants are becoming increasingly selected by older adults with sensorineural hearing loss. This implant is surgically placed in the mastoid bone (behind the ear) where it transmits electrical signals by way of the auditory nerve to the brain’s hearing center (Ham, Sloane, Warshaw et al., 2013).
Presbycusis Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones and conversational speech. It affects men more than women. The cause of presbycusis remains unclear. Studies designed to identify a direct cause have proven no clear correlation. Therefore, the diagnosis is one of exclusion, which involves ruling out other causes of hearing loss:
• Noise-induced hearing loss (i.e., prolonged exposure to loud noise)
• Infection
• Head injury
• Metabolic disease (of the pancreas or kidneys)
• Vascular disease
• Heart disease
• Genetic factors
Signs and symptoms displayed by the patient include the following:
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• Increasing the volume on the television or the radio
• Tilting the head toward the person speaking
• Cupping the hand around one ear
• Watching the speaker’s lips
• Speaking loudly
• Not responding when spoken to
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Nursing management Assessment
Subjective data that should be obtained from an older patient with hearing loss include onset, type, and progression of hearing loss, including differences in either ear; a family history of hearing loss; the presence of other symptoms such as pressure or pain in the ears, ringing in the ear, or dizziness; a history of head injury or noise exposure; and current medications with known ototoxic effects. Objectively, the patient may display some behavioral symptoms of hearing loss (Box 29-9). A complete hearing evaluation should be conducted.
Box 29-9
Behavioral Clues Indicating Difficulty Hearing • Difficulty hearing over the telephone
• Trouble following conversation when two or more persons are talking at the same time
• Turning up the volume on the television
• Leaning forward to hear better or straining to understand conversations
• Shunning large-group and small-group audience situations
• Complaining about people mumbling
• Difficulty understanding women and children talking
• Asking for frequent repetition and answering questions inappropriately
• Losing sense of humor or becoming grim
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Data from U.S. Department of Health and Human Services. (2009a). Age page: Hearing loss, Bethesda, MD: National Institute on Aging.
Diagnosis Nursing diagnoses based on analysis of the patient’s hearing loss include the following:
• Social Isolation, related to difficulty with communication
• Risk for Chronic Low Self-Esteem, related to hearing loss (Ackley & Ladwig, 2014)
Planning and Expected Outcomes Expected outcomes for a patient with a hearing loss include the following:
1. The patient will effectively use aural rehabilitative techniques.
2. The patient will maintain satisfactory social contacts and activities with others.
3. The patient will perceive himself or herself positively, as evidenced by positive self-talk and behaviors.
Intervention Interventions for the patient with a hearing impairment focus on aural rehabilitation and facilitation of communication. Patients often deny their hearing loss and need much encouragement and support to explore the various methods to improve hearing. The nurse should provide patients with a printed information sheet on hearing loss (Box 29-10).
Box 29-10
Hearing and Older Adults
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1. Presbycusis is the normal hearing loss associated with aging. Changes in the structure and function of the inner ear make it difficult to understand certain types of speech sounds and produce intolerance for loud noise. The sounds that are usually lost first are f, s, th, ch, and sh. As hearing loss progresses, the ability to hear the sounds of b, t, p, k, and s is also impaired.
2. Some of the most common signs and symptoms of hearing loss include the following:
a. Difficulty understanding speech
b. Certain sounds being too annoying or loud
c. Difficulty discriminating speech; another person’s speech sounding slurred or mumbled
d. Trouble hearing at large gatherings, especially where background noise is present
e. Constant ringing or hissing background noise
3. Do not be afraid to tell your family and friends to face you and to speak at a normal rate, in lower tones (not necessarily louder), and with greater clarity. If you do not understand, ask the person to repeat. Listen carefully while watching the person’s face and lips.
4. If you are having a hearing problem, see your health care provider. A hearing problem may be caused by a serious medical condition that your health care provider may be able to diagnose and treat, or your health care provider may wish to refer you to a specialist (otolaryngologist or audiologist) for further evaluation.
5. A hearing aid may be recommended. Seek professional guidance in obtaining the best aid suited to your needs. Find a reputable dealer by checking with the Better Business Bureau. Because of the high cost of hearing aids and their upkeep, it is wise to choose carefully.
Data from U.S. Department of Health and Human Services. (2009a). Age page: Hearing loss, Bethesda, MD: National Institute on Aging.
Aural rehabilitation includes auditory training, speech and
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reading training, and hearing aids. Auditory training helps the person with a hearing impairment listen to a speaker by differentiating among gross sounds. Speech and reading training includes lip reading and speech skills. Lip reading requires understanding of verbal communication by integrating lip movements, facial expressions, gestures, and environmental clues. This process is extremely difficult without auditory clues. Speech skills must be conserved with the reduced auditory feedback experienced by the patient with impaired hearing. Older adults who have hearing impairments must learn to work intelligently with inefficient communication and decreased speech (see Patient/Family Teaching: Strategies to Improve Communication When There Is Hearing Loss). Hearing aids amplify sound but do not improve the ability to hear. Technologic advances currently offer patients a wide variety of amplification options to suit their changing environmental needs (i.e., quiet to noisy). Patients and their families should be instructed on the basics of hearing aid use and care (see Patient/Family Teaching: Assisted-Listening Devices). All nurses and nursing assistants should have a basic understanding of how to work with a hearing aid to assist the patient who is unable to care for the aid. Patients and their families should be taught where to obtain and how to use assisted-listening devices (see Patient/Family Teaching Box: Hearing Aid Assessment Tool for Cleaning, Inserting, and Troubleshooting and Health Promotion/Illness Prevention: The Ear).
Patient/Family Teaching
Strategies to Improve Communication When There Is Hearing Loss Provide good visual contact with patients. Individuals with
hearing impairment need to supplement hearing with lip reading. They need to be able to see the speaker’s face and lips. Avoid situations where glare or shadows are present on the patient’s field of vision.
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Reduce or eliminate background noise.
Speak at a normal rate and volume. Do not overarticulate or shout.
Use short sentences, and pause at the end of each sentence.
Use facial expressions or gestures to give useful clues.
Ask how you can help the listener.
Be patient, and stay positive and relaxed. Data from U.S. Department of Health and Human Services. (2013). Age page: Hearing loss. Bethesda, MD: National Institute on Aging.
Patient/Family Teaching
Assisted-Listening Devices These devices are designed to amplify sound or transform sound into tactile or visual signals. These systems allow a hearing impaired person to communicate more effectively and function more independently.
• Microphones placed close to the sound source
• Amplifiers for the telephone, television, or radio
• Closed-captioned television
• Teletypewriters
• Doorbell and telephone that light as well as ring
• Flashing smoke detectors and alarm clocks
• Burglar alarms that both light up and sound From Patt, B.S. (2007). Otologic disorders. In: Duthie, E.H., Katz, P.R., Malone, M. (Eds.). Practice of geriatrics (4th ed.). Philadelphia: Saunders.
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Patient/Family Teaching
Hearing Aid Assessment Tool for Cleaning, Inserting, and Troubleshooting
Component Look Listen Earmold or in-the-ear aid
Opening clear? Cracks or rough areas? Check fit. Use sounds (a/u/c/s).
Battery Using battery tester, check voltage (replace at 1.1 or below). Compartment clean? Battery contacts clean? Battery inserted properly (match + on battery to + on battery compartment)? Is battery compartment shut all the way?
Case Cracks? Separating? Press case gently. Microphone Clean? Visible damage? Interruption in amplification? Dials Clean? Easily rotated? Rotate. Reasonable gain
variation? Static? Switches Clean? Easy to move? Turn on and off. Static? Cord (body aid)
Cracked? Frayed? Connection plugs clean? Run fingers down cord. Clean? Interruption in amplification? Connections tight?
Tubing (behind-ear aid)
Cracks? Good connection to earmold and aid? Moisture? Debris? Cover opening of earmold and turn to maximum gain. Feedback? Distortion? Static?
Receiver (body aid)
Cracks? Firmly attached to earmold snap? Reduced gain? Substitute spare receiver and recheck. Five speech sounds clearly amplified?
Volume control distortion
Smooth, gradual increase? Clear quality? Turn to maximum gain to check.
Feedback Recheck receiver snap, tubing, and earmold. External feedback? Internal?
Health Promotion/Illness Prevention The Ear Health Promotion • Notify physician of any pain, discharge, redness, swelling,
dizziness, ringing in ears, or loss of hearing.
• See physician for early detection and appropriate treatment of hearing difficulties and ear disease (e.g., cerumen impaction, tinnitus, presbycusis, and vertigo).
• Maintain prescribed hearing aids, assistive listening devices, and medications.
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Prevention of Disease • Have a periodic ear examination and screening for ear disease
and hearing problems.
• Avoid exposure to hazardous noise.
• Use protective earplugs in high-risk occupations and activities.
Evaluation Evaluation is based on documentation of the achievement of expected patient outcomes, as evidenced by the patient using aural rehabilitation techniques and devices to enhance communication. The patient and family should demonstrate the proper use, cleaning, and troubleshooting of the hearing aid. The older patient should remain actively involved with others and the environment. Those older patients displaying signs and symptoms of depression and social isolation will require further encouragement and support to explore other methods to improve hearing.
Dizziness and Dysequilibrium Dizziness and dysequilibrium are common complaints of older adults. Although a general decrease occurs in vestibular sensitivity with aging, the symptoms of dizziness or imbalance should not be considered a normal part of aging. Balance disorders contribute to deficits in ambulation that may interfere with an older person’s ability to carry out normal ADLs. The five age-related conditions of dysequilibrium that have been documented in older adults are as follows:
1. Benign paroxysmal positional vertigo: severe episodes of vertigo precipitated by a particular change in head position
2. Ampullary dysequilibrium: vertigo or dysequilibrium associated with rotational head movements
3. Macular dysequilibrium: vertigo precipitated by a change of head position in relation to the direction of gravitational force (e.g., severe dizziness when rising from bed)
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4. Vestibular ataxia of aging: constant feeling of imbalance with ambulation (Tideiksaar, 2010)
5. Meniere’s disease: an uncommon disease seen most often in older women, characterized by severe vertigo accompanied and usually preceded by tinnitus and progressive low-frequency sensorineural hearing loss
Although the vestibular system of the inner ear is the most common source of dizziness and balance disorders, the following causes must also be considered:
• Visual disturbances
• Musculoskeletal disorders
• Neurologic dysfunctions
• Metabolic abnormalities
• Cardiovascular disease
• Medications
Signs and symptoms vary for each disorder but may include any of the following:
• Whirling dizziness when the head is moved in a certain position
• Dizziness or imbalance when the head is moved quickly to the right, left, up, or down
• Constant feeling of imbalance when walking
Meniere Disease Meniere disease is caused by pressure within the labyrinth of the inner ear, which is a result of excessive endolymphatic fluid that causes swelling in the cochlea. What causes the excessive fluid is unclear. The three major characteristics are vertigo, tinnitus, and hearing loss. Other associated symptoms include loss of balance, nausea and vomiting, and spasmodic eye movements. Roughly 615,000 people have been diagnosed with Meniere disease in the United States, and another 45,500 are newly diagnosed each year (NIH, 2013).
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Nursing management Assessment
Subjective data include a description of vertigo episodes (including frequency and duration); a list of accompanying symptoms, such as nausea and vomiting, hearing loss, or tinnitus; a history of balance problems; and a drug history. Objective data include a complete assessment of hearing and balance.
Diagnosis Potential nursing diagnoses for the patient with vertigo and Meniere disease include the following:
• Risk for Injury, related to acute onset of vertigo
• Deficient Knowledge, related to lack of exposure and inexperience with regard to cause of vertigo and its treatment
• Deficient Knowledge, related to lack of exposure to preoperative and postoperative surgical care for Meniere’s disease
• Anxiety, related to uncertainty of future vertigo attacks
Planning and Expected Outcomes Expected outcomes for the patient include the following:
1. The patient will accurately follow the prescribed medication regimen and exercise protocol.
2. The patient will safely follow measures to reduce dizziness and prevent falls.
3. The patient will state the causes and treatment of vertigo.
4. The patient will ask questions about the surgical care for Meniere disease.
5. The patient will meet his or her own self-care needs, as evidenced
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by reports of normal appetite, sleep, and activity.
Intervention Pharmacologic treatment includes antivertiginous drugs such as meclizine (Antivert) or diphenhydramine (Benadryl). Meclizine may cause drowsiness; patients should be instructed to avoid alcoholic beverages while taking this drug. Patients with a history of asthma, glaucoma, or enlargement of the prostate gland must be monitored carefully while taking meclizine because of its anticholinergic action. Diphenhydramine, an antihistamine, is likely to cause dizziness, sedation, and hypotension in older patients. A diuretic such as hydrochlorothiazide (HCTZ) and a low-sodium diet help remove excess endolymphatic fluid. Older patients undergoing diuretic therapy need to be monitored for evidence of fluid or electrolyte imbalances.
Vestibular rehabilitation therapy is conducted by a physical therapist, who designs an exercise program consisting of oculomotor and postural tasks that are taught to the older patient and incorporated into daily living (Patt, 2007).
Surgery may be performed for Meniere disease to prevent further damage and sensorineural hearing loss. An older patient undergoing ear surgery is given a local anesthetic. Preoperative care includes giving instructions for postoperative care and sedating the patient. Postoperative care includes (1) positioning the operative ear up for 4 hours after surgery, (2) medicating for pain and vertigo, (3) following safety precautions (e.g., side rails up, call light in reach, and assistance with ambulation), (4) monitoring the patient for changes in hearing, vertigo, neurologic symptoms (e.g., headache), or facial paralysis, and (5) instructing the patient to keep his or her mouth open when sneezing or coughing.
No complete cure for vertigo exists. Therefore, patients must be taught the following measures to reduce dizziness: (1) move slowly, (2) avoid bright, glaring lights (a quiet, darkened room is best), and (3) if vertigo occurs during ambulation, lie down immediately and hold the head still. The patient with vertigo must be taught the causes of vertigo and the pharmacologic treatment, vestibular
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exercises, and measures to reduce vertigo and promote safety during an acute attack.
Evaluation Evaluation includes achievement of the expected outcomes, as evidenced by patients accurately following the prescribed medication regimen and exercise protocol. Patients displaying adverse side effects should report these to their health care provider for a modification in their medication regimen. Patients should be free from falls by following measures to reduce dizziness. Those with reported falls should be evaluated with a fall assessment tool and taught alternative safety measures.
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Taste and smell The senses of taste and smell detect the aesthetics and safety of the environment. Some evidence suggests that the senses of smell and taste diminish with aging. Loss of smell and taste may affect an older person’s food choices and intake and subsequently impair nutritional and immune status, which may exacerbate disease states. A decreased sensitivity to odors puts the older person at risk for noxious chemicals and poisonings (e.g., a person may fail to detect the odor of smoke or leaking gas).
Age-Related Changes in Structure and Function Age-related changes in the senses of smell and taste are related to alterations in the oral mucosa and tongue and the pathologic state of the nasal cavity. Anatomic and physiologic changes occur with aging (e.g., reductions in cell number, damage to cells, and diminished levels of neurotransmitters). In healthy older adults, olfactory losses result from normal aging, medications, viral infections, long-term exposure to toxic fumes, and head trauma. The majority of studies indicate a dramatic decline in sensitivity to airborne chemical stimuli with aging. Additionally, recognition of odors declines dramatically with age.
The cause of taste changes in normal aging is not fully understood. Studies of anatomic losses in the structures of the taste system in older adults report conflicting findings. Taste losses result from disease states of the nervous and endocrine systems, nutritional and upper respiratory conditions, viral infections, and medications. Beginning in the early 60s a decreased sense of taste is often noticed. By age 70, a severe loss is typical (Seiberling & Conley, 2003).
Common Problems and Conditions Xerostomia
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Xerostomia, commonly referred to as dry mouth, is a subjective sensation of abnormal oral dryness. Reduced salivary flow is a common complaint of older adults. Longitudinal studies have established that salivary flow from the parotid gland is unchanged with advancing age. Factors leading to a dry mouth include disease states (e.g., Alzheimer disease, depression, Sjögren syndrome), conditions (e.g., radiotherapy of the head and neck or mouth breathing), and medications (e.g., sedatives, antihistamines, antidepressants, diuretics, chemotherapy, or anticholinergics).
Dry mouth in older adults may lead to increased risk of serious respiratory infection, impaired nutritional status, and reduced ability to communicate. Complaints of abnormal taste sensations, burning of the oral tissues and tongue, and cracking of the lips are common. The oral mucosa is dry, thin, and smooth, and the tongue may have a thick, white, foul-smelling coating. The decrease in salivary flow interferes with chewing and swallowing. Patients with dentures may complain of sore gums and tissues and denture slippage from the loss of salivary flow, which forms a mechanical barrier.
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Nursing management Assessment
Subjective assessment should include a health history of factors leading to a decrease in salivary flow and the patient’s oral complaints. Objective assessment of the lips of a patient with xerostomia reveals red, inflamed, cracked, and dry lips, and they may bleed. The tongue has red areas and a coated base; it appears thicker, with a prominent lingual groove and papillae. The mucous membranes of the palate and the lining of the mouth and gums appear dry, red, and edematous. The saliva is scant, ropy, and viscid. The amount of moisture in the oral cavity is assessed by running a gloved finger over the oral mucosa to evaluate stickiness, which indicates dry mucous membranes. The patient’s voice may be dry and raspy, and he or she may complain of difficulty articulating words. Taste testing is performed to evaluate taste sensation, which may be diminished.
Diagnosis Potential nursing diagnoses for the patient with xerostomia include the following:
• Impaired Oral Mucous Membrane, related to changes induced by xerostomia
• Imbalanced Nutrition, Less than body requirements, related to changes induced by xerostomia
Planning and Expected Outcomes Expected outcomes for the patient with xerostomia include the following:
1. The patient will verbalize increase in taste sensation.
2. The patient will exhibit unimpaired oral mucosa tissue integrity,
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as evidenced by moist, pink, smooth mucosal surfaces.
3. The patient will verbalize no oral discomfort.
4. The patient will state contributing factors, symptoms, and treatment of xerostomia.
5. The patient will demonstrate a correct oral hygiene regimen.
Intervention Nursing interventions for the patient with xerostomia focus on attaining intact oral mucosa tissue integrity. Teaching patients about the factors leading to a decrease in salivary flow, as well as the associated symptoms, is key to the prevention and treatment of xerostomia. The treatment regimen focuses on increasing salivary flow. Patients need to be taught the basic oral hygiene of brushing teeth twice daily with a soft toothbrush and a nonabrasive fluoride toothpaste, as well as daily flossing. Fluid balance is vital for maintaining moisture in the oral cavity. Patients need to take in 2 to 3 liters (L) of fluid per day, if not contraindicated. Also, foods prepared with gravy or sauces contain moisture and should be included in the diet, if not contraindicated. Additional methods to teach patients to increase salivary flow include the use of artificial saliva, sugar-free hard candy, and gum.
Evaluation Evaluation of the interventions is based on the appearance of the oral mucous membranes, the patient’s relief of symptoms, and an increased level of comfort through effective daily treatment practices.
Home Care
1. Sensory changes may lead to social isolation in homebound
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older adults (e.g., not being able to interact effectively with family members as a result of visual or hearing deficits).
2. Sensory changes increase safety hazards (e.g., burning or falling) for homebound older adults.
3. Instruct caregivers and homebound older adults about signs and symptoms of age-related sensory changes. Instruct them to report to their physician or home care nurse any signs and symptoms that interfere with independent function or present safety hazards.
4. Instruct caregivers and homebound older adults about prescribed treatments or surgical procedures (e.g., preoperative and postoperative care of cataract surgery, eye drops, eardrops, and antibiotics).
5. Assist caregivers and homebound older adults in organizing the environment to accommodate any decreased sensory function (e.g., use of color contrast, bold print books, hearing aid on the telephone).
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Touch At birth, touch is the most developed sense. Touch involves tactile information on pressure, vibration, and temperature. Although touch, pressure, and vibration are commonly classified as separate sensations, they are detected by the same types of receptors. The only differences among these three are that (1) touch sensation usually results from stimulation of receptors in the skin or in tissues immediately beneath the skin; (2) pressure sensation generally results from deformation of deeper tissues; and (3) vibration sensation results from rapidly repetitive sensory signals.
Sensitivity to light touch diminishes in older adults and may be related to a decreased density of cutaneous receptors for touch sensation. Tactile vibratory thresholds progressively increase with age, most likely because of changes in Pacinian corpuscle receptor sensitivity. Studies to evaluate the influence of age on thermal perception report conflicting findings. The warm–cold difference threshold increases with age.
The most common disorders affecting tactile information include cerebrovascular accident (CVA), peripheral vascular disease (PVD), and diabetic neuropathy. All three conditions involve changes in the vascular system that result in decreased blood flow to various parts of the body. Signs and symptoms of a CVA depend on the cerebral artery affected and the portion of the brain supplied by that artery. In PVD and diabetic neuropathy, the impaired blood flow manifests as a loss of sensation most commonly noted in the lower extremities.
The common thread among these disorders is the alteration of peripheral tissue perfusion. Nursing interventions are directed toward preventing accidental trauma and injury in the affected limbs. Patient education focuses on skin, leg, and foot care. The effectiveness of nursing interventions is determined by the absence of trauma, especially in the lower extremities.
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Summary The senses of older adults are the key to their interaction with the environment. As these senses decline because of normal age-related changes or pathologic conditions, nurses in every setting must adapt interventions to promote the highest level of independent functioning.
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Key points • Studies have documented age-related changes in the senses of
vision and hearing.
• Age-related changes in the senses of taste and smell remain questionable.
• A cataract is opacity of the lens and requires surgery for successful treatment.
• Glaucoma is caused by increased IOP and requires lifelong treatment with medications to lower the pressure.
• Retinal detachment requires immediate medical attention and can be repaired only by surgical intervention.
• Wet macular degeneration and diabetic retinopathy can be treated successfully with laser surgery.
• Organizing the environment, using the clock method of eating, and assisting ambulation with a sighted guide help an older adult who is visually impaired maintain independence.
• Hearing loss affects an older person’s ability to communicate and may lead to depression, social isolation, and loss of self-esteem.
• Prevention and treatment of cerumen impaction is an important nursing function in the care of older adults, especially in the long- term care setting.
• Vertigo may be a chronic and annoying condition, but the use of proper safety measures and methods of reducing dizziness may facilitate daily functioning.
• Xerostomia may cause pain in the oral mucosa, gums, and tongue, leading to alterations in taste. Treatment includes a daily oral care regimen and methods to increase salivary production.
• Older adults with a diminished sense of touch are at risk for injury, especially in the affected limbs.
2188
Critical thinking exercises 1. A 69-year-old woman has tinnitus and episodes of imbalance. Her son and daughter-in-law are concerned about having to leave her alone during the day while they are at work. What strategies could you suggest to the family regarding safety measures in the home?
2. Discuss how loss of sensory function in older adults affects their self-esteem, performance of ADLs, safety, independence, and interactions with others.
2189
References Ackley BJ, Ladwig GB. Nursing diagnosis handbook: An
evidenced-based guide to planning care. 10th ed. Elsevier; 2014.
American Council of the Blind (ACB). Resources. 2013. Retrieved on November 22, 2013 from http://www.acb.org.
Black JM. Medical-surgical nursing: clinical management for positive outcomes. ed 8 St Louis: Saunders; 2008.
Bressler NM. Age-related macular degeneration is the leading cause of blindness. JAMA. 2004;291(15):1900–1901.
Brodie SE. Aging and disorders of the eye. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s textbook of geriatric medicine and gerontology. ed 7 London: Churchill Livingstone; 2010.
Gohdes DM, Balamurugan A, Larsen BA, Maylahn C. Age- related eye diseases: an emerging challenge for public health professionals. Preventing Chronic Disease. 2005;2(3):17.
Goldzweig CI, Rowe S, Wenger NS, et al. Preventing and managing visual disability in primary care: clinical applications. JAMA. 2004;291(12):1497–1502.
Gulanick M, Myers JL. Nursing diagnosis and intervention: planning for patient care. ed 8 St Louis: Mosby; 2013.
Ham R, Sloane D, Warshaw G, et al. Ham’s primary care geriatrics: A case-based approach. ed 6 St. Louis: Mosby; 2013.
Jarvis C. Chapter 14: Eyes, 284-285. In: Jarvis, C., Physical examination and health assessment. (ed 7). St. Louis: Saunders Elsevier; 2012.
Kollarits CR. The aging eye. In: Duthie EH, Katz PR, Malone M, eds. Practice of geriatrics. ed 4 Philadelphia: Saunders; 2007.
Lueckenotte AG. Pocket guide to gerontologic assessment. ed 3 St Louis: Mosby; 1998.
2190
Maas ML, Buckwalter KC, Hardy M, et al. Nursing care of older adults: diagnoses, outcomes, and interventions. St Louis: Mosby; 2001.
McCombe A, Bagueley D, Coles R, McKenna L, McKinney C, Windle-Taylor P. Guidelines for the grading of tinnitus severity: The results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons. Clinical Otolaryngology. 2001;26:388–393.
McNeely E, Griffin-Shirley M, Hubbard A. Teaching caregivers to recognize diminished vision among nursing home residents. Geriatric Nursing. 1992;13(6):332.
Meador JA. Cerumen impaction in the elderly. Journal of Gerontological Nursing. 1995;21(12):43.
Monahan F, Sands J, Neighbors M, et al. Phipps medical- surgical nursing: health & illness perspectives. ed 8 St. Louis: Mosby; 2006.
National Institutes of Health (NIH). National Institute on Deafness and Other Communication Disorders (NIDCD) Statistics, Bethesda, Maryland. retrieved on November 22, 2013 from http://www.nidcd.nih.gov/health/statistics/Pages/quick.aspx 2013.
Newman CW, Jacobson GP, Spitzer JB. Development of the tinnitus handicap inventory. Archives of Otolaryngology - Head and Neck Surgery. 1996;122:142.
O’Neil PA. Caring for the older adult: a health promotion perspective. Philadelphia: Saunders; 2002.
Patt BS. Otologic disorders. In: Duthie EH, Katz PR, Malone M, eds. Practice of geriatrics. ed 4 Philadelphia: Saunders; 2007.
Redford JB. Assistive devices. In: Duthie EH, Katz PR, Malone M, eds. Practice of geriatrics. ed 4 Philadelphia: WB Saunders; 2007.
Roach S. Introductory gerontological nursing. ed 2 Philadelphia:
2191
Lippincott Williams & Wilkins; 2005.
Ross V, Echevarria KH, Robinson B. Geriatric tinnitus: causes, clinical treatment and prevention. Journal of Gerontological Nursing. 1991;17(10):6.
Seiberling KA, Conley DB. Aging and olfactory and taste function. Otolaryngologic Clinics of North America. 2003;37:1209–1228.
Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngologic Clinics of North America. 1996;29(3):455.
Taylor RA. Manual of family practice. ed 2 Philadelphia: Lippincott Williams & Wilkins; 2002.
Tideiksaar R. Disturbances of gait, balance, and the vestibular system. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s textbook of geriatric medicine and gerontology. ed 7 London: Churchill Livingstone; 2010.
Touhy TA, Jett KF. Ebersole & Hess’ Toward healthy aging: Human needs and nursing response. ed 8 St Louis: Mosby Elsevier; 2012.
U.S. Department of Health and Human Services (USDHHS). Age page: Hearing Loss. Bethesda, MD: National Institute on Aging; 2013.
U.S. Department of Health and Human Services. Age page: hearing loss. Bethesda, Md: National Institute on Aging; 2009a.
U.S. Department of Health and Human Services. Aging and your eyes. Bethesda, Md: National Institute on Aging; 2009b.
* Previous author: Sandra Lynne Hensel, MSN(R), RN, C; Revised: Sabrina Friedman, PhD, EdD, MSN, RN, FNP.
2192
Index
Note: Page numbers followed by f indicate figures, t indicate tables and b indicate boxes.
A
AAA See Area Agencies on Aging (AAA).
AARP See American Association of Retired Persons (AARP).
Abdomen
acute 481
pain in 480–481, 481f
ultrasonography of 484t
wall of, age-related changes in 490t
Absorption
of cerebrospinal fluid 564f
of fat 490t
in pharmacokinetic process 362
Abuse See Alcohol, abuse of See also Elder abuse; Substance abuse.
Acarbose 464t
Accreditation, by JCAHO 30 See also Credential
Acculturation 88
ACEIs See Angiotensin-converting enzyme inhibitors (ACEIs).
Acetaminophen 265t
Acid phosphatase, serum levels of 354
Acrochordon 610
2193
ACS See Acute confusional state (ACS).
Actinic keratosis 615
Active composure 21b
Activities of daily living (ADLs) 125, 211
active composure and 21b
assessment of
Barthel Index in 71, 72f
functional status 71–75
exercises for 21
help with, need for 105
instrumental 71, 73f, 211
Katz Index of 71
Activity
Alzheimer disease’s effect on 214–215
assessment of 148
dementia’s effect on 214–215
in facilities 215b
heart disease from lack of 389
in home care 215b
intolerance of 287
lifestyle changes effect on 213–214
and older adults 211–215
relocation’s effect on 213
retirement’s effect on 213
spouse loss’ effect on 214
Activity theory 22–23, 22b
Acupuncture 378
2194
Acute abdomen 481
Acute care setting 153. See also Subacute care
assessment of function in 74b
critical care in 156–157
environment of 154–155, 155b
falls in 154–155
hazards of immobility in 155
health status and 9–10
infection in 155
medication in 154
nursing in 155–157
older adults’ characteristics in 154
philosophy of care in 154
risk in 154–155
safety features of 155
trauma care in 156–157
Acute confusional state (ACS) 57
assessment of 59
causes of 58b
clinical features of 59t
differentiating dementia and 59t
Acute respiratory tract infections, coughing and 427
ADAM See Androgen decline in the aging male (ADAM).
Adaptation, Partnership, Growth, Affection and Resolve (APGAR),
Adhesion, in intestine 494f
ADLs See Activities of daily living (ADLs).
Adrenal cortex 457t
2195
Adrenal gland 458
Adrenal medulla 457t
Adrenopause 458
Adult See Older adults.
Adult day care services 161, 584
Adult protective services 32, 236
Adult respiratory distress syndrome 447–448
Advance medical directives 39
Advanced health directive 102t
Adventist religion 90b
Advocacy, need for 134–135
Affordable Care Act (ACA) 37
African American seniors
cancer incidence rates of 298t
demographics of 84f
Age cohorts 121
Great Depression 121
World War II 121
Age stratification theory 22b, 23
Ageism 11
pain and 256
Aging See also Biologic theories of aging; Psychologic theories of aging; Sociologic theories of aging
cancer’s relationship to 299–301
changes in cell-mediated immune function as result of 19b
as continuum 16
developmental landmarks in 57
2196
illness’ changes with 58t
moral/spiritual theory of 17b, 27
norms in, lack of standards for health and illness 56–57
organizations of professionals working in field of 138
physical and psychosocial aspects of 55–56
theories of 16–28
Aging in place 6–7
Aging population, demographics of 183–184
Agitation, behavior management of 580t
Alaskan seniors See Native American or Alaskan Native.
Albumin 191, 349t, 352–353
Alcohol
abuse of 379–380
assessment of 379–380
BMAST for 375, 378f
CAGE tool for 375
interventions for 380
MAST for 375, 377f
prevalence of 379
consumption of See also Cirrhosis
advantages and disadvantages of 144t
age-related changes and 379t
guidelines for 143t
trends in 382–384
medications affected by 380t
sexual side effects of 245t
Aldehyde dehydrogenase inhibitors, alcohol’s effect on 380t
2197
Aldosterone receptor blockers, adverse effects of 394t
Alkaline phosphatase, serum levels of 354
Alkaloids, plant 311t
Alkylating agents 311t
Alopecia, as cancer complication 316
Alpha1-blockers, adverse effects of 394t
Alpha2-agonists, adverse effects of 394t
Altered thought processes
behavior management for 575–576
diagnostic assessment of 574–575
diagnostic studies in 575
DSM-V criteria in 575
examination in 574
laboratory studies in 575
management of 575
pharmacotherapy of 575–577, 576t
treatment of 575–577
Alzheimer disease 570–572
activity affected by 214–215
clinical manifestations of 572
deaths from 282t
diagnostic studies of 572
genetic factors for 571–572
nursing management for 572
risk factors for 571
treatment of 572
Amebiasis 492
2198
American Association of Retired Persons (AARP) 5
American Indian seniors See Native American or Alaskan Native.
American Journal of Nursing (AJN) 1–2
American Nurses Association (ANA) 2, 30
Americans with Disabilities Act (ADA) 289–290
Amish religion 90b
Amitriptyline 597
Amnesic disorders 574
Ampullary dysequilibrium 655
Amputation 532–533
assessment of 533
diagnosis of 533
evaluation after 534
intervention for 533–534
nursing care plan for 535b
planning and expected outcomes of 533
postoperative care after 533
preoperative care before 533
as preventable problem in diabetes 466, 466f
prosthetic fitting and adaptation after 534
rehabilitative care after 534
Amylase, serum levels of 352, 484t
ANA See American Nurses Association (ANA).
Anafranil See Clomipramine (Anafranil).
Analgesics
alcohol’s effect on 380t
equianalgesic dose charts for 265t
2199
as first-line approach 263
ladder of 337f
list of 265t
nonopioid 263
opioid 263
trials on 256–257
Androgen decline in the aging male (ADAM) 243
Andropause 456–458
Anemia 221b, 417–418
assessment of 418, 418b
autoimmune hemolytic 273b
diagnosis of 418
diagnostic tests, procedures, and treatment of 417
evaluation of 419
expected outcomes of 418
interventions for 418–419
pernicious 489
planning for 418
prognosis of 418
Anesthesia, respiratory effects of 426
Angina 397
Angioma, cherry 608
Angioplasty, percutaneous transluminal coronary 399
Angiotensin receptor blockers 370
Angiotensin-converting enzyme inhibitors (ACEIs) 393, 394t, 410
Anglican religion 90b
Anglo-American culture 87b
2200
Anorexia 480
as cancer complication 315
in dying process 338b
Anorexia nervosa 480
Anorgasmia 243
Anthropometrics 190–191
Antianxiety agents 596
alcohol’s effect on 380t
Antibiotics, antitumor 311t
Anticholinergics
asthma treatment with 429
COPD treatment with 433
for Parkinson disease 588t
sexual side effects of 245t
Anticoagulants 348b, 398
Anticonvulsants 597
as adjuvant medications 265
for altered thought process 576t
for cognitive disorders 576–577
sexual side effects of 245t
Antidepressants 368, 596–597
alcohol’s effect on 380t
for altered thought process 576t
profiles of 369t
side effects of 245t, 576b
tricyclic 597
drowsiness caused by 206
2201
Antiepileptic medication, for cognitive disorders 576–577
Antihistamines
alcohol’s effect on 380t
drowsiness caused by 206
for Parkinson disease 588t
Antihyperlipidemics, CAD treatment with 399
Antihypertensives 245t, 365t, 371t
Antiinflammatory agents, asthma treatment with 428
Antimalarials 524t
Antimetabolites 311t
Antimicrobials 371
Antioxidants, aging delayed by 18
Antiparkinsonian agents 598
Antiplatelets 398
Antipsychotics 245t, 368–369, 370t, 598
alcohol’s effect on 380t
indications for use of 35
Antirheumatics 524t
Antiseptic solution 632–633
Anus, age-related changes in 490t
Anxiety 592
assessment of 592–593, 593b
diagnosis of 593
evaluation after 593
in health history taking 67t
intervention for 593
planning and expected outcomes of 593
2202
Anxiolytics 368
for altered thought process 576t
Aortic regurgitation 406b
Aortic stenosis 406b
Apartment, accessory 159t
APGAR See Adaptation, Partnership, Growth, Affection and Resolve (APGAR).
Apnea See Obstructive sleep apnea syndrome (OSAS) See also Sleep apnea.
Apoptosis 456
Appalachian culture 87b
Appendages, age-related changes in 608
Arab-American Muslim culture 88b
Arcus senilis 641
Area Agencies on Aging (AAA) 128, 160
Aricept See Donepezil (Aricept).
Aripiprazole 598
Aromatherapy 175
Arrhythmia 221b, 402
assessment of 403
diagnosis of 403
diagnostic tests and procedures for 402
evaluation of 404
expected outcomes of 403
interventions for 403–404
planning for 403
prognosis of 402
symptoms of 402
2203
treatment of 402, 403b
Arterial blood gas testing
bicarbonate in 357
blood pH in 356t, 357
carbon dioxide in 357
components of 356–357, 356t
oxygen in 357
Arterial insufficiency 416t
Arterial ulcers 619–620
Arteriosclerosis obliterans 413
Arthritis See Gouty arthritis See also Osteoarthritis; Rheumatoid arthritis.
Asian seniors 66b
attitudes toward 99b
Aspartate aminotransferase 354
Aspiration, coughing and 427
Aspirin 143t, 265t, 398, 524t
Assembly of God 90b
Assessment See also Cognitive function; Health history specific condition or ability
additional measures 71–80
affective 75–78
Beck Depression Inventory for 78
Geriatric Depression Scale for 78, 78b
cultural 60b
interviewer in 65b
introductions and names in 64b
language barriers in 66b, 67b
2204
of nutritional needs 69b
space and distance in 65b
touch in 66b
gerontologic 54–81
guided reminiscence 65
interview in 60–65
nursing-focused 54
patient participation in 65–66
physical 70
prevention and 146
social 78–80
APGAR for 78
OARS for 79f
special considerations affecting 55
symptom analysis factors in 68t
tailoring to older person 59–60
Assisted-listening devices 654b
Assisted living facility 159t, 174
Assisted suicide 45–46
Asthma 427–429
assessment of 429–430, 430f
classification of 430t
diagnosis of 430
interventions for 431
physical evaluation of 431
planning and expected outcomes of 431
prognosis of 428
2205
treatment of 428
long-term control medications for 428–429
quick-relief medications for 429
stepwise approach to 429
Asymptomatic bacteriuria (ASB) 555
Ataxia, of aging, vestibular 655
Atherosclerosis 397, 413
Atrial fibrillation 402, 405
Atrioventricular (AV) node 389
Attitude 64–65
concerning finances 53
overall
toward illness, dying and death 52
toward life 52
towards health 51
Auranofin 524t
Autoimmune diseases 273–274, 273b
Autoimmune hemolytic anemia 273b
Autoimmune hepatitis 274
Autolysis 632b
Automobile safety 234–235 See also Driving
Autonomic nervous system, age-related changes in 563t
Autonomy 37–42
Avulsion fracture 513f
Awakenings, nocturnal 203
B
Bacteria, in urine 355–356, 355t
2206
Bacteriuria 356b
Balance 649–650
abnormalities of 222t, 223t
age-related changes, in structure and function of 650
age-related changes in 565
health as sign of 89
Tinetti test of 227f
Bananas, rice, applesauce, toast (BRAT) diet 482
Baptist religion 90b
Barium enemas 142t, 479t, 484t
Barium swallow 484t
Barthel Index, of ADL 71, 72f
Basal cell carcinoma, of skin 616
Basophils, in hematology test 345t
Beck Depression Inventory 78
Beers, Mark 363
Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (Beers et al) 363
Behavior
assessment of 578
interventions on 579–581, 580t
management of 575–576, 580t
Behavior modification
fall prevention with 223, 228b
smoking cessation with 382
Belching 481
Beliefs 52
2207
Benefits 127–128
Benign prostatic hypertrophy (BPH) 556, 557b
Benzodiazepines 576
sleep affected by 206
Bereavement 324–325
Bereavement Risk Assessment Tool (BRAT) 329, 330f
Beta-blockers
adverse effects of 394t
CAD treatment with 398
CHD treatment with 410
hypertension treatment with 393
Beta2-agonists, COPD treatment with 433
Bicarbonate, as arterial blood gas 357
Bile ducts 478
Biographic data, in health history 66
Biologic clock See Programmed theory.
Biologic theories of aging 17–22, 17b
cross-linkage theory as 17b, 18
emerging 19–20, 20b
error theory as 17–18, 17b
free radical theory as 17b
immunity theory as 17b, 19
metabolic theory as 20
neuroendocrine control theory as 19–20
nonstochastic 19
programmed theory as 17b, 19
stochastic 17–19
2208
wear and tear theory as 17b, 18–19
Biologic therapy 312
Biomedical perspective 91
Biophysical agents 636
Biopsy, liver 484t
Biotin, DRI of 194t
Bipedal falls 224
Birth rate, decrease in 98
Black culture 88b, 89
Black Muslim religion 90b
Black seniors 66b
attitudes toward 99b
Bladder
age-related changes in 541–542
diary 546f
habits 545
retraining of 548
Bladder cancer 555
diagnosis of 556
intervention for 556
Blepharitis 642–643
Bloating 481
Blood See also Arterial blood gas testing; Fecal occult blood test; Hematology test
cells of
red 345t, 346
white 345t, 346–347, 355–356
2209
drug level monitoring in 357
medication level in, monitoring of 357–358
oxygen-carrying capacity of 423–424
pH of 356t, 357
in urine 355t, 356
vessels, age-related changes in 389
Blood chemistry testing
acid phosphatase in 349t, 354
albumin in 349t, 352–353
alkaline phosphatase in 349t, 354
amylase in 349t, 352, 484t
aspartate aminotransferase in 349t, 354
brain natriuretic peptide in 354
calcium in 349t, 351
chloride in 349t, 351
cholesterol in, total 349t, 353
components of 348–354, 349t
creatinine in 349t, 353
creatinine kinase in 349t, 354
electrolytes in 349–352
glucose in 352
lactate dehydrogenase in 354
magnesium in 349t, 351–352
phosphorus in 349t, 351
potassium in 349t, 351
protein in, total 349t, 352
PSA in 354
2210
sodium in 349–351, 349t
of thyroid function 354, 355t
triglycerides in 353
troponin in 354
TSH in 354, 355t
urea nitrogen in 349t, 353
Blood urea nitrogen test (BUN) test 349t, 353
BMI See Body mass index (BMI).
Board and care homes 130–131
Body dysmorphic disorder 595t
Body mass index (BMI) 390
Bone See also Fractures specific bone
healing of 513
long, composition of, biocultural variation in 512t
marrow, suppression of 313
metastases, prostate cancer with 264b
Borborygmi 494
Boron, DRI of 194t
Boutonnière 523f
Bowel
obstructions 494f
training 483b
BPH See Benign prostatic hypertrophy (BPH).
Brachytherapy 310
Braden Scale for Predicting Pressure Sore Risk 625, 626f
Bradyarrhythmias 405
Brain attack 589–591
2211
Brain natriuretic peptide, plasma concentration of 354
BRAT diet See Bananas, rice, applesauce, toast (BRAT) diet.
Breast cancer 302–304
quality of life and 307b
risk factors for 302–303
screening for 303b
sexuality affected by 245
signs and symptoms of 303
survivors of 304, 307b
treatment of 303–304
Breast self-examination (BSE) 303
Breathing
diaphragmatic 436b, 437f
mechanics of 423t
pattern 423t
pursed-lip 436b, 437f
retraining 436–437
sleep and 423t
Brief Michigan Alcoholism Screening Test (BMAST) 375, 378f
Brittle bone disease 526
Bronchitis, chronic 431
coughing and 427
Bronchodilators
asthma treatment with 428
COPD treatment with 433
Bronchopulmonary infection 442–443
BSE See Breast self-examination (BSE).
2212
Buck extension 514f
Buddhist Churches of America 90b
Bullectomy, COPD treatment with 434
BUN test See Blood urea nitrogen test (BUN) test.
Bundle of His 389
Bunions 537, 537f
Bupropion 597
Burn injuries 229–230 See also Fire
Buspirone 576, 576t
C
CABG See Coronary artery bypass graft (CABG).
CAD See Coronary artery disease (CAD).
Caffeine
products containing 547
sleep affected by 206
CAGE tool 375
Calcium
dietary sources of 528t
DRI of 194t
serum levels of 351
Calcium channel blockers 365t, 393–396, 394t, 398
Calluses 513, 536
Caloric restriction 20
Calories
DRI of 194t
in renal diet 554b
CAM See Complementary and alternative medicine (CAM).
2213
Cancer 296–323 See also Basal cell carcinoma; Bladder cancer; Breast cancer; Colorectal cancer; Esophageal cancer; Gastric cancer; Lung cancer; Melanoma; Oral cancer; Prostate cancer; Squamous cell carcinoma
aging’s relationship to 299–301
complications with 312–316
alopecia as 316
anorexia as 315
bone marrow suppression as 313
chemotherapy-induced oral mucositis as 314–315
diarrhea as 315–316
infection as 313–314
nausea and vomiting as 314
coughing and 427
cultural considerations with 302b
death rates from 282t, 297t
depression and 317–318
experience of 316–320
of GI system 504–505
grief and loss and 318–319
growth stages of 299, 299f, 300b
home care and 320b
immune function and 273
incidence of 296–299, 297t
ethnic and racial patterns of 297–299, 297t
prevention of 300–301
quality of life with 307b, 316–317
screening for 305–308
2214
social isolation and 319
support resources with 319–320
treatment of 308–312 See also Chemotherapy; Radiation therapy
agents used in 311t
biologic therapy in 312
endocrine therapy in 312
nutritional consequences of 315b
palliation in 308
surgery in 309
Candida albicans 483
Candidiasis 612
Cane 518f
Capillary pressure 623
Capsule endoscopy 484t
Carbamazepine 576t
Carbohydrates, DRI of 194t
Carbon dioxide, as arterial blood gas 357
Carbon monoxide, poisoning with 230, 231b
Cardiac rehabilitation 400
Cardiopulmonary resuscitation (CPR)
DNR and 38
patient wishes concerning 51
Cardiovascular disease (CVD) 389, 389b
Cardiovascular function 388–421 See also Cardiovascular system
Cardiovascular system
age-related changes in 388–389
conduction system in 389
2215
exercise program for 390
fall related to 220
home care for 419b
medication for 369–371
response to stress and exercise of 389
vessels in 389
Care See also Acute care setting; Family; Home care; Palliative care specific care type; specific condition
agents 39, 41b
community standard of 30
comprehensive plan for 33–34
continuum of 10–11
critical 156–157, 157t
culturally sensitive 84–92
awareness 86
knowledge 86
day 161
delivery of 9
during dying process 334
expenditures for 9
intensive 156–157
JCAHO accreditation of 30
long-distance 105–106
long-term 167–169, 168t
religious beliefs of different groups affecting 90b
special 174–175
subacute 175
2216
trauma 156–157
Care setting See Acute care setting See also Home care; Hospital; Nursing facilities; Nursing home.
Caregivers, chronic illness’ effect on 287–288, 288f
Caribbean culture 89
Cascade effect 155
Casts and cast care 517–518, 517b
Cataracts 644
management of 644–646, 645b
surgery for 644–645, 645b
Catastrophic reactions
behavior management of 580t
from cognitive disorders 583
Catechol-O-methyltransferase (COMT), for Parkinson disease 588t
Catheter
condom 549
indwelling, indications for use of 549b
CCRC See Continuing care retirement community (CCRC).
Cells
blood
red 345t, 346
white 345t, 346–347, 355–356
Schwann 562–563
Census, United States 297b
Central nervous system
age-related changes in 563t
divisions of 562, 562f
2217
Cerebellum, neurodegenerative and neurochemical changes in 565
Cerebrospinal fluid 563–566
absorption of 564f
flow of 564f, 565f
production of 564f
Cerebrovascular accident 589–591
clinical manifestations of 590–591
diagnosis of 591
test in 591
evaluation after 592
intervention for 592
management of 591
medical and pharmacologic therapy 591
planning and expected outcomes of 591
risk factors for 590
Cerebrovascular disease 282t
Cerumen impaction 650
Cervical smear test
advantages and disadvantages of 144t
recommended frequency of 143t
Charcot joint 222t
CHD See Coronary heart disease (CHD).
Chemical injuries 230–231
Chemical restraints 35–36
Chemotherapy 310–312
agents used in 311t
pharmacodynamics of 310–312
2218
pharmacokinetics of 310
immune function after 278b
myelosuppressive toxicities of 312b
nutritional consequences of 315b
Cherry angiomas 608
Chest pain, assessment of 399b
Chest physiotherapy 437
CHF See Congestive heart failure (CHF).
Chloride
DRI of 194t
serum levels of 351
Cholangiography 484t
Cholecystitis 498
assessment of 499
diagnosis of 499
expected outcomes of 499
interventions for 499
Cholelithiasis 498
assessment of 499
diagnosis of 499
expected outcomes of 499
interventions for 499
Cholestasis 504
Cholesterol
HDL 349t, 353
heart disease risk and 390
LDL 349t, 353
2219
serum levels of 353
Choline 194t See also Anticholinergics
Choline salicylate 265t
Chromium, DRI of 194t
Chronic conditions
definition of 154
spirituality and 147b
Chronic disease, health status affected by 8
Chronic illness
adaptation with 285
adherence in 284–285
case study in 292b
deaths from 282t
experience of 282–283
family and caregivers affected by 287–288
fatigue from 287
health within 283
immobility from 287
life issues with 291–292
meaning of life and 286
nursing strategies in 292
in older adults 285–287
pain from 287
physiologic needs with 287
powerlessness from 285
prevalence of 282–283
psychosocial needs with 285
2220
quality of life and 285
sexuality and 287
shifting perspectives model of 285
social isolation from 286
as stigma 286
trajectory of 285
Chronic lower respiratory disease 282t
Chronic obstructive pulmonary disease (COPD) 431–434
assessment of 434
coughing and 432
diagnosis of 434
diagnostic tests and procedures for 432
dyspnea and 427b
evaluation of 438
expected outcomes of 434
family dynamics and 427b
interventions for 434–438, 435b
nutrition and 436, 436b
planning for 434
pulmonary rehabilitation and 435–436
signs and symptoms of 432
smoking cessation and 436, 436t
staging of 432t
surgical options for 434
treatment of 432–433
Chronicity 281–288
Church of Christ Scientist 90b
2221
Church of God religion 90b
Church of Jesus Christ of Latter Day Saints 90b
Cigarettes See Nicotine See also Smoking; Smoking cessation.
Circadian rhythm 203
Cirrhosis
alcoholic 502–503
assessment of 503
clinical manifestations of 502f
diagnosis of 503
expected outcomes of 503
interventions for 503
Citalopram 597
Claudication, intermittent, in PAOD 413
Clavicular fracture 517–518
Clinical nurse specialist See Nurse specialist, gerontologic clinical.
Clomipramine (Anafranil) 598
Clostridium difficile 274
Clozapine 598
Cocaine 376b
Codeine 265t
Cognex See Tacrine (Cognex).
Cognitive disorders
assessment of 577–578
behavioral 578
depression 577
level of consciousness 577
mental status examination in 577
2222
neurologic 578
pupil 577–578
care of
challenges with 582–584
principles for 579b
diagnosis of 578
effects of
catastrophic reactions as 583
hallucinations and delusions as 583
paranoia as 583
sundown syndrome as 582–583
suspiciousness as 583
wandering as 583
evaluation after 582
interventions for 578–582
behavioral 579–581, 580t
communication 579
environmental 582
family 581–582
mental 579
nutritional 579
physical 579
safety and self-esteem 582
social 581
planning and expected outcomes of 578
problems and condition in 584–585
resources for 583–584
2223
adult day care 584
community mental health centers as 584
family support group as 583
home health care 584
legal services as 584
psychiatric hospitals as 584
respite services as 583–584
Cognitive function 561–606
assessment of 75–78, 566–567
depression 567
examination in 567
functional 566–567
Mini-Cog for 76, 77f, 567
MMSE in 75–76, 567
SPMSQ for 75
case study on 602b
examination of 577
home care and 158, 592b
memory in aging and 567
Cognitive impairment 57–59 See also Acute confusional state (ACS)
as delirium risk factor 570t
in dying process 338
urinary incontinence management and 548
Cognitive/perceptual pattern 147
Cognitive status, in critical care 157t
Cognitively intact patients, urinary function in 547
Cohorts, age 121
2224
Coital positioning 250f
Collagen, cross-linkage of 18
Colles fracture 516–517
Colon, sigmoid, volvulus of 494f
Colon cancer, sexuality affected by 246
Colonoscopy 142t
GI diagnostic testing with 484t
guidelines for 479t
virtual 484t
Colorectal adenoma, screening for, guidelines for 479t
Colorectal cancer 305
detection of 305
risk factors for 305
screening for 142t, 307b
guidelines for 479t
signs and symptoms of 305
survival rates with 305
treatment of 305
Colorectal carcinoma 507
Comminuted fracture 513f
Community-based services 159–162
as cognitive disorder resources 160b
for Latino older adults 160b
profile of 160–162
use of 159–160
Community standard of care 30
Complementary and alternative medicine (CAM) 265–266 See also
2225
Herbal remedies
Composure 21b
Comprehensive geriatric assessment (CGA) 306
Computed tomography (CT) 484t
Condom catheter 549
Conduction system, age-related changes in 389
Confusion See Acute confusional state (ACS).
Congestive heart failure (CHF) 411b, 412b
aging’s effect on 58t
assessment of 410, 411b
classification of 410, 411t
coughing and 427
diagnosis of 411
diagnostic tests and procedures for 408–409
diastolic 409
evaluation of 412–413
expected outcomes of 411
hypertension’s contribution to 389
interventions for 411–412
planning for 411
prognosis of 410
systolic 409
treatment of 409, 409t
ACEIs in 410
beta-blockers in 410
digitalis in 410
diuretics in 410
2226
sympathomimetics in 410
Congregate housing 159t
Consciousness, level of 577
Conservator 40–41, 128, 129b
Constipation 482–483
in dying process 338
high-fiber foods for 264b
from opioids 263, 264b
from polypharmacy 482
Continuing care retirement community (CCRC) 159t
Continuity of care 163–165, 168t
Continuity theory 22b, 23
Continuous ambulatory peritoneal dialysis (CAPD) 554b
Continuous cyclic peritoneal dialysis (CCPD) 554b
Continuum of care 10–11
Conversion disorder 595t
Cooling fans, injuries from 231
COPD See Chronic obstructive pulmonary disease (COPD).
Coping 147
Copper, DRI of 194t
Corns 536, 536f
Coronary artery bypass graft (CABG) 399
Coronary artery disease (CAD) 397–399
assessment of 399–400, 399b
diagnosis of 400
diagnostic tests and procedures for 397–398
evaluation of 401–402
2227
expected outcomes of 400
hypertension’s contribution to 389
intervention for 400–401
nonpharmacologic treatment of
CABG in 399
PTCA for 399
stents for 399
pharmacologic treatment of 398
anticoagulants in 398
antihyperlipidemics in 399
antiplatelets in 398
beta-blockers in 398
calcium channel blockers in 398
fibrinolytics in 398
nitrates in 398
planning for 400
prognosis of 399
symptoms of 397b
Coronary heart disease (CHD) 389 See also Coronary artery disease (CAD)
Coronary vascular disease (CVD) 141
Corticosteroids, asthma treatment with 428
Coughing 427, 437b
Coumadin See Warfarin.
Countermigration 6–7
CPR See Cardiopulmonary resuscitation (CPR).
Cramps, muscle 538
2228
Cranberry juice, bacteriuria affected by 356b
Creatinine
clearance of 353
serum levels of 353
Creatinine kinase, serum levels of 354
Crede method 549
Credential
for gerontologic nurse 3b
from JCAHO 30
Crepitus 518–519
Crime
fraud as 133b
types of 132b
victimization 132–134, 132b
Critical care 156–157, 157t
Cromolyn 429
Cross-linkage theory 17b, 18
Cross-reactive protein, in hematology test 348
Cruzan, Nancy 42
CT See Computed tomography (CT).
Cultural awareness
cancer and 302b
of end-of-life issues 326b
of loss 326b
with mammography 303b
of older adults 99b
of pain 260
2229
Cultural competency 283
Cultural concepts 86–89
transcending 91–92
Cultural conflict 89
Cultural influences 83–96
context in 92
diversity and 87b
health and illness beliefs in 89–91
individualist and collectivist orientations 91–92
religion in 90b
self-assessment 87b
skills for 92–93
eye contact as 93
handshake as 92–93
interpreters 93
theoretical model for
explanatory model 94–95, 95b
Learn model 95
Leininger theory 93–94, 94f
Sunrise model 94
of time orientation 91
Curbs, as risk factor for falling 223
CVD See Cardiovascular disease (CVD).
Cyanosis, identification of 609b
D
DASH diet 418t
Dating 242
2230
Day care services 161
D-dimer test 345t, 348
Death and dying 332
age-related changes in process of 334–335
assessment of 335
care needs during 334
causes of, leading 282t, 297t
cognitive impairment and 338
definition of 333–334
environmental setting of 339, 339b
at home 339, 340b
in hospital 339
legislation affecting 339–340
meaning fulfillment and 336f
needs hierarchy and, Maslow’s 335, 337f
nursing care for 335–339
in nursing facilities 339
perspectives on, elders’ 332–340
physical aspects of 333–334
anorexia as 338b
constipation as 338
dyspnea as 337–338
nutrition as 338, 338b
pain as 337
restlessness as 338
urinary incontinence as 338
psychological aspects of 332–333
2231
social aspects of 333
spiritual aspects of 333
stages of 332
strategies of 335–339
Débridement 632b, 633–634
Decision-making model 116–117
Decisions
care facility 100–101
diagram 40–41
end-of-life, algorithm for 40, 40b
Deep vein thrombosis (DVT) 414
Degenerative joint disease 518
Dehydration 184, 184b, 349
as delirium risk factor 570t
Delirium 568–569 See also Acute confusional state (ACS)
characteristics of 157t
clinical features of 568t
clinical manifestations of 569
DSM-V criteria for 575
management of 569
nonpharmacologic interventions 569
pharmacotherapy 569
risk factors for 569, 570t
volunteers for patients with 571b
Delirium tremens 380b
Delusion 583
Delusional disorders 594
2232
Dementia 157t, 569–570 See also Amnesic disorders; Intracranial tumors; Normal pressure hydrocephalus; Subdural hematomas; Vascular dementia
activity affected by 214–215
acute confusional state differentiated from 59t
characteristics of 157t
clinical features of 59t, 568t
disturbed sleep and 207
DSM-V criteria for 575
frontotemporal 573–574
Lewy body 573
pain management with 258, 258f
related diseases of 574
reversible 570
causes of 571b
sexuality affected by 246
vascular 572–573
Demerol See Meperidine (Demerol).
Demographics 4–7
of aging population 183–184
education in 7
employment in 7
gender in 6, 123t
geographic distribution in 6–7
income in 7, 8f
living arrangements in 6
marital status in 6
medication use and 361
2233
of older Americans 5, 5f
of older population 4–7
poverty in 7, 8f
race and ethnicity in 6
Deoxyribonucleic acid (DNA) 21f
error theory and 17–18
free radicals’ effect on 18
research on 20, 20b
Depression 157t
aging’s effect on 58t
assessment of 567
Beck Depression Inventory for 78
Geriatric Depression Scale for 78, 78b
cancer and 317–318
characteristics of 157t
clinical manifestations of 567–568, 568t
immune function affected by 272
insomnia with 207
management of 576
medications causing 568b
pain and 262
Dermatitis, seborrheic 610
Dermatoses, inflammatory 610
Dermis, age-related changes in 608
Desipramine 597
“Determine Your Nutritional Health,” screening tool 185
Detrusor, abnormal contractions of, caffeine and 547
2234
Development
landmarks in 57
moral and spiritual 27
Developmental task theory 22–23, 22b
Diabetes See also Retinopathy, diabetic
as contributing factor to heart disease 390–391
deaths from 282t
diagnosing and classification of 352t
screening for 142t
Diabetes mellitus 459–461
assessment of 461–462
continuum of 458–459
diagnosis of 462
evaluation of 467
expected outcomes of 462–463
hypoglycemia levels and 465t
insulin defects in 460f
interventions for 463–467, 466b
diet in 463, 463b
education in 463
emergency identification in 465
exercise in 465
insulin and other medications in 463–465
lifestyle changes in 465
monitoring in 465
sick day management in 465–466, 466b
management of 461
2235
medical 461b, 461f, 464t
pathophysiology of 459–460
planning for 462–463
signs and symptoms of 460
skin alterations in 466–467, 466f
visually impaired persons with 463–464
wound infections with 467
Diabetic foot syndrome 467
Diabetic neuropathic ulcers 620
Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
cognitive function criteria in 575
dementia criteria in 575
Dialysis, peritoneal 554b
Diarrhea 315–316, 482
Diet
BRAT 482
as contributing factor to heart disease 390
DASH 418t
with diabetes 463, 463b
fiber in 482
history 190
religious prohibitions in 182b
sleep affected by 206
supplements 371–372
Dietary reference intakes (DRIs) 193, 194t
Digitalis, CHF treatment with 410
Dihydropyridines, adverse effects of 394t
2236
Disability
Americans with Disabilities Act and 289–290
effect on functional status 56–59
life issues with 291–292
management of 291
Disasters, older adults’ susceptibility to 234
Disease(s) See also specific disease
altered presentation and response to 57–59
effect on functional status 56–59
Disease-drug interactions 364–365, 365t
Disease-modifying antirheumatic drugs (DMARDS) 523–525
Disengagement theory 22, 22b
Dislocation 516
Displaced fracture 513f
Distraction, as alternative therapy 266
Distribution, in pharmacokinetic process 362
Diuretics
adverse effects of 394t
CHD treatment with 410
hypertension treatment with 393
sexual side effects of 245t
Diverticula 495
Diverticulitis 495, 496b
Diverticulosis 495
Divorce, increase in 98
Dizziness 654–655
DNA See Deoxyribonucleic acid (DNA).
2237
Do not resuscitate (DNR) orders 38–39, 102t
Doctor, patient perception of role of 51
Domiciliary care See Board and care homes.
Donepezil (Aricept) 572
Dopamine agonists
for Parkinson disease 588t
sexual side effects of 245t
Dopaminergics, for Parkinson disease 588t
Double contrast barium enema (DCBE) 479t
Dressing, wound, types of 634–636, 635t
Driving 103
pedestrian accidents while 235b
resources for 104t
Drug-disease interactions 364–365, 365t
Drug-drug interactions 364, 364t
Drug-food interactions 364, 365t
Drug-induced hepatitis 503–504
Drug-nutrient interactions 195, 197t
Drugs See also Medication(s)
drowsiness caused by 206
insomnia caused by 207
sleep affected by 206, 207t
used to promote sleep 206
Drusen 641
Dry eye syndrome 641
Dry eyes 641
Dry mouth 656
2238
Dry skin, prevention and treatment of 612b
DSM-V See Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
Duloxetine 597
Dumping syndrome 492
Duodenal ulcers 491–492
Dysequilibrium 654–655
Dyspareunia 243–244
Dysphagia 487
diagnosis of 487–488
interventions for 488
Dyspnea 426–427
COPD and 427b, 434
in dying process 337–338
E
Ear 649
age-related changes in structure and function of 650
anatomy of 649f
health promotion/illness prevention for 654b
problems and conditions in 650
Eastern Orthodox religion 90b
ECG See Electrocardiography (ECG).
ECHO See Elder Cottage Housing Opportunity (ECHO).
Ectropion 642
Edema See Pulmonary edema.
Edges, as risk factor for falling 223
Education 124, 266
2239
demographics of 7
of diabetic patients 463
for family caregivers 106–107
in gerontologic nursing 11–12
of lung cancer patients 439b
in nursing 11–12
strategies for 124b
EGD See Esophagogastroduodenoscopy (EGD).
Ejaculation
premature 243
retarded 243
Elder See Older adults.
Elder abuse 236
laws on 31–33
NCEA and 31
nursing training on 32
pain undertreatment as 260
reporting of 32
types of 32
Elder Cottage Housing Opportunity (ECHO) 159t
Elderly onset rheumatoid arthritis (EORA) 521–522
Electrocardiography (ECG)
aging changes reflected by 389
arrhythmia diagnosis with 402
valvular disease diagnosis with 406
Electroconvulsive therapy (ECT) 597
Electrolytes 349–352
2240
Elimination 483b
Emergency identification, for diabetic patients 465
Emerging majority 83
Emotional status, support systems affecting 127
Emphysema 431
Employment
demographics of 7
of women 98
Empowerment 149
Encephalopathy 503
Enculturation 86–87
Endocrine function 455–476
Endocrine system
aging changes in 457t
feedback loops in 456f
glands of 457t
home care for 472b
pathophysiology in 458–461
physiology of 455–458, 456f
Endocrine therapy 312
Endocrinology of aging 455
End-of-life
common documents 102t
cultural awareness of 326b
decisions, health care 102–103
decisions on, algorithm for 40, 40b
ethics of 44
2241
in nursing facility care 173
Endoscopic retrograde cholangiopancreatography (ERCP) 484t
Endoscopic ultrasonography, GI diagnostic testing with 484t
Endoscopy, capsule 484t
Enema, barium 142t, 479t, 484t
Energy assistance 128
Energy level, reduced, in health history taking 67t
Enteral nutrition 196–198
Enteritis 492–493 See also Gastritis; Gastroenteritis
Entitlements 127–128
Entropion 642
Environmental influences 128–134
in home care 134b
EORA See Elderly onset rheumatoid arthritis (EORA).
Eosinophils, in hematology test 345t
Epidermis, age-related changes in 608
Episcopal religion 90b
Epithelialization 632b
ERCP See Endoscopic retrograde cholangiopancreatography (ERCP).
Erectile dysfunction 243
Error theory 17–18, 17b
Erythema, observation of 609b
Erythrocyte sedimentation rate, in hematology test 348
Erythroderma 610
Eschar 632b
Escitalopram 597
2242
Esophageal cancer 504–505
assessment of 505
diagnosis of 505
expected outcomes of 505
interventions for 505, 506b
Esophageal endoscopic ultrasonography 484t
Esophagitis 488
Esophagogastroduodenoscopy (EGD) 484t
Esophagus, age-related changes in 478, 490t
Estrogen, as contributing factor to heart disease 391
Ethics
of assisted suicide 45–46
committees 46–47
in end-of-life care 44–47
nurse’s code of 44–47
PSDA-associated dilemmas in 43–44
Ethnic identity 88
Ethnicity 88 See also specific ethnicity
cancer patterns with 297–299, 297t
in demographics 6
U.S. Census definition of 297–298, 297b
Ethnocentrism 89
Evidence-based practice 13, 21b
Excretion, in pharmacokinetic process 363
Exelon See Rivastigmine (Exelon).
Exercise(s) 266
for ADLs 21
2243
advantages of 144t
assessment of 148
capacity for 423t
for diabetic patients 465
as health promoting activity 143t
Kegel 548
lung function and 425
pattern of 148
of pelvic floor muscle 548, 548b
with physical impairment 291
program for older adults 390
quality of life and 284b
rehabilitation and 290
response to, age-related changes in 389
wear and tear theory and 19
Expenditure, health status and 9
Experimentation
law on 46
patient rights regarding 46
Expiratory reserve volume (ERV) 424t
Explanatory model 94–95, 95b
Extrapyramidal symptoms 598, 598t
Extremity, lower, ulcers of 619–621, 619t
Exudate 632b
Eye
aging and 642b
anatomy of 641f
2244
dry 641
health promotion/illness prevention of 642b
injuries of, emergency treatment of 647b
REM sleep and 202
F
Facility See Hospital See also Nursing facilities; Nursing home.
Fagerström Test for Nicotine Dependence 382, 383f
Failure to thrive 198
Falls 218–226
in acute care setting 154–155
age-related changes contributing to 220–221
cardiovascular 220
hearing as 220
musculoskeletal 220–221
neurologic 221
vision as 220
antecedents of 224
behavior modification and 223, 228b
bipedal 224
changes to home environment after, identifying location of 515b
classification of 224, 224b
cluster 224
consequences of
physical injury as 224–226
psychological trauma as 225
definition of 219–220, 219b
diary of 227b
2245
emergency treatment for 156b
evaluation after
health history in 226, 226t
physical examination in 226
special testing of 226
Tinetti test in 227f
extrinsic risk for 222
fear of 225–226, 225b
in geriatric triad 156
incidence of 512
intentional 224
intrinsic risk for 222
isolated 224
joints and 220–221
management of 227–228
meaning of 220
multifactorial and interacting causes of 225b
nonbipedal 224
in nursing home 512
premonitory 224
prevention guidelines 219b, 228b
prodromal 220, 224
restraint associated with 223b
risk for 221–224, 228b
serious injury in 223, 223b, 223t
treatable causes of 221b
Family
2246
assessing 111–113
caregiver workplace issues 98–99
caregiving by 102t, 103–110
challenges and opportunities 104–105
education for 106–107
long-distance 105–106
resources 109b
respite programs in 107–108
stress 106t, 113
support groups for 108–110
types of 103–104
chronic illness’ effect on 287–288
cognitive disorder interventions with 581–582
common late-life issues and decisions 99–106
communicate their concerns 113–114
conflicts between directives and desires 41–42
COPD and 427b
decisions by
care facility 100–101
creating a plan 116
end-of life 102–103
evaluating options 116
formulating options 116
gathering information 116
implementing plan 117
involving older person in 114
model for 116–117
2247
reassessing 117
dependence and independence 112–113
disability and activity 98
driving and 103
dynamics 111
emphasizing goodness of intent of actions 115
encouraging to plan in advance of need 113–114
expressing good intentions and willingness to listen 113
financial concerns with 101–102
function of 97–99
guilt 115
increased in blended 98
increasing aging population 98
influences 97–119
legal concerns with 101–102
living arrangements 98, 101b
long-distance versus nearby 105–106
loyalties in 112
meetings 110
mobility of 98
natural opportunities to talk 113
obligations for 112
past relationships in 111
role and 97–99
sharing personal preferences and plans 113
state of senior housing industry 98
talking about “what ifs,” 113
2248
validating feelings 114–115
Family Medical Leave Act (FMLA) 98–99
Family profile, in health history 66
Fat
absorption of 490t
DRI of 194t
subcutaneous, age-related changes in 608
Fatigue
chronic illness with 287
in rheumatoid arthritis 525
FDA See Food and Drug Administration (FDA).
Fear, of falls 225–226, 225b
Fecal analysis, GI diagnostic testing with 484t
Fecal incontinence 483
Fecal occult blood test 142t
advantages and disadvantages of 144t
colorectal cancer and adenoma screening with 479t
recommended frequency of 143t
Femur, biocultural variation in 512t
Fentanyl 263
Festinating gait 587b
Fiber
DRI of 194t
education about 482
Fibrinolytics, CAD treatment with 398
Filipino-American culture 89
Finances, family concerns with 101–102
2249
Financial status, support systems affecting 127
Fire
burn injuries from 229–230
cigarette smoking and 229
fireplace hazards and 229
kitchen hazards and 229–230
safety tips for 230, 230b
space heaters and 230
Firearms 236–237
Flashers 641
Flatus 481
Floaters 641
Floor surfaces, as risk factor for falling 222
Fluid, in renal diet 554b
Fluoride, DRI of 194t
Fluoroscopy, GI diagnostic testing with 484t
Fluoxetine 597
Fluvoxamine 597
Folate, DRI of 194t
Folic acid, in hematology test 345t, 347
Food See also Nutrition
drug interactions with 364, 365t
handling of 231b
illnesses from 231–232
labeling of 193
FDA approved terms on 196t
recall of 190
2250
religious prohibitions on 182b
social and cultural aspects of 181–183, 182b
Food and Drug Administration (FDA) 196t
Food stamps 128
Foot
care of, patient education on 538
diabetic 467
infection 468b
problems with 536–538
ulcers of 466, 467b
Fractures See also Hip
avulsion 513f
clavicular 517–518
Colles 516–517
comminuted 513f
definition of 513
displaced 513f
emergency treatment for 513b
greenstick 513f
impacted 513f
interarticular 513f
longitudinal 513f
oblique 513f
pathologic 513f
spiral 513f
stress 513f
transverse 513f
2251
Fraud 133b
Free radical theory 17b, 18
Free radicals, DNA affected by 18
Freezing 587b
Friction 632b
Friendly visitors, telephone monitoring and 161
Frontal bone, biocultural variation in 512t
Frontotemporal dementia 573–574
Fullness 481
Functional incontinence 543
diagnosis of 546
nursing care plan for 550b
planning and expected outcomes for 547
Functional residual capacity (FRC) 424t
Functional status
assessment of 71–75
chronic conditions affecting 125
disability’s effect on 56–59
disease’s effect on 56–59
effect of selected variables on 56t
in health status 8–9
home care and 158
Funeral, patient wishes concerning 53
G
Gaba (magico-religious theory) 89
Gait
abnormalities of 222t, 223t
2252
Tinetti test of 227f
Galantamine (Razadyne) 572
Gallbladder, age-related changes in 478
Gallstones, age-related increase in 478
Gas, complaints associated with 481–482
Gas exchange 423
Gas testing See Arterial blood gas testing.
Gastric analysis, GI diagnostic testing with 484t
Gastric cancer 505–506
assessment of 506
diagnosis of 506
interventions for 507
Gastric emptying, GI diagnostic testing of 484t
Gastric mucosa, degeneration of 489
Gastric secretions 478
Gastric ulcers 491
Gastritis 489–490
diagnosis of 490–491
interventions for 491
stress-induced 490
Gastroenteritis 492
Gastroesophageal reflux disease (GERD) 488
coughing and 427
diagnosis of 489
interventions for 489
Gastrointestinal function 477–510
Gastrointestinal (GI) system See also Intestine
2253
age-related changes in 477–478, 490t
cancers of 504–505
diagnostic studies for 484t
diseases of 483
prevention of 478, 479t
home care for 509b
symptoms in 480–483
Gauze dressing 635t
Gender, demographics of 6, 123t
Genetics, as Alzheimer’s disease risk factor 571–572
Genome 300
Geographic distribution, demographic profile of 6–7
Geographic location, of residence 129
GERD See Gastroesophageal reflux disease (GERD).
Geriatric Depression Scale 78, 78b
Geriatric triad 156
Geriatrics, definition of 4
Gerontic nursing, definition of 4
Gerontologic assessment 54–81
Gerontologic clinical nurse specialist See Nurse specialist, gerontologic clinical.
Gerontologic nurse See Nurse, gerontologic.
Gerontologic nurse practitioner See Nurse practitioner, gerontologic.
Gerontologic nursing 1–15 See also Nursing
American Nurses Credentialing Center eligibility requirements for 3b
culturally sensitive care 84–92
2254
definition of 4
development of 2t
foundations of specialty of 1–4
impact of aging population on 11–13
Gerontology
boom in 1
definition of 4
GI system See Gastrointestinal (GI) system.
Gingivitis 483
assessment of 483
diagnosis of 483
evaluation of 487
interventions for 487
Glasgow Coma Scale (GCS) 577
Glaucoma 643
assessment of 643
chronic open-angle 643
closed-angle 643
diagnosis of 643
evaluation after 644
intervention for 643–644, 644b
planning and expected outcomes of 643
screening for 142t
secondary 643
Glucocorticosteroids, COPD treatment with 433
Glucose, in urine 355, 355t
Goiter, simple 469f
2255
Gout 256b, 347, 379t, 525, 525f, 526
Goodpasture syndrome 273b
Gouty arthritis 525–526, 525f
assessment of 526
diagnosis of 526
intervention for 526
Grab bars, as risk factor for falling 223
Granulation tissue 632b
Graying of America 4
Great Depression 121
Greek Orthodox religion 90b
Greenstick fracture 513f
Grief 324–327
cancer and 318–319
counseling for 329–332
psychological responses to 326, 328t
reactions 327
social responses to 326
spasms 326
spiritual aspects of 326–327
symptoms of 326, 326b
therapy for 329–331
types of 327–328
Guardians 40–41, 128, 129b
Guided reminiscence 65
Gum disease 477–478
H
2256
Habit, bladder 545
Habit training 549
Hallucination 583
Hallux valgus 523f, 537, 537f
Haloperidol 576t, 598
Hammertoe 222t, 537, 537f
Hayflick limit theory 19
HDL See High-density lipoprotein (HDL).
Health See also Mental health
as balance 89
behaviors 140t
cultural beliefs about 89–91
lack of standards for 56–57
optimal 140
perception of 146–147
protection of 142
Health Belief Model 141
Health care delivery settings, and older adults 153–180
Health care proxy 102t
Health history 60–71 See also specific condition
allergies in 69
biographic data in 66
components of 68b
description of typical day in 68
family history in 69
family profile in 66
format 61f, 66–70
2257
immunization and health screening status in 69
living environment profile in 67
medications in 68
nutrition in 69
occupational profile in 66–67
past health status in 69
patient profile in 66
present health status in 68
recreation/leisure profile in 67
resources/support systems used in 67–68
review of systems in 69–70
taking of, factors affecting 67t
Health insurance 125
Health Insurance Portability and Accountability Act of 1996 (HIPAA) 31
Health patterns 146
activity or exercise 148
cognitive or perceptual 147
coping or stress-tolerance 147
elimination 148
health perception or health management 146–147
nutritional or metabolic 147
rest or sleep 148, 565–566
roles or relationships 146
self-perception or self-concept 146
sexuality or reproductive 148
value or belief 147–148
2258
Health promotion 290–291, 291f
for aging adults 139–141
assessment and 146
barriers to 141–142
evaluation in 149
health care professionals’ barriers to 141
and illness/disability prevention 139–152
implementation in 148–149
intervention advantages and disadvantages in 144t
models of 141
nurse’s role in 145–149
physical fitness and 140b
planning in 148
for respiratory system 425b
terminology in 140–141
USPSTF’s guidelines for 143t
Health Promotion Model 141
Health status
acute care setting and 9–10
aging norms and, lack of 56–57
chronic disease in 8
continuum of care and 10–11
functional ability in 8–9
health care delivery and 9
health care expenditure and 9
home care and 10
nursing facilities and 10
2259
of older adults 8–11
past 69
present 68
self-assessed 8
socioeconomic status and 125
Hearing 649–650
age-related changes, in structure and function of 650
falls related to 220
Hearing Aid Assessment Tool, for cleaning, inserting, and troubleshooting 654t
Hearing deficit, in health history taking 67t
Hearing loss 652–653
assessment of 653, 653b
diagnosis of 653
evaluation after 654–655
intervention for 653–654, 653b
planning and expected outcomes of 653
strategies for communication in 653b
Heart block 402
Heart disease See also Coronary heart disease (CHD)
contributing factors to 389–391, 389b
diabetes as 390–391
diet as 390
estrogen as 391
hypertension as 389–390, 391–396
obesity as 390
sedentary lifestyle as 390
2260
smoking as 390
stress as 391
deaths from 282t
as leading cause of death 388
Heart failure
admissions 408b
New York Heart Association functional classification of 411b
Heat and cold, as alternative therapy 266
Heberden nodes 518–519, 518f
Height, biocultural variation in 512t
Helicobacter pylori 491
Heloma duram 536
Hematocrit, in hematology test 345t, 346
Hematology test 345t
components of 344–348
cross-reactive protein in 348
D-dimer test in 345t, 348
erythrocyte sedimentation rate in 348
folic acid in 345t, 347
hematocrit in 345t, 346
hemoglobin in 345t, 346
iron in 345t, 347
partial thromboplastin time in 345t, 348
platelets in 345t, 348
prothrombin time in 345t, 347–348
red blood cells in 345t, 346
TIBC in 345t, 347
2261
uric acid in 345t, 347
vitamin B12 in 345t, 347
white blood cells in 345t, 346–347
Hematomas, subdural 574
Hematopoietic growth factors 312
Hemiarthroplasty 516
Hemiparesis 222t
Hemodialysis 555b
Hemoglobin, in hematology test 345t, 346
Hemorrhoids 497–498
assessment of 498
diagnosis of 498
expected outcomes of 498
interventions for 498
Heparin 398
Hepatitis 500–501
A 501t
assessment of 501
B 500, 501t
C 501t
diagnosis of 501
drug-induced 503–504
expected outcomes of 501
interventions for 501–502
viral 501t
Hepatitis B vaccination 142t
Hepatobiliary scintigraphy 484t
2262
Hepatobiliary ultrasonography 484t
Herbal remedies
immune function affected by 272
sleep and 207
tips for 207b
Hernia
hiatal 488, 489f
strangulated inguinal 494f
Herpes zoster 613–614
assessment of 614
diagnosis of 614
evaluation after 615
intervention for 614–615
nursing care plan for 615b
planning and expected outcomes of 614
Hex (magico-religious theory) 89
HHA See Home health aide (HHA).
Hiatal hernia 488, 489f
Hierarchy of human needs 335, 337f
High-density lipoprotein (HDL) 349t, 353
Hinduism religion 90b
Hip
fracture of 514, 514f, 517b
assessment of 514–515
Buck extension for 514f
diagnosis of 515
evaluation after 516
2263
intervention for 515–516
Küntscher nail for 514f
Neufeld nail and screws for 514f
planning and expected outcomes of 515
surgery on
options for 519–520
precautions after 520b
HIPAA See Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Hippocampus 564
Hispanic seniors 66b
attitudes toward 99b
HIV See Human immunodeficiency virus (HIV).
Home
burn injuries in 229–230
carbon monoxide poisoning in 230, 231b
cooling fan injuries in 231
dying in 339, 340b
foodborne illnesses in 231–232
knife injuries in 230–231
medications stored in 234
safety in 228–232, 229b
sharing 159t
Home care 88b, 157–158, 158b, 162–163
assessment of 164
benefits of 163
cancer and 320b
2264
in care continuum 168t
cognitive disorders in 584
cognitive function and 158, 592b
for endocrine system 472b
environmental influences in 134b
with facility-based agencies 162–163
functional status and 158
for gastrointestinal system 509b
health status and 10
HHA’s role in 165
with home health agency 162, 164–165
immune function and 279b
indicators for 164b
laboratory and diagnostic tests 358b
medication use in 373b
nurse’s role in 165
nutrition in 199b
OASIS in 166
organizations 162
and pain 267b
plan of treatment in 165–166
with proprietary agencies 162
for respiratory system 452b
safety in 237b
sexuality in 252b
of skin 637b
sleep and activity in 215b
2265
socioeconomic influences in 134b
standards for 47b
substance abuse and 384b
Home health agency 162, 164
Home health aide (HHA) 165–166
Home matching programs 130
Homemaker services 161
Homeopathic remedies 207b
Homeostatic mechanisms, decreased efficiency of 56
Homosexuality 246
Hormone replacement therapy 457–458
Hormones
as contributing risk factor to heart disease 391
estrogen 391
testosterone 456–457
thyroid-stimulating 354, 355t
Hospice 157–158, 158b, 166–167
location of 167
Medicare coverage of 167
and palliative care 166
philosophy of 166–167, 339
services 166–167
Hospital See also Acute care setting
discharge data from 283t
dying in 339
psychiatric 584
risks in 154–155
2266
sleep in 204
as technologic system 154
Hot/cold theory 91
Housing 129–132 See also Living arrangements
congregate 159t
options for older adults 158–159, 159t
subsidized 127–128
Human immunodeficiency virus (HIV) 19, 244–245, 251b, 274, 301
Humerus, biocultural variation in 512t
Hydration, artificial See also Dehydration
patient wishes concerning 51
Hydrocodone 265t
Hydrocolloidal dressing 635t
Hydrogel dressing 635t
Hygiene
oral 487
pulmonary 437
sleep 210
Hypercapnia 426, 433
Hyperglycemia, heart disease risk from 390–391
Hypersexuality 246
Hypertension 391–396
assessment of 396
as contributing factor to heart disease 389–390, 391–396
diagnosis of 396
drug-induced 392
evaluation of 397
2267
expected outcomes of 396
intervention for 396
lifetime risk of 389–390, 391
motivational intervention for 145b
pharmacologic treatment of 393, 394t
angiotensin-converting enzyme inhibitors for 393
beta-blockers for 393
calcium channel blockers for 393–396
diuretics for 393
planning for 396
primary 392
prognosis of 396
pseudo- 392
secondary 392
Hyperthermia 232–234
Hyperthyroidism 354, 467–469
aging’s effect on 58t
medical management of 469, 469t
pathophysiology of 467–468
signs and symptoms of 468
Hypertonic dehydration 185
Hypnosis 266
Hypnotics 368
Hypochondriasis 595t
Hypoglycemia 221b, 465t
Hypokalemia 351b
Hyponatremia 350
2268
Hypotension 221b See also Orthostatic hypotension
Hypothalamic-pituitary-adrenal axis 564
Hypothalamus 456f, 457t
Hypothermia 232–234
Hypothyroidism 354, 469–470, 470t
aging’s effect on 58t
drug-induced 470
medical management of 470
pathophysiology of 469–470
primary 469–470
secondary 469–470
signs and symptoms of 470
tertiary 469–470
Hypotonic dehydration 185
Hypoxemia 426
Hysterectomy prevalence, racial differences in 87b
I
ICU See Intensive care unit (ICU).
Identification, emergency, for diabetic patients 465
Idiopathic thrombocytopenic purpura 273b
Idiosyncratic toxicity, of drugs 504
Ileocecal intussusception 494f
Ileus, paralytic 493
Illicit drugs 376b
Illness
aging’s effect on 58t
cultural beliefs about 89–91
2269
foodborne 231–232
lack of standards for health and 56–57
prevention See Health promotion
Imipramine 597
Immobility
from chronic illness 287
as delirium risk factor 570t
hazards from, in acute care setting 155
lung function and 425
Immune system
age-related changes in 271, 271b
cancer and 273
depression’s effect on 272
effects of chemotherapy on 278b
herbs’ effect on 272
home care and 279b
medications’ effect on 272
nutritional factors on 271–272
protein-energy malnutrition and 272
psychosocial factors’ effect on 272
Immunity theory 17b, 19
Immunizations 142–143
Immunosenescence 19
Immunosuppressives 524t
Impacted fracture 513f
Impotence 248b, 304
Inactivity, heart disease from 389 See also Immobility
2270
Income
for ages 55 to 64 122
for ages 65 to 74 122
for ages 75 to 84 122–123
for ages 85 and older 123
demographics of 7, 8f
sources of 121–123
Social Security benefits as 122t
veterans’ benefits as 122b
Incontinence See also Urinary incontinence
behavior management of 580t
bowel training and 483b
fecal 483
in geriatric triad 156
in nursing facilities 170–171
Independence
and control 51
self-management for 125
Individualism theory 24b, 25
2271
Indwelling catheter, indications for use of 549b
Ineffective sexuality patterns 248b
Infection 270–280, 277b See also Urinary tract infection (UTI)
in acute care setting 155
assessment of 275–279, 275b
bronchopulmonary 442–443
as cancer complication 313–314
chain of 270–271
common 272–274
control of, in nursing facilities 172–173
diagnosis of 276, 276b
evaluation for 277–279
with Helicobacter pylori 491
intervention for 276–277
with nosocomial pathogens 274–275
planning for 276
wound, diabetic patients with 467
Inflammatory dermatoses 610
Influenza 272–273, 442–443
assessment of 443
deaths from 282t
diagnosis of 443
evaluation of 443
expected outcomes of 443
interventions for 443
planning for 443
prognosis of 443
2272
treatment of 442–443
vaccination for 142t, 433
Informed consent 37
Insomnia 203
depression with 207
drugs causing 207
Inspiratory reserve volume (IRV) 424t
Institutionalization, factors associated with 168
Instrumental activities of daily living (IADLs) 71, 73f, 125, 211 See also Activities of daily living (ADLs)
Insulin
deficiency of, pathophysiology of 460f
in diabetes management 463–465
Insulin-dependent diabetes mellitus 273b
Insurance See also Health Insurance Portability and Accountability Act of 1996 (HIPAA)
coverage 125–126
Integumentary function 607–639
Intensive care unit (ICU) 156–157
Interaction Model of Client Health Behavior 21b
Interarticular fracture 513f
Interface pressure 632b
Interferons 312
Interleukins 312
Interrelated health problems, in health history taking 67t
Interstitial lung disease, coughing and 427
Intertrigo 610
Intestinal obstruction 493–494, 494f
2273
assessment of 494–495
complications of 494
diagnosis of 495
evaluation of 495
expected outcomes of 495
interventions for 495
Intestine
adhesion in 494f
age-related changes in 478, 490t
Intimacy
importance of 241–242
older adult needs for 241
Intraarticular drugs 524t
Intracranial tumors 574
Intussusception, from polyp 494f
Iodine, DRI of 194t
Iron
deficiency of 272
DRI of 194t
in hematology test 345t, 347
TIBC of 345t, 347
Ischemic heart disease See Coronary heart disease (CHD).
Ischemic ulcer 619
Islam (Muslim/Moslem), religious beliefs of 90b
Isolation, social, cancer and 319
Isoniazid 442t
Isotonic dehydration 185
2274
J
Jaundice, identification of 609b
JCAHO See Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Jehovah’s Witness religion 90b
John A. Hartford Foundation Institute for Geriatric Nursing 100b
Joint
Charcot 222t
falls and 220–221
replacement of, complications after 520
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 30
Judaism 90b
Jung’s theory of individualism 24b, 25
K
Katz Index of ADLs 71
Kegel exercises 548
Keratosis
actinic 615
seborrheic 609–610
Ketones, in urine 355t, 356
Kevorkian, Jack 45
Kidney See also Renal failure
age-related changes in 549–551
dialysis, patient wishes concerning 50
problems and conditions in 551–552
Kidney injury
acute 551, 551b
2275
assessment of 552, 553b
chronic 551–552, 551b
patient/family teaching for 552b
diagnosis of 552–553
evaluation after 553
intervention for 553
management of 553b
planning and expected outcomes of 553
Kinetic labyrinth 650
Knee, replacement surgery for 520
Knife injuries, in home 230–231
Küntscher nail 514f
Kyphosis 422
L
Laboratory and diagnostic tests 344–360 See also Hematology test
in home care 358b
sexuality and 248b
Laboratory data 80
Laboratory values, in nutrition assessment 191–192
Lactate dehydrogenase 354
Laparoscopy, GI diagnostic testing with 484t
Large intestine, age-related changes in 478
Laser surgery 641
Latino older adults, community-based services for 160b
Law See also Omnibus Budget Reconciliation Act of 1987 (OBRA)
on advance medical directives 39
on DNR 38–39
2276
documents 50–51
on elder abuse 31–33
on experimentation and research 46
family concerns with 101–102
federal 30–31
HIPAA as 31
on living will 39
for Medicare and Medicaid 30
organ donation 46
overview of relevant 30–31
on power of attorney 40
professional standards and 29–30
proposed legislative changes to 37
rehabilitation and 289–290
sources of 30
state 30–31
LDL See Low-density lipoprotein (LDL).
Lead-time bias 307
LEARN model 95
Legal and ethical issues 29–53
Legal services, cognitive disorders and 584
Length bias 307
Leukocytes 346–347, 355–356
in hematology test 345t
Leukotriene antagonists, asthma treatment with 428
Levorphanol (Levo-Dromoran) 265t
Lewy body dementia 573
2277
Libido, loss of 243
Life See also End-of-life; Quality of life
expectancy 299
rise in 184
insurance 125
meaning of 286
span, maximum 16–17, 184
Life stages theory 24b, 25–26, 25t
Lifestyle
activity and 213–214
changes in, for diabetes mellitus 465
sleep affected by 205–207
Lighting, as risk factor for falling 223
Lipase, serum, GI diagnostic testing with 484t
Lipofuscin 18
Lipoprotein See High-density lipoprotein (HDL) See also Low- density lipoprotein (LDL).
Lithium 597
Liver
age-related changes in 478, 490t
biopsy of, GI diagnostic testing with 484t
Liver cancer 509
Liver disease 501t, 509
Living alone 234
Living arrangements
by age group 131f
changes in 99–100
2278
demographic profile in 6
family and 98
independent to supervised 101b
of older adults 6, 7f
Living environment 53
in health history 67
Living wills 39, 41b, 50, 102t
general provisions in 39–40
Long-acting beta2-agonists (LABAs), asthma treatment with 428
Long-term care facilities 10 See also Nursing facilities; Nursing home
sleep in 204
Longitudinal fracture 513f
Lorazepam 576t
Lordosis 527f
Loss 324–328
cancer and 318–319
of spouse
activity affected by 214
sleep affected by 205
types of 325
Low-density lipoprotein (LDL) 349t, 353
Low-vision aids 647b
Lower extremity ulcers 619–621, 619t
Lung
capacity of 424t
defense mechanisms of 423t
function of 425–426
2279
exercise and 425
factors affecting 425–426
immobility and 425
volume of 424t
surgical reduction of 434
tidal 424t
Lung cancer 301–302, 438
detection of 301
risk factors for 301
signs and symptoms of 301
survival rates with 301
treatment of 301–302
Lung carcinoma 438–439
assessment of 439
diagnosis of 439
diagnostic test and procedures for 438–439
evaluation of 440
expected outcomes of 439–440
interventions for 440
patient education on 439b
planning for 439–440
staging of non-small-cell 439t
treatment of 439
Lung disease, restrictive 438–439
Lupus 273–274, 273b
Lutheranism 90b
Lymphocytes
2280
in hematology test 345t
total count of 192
M
Macular degeneration
age-related 646
assessment of 646
dry 646
evaluation after 647–648
intervention for 647
wet 646
Macular dysequilibrium 655
Magico-religious theory 89
Magnesium
DRI of 194t
serum levels of 351–352
Magnesium salicylate 265t
Magnetic resonance cholangiopancreatography (MRCP) 484t
Magnetic resonance imaging (MRI) 484t
Malnutrition
immune function and 272
psychosocial factors related to 185
socioeconomic factors related to 185
Mammography 142t, 303
advantages and disadvantages of 144t
cultural considerations with 303b
recommended frequency of 143t
Mandible, biocultural variation in 512t
2281
Manganese, DRI of 194t
MAOI See Monoamine oxidase inhibitor (MAOI).
Marijuana 376b
Marital status
affecting older persons 127
in demographic profile 6
Maslow’s hierarchy of human needs 24–25, 24b, 25f
Massage 265–266
MAST See Michigan Alcoholism Screening Test (MAST).
Masturbation 242
Meals-on-Wheels 161, 391
Medicaid
coverage with 126
laws on 30
rehabilitation reimbursed by 289
Medical directives, advance 39
Medical power of attorney 102t
Medicare
coverage of 125
Part A 125–126
Part B 126
Part D 126
hospice covered by 167
laws on 30
prevention reimbursement by 142t
rehabilitation reimbursed by 289
screening reimbursement by 142t
2282
Medication(s) See also Chemotherapy; Polypharmacy
abuse of 374
in acute care setting 154
adherence to 372–374
risk factors affecting 372–373
strategies for 373
adjuvant 265
alcohol’s effect on 379–382
for altered thought process 576t
asthma treatment with 428–429
Beers criteria on 363
behavior management with 575
blood level monitoring of 357–358
CAD treatment with 398
cardiovascular 369–371
depression caused by 568b
depression management with 576
diabetes management with 461, 461b, 461f, 464t
errors 367
in home care setting 373b
home storage of 234
hypertension treatment with 393, 394t
immune function affected by 272
inappropriate, for older patients 363–364
interactions with 381t
drug-disease 364–365, 365t
drug-drug 364, 364t
2283
drug-food 364, 365t
nicotine’s 384t
nutrient 195, 197t
management of 596–599
in nursing facilities 171–172
over-the-counter
safe 366t
use of 371
pain management with 262–266, 262f, 265t
equianalgesic dose charts for 265t
for Parkinson disease 587, 588t
patient education regarding 437–438
prescription 381–382
psychotropic 596–598
quality of life and 364
response to, aging’s effect on 361
rheumatoid arthritis treatment with 524t
sexuality affected by 244, 245t
side effects of 598
extrapyramidal symptoms 598, 598t
neuroleptic malignant syndrome 598
tardive dyskinesia 598
tuberculosis treatment with 442t
use of, demographics of 361
Medigap policy 126
Meditation 265–266
Melanoma 618
2284
assessment of 618
diagnosis of 619
intervention for 619
Memantine See Namenda (Memantine).
Memory, in aging 567
Men, androgen decline in 243
Meniere disease 655
diagnosis of 655
intervention for 655
Mennonite religion 90b
Menopause 456–458
Mental health
community centers for 584
in nursing facilities 173
trends and needs in 600, 600b
Mental health care, resources of 599–600
Mental retardation 594, 594b
Mental status, assessment of 75t
MMSE for 75–76
SPMSQ for 75, 76f
Mental status changes See Acute confusional state (ACS).
Meperidine (Demerol) 265t
Mesenteric occlusion 494f
Metabolic syndrome 458
assessment of 459t
diagnosis of 459t
evaluation of 459t
2285
interventions for 459t
medical management of 458–459
pathophysiology of 458
planning for 459t
signs and symptoms of 458
Metabolic theory 20, 20b
Metabolism, in pharmacokinetic process 362–363
Metered-dose inhaler (MDI) 433f, 437–438, 438b
Metformin 464t
Methicillin-resistant Staphylococcus aureus 275
Methodist religion 90b
Mexican-American culture 89
Michigan Alcoholism Screening Test (MAST) 375, 377f
Migration See Countermigration.
10-Mile Mourning Bridge 329, 331f
Minerals, in renal diet 554b
Mini-Cog 76, 77f
Mini-Mental State Examination (MMSE) 75–76, 567
Minimum Data Set (MDS) 70
Minority population, increase of 6
Mirtazapine 597
Mitral regurgitation 406, 406b
Mitral stenosis 406, 406b
Mixed incontinence 543
nursing care plan for 550b
MMSE See Mini-Mental State Examination (MMSE).
Molybdenum, DRI of 194t
2286
Mongolian spots 609b
Monoamine oxidase inhibitor (MAOI) 596
for Parkinson disease 588t
Monoclonal antibodies 312
Monocytes, in hematology test 345t
Montgomery GI Bill 124
Mood stabilizers 597
Moral aging theory 17b
Moral development 17b, 27
Mormonism 90b
Motility, decrease in 477
Motor function, age-related changes in 565
Mourning 324–325, 328–332
assessment of 329
meaning making with 329
nursing care for 329–332
stage/phase perspectives of 328–329
tasks of 328–329
Mouth, dry 656
MRCP See Magnetic resonance cholangiopancreatography (MRCP).
MRI See Magnetic resonance imaging (MRI).
Muscle
cramps of 538
pelvic floor, exercises for 548, 548b
strength of, decline in 422–423
Musculoskeletal function 511–540
age-related changes in structure and 511–513
2287
home care for 538b
problems with 511
Musculoskeletal system
biocultural variations in 512t
falls related to 220
problems and conditions of 513–514
Music therapy 175, 266
Myasthenia gravis 273b
Mycobacterium tuberculosis 440
Myelotoxicity 313
Myocardial infarction
aging’s effect on 58t
interventions for 401b
MyPlate 192–193, 192f
MyPyramid, modified for older adults 192f
N
Nail, disorders of 537
Namenda (Memantine) 572
Napping, daytime 204
National Center for Elder Abuse (NCEA) 31
Native American or Alaskan Native 66b, 83
attitudes toward 99b
Natural disasters, older adults’ susceptibility to 234
Nausea 480
as cancer complication 314
interventions for 480
Nazarene religion 90b
2288
NCEA See National Center for Elder Abuse (NCEA).
Nebulizer 437–438
Nedocromil 429
Need See Hierarchy of human needs.
Neglect 236
Nerve stimulation, with TENS 266
Nervous system
autonomic, age-related changes in 563t
central
age-related changes in 563t
divisions of 562, 562f
peripheral, age-related changes in 563t
Neufeld nail 514f
Neuralgia, postherpetic 614
Neuroendocrine control theory 19–20, 20b
Neuroglia 562–563, 564f
Neuroleptic malignant syndrome (NMS) 598
Neuroleptics, for altered thought process 576t
Neurologic function 561–606
Neurologic system
falls related to 221
structural age-related changes of 561–566
Neuron 562, 563f
Neuropathic pain 256, 256b
Neuropathic ulcers, diabetic 620
Neuropathy, peripheral 222t
Neurotransmitters 562
2289
Neutrophils, in hematology test 345t
Niacin, DRI of 194t
Nickel, DRI of 194t
Nicotine
dependence test 382, 383f
interventions for 382, 382b
medications’ interactions with 384t
prevalence of 382
replacement 382
Nigrostriatal disorders 587f
Nitrates, CAD treatment with 398
Nitroglycerin, alcohol’s effect on 380t
Nociceptive pain 256, 256b
Nocturia 541–542
management of 547b
Nocturnal awakenings 203
Non-small cell lung cancer (NSCLC) 301–302
Nonadherent dressing 635t
Nonbipedal falls 224
Nondihydropyridines, adverse effects of 394t
Noninstitutionalized older adults, factors affecting health care needs of 158–159
Nonprescription agents 371
Nonsteroidal antiinflammatory drugs (NSAIDs) 524t
alcohol’s effect on 380t
Normal pressure hydrocephalus 574
Norton Risk Assessment Scale 624, 625f
2290
Nortriptyline 597
NSAIDs See Nonsteroidal antiinflammatory drugs (NSAIDs).
Nuclear imaging, GI diagnostic testing with 484t
Nurse, gerontologic
association of
ANA 2, 30
visiting nurses 163
certification of 3b
credential for 3b
ethical code for 44–47
health promotion and disease prevention role of 145–149
home care characteristics of 165
home care role of 165
as permission giver 115–116
PSDA required responsibilities of 43
roles of 3–4
visiting 163
Nurse practitioner, gerontologic
certification of 3b
in nursing facility 177
roles of 3–4
Nurse specialist, gerontologic clinical
certification of 3b
roles of 3–4
Nursing See also Specific condition; Specific medical activity
in acute care setting 155–157
assessment focused around 54
2291
biologic aging theories’ implications for 20–22
care delivery systems 174
definition of 4
department of 173–174
education in 11–12
elder abuse training in 32
foundations of specialty of 1–4
history and evolution of 1–2
practice of 12–13
as problem-solving process 54
professional origins of 2
psychologic implications for 26–27
research on 13
roles in 3–4
sociologic theories’ implications for 23–24
specific competency and expertise of 156
standards of practice for 2–3
terminology for 4
Nursing facilities 131
activities in 215b
admission agreement for 34
assisted living in 159t, 174
in care continuum 168t
care models in 168–169
certification of 36
clinical aspects of 169–173
creativity in 175, 176b
2292
DNR guidelines in 39
drug use requirements in 35–36
dying in 339
end-of-life care in 173
enforcement mechanisms for 36–37
family decisions about 100–101
future of 177
health status and 10
home care based in 162
infection control in 172–173
innovations in 175–177
intermediate 30
management of 173–174
nurse practitioners in 177
quality of care requirements 33–37
reform of 33–37
resident assessment in 169–170, 170b
resident rights in 34–35, 169
sanctions of 36–37
skilled 30
urinary incontinence requirements in 36
Nursing home
admission factors 168b
fall incidence in 512
as nursing facility 10
Nutriceuticals 183
Nutrition 181–201 See also Malnutrition
2293
artificial, patient wishes concerning 51
assessment of 190–192, 190b
anthropometrics in 190–191
diet history in 190
laboratory values in 191–192
cancer treatment’s effect on 315b
cognitive disorders and 579
COPD and 436, 436b
with diabetes 463b
diagnoses with 195–196, 198b
in dying process 338, 338b
enteral 196–198
failure to thrive and 198
guidelines for 192–193, 193b
dietary reference intakes in 193, 194t
food labeling in 193
food pyramid in 192f
recommended dietary allowances in 193, 194t
in home care 199b
immune function affected by 271–272
in nursing facilities 171
parenteral 198
pattern 147
screening for 185–190
Level II 188f
tool for 186f
services 161
2294
specialized 196–198
status of, physiologic changes affecting 184–185
O
OAA See Older Americans Act (OAA).
OARS See Older Adults Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire.
OASIS, home care assessment with 166
Obesity
as contributing factor to heart disease 390
respiratory effects of 426
Oblique fracture 513f
OBRA See Omnibus Budget Reconciliation Act of 1987 (OBRA).
Obstructive sleep apnea syndrome (OSAS) 450–451
assessment of 451
diagnosis of 451
diagnostic tests and procedures for 451
evaluation of 451–452
expected outcomes of 451
interventions for 451, 452f
planning for 451
prognosis of 451
treatment of 451
Occipital bone, biocultural variation in 512t
Occupational profile, in health history 66–67
Occupational Safety and Health Administration (OSHA) 172
Olanzapine 576t
Old age, discretionary definition of 4
2295
Older adults
in acute care setting 154
acute confusional states in 58b
barriers to health promotion 141–142
cancer screening and early detection in 305–308
chronic illness in 285–287
cultural attitudes toward 99b
decision making 114
demographics of 4–7
diversity of 83–84, 84f, 85f, 86f
evaluating sexual risk in 247t
health status of 8–11
living arrangements of 6, 7f
malignancies in 301–305
needs for sexuality 241
organizations of 138
and professionals 138
sleep of, homebound 210–211
as support providers 98
values history of 44, 50b
weight table for 191t
working with families of 110–117
Older Adults Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire 78, 79f
Older Americans Act (OAA) 160
Omnibus Budget Reconciliation Act of 1987 (OBRA) 30–31
enforcement mechanisms with 37
2296
facility survey and certification and 36
major parts 33
provision of service requirements in 33
quality of care requirements in 33–37
regulatory "level A" requirements by 169b
resident rights requirements in 34–35
restraint requirements in 35–36
sanctions authorized by 36–37
urinary incontinence requirements in 36
Oncology Nursing Society 320
ONPRIME Model 141
Onychauxis 537
Onychomycosis 537
Opioids 263
equianalgesic dose charts for 265t
indications for 263
list of 265t
side effects of 263–265
Oral cancer 504
Oral cavity, age-related changes in 477–478
Oral hygiene 487
Oral mucositis, chemotherapy-induced, as cancer complication 314– 315
Organ donation
law on 46
patient wishes concerning 50
Orgasm, age related changes to 243
2297
Orthostatic hypotension 404
assessment of 404
diagnosis of 404
evaluation of 404
expected outcomes of 404
intervention for 404
planning for 404
OSAS See Obstructive sleep apnea syndrome (OSAS).
OSHA See Occupational Safety and Health Administration (OSHA).
Osler maneuver, for pseudohypertension 392
Osteitis deformans See Paget disease.
Osteoarthritis 518–519, 518f
assessment of 519
diagnosis of 519
differentiated from rheumatoid arthritis 523t
evaluation after 520
intervention for 519–520
planning and expected outcomes of 519
and regular exercise 519b
Osteomyelitis 531–532
Osteoporosis 221b, 223b, 223t, 526–529, 527f
assessment of 529
diagnosis of 529
evaluation after 530–531
with fractured thoracic vertebrae 530b
health promotion/illness prevention for 529b
2298
intervention for 530
planning and expected outcomes of 529–530
primary 470–471, 471t
medical management of 471
pathophysiology of 470–471
signs and symptoms of 471
risk factors for development of 527b
screening for 142t
x-rays for 527–528
Ovaries 457t
Overdetection bias 307
Overflow incontinence 543
diagnosis of 546
planning and expected outcomes for 547
Over-the-counter medication
safe 366t
use of 371
Oxycodone 265t
Oxygen
as arterial blood gas 357
blood’s capacity for 423–424
saturation 356t, 357
Oxygen therapy
COPD treatment with 433–434
home use of 438
Oxygenation 422, 423t
Oxyphenbutazone 524t
2299
P
Pacemaker, arrhythmia treatment with 403b
Pacemaker theory 19–20, 20b
Pacific Islanders 66b
Paget disease 531
Pain 255–269, 267b See also Palliative care
abdominal 480–481, 481f
acute, atypical 257–258
ageism and 256
assessment of 259–262, 259t
cultural 260
functional impairment in 261–262, 262t
history in 260
pharmacologic treatment for 262–266, 262f, 265t
physical examination in 260–261
quality of life in 262
self-treatment for 260, 261f
tools for 260–262, 261f
chest, assessment of 399b
from chronic illness 287
classification of 256, 256b
controlling of, by team approach 259b
definition of 255–256
depression and 262
diary of 261f
in dying process 337
epidemiology of 257
2300
in health history taking 67t
home care and 267b
management of 258–259, 267b
barriers to 258–259
CAM in 265–266
cognitive therapy in 266
dementia and 258, 258f
equianalgesic dose charts for 265t
physical therapies in 266
planning for 266
mixed or unspecified 256, 256b
neuropathic 256, 256b
nociceptive 256, 256b
pathophysiology of 257–258
sleep affected by 205
undertreatment of 258
abuse as 260
unrelieved, consequences of 257
Pain disorder 595t
Palate, biocultural variation in 512t
Paliperidone 598
Palliative care 166
in cancer care 308
hospice as subset of 166
Pallor, observation of 609b
Palmaris longus, biocultural variation in 512t
Pancreas 457t
2301
age-related changes in 478, 490t
Pancreatic cancer 508, 509
Pancreatitis 499
acute, amylase in 352
assessment of 499–501
diagnosis of 499
evaluation of 500
expected outcomes of 500
interventions for 500
Pannus 522
Pantothenic acid, DRI of 194t
PAOD See Peripheral artery occlusive disease (PAOD).
Papanicolaou test 142t
Paralytic ileus 493
Paranoia
behavior management of 580t
from cognitive disorders 583
Parathyroid 457t
Parenteral nutrition 198
Parietal bone, biocultural variation in 512t
Parkinson disease 586–588
clinical manifestations of 587
diagnosis of 588–591
diagnostic studies for 587
evaluation after 589
intervention for 589
management of 587
2302
medication 587, 588t
surgical 587–588
planning and expected outcomes of 588–589
postures and gaits in 587b
risk factors for 586–587
Paroxetine 597
Partial thromboplastin time, in hematology test 345t, 348
Pathologic fracture 513f
Patient education, on foot care 538
Patient Self-Determination Act (PSDA) 42–44, 339
clear and convincing proof 42–43
Cruzan case and 42
ethical dilemmas associated with 43–44
nurse’s responsibilities with 43
significant provisions of 43
Patient teaching 391b
Patterned urge response training (PURT) 549
Pedestrian accidents 235b
Pelvic examination 142t, 143t
Pelvic floor muscle exercises 548, 548b
Pelvis, biocultural variation in 512t
Penicillamine 524t
Pentazocine (Talwin) 265t
Pentecostal 90b
Peptic ulcer disease (PUD) 491–492, 491f
Percutaneous transhepatic cholangiography (PTC) 484t
Percutaneous transluminal coronary angioplasty (PTCA) 399
2303
Periodic Limb Movements in Sleep (PLMS) 209
Periodontal gum disease 477–478
Periodontitis 483
assessment of 483
diagnosis of 483
evaluation of 487
interventions for 487
Peripheral artery occlusive disease (PAOD) 413–414, 414b
assessment of 414, 414b
diagnosis of 414
diagnostic tests and procedures for 413
evaluation of 414, 415b
expected outcomes of 414
interventions for 414
planning for 414
prognosis of 414
surgical procedures for 413
treatment of 413
Peripheral nerve stimulation, with TENS 266
Peripheral nervous system, age-related changes in 563t
Peripheral vascular disease (PVD) 389, 532–533
assessment of 416, 416t
causes of 414
diagnosis of 416
diagnostic tests and procedures for 415–416
evaluation of 417
expected outcomes of 416
2304
hypertension’s contribution to 389
interventions for 416–417
planning for 416
prognosis of 416
treatment of 416
Peritoneal dialysis 554b
Peritoneoscopy, GI diagnostic testing with 484t
Pernicious anemia 489
Peroneus tertius, biocultural variation in 512t
Personal care homes See Board and care homes.
Personal care tasks, difficulty with, behavior management of 580t
Personal emergency response systems (PERSs) 161–162
Personal relationships 52
Person-environment fit theory 22b, 23
PERSs See Personal emergency response systems (PERSs).
Petechiae, identification of 609b
pH
arterial 424
of blood 356t, 357
of urine 355t, 356
Phantom limb pain 533
Phantom limb sensation 533
Pharmacodynamics 363
age-related changes in 363–364
of chemotherapeutic agents 310–312
Pharmacokinetics 361–363
absorption in 362
2305
age-related changes in 362t
of chemotherapeutic agents 310
distribution in 362
excretion in 363
metabolism in 362–363
Pharmacologic management 361–387
risk factors in 364–367
Pharynx, age-related changes in 477–478
Phenytoin (Dilantin), alcohol’s effect on 380t
Phosphatase
acid 349t, 354
alkaline 349t, 354
Phosphorus
DRI of 194t
serum levels of 351
Physical examination 70
after falls 226
equipment and skills for 71
guidelines for 70
Medicare reimbursement for 142t
pain assessment with 260–261
in urinary incontinence assessment 545
Physical exercise 211–213, 214f
Physical fitness
health promotion relevant to 140b
rehabilitation’s enhancement of 290
Physical problems, conditions associated with 595
2306
Physical restraints 35–36
Physical therapy, pain management with 266
Physician-assisted suicide 45
Physiotherapy, chest 437
Pineal gland 457t
Pituitary gland 456f, 457t
Plan, do, check, act cycle 164b
Plant alkaloids 311t
Platelets
anti- 398
in hematology test 345t, 348
PLMS See Periodic Limb Movements in Sleep (PLMS).
Pneumococcal infection vaccination 142t
Pneumonia 272–273, 277b, 444–445
aspiration 444–445
assessment of 445–446
bacterial, aging’s effect on 58t
community-acquired 444, 444t
deaths from 282t
diagnosis of 446
diagnostic tests and procedures for 445
evaluation of 446–447
expected outcomes of 446
health care-associated 444
hospital-acquired 444
interventions for 446
nosocomial 444
2307
planning for 446
prognosis of 445
risk variables for 445t
treatment of 445
ventilator-associated 444
viral 444
Podagra 526
Polymyalgia rheumatica 534
assessment of 534
diagnosis of 535
evaluation after 536
intervention for 536
planning and expected outcomes of 535
Polyp(s) 494f
adenomatous 497
assessment of 497
colon 497
diagnosis of 497–498
expected outcomes of 497
interventions of 497
Polypharmacy 143, 365–367, 366b, 381, 381f
adverse drug reaction with 154
constipation from 482
Population needs See Demographics.
Porous bone disease 526
Postherpetic neuralgia 614
Potassium
2308
DRI of 194t
hypokalemia and 351b
in renal diet 554b
serum levels of 351
Poverty 123
in demographics 7, 8f
malnutrition and 185
rates of 124f
Power of attorney 40, 50
Prealbumin 191
PRECEDE/PROCEED Model 141
Presbycusis 220, 652–653
Presbyopia 642
Presbyterianism 90b
Pressure ulcers 621–636
definition of 629–632, 632b
epidemiology of 622
etiology of 622–624
factors contributing to 623f
management of 628–636
biophysical agents in 636
débridement for 632–633, 632b
dressing types for 634–636, 635t
nursing care plan in 637b
principles of 632–633, 636t
prevention of
device use in 625b
2309
repositioning schedule 627f
strategies for 626–628, 629b
risk assessment tools for 624–625, 625f, 626f
sites of 622f
staging criteria of 629–632, 630b
wound healing physiology and 628–629
Prevention See also Specific condition
assessment and 146
barriers to 141–142
disease 142–145
Medicare reimbursement for 142t
nurse’s role in 145–149
primary 140, 142–145, 143t
quaternary 141
secondary 140–141, 143–144, 143t
tertiary 141, 144–145
Problem, magnitude of 218–219
Prodromal falling 220
Professional standards 29–30
Program of All-inclusive Care for the Elderly (PACE) 125
Programmed theory 17b, 19
Progressive relaxation, as alternative therapy 266
Prompted voiding 549, 549b
Propulsive gait 587b
Prostate cancer 304, 557–558
assessment of 558
with bone metastases 264b
2310
detection of 304
diagnosis of 558
evaluation after 559
intervention for 558–559
nursing care plan for 558b
planning and expected outcomes of 558
risk factors for 304
sexuality affected by 245–246
signs and symptoms of 304
survival rates with 304
treatment of 304
Prostate examination
advantages and disadvantages of 144t
evidence on 143t
Prostate-specific antigen (PSA) 354
Prostatic hypertrophy See Benign prostatic hypertrophy (BPH).
Prosthesis, fitting of 534
Protamine sulfate 398
Protective services 31–33, 236
Protein
in blood chemistry testing 349t, 352
C-reactive 348
DRI of 194t
HDL 349t, 353
LDL 349t, 353
in urine 355, 355t
Proteinuria 355
2311
Prothrombin time, in hematology test 345t, 347–348
Pruritus 611, 650
assessment of 611
diagnosis of 611–612
evaluation after 612
intervention for 612
planning and expected outcomes of 612
PSA See Prostate-specific antigen (PSA).
PSDA See Patient Self-Determination Act (PSDA).
Pseudohypertension 392
Psoriasis 610
assessment of 610
diagnosis of 610
intervention for 611
Psychiatric hospital 584
Psychoactive medications 598–599
Psychologic theories of aging 17b, 24–27, 24b
Erikson’s eight stages of life as 24b, 25–26, 25t
Jung’s theory of individualism as 24b, 25
Maslow’s hierarchy of human needs as 24–25, 24b, 25f
selective optimization with compensation as 24b, 26
Psychotropics 367–368, 596–598
PTC See Percutaneous transhepatic cholangiography (PTC).
PTCA See Percutaneous transluminal coronary angioplasty (PTCA).
PUD See Peptic ulcer disease (PUD).
Pulmonary disease
2312
obstructive 427–429
restrictive 438–439
Pulmonary edema 447
assessment of 448
cardiogenic 447
diagnostic tests and procedures for 447
prognosis of 447
treatment of 447
diagnosis of, nursing 448
evaluation of 449
expected outcomes of 448
interventions for 448–449
noncardiogenic 447–448
diagnostic tests and procedures for 447–448
prognosis of 448
treatment of 448
planning for 448
Pulmonary emboli 449–450
assessment of 450
diagnosis of 450
diagnostic tests and procedures for 449
evaluation of 450
expected outcomes of 450
interventions for 450
planning for 450
prognosis of 450
treatment of 449
2313
Pulmonary function See Lung.
Pulmonary hygiene 437
Pulmonary rehabilitation 435–436
Pulse oximetry 433–434
Pupil, assessment of 577–578
Purpura 273b
PVD See Peripheral vascular disease (PVD).
Pyrazinamide 442t
Q
Quaker religion 90b
Quality of life
with cancer 307b, 316–317
chronic illness and 285
exercise and 284b
functioning for 163b
health-related 283–284
in hospice patients 317b
medication use and 364
multidimensionality of 317f
in pain assessment 262
Quetiapine 598
R
Race 88
cancer patterns and 297–299
in demographics 6
U.S. Census definition of 297–298, 297b
Racism 89
2314
Radiation therapy
for breast cancer 303–304
cancer treatment with 309–310
nutritional consequences of 315b
Radiology, GI diagnostic testing with 484t
Radius, biocultural variation in 512t
Rails, as risk factor for falling 223
Rapid eye movement (REM) 202
RDAs See Recommended dietary allowances (RDAs).
Reactive hyperemia 632b
Recommended dietary allowances (RDAs) 193, 194t
Recreation/leisure profile, in health history 67
Rectum, age-related changes in 490t
Red blood cells, in hematology test 345t, 346
Regurgitation, aortic and mitral 406b
Rehabilitation 288–292, 295
after amputation 534
care environments of 289, 289f
exercise and 290
fitness enhancement with 290
functional assessment in 290
goals of 288–289
in nursing facilities 172
public policy and legislation in 289–290
pulmonary 435–436
reimbursement issues for 289
Relaxation, progressive, as alternative therapy 266
2315
Relaxation therapies, sleep promotion with 211
Religion
beliefs of 90b
dietary prohibitions in 182b
in values history form 52
REM See Rapid eye movement (REM).
Renal diet 554b
Renal failure, hypertension’s contribution to 389
Requisite knowledge, for health promotion and disease prevention 145–146
Research
on DNA 20, 20b
on gerontologic nursing 13
law on 46
patient rights regarding 46
Residence, location of 129
Residential care facilities See Board and care homes.
Residual volume (RV) 424t
Residual volume/total lung capacity (RV/TLC) 424t
Resources
financial 600
in health history 67–68
human 599
of mental health care 599–600
physical 599–600
Respirators, use of, patient wishes concerning 51
Respiratory disorders See Adult respiratory distress syndrome See also Chronic lower respiratory disease; Severe acute respiratory
2316
syndrome (SARS).
Respiratory function 422–454
Respiratory rate 423
Respiratory syncytial virus (RSV) 443b
Respiratory system See also Lung
age-related changes in 422–425
alterations in 427
anesthesia’s effect on 426
gas exchange in 423
health promotion for 425b
home care for 452b
neurochemical control of 452
obesity’s effect on 426
sleep’s effect on 426
surgery’s effect on 426
symptoms in, common 426–427
Respite care 161
Respite programs, in family caregiving by 107–108
Restlessness, in dying process 338
Restraints
falls associated with 223b
OBRA’s requirements for 35–36
Resuscitation See Cardiopulmonary resuscitation (CPR) See also Do not resuscitate (DNR) orders.
Retardation, mental 594, 594b
Reticular formation 565–566
Retina
2317
detachment of 646
disorders of 646
Retinopathy, diabetic 646
assessment of 646
evaluation after 647–648
intervention for 647
Retirement
activity affected by 213
age of 122
community 159t
sleep affected by 205
Retropulsion 587b
Reverse mortgage 129
Reversible dementia 570
Rheumatic fever, as cause of valvular disease 406
Rheumatoid arthritis (RA) 273b, 274, 521–522, 522f
assessment of 522
deformities of 523f
diagnosis of 522
differentiated from osteoarthritis 523t
evaluation after 525
intervention for 523–525
medications for 524t
planning and expected outcomes of 522
Riboflavin, DRI of 194t
Ribonucleic acid (RNA) 17
Ribs, age-related changes in 422
2318
Rifampin 442t
Rights
in experimentation and research 46
resident
bill of 34b
OBRA’s requirements for 34–35
to self-determination 37
Risperidone 576t, 598
Rivastigmine (Exelon) 572
RNA See Ribonucleic acid (RNA).
Roman Catholic religion 90b
Root work (magico-religious theory) 89
RSV See Respiratory syncytial virus (RSV).
r-TPA therapy, intravenous, for acute ischemic stroke 591, 591b
Russell traction 514
Russian Orthodox religion 90b
S
Safety 218–240
of automobile 234–235
cognitive disorder interventions with 582
with fire 230, 230b
in homes 228–232, 229b, 237b
OSHA on 172
of over-the-counter medications 366t
seasonal 232–234
for women 130b
Salicylates 524t
2319
Saliva, volume of 490t
Sanctions 36–37
SARS See Severe acute respiratory syndrome (SARS).
Schizophrenia 593
Schwann cells 562–563
Scintigraphy
of GI bleeding 484t
GI diagnostic testing with 484t
hepatobiliary 484t
Scleroderma 273b
Scoliosis 422
Scope and Standards of Gerontological Nursing Practice 30
Screening See also Mammography
adenoma and cancer, colorectal 479t
for alcoholism
with BMAST 375, 378f
with MAST 375, 377f
cancer 305–308
breast 303b
colorectal 142t, 307b
for diabetes 142t
for glaucoma 142t
for hepatitis B 142t
for influenza 142t
Medicare reimbursement for 142t
nutritional 185–190, 186f, 188f
for osteoporosis 142t
2320
with Papanicolaou test 142t
with pelvic examination 142t
for pneumococcal infection 142t
for substance abuse 375–376
Seborrheic dermatitis 610
Seborrheic keratoses 609–610
Sedative-hypnotics 598–599
alcohol’s effect on 380t
Sedatives
sexual side effects of 245t
sleep promotion with 206
Sedentary lifestyle, heart disease risks from 390
Selective optimization with compensation 24b, 26
Selective serotonin norepinephrine reuptake inhibitors (SNRIs) 597
Selective serotonin reuptake inhibitors (SSRIs) 597
Selenium, DRI of 194t
Self-determination 37–42 See also Patient Self-Determination Act (PSDA)
Self-esteem, cognitive disorder interventions with 582
Self-management 125
Self-perception 146
Semipermeable polyurethane foam dressing 635t
Senescence 16–17
immuno- 19
Senior See Older adults.
Senior centers, multipurpose 160–161
Sensorimotor function, age-related changes in 566
2321
Sensory function 640–658
home care and 657b
Serial Trial Care Protocol (STCP) 258, 258f
Sertraline 597
Serum See Blood chemistry testing See also specific compound.
Servicemen’s Readjustment Act of 1944 124
Seventh Day Adventist religion 90b
Severe acute respiratory syndrome (SARS) 447
Sexual behavior, inappropriate/impulsive, behavior management of 580t
Sexual concerns 248b
Sexual disinhibition See Hypersexuality.
Sexual dysfunction 249b, 471–472, 473t
medical management of 472
pathophysiology of 472
signs and symptoms of 472
Sexual function, conditions affecting 244b
Sexuality
alternative 246
barriers to, environmental and psychosocial 246
chronic illness and 287
coital positioning for 250f
enhancement of 251b
female 250b
health patterns of 148
in home care 252b
homosexuality as 246
2322
illness, surgery, and medication affecting 244, 245t
loss of libido in 243
male 250b
normal changes of aging in 243
nursing management of
assessment in 247–248
diagnosis in 248–249
evaluation in 252
intervention in 249–252
laboratory tests in 248b
planning and expected outcomes in 249
reluctance to 242–243
older adults’ needs for 241
pathologic conditions affecting 244–246, 244b
dementia as 246
HIV as 244–245
malignancies as 245–246
physiologic changes in 243–244
questions on 247b
Sexually inappropriate behavior See Hypersexuality.
Shearing force 624f, 632b
Sheltered housing See Board and care homes.
Shingles 613–614
Short Portable Mental Status Questionnaire (SPMSQ) 75, 76f
Sick days 465–466
Sick sinus syndrome 402
Sighted guide 648–649, 649b
2323
Sigmoid colon, volvulus of 494f
Sigmoidoscopy 142t, 484t
flexible 479t
GI diagnostic testing with 479t
Sinoatrial (SA) node 389
Sinus syndrome, sick 402
Sinus tract 632b
Skin
age-related changes in, structure and function of 608, 608b
alterations in, in diabetes mellitus 466f
biocultural variations in 609b
care of
home 637b
nursing facility 170
dry, prevention and treatment of 612b
growths of
benign 608–610
malignant 616
premalignant 615
problems and conditions related to 608–610
Skin tags 610
SLE See Systemic lupus erythematosus (SLE).
Sleep
age-related changes in 203–204, 203b, 565
assessment of 210, 212t
biologic brain functions responsible for 202
breathing and 423t
2324
circadian rhythm and 203
daytime 204
deprivation, as delirium risk factor 570t
disorders and conditions 207–209 See also Sleep apnea
PLMS as 209
disturbance of
behavior management of 580t
dementia and 207
factors affecting 204–205
caffeine 206
dietary influences as 206
drugs as 206, 207t
environment as 204
facilities as 204
home environment as 204
hospitals as 204
lifestyle changes as 205–207
lighting as 205, 209b
noise as 204, 204b, 209b
pain and discomfort as 205
relocation as 205
retirement as 205
roommate as 205–206
spouse loss as 205
temperature as 205
herbal remedies and 207
history 209–210, 209b
2325
in home care 215b
of homebound older adults 210–211
hygiene 210
insomnia and 203
latency 203
and older adults 202–211
patterns of 148, 565–566
disturbance of 208b
promotion of, therapies for 211
protocol for 212t
quality of 209
relaxation therapies and 211
REM 202
respiratory effects of 426
stages of 202–203, 203t
stimulus control therapy for 211
Sleep apnea 207–209
Sleep restriction therapy 211
Small cell lung cancer (SCLC) 301
Small intestine, age-related changes in 478, 490t
Smell 656
age-related changes in, structure and function of 656
decreased sense of 490t
problems and conditions of 656
Smoking 425–426 See also Nicotine
as contributing factor to heart disease 390
fire risk with 229
2326
Smoking cessation 143, 390
advantages of 144t
with behavior modification 382
components of 425–426
COPD and 436
with help 436t
Medicare reimbursement for 142t
multicomponent, intervention for 425b
SNRIs See Selective serotonin norepinephrine reuptake inhibitors (SNRIs).
Social isolation 185
Social Security benefits 122t
Social security program 4–5
Social-ecologic model, motivation with 149t
Socioeconomic factors 121–128
health status and 125
in home care 134b
related to malnutrition 185
Sociologic theories of aging 17b, 22–24, 22b
activity theory as 22–23, 22b
age stratification theory as 22b, 23
continuity theory as 22b, 23
developmental task theory as 22–23, 22b
disengagement theory as 22, 22b
person-environment fit theory as 22b, 23
Sodium
DRI of 194t
2327
in renal diet 554b
serum levels of 349
Sodium salicylate 265t
Somatization 595t
Somatoform disorders, types of 595t
Somatopause 458
Special care units 175
Sphincter, anal, decreased tone of 490t
Spinal stenosis 520–521, 521f
Spiral fracture 513f
Spiritual aging theory 17b
Spiritual development 17b, 27
Spirituality
chronic condition management and 147b
dying and 333
SPMSQ See Short Portable Mental Status Questionnaire (SPMSQ).
Spouse, loss of
activity affected by 214
sleep affected by 205
Squamous cell carcinoma, of skin 617
SSRIs See Selective serotonin reuptake inhibitors (SSRIs).
Standard of care 30
Staphylococcus aureus 275
STCP See Serial Trial Care Protocol (STCP).
Stenosis
aortic and mitral 406, 406b
spinal 520–521, 521f
2328
Stents, CAD treatment with 399
Steps, as risk factor for falling 222, 222f
Steroids 524t See also Corticosteroids; Glucocorticosteroids
Stimulus control therapy, sleep promotion with 211
Stomach, age-related changes in 478, 490t
Stomatitis 278b
Stool culture, GI diagnostic testing with 484t
Strangulated inguinal hernia 494f
Streptococcus pneumoniae 444
Stress
as contributing factor to heart disease 391
in family caregiving 113
response to, age-related changes in 389
tolerance 147
Stress fracture 513f
Stress incontinence 543
diagnosis of 545
planning and expected outcomes for 547
Stress ulcer 490
Stroke, levels of prevention of 590t
Stump shrinker 534
Subacute care 175
Subcutaneous fat, age-related changes in 608
Subdural hematomas 574
Substance abuse See also Alcohol, abuse of; Nicotine
assessment of 375–376
screening tools for 375–376
2329
caveats 376
definitions and common usage of 374–375
diagnoses of 376
evaluation for 378–379
history of 375
home care and 384b
interventions for 378
management of 378–379
medical manifestations of 375b
of medication 374
physiologic changes with 374
psychological changes with 374–375, 374f, 376b
sociologic changes with 375
trends in 382–384
Suicide 584–585
assessment of 585, 585b
assisted 45–46
ethics of 45–46
diagnosis of 585
evaluation after 586
with firearms 236–237
intervention for 586
planning and expected outcomes for 585–586
risk factors of 585, 585b
Sulfonylureas 464t
Sundown syndrome 582–583
"Sundowning," behavior management of 580t
2330
Sunrise Model, of culturally sensitive care 94, 94f
Supplements, dietary 371–372
Support
for cancer 319–320
groups
as cognitive disorder resource 583
for family caregivers 108–110
older adults providers 98
systems 126–127, 127f
Surgery
for breast cancer 303
cancer treatment with 309
for cataracts 645b
COPD treatment with 434
on hip 520, 520b
knee replacement 520
laser 641
lung volume reduction with 434
nutritional consequences of 315b
for Parkinson disease 587–588
respiratory effects of 426
Surgical cholangiography 484t
Suspiciousness 583
behavior management of 580t
Swan-neck deformity 523f
Sympathomimetics, CHD treatment with 410
Syncope, with cardiac causes 405
2331
assessment of 405
diagnosis of 405
expected outcomes of 405
Systemic lupus erythematosus (SLE) 273–274, 273b
T
Tacrine (Cognex) 572
Talwin See Pentazocine (Talwin).
Tardive dyskinesia 598
Tarsal, second, biocultural variation in 512t
Taste 656
age-related changes in, structure and function of 656
buds, age-related changes in 478, 490t
problems and conditions of 656
TCAs See Tricyclic antidepressants (TCAs).
Teeth, loss of 477–478
Telephone monitoring 161
Temperature, sleep affected by 205
Tendency to reminisce, in health history taking 67t
TENS See Transcutaneous electrical nerve stimulation (TENS).
Testes 457t
Testosterone, replacement of 457–458
The Cancer Genome Atlas (TCGA) project 300
Therapeutic lifestyle changes (TLC) 458–459
for metabolic risk factors 458b
Thiamin, DRI of 194t
Thiothixene 598
Thought process See Cognitive function.
2332
Thromboplastin time, partial, in hematology test 345t, 348
Thrush 483
Thymus 457t
Thyroid 457t See also Hyperthyroidism; Hypothyroidism
feedback regulation by 456f
functional testing of 354, 355t
Thyroid storm 468
Thyroiditis, autoimmune 470
Thyroid-stimulating hormone (TSH) 354, 355t
Thyroxine 354, 355t
TIBC See Total iron binding capacity (TIBC).
Tidal volume (VT) 424t
Time orientation 91
Tinetti Balance and Gait Evaluation 227f
Tinnitus 651
assessment of 651, 651b
diagnosis of 651
intervention for 651–652, 652b
Tissue tolerance 632b
Tobacco use 382 See also Nicotine; Smoking
Toenail, problems of 537
Toileting, scheduled 548
Tophaceous gout 525f
Tophi 525
Total client care 174
Total iron binding capacity (TIBC) 347
in hematology test 345t
2333
Total lung capacity (TLC) 424t
Touch 657
in cultural assessment 66b
deprivation of 242
importance of 242
Touch therapy 175
Trabeculectomy 643–644
Trabeculoplasty 643
Trajectory framework 285
Transcutaneous electrical nerve stimulation (TENS) 266
Transferrin, in nutritional assessment 191
Transparent film dressing 635t
Transportation 129, 161 See also Driving
Transverse fracture 513f
Trauma
care 156–157
psychologic, fall resulting in 225
Trazodone 576t
Trichinosis 492–493
Tricyclic antidepressants (TCAs) 597
Trifluoperazine 598
Triglycerides, serum levels of 353
Triiodothyronine 354, 355t
Troglitazone 464t
Troponin, serum levels of 354
TSH See Thyroid-stimulating hormone (TSH).
Tuberculosis 440–441
2334
assessment of 441
diagnosis of 441
diagnostic tests and procedures for 440–441
evaluation of 442
expected outcomes of 441
interventions for 441–442
medications for 442t
planning for 441
prognosis of 441
treatment of 441
Tumor necrosis factor (TNF) receptor antagonists 525
Tumors
antibiotics for 311t
intracranial 574
U
UI See Urinary incontinence (UI).
Ulcer(s) See also Pressure ulcers
arterial 619–620
diabetic neuropathic 620
duodenal 491–492
foot 466, 467b
gastric 491
ischemic 619
of lower extremity 619–621, 619t
peptic 491–492, 491f
stress 490
venous 620–621
2335
Ulcerative colitis 273b
Ulna, biocultural variation in 512t
Ulnar drift 523f
Ultrasonography
abdominal 484t
endoscopic 484t
gallbladder 484t
GI diagnostic testing with 484t
hepatobiliary 484t
Undermining 632b
Union 513
Unitarian Universalist religion 90b
United States Census Bureau 297b
United States Preventive Services Task Force (USPSTF) 143t
Urea nitrogen, blood test of 349t, 353
Urge incontinence 543
diagnosis of 545–546
planning and expected outcomes for 547
strategies for 548b
Uric acid, in hematology test 345t, 347
Urinary function 541–560
health promotion/illness prevention for 559b
home care 560b
problems and conditions in 542–543
Urinary incontinence (UI) 541
acute 542
causes of 542b
2336
assessment of 543–545
bladder habits 545
environmental 544
functional 544
patient history in 544
physical examination in 545
provocation tests in 545
psychosocial 544–545
chronic 542–543
functional incontinence as 543
mixed incontinence as 543
overflow incontinence as 543
stress incontinence as 543
urge incontinence as 543
cognitive impairment and 548
diagnosis of 543, 545–546
in dying process 338
evaluation of 549
interventions for 547–549
bladder retraining as 548
habit training as 549
lifestyle modifications as 547
pelvic floor muscle exercises as 548, 548b
prompted voiding as 549, 549b
scheduled toileting as 548
myths and attitude about 542
nursing facility requirements regarding, OBRA’s 36
2337
planning and expected outcomes of 546–547
prevalence of 542
Urinary tract, age-related changes in structure and function of 541– 542, 542f
Urinary tract infection (UTI) 221b, 553–555
aging’s effect on 58t
assessment of 555
clinical signs of 357b
diagnosis of 555
evaluation after 555
intervention for 555
planning and expected outcomes of 555
Urine
bacteria in 355–356, 355t
blood in 355t, 356
chemistry testing of 355–356, 355t
glucose in 355, 355t
ketones in 355t, 356
leukocytes in 355–356
pH of 355t, 356
protein in 355, 355t
USPSTF See United States Preventive Services Task Force (USPSTF).
UTI See Urinary tract infection (UTI).
V
Vaccination 142–143
Vaccines 433
Valproic acid 576t
2338
Values 87–88
health patterns of 147–148
history 44, 50b
Valvular disease 406–407
assessment of 407
diagnosis of 407
diagnostic tests and procedures for 406
evaluation of 408
expected outcomes of 407
interventions for 407–408
manifestations of 406b
planning for 407
prognosis of 406–407
treatment of 406
Vanadium, DRI of 194t
Vancomycin-resistant Enterococcus (VRE) 274
Varicose veins 414
Vascular dementia 572–573
clinical manifestations of 573
diagnostic studies for 573
risk factors of 572
treatment for 573
Vasodilators, direct, adverse effects of 394t
Vasovagal syncope 405
Venlafaxine 597
Venous disorders 414–416
Venous insufficiency 416t
2339
Venous ulcers 414, 620–621
Ventilation 422, 423t
Ventricular system 563–566
Ventricular tachycardia 405
Vertebrae
age-related changes in 422
biocultural variation in 512t
Vertigo
assessment of 655
benign paroxysmal positional 655
diagnosis of 655
intervention for 655
Vestibule 650
Veterans, benefits for 122b, 128, 128f
Victimization See Crime.
Vision 640–643, 641f See also Eye; Visual deficit
age-related changes, in structure and function 641
complaints with 641
flashers in 641
floaters in 641
falls related to 220
problems and conditions with 642–643
Visiting nurse association (VNA) 163
Visual deficit, in health history taking 67t
Visual impairment 647–648
assessment of 648
as delirium risk factor 570t
2340
diagnosis of 648
evaluation after 649
intervention for 648–649, 648b, 649b
planning and expected outcomes of 648
Visualization, as alternative therapy 266
Vital capacity (VC) 424t
Vitamin A, DRI of 194t
Vitamin B6, DRI of 194t
Vitamin B12
deficiency of 489
DRI of 194t
in hematology test 345t
Vitamin C, DRI of 194t
Vitamin D, DRI of 194t
Vitamin E, DRI of 194t
Vitamin K 398
as anticoagulant 348b
DRI of 194t
Vitamins, in renal diet 554b
Vitiligo 609b
Voiding, prompted 549, 549b
Volvulus, of sigmoid colon 494f
Vomiting 480
as cancer complication 314
interventions for 480
stimuli involved in 480f
Voodoo 89
2341
VRE See Vancomycin-resistant Enterococcus (VRE).
W
Walkers 516f
correct use of 516b
types of 518f
Walking, benefits of 21
Wandering 583
behavior management of 580t
Warfarin 398
Water, DRI of 194t
Wear and tear theory 17b, 18–19
Weight table 191t
White blood cells 346–347, 355–356
in hematology test 345t
White seniors, attitudes toward 99b
Widowhood, prevalence of 205
Wills, living 39, 41b, 50
Women
employment of 98
homeless 132b
safety of 130b
sexuality of 250b
World War II 121
Wound
care of, principles of 634–636
dressing for, types of 634–636, 635t
healing physiology of 628–629
2342
infection of, in diabetic patients 467
X
X-ray imaging, for osteoporosis 527–528
Xerosis, prevention and treatment of 612b
Xerostomia 656
Y
Yin/yang theory 91
Z
Zinc 272
DRI of 194t
Ziprasidone 598
2343
Disorders Index
Note: Page numbers followed by bindicate boxes, findicate figures and tindicate tables.
A
Acute abdomen 481
Acute confusional state 57, 58b, 59, 59t
Adult respiratory distress syndrome 447–448
Alopecia, as cancer complication 316
Alzheimer’s disease 214–215, 282t, 570–572
Amebiasis 492
Anemia 221b, 273b, 417–419, 418b, 489
Angioma, cherry 608
Anorexia nervosa 480
Anxiety 67t, 592–593, 593b
Arrhythmia 221b, 402, 403–404, 403b
Arterial insufficiency 416t
Arthritis. See Gout. See also See also Osteoarthritis, Rheumatoid arthritis
Asthma 427–430, 430f, 430t, 431
Ataxia, vestibular 655
Atrial fibrillation 402, 405
B
Basal cell carcinoma, of skin 616
2344
Benign prostatic hypertrophy 556, 557b
Bladder cancer 555, 556
Blepharitis 642–643
Bowel obstructions 494f
Breast cancer 245, 302–304, 303b, 307b
Bronchitis, chronic 427, 431
Bronchopulmonary infection 442–443
Bunion 537, 537f
Burn injury 229–230 see alsoFire
C
Callus 513, 536
Cancer, reader-see See specific cancer
Candidiasis 612
Cardiovascular disease 389, 389b
Cataracts 644–646, 645b
Cerebrovascular accident 589–591, 592
Cerebrovascular disease 282t
Cerumen impaction 650
Charcot’s joint 222t
Chest pain, assessment of 399b
Cholecystitis 498, 499
Cholelithiasis 498, 499
Chronic lower respiratory disease 282t
Chronic obstructive pulmonary disease 427b, 431–438, 432t, 435b, 436b, 436t
Cirrhosis 502–503, 502f
Colorectal cancer 142t, 305, 307b
2345
Congestive heart failure 58t, 389, 408–409, 409t, 410, 411–413, 411b, 411t, 412b, 427
Constipation 263, 264b, 338, 482–483
Corn 536, 536f
Coronary artery disease 389, 397–402, 397b, 399b
Coronary heart disease 389. See also See also Coronary artery disease
Cyanosis, identification of 609b
D
Deep vein thrombosis 414
Delirium 157t, 568–569, 568t, 570t, 571b, 575. See also See also Acute confusional state
Delirium tremens 382b
Delusion 583
Dementia 59t, 157t, 207, 214–215, 246, 258, 258f, 568t, 569–570, 572– 574, 575
Depression 58t, 157t, 207, 262, 272, 317–318, 567–568, 568b, 568t, 576
Dermatitis, seborrheic 610
Dermatoses, inflammatory 610
Diabetes 142t, 282t, 354t, 390–391, 458–467, 460f, 465t, 466b, 466f
Diabetic foot syndrome 467
Diarrhea 315–316, 482
Dysequilibrium 654–655
Diverticulitis 495, 496b
Diverticulosis 495
Dumping syndrome 492
Dyspepsia 502f
Dysphagia 487–488
Dyspnea 337–338, 426–427, 427b, 434
2346
E
Ectropion 642
Emphysema 431
Encephalopathy 503
Enteritis 492–493. See also See also Gastritis, Gastroenteritis
Entropion 642
Erythroderma 610
Esophageal cancer 504–505, 506b
Esophagitis 488
G
Gastric cancer 505–506, 507
Gastritis 489–491
Gastroenteritis 492
Gastroesophageal reflux disease 427, 488, 489
Gingivitis 483, 487
Glaucoma 142t, 643–644, 644b
Goiter, simple 469f
Goodpasture’s syndrome 273b
Gout 256b, 349, 381t, 000025:f0060, 526
Gum disease 477–478
H
Hallux valgus 523f, 537, 537f
Hammertoe 222t, 537, 537f
Heart disease 282t, 388, 389–391, 389b. See also See also Coronary heart disease
Heberden’s node 518–519, 518f
Hematoma, subdural 574
2347
Hemiparesis 222t
Hemorrhoids 497–498
Hepatitis 500–502, 501t, 503–504
Hernia 488, 489f, 494f
Herpes zoster 613–615, 615b
Human immunodeficiency virus 19, 244–245, 251b, 274, 301
Hypercapnia 426, 433
Hyperglycemia, heart disease risk from 390–391
Hypertension 145b, 389–390, 391–396, 394t, 397
Hyperthermia 232–234
Hyperthyroidism 58t, 356, 467–469, 469t
Hypoglycemia 221b, 465t
Hypokalemia 353b
Hyponatremia 352
Hypotension 221b. See also See also Orthostatic hypotension
Hypothermia 232–234
Hypothyroidism 58t, 356, 469–470, 470t
Hypoxemia 426
I
Idiopathic thrombocytopenic purpura 273b
Impotence 248b, 304
Incontinence 156, 170–171, 483, 483b, 580t. See also See also Urinary incontinence
Infection 155, 172–173, 270–280, 275b, 276b, 277b, 313–314, 442–443, 467, 491. See also See also Urinary tract infection
Influenza 142t, 272–273, 282t, 433, 442–443
Insomnia 203, 207
Intertrigo 610
2348
Intussusception, from polyp 494f
J
Jaundice, identification of 609b
K
Keratosis 609–610, 615
Kyphosis 422
L
Liver disease 501t, 509
Lordosis 527f
Lung cancer 301–302, 438
Lung disease, restrictive 438–439
Lupus 273–274, 273b
M
Macular degeneration 646, 647–648
Melanoma 618, 619
Meniere’s disease 655
Mental retardation 594, 594b
Mesenteric occlusion 494f
Metabolic syndrome 458–459, 459t
Myasthenia gravis 273b
Myocardial infarction 58t, 401b
N
Nausea 314, 480
Neuralgia, postherpetic 614
Neuroleptic malignant syndrome 598
Neuropathy, peripheral 222t
Nocturia 541–542, 547b
2349
O
Obesity 390, 426
Onychauxis 537
Onychomycosis 537
Oral cancer 504
Orthostatic hypotension 404
Osteitis deformans. See Paget’s disease
Osteoarthritis 518–520, 518f, 519b, 523t
Osteomyelitis 531–532
Osteoporosis 142t, 221b, 223b, 223t, 470–471, 471t, 526–531, 527b, 527f, 529b, 530b
P
Paget’s disease 531
Pancreatic cancer 508, 509
Pancreatitis 354, 499–501
Parkinson’s disease 586–591, 587b
Periodontitis 483, 487
Peripheral artery occlusive disease 413–414, 414b, 415b
Peripheral vascular disease 389, 414, 415–417, 416t, 532–533
Petechiae, identification of 609b
Pneumonia 58t, 272–273, 277b, 282t, 444–447, 444t, 445t
Polymyalgia rheumatica 534, 535, 536
Polyp 494f, 497–498
Presbycusis 220, 652–653
Presbyopia 642
Pressure ulcer 621–636, 622f, 623f, 625f, 626f, 630b, 632b
Prostate cancer 245–246, 264b, 304, 557–559, 558b
2350
Prostatic hypertrophy. See Benign prostatic hypertrophy
Proteinuria 357
Pruritus 611–612, 650
Pseudohypertension 392
Psoriasis 610, 611
Pulmonary disease, restrictive 438–439
Pulmonary edema 447–449
Pulmonary embolus 449–450
Purpura 273b
R
Regurgitation, aortic and mitral 406b
Renal failure, hypertension's contribution to 389
Respiratory syncytial virus 443b
Retinopathy, diabetic 646, 647–648
Rheumatoid arthritis 273b, 274, 521–522, 522f, 523–525, 523f, 523t, 524t
S
Schizophrenia 593
Scleroderma 273b
Scoliosis 422
Severe acute respiratory syndrome 447
Sexual dysfunction 249b, 471–472, 473t
Sick sinus syndrome 402
Skin tag 610
Sleep apnea 207–209
Squamous cell carcinoma, of skin 617
Stenosis 406, 406b, 520–521, 521f
2351
Stomatitis 278b
Stroke. See Cerebrovascular accident
Swan-neck deformity 523f
Syncope, with cardiac causes 405
Systemic lupus erythematosus 273–274, 273b
T
Tardive dyskinesia 598
Thrush 483
Tinnitus 651–652, 651b, 652b
Tophaceous gout 525f
Trichinosis 492–493
Tuberculosis 440–442, 442t
Tumor 311t, 574
U
Ulcer 466, 467b, 490, 491–492, 491f, 619–621, 619t. See also See also Pressure ulcer
Ulcerative colitis 273b
Urinary incontinence 36, 338, 541, 542–549
Urinary tract infection 58t, 221b, 359b, 553–555
V
Valvular disease 406–408, 406b
Varicose veins 414
Venous insufficiency 416t
Vertigo 655
Volvulus, of sigmoid colon 494f
Vomiting 314, 480, 480f
2352
Table of Contents
Table of Contents 3 Copyright 16 Dedication 19 About the Author 20 Contributors and Reviewers 23 Preface 26
Organization 28 Format 31 Features 32
Acknowledgments 33 Part 1: Introduction to Gerontologic Nursing 34
Chapter 1: Overview of Gerontologic Nursing 35 Foundations of the specialty of gerontologic nursing 38 Demographic profile of the older population 48 Health status of older adults 58 Impact of an aging population on gerontologic nursing 67 Summary 76 Key points 77 Critical thinking exercises 79
Chapter 2: Theories of aging 84 Biologic theories of aging 88 Sociologic theories of aging 105 Psychologic Theories of Aging 112 Moral and spiritual development 121 Summary 122 Key points 123 Critical thinking exercises 124
Chapter 3: Legal and ethical issues 129 Professional standards: their origin and legal significance 132 Overview of relevant laws 134
2353
Elder abuse and protective services 138 Nursing facility reform 143 Autonomy and self-determination 158 The patient self-determination act 172 Values history 179 Nurses’ ethical code and end-of-life care 181 Summary 190 Key points 191 Critical thinking exercises 193 Appendix 3A Values History Form 199 Section 1 200 Section 2 204 Optional Questions 212 Suggestions for Use 213
Chapter 4: Gerontologic Assessment 215 Special considerations affecting assessment 220 Interrelationship between physical and psychosocial aspects of aging
221
Nature of disease and disability and their effects on functional status
223
Tailoring the nursing assessment to the older person 233 The health history 236 Additional assessment measures 263 Laboratory data 283 Summary 284 Key points 285 Critical thinking exercises 287
Part 2: Influences on Health and Illness 291 Chapter 5: Cultural Influences 292
Diversity of the older adult population in the united states 294 Culturally sensitive gerontologic nursing care 299 Skills 321 Putting it together 324 Summary 329
2354
Key points 330 Critical thinking exercises 331
Chapter 6: Family Influences 335 Role and function of families 338 Common late-life family issues and decisions 343 Interventions to support family caregivers 364 Working with families of older adults: considerations and strategies
380
Summary 400 Key points 401 Critical thinking exercises 403
Chapter 7: Socioeconomic and Environmental Influences 409 Socioeconomic factors 413 Environmental influences 439 Advocacy 456 Summary 459 Key points 460 Critical thinking exercises 462 Appendix 7A Resources 469 Organizations of Professionals Working in the Field of Aging
470
Organizations of Both Professionals and Older Adults 472 Chapter 8: Health Promotion and Illness/Disability Prevention 473
Essentials of health promotion for aging adults 475 Models of health promotion 480 Barriers to health promotion and disease prevention 482 Health protection 485 Disease prevention 486 The nurse’s role in health promotion and disease prevention 490 Supporting empowerment of older adults 505 Summary 507 Key points 509 Critical thinking exercises 510
Chapter 9: Health care delivery settings and older adults 518
2355
Characteristics of older adults in acute care 522 Characteristics of the acute care environment 523 Nursing in the acute care setting 529 Home care and hospice 535 Factors affecting the health care needs of noninstitutionalized older adults
537
Community-based services 541 Home health care 548 Continuity of care 554 Implementing the plan of treatment 559 Oasis 563 Hospice 564 Overview of long-term care 570 Clinical aspects of the nursing facility 575 Management aspects of the nursing facility 589 Specialty care settings 593 Innovations in the nursing facility 596 The future of the nursing facility 602 Summary 603 Key points 605 Critical thinking exercises 608
Part 3: Wellness Issues 616 Chapter 10: Nutrition 617
Social and cultural aspects of food 619 Demographics of the aging population 626 Physiologic changes in aging that affect nutritional status 629 Psychosocial and socioeconomic factors related to malnutrition
633
Nutritional screening and assessment 635 Nutritional guidelines for all ages 647 Drug–nutrient interactions 656 Nursing diagnoses associated with nutritional problems 659 Specialized nutritional support 662 Failure to thrive 664
2356
Summary 665 Key points 668 Critical thinking exercises 669
Chapter 11: Sleep and Activity 675 Sleep and older adults 678 Activity and older adults 708 Summary 719 Key points 720 Critical thinking exercises 722
Chapter 12: Safety 727 Falls 730 Nursing management of falls 757 Safety and the home environment 763 Seasonal safety issues 774 Disasters 781 Storage of medications and health care supplies in the home 782 Living alone 784 Automobile Safety 785 Abuse and neglect 789 Firearms 792 Summary 794 Key points 795 Critical thinking exercises 797
Chapter 13: Sexuality and Aging 805 Older adult needs for sexualality and intimacy 807 The importance of intimacy among older adults 809 Nursing’s reluctance to manage the sexuality of older adults 812 Normal changes of the aging sexual response 814 Physiologic changes 815 Pathologic conditions affecting older adults’ sexual responses
818
Environmental and psychosocial barriers to sexual practice 825 Alternative sexual practice among older adults 827 Nursing management 829
2357
Summary 847 Key points 848 Critical thinking exercises 849
Part 4: Common Psychophysiologic Stressors 854 Chapter 14: Pain 855
Understanding pain 858 Pathophysiology of pain in older adults 864 Barriers to effective pain management in older adults 866 Pain assessment 870 Nursing care of older adults with pain 877 Summary 892 key Points 896 Critical thinking exercises 898
Chapter 15: Infection 903 Learning objectives 905 The chain of infection 907 Age-related changes in the immune system 909 Factors affecting immunocompetence 912 Common problems and conditions 915 Human immunodefiency virus infection in older adults 920 Significant nosocomial pathogens 921 Nursing management 923 Summary 937 Key points 939 Critical thinking exercises 940
Chapter 16: Chronic Illness and Rehabilitation 943 Chronicity 945 Rehabilitation 970 Summary 983 Key points 984 Critical thinking exercise 985 Appendix 16A Resources 992
Chapter 17: Cancer 995 Incidence 998
2358
Aging and its relationship to cancer 1004 Common malignancies in older adults 1011 Screening and early detection: issues for older adults 1026 Major treatment modalities 1035 Common physiologic complications 1046 Older adults’ experience of cancer 1057 Summary 1069 Key points 1071 Critical thinking exercises 1073
Chapter 18: Loss and End-of-Life Issues 1083 Definitions 1086 Losses 1087 Mourning 1098 Approaching death: older persons’ perspectives 1109 Summary 1131 Key points 1132 Critical thinking exercises 1134
Part 5: Diagnostic Studies and Pharmacologic Management
1143
Chapter 19: Laboratory and Diagnostic Tests 1144 Components of hematologic testing 1148 Components of blood chemistry testing 1158 Components of urine chemistry testing 1175 Components of arterial blood gas testing 1178 Blood level monitoring 1183 Summary 1184 Key points 1186 Critical thinking exercises 1187
Chapter 20: Pharmacologic Management 1193 Overview of medication use and problems 1196 Commonly used medications 1212 Medication adherence 1225 Substance abuse 1231 Definitions and common usage 1233
2359
Assessment 1237 Nursing diagnoses 1245 Nursing management 1246 Commonly abused substances in older adults 1248 Future trends 1260 Summary 1262 Key points 1263 Critical thinking exercises 1265
Part 6: Nursing Care of Physiologic and Psychologic Disorders
1275
Chapter 21: Cardiovascular Function 1276 Age-related changes in structure and function 1279 Common cardiovascular problems 1281 Nursing management 1299 Nursing management 1310 Nursing management 1322 Nursing management 1327 Nursing management 1331 Nursing management 1337 Nursing management 1349 Nursing management 1361 Nursing management 1369 Nursing management 1374 Summary 1378 Key points 1380 Critical thinking exercises 1382
Chapter 22: Respiratory Function 1390 Age-related changes in structure and function 1393 Factors affecting lung function 1399 Respiratory symptoms common in older patients 1404 Respiratory alterations in older patients 1407 Obstructive pulmonary disease 1409 Nursing management 1415 Nursing management 1428
2360
Restrictive pulmonary disease 1445 Nursing management 1448 Nursing management 1455 Bronchopulmonary infection 1458 Nursing management 1460 Nursing management 1468 Other respiratory alterations 1472 Nursing management 1476 Nursing management 1482 Nursing management 1487 Summary 1490 Key points 1492 Critical thinking exercises 1493
Chapter 23: Endocrine Function 1500 Endocrine physiology in older adults 1503 Common endocrine pathophysiology in older adults 1510 Nursing management 1519 Nursing management 1541 Nursing management 1545 Nursing management 1548 Nursing management 1553 Summary 1554 Key points 1556 Critical thinking exercises 1558
Chapter 24: Gastrointestinal Function 1568 Age-related changes in structure and function 1571 Prevention 1576 Common gastrointestinal symptoms 1578 Common diseases of the gastrointestinal tract 1589 Nursing management 1594 Nursing management 1597 Nursing management 1602 Nursing management 1607 Nursing management 1612
2361
Nursing management 1616 Nursing management 1621 Nursing management 1628 Nursing management 1631 Nursing management 1633 Disorders of the accessory organs 1635 Nursing management 1637 Nursing management 1640 Nursing management 1645 Nursing management 1650 Nursing management 1654 Gastrointestinal cancers 1656 Nursing management 1658 Nursing management 1664 Nursing management 1668 Nursing management 1671 Summary 1675 Key points 1676 Critical thinking exercises 1678
Chapter 25: Musculoskeletal Function 1682 Age-related changes in structure and function 1685 Common problems and conditions of the musculoskeletal system
1688
Nursing management 1695 Nursing management 1710 Nursing management 1718 Nursing management 1724 Nursing management 1731 Nursing management 1743 Nursing management 1750 Nursing management 1753 Nursing management 1756 Nursing management 1762 Foot problems 1768
2362
Muscle cramps 1775 Summary 1776 Key points 1778 Critical thinking exercises 1779
Chapter 26: Urinary Function 1787 Age-related changes in structure and function 1790 Prevalence of urinary incontinence 1792 Common problems and conditions 1793 Nursing management 1798 Age-related renal changes 1817 Common problems and conditions 1822 Nursing management 1829 Nursing management 1839 Nursing management 1842 Nursing management 1845 Nursing management 1850 Summary 1854 Key points 1855 Critical thinking exercises 1857
Chapter 27: Cognitive and Neurologic Function 1863 Structural age-related changes of the neurologic system 1866 Assessment of cognitive function 1877 Cognitive disorders associated with altered thought processes
1881
Diagnostic assessment of altered thought processes 1903 Treatment of altered thought processes 1906 Nursing management 1911 Challenges in the care of older adults with cognitive disorders
1925
Other common problems and conditions 1931 Nursing management 1935 Nursing management 1946 Nursing management 1956 Nursing management 1961
2363
Nursing management 1964 Nursing management 1968 Nursing management 1971 Medication management 1973 Mental health care resources 1982 Trends and needs 1986 Summary 1988 Key points 1990 Critical thinking questions 1995 Appendix 27A Resources 2005
Chapter 28: Integumentary Function 2009 Age-related changes in skin structure and function 2012 Common problems and conditions 2019 Nursing management 2023 Nursing management 2027 Nursing management 2031 Nursing management 2036 Premalignant skin growths: actinic keratosis 2041 Nursing management 2042 Malignant skin growths 2044 Nursing management 2045 Nursing management 2048 Nursing management 2053 Lower extremity ulcers 2056 Nursing management 2061 Pressure ulcers 2063 Summary 2109 Key points 2111 Critical thinking exercises 2113
Chapter 29: Sensory Function 2119 Vision 2122 Nursing management 2131 Nursing management 2135 Nursing management 2143
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Nursing management 2149 Hearing and balance 2156 Nursing management 2159 Nursing management 2163 Nursing management 2170 Nursing management 2178 Taste and smell 2181 Nursing management 2183 Touch 2186 Summary 2187 Key points 2188 Critical thinking exercises 2189
Index 2193 Disorders Index 2344
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- Table of Contents
- Copyright
- Dedication
- About the Author
- Contributors and Reviewers
- Preface
- Organization
- Format
- Features
- Acknowledgments
- Part 1: Introduction to Gerontologic Nursing
- Chapter 1: Overview of Gerontologic Nursing
- Foundations of the specialty of gerontologic nursing
- Demographic profile of the older population
- Health status of older adults
- Impact of an aging population on gerontologic nursing
- Summary
- Key points
- Critical thinking exercises
- Chapter 2: Theories of aging
- Biologic theories of aging
- Sociologic theories of aging
- Psychologic Theories of Aging
- Moral and spiritual development
- Summary
- Key points
- Critical thinking exercises
- Chapter 3: Legal and ethical issues
- Professional standards: their origin and legal significance
- Overview of relevant laws
- Elder abuse and protective services
- Nursing facility reform
- Autonomy and self-determination
- The patient self-determination act
- Values history
- Nurses’ ethical code and end-of-life care
- Summary
- Key points
- Critical thinking exercises
- Appendix 3A Values History Form
- Section 1
- Section 2
- Optional Questions
- Suggestions for Use
- Chapter 4: Gerontologic Assessment
- Special considerations affecting assessment
- Interrelationship between physical and psychosocial aspects of aging
- Nature of disease and disability and their effects on functional status
- Tailoring the nursing assessment to the older person
- The health history
- Additional assessment measures
- Laboratory data
- Summary
- Key points
- Critical thinking exercises
- Part 2: Influences on Health and Illness
- Chapter 5: Cultural Influences
- Diversity of the older adult population in the united states
- Culturally sensitive gerontologic nursing care
- Skills
- Putting it together
- Summary
- Key points
- Critical thinking exercises
- Chapter 6: Family Influences
- Role and function of families
- Common late-life family issues and decisions
- Interventions to support family caregivers
- Working with families of older adults: considerations and strategies
- Summary
- Key points
- Critical thinking exercises
- Chapter 7: Socioeconomic and Environmental Influences
- Socioeconomic factors
- Environmental influences
- Advocacy
- Summary
- Key points
- Critical thinking exercises
- Appendix 7A Resources
- Organizations of Professionals Working in the Field of Aging
- Organizations of Both Professionals and Older Adults
- Chapter 8: Health Promotion and Illness/Disability Prevention
- Essentials of health promotion for aging adults
- Models of health promotion
- Barriers to health promotion and disease prevention
- Health protection
- Disease prevention
- The nurse’s role in health promotion and disease prevention
- Supporting empowerment of older adults
- Summary
- Key points
- Critical thinking exercises
- Chapter 9: Health care delivery settings and older adults
- Characteristics of older adults in acute care
- Characteristics of the acute care environment
- Nursing in the acute care setting
- Home care and hospice
- Factors affecting the health care needs of noninstitutionalized older adults
- Community-based services
- Home health care
- Continuity of care
- Implementing the plan of treatment
- Oasis
- Hospice
- Overview of long-term care
- Clinical aspects of the nursing facility
- Management aspects of the nursing facility
- Specialty care settings
- Innovations in the nursing facility
- The future of the nursing facility
- Summary
- Key points
- Critical thinking exercises
- Part 3: Wellness Issues
- Chapter 10: Nutrition
- Social and cultural aspects of food
- Demographics of the aging population
- Physiologic changes in aging that affect nutritional status
- Psychosocial and socioeconomic factors related to malnutrition
- Nutritional screening and assessment
- Nutritional guidelines for all ages
- Drug–nutrient interactions
- Nursing diagnoses associated with nutritional problems
- Specialized nutritional support
- Failure to thrive
- Summary
- Key points
- Critical thinking exercises
- Chapter 11: Sleep and Activity
- Sleep and older adults
- Activity and older adults
- Summary
- Key points
- Critical thinking exercises
- Chapter 12: Safety
- Falls
- Nursing management of falls
- Safety and the home environment
- Seasonal safety issues
- Disasters
- Storage of medications and health care supplies in the home
- Living alone
- Automobile Safety
- Abuse and neglect
- Firearms
- Summary
- Key points
- Critical thinking exercises
- Chapter 13: Sexuality and Aging
- Older adult needs for sexualality and intimacy
- The importance of intimacy among older adults
- Nursing’s reluctance to manage the sexuality of older adults
- Normal changes of the aging sexual response
- Physiologic changes
- Pathologic conditions affecting older adults’ sexual responses
- Environmental and psychosocial barriers to sexual practice
- Alternative sexual practice among older adults
- Nursing management
- Summary
- Key points
- Critical thinking exercises
- Part 4: Common Psychophysiologic Stressors
- Chapter 14: Pain
- Understanding pain
- Pathophysiology of pain in older adults
- Barriers to effective pain management in older adults
- Pain assessment
- Nursing care of older adults with pain
- Summary
- key Points
- Critical thinking exercises
- Chapter 15: Infection
- Learning objectives
- The chain of infection
- Age-related changes in the immune system
- Factors affecting immunocompetence
- Common problems and conditions
- Human immunodefiency virus infection in older adults
- Significant nosocomial pathogens
- Nursing management
- Summary
- Key points
- Critical thinking exercises
- Chapter 16: Chronic Illness and Rehabilitation
- Chronicity
- Rehabilitation
- Summary
- Key points
- Critical thinking exercise
- Appendix 16A Resources
- Chapter 17: Cancer
- Incidence
- Aging and its relationship to cancer
- Common malignancies in older adults
- Screening and early detection: issues for older adults
- Major treatment modalities
- Common physiologic complications
- Older adults’ experience of cancer
- Summary
- Key points
- Critical thinking exercises
- Chapter 18: Loss and End-of-Life Issues
- Definitions
- Losses
- Mourning
- Approaching death: older persons’ perspectives
- Summary
- Key points
- Critical thinking exercises
- Part 5: Diagnostic Studies and Pharmacologic Management
- Chapter 19: Laboratory and Diagnostic Tests
- Components of hematologic testing
- Components of blood chemistry testing
- Components of urine chemistry testing
- Components of arterial blood gas testing
- Blood level monitoring
- Summary
- Key points
- Critical thinking exercises
- Chapter 20: Pharmacologic Management
- Overview of medication use and problems
- Commonly used medications
- Medication adherence
- Substance abuse
- Definitions and common usage
- Assessment
- Nursing diagnoses
- Nursing management
- Commonly abused substances in older adults
- Future trends
- Summary
- Key points
- Critical thinking exercises
- Part 6: Nursing Care of Physiologic and Psychologic Disorders
- Chapter 21: Cardiovascular Function
- Age-related changes in structure and function
- Common cardiovascular problems
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Summary
- Key points
- Critical thinking exercises
- Chapter 22: Respiratory Function
- Age-related changes in structure and function
- Factors affecting lung function
- Respiratory symptoms common in older patients
- Respiratory alterations in older patients
- Obstructive pulmonary disease
- Nursing management
- Nursing management
- Restrictive pulmonary disease
- Nursing management
- Nursing management
- Bronchopulmonary infection
- Nursing management
- Nursing management
- Other respiratory alterations
- Nursing management
- Nursing management
- Nursing management
- Summary
- Key points
- Critical thinking exercises
- Chapter 23: Endocrine Function
- Endocrine physiology in older adults
- Common endocrine pathophysiology in older adults
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Summary
- Key points
- Critical thinking exercises
- Chapter 24: Gastrointestinal Function
- Age-related changes in structure and function
- Prevention
- Common gastrointestinal symptoms
- Common diseases of the gastrointestinal tract
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Disorders of the accessory organs
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Gastrointestinal cancers
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Summary
- Key points
- Critical thinking exercises
- Chapter 25: Musculoskeletal Function
- Age-related changes in structure and function
- Common problems and conditions of the musculoskeletal system
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Foot problems
- Muscle cramps
- Summary
- Key points
- Critical thinking exercises
- Chapter 26: Urinary Function
- Age-related changes in structure and function
- Prevalence of urinary incontinence
- Common problems and conditions
- Nursing management
- Age-related renal changes
- Common problems and conditions
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Summary
- Key points
- Critical thinking exercises
- Chapter 27: Cognitive and Neurologic Function
- Structural age-related changes of the neurologic system
- Assessment of cognitive function
- Cognitive disorders associated with altered thought processes
- Diagnostic assessment of altered thought processes
- Treatment of altered thought processes
- Nursing management
- Challenges in the care of older adults with cognitive disorders
- Other common problems and conditions
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Medication management
- Mental health care resources
- Trends and needs
- Summary
- Key points
- Critical thinking questions
- Appendix 27A Resources
- Chapter 28: Integumentary Function
- Age-related changes in skin structure and function
- Common problems and conditions
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Premalignant skin growths: actinic keratosis
- Nursing management
- Malignant skin growths
- Nursing management
- Nursing management
- Nursing management
- Lower extremity ulcers
- Nursing management
- Pressure ulcers
- Summary
- Key points
- Critical thinking exercises
- Chapter 29: Sensory Function
- Vision
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Hearing and balance
- Nursing management
- Nursing management
- Nursing management
- Nursing management
- Taste and smell
- Nursing management
- Touch
- Summary
- Key points
- Critical thinking exercises
- Index
- Disorders Index
