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SueE.Meiner-GerontologicNursing-Mosby2014.pdf

Gerontologic Nursing

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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

3251 Riverport Lane Maryland Heights, Missouri 63043

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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 definitions and defining characteristics of the diagnoses listed in this work.

The Publisher

Library of Congress Cataloging-in-Publication Data Gerontologic nursing (Lueckenotte) Gerontologic nursing / [edited by] Sue E. Meiner. – Fifth edition. 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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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

http://www.elsevier.com/permissions

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.

Sue E. Meiner

A B O U T T H E A U T H O R

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 pro- grams in the Midwest. She graduated from the second class of 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 cer- tifications 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 counsel- ing 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 nurs- ing, 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 advo- cacy of both nurses and patients and their families by serv- ing 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 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.

vii

C O N T R I B U T O R S A N D R E V I E W E R S

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

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, 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

viii CONTRIBUTORS AND REVIEWERS

P R E FA C E

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 text- book provides comprehensive, theoretic, and practical informa- tion 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 emphasiz- ing the concepts, skills, and techniques of gerontologic nurs- ing 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 content throughout the educational program.

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 rel- evant 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 assess- ment, special considerations affecting assessment of older people, and strategies and techniques for collecting a compre- hensive 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 influ- ences. 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 availabil- ity. 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 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, screen- ings 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 func- tion 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 reha- bilitation in aging, as well as the related concepts of compli- ance, 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 occur- ring 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 phar- macologic management. Principles of laboratory testing in older adults, including age-related factors that influence labo- ratory 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 manage- ment of older adults with diseases or conditions of cardiovas- cular, 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.

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 con- ditions within each of the chapters are presented in a format that includes the definition, etiology, pathophysiology, and typ- ical 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 con- ditions 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.

FEATURES Each chapter begins with Learning Objectives to help the stu- dent 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 pre- vent 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 find- ings 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 appli- cable 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 dis- cussed 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.

Sue E. Meiner

x PREFACE

The development of this fifth edition would not have been possible without the combined efforts of many talented profes- sionals 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.

Sue E. Meiner

A C K N O W L E D G M E N T S

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xiii

PA R T 1 Introduction to Gerontologic Nursing

1 Overview of Gerontologic Nursing, 1 FOUNDATIONS OF THE SPECIALTY OF GERONTOLOGIC NURSING, 1

History and Evolution, 1 Professional Origins, 2 Standards of Practice, 2 Roles, 3 Terminology, 4

DEMOGRAPHIC PROFILE OF THE OLDER POPULATION, 4

The Older Population, 5 Highlights of the Profile of Older Americans, 5 Gender and Marital Status, 6 Race and Ethnicity, 6 Living Arrangements, 6 Geographic Distribution, 6 Education, 7 Income and Poverty, 7 Employment, 7

HEALTH STATUS OF OLDER ADULTS, 8 Self-Assessed Health and Chronic Disease, 8 Functional Status, 8 Health Care Expenditure and Use, 9 Implications for Health Care Delivery, 9 Acute Care Setting, 9 Nursing Facilities, 10 Home Care, 10 Continuum of Care, 10

IMPACT OF AN AGING POPULATION ON GERONTOLOGIC NURSING, 11

Ageism, 11 Nursing Education, 11 Nursing Practice, 12 Nursing Research, 13

SUMMARY, 13

REFERENCES, 14

2 Theories of Aging, 16 BIOLOGIC THEORIES OF AGING, 17

Stochastic Theories, 17 Nonstochastic Theories, 19 Emerging Theories, 19 Implications for Nursing, 20

SOCIOLOGIC THEORIES OF AGING, 22 Disengagement Theory, 22

Activity Theory or Developmental Task Theory, 22 Continuity Theory, 23 Age Stratification Theory, 23 Person–Environment Fit Theory, 23 Implications for Nursing, 23

PSYCHOLOGIC THEORIES OF AGING, 24 Maslow’s Hierarchy of Human Needs, 24 Jung’s Theory of Individualism, 25 Eight Stages of Life, 25 Selective Optimization with Compensation, 26 Implications for Nursing, 26

MORAL AND SPIRITUAL DEVELOPMENT, 27

SUMMARY, 27

REFERENCES, 28

3 Legal and Ethical Issues, 29 PROFESSIONAL STANDARDS: THEIR ORIGIN AND LEGAL SIGNIFICANCE, 29

OVERVIEW OF RELEVANT LAWS, 30 Sources of Law, 30 Federal and State Laws, 30 Health Insurance Portability and Accountability Act of 1996 (HIPAA), 31

ELDER ABUSE AND PROTECTIVE SERVICES, 31

NURSING FACILITY REFORM, 33 OBRA’s Three Major Parts, 33 Provision of Service Requirements, 33 Proposed Legislative Changes, 37

AUTONOMY AND SELF-DETERMINATION, 37 Do Not Resuscitate Orders, 38 Advance Medical Directives, 39 Legal Tools, 39 Decision Diagram, 40 Conflicts between Directives and Family Desires, 41

THE PATIENT SELF-DETERMINATION ACT, 42 Background: The Cruzan Case, 42 Clear and Convincing Proof, 42 The Four Significant Provisions of the PSDA, 43 Nurses’ Responsibilities, 43 Problems and Ethical Dilemmas Associated with Implementation of the PSDA, 43

VALUES HISTORY, 44

NURSES’ ETHICAL CODE AND END-OF-LIFE CARE, 44 Ethical Dilemmas and Considerations, 45 Experimentation and Research, 46 Organ Donation, 46 Ethics Committees, 46

C O N T E N T S

xiv CONTENTS

SUMMARY, 47

REFERENCES, 48 APPENDIX 3A, 50 Values History Form, 50

SECTION 1, 50 A. Written Legal Documents, 50 B. Wishes Concerning Specific Medical

Procedures, 50 C. General Comments, 51

SECTION 2, 51 A. Your Overall Attitude toward Your Health, 51 B. Your Perception of the Role of Your Doctor and

Other Health Caregivers, 51 C. Your Thoughts about Independence and

Control, 51 D. Your Personal Relationships, 52 E. Your Overall Attitude toward Life, 52 F. Your Attitude toward Illness, Dying, and

Death, 52 G. Your Religious Background and Beliefs, 52 H. Your Living Environment, 53 I. Your Attitude Concerning Finances, 53 J. Your Wishes Concerning Your Funeral, 53

OPTIONAL QUESTIONS, 53

SUGGESTIONS FOR USE, 53

4 Gerontologic Assessment, 54 SPECIAL CONSIDERATIONS AFFECTING ASSESSMENT, 55

INTERRELATIONSHIP BETWEEN PHYSICAL AND PSYCHOSOCIAL ASPECTS OF AGING, 55

NATURE OF DISEASE AND DISABILITY AND THEIR EFFECTS ON FUNCTIONAL STATUS, 56

Decreased Efficiency of Homeostatic Mechanisms, 56 Lack of Standards for Health and Illness Norms, 56 Altered Presentation of and Response to Specific Diseases, 57

TAILORING THE NURSING ASSESSMENT TO THE OLDER PERSON, 59

THE HEALTH HISTORY, 60 The Interviewer, 60 The Patient, 65 The Health History Format, 66 The Physical Assessment Approach and Sequence, 70 Equipment and Skills, 71

ADDITIONAL ASSESSMENT MEASURES, 71 Functional Status Assessment, 71 Cognitive or Affective Assessment, 75 Social Assessment, 78

LABORATORY DATA, 80

SUMMARY, 80

REFERENCES, 81

PA R T 2 Influences on Health and Illness

5 Cultural Influences, 83 DIVERSITY OF THE OLDER ADULT POPULATION IN THE UNITED STATES, 83

CULTURALLY SENSITIVE GERONTOLOGIC NURSING CARE, 84

Awareness, 86 Knowledge, 86 Cultural Concepts, 86 Beliefs about Health and Illness, 89 Transcending Cultural Concepts, 91

SKILLS, 92 Handshake, 92 Eye Contact, 93 Interpreters, 93

PUTTING IT TOGETHER, 93 Leininger, 93 The Explanatory Model, 94 The LEARN Model, 95

SUMMARY, 95

REFERENCES, 96

6 Family Influences, 97 ROLE AND FUNCTION OF FAMILIES, 97

COMMON LATE-LIFE FAMILY ISSUES AND DECISIONS, 99

Changes in Living Arrangements, 99 Making a Decision About a Care Facility, 100 Financial and Legal Concerns, 101 End-of-Life Health Care Decisions, 102 The Issue of Driving, 103 Family Caregiving, 103

INTERVENTIONS TO SUPPORT FAMILY CAREGIVERS, 106 Education, 106 Respite Programs, 107 Support Groups, 108 Family Meetings, 110

WORKING WITH FAMILIES OF OLDER ADULTS: CONSIDERATIONS AND STRATEGIES, 110

Identifying Who the Patient Is and Who the Family Is, 110 Assessing the Family, 111 Encouraging Families to Plan in Advance of Need, 113 Involving the Older Person in Decision Making, 114 Validating Feelings, 114 Addressing Feelings of Guilt, 115 Emphasizing Goodness of Intent of Actions, 115 Recognizing the Nurse’s Role as Permission Giver, 115 Recommending a Decision-Making Model to Families, 116

SUMMARY, 117

REFERENCES, 118

CONTENTS xv

7 Socioeconomic and Environmental Influences, 120 SOCIOECONOMIC FACTORS, 121

Age Cohorts, 121 Income Sources, 121 Poverty, 123 Education, 124 Health Status, 125 Insurance Coverage, 125 Support Systems, 126 Benefits and Entitlements, 127 Area Agencies on Aging, 128 Conservators and Guardians, 128

ENVIRONMENTAL INFLUENCES, 128 Geographic Location of Residence, 129 Transportation, 129 Housing, 129 Criminal Victimization, 132

ADVOCACY, 134

SUMMARY, 135

REFERENCES, 136

RESOURCES, 138

ORGANIZATIONS OF OLDER ADULTS, 138

ORGANIZATIONS OF PROFESSIONALS WORKING IN THE FIELD OF AGING, 138

ORGANIZATIONS OF BOTH PROFESSIONALS AND OLDER ADULTS, 138

8 Health Promotion and Illness/ Disability Prevention, 139 ESSENTIALS OF HEALTH PROMOTION FOR AGING ADULTS, 139

Terminology, 140

MODELS OF HEALTH PROMOTION, 141

BARRIERS TO HEALTH PROMOTION AND DISEASE PREVENTION, 141

Health Care Professionals’ Barriers to Health Promotion, 141 Older Adults’ Barriers to Health Promotion, 141

HEALTH PROTECTION, 142

DISEASE PREVENTION, 142 Primary Preventive Measures, 142 Secondary Preventive Measures, 143 Tertiary Preventive Measures, 144

THE NURSE’S ROLE IN HEALTH PROMOTION AND DISEASE PREVENTION, 145

Requisite Knowledge, 145 Assessment, 146 Self-Perception or Self-Concept Pattern, 146 Roles or Relationships Pattern, 146 Health Perception or Health Management Pattern, 146 Nutritional or Metabolic Pattern, 147

Coping or Stress-Tolerance Pattern, 147 Cognitive or Perceptual Pattern, 147 Value or Belief Pattern, 147 Activity or Exercise Pattern, 148 Rest or Sleep Pattern, 148 Sexuality or Reproductive Pattern, 148 Elimination Pattern, 148 Planning, 148 Implementation, 148 Evaluation, 149

SUPPORTING EMPOWERMENT OF OLDER ADULTS, 149

SUMMARY, 150

REFERENCES, 151

WEBSITES, 152

9 Health Care Delivery Settings and Older Adults, 153 CHARACTERISTICS OF OLDER ADULTS IN ACUTE CARE, 154

CHARACTERISTICS OF THE ACUTE CARE ENVIRONMENT, 154

Philosophy of Care, 154 Risks of Hospitalization, 154 Safety Features, 155

NURSING IN THE ACUTE CARE SETTING, 155 Nursing-Specific Competency and Expertise, 156 Critical Care and Trauma Care, 156

HOME CARE AND HOSPICE, 157

FACTORS AFFECTING THE HEALTH CARE NEEDS OF NONINSTITUTIONALIZED OLDER ADULTS, 158

Functional Status, 158 Cognitive Function, 158 Housing Options for Older Adults, 158

COMMUNITY-BASED SERVICES, 159 Use of Community and Home-Based Services by Older Adults, 159 Profile of Community- and Home-Based Services, 160

HOME HEALTH CARE, 162 Home Health Agency, 162 Proprietary Agencies, 162 Facility-Based Agencies, 162 Visiting Nurse Associations, 163 Benefits of Home Care, 163

CONTINUITY OF CARE, 163 Role of the Home Care Agency, 164

IMPLEMENTING THE PLAN OF TREATMENT, 165 The Nurse’s Role, 165 Role of the Home Health Aide, 165

OASIS, 166

HOSPICE, 166 Hospice Philosophy, 166

xvi CONTENTS

OVERVIEW OF LONG-TERM CARE, 167 Definition, 167 Factors Associated with Institutionalization, 168 Medical and Psychosocial Models of Care, 168

CLINICAL ASPECTS OF THE NURSING FACILITY, 169 Resident Rights, 169 Resident Assessment, 169 Skin Care, 170 Incontinence, 170 Nutrition, 171 Medications, 171 Rehabilitation, 172 Infection Control, 172 Mental Health, 173 End-of-Life Care, 173

MANAGEMENT ASPECTS OF THE NURSING FACILITY, 173

The Nursing Department, 173 Nursing Care Delivery Systems, 174

SPECIALTY CARE SETTINGS, 174 Assisted Living Programs, 174 Special Care Units, 175 Subacute Care, 175

INNOVATIONS IN THE NURSING FACILITY, 175 Creativity in "Everyday" Nursing Facilities, 175 Nurse Practitioners in the Nursing Facility, 177

THE FUTURE OF THE NURSING FACILITY, 177

SUMMARY, 177

REFERENCES, 179

PA R T 3

Wellness Issues

10 Nutrition, 181 SOCIAL AND CULTURAL ASPECTS OF FOOD, 181

DEMOGRAPHICS OF THE AGING POPULATION, 183

PHYSIOLOGIC CHANGES IN AGING THAT AFFECT NUTRITIONAL STATUS, 184

PSYCHOSOCIAL AND SOCIOECONOMIC FACTORS RELATED TO MALNUTRITION, 185

NUTRITIONAL SCREENING AND ASSESSMENT, 185 Nutritional Screening, 185 Nutritional Assessment, 190

NUTRITIONAL GUIDELINES FOR ALL AGES, 192 Dietary Reference Intakes, 193 Food Labeling, 193

DRUG–NUTRIENT INTERACTIONS, 195

NURSING DIAGNOSES ASSOCIATED WITH NUTRITIONAL PROBLEMS, 195

SPECIALIZED NUTRITIONAL SUPPORT, 196

FAILURE TO THRIVE, 198

SUMMARY, 199

REFERENCES, 200

11 Sleep and Activity, 202 SLEEP AND OLDER ADULTS, 202

Biologic Brain Functions Responsible for Sleep, 202 Stages of Sleep, 202 Sleep and Circadian Rhythm, 203 Insomnia, 203 Age-Related Changes in Sleep, 203 Factors Affecting Sleep, 204 Lifestyle Changes, 205 Sleep Disorders and Conditions, 207 Getting a Good Night’s Sleep, 209

ACTIVITY AND OLDER ADULTS, 211 Activities of Daily Living, 211 Physical Exercise, 211 Activity as Affected by Lifestyle Changes, 213 Activity Affected by Alzheimer Disease and Other Dementias, 214

SUMMARY, 216

REFERENCES, 216

12 Safety, 218 FALLS, 218

Overview and Magnitude of the Problem, 218 Definition of Falling, 219 Meaning of Falling to Older Adults, 220 Normal Age-Related Changes Contributing to Falling, 220 Fall Risk, 221 Fall Antecedents and Fall Classification, 224 Fall Consequences, 224 Evaluation of Patients Who Fall, 226

NURSING MANAGEMENT OF FALLS, 227

SAFETY AND THE HOME ENVIRONMENT, 228 Burn Injuries in the Home, 229 Other Injuries in the Home, 230 Foodborne Illnesses, 231

SEASONAL SAFETY ISSUES, 232 Hypothermia and Hyperthermia in Older Adults, 232

DISASTERS, 234

STORAGE OF MEDICATIONS AND HEALTH CARE SUPPLIES IN THE HOME, 234

LIVING ALONE, 234

AUTOMOBILE SAFETY, 234

ABUSE AND NEGLECT, 236

FIREARMS, 236

CONTENTS xvii

SUMMARY, 237

REFERENCES, 238

13 Sexuality and Aging, 241 OLDER ADULT NEEDS FOR SEXUALALITY AND INTIMACY, 241

THE IMPORTANCE OF INTIMACY AMONG OLDER ADULTS, 241

NURSING’S RELUCTANCE TO MANAGE THE SEXUALITY OF OLDER ADULTS, 242

NORMAL CHANGES OF THE AGING SEXUAL RESPONSE, 243

PHYSIOLOGIC CHANGES, 243

PATHOLOGIC CONDITIONS AFFECTING OLDER ADULTS’ SEXUAL RESPONSES, 244

Illness, Surgery, and Medication, 244 Human Immunodeficiency Virus, 244 Malignancies, 245 Dementia, 246

ENVIRONMENTAL AND PSYCHOSOCIAL BARRIERS TO SEXUAL PRACTICE, 246

ALTERNATIVE SEXUAL PRACTICE AMONG OLDER ADULTS, 246

NURSING MANAGEMENT, 247

SUMMARY, 252

REFERENCES, 253

PA R T 4 Common Psychophysiologic Stressors

14 Pain, 255 UNDERSTANDING PAIN, 255

Definition, 255 Pain Classification, 256 Scope of the Problem of Pain, 256 Consequences of Unrelieved Pain, 257 Epidemiology of Pain, 257

PATHOPHYSIOLOGY OF PAIN IN OLDER ADULTS, 257 Atypical Acute Pain in Older Adults, 257

BARRIERS TO EFFECTIVE PAIN MANAGEMENT IN OLDER ADULTS, 258

PAIN ASSESSMENT, 259 Pain Assessment and Culture, 260 Pain Assessment Tools, 260

NURSING CARE OF OLDER ADULTS WITH PAIN, 262 Pharmacologic Treatment, 262 Planning Pain Relief, 266

SUMMARY, 266

REFERENCES, 268

15 Infection, 270 THE CHAIN OF INFECTION, 270

AGE-RELATED CHANGES IN THE IMMUNE SYSTEM, 271

FACTORS AFFECTING IMMUNOCOMPETENCE, 271 Nutritional Factors, 271 Psychosocial Factors, 272 Medications, 272 Herbs, 272

COMMON PROBLEMS AND CONDITIONS, 272 Influenza and Pneumonia, 272 Cancer, 273 Autoimmunity, 273

HUMAN IMMUNODEFIENCY VIRUS INFECTION IN OLDER ADULTS, 274

SIGNIFICANT NOSOCOMIAL PATHOGENS, 274 Clostridium difficile, 274 Vancomycin-Resistant Enterococcus, 274 Methicillin-Resistant Staphylococcus aureus, 275

NURSING MANAGEMENT, 275

SUMMARY, 279

REFERENCES, 279

16 Chronic Illness and Rehabilitation, 281 CHRONICITY, 281

Prevalence of Chronic Illness, 282 Cultural Competency, 283 Quality of Life and Health-Related Quality of Life, 283 Adherence in Chronic Illness, 284 Psychosocial Needs of Older Adults with Chronic Illness, 285 Trajectory Framework, 285 Older Adults and Chronic Illness, 285 Physiologic Needs of Chronically Ill Older Adults, 287 Effect of Chronic Illness on Family and Caregivers, 287 Nursing Implications of Caregiver Stress, 288

REHABILITATION, 288 Care Environments, 289 Reimbursement Issues, 289 Public Policy and Legislation, 289 Enhancement of Fitness and Function, 290 Functional Assessment, 290 Keys for Completing a Functional Assessment, 290 Health Promotion, 290 Management of Disabling Disorders, 291 Life Issues, 291 Nursing Strategies, 292

SUMMARY, 292

REFERENCES, 293

RESOURCES, 295

xviii CONTENTS

17 Cancer, 296 INCIDENCE, 296

Racial and Ethnic Patterns, 297

AGING AND ITS RELATIONSHIP TO CANCER, 299 Aging and Cancer Prevention, 300

COMMON MALIGNANCIES IN OLDER ADULTS, 301 Lung Cancer, 301 Breast Cancer, 302 Prostate Cancer, 304 Colorectal Cancer, 305

SCREENING AND EARLY DETECTION: ISSUES FOR OLDER ADULTS, 305

MAJOR TREATMENT MODALITIES, 308 Surgery, 309 Radiation Therapy, 309 Chemotherapy, 310 Biologic Therapy, 312 Endocrine Therapy, 312

COMMON PHYSIOLOGIC COMPLICATIONS, 312 Bone Marrow Suppression, 313 Infection, 313 Nausea and Vomiting, 314 Chemotherapy-Induced Oral Mucositis, 314 Anorexia, 315 Diarrhea, 315 Alopecia, 316

OLDER ADULTS’ EXPERIENCE OF CANCER, 316 Quality of Life, 316 Depression, 317 Grief and Loss, 318 Social Isolation, 319 Resources and Support, 319

SUMMARY, 320

REFERENCES, 321

18 Loss and End-of-Life Issues, 324 DEFINITIONS, 324

LOSSES, 325 Bereavement, 325 Grief, 325 Types of Grief, 327

MOURNING, 328 Stage or Phase Perspectives, 328 Nursing Care, 329

APPROACHING DEATH: OLDER PERSONS’ PERSPECTIVES, 332

Psychological Aspects, 332 Spiritual Aspects, 333 Social Aspects, 333 Physical Aspects, 333 General Health Care Needs, 334 Effect of Age-Related Changes, 334 Nursing Care, 335

Environment and Care Services, 339 Legislative Initiatives, 339

SUMMARY, 340

REFERENCES, 341

PA R T 5 Diagnostic Studies and Pharmacologic Management

19 Laboratory and Diagnostic Tests, 344 COMPONENTS OF HEMATOLOGIC TESTING, 344

Red Blood Cells, 346 Hemoglobin, 346 Hematocrit, 346 White Blood Cells, 346 Folic Acid, 347 Vitamin B12, 347 Total Iron Binding Capacity, 347 Iron, 347 Uric Acid, 347 Prothrombin Time, 347 Partial Thromboplastin Time, 348 D-dimer Test, 348 Erythrocyte Sedimentation Rate, 348 Cross-Reactive Protein, 348 Platelets, 348

COMPONENTS OF BLOOD CHEMISTRY TESTING, 348 Electrolytes, 349 Amylase, 352 Total Protein, 352 Albumin and Prealbumin, 352 Blood Urea Nitrogen, 353 Creatinine, 353 Creatinine Clearance, 353 Triglycerides, 353 Total Cholesterol, 353 High-Density Lipoprotein, 353 Low-Density Lipoprotein, 353 Brain Natriuretic Peptide, 354 Alkaline Phosphatase, 354 Acid Phosphatase, 354 Aspartate Aminotransferase, 354 Creatine Kinase, 354 Lactate Dehydrogenase, 354 Troponin, 354 Thyroid Function Tests, 354 Prostate-Specific Antigen, 354

COMPONENTS OF URINE CHEMISTRY TESTING, 355 Protein, 355 Glucose, 355 Bacteria and Leukocytes, 355 Ketones, 356 pH, 356 Blood, 356

CONTENTS xix

COMPONENTS OF ARTERIAL BLOOD GAS TESTING, 356 Oxygen, 357 pH of the Blood, 357 Carbon Dioxide, 357 Oxygen Saturation, 357

BLOOD LEVEL MONITORING, 357

SUMMARY, 358

REFERENCES, 359

20 Pharmacologic Management, 361 OVERVIEW OF MEDICATION USE AND PROBLEMS, 361

Demographics of Medication Use, 361 Changes in Drug Response with Aging, 361 Pharmacokinetic Changes: What the Body Does to the Drug, 361 Pharmacodynamic Changes: What the Drug Does to the Body, 363 Medications and Quality of Life, 364 Pharmacologic Contributors to Risk, 364

COMMONLY USED MEDICATIONS, 367 Psychotropics, 367 Anxiolytics and Hypnotics, 368 Antidepressants, 368 Antipsychotics, 368 Cardiovascular Medications, 369 Antimicrobials, 371 Nonprescription Agents, 371 Dietary Supplements, 371

MEDICATION ADHERENCE, 372 Assessing for Risk Factors, 372 Strategies for Improving Adherence, 373 Reviewing the Medication List for Problems, 373

SUBSTANCE ABUSE, 374

DEFINITIONS AND COMMON USAGE, 374 Difficulty in Identification of Abuse, 374 Physiologic Changes, 374 Psychological Changes, 374 Sociologic Changes, 375

ASSESSMENT, 375 Substance Abuse History, 375 Screening Tools, 375 Nursing Caveats, 376

NURSING DIAGNOSES, 376

NURSING MANAGEMENT, 378 Interventions, 378 Evaluation, 378

COMMONLY ABUSED SUBSTANCES IN OLDER ADULTS, 379

Alcohol, 379 Prescription Medications, 381 Nicotine, 382

FUTURE TRENDS, 382

SUMMARY, 384

REFERENCES, 385

PA R T 6 Nursing Care of Physiologic and Psychologic Disorders

21 Cardiovascular Function, 388 AGE-RELATED CHANGES IN STRUCTURE AND FUNCTION, 388

Conduction System, 389 Vessels, 389 Response to Stress and Exercise, 389

COMMON CARDIOVASCULAR PROBLEMS, 389 Contributing Factors to Heart Disease, 389 Hypertension, 391

NURSING MANAGEMENT, 396 Coronary Artery Disease, 397

NURSING MANAGEMENT, 399 Arrhythmia, 402

NURSING MANAGEMENT, 403 Orthostatic Hypotension, 404

NURSING MANAGEMENT, 404 Syncope with Cardiac Causes, 405

NURSING MANAGEMENT, 405 Valvular Disease, 406

NURSING MANAGEMENT, 407 Congestive Heart Failure, 408

NURSING MANAGEMENT, 410 Peripheral Artery Occlusive Disease, 413

NURSING MANAGEMENT, 414 Venous Disorders, 414

NURSING MANAGEMENT, 416 Anemia, 417

NURSING MANAGEMENT, 418

SUMMARY, 419

REFERENCES, 419

22 Respiratory Function, 422 AGE-RELATED CHANGES IN STRUCTURE AND FUNCTION, 422 FACTORS AFFECTING LUNG FUNCTION, 425

Exercise and Immobility, 425 Smoking, 425 Obesity, 426 Sleep, 426 Anesthesia and Surgery, 426

RESPIRATORY SYMPTOMS COMMON IN OLDER PATIENTS, 426

RESPIRATORY ALTERATIONS IN OLDER PATIENTS, 427

xx CONTENTS

OBSTRUCTIVE PULMONARY DISEASE, 427 Asthma, 427

NURSING MANAGEMENT, 429 Chronic Bronchitis, 431 Emphysema, 431 Chronic Obstructive Pulmonary Disease, 431

NURSING MANAGEMENT, 434

RESTRICTIVE PULMONARY DISEASE, 438 Lung Carcinoma, 438

NURSING MANAGEMENT, 439 Tuberculosis, 440

NURSING MANAGEMENT, 441

BRONCHOPULMONARY INFECTION, 442 Influenza, 442

NURSING MANAGEMENT, 443 Pneumonia, 444

NURSING MANAGEMENT, 445 Other respiratory alterations, 447 Severe Acute Respiratory Syndrome, 447 Cardiogenic and Noncardiogenic Pulmonary Edema, 447 Cardiogenic Pulmonary Edema, 447 Noncardiogenic Pulmonary Edema: Adult Respiratory Distress Syndrome, 447

NURSING MANAGEMENT, 448 Pulmonary Emboli, 449

NURSING MANAGEMENT, 450 Obstructive Sleep Apnea, 450

NURSING MANAGEMENT, 451

SUMMARY, 452

REFERENCES, 453

23 Endocrine Function, 455 ENDOCRINE PHYSIOLOGY IN OLDER ADULTS, 455

Andropause and Menopause, 456 Adrenopause, 458 Somatopause, 458

COMMON ENDOCRINE PATHOPHYSIOLOGY IN OLDER ADULTS, 458

The Metabolic Syndrome–Diabetes Continuum, 458 Diabetes Mellitus–Type 2, 459

NURSING MANAGEMENT, 461 Hyperthyroidism, 467

NURSING MANAGEMENT, 469 Hypothyroidism, 469

NURSING MANAGEMENT, 470 Primary Osteoporosis, 470

NURSING MANAGEMENT, 471 Sexual Dysfunction, 471

NURSING MANAGEMENT, 472

SUMMARY, 473

REFERENCES, 474

WEBSITES, 476

24 Gastrointestinal Function, 477 AGE-RELATED CHANGES IN STRUCTURE AND FUNCTION, 477

Oral Cavity and Pharynx, 477 Esophagus, 478 Stomach, 478 Small Intestine, 478 Large Intestine, 478 Gallbladder, 478 Pancreas, 478 Liver, 478

PREVENTION, 478

COMMON GASTROINTESTINAL SYMPTOMS, 480

Nausea and Vomiting, 480 Anorexia, 480 Abdominal Pain, 480 Gas, 481 Diarrhea, 482 Constipation, 482 Fecal Incontinence, 483

COMMON DISEASES OF THE GASTROINTESTINAL TRACT, 483

Gingivitis and Periodontitis, 483

NURSING MANAGEMENT, 483 Dysphagia, 487

NURSING MANAGEMENT, 487 Gastroesophageal Reflux and Esophagitis, 488

NURSING MANAGEMENT, 488 Vitamin B12 Deficiency, 489 Gastritis, 489

NURSING MANAGEMENT, 490 Peptic Ulcer Disease, 491

NURSING MANAGEMENT, 492 Enteritis, 492

NURSING MANAGEMENT, 493 Intestinal Obstruction, 493

NURSING MANAGEMENT, 494 Diverticula, 495

NURSING MANAGEMENT, 496 Colon Polyps, 497

NURSING MANAGEMENT, 497 Hemorrhoids, 497

NURSING MANAGEMENT, 498

CONTENTS xxi

DISORDERS OF THE ACCESSORY ORGANS, 498 Cholelithiasis and Cholecystitis, 498

NURSING MANAGEMENT, 499

PANCREATITIS, 499 Nursing Management, 499

HEPATITIS, 500 Nursing Management, 501

ALCOHOLIC CIRRHOSIS, 502 Nursing Management, 503

DRUG-INDUCED HEPATITIS, 503 Nursing Management, 504

GASTROINTESTINAL CANCERS, 504

ESOPHAGEAL CANCER, 504 Nursing Management, 505

GASTRIC CANCER, 505 Nursing Management, 506

COLORECTAL CARCINOMA, 507 Nursing Management, 507

PANCREATIC CANCER, 508 Nursing Management, 508

LIVER CANCER, 509 SUMMARY, 509 REFERENCES, 510

25 Musculoskeletal Function, 511 AGE-RELATED CHANGES IN STRUCTURE AND FUNCTION, 511 COMMON PROBLEMS AND CONDITIONS OF THE MUSCULOSKELETAL SYSTEM, 513

HIP FRACTURE, 514 Nursing Management, 514

COLLES FRACTURE, 516

CLAVICULAR FRACTURE, 517

OSTEOARTHRITIS, 518 Nursing Management, 519

SPINAL STENOSIS, 520 Nursing Management, 521

RHEUMATOID ARTHRITIS, 521 Nursing Management, 522

GOUTY ARTHRITIS, 525 Nursing Management, 526

OSTEOPOROSIS, 526 Nursing Management, 529

PAGET DISEASE, 531 Nursing Management, 531

OSTEOMYELITIS, 531 Nursing Management, 532

AMPUTATION, 532

Nursing Management, 533

POLYMYALGIA RHEUMATICA, 534 Nursing Management, 534

FOOT PROBLEMS, 536 Corns, 536 Calluses, 536 Bunions, 537 Hammertoe, 537 Nail Disorders, 537 Patient Education, 538

MUSCLE CRAMPS, 538

SUMMARY, 538

REFERENCES, 539

26 Urinary Function, 541 AGE-RELATED CHANGES IN STRUCTURE AND FUNCTION, 541

PREVALENCE OF URINARY INCONTINENCE, 542 Myths and Attitudes, 542

COMMON PROBLEMS AND CONDITIONS, 542

ACUTE INCONTINENCE, 542

CHRONIC INCONTINENCE, 542 Nursing Management, 543

AGE-RELATED RENAL CHANGES, 549

COMMON PROBLEMS AND CONDITIONS, 551

ACUTE KIDNEY INJURY, 551

CHRONIC KIDNEY DISEASE, 551 Nursing Management, 552

URINARY TRACT INFECTION, 553 Nursing Management, 555

BLADDER CANCER, 555 Nursing Management, 556

BENIGN PROSTATIC HYPERTROPHY, 556 Nursing Management, 556

PROSTATE CANCER, 557 Nursing Management, 558

SUMMARY, 559

REFERENCES, 560

27 Cognitive and Neurologic Function, 561 STRUCTURAL AGE-RELATED CHANGES OF THE NEUROLOGIC SYSTEM, 561

Cellular and Structural Changes, 562 Cerebrospinal Fluid and Ventricular System, 563

ASSESSMENT OF COGNITIVE FUNCTION, 566 Selected Cognitive Function Screening Instruments, 566 Cognitive Function and Memory in Typical Aging, 567

xxii CONTENTS

COGNITIVE DISORDERS ASSOCIATED WITH ALTERED THOUGHT PROCESSES, 567

Depression, 567 Delirium, 568 Dementia, 569 Alzheimer Disease, 570 Vascular Dementia, 572 Lewy Body Dementia, 573 Frontotemporal Dementia, 573 Other Dementia-Related Diseases, 574

DIAGNOSTIC ASSESSMENT OF ALTERED THOUGHT PROCESSES, 574

Examination, 574 Diagnostic Studies, 575 Laboratory Studies, 575 DSM-V Criteria, 575

TREATMENT OF ALTERED THOUGHT PROCESSES, 575

PHARMACOTHERAPY, 575 Nursing Management, 577

CHALLENGES IN THE CARE OF OLDER ADULTS WITH COGNITIVE DISORDERS, 582

Sundown Syndrome, 582 Wandering, 583 Paranoia or Suspiciousness, 583 Hallucinations and Delusions, 583 Catastrophic Reactions, 583 Resources, 583

OTHER COMMON PROBLEMS AND CONDITIONS, 584

SUICIDE, 584 Nursing Management, 585

PARKINSON DISEASE, 586 Nursing Management, 588

CEREBROVASCULAR ACCIDENT (BRAIN ATTACK), 589 Management, 591 Nursing Management, 591

ANXIETY, 592 Nursing Management, 592

SCHIZOPHRENIA, 593 Nursing Management, 593

DELUSIONAL DISORDERS, 594

MENTAL RETARDATION, 594 Nursing Management, 594

CONDITIONS ASSOCIATED WITH PHYSICAL PROBLEMS, 595

Nursing Management, 595

MEDICATION MANAGEMENT, 596 Psychotropic Medications, 596 Side Effects, 598 Other Psychoactive Medications Used in Older Adults, 598

MENTAL HEALTH CARE RESOURCES, 599 Human Resources, 599

Physical Resources, 599 Financial Resources, 600

TRENDS AND NEEDS, 600

SUMMARY, 600

REFERENCES, 602

RESOURCES, 606

DEMENTIA AND ALZHEIMER DISEASE, 606

ALZHEIMER’S DISEASE EDUCATION & REFERRAL CENTER, 606

CHRONIC NEUROLOGIC DISORDERS AND PARKINSON DISEASE, 606

STROKE, 606

OTHER RESOURCES, 606

28 Integumentary Function, 607 AGE-RELATED CHANGES IN SKIN STRUCTURE AND FUNCTION, 608

Epidermis, 608 Dermis, 608 Subcutaneous Fat, 608 Appendages, 608

COMMON PROBLEMS AND CONDITIONS, 608 Benign Skin Growths, 608 Inflammatory Dermatoses, 610 Psoriasis, 610 Nursing Management, 610

PRURITUS, 611 Nursing Management, 611

CANDIDIASIS, 612 Nursing Management, 612

HERPES ZOSTER (SHINGLES), 613 Nursing Management, 614

PREMALIGNANT SKIN GROWTHS: ACTINIC KERATOSIS, 615

Nursing Management, 615 MALIGNANT SKIN GROWTHS, 616

BASAL CELL CARCINOMA, 616 Nursing Management, 616

SQUAMOUS CELL CARCINOMA, 617 Nursing Management, 617

MELANOMA, 618 Nursing Management, 618

LOWER EXTREMITY ULCERS, 619

ARTERIAL ULCERS, 619

DIABETIC NEUROPATHIC ULCERS, 620

VENOUS ULCERS, 620 Nursing Management, 621

PRESSURE ULCERS, 621 Epidemiology of Pressure Ulcers, 622 Etiology of Pressure Ulcers, 622

CONTENTS xxiii

Risk Assessment Tools, 624 Preventive Strategies, 626 Pressure Ulcer Management, 628

SUMMARY, 636

REFERENCES, 638

29 Sensory Function, 640 VISION, 640

Age-Related Changes in Structure and Function, 641 Common Complaints, 641 Common Problems and Conditions, 642

GLAUCOMA, 643 Nursing Management, 643

CATARACTS, 644 Nursing Management, 644

RETINAL DISORDERS, 646 Nursing Management, 646

VISUAL IMPAIRMENT, 647 Nursing Management, 648

HEARING AND BALANCE, 649 Age-Related Changes in Structure and Function, 650

Common Problems and Conditions, 650

PRURITIS, 650 CERUMEN IMPACTION, 650

Nursing Management, 650

TINNITUS, 651 Nursing Management, 651

HEARING LOSS, 652 Nursing Management, 653

DIZZINESS AND DYSEQUILIBRIUM, 654

MENIERE DISEASE, 655 Nursing Management, 655

TASTE AND SMELL, 656 Age-Related Changes in Structure and Function, 656 Common Problems and Conditions, 656

XEROSTOMIA, 656 Nursing Management, 656

TOUCH, 657

SUMMARY, 657

REFERENCES, 658

Index, 659

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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 sub- stance abuse problems, teenage mothers, homeless individuals, and those infected with the human immunodeficiency virus (HIV), nurses are reminded that these patients and their prob- lems 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, alms- houses, and private duty nursing, as well as early case studies

Overview of Gerontologic Nursing

Sue E. Meiner, EdD, APRN, BC, GNP

Previous author: Annette G. Lueckenotte, MS, RN, BC, GNP, GCNS; Revisions by: Sue E. Meiner, EdD, APRN, BC, GNP.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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 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

2 PART I Introduction to Gerontologic Nursing

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 expectancy by its steady research and implementation of medi- cal actions fighting preventable diseases. Therefore, nursing professionals must expect to care for steadily increasing num- bers 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; plan- ning 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 clin- ical 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 certifica- tion 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, work- shops and seminars, formal education programs, professional certification, and research with a focus on gerontologic nurs- ing have since evolved. However, the singular event that truly legitimized the 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 comprehen- sive 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 incor- porated 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 expecta- tions 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/.

Another hallmark in the continued growth of the geronto- logic nursing specialty occurred in 1973, when the first geron- tologic 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 knowl- edge and expertise has been achieved. In some cases, certifica- tion may mean eligibility for third-party reimbursement for nursing services rendered. From the initial certification offering

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.

TABLE 1-1 DEVELOPMENT OF GERONTOLOGIC NURSING: 1960–1970

Modified from Burnside, I.M. (1988). Nursing and the aged: a self-care approach (3rd ed). New York: McGraw-Hill.

http://www.nursingworld.org/

CHAPTER 1 Overview of Gerontologic Nursing 3

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 con- tinued to grow and attract a high level of interest. Changes were being made as this edition was being written. The first com- bined certification for either acute care Adult-Gerontologic Nurse Specialist (AGCNS) or primary care AGCNS examina- tion 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.

Roles The growth of the nursing profession as a whole, increasing edu- cational 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 prac- tice in a wide variety of environments, including the home and the community. The challenge of the gerontologic nurse gener- alist 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 interdisci- plinary 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 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

Gerontologic Nurse (Registered Nurse—Board Certified [RN-BC]) 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 nurs-

ing 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 all human systems, advanced assessment techniques, concepts, and approaches

c. Advanced pharmacology, which includes pharmacodynamics, pharmacoki- netics, 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, pharmacoki-

netics, and pharmacotherapeutics 4. Content in:

a. Health promotion and/or maintenance b. Differential diagnosis and disease management, including the use and pre-

scription of pharmacologic and nonpharmacologic interventions More details on these options can be found by contacting the ANCC directly

or online at www.nursingworld.org/ancc/certification.

BOX 1-1 AMERICAN NURSES CREDENTIALING CENTER ELIGIBILITY REQUIREMENTS FOR CERTIFICATION IN GERONTOLOGIC NURSING

Modified from American Nurses Credentialing Center Certification, 2013. Washington DC. www.nursingworld.org/ancc/certify.htm. Accessed September 17, 2013. 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.

http://www.nursingworld.org/ancc/certify.htm

http://www.nursingworld.org/ancc/certification

http://www.nursingworld.org/ancc/certify.htm

4 PART I Introduction to Gerontologic Nursing

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 pre- pared 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 nurs- ing 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 deliv- ery 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.

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,” geriat-

rics is the branch of medicine that deals with the diseases and problems of old age. Viewed by many nurses as having lim- ited 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,” ger- ontology is the scientific study of the process of aging and the problems of aged persons; it includes biologic, socio- logic, 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 specialty continues to grow and develop, it is likely that the ter- minology will, too.

DEMOGRAPHIC PROFILE OF THE OLDER POPULATION Far from the beginnings of gerontologic nursing practice in almshouses and nursing homes, nurses today find them- selves 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 agen- cies, 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 first- hand 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 fol- lowing review of basic demographic facts about older persons, the reader is cautioned against believing that the age 65 auto- matically 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 discre- tionary 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 legis- lation in Germany in the 1880s) primarily for the purpose of determining a point for retirement and eligibility for ser- vices and financial entitlements for the elderly.

When the Social Security program was established in 1935, it was 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

CHAPTER 1 Overview of Gerontologic Nursing 5

purposes. Consequently, it is not uncommon to see older per- sons classified as young-old, middle-old, or old-old.

Although grouping older persons is useful in some circum- stances, 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 ulti- mately 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, com- paring a patient’s previous level and pattern of health and func- tion 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 mem- bership organization for people age 50 or older. The AARP is dedicated to enhancing the quality of life for all Americans as they age. The 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 com- piling 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 appro- priate. 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 fertil- ity 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.

206020402020

79.7

2011

41.4

2000

Year (as of July 1)

1980

25.5

1960

16.6

1940

1920

4.9

1900

3.1 0

100

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.)

http://www.aarp.org

http://www.aoa.gov/Aging_Statistics/Profile/Index.aspx

6 PART I Introduction to Gerontologic Nursing

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 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 ori- gins are in the Spanish-speaking countries of Central or South America. They are counted in the census by racial groups, usu- ally 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 popu- lations 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 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 set- tings are discussed in more detail later in this chapter. A per- son’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 nurs- ing homes. About 30% of noninstitutionalized older adults, or 10.8 million persons, live alone, according to living arrange- ment 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 effec- tively 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 inter- acting 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 cogni- tive impairment. Additionally, psychologic, social, environmen- tal, and financial factors play a significant role in the level of frailty. Nevertheless, not all older adults are frail. The expectation of wellness, even in the presence of chronic illness and signifi- cant impairment, must be incorporated into the consciousness and practice of nurses who interact with this population. (See Figure 1-2 for living arrangements).

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 com- pared with other age groups. For many years, this phenomenon

CHAPTER 1 Overview of Gerontologic Nursing 7

of aging in place has been an important factor in the growth of the population that is 65 or older living in metropolitan and 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 previ- ous migration to the Sunbelt states for retirement. Dwindling financial resources may necessitate a move to a more economi- cal 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, rec- ognize 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 infor- mation 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 $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 origi- nally 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 counter- parts. 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).

Approximately 3.6 million older adults were below the pov- erty level in 2011. Another 2.4 million older persons were clas- sified 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 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 increas- ing 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 retire- ment 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 retire- ment 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.

Men

72%

46%

Living with spouse

Living alone

Other

36%

19%

Women

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.)

8 PART I Introduction to Gerontologic Nursing

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 emphasiz- ing 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 fre- quent 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 proac- tive 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 posi- tively despite the presence of chronic illness, disease, and impairment.

Self-Assessed Health and Chronic Disease Noninstitutionalized older adults routinely assessed (44%) their 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 finan- cial 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 com- pared 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 measure- ment tools by activities of daily living (ADLs) such as bathing, dressing, eating, transferring, and toileting (Katz, 1963) and instrumental ADLs, which include home- management activi- ties such as shopping, cooking, housekeeping, laundry, and handling money (Lawton & Brody, 1969). These measurement

Under $10,000 2.0%

100%80%60%40%20%0%

$10,000 - $14,999 3.0%

$15,000 - $24,999 12.0%

$25,000 - $34,999 16.0%

$35,000 - $49,999 19.0%

$50,000 - $74,999 20.0%

$75,000 and over

$48,538 median for 14.4 million family households 65

29.0%

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.)

CHAPTER 1 Overview of Gerontologic Nursing 9

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, psy- chological, 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 func- tional status enables the nurse to determine needs, plan inter- ventions, 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 cogni- tive 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 insur- ance 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 pre- scriptions until $4550 was spent. Then the recipient was only responsible for about 5% of the cost of the remainder of medi- cations 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 cover- age gap will be closed, that is, there will be no more “donut hole,” and recipients will pay only 25% of the costs of medica- tions 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 chal- lenged 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 popu- lation across the continuum of care; (2) develop models of care delivery directed at all levels of prevention, with special empha- sis on primary prevention and health promotion services in community-based settings; and (3) assume positions of leader- ship and influence not only in institutions and settings where care is currently provided to older persons but also in the politi- cal 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 deliv- ery system has clearly passed. Political climate, market forces, technologic advances, and economics are a few of the major 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 hos- pitals adequately manage the care of their older adult patients in terms of preventing functional decline and promoting inde- pendence, 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 princi- ples as they apply to the maintenance and promotion of func- tional ability in older adults; and (5) sensitivity and patience

http://www.medicare.gov

10 PART I Introduction to Gerontologic Nursing

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 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 tradi- tionally 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 pro- vide the complex care these residents require, or the staff does not have up-to-date knowledge and skills. In addition, the nurs- ing 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 increas- ing in size and represents the group typically found in nurs- ing facilities. Their care needs, coupled with those of the more acutely ill residents who are increasingly being placed in nurs- ing 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 pro- gress, 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 nurs- ing 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 ways. Although the momentum is growing, these advanced practice nurses are challenged to con- tinue 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 influ- encing 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 judg- ment 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 determin- ing 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 respon- sibility of the home care nurse. Excellent coordination and col- laboration 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 assess- ments 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 specifically at refinement of health screening, health pro- motion, and health maintenance activities. Linking these activi- ties 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 move- ment toward keeping frail and impaired older persons at home gains momentum. The models are all capitated plans that pro- vide Medicare benefits such as home health care, durable medi- cal 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 dem- onstration 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 per- manent 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

CHAPTER 1 Overview of Gerontologic Nursing 11

widely ranging 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 elo- quently 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 effec- tively meeting the needs of a growing and demographically changing population.

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 spe- cialty, 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, prac- tice, 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 dis- taste for growing old, disease, disability; and fear of powerless- ness, ‘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 gen- eration 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 build- ing coalitions among advocates of all age groups; recognizing that older persons themselves are an economic market and developing ways to capitalize on it; investing 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 philoso- phy 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 educa- tion at the master’s degree level, and (5) nurses with graduate education at the doctoral level. Although no reports in the nurs- ing literature describe the use of this framework for curricu- lum 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 con- ceptual 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 nurs- ing content in the associate degree program have been offered (Waters, 1991). However, despite the many recommendations that have been made, unanimous agreement as to what consti- tuted 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 nurs- ing 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 chal- lenges 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

12 PART I Introduction to Gerontologic Nursing

students at the baccalaureate, master’s, and doctoral levels for this new environment. In addition, the position statement iden- tifies 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 infor- mation 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 with clinical experiences to enhance nurses’ responsibilities, knowledge, and skills to the practice of nursing.

In terms of program evaluation and outcomes, these docu- ments 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 pres- ervation 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 pre- pared 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 geron- tologic 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 stu- dents 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 geronto- logic 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 con- tinuing movement of health care away from acute care hospi- tals, 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.

Today’s older adult health care consumers are more knowl- edgeable 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 pro- motion, 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, includ- ing 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 col- laborating 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 expan- sion 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 situations. For this to be successful, nurses need to take a greater role in the education of such person- nel 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 rehabili- tative 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 pro- vide anticipatory guidance for the possible psychological reac- tions to a relevant life experience such as retirement.

http://hartfordign.org

CHAPTER 1 Overview of Gerontologic Nursing 13

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 vari- ables. 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 responsi- bility for the care and treatment of older adults in all settings. Equally important will 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, pre- vention 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 impera- tive 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 fed- eral 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 fund- ing 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 prac- tice. 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, research done, and analyses completed, the findings are dissemi- nated to those who will implement the findings. Professional journals are one of the main sources of dissemination of infor- mation. 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 prob- lems. 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) 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.

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 profes- sional responsibility of providing quality care to older per- sons 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.

14 PART I Introduction to Gerontologic Nursing

K E Y P O I N T S

• The growth of the nursing profession as a whole, increas- ing 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, turn- ing 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 neo- plasms, 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. • Gerontologic nursing content should be included in all nurs-

ing education programs. • Evidence-based practice has the potential to improve care for

the older adult.

C R I T I C A L T H I N K I N G E X E R C I S E S 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.

REFERENCES Administration on Aging (AOA). (2012). A profile of older Americans:

2012. Washington, DC: U. S. Department of Health and Human Services, The Agency.

Agency for Healthcare Quality and Research. (2002). 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.

American Association of Colleges of Nursing (AACN). (1993). Position statement: Nursing education’s agenda for the 21st century. Washington, DC: The Association.

American Association of Retired Persons (AARP). (2004). Images of aging in America 2004: Summary information. Washington, DC: The Association.

American Nurses Association (ANA). (1991). Nursing practice stan- dards and guidelines. Oasis: Council on Gerontological Nursing Practice, 8(4), 2.

American Nurses Association (ANA). (1995). Scope and standards of gerontological nursing practice. Washington, DC: The Association.

American Nurses Association (ANA). 2010a. Nursing: Scope & stan- dards of practice (2nd ed.). Washington, DC: The Association.

American Nurses Association (ANA). 2010b. Nursing’s social policy state- ment: The essence of the profession. Washington, DC: The Association.

American Nurses Association (ANA). 2010c. Guide to the code of eth- ics for nurses: Interpretation and application. Washington, DC: The Association.

American Nurses Association (ANA). (2010). Scope and standards of gerontological nursing practice. Washington, DC: The Association.

American Nurses Credentialing Center (ANCC). (2013). ANCC certifi- cation catalog: 2013. Washington, DC: The Center.

Burnside, I. M. (1988). Nursing and the aged: A self-care approach (3rd ed.). New York: McGraw-Hill.

Butler, R. N. (1969). Age-ism: Another form of bigotry. Gerontologist, 9, 243.

Butler, R. N. (1975). Why survive? Being old in America. New York: Harper & Row.

Butler, R. N. (1993). Dispelling ageism: The cross-cutting intervention. Generations, 17(2), 75.

Butler, R. N., & Lewis, M. I. (1977). Aging and mental health (ed 2). St Louis: Mosby.

Centers for Medicare and Medicaid Services (CMS). (2013). Medicare basics. In Medicare & you. Washington, DC: The Centers.

Ebersole, P., & Hess, P. (1990). Toward healthy aging: Human needs and nursing response (3rd ed.). St Louis: Mosby.

Fitzpatrick, J. J. (Ed.). (2002). Annual review of nursing research: Vol. 20. New York: Springer.

Gebhardt, M. C., Sims, T. T., & Bates, T. A. (2009). Enhancing geriat- ric content in a baccalaureate nursing program. Nursing Education Perspectives, 30, 245.

Gunter, L., & Estes, C. (1979). Education for gerontic nursing. New York: Springer.

CHAPTER 1 Overview of Gerontologic Nursing 15

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. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.

Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2010). The future of nursing: Leading change, advanc- ing health (Report Brief). Washington, DC: National Academies Press.

Katz, L., et al. (1963). Studies of illness in the aged. The index of ADL: a standardized measure of biological and psycho- social function. JAMA: The Journal of the American Medical Association, 185, 94.

Landers, S. J. (2010). Why health care is going home. New England Journal of Medicine, 363, 1690.

Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179.

Linton, A. D., & Lach, H. W. (2007). Matteson & McConnell’s geronto- logical nursing: Concepts and practice (3rd ed). St. Louis: Saunders.

Luggen, A. S., & Meiner, S. E. (2002). NGNA core curriculum for geron- tological nursing (2nd ed.). St. Louis: Mosby.

The Medicare Blog (2013). Retrieved from www.blog.medicare. gov/?s=prescription+savings. Accessed on July 8, 2014.

Titler, M. G., Kleiber, C., Steelman, V. J., et al. (2001). The Iowa model of evidence-based practice to promote quality care. .Critical Care Nursing Clinics of North America, 13(4), 497.

U. S. Bureau of the Census. (2012). Sixty-five plus in the United States: 2012, Statistical Brief. Washington, DC: Economics and Statistics Administration, U. S. Department of Commerce.

Waters, V. (Ed.). (1991). Teaching gerontology: The curriculum impera- tive. New York: National League for Nursing Press.

http://www.hhs.gov/healthcare/rights/law/index.html

http://www.blog.medicare.gov/?s=prescription%2bsavings

C H A P T E R

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 pre- determination 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 study- ing the structure of the human body. Studies were few until the late 1900s when world populations began to have increas- ing 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 we call aging.

Theories function to help make sense of a particular phe- nomenon; 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 bio- technology and, as such, provide glimpses into our future.

Human aging is influenced by a composite of biologic, psy- chologic, sociologic, functional, and spiritual factors. Aging may be viewed as a continuum of events that occur from concep- tion to death (Ignatavicius & Workman, 2013). Biologic, socio- logic, 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).

By incorporating a holistic approach to the care of older adults, nurses can view this ever-increasing portion of the pop- ulation more comprehensively. Interactions between geronto- logic nurses and older adults are not limited to specific diseases or physiologic processes, absolute developmental tasks, or psy- chosocial 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 phys- ical, 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

L E A R N I N G O B J E C T I V E S 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.

Theories of Aging

Sue E. Meiner, EdD, APRN, BC, GNP

Previous authors: Marjorie A. Maddox, EdD, MSN, ARNP, ANP-C, and Holly Evans Madison, RN, MS

http://evolve.elsevier.com/Meiner/gerontologic

CHAPTER 2 Theories of Aging 17

maximum of approximately 120 years. Several basic assump- tions 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 con- ception. Because individuals have unique genetic, social, psy- chologic, 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.

BIOLOGIC THEORIES OF AGING Biologic theories are concerned with answering basic ques- tions 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 influ- ence. The primary question being addressed relates to the fac- tors 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 fol- lowing: (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 decreas- ing 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 divi- sions: stochastic and nonstochastic. Stochastic theories explain aging as events that occur randomly and accumulate over time, whereas nonstochastic theories view aging as certain predeter- mined, timed phenomena (Box 2-2).

Stochastic Theories Error Theory As a cell ages, various changes occur naturally in its deoxyribo- nucleic acid (DNA) and ribonucleic acid (RNA), the building blocks of the cell. DNA, found in the nucleus of the cell, con- tains 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 gen- erations 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 auto- matically or necessarily accelerated if misspecified proteins

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 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).

BOX 2-1 THEORIES OF AGING Stochastic Theories Error Theory The error theory is based on the idea that errors can occur in the tran- scription of the synthesis of deoxyribonucleic acid (DNA). These errors are perpetuated and eventually lead to systems that do not function at the op- timal 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 accumu- late, 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 opti- mal 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 num- ber 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).

BOX 2-2 BIOLOGIC THEORIES OF AGING

18 PART I Introduction to Gerontologic Nursing

or enzymes are introduced to a cell (Hayflick, 1996, 2004; Schneider, 1992; Weinert & Timiras, 2003).

Radical Theory Free radicals are byproducts of fundamental metabolic activi- ties 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 neu- tralized, 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 called lipid peroxidation. Therefore, the mitochondria, for example, can no longer func- tion as efficiently, and their cell membranes may become dam- aged, 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 mol- ecules 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 pro- tein. 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 mate- rial, 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 nutri- ent supply. Further degeneration of surrounding tissue even- tually 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 administra- tion 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 anti- oxidants postpones the appearance of diseases such as cardio- vascular 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 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 pas- sage 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 mol- ecule 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 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 mech- anism cannot remove the cross-linking agent before it becomes securely established. Cross-linkage has been proposed as a pri- mary 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.

CHAPTER 2 Theories of Aging 19

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 accel- erate 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 lim- iting 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 cor- rect? 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 expec- tancy 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 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 func- tions less effectively. The term immunosenescence has been given to this age-related decrease in function.

Essential components of the immune system are T lympho- cytes, 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 auto- antibodies, which lead to a propensity to develop autoimmune- related diseases (De la Fuente, 2008; Hayflick, 1996; Weinert & Timiras, 2003) (Box 2-3).

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 devel- opment 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 autoanti- gens, often leading to an increase in autoimmune-related diseases.

Immunodeficient conditions such as human immunodefi- ciency 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 popula- tion (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

• Increase in autoantibodies as a result of altered immune system regulation: This predisposes an individual to autoimmune 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 cer- tain viral antigens, allografts, and tumor cells: This results in an increased incidence of cancer in older adults.

BOX 2-3 CHANGES IN CELL-MEDIATED IMMUNE FUNCTION AS A RESULT OF AGING

20 PART I Introduction to Gerontologic Nursing

and controls many important metabolic activities. It has been observed 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.

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 meno- pause, although 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 dehy- droepiandrosterone (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 ani- mals 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 capa- bility but also from studies on rodents that demonstrated an increased life span when melatonin was administered. These studies also found that rodents fed supplementary melato- nin 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 showing that certain fish, when the water temperature is low- ered, 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 sys- tems such as the immune system may lead to greater under- standing of the process of aging.

The second development that has occurred involves the dis- covery of telomeres, which are the regions at the ends of chro- mosomes 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 pro- duce 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).

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 difference between age-related changes and those that may actually be pathologic. Nurses must remem- ber that scientists are still in the process of discovering what “normal” aging is.

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 hypo- thalamus 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 chromo- somes, which may function as the cells’ biologic clocks (Hayflick, 1996).

BOX 2-4 EMERGING THEORIES OF AGING

CHAPTER 2 Theories of Aging 21

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 expo- sure. Excessive exposure to ultraviolet light is another exam- ple 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 contin- ues 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 inter- acting with these patients (see the Evidence-Based Practice box) (Carter, 2003).

Performing activities of daily living (ADLs) requires the functional use of extremities. Daily exercises that enhance upper arm strength and hand dexterity contribute to older adults’ abil- ity 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 cogni- tion, 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 prob- lem 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 dis- ease 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 nec- essary for patient teaching to stress the concept that certain con- ditions or diseases are not inevitable just because of advancing

T T

A G

G G

FIGURE 2-1 A deoxyribonucleic acid (DNA) model against a background of chromosomes. The light ends on the chro- mosomes 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.)

EVIDENCE-BASED PRACTICE

Sample/Setting A nonrandomized study of 184 male veterans, older than 65, and not living in an institution.

Methods The Interaction Model of Client Health Behavior was administered. The inde- pendent variables were age, education, race, marital status, children, siblings, income, spiritual well-being, functional status, motivation, health concep- tions, and loneliness. The dependent variable was Schwirian’s (1992) active composure, conceptualized as activities producing rest, relaxation, and anxi- ety 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 compo- sure 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 strate- gies 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.

22 PART I Introduction to Gerontologic Nursing

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 recogni- tion 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 options, including heat or cold application, therapeutic touch, and massage therapy, could be explored. Being aware of indi- vidual cultural preferences and sharing these with other health care professionals will further promote positive interactions with older adults in all settings.

SOCIOLOGIC THEORIES OF AGING Sociologic theories focus on changing roles and relationships (Box 2-5). In some respects, sociologic theories relate to vari- ous 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 diver- sity of the aging population.

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 socioeco- nomic 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 concep- tualized as a mutual agreement between older adults and soci- ety 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 soci- ety and to voluntarily decrease their interactions with others was not readily accepted by the general public, much less the older persons 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 dis- cussion 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 suc- cessfully 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 with- draw 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,

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 pre- vious life events. The same habits, commitments, preferences, and other per- sonality 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 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 affect- ing the older person’s ability to interrelate with the environment (Lawton, 1982).

BOX 2-5 SOCIOLOGIC THEORIES OF AGING

CHAPTER 2 Theories of Aging 23

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 disen- gagement 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 be through the remainder of life (Havighurst et al., 1963).

Old age is not viewed as a terminal or final part of life sepa- rated 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 devel- opmental 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 interdepen- dence 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, biologi- cally, 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.

Person–Environment Fit Theory Another aging theory relates to the individual’s personal com- petence 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 per- sons, 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 rheuma- toid 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 envi- ronment 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 expe- riences, 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. 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 “typ- ical” 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 pro- tect 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 appro- priate interventions to help resolve a potentially adverse situa- tion. 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 oppor- tunity 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 pro- vider can develop a deeper understanding of why these par- ticular 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.

24 PART I Introduction to Gerontologic Nursing

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 hall- ways, and working elevators. Although these changes assist younger members of society with limited physical capabili- ties, they also benefit older adults. In addition, older adults might consider the installation of medical alert devices, pre- programmed 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 com- munity, perhaps even in the family home, instead of being pre- maturely institutionalized. Older adults continue to feel valued and viewed as active members of society when allowed to main- tain a sense of control over their living environment.

In some cities in the United States, multigenerational com- munities are developing, fostering a sharing of different cultures as well as generations. Schools are promoting “adopt a grand- parent” programs, day care centers are combining services for children and older adults, and older volunteers visit hospital- ized 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.

PSYCHOLOGIC THEORIES OF AGING The basic assumption of the psychologic theories of aging is that development does not end when a person reaches adult- hood 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, psy- chologic aging cannot readily be separated from biologic and sociologic influences.

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, intel- lectual 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 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).

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 moti- vated 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 beings; satisfying and changing relationships with other people; a democratic character structure; creativity;

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 partici- pants 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 life- time. Each stage represents a crisis, where the goal is to integrate physical maturation and psychosocial demands. At each stage the person has the op- portunity to resolve the crisis. Successful mastery prepares an individual for continued development. Individuals always have within themselves an oppor- tunity 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 tran- scendence 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 compen- sation (Schroots, 1996).

BOX 2-6 PSYCHOLOGIC THEORIES OF AGING

CHAPTER 2 Theories of Aging 25

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 per- sonality 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 experi- ences (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 behav- ioral, 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 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 devel- opment 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 develop- ment 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 con- flict between generativity and stagnation. During older adult- hood, the developmental task needing resolution is balancing the search for integrity and wholeness with a sense of despair (Table 2-1) (Potter & Perry, 2004).

In 1968, Peck expanded Erikson’s original theory regard- ing 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

Self- actualization

Self-esteem

Love and belonging needs

Safety and security

Physiologic

Physical safety Psychologic safety

Oxygen Fluids Nutrition Elimination Shelter SexBodytemperature

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 per- mission of Pearson Education, Inc.)

STAGES AND AGES

CHARACTERISTICS OF STAGES THEORY ADDENDUM

Generativity versus Self-Absorption or Stagnation 40 to 65 years old;

middle adulthood Mode: nurturing Virtue: care

Mature adults are concerned with establishing and guiding the next generation. Adults look beyond the self and express concern for the future of the world in general.

Self-absorbed adults will be preoccupied with their personal well-being and material gains. Preoccupation with self leads to stagnation of life.

Ego Integrity versus Despair 65 years to death;

older adulthood Mode: acceptance Virtue: wisdom

Older adults can look back with a sense of satisfaction and acceptance of life and death.

Unsuccessful resolution of this crisis may result in a sense of despair, in which individuals view life as a series of misfortunes, disappointments, and failures.

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. Louis: Mosby.

26 PART I Introduction to Gerontologic Nursing

role preoccupation, (2) body transcendence versus body preoc- cupation, 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 preoccu- pation, 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 focus- ing 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 even- tual 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 psy- chologic processes of development and aging from a life span perspective and formulated a psychologic model of successful aging. This 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 increas- ing 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 compen- sation 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 (optimiza- tion); 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 contin- ues 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 storytell- ing. Looking back over life’s accomplishments or failures is cru- cial 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 age. An older person talking about retirement, wor- rying about physical living space, and even planning funeral arrangements are all part of the developmental tasks appro- priate 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 achieve- ment, the nurse should facilitate them.

Nurses also need to keep in mind that intellectual function- ing 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 foun- dation 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 remem- ber 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 impor- tant 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 reliev- ing stress; many older adults no longer experience any type of meaningful physical contact with others, yet all individuals need this type of contact.

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 vegeta- bles 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 pleas- ant activity filled with memories of holidays and loved ones or prizes at the county fair. Older men may also enjoy cooking and

CHAPTER 2 Theories of Aging 27

should not be left out of this activity. Preparing muffins for a morning snack would be an activity in which everyone could participate.

MORAL AND SPIRITUAL DEVELOPMENT Human beings seek to explain and validate their existence in the world. For many individuals, this occurs through their develop- ment 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 con- template 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 spiritual- ity. 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).

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 back- ground 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 understand- ing 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 integrat- ing 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.

K E Y P O I N T S • No one theory explains the biologic, sociologic, or psycho-

logic aging processes. • An eclectic approach incorporating concepts from biology, soci-

ology, 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 predis-

pose 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 cur- rent 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 bio- logic changes.

• Human development is a process that occurs over the life span.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 commu- nity 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 criti- cizes 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.

28 PART I Introduction to Gerontologic Nursing

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Legal and Ethical Issues

Sue E. Meiner, EdD, APRN, BC, GNP

C H A P T E R

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 capabili- ties. Their quality of life often depends on the type and qual- ity 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.

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 deter- mined on a regional or national basis. Nurses are responsible

L E A R N I N G O B J E C T I V E S 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 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.

Original author: Diana C. Ballard, RN, MBA, JD; Revisions by: Sue E. Meiner, EdD, APRN, BC, GNP.

http://evolve.elsevier.com/Meiner/gerontologic

30 PART I Introduction to Gerontologic Nursing

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 practic- ing in the area of gerontology. The advanced practice geronto- logic 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 fed- eral statutes may help establish standards, although confor- mity with a state’s minimum standards does not necessarily prove that due care was provided. Conformity with local stan- dards 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 impor- tant in 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 accredita- tion status. This means that they voluntarily undergo a detailed survey by an organization with the skill and expertise to evalu- ate their services. One of the best known accreditation orga- nizations 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 stan- dard,” 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 circum- stances, 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.

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 inter- pret statutes and to prescribe methods for carrying out statu- tory 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 cer- tain older adults, those with disabilities, or certain other classi- fied 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 modifica- tions of amendments are still being debated at the time of publi- cation 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 ben- eficiaries 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.”

Two levels of care are generally associated with nursing facili- ties: 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 super- vised 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

1 42 U.S.C. §3001 (1965).

http://www.nursingworld.org

CHAPTER 3 Legal and Ethical Issues 31

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 insur- ance. These important laws affect the health benefits of mil- lions 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 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 pro-

vides. 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 cov- erage they had in their old job when they move to a new job.

6. HIPAA does not eliminate all use of preexisting condition exclusions.

7. HIPAA does not replace the state as the primary regulator of health insurance (HIPAA, 2004).

ELDER ABUSE AND PROTECTIVE SERVICES It has already been noted that the incidence of illness and dis- ability 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 arrange- ments 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 mis- treatment. 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 inci- dent (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 set- tings 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 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 identi- fied 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

32 PART I Introduction to Gerontologic Nursing

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 indi- vidual 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 com-

plex factors. Abuse may be a result of caregiver stress. The physi- cal and emotional demands of caring for a physically or mentally impaired person can be great, and the caregiver may not be pre- pared 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, 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 condi- tions or the older adult being malnourished or dehydrated. In addition, the nurse should be alert to signs of financial or mate- rial 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 nurs- ing 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 improve- ment in attitudes toward residents, conflict with residents, res- ident 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 protec- tive 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 resi- dents of 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 per- sons, 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 com- mitted 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, medi- cation, 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 care- givers 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 penal- ties, or both.

A report of suspected abuse may be required on a “reason- able suspicion.” This implies that actual knowledge or certainty is not necessary. Most states provide immunity from civil liabil- ity for anyone reporting older adult abuse based on reasonable suspicion 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.

2 Delaware Title 16 § §1132 and 1135. 3 Illinois Chapter 111½¶ 4161–176. 4 California Welfare and Institutions § §15600–15637.

CHAPTER 3 Legal and Ethical Issues 33

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 identifica- tion 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 com- municate and understand their wishes. This presents both an unequaled opportunity and a legally recognizable and indis- putable responsibility to advocate on their behalf. Thus, the need to be legally informed and professionally conscientious is greater than ever.

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 per- sons 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 cer- tified 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 sepa- rate 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 resi- dents 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 inspec- tions may be inadequate. Nursing facility residents continue to suffer from pressure ulcers and skin breakdown, malnu- trition 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 following section.

OBRA’s Three Major Parts The OBRA provisions are divided into three parts: (1) provi- sion 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 screen- ing of residents, maintenance of minimal nurse staffing levels, required and approved nurse aide training programs and com- petency 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 mecha- nisms 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 dis- cussed 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 environ- ment 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).

Provision of Service Requirements Quality of Care Nursing facility residents must be assessed to identify medical problems, describe their capacity to perform daily life func- tions, 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 condi- tion 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), estab- lished by the DHHS.

The assessment is used to develop a written and compre- hensive 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, psychoso- cial status, health problems, and specific body systems. Certain

34 PART I Introduction to Gerontologic Nursing

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 agen- cies that include the required collection of OASIS-C data.

The assessment and planning of care for nursing facility resi- dents is an important role for the professional nurse. As can be seen from this discussion of nursing facility reform, it is a cen- tral point for determining the care and services that particular residents will need. Careful assessment and planning are time consuming and 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 interper- sonal 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 provi- sions 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).

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 agree- ment. 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, 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 understand- ing 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 pro- visions 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 resi- dent rights requirements for some time. The OBRA strength- ened 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,

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 tele- phone 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 accommoda-

tion of individual needs and preferences 6. Protesting one’s treatment or care without discrimination or reprisal, in-

cluding 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

BOX 3-1 RESIDENT BILL OF RIGHTS

Modified from 42 CFR §483.10.

5 OBRA’ 87 at §4211(a), 42 U.S.C.A. § 139r(c) (West Supp 1989).

CHAPTER 3 Legal and Ethical Issues 35

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 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 appli- ances 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 under- recognized 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 main- tain 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) effec- tive 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 atten- tion to the need for comprehensive assessment and review of drug use. Surveyors review the duration of drug therapy regi- mens 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 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 interdis- ciplinary 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 behav- iors 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 behav- iors (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 condi- tion that led to the order for a restraint and monitor the resi- dent’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 activi- ties must be kept.

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 indi- cation for the use of the drug on the basis of one of the follow- ing 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 docu-

mented 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 decom- pensation 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

http://www.medicare.gov

36 PART I Introduction to Gerontologic Nursing

to note the return of 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 involv- ing patient care issues. Such procedures generally provide an avenue of communication that may be used to resolve ques- tions or disagreements that arise between health care profes- sionals. 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 uni- versal 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 posi- tion to 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 impli- cations 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 pro- vide 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 mechani- cal or chemical therapies.

Facility Survey and Certification The CMS is determined to see that every nursing facility imple- ments 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.

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 compli- ance with residents’ rights. The OBRA’s long-term care survey pro- cesses 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 facili- ties. 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 fed- eral 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 com- plaints, known as an ombudsman. Surveyors interview resi- dents 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 temporary manager to run a facility while deficiencies are

CHAPTER 3 Legal and Ethical Issues 37

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 defi- ciency—that is, whether it constitutes a pattern of activity or whether it is an isolated or sporadic occurrence—and the sever- ity 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 sanc- tions 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 insti- tution 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 addi- tional 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 for- mulating a plan of correction to submit to the regulatory officials.

In the course of an inspection a surveyor may find informa- tion 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 medica- tion 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 appropri- ate state agency or board for review of the nurse’s practice, request- ing 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 mea- sures that could lead to disciplinary action. Disciplinary action could range from a reprimand, to required educational remedia- tion, 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 improve- ments 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 data- base and not a national database. This permits unsuitable work- ers 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 activities. Specifically, he announced steps to make facil- ity 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 assis- tants, 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).

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 treat- ment 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,

38 PART I Introduction to Gerontologic Nursing

the risks of the treatment, the probability of success of the treat- ment, available treatment alternatives, and the consequences of not receiving the treatment.

Informed consent has developed from strong judicial def- erence toward individual autonomy, reflecting a belief that individuals have a right to be free from nonconsensual interfer- ence 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, how- ever, 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 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 treat- ment 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 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 deci- sions 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 spe- cific 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 deci- sion 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 com- petency on that information (Furrow et al., 1987).

The capacity to make decisions is applicable only to the deci- sion 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 right to self-determination, and in such matters, patients’

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.

CHAPTER 3 Legal and Ethical Issues 39

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 accu- rately 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 guide- lines 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 physi- cian consultations regarding medical conditions and docu- mented discussions with the patient and family members.

• That competency is established, again with proper docu- mentation or medical consultation, as may be indicated by applicable state law.

• 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 appro- priate 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 direc- tives 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 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 codi- fication 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 designa- tions 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 designa- tion of a health care agent.

General Provisions in Living Wills Living wills may be executed by any competent adult. Most stat- utes contain specific language excluding euthanasia and declar- ing that withholding care in compliance with the document does not 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 indi- cate 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 signa- ture, 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.

40 PART I Introduction to Gerontologic Nursing

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 enforce- able surrogate decision maker. The role of the designated sur- rogate 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 desig- nated 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 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 man- agement staff, legal counsel, or another appropriate source.

Decision Diagram The decision diagram assists in understanding the thought pro- cess that should be followed when trying to analyze end-of-life decision-making situations (Box 3-2).

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 personal wishes with health care professionals and family members so that they fully understand that person’s spe- cific 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 exe- cuted an AMD, other people are looked to for their knowledge about the patient’s wishes. If all agree about the patient’s medi- cal 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

Person is competent

Determination of competence

if indicated

Not competent: Substitute decision

Court appointed conservator if needed

Durable power of attorney:

Non–life support decisions

The living will speaks

The health care agent speaks: Withholding or withdrawing

Case law: Proof of

their wishes

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?

BOX 3-2 END-OF-LIFE DECISION DIAGRAM

CHAPTER 3 Legal and Ethical Issues 41

these terms.) The conservator then acts as the surrogate and decides according to the patient’s wishes as can best be deter- mined 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 prop- erty, 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 par- adigm 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 appoint- ment of a health care agent is presented in Box 3-4. States

usually provide forms for 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.

Conflicts between Directives and Family Desires 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 physi- cians and nurses in confusing and conflicting situations.

Although the law consistently upholds the expressed desires of patients, families continue to exert influence over medical deci- sions, 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 phy- sicians 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 effec- tive communication with the physician, the patient, and the

Any person 18 years of age or older may execute a document which shall con- tain 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 termi- nal 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 attend- ing 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 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 3-3 LIVING WILL: CONNECTICUT GENERAL STATUTES § 19A-575. FORM OF DOCUMENT

(a) Any person 18 years of age or older may execute a document that may, but need not, be in substantially the following form:

Document Concerning the Appointment of Health Care Agent I appoint..................... (NAME) to be my health care agent. If my attending phy- sician 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 ap-

point..................... (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)

BOX 3-4 HEALTH CARE AGENT: CONNECTICUT HEALTH CARE AGENT (C.G.S. § 19A-577)

42 PART I Introduction to Gerontologic Nursing

family, and on the quality of the facility’s policies and proce- dures, 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.

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 regard- ing 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 judg- ment 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 circum- stances, 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 indi- cate 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 constitution- ally permissible) to require “clear and convincing proof” as the standard needed to determine a person’s wishes regarding the withdrawal of life support.

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” stan- dard. 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 stan- dard is not applied in most states, a discussion is presented here to provide insight into the Cruzan case, to help under- stand the significance of the Court’s decision to initiate AMD legislation nationwide and to enact the PSDA and to pro- vide some clarification for understanding a lesser standard of proof.

The clear and convincing standard is an intermediate stan- dard 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 pro- duce 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 stan- dard 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 unneces- sarily 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 devel- opment 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:

A competent person has a constitutionally protected right under the Fourteenth Amendment to refuse medical treat- ment, even life saving nutrition and hydration; an incom- petent 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 interpre- tation is the author’s analysis of points taken from the concur- ring opinion of O’Connor):

Artificial provision of nutrition and hydration involves in- trusion and restraint and invokes the same due process con- cerns 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

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.

CHAPTER 3 Legal and Ethical Issues 43

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 informa- tion 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, facili- ties 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 admis- sion as a resident, hospice programs at the time of the initial receipt of hospice care, HMOs at the time of enroll- ment, and home health agencies in advance of the indi- vidual coming under the agencies’ care.

• The PSDA further requires distribution of written infor- mation 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 discrimina- tion or refusal to provide care based on whether an indi- vidual 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 com- munity 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 partici- pate 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 famil- iar 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.”

The ANA recommends that the following questions be part of the nursing admission assessment: • Do you have basic information about advance medical direc-

tives, 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 work- ers? (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 sup- ported 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 deci- sions 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 nec- essary for young healthy patients. Other studies have found that patients’ personal desires do not always get attention, and physi- cians try to avoid discussion of grim subjects (Parkman, 1997).

Questions arise about the effectiveness of AMDs in situ- ations where, for example, the person is away from home, a person 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 juris- diction 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 impor- tant and personal decisions into just another piece of paper.” AMDs must be part of a clinical process, not an administra- tive 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

44 PART I Introduction to Gerontologic Nursing

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 under- standing and level of competence. It is important for the nurse to facilitate this process using the professional skills and under- standing necessary to comply with the PSDA in such circum- stances (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 patient’s wishes notify the patient when it is appropri- ate 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 pro- vider. 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 surro- gate 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 real- istic 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 under- standing. The nurse’s role in clarifying matters and in explain- ing information may help alleviate the emotional dilemma associated with carrying out end-of-life decisions.

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 situa- tions. It presents the types of treatment that may be available in each situation and describes the persons with whom these mat- ters 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 ques- tions and answers. It is a process of reflection. These reflections add information that is gained over a lifetime. The close inter- personal 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 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.

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 nurs- ing 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 ethi- cal principles should serve as a framework for nursing deci- sion 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

CHAPTER 3 Legal and Ethical Issues 45

acknowledged and addressed if the moral and ethical prin- ciples 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 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 participat- ing in assisted suicide. The ANA’s position statement holds that “nurses, individually and collectively, have an obligation to pro- vide 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 nation- ally 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 physi- cian aid-in-dying on request of the patient and family; approval rose from 34% to 63% between 1950 and 1991. Other polls sug- gested 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 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 adminis- tration 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 wait- ing 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 han- dled 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 admin- istering 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 affirma- tive 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 com- mittee to help cope with such dilemmas.

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 deter- mine what was to be done with her body. It found that refrain- ing 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

19 In re Application of Brooks, NY Sup CT, Albany County, June 10, 1987.

46 PART I Introduction to Gerontologic Nursing

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 physi- cian, 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 par- ticipate in experimental research,20 and they may refuse to be examined, observed, or treated by students or other staff with- out 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 car- ried 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 justi- fied. 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 appropri- ate 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 pro- fessional 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 the details of the proposed study and the delib- erations 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 exacer- bated 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 per- mitted 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 dona- tions 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 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 con- flicts 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 deci- sions “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

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. 21 For example, see 1990 edition, General Laws of Massachusetts, sup- plemented by the 1991 Supplement, Chapter 111: 70E9h.

CHAPTER 3 Legal and Ethical Issues 47

technical, to help maintain a balanced view among profession- als and special interest groups, and to offer a variety of perspec- tives 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 edu- cation 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).

Issues and topics that might be discussed by an ethics com- mittee 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 commit- ment 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.

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 prac- tice 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 vulner- able, 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 dona- tion. 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 nurs- ing care he or she receives.

K E Y P O I N T S • 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 consid- ered a vulnerable population; therefore, their treatment in licensed health care institutions and other settings (includ- ing 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 sweep- ing reform affecting Medicare and Medicaid nursing facili- ties 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 nurs- ing 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 pro- cess 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 addition- ally interpreted in case law and state laws.

• Legal tools and instruments such as AMDs, DNR orders, des- ignation of health care agents, and durable powers of attor- ney 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 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 instru- ments themselves with the existence of these fundamental human rights.

• 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.

• To help caregivers and homebound older adults make decisions about treat- ment used to prolong life, consider using a values history. The values his- tory 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.

HOME CARE

48 PART I Introduction to Gerontologic Nursing

• The right to self-determination was given even more empha- sis 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 inter- est 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 dilem- mas that exist in the care of older adults. Ethics committees help in these matters by responding to the need for the educa- tion of and communication between caregivers and patients.

• It is preferable to resolve patient care dilemmas at the bed- side 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 per- son’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?

REFERENCES Administration on Aging (AOA). (2012). A profile of older Americans:

2012. Washington, DC: U.S. Department of Health and Human Services.

Alliance for Quality Nursing Home Care and American Health Care Association (AQNHC & AHCA). (2014). 2014 Nursing facilities’ standard health survey reports. Retrieved from www.ahcancal.org/ research_data/oscar_data/Pages/Default.aspx Accessed 09.04.14.

American Health Care Association (AHCA). (2012). 2012 Annual quality report: A comprehensive report on the quality of care in America’s nursing homes and rehabilitation facilities. Available at http:// www.hacancal.org/quality_improvement/Documents/AHCA%20 Quality%20Report%20FINAL.pdf. Accessed September 29, 2013.

American Nurses Association (ANA). (2010). Guide to the code of eth- ics for nurses: Interpretation and application. Washington, DC: The Association.

American Nurses Association (ANA). (2004). Scope and standards of practice. Washington, DC: The Association.

American Nurses Association (ANA). (2001). Code for nurses with in- terpretive statements. Washington, DC: The Association.

American Nurses Association praises Supreme Court for suicide rul- ing. (June 26, 1997). US Newswire.

American Nurses Association (ANA). (1995). Scope and standards of gerontological nursing practice. Washington, DC: The Association.

American Nurses Association (ANA). (1992). Position statement on nursing and the Patient Self-Determination Act. Washington, DC: The Association.

Black, H. C. (1979). Black’s law dictionary (5th ed.). St. Paul, MN: West Publishing.

Blendon, R. I., et al. (1992). Should physicians aid their patients in dy- ing? JAMA, 267(19), 2658.

Brett, A. & Grodin, M. (1991). Ethical aspects of human experimenta- tion in health services research. JAMA, 265(14), 1854.

Centers for Medicare and Medicaid Services (CMS). (2004). Protecting your health insurance coverage. Washington, DC: The Agency.

Centers for Medicare and Medicaid Services (CMS). (2012). Medicare and you, 2012. Baltimore: The Agency.

Coleman, C. H. (1994). Surrogate decision-making in New York: The legislative proposal of the New York State Task Force on Life and the Law. In American Bar Association (Eds.), Newsletter of the Medicine and Law Committee. Chicago: The Association.

Collier, H. G. (1990). Current issues in federal regulation of long-term care. In A. G. Gosfield (Ed.), Health law handbook. New York: Clark Boardman Callaghan.

Death with Dignity National Center (DDNC). (2010). Death with dig- nity around the U.S. Available at: http://www.deathwithdignity.org/ 2009/06/16death-dignity-around-us. Accessed September 19, 2013.

Furrow, B. R., Johnson, S. H., Jost, T. S., & Schwartz, R. L. (1987). Health law cases, materials and problems. St Paul, MN: West Publishing.

Giuliano, K. K. (1997). Organ transplants: Tackling the tough ethical questions. Nursing, 27(7), 34.

Hawes, C., Mor, V., Phillips, C. D., et al. (1997). The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: Effects on process quality. Journal of the American Geriatrics Society, 45(8), 977–985. Retrieved from: www.ncbi.nlm. nih.gov/pubmed/9256852. Accessed September 29, 2013.

Health Care Financing Administration (HCFA). (1998). Fact sheet. Health and Human Services (HHS). (2013). Read the law: The afford-

able care act, section by section. Retrieved from http://www.hhs.gov/ healthcare/rights/law/index.html. Accessed September 23, 2013.

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Hollerman, C. E. (1991). Membership of institutional ethics commit- tees. Physician Executive, 17(3), 34.

Houge, E. E. (1993). Ethics committees help facilities to cope with the PSDA. Brown Univ Long Term Care Newsletter, 5(3), 5.

Jett, K. (2012). Economic, legal, and ethical issues. In Ebersole & Hess’ toward healthy aging: Human needs and nursing response (8th ed.). St. Louis, MO: Elsevier/Mosby.

http://www.ahcancal.org/research_data/oscar_data/Pages/Default.aspx

http://www.hacancal.org/quality_improvement/Documents/AHCA%20Quality%20Report%20FINAL.pdf

http://www.deathwithdignity.org/2009/06/16death-dignity-around-us

http://www.ncbi.nlm.nih.gov/pubmed/9256852

http://www.hhs.gov/healthcare/rights/law/index.html

http://www.hhs.gov/ocr/privacy/hipaa/understanding/training/index.html

CHAPTER 3 Legal and Ethical Issues 49

Johnson, S. H. (1991). Residents’ rights under OBRA of 1987. In National Health Lawyers Association (Eds.), Long term care hand- book. Washington, DC: The Association.

Keller, H. B. (1996). Training course reduces abuse in nursing homes (preventing abuse in nursing homes). Aging, 3, 110.

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Lieberson, A. D. (Sept 1997). In Advance medical directives, Vol. 1. Clark Boardman Callaghan.

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McCormick, B. (1991). Right to die dilemma: Are ethics committees equipped to fill their roles? American Medical News, 34(42), 3.

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Neus, E. (June 17, 1998). Hospital must report all deaths to find more organ donors. Gannett News Service.

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Pear, R. (July 22, 1998). Clinton orders crackdown on substandard nursing homes. New York Times.

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Rushton, H. C., & Scanlon, C. (1998). A road map for navigating end- of-life care. Medsurg Nursing, 7(3), 57.

Sabatini, M. M. (1998). Health care ethics: Models of the provider– patient relationship. Dermatology Nursing, 10(5), 201.

Schreiber, J. C. (1990). Decision-making in treatment issues. In A. G. Gosfield (Ed.), Health law handbook. New York: Clark Boardman Callaghan.

Stillman, D., Strumpf, N., Capezuti, E., et al. (2005). Staff perceptions concerning barriers and facilitators to end-of-life care in nursing homes. Geriatric Nursing, 26, 259.

Strauss, P. J., Wolf, R., & Shilling, D. (1990). Aging and the law. Chicago: Commerce Clearing House.

Suffering in silence. (June 2, 1993). Long Term Care Management. The Joint Commission, Standards. (September 18, 2013). Retrieved

from www.joincommission.org. Touhy, T. A., & Jett, K. (2012). Ebersole & Hess’ toward healthy ag-

ing: Human needs & nursing response. St. Louis, MO: Elsevier/ Mosby.

U.S. Department of Health and Human Services (HHS). (June 18, 1998). HHS announces new hospital rules to increase organ dona- tion. M2 Press WIRE.

Vaca, B. L., & Daake, C. J. (1998). Review of nursing home regulations. Medsurg Nursing, 7(6), 165.

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http://www.aoa.gov/ncea

http://www.joincommission.org

50 PART I Introduction to Gerontologic Nursing

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.

APPENDIX 3A

Values History Form

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?) ___________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

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 com- plete the requested information. If you have not previously indi- cated 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:_________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

Kidney Dialysis To whom expressed: __________________________________ If oral, when? _______________________________________ If written, when? ____________________________________ Document location: __________________________________ Comments:_________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

CHAPTER 3 Legal and Ethical Issues 51

Cardiopulmonary Resuscitation (CPR) To whom expressed: If oral, when? _______________________________________ If written, when? ____________________________________ Document location: __________________________________ Comments:_________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

Respirators To whom expressed: __________________________________ If oral, when? _______________________________________ If written, when? ____________________________________ Document location: __________________________________ Comments:_________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

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?

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 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, ther- apists, 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 abil- ities, how would that affect your attitude toward indepen- dence and self-sufficiency? ___________________________ ________________________________________________ ________________________________________________ ________________________________________________

3. Do you wish to make any general comments about the value of independence and control in your life? ______________ ________________________________________________ ________________________________________________ ________________________________________________

52 PART I Introduction to Gerontologic Nursing

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 cir- cumstances? _____________________________________ ________________________________________________ ________________________________________________ ________________________________________________

3. What, if any, unfinished business from the past are you con- cerned about (e.g., personal and family relationships, busi- ness, 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 per- sonal relationships in your life?__________________________ ________________________________________________ ________________________________________________ ________________________________________________

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 atti- tude toward life?__________________________________ ________________________________________________ ________________________________________________ ________________________________________________

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 pres- ent)?____________________________________________ ________________________________________________ ________________________________________________

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 atti- tude toward illness, dying, and death? ___________________ ________________________________________________

G. Your Religious Background and Beliefs 1. What is your religious background? ___________________

________________________________________________ ________________________________________________

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 reli- gious background and beliefs?________________________ ________________________________________________ ________________________________________________ ________________________________________________

CHAPTER 3 Legal and Ethical Issues 53

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 environ- ment 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 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? _____________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

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).___________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

SUGGESTIONS FOR USE After you have completed this form, you may wish to pro- vide 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.

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 remain- ing 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 understand- ing 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 elabo- rated 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 con- temporary 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 diag- nosis and treatment and provision of a caring relationship that facilitates health and healing (ANA, 1995).

Gerontologic Assessment

Sue E. Meiner, EdD, APRN, BC, GNP

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.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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 patient.

http://evolve.elsevier.com/Meiner/gerontologic

CHAPTER 4 Gerontologic Assessment 55

It is clear from these elements that the nurse collects subjec- tive and objective data about the patient to assist in determining the 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 physi- cal 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 coun- try. 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 contem- porary 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 pro-

vide individualized care to their health care consumers. 5. A strong link exists between the professional work environ-

ment 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 tradi-

tional settings, that is, hospitals, homes, or long-term care facili- ties, 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 col- lection 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 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, sci- entific 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 assess- ing 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.

SPECIAL CONSIDERATIONS AFFECTING ASSESSMENT Nursing assessment of older adults is a complex and challeng- ing process that must take into account the following points to ensure an age-specific approach. The first is the interrelation- ship 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.

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 environ- ment 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 associ- ated 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 associ- ated 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 conges- tive 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 devel- oped 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 inter- acting physical and psychosocial factors in this case (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 situ- ation 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.

56 PART I Introduction to Gerontologic Nursing

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.

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 func- tion 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 contribut- ing 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 indica- tor of disease or disability so that treatable conditions are not disregarded.

Decreased Efficiency of Homeostatic Mechanisms Declining physiologic function and increased prevalence of dis- ease, 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 emo- tional stress.

The immune system, as the body’s major defense against illness and disease, has a decreased ability to provide protec- tion 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 immunocompe- tence, 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 occur- rences of these losses is often short, resulting in an inad- equate 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 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

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)

TABLE 4-1 EFFECT OF SELECTED VARIABLES ON FUNCTIONAL STATUS

Adapted from Lueckenotte, A.G. (1998). Pocket guide to gerontologic assessment (3rd ed.). St. Louis, MO: Mosby.

CHAPTER 4 Gerontologic Assessment 57

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 interpreta- tion for older adults (see Chapters 19 and 20).

In addition, no definitive aging norms exist for many patho- logic 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 charac- teristics of older people for each decade of life is a pressing need. This is an important area for scientific inquiry.

To compensate for the lack of definitive standards, the nurse should first assume heterogeneity rather than homoge- neity 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 charac- teristic 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 exam- ple, the confusion that may accompany urinary tract infec- tion. 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 presen- tations 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 presenting signs and symptoms with the older adult’s normal baselines.

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 delir- ium are some of the terms used to describe one of the most common 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 simultane- ous disturbances of the sleep–wake cycle, psychomotor behav- ior, 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 mul- tivariate causes of an ACS that the nurse must consider during assessment.

One of the more challenging aspects of assessment of an older adult is distinguishing a reversible ACS from irrevers- ible 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 deteriora- tion of cognitive function in an alert patient. Other diag- nostic features of dementia include memory impairment and one or more of the following cognitive disturbances: aphasia, apraxia, agnosia, or disturbance in executive func- tioning (e.g., planning, organizing, sequencing, abstracting) (American Psychiatric Association, 1994). Primary dementias include senile dementia of the Alzheimer type, Lewy body dis- ease, Pick disease, Creutzfeldt-Jakob disease, and multiinfarct dementia. Secondary dementias that have the same present- ing symptoms but that are often reversible with early diag- nosis include normal pressure hydrocephalus, intracranial masses or lesions, pseudodementia, and Parkinson dementia. Table 4-3 depicts the distinguishing features of an ACS and

58 PART I Introduction to Gerontologic Nursing

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.

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

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 de- creased states

c. Vascular occlusion—disseminated intravascular coagulopathy, emboli 2. Pulmonary abnormalities

a. Inadequate gas exchange states—pulmonary disease, alveolar hypoven tilation

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 hyper-

natremia, hypokalemia and hyperkalemia, hypochloremia and hyper- chloremia, 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 g. Porphyria

CHAPTER 4 Gerontologic Assessment 59

dementia. See Chapter 27 for a complete description of these primary and secondary dementing diseases.

Assessment may be complex because of the multiple associ- ated 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 evi- dence 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 con- ducting 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.

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 confi- dentiality. The following general suggestions related to prepara- tion of the environment and consideration of individual patient

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

TABLE 4-3 DIFFERENTIATING DEMENTIA AND ACUTE CONFUSIONAL STATE (ACS)

Modified from Foreman, M.D. (1986). Acute confusional states in hospitalized elderly: a research dilemma. Nursing Research, 35(1):34.

Modified from Foreman, M.D. (1966). Acute confusional states in hospitalized elderly: a research dilemma. Nursing Research, 35(1):34.

BOX 4-1 PHYSIOLOGIC, PSYCHOLOGIC, AND ENVIRONMENTAL CAUSES OF ACUTE CONFUSIONAL STATES IN HOSPITALIZED OLDER ADULTS—Cont'd

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

pseu dodelirium

Psychological 1. Severe emotional stress—postoperative states, relocation, hospitalization 2. Depression 3. Anxiety 4. Pain—acute and chronic 5. Fatigue 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

needs foster the collection of meaningful data (see the Cultural Awareness box).

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 direc-

tional or localized light. • Avoid glossy or highly polished surfaces, including floors,

walls, ceilings, and furnishings. • Place the patient in a comfortable seating position that facili-

tates 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 col-

lect thoughts before responding. • Be alert to signs of increasing fatigue such as sighing, grimac-

ing, 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 capabili- ties 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 inac- curate 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, groom- ing, 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 pro- mote 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.

THE HEALTH HISTORY The nursing health history and interview, as the first phase of a comprehensive, nursing-focused health assessment, pro- vide 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 pur- poseful, 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, cogni- tive, affective, and social well-being. Specific tools for the collec- tion of these data are addressed later in this chapter.

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 knowl- edge 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).

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 deter- mine 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 compre- hensive, 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 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.

CULTURAL AWARENESS Cultural Assessment

60 PART I Introduction to Gerontologic Nursing

FIGURE 4-1 Sample older adult health history format. (From Lueckenotte, A.G. (1998). Pocket guide to gerontologic assessment (3rd ed.). St. Louis: Mosby.)

1. Client Profile/Biographic Data

Name Address

Telephone Date and place of birth/Age

Sex Race Religion Marital status

Education Nearest contact person

Address/telephone

Advance directives: Living will:

Code status:

DPOA-Health care: POA-Finance:

2. Family Profile

Spouse(s) Children

Living Living

Names and addresses

Health status Age

Occupation

Deceased Deceased

Year of death Year of death

Cause of death Cause of death

3. Occupational Profile

Current work status

Previous occupations

Source(s) of income and adequacy for needs

4. Living Environment Profile

Type of dwelling

Number of rooms Number of levels

Number of people living in dwelling

Degree of privacy Nearest neighbor

Address/Telephone

5. Recreation/Leisure Profile

Hobbies/Interests

Organizational memberships

Vacations/Travel

6. Resources/Support Systems Used

Religious preference/Affiliation

Confidants

Who helps when need arises

Physician(s)

Hospital

Clinic

Home health agency

Meals on Wheels

Adult day care

Other

7. Description of Typical Day (Include Usual Bedtime Ritual)

Dosages

How/When taken

Prescribing physician

Date of prescription

Problems with adherence (complicated regimen with large num-

ber and variety of drugs, visual deficits, unpleasant side effects,

perception of effectiveness, difficulty obtaining, and affordability)

IMMUNIZATION STATUS (NOTE DATE OF MOST RECENT

IMMUNIZATION)

Tetanus, diphtheria PPD

Influenza Pneumovax

ALLERGIES (NOTE SPECIFIC AGENT AND REACTION)

Drugs Foods

Contact substances Environmental factors

NUTRITION

24-hour diet recall (include fluid intake)

Special diet, food restrictions, or preferences

History of weight gain/loss

Food consumption patterns (e.g., frequency, alone or with

others)

Problems affecting food intake (e.g., inadequate income, lack of

transportation, chewing/swallowing problems, emotional stress)

Habits

9. Past Health Status

Childhood illnesses

Serious or chronic illnesses

Trauma

Hospitalizations (note reason, date, place, duration, physician[s])

Operations (note type, date, place, reason, physician[s])

Obstetric history

8. Present Health Status

General health status during past year

General health status during past 5 years

Chief complaint

Knowledge, understanding, and management of health problems

(e.g., special diet, dressing changes)

Overall degree of function relative to health problems and

medical diagnoses

MEDICATIONS

Name(s)

62 PART I Introduction to Gerontologic Nursing

Postnasal drip

Allergies

History of infections

Self-rating of olfactory ability

MOUTH AND THROAT YES NO

Sore throat

Lesions/Ulcers

Hoarseness

Voice changes

Difficulty swallowing

Bleeding gums

Caries

Altered taste

Difficulty chewing

Prosthetic device(s)

EYES, cont’d YES NO

Pruritus

Pigmentation changes

Texture changes

Nevi changes

Frequent bruising

Hair changes

Nail changes

Corns, bunions, calluses

Chronic sun exposure

Healing pattern of lesions, bruises

HEMATOPOIETIC YES NO

Abnormal bleeding/bruising

Lymph node swelling

Anemia

Blood transfusion history

HEAD YES NO

Headache

Past significant trauma

Dizziness

Scalp itching

EYES YES NO

Vision changes

Glasses/Contact lenses

Pain

10. Family History

Draw pedigree (identify grandparents, parents, aunts, uncles,

siblings, spouse[s], children)

Survey the following: cancer, diabetes mellitus, heart disease,

hypertension, seizure disorder, renal disease, arthritis, alco-

holism, mental health problems, anemia

11. Review of Systems

Check Yes or No for each symptom and include full symptom

analysis on positive responses at end of each system.

GENERAL YES NO

Fatigue

Weight change in past year

Appetite change

Fever

Night sweats

Sleeping difficulty

Frequent colds, infections

Self-rating of overall health status

Ability to carry out activities of daily living (ADLs)

INTEGUMENT YES NO

Lesions/Wounds

Excessive tearing

Pruritus

Swelling around eyes

Floaters

Diplopia

Blurring

Photophobia

Scotomata

History of infections

Date of most recent vision examination

Date of most recent glaucoma check

Impact on ADL performance

EARS YES NO

Hearing changes

Discharge

Tinnitus

Vertigo

Hearing sensitivity

Prosthetic device(s)

History of infection

Date of most recent auditory examination

Usual ear care habits

Impact on ADL performance

NOSE AND SINUSES YES NO

Rhinorrhea

Discharge

Epistaxis

Obstruction

Snoring

Pain over sinuses

FIGURE 4-1, cont'd

CHAPTER 4 Gerontologic Assessment 63

GASTROINTESTINAL YES NO

Dysphagia

Indigestion

Heartburn

Nausea/Vomiting

Hematemesis

Appetite changes

History of infections

Date of most recent dental examination

Brushing pattern

Flossing pattern

Denture cleaning routine and problems

NECK YES NO

Stiffness

Pain/Tenderness

Lumps/Masses

Limited movement

BREASTS YES NO

Lumps/Masses

Pain/Tenderness

Swelling

Nipple discharge

Nipple changes

Breast self-examination pattern

Date and results of most recent mammogram

RESPIRATORY YES NO

Cough

Shortness of breath

Hemoptysis

Wheezing

Asthma/Respiratory allergy

Date and results of most recent chest x-ray examination

CARDIOVASCULAR YES NO

Chest pain/Discomfort

Palpitations

Shortness of breath

Dyspnea on exertion

Paroxysmal nocturnal dyspnea

Orthopnea

Murmur

Edema

Varicosities

Claudication

Paresthesias

Leg color changes

Food intolerances

Ulcers

Pain

Jaundice

Lumps/Masses

Change in bowel habits

Diarrhea

Constipation

Melena

Hemorrhoids

Rectal bleeding

Usual bowel pattern

URINARY YES NO

Dysuria

Frequency

Dribbling

Hesitancy

Urgency

Hematuria

Polyuria

Oliguria

Nocturia

Incontinence

Painful urination

Stones

Infections

GENITOREPRODUCTIVE—MALE YES NO

Lesions

Discharge

Testicular pain

Testicular mass(es)

Prostate problems

Venereal disease(s)

Change in sex drive

Impotence

Concerns re: sexual activity

GENITOREPRODUCTIVE—FEMALE YES NO

Lesions

Discharge

Dyspareunia

Postcoital bleeding

Pelvic pain

Cystocele/Rectocele/Prolapse

Venereal disease(s)

Infections

Concerns re: sexual activity

GASTROINTESTINAL, cont’d YES NO

FIGURE 4-1, cont'd

64 PART I Introduction to Gerontologic Nursing

Attitude is a feeling, value, or belief about something that determines behavior. If the nurse has an attitude that character- izes older adults as less healthy and alert and more dependent, then the interview structure will reflect this attitude. For exam- ple, 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 func- tional 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

ENDOCRINE SYSTEM YES NO

Heat intolerance

Cold intolerance

Goiter

Skin pigmentation/Texture changes

Hair changes

Polyphagia

Polydipsia

Polyuria

PSYCHOSOCIAL YES NO

Anxious

Depressed

Insomnia

Crying spells

Nervous

Fearful

Trouble with decision making

Difficulty concentrating

Statement of general feelings of satisfaction/Frustration

Usual coping mechanisms

Current stresses

Concerns about death

Impact on ADL performance

Menstrual history (age of onset, date of last menstrual period)

Menopausal history (age, symptoms, postmenopausal problems)

Date and result of most recent Pap test

GR P A

MUSCULOSKELETAL YES NO

Joint pain

Stiffness

Joint swelling

Deformity

Spasm

Cramping

Muscle weakness

Gait problems

Back pain

Prosthesis(es)

Usual exercise pattern

Impact on ADL performance

CENTRAL NERVOUS SYSTEM YES NO

Headache

Seizures

Syncope/Drop attacks

Paralysis

Paresis

Coordination problems

Tic/Tremor/Spasm

Paresthesias

Head injury

Memory problems

GENITOREPRODUCTIVE—FEMALE, cont’d

FIGURE 4-1, cont'd

Because initial impressions are important in all human relationships, if a mu- tually 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 informa- tion 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.

CULTURAL AWARENESS Cultural Considerations during the Interview: Introductions and Names

CHAPTER 4 Gerontologic Assessment 65

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 pre- viously 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,

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 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 gather- ing 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

• Be respectful of, interested in, and understanding of other cultures without being judgmental.

• Avoid stereotyping by race, gender, age, ethnicity, religion, sexual orienta- tion, 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 remain- ing 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.

CULTURAL AWARENESS Cultural Considerations and the Interviewer

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 ex- ist 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 comfort- able to them. Although nurses may be uncomfortable with the physical proxim- ity 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 cul- tural pattern. For example, sitting closely may be perceived by one patient as an expression of warmth and friendliness but by another as a threatening inva- sion 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.

CULTURAL AWARENESS Space and Distance

66 PART I Introduction to Gerontologic Nursing

deficits, anxiety, reduced energy level, pain, multiple and inter- related health problems, and the tendency to reminisce are the major patient factors requiring special consideration while the nurse elicits the health history (see Cultural Awareness boxes). Table 4-4 contains recommendations for managing these fac- tors (Lueckenotte, 1998).

The Health History Format The components of the sample format for collecting a health history (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 physi- cal 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 ques- tions. Box 4-2 is a discussion of each of the components. When

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 abil- ity prevents giving accurate information, secondary sources such as family, friends, or other medical records should be con- sulted. 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 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

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 vari- ous meanings cross-culturally. In many cultures (e.g., Middle Eastern, Hispanic), male health care providers may be prohibited from touching or examining either all or certain parts of the female body. Older women (e.g., those having a gyne- cologic 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 vali- dated 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 permis-

sible 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.

CULTURAL AWARENESS Culture and Touch

• 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, re- gion, 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 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).

CULTURAL AWARENESS Overcoming Language Barriers: Use of an Interpreter

CHAPTER 4 Gerontologic Assessment 67

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 interde- pendent relationship.

Living Environment Profile Any nursing interventions for the patient must be planned with consideration of the living environment. The degree of func- tion, 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 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 pro- viders and agencies used by the patient may alert the

• 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 ten- dency 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 medi- cal 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 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 instruc- tions, 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.

CULTURAL AWARENESS Overcoming Language Barriers: No Interpreter

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.

68 PART I Introduction to Gerontologic Nursing

nurse to patterns of use of health care and related services, perceptions of such resources, and attitudes about the impor- tance 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 dura- tion is also included. A complete and careful symptom analysis

may be carried out for the chief complaint by collecting infor- mation on the factors identified in Table 4-5 (Barkauskas et al., 1998). When the patient does not display specific symp- tomatology but instead has broader health concerns, the nurse should identify those concerns to begin establishing potential nursing interventions.

Information about the patient’s knowledge and understand- ing 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 strate- gies, 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 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 com- pliance), his or her knowledge of medications, the expiration dates of medications, and the potential risk for drug interactions.

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 member- ships, vacations or travel

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

BOX 4-2 BASIC COMPONENTS OF A NURSING HEALTH HISTORY 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?”

TABLE 4-5 SYMPTOM ANALYSIS FACTORS

From Barkauskas, V.H., et al. (1998). Health and physical assessment (2nd ed.). St. Louis: Mosby.

CHAPTER 4 Gerontologic Assessment 69

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, primar- ily 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) boost- ers 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 expe- rience a reactivation as a result of age-related immune system changes, chronic illness, and poor nutrition. Frail and institu- tionalized 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 inter- ventions. It is particularly important to note the patient’s reac- tion to the allergen and the usual treatment.

Nutrition A 24-hour diet recall is a useful screening tool that provides information about the intake of daily requirements, includ- ing 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 impair- ments, 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, hospital- izations, 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 con- sidered 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

diseases. It is also important to note the dates of onset or occur- rence 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 information gathered about previous hospitalizations, opera- tions, 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 forgetful- ness 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 envi- ronmental 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 over- all 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 sys- tems. 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

• 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., 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, dur- ing, and after preparation)?

• Has the patient chosen a particular nutritional practice such as vegetarian- ism 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.

CULTURAL AWARENESS Cultural Assessment of Nutritional Needs

70 PART I Introduction to Gerontologic Nursing

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 com- ponents serve as the basis for establishing nursing diagnoses and planning, developing interventions, and evaluating nursing care.

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 assess- ment 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 compre- hensive 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, delir- ium, 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 cor- relation 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 fail- ure 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 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 deter- mining 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 experi-

ence with a nurse conducting a physical assessment; an expla- nation may be warranted. The examiner needs to pro ject 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 assess- ment 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 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 mini- mum. Patients with limited range of motion and strength may require assistance. Be prepared to use alternative posi- tions 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 consis- tently followed. Working from one side of the patient, gener- ally 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 direc- tions 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 pos-

sible. 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 find-

ings. Not all data need to be recorded, but the goal is to reduce the potential for forgetting certain data, particularly measurements.

CHAPTER 4 Gerontologic Assessment 71

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 tradi- tional techniques of inspection, palpation, percussion, and aus- cultation are used with older adults, with age-specific variations for some areas. See Chapters 21 through 29 for these variations.

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 mecha- nisms 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 pre- carious 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 stan- dardized tools and measures of functional status are impor- tant 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 evalua- tion of an older person. Functional status assessment is a mea- surement of the 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 treat- ment 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, propel- ling 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; 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 nec- essarily mean one could live alone or without assistance. The Barthel Index is most appropriate for use in rehabilitation set- tings for documenting improvement in performance and ability.

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, shop- ping, preparing food, housekeeping, doing laundry, using transpor- tation, 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.

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 typi- cally advanced age, level of acuity, comorbidity, and risk for iat- rogenic 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, includ- ing 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

http://www.AMA.org

ACTION WITH HELP INDEPENDENT

1. Feeding (if food needs to be cut up—help) 5 10

2. Moving from wheelchair to bed and return (includes sitting up in bed) 5–10 15

3. Personal toilet (wash face, comb hair, shave, clean teeth) 0 5

4. Getting on and off toilet (handling clothes, wipe, flush) 5 10

5. Bathing self 0 5

6. Walking on level surface (or if unable to walk, propel wheelchair) 0* 5*

7. Ascend and descend stairs 5 10

8. Dressing (includes tying shoes, fastening fasteners) 5 10

9. Controlling bowels 5 10

10. Controlling bladder 5 10

A client scoring 100 BDI is continent, feeds himself, dresses himself, gets up out of bed and chairs, bathes himself, walks at least a

block, and can ascend and descend stairs. This does not mean that the client is able to live alone: The client may not be able to cook,

keep house, and meet the public but may be able to get along without attendant care.

DEFINITION AND DISCUSSION OF SCORING

1. Feeding

10 = Independent. The client can feed himself a meal from

a tray or table when someone puts the food within his

reach. He must put on an assistive device if this is

needed, cut up the food, use salt and pepper, spread

butter, etc. He must accomplish this in a reasonable

time.

5 = Some help is necessary (with cutting up food, etc., as

listed above).

2. Moving from wheelchair to bed and return

15 = Independent in all phases of this activity. Client can

safely approach the bed in her wheelchair, lock brakes,

lift footrests, move safely from bed, lie down, come to

a sitting position on the side of the bed, change the

position of the wheelchair, if necessary, to transfer

back into it safely and return to the wheelchair.

10 = Either some minimal help is needed in some step of

this activity or the client needs to be reminded or sup-

ervised for safety of one or more parts of this activity.

5 = Client can come to a sitting position without the help

of a second person but needs to be lifted out of bed,

or if she transfers, with a great deal of help.

3. Doing personal toilet

5 = Client can wash hands and face, comb hair, clean

teeth, and shave. He may use any kind of razor but he

must put in blade or plug in razor without help, as well

as get it from the drawer or cabinet. Female clients

must put on own makeup, if used, but need not braid

or style hair.

4. Getting on and off toilet

10 = Client is able to get on and off toilet, fasten and un-

fasten clothes, prevent soiling of clothes, and use

toilet paper without help. She may use a wall bar or

other stable object for support if needed. If it is neces-

sary to use a bed pan instead of toilet, he must be

able to place it on a chair, empty it, and clean it.

5 = Client needs help because of imbalance, in handling

clothes, or in using toilet paper.

5. Bathing self

5 = Client may use a bathtub or a shower or take a com-

plete sponge bath. He must be able to do all the steps

involved in whichever method is employed without

another person being present.

6. Walking on a level surface

5 = Client can walk at least 50 yards without help or super-

vision. She may wear braces or prostheses and use

crutches, canes, or a walker (but not a rolling walker).

She must be able to lock and unlock braces if used,

assume the standing position and sit down, get the

necessary mechanical aids into position for use, and

dispose of them when she sits. (Putting on and taking

off braces is scored under Dressing.)

6a. Propelling a wheelchair

5 = If a client cannot ambulate but can propel a wheelchair

independently, he must be able to go around corners,

turn around, maneuver the chair to a table, bed, toilet,

etc. He must be able to push a chair at least 50 yards.

Do not score this item if the client gets a score for

walking.

7. Ascending and descending stairs

10 = Client is able to go up and down a flight of stairs safely

without help or supervision. She may, and should, use

handrails, canes, or crutches when needed. She must

be able to carry canes or crutches as she ascends or

descends stairs.

5 = Client needs help with or supervision of any one of the

above items.

8. Dressing and undressing

10 = Client is able to put on and remove and fasten all

clothing, and tie shoe laces (unless it is necessary to

use adaptations for this). This activity includes putting

on and removing and fastening corset or braces when

these are prescribed. Such special clothing as suspen-

ders, loafer shoes, or dresses that open down the front

may be used when necessary.

FIGURE 4-2 Barthel Index. (Modified from Mahoney, F.I. & Barthel, D.W. (1965). Functional evalu- ation: the Barthel Index. Maryland State Medical Journal, 14:61.)

Score

1. Ability to use telephone

A. Operates telephone on own initiative—looks

up and dials numbers, etc.

B. Dials a few well-known numbers 1

C. Answers telephone but does not dial 1

D. Does not use telephone at all 0

2. Shopping

A. Takes care of all shopping needs independently 1

B. Shops independently for small purchases 0

C. Needs to be accompanied on any shopping trip 0

D. Completely unable to shop 0

3. Food preparation

A. Plans, prepares, and serves adequate meals

independently

B. Prepares adequate meals if supplied with

ingredients

C. Heats and serves prepared meals, or prepares

meals but does not maintain adequate diet

D. Needs to have meals prepared and served 0

4. Housekeeping

A. Maintains house alone or with occasional

assistance (e.g., “heavy work—domestic help”)

B. Performs light daily tasks such as dishwashing

and bed making 1

C. Performs light daily tasks but cannot maintain

acceptable level of cleanliness

D. Needs help with all home maintenance tasks 1

E. Does not participate in any housekeeping tasks 0

Score

5. Laundry

A. Does personal laundry completely 1

B. Launders small items—rinses socks,

stockings, etc.

C. All laundry must be done by others 0

6. Mode of transportation

A. Travels independently on public transportation

or drives own car 1

B. Arranges own travel via taxi but does not other-

wise use public transportation

C. Travels on public transportation when assisted

or accompanied by another

D. Travel limited to taxi or automobile with assis-

ance of another

E. Does not travel at all 0

7. Responsibility for own medications

A. Is responsible for taking medication in correct

dosages at correct time

B. Takes responsibility if medication is prepared in

advance in separate dosages

C. Is not capable of dispensing own medication 0

8. Ability to handle finances

A. Manages financial matters independently

(budgets, writes checks, pays rent, bills, goes

to bank), collects and keeps track of income

B. Manages day-to-day purchases but needs help

with banking, major purchases, etc.

C. Incapable of handling money 0

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.)

5 = Client needs help in putting on and removing or fast-

ening any clothing. He must do at least half the work

himself. He must accomplish this in a reasonable time.

Women need not be scored on use of a brassiere or

girdle unless these are prescribed garments.

9. Continence of bowels

10 = Client is able to control her bowels and have no acci-

dents. She can use a suppository or take an enema

when necessary (as for spinal cord injury patients who

have had bowel training).

5 = Client needs help using a suppository or taking an

enema or has occasional accidents.

10. Controlling bladder

10 = Client is able to control his bladder day and night.

Spinal cord injury clients, who wear an external device

and leg bag, must put them on independently, clean

and empty bag, and stay dry day and night.

5 = Client has occasional accidents, cannot wait for the

bed pan, cannot get to the toilet in time, or needs help

with an external device.

The total score is not as significant or meaningful as the

breakdown into individual items, since these indicate where the

deficiencies are.

Any applicant to a chronic hospital who scores 100 BDI

should be evaluated carefully before admission to see whether

such hospitalization is indicated. Discharged clients with 100

BDI should not require further physical therapy but may benefit

from a home visit to see whether any environmental adjustments

are indicated.

*Score only if unable to walk.

FIGURE 4-2, cont'd

74 PART I Introduction to Gerontologic Nursing

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 symp- tom of acute illness such as infections (pneumonia, urinary tract infection). These declines are usually reversible.

E. Functional status is contingent on cognition and sensory 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 indepen-

dent 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

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 ad- minister 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 en- courage reading the newspaper.

2. Educate older adults and caregivers on the value of independent function- ing 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. 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 com-

mon complications. Alternative care settings may be required to ensure safety.

6. Provide sufficient protein and calories to ensure adequate intake and pre- vent further decline.

7. Provide caregiver support and community services such as home care, nursing, and physical and occupational therapy services to manage func- tional decline.

IV. Expected Outcomes A. Patients can

1. Maintain a safe level of ADLs and ambulation. 2. Make necessary adaptations to maintain safety and independence, includ-

ing assistive devices and environmental adaptations. B. Provider can demonstrate

1. Increased assessment, identification, and management of patients sus- ceptible to or experiencing functional decline.

2. Ongoing documentation of capacity, interventions, goals, and outcomes. 3. Competence in preventive and restorative strategies for function.

CHAPTER 4 Gerontologic Assessment 75

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. Research is being conducted to determine the impact of this age-specific, comprehensive approach on reducing morbidity and mortality associated with hospitalizing older adults.

Nurses practicing in all settings should begin incorporat- ing 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 abil- ity. 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 intel- lectual function) and the effect of the assessed degree of impair- ment on functional ability. This assessment is usually integrated into the interview and physical examination, and testing is conducted in a natural, nonthreatening manner with consider- ation of ethnicity. Table 4-6 identifies typical areas to assess in a mental status assessment. Note that this mental status assess- ment provides a baseline that identifies the need for the admin- istration of one of the standardized mental status examinations.

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 iden- tification 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 orienta- tion, 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.

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 assess- ment and neuropsychiatric evaluation may be warranted.

The Mini-Mental State Examination (MMSE) tests the cogni- tive aspects of mental functions: orientation, registration, atten- tion 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 fur- ther investigation. The examination takes only a few minutes

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 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.

TABLE 4-6 MENTAL STATUS ASSESSMENT

Modified from Kresevic, D.M., & Mezey, M. (1997). Assessment of function: Critically important to acute care of elders. Geriatric Nursing, 18(5):216.

BOX 4-3 NURSING STANDARD OF PRACTICE PROTOCOL: ASSESSMENT OF FUNCTION IN ACUTE CARE—Cont'd

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 func-

tional 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.

76 PART I Introduction to Gerontologic Nursing

to complete and is easily 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 cre- ated 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.

Instructions: Ask questions 1–10 in this list, and record all

answers. Ask question 4a only if patient does not have a

telephone. Record total number of errors based on 10 questions.

� � 1. What is the date today? Month/Day/Year

2. What day of the week is it?

3. What is the name of this place?

4. What is your telephone number?

4a. What is your street address? (Ask only if

patient does not have a telephone.)

5. How old are you?

6. When were you born?

7. Who is the President of the United States

now?

8. Who was the President just before him?

9. What was your mother’s maiden name?

10. Subtract 3 from 20 and keep subtracting 3

from each new number, all the way down.

Total Number of Errors

TO BE COMPLETED BY INTERVIEWER

Patient’s name Date

Sex Male Race White

Female Black

Other

Years of education Grade school

High school Beyond high school

Interviewer’s name

Instructions for Completion of the Short Portable Mental

Status Questionnaire (SPMSQ)

All responses to be scored as correct must be given by subject

without reference to calendar, newspaper, birth certificate, or

other aid to memory.

Question 1 is to be scored as correct only when the exact month,

exact date, and the exact year are given correctly.

Question 2 is self explanatory.

Question 3 should be scored as correct if any correct description

of the location is given. “My home,” correct name of the town or

city of residence, or the name of hospital or institution if subject

is institutionalized are all acceptable.

Question 4 should be scored as correct when the correct tele-

phone number can be verified, or when the subject can repeat

the same number at another point in the questioning.

Question 5 is scored as correct when stated age corresponds to

date of birth.

Question 6 is to be scored as correct only when the month, exact

date, and year are all given.

Question 7 requires only the last name of the President.

Question 8 requires only the last name of the previous President.

Question 9 does not need to be verified. It is scored as correct if

a female first name plus a last name other than subject’s last

name is given.

Question 10 requires that the entire series must be performed

correctly in order to be scored as correct. Any error in the series

or unwillingness to attempt the series is scored as incorrect.

Scoring of the Short Portable Mental Status Questionnaire

(SPMSQ)

The data suggest that both education and race influence perfor-

mance on the Mental Status Questionnaire and they must

accordingly be taken into account in evaluating the score attained

by an individual.

For the purposes of scoring, three educational levels have been

established: (1) persons who have had only a grade school

education; (2) persons who have had any high school education

or who have completed high school; (3) persons who have had

any education beyond the high school level, including college,

graduate school, or business school.

For white subjects with at least some high school education, but

not more than high school education, the following criteria have

been established:

0–2 errors Intact intellectual functioning

3–4 errors Mild intellectual impairment

5–7 errors Moderate intellectual impairment

8–10 errors Severe intellectual impairment

Allow one more error if subject has had only a grade school

education.

Allow one less error if subject has had education beyond high

school.

Allow one more error for black subjects, using identical education

criteria.

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.)

CHAPTER 4 Gerontologic Assessment 77

DATE PT INITIALS # AGE GENDER M F CLINIC NAME PROVIDER TESTED BY

1) GET THE PATIENT‘S ATTENTION, THEN SAY: “I am going to say three words that I want you to remember. The words are

2) SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED: “Please draw a clock in the space below. Start by drawing a large circle.” (When this is done, say) “Put all the numbers in the circle.” (When done, say) “Now set the hands to show 11:10 (10 past 11).”

Score the clock (see other side for instructions): Normal clock Abnormal clock

2 points

(Score 1 point for each) 3-Item Recall Score

Clock Score 0 points

3) SAY: “What were the three words I asked you to remember?”

Total Score � 3-item recall plus clock score 0, 1, or 2 possible impairment; 3, 4, or 5 suggests no impairment

Please say them for me now.” (Give the patient 3 tries to repeat the words. If unable after 3 tries, go to next item.) (Fold this page back at the TWO dotted lines BELOW to make a blank space and cover the memory words. Hand the patient a pencil/pen.)

MINI-COG

Banana Sunrise Chair

9 3

6 7

9 3

6 7

11 12

1 2

678

11 9 3

4 5

1 2

67 8

10 11

CLOCK SCORING

NORMAL CLOCK

SOME EXAMPLES OF ABNORMAL CLOCKS (THERE ARE MANY OTHER KINDS)

A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS: All numbers 1-12, each only once, are present in the correct order and direction (clockwise). Two hands are present, one pointing to 11 and one pointing to 2.

ANY CLOCK MISSING EITHER OF THESE ELEMENTS IS SCORED ABNORMAL. REFUSAL TO DRAW A CLOCK IS SCORED ABNORMAL.

Abnormal Hands Abnormal Spacing Abnormal Spacing/Numbers

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].)

mailto:[email protected]

78 PART I Introduction to Gerontologic Nursing

Affective status measurement tools are used to differenti- ate 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 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 scor- ing 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 depres- sion (Yesavage & Brink, 1983). Questions answered as indicated score one point. A score of 5 or more may indicate depression.

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 nega- tively affect physical and mental health, and vice versa. Second, an individual’s 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 func- tion 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 cen- tral role in the overall level of health and well-being. The assess- ment of this aspect of the patient’s social system may yield vital information about an important part of the total support net- work. 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 func- tion 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.

Many other measures of social function can be found in the literature, but a lack of consensus by experts as to which are most 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.

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) 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.

BOX 4-4 YESAVAGE GERIATRIC DEPRESSION SCALE, SHORT FORM

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.

CHAPTER 4 Gerontologic Assessment 79

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).

Now I’d like to ask you some questions about your family and

friends.

Are you single, married, widowed, divorced, or separated?

1 Single 3 Widowed 5 Separated

2 Married 4 Divorced Not answered

If “2” ask following:

Does your spouse live here also?

1 yes 0 no

Not answered

Who lives with you?

(Check “Yes” or “No” for each of the following.)

Yes No

No one

Husband or wife

Children

Grandchildren

Parents

Grandparents

Brothers and sisters

Other relatives (does not include in-laws

covered in the above categories)

Friends

Nonrelated paid help (includes free room)

Others (specify)

In the past year about how often did you leave here to visit your

family and/or friends for weekends or holidays or to go on shop-

ping trips or outings?

1 Once a week or more

2 One to three times a month

3 Less than once a month or only on holidays

4 Never

Not answered

How many people do you know well enough to visit with in their

homes?

3 Five or more

2 Three to four

1 One to two

0 None

Not answered

About how many times did you talk to someone—friends,

relatives, or others—on the telephone in the past week (either

you called them or they called you)? (If subject has no phone,

question still applies.)

3 Once a day or more

2 Twice

1 Once

0 Not at all

Not answered

How many times during the past week did you spend some time

with someone who does not live with you, that is, you went to

see them, or they came to visit you, or you went out to do things

together?

3 Once a day or more

2 Two to six

1 Once

0 Not at all

Not answered

How many times in the past week did you visit with someone,

either with people who live here or people who visited you here?

3 Once a day or more

2 Two to six

1 Once

0 Not at all

Not answered

Do you have someone you can trust and confide in?

1 Yes

0 No

Not answered

Do you find yourself feeling lonely quite often, sometimes, or

almost never?

0 Quite often

1 Sometimes

2 Almost never

Not answered

Do you see your relatives and friends as often as you want to,

or not?

1 As often as wants to

0 Not as often as wants to

Not answered

Is there someone (outside this place) who would give you any

help at all if you were sick or disabled (e.g., your husband/wife,

a member of your family, or a friend)?

1 Yes

0 No one willing and able to help

Not answered

If “yes,” ask A and B.

A. Is there someone (outside this place) who would take care

of you as long as needed, or only for a short time, or only

someone who would help you now and then (e.g., taking

you to the doctor, or fixing lunch occasionally)?

3 Someone who would take care of subject indefinitely

(as long as needed)

2 Someone who would take care of subject for a short time

(a few weeks to six months)

1 Someone who would help subject now and then

(taking him to the doctor or fixing lunch, etc.)

Not answered

B. Who is this person?

Name

Relationship

RATING SCALE

Rate the current social resources of the person being evaluated

along the 6-point scale presented below. Circle the one number

80 PART I Introduction to Gerontologic Nursing

For all the additional assessment measures discussed pre- viously, 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 appropri- ately with regard to purpose, setting, timing, and safety. Doing so leads to a more accurate appraisal on which to base nurs- ing diagnostic statements and to plan suitable and effective interventions.

LABORATORY DATA The last component of a comprehensive assessment is evalua- tion 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.

SUMMARY This chapter presented the components of a comprehensive nursing-focused assessment for an older adult, including spe- cial 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.

K E Y P O I N T S • 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 pre- sentation 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 interven- tions 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 his- tory 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 compre- hensive 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 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

that best describes the person’s present circumstances.

1. Excellent Social Resources: Social relationships are very

satisfying and extensive; at least one person would take care

of him (her) indefinitely.

2. Good Social Resources: Social relationships are fairly satisfy-

ing and adequate and at least one person would take care of

him (her) indefinitely, or social relationships are very satisfy-

ing and extensive, and only short-term help is available.

3. Mildly Socially Impaired: Social relationships are unsatis-

factory, of poor quality, few; but at least one person would

take care of him (her) indefinitely, or social relationships are

fairly satisfactory and adequate, and only short-term help is

available.

4. Moderately Socially Impaired: Social relationships are

unsatisfactory, of poor quality, few; and only short-term care

is available, or social relationships are at least adequate or

satisfactory, but help would only be available now and then.

5. Severely Socially Impaired: Social relationships are unsatis-

factory, of poor quality, few; and help would be available only

now and then, or social relationships are at least satisfactory

or adequate, but help is not available even now and then.

6. Totally Socially Impaired: Social relationships are unsatis-

factory, of poor quality, few; and help is not available even

now and then.

FIGURE 4-6, cont'd

CHAPTER 4 Gerontologic Assessment 81

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.

C R I T I C A L T H I N K I N G E X E R C I S E S 1. You are interviewing a 79-year-old man, who was just admit-

ted 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 hyper- tensive. 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?

REFERENCES American Nurses Association (ANA). (1995). Nursing’s social policy

statement. Washington, DC: The Association. American Nurses Association (ANA). (1980). Nursing: A social policy

statement. Kansas City, MO: The Association. American Nurses Association (ANA). (2004). Nursing: Scope and stan-

dards of practice. Silver Spring, MD: The Association. American Nurses Association (ANA). (2010). Nursing: Scope and stan-

dards of practice (2nd ed.). Silver Spring, MD: Nursesbooks.org. American Psychiatric Association. (1994). Diagnostic and statistical man-

ual of mental disorders (4th ed.). Washington, DC: The Association. Augustine, N., & Capitosti, S. (2010). The road ahead: Be prepared

for a new direction in providing care. Advances in Long-Term Care Management.

Barkauskas, V. H., et al. (1998). Health and physical assessment (2nd ed.). St. Louis: Mosby.

Beck, A. T., & Beck, R. W. (1972). Screening depressed patients in family practice: A rapid technique. Postgraduate Medicine, 52, 81.

Borson, S., et al. (2003). The Mini-Cog as a screen for dementia: Validation in a population-based sample. Journal of the American Geriatrics Society, 51(10), 1451.

Burnside, I. M. (1988). Nursing and the aged: A self-care approach (3rd ed.). New York: McGraw-Hill.

Duke University Center for the Study of Aging and Human Development. (1988). OARS multidimensional functional assess- ment: Questionnaire. Durham, NC: Duke University.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: Practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189.

Foreman, M. D. (1986). Acute confusional states in hospitalized el- derly: A research dilemma. Nursing Research, 35(1), 34.

Jett, K. (2012). Health assessment. In T. A. Touhy & K. Jett (Eds.), Ebersole & Hess’ toward healthy aging: Human needs & nursing response (8th ed.). St Louis: Elsevier/Mosby.

Kane, R. A., & Kane, R. L. (1981). Assessing the elderly: A practical guide to measurement. Lexington, MA: Lexington Books.

Katz, S., Ford, A. B., & Moskowitz, R. W. (1963). Studies of illness in the aged: The index of ADL—A standardized measure of biological and psychosocial function. JAMA, 185, 914.

Kresevic, D. M., & Mezey, M. (1997). Assessment of function: Critically important to acute care of elders. Geriatric Nursing, 18(5), 216.

Lawton, H. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179.

Lueckenotte, A. G. (1998). Pocket guide to gerontologic assessment (3rd ed.). St. Louis: Mosby.

Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61.

Montgomery, J., Mitty, E., & Flores, S. (2008). Resident condition change: Should I call 911? Geriatric Nursing, 29, 159.

Moser, M. (2007). Update on the management of hypertension: Recent clinical trials and the JNC 7. Journal of Clinical Hypertension, 6(Suppl. 10), 4.

National High Blood Pressure Education Program. (2003). U. S. Department of Health and Human Services, Public Health Service: The seventh report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Washington, DC: National Institutes of Health, National Heart, Lung, and Blood Institute. Available at, www.nhlbi.nih.gov/guidelines/hypertension/ index.htm. Accessed September 9, 2013.

Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23, 433.

Shephard, R. (2010). MDS 3.0 are you ready? Advance For Health Information Professionals.

Touhy, T. A., & Jett, K. (2012). Ebersole & Hess’ toward healthy aging: Human needs & nursing response (8th ed.). St. Louis: Elsevier.

Wattmo, C., Wallin, A. K., Londos, E., et al. (2010). Long-term outcome and predictive models of activity of daily living in Alzheimer dis- ease with cholinesterase inhibitor treatment. Alzheimer Disease and Associated Disorders.

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.

http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm

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Cultural Influences

Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD(c)

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

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 pro- jected 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).

It must be noted, however, that these and many of the figures we have today are drawn from the U.S. Census, in which per- sons 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, consider- able 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 com- monalities 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 than that of the native born. Although access to the United

L E A R N I N G O B J E C T I V E S 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.

Original authors: Alice Welch, PhD, RN, CTN, and Kem Louis, PhD, RN, CS, FAAN; and Kathleen F. Jett, MSN, PhD, GNP-BC.

http://evolve.elsevier.com/Meiner/gerontologic

84 PART II Influences on Health and Illness

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.

CULTURALLY SENSITIVE GERONTOLOGIC NURSING CARE

The diversity of values, beliefs, languages, and historical life expe- riences of older adults today challenges nurses to gain new aware- ness, 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 sensi- tive 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

20,000,000 18,000,000 16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000

0 2000 2010

Hispanic or Latino alone Black or African-American alone Asian and Pacific Islander alone American Indians and Alaskan Native alone

2020

Census year

2030 2040 2050

FIGURE 5-1 Projected Population of Persons 65 and Older by Race, 2000-2050. (From U.S. Bureau of the Census, 2011.)

Data Classes Percent

0.1–1.5

1.6–4.9

5.0–9.9

10.0–14.0

14.1–24.3

FIGURE 5-2 Percent of persons 65 years or older (black or African American alone). (From U.S. Bureau of the Census, 2011.)

Data Classes Percent

0.0–0.1

0.2–0.3

0.4–0.7

0.8–1.9

2.0–14.2

FIGURE 5-4 Percent of persons 65 or older (American Indian or Alaskan native only). (From U.S. Bureau of the Census, 2011.)

Data Classes Percent

0.1–0.7

0.8–1.1

1.2–2.3

2.4–4.7

4.8–70.5

FIGURE 5-3 Percent of persons 65 or older (Asian alone). (From U.S. Bureau of the Census, 2011.)

86 PART II Influences on Health and Illness

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 Increased knowledge is a prerequisite for culturally appro- priate care given to all persons, regardless of race or ethnic- ity. 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, eco- nomic, and cultural), world religions, intercultural commu- nication, 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 interchange- ably 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 simi- larities, but no two are exactly alike. Cultural knowledge is transmitted from one member to another through the pro- cess 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

Data Classes Percent

0.1–1.0

1.1–2.0

2.1–4.0

4.1–10.9

11.0–31.3

FIGURE 5-5 Percent of persons 65 or older (Hispanic or Latino, any race). (From U.S. Bureau of the Census, 2011.)

CHAPTER 5 Cultural Influences 87

group to predict each other’s behavior and respond appro- priately, including during one’s own aging and that of com- munity members. Culture is universal, adaptive, and exists at the microlevel of the individual or family and at the macro- level in terms of a region, country, or a specific group. Review Boxes 5-1 through 5-4.

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

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) • Becoming as independent as possible • Reliance on technology

• Health instruction: • Explaining how “to do” this care for self • Giving the “medical” facts

BOX 5-1 ANGLO-AMERICAN (EUROPEAN AMERICAN) CULTURE (MAINLY U.S. MIDDLE AND UPPER CLASS)

From Leininger, M (Ed.). (1991). Culture care diversity and universality: A theory of nursing. Sudbury, MA: National League for Nursing, Jones and Bartlett.

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 • 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”

BOX 5-2 APPALACHIAN CULTURE

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 dispro- portionate degree of invasive gynecologic 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 demon- strated that significant predictors among all study participants for hysterec- tomy 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 knowl- edge 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? • 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?

88 PART II Influences on Health and Illness

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 surround- ing acculturation are particularly relevant for ethnic older per- sons. 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 influ- enced, hereditary traits such as skin color and eye color, facial structures, 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 character- istics. 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).

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 mam- mography, 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

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 appropri- ate agency or social worker for assistance, if necessary.

2. Assess the caregiver’s and patient’s own concepts of health and illness. 3. Communicate with persons with different linguistic or cultural pat-

terns (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 deter- mine views on health and illness concepts. Incorporate these data into the care plan to meet the cultural needs of the individual and family.

HOME CARE

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

BOX 5-3 BLACK CULTURE

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.

CHAPTER 5 Cultural Influences 89

awareness of, sensitivity to, and knowledge of, both overt and covert barriers to our caring (Galanti, 2008). Among these bar- riers 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 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 envi- ronments (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 descrip- tion may be applied to discrimination based on age. The fol- lowing example illustrates racism.

A gerontologic nurse responded to a call from an older patient’s room. For some unknown reason, the patient, re- peatedly 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 at- tempting 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 be- havior: He was white and so was she, but the aide was black.

Cultural conflict is the anxiety experienced when people inter- act 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 American nurse manager reprimanded

the immigrant Korean nurse for not walking with the patient as ordered. The immigrant Korean nurse commented to an- other 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 con- flicts 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 treat- ment are grounded in culture. The significance attached to ill- ness 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 nurs- ing because elders have had a lifetime of experience with ill- ness of self, family, and others within their ethnic and cultural groups (Spector, 2012). Beliefs about health, illness, and treat- ment 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 displeas- ing 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 differ- ent groups, see Box 5-5.

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 rela- tionships, or geophysical and metaphysical forces in the uni- verse, 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 mani- festations of philosophies of balance are the “yin and yang” of ancient China and the “hot and cold theory” common throughout the world.

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.

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 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 • Accept most modern medical practices

Islam (Muslim/Moslem) • Faith healing not acceptable unless patient’s psychological condition is dete-

riorating; 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 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 interven-

tion 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

Unitarian Universalist • Most believe in general goodness of fellow humans and appreciate expres-

sion of that goodness through visits from clergy and fellow parishioners dur- ing times of illness

CHAPTER 5 Cultural Influences 91

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 seat of the energy forces is within the autonomic nervous system. Health is a state of perfect bal- ance between yin and yang. When a person is in balance, he or she experiences a feeling of inner and outer peace. Illness repre- sents 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 classi- fied 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 cultur- ally 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 treat- ment is called the biomedical or Western perspective. The body is viewed as a functioning machine. A part may fall into disre- pair 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 natu- ral 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 success- fully treated in the past, based on one or several of the beliefs just described. When self-treatment fails, a person may con- sult 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 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 neigh- borhood 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 medi- cine. 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 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 preven- tive 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 noncompli- ant 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 individ- ual 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

92 PART II Influences on Health and Illness

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 (HIPAA) further codified the role of the individual as the ultimate “owner” of health informa- tion (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 affili- ation 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 diagno- sis or prognosis. Instead, it is expected that this information be conveyed to the oldest male in the family, for example, the hus- band 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 con- flict exists, as illustrated by the following scenario:

An older Filipino woman is seen in her home by a pub- lic 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 im- mediate 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.

Context A final perspective is that of context. In the 1970s, E.T. Hall described the interactional patterns of high context (uni- versalism) and low context (particularism). This theory has stood the test of time and is very useful when relat- ing 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 lan- guage is more important than spoken words because it is there that the true meaning of the communication is con- sidered 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 commu- nication, 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.

SKILLS The most important skills are those associated with sensi- tive intercultural communication. The linguistically compe- tent 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 inap- propriate. 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

http://changingminds.org/explanations/culture/hall_culture.htm

CHAPTER 5 Cultural Influences 93

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 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 conclu- sions but may also cause the nurse to reflect the apparent appro- priate behavior with this patient.

In many Asian cultures, looking one directly in the eyes implies equality. Older adults may avoid eye contact with physi- cians 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 oppo- site 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 “inter- preter” and “translator.” An interpreter decodes the spoken word, whereas a translator decodes the written word. The translator must further 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 translat- ing 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 per- son’s wishes regarding life-prolonging measures (Bramberg & Sandman, 2012).

It is ideal to engage persons who are trained in medical inter- pretation 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).

PUTTING IT TOGETHER A number of nursing frameworks are available to assist in provid- ing 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 discov- ering ways to provide culturally appropriate care to people who have different cultural perspectives than those of the profes- sional nurse (Leininger & McFarland, 2002).

Leininger’s theory uses worldview, social structure, language, ethnohistory, environmental context, folk systems, and profes- sional 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, philo- sophical, kinship, social, political, legal, economic, and educa- tional factors, as well as cultural values and lifeways.

Leininger theorizes three modes of action for the profes- sional nurse to provide culturally congruent care: (1) cultural care preservation or maintenance, (2) cultural care accom- modation or negotiation, and (3) cultural care repatterning or restructuring. Leininger defines the three modes of nurse deci- sions 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 or death.

2. Cultural care accommodation or negotiation refers to those assistive, supportive, facilitative, or enabling creative profes- sional actions and decisions that help people of a designated culture adapt to or negotiate with others for a beneficial or satisfying health outcome.

http://www.tcns.org

94 PART II Influences on Health and Illness

3. Cultural care repatterning or restructuring refers to those assis- tive, 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 interrelation- ship 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.

The Explanatory Model Kleinman, Eisenberg, and Good (1978) presented an alternative far-reaching proposition. They suggested that to provide cultur- ally 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.

Cultural care World view

Cultural and social structure dimensions

Cultural values and lifeways

Ethnohistory Language

Environmental context

Influences, care expressions,

patterns, and practices

Health (well-being)

Individuals, families, groups, communities, and institutions in diverse health systems

Nursing care decisions and actions

Cultural care preservation/maintenance Cultural care accommodation/negotiation Cultural care repatterning/restructuring

Culture congruent care

Generic or

folk systems

Nursing care

Professional systems

Political and legal

factors

Kinship and social factors

Economic factors

Religious and philosophic

factors

Educational factors

Technologic factors

Code: Influencers Directional influencers

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].)

CHAPTER 5 Cultural Influences 95

See Box 5-6 for an assessment approach that the gerontologic nurse might use in coming to know the older adult from a cul- ture different from that of the nurse.

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 instru- mental in providing more culturally competent care, and con- sequently contributes to the 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.

SUMMARY Gerontologic nurses develop awareness, sensitivity, knowledge, and skills in the delivery of culturally sensitive and linguisti- cally competent care to a steadily diversifying older adult popu- lation. 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 pur- suit and receipt of health care. Gerontologic nurses are in a unique position to take the lead in providing culturally and lin- guistically appropriate care. In doing so, they can contribute to the national agenda to reduce health disparities.

K E Y P O I N T S • The current older adult population in the United States is

becoming more culturally diverse. • Culture is a universal phenomenon that is learned and trans-

mitted from one generation to another, providing the blue- print 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 predomi- nant 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 cul- tural backgrounds should be aware that nurse–patient relationships may be based on different orientations to com- munication than the typical Western mode.

• Nurses should conduct a cultural self-assessment to deter- mine how they are influenced by their own cultures and how their cultures affect their interactions with people of differ- ent cultures.

• Nursing interventions should be adapted to meet the cul- tural needs of older adult patients.

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 con-

versations about this problem or the plan for what to do about the problem? • Does anyone else need to be involved in your healing?

BOX 5-6 THE EXPLANATORY MODEL

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.

96 PART II Influences on Health and Illness

REFERENCES Administration on Aging. (June 6, 2011). Minority aging. Retrieved

September 24, 2013 from: http://www.aoa.gov/AoARoot/Aging_ Statistics/minority_aging/Index.aspx.

American Bar Association (ABA). (2014). Patient self determination act. Retrieved from: www.americanbar.org/groups/public_ education/ resources/law_issues_for_consumers/patient_self_determination_ act.html. Accessed on July 11, 2014.

Berlin, E., & Folkes, W. (1992). A teaching framework for cross-cultural health care: Application in family practice. The Western Journal of Medicine, 39, 934.

Betancourt, J. R., & Maina, A. W. (2004). The Institute of Medicine re- port “Unequal treatment”: Implications for academic health cen- ters. Mt Sinai J Med, 71(5), 314.

Bower, J. K., Schreiner, P. J., Sternfeld, B., & Lewis, C. E. (2009). Black- white differences in hysterectomy prevalence, the CARDIA study. American Journal of Public Health, 99(2), 300.

Bramberg, E. B., & Sandman, L. (2012). Communication through in-person interpreters: A qualitative study of home care provid- ers’ and social workers’ views. Journal of Clinical Nursing, 22, 159–167.

Chatterjee, N. A., He, Y., & Keating, N. L. (2013). Racial differences in breast cancer stage at diagnosis in the mammography era. American Journal of Public Health, 103(1), 170–176.

Davis, J. L., Buchanan, K. L., & Green, L. (2013). Racial/ethnic differ- ences in cancer prevention beliefs: Applying the health belief model framework. American Journal of Health Promotion, 27(6), 384–389.

Fadiman, A. (2012). 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.

Galanti, G.-A. (2008). Caring for patients from different cultures (4th ed.). Philadelphia: University of Pennsylvania Press.

Gelfand, D. (2003). Aging and ethnicity: Knowledge and service (2nd ed.). New York: Springer.

Gurman, T., & Moran, A. (2008). Predictors of appropriate use of in- terpreters: Identifying professional development training needs for labor and delivery clinical staff serving Spanish-speaking patient. Journal of Health Care for the Poor and Underserved, 19(4), 1303.

Hadziabdic, E., Heikkila, K., Albin, B., & Hjelm, K. (2011). Problems and consequences in the use of professional interpreters: Qualitative

analysis of incidents from primary healthcare. Nursing Inquiry, 18, 253–261.

Hall, E. T. (1977). Beyond culture. Garden City, NY: Anchor Press. Hall, E. T. (1990). Understanding cultural differences. Yarmouth, ME:

Intercultural Press. Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness and

care: Clinical lessons from anthropological and cross-cultural re- search. Annals of Internal Medicine, 88, 251.

Leininger, M. (1991). The theory of culture care diversity and univer- sality. In M. Leininger (Ed.), Culture care diversity and universal- ity: A theory of nursing. Sudbury, MA: National League for Nursing, Jones and Bartlett.

Leininger, M., & McFarland, M. (2002). Transcultural nursing: Concepts, theories and practice (3rd ed.). New York: McGraw-Hill.

McCaffrey, R. G. (2007 Dec). Integrating Haitian older adults into a senior center in Florida. Journal of Gerontological Nursing, 33(12), 13.

Mebrouk, J. (2008 Apr). Perception of nursing care: Views of Saudi Arabian female nurses. Contemporary Nurse, 28(1–2), 149–161.

National Institutes of Health (NIH). (2014). HIPAA resources. Retrieved from: http://privacyruleandresearch.nih.gov. Accessed on July 11, 2014.

Ngo-Metzer, Q., Sorkin, D. H., & Phillips, R. S. (2007). Providing high- quality care for limited English proficient patients: The importance of language concordance and interpreter use. Journal of General Internal Medicine, 22(Suppl. 2), 324.

Purnell, L. (2012). Transcultural health care: A culturally competent ap- proach (4th ed.). New York: FA Davis.

Rathbone-McCune, E. (1982). Isolated elders: Health and social inter- vention. Rockville, MD: Aspen.

Sharkey, S. S., Hudak, S., Horn, S. D., James, B., & Howes, J. (2010). Frontline caregiver daily practices: A comparison of traditional nursing homes and the green house project sites. Journal of the American Geriatrics Society, 59, 126–131.

Smedley, B., Stith, S. & Nelson. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Institute of Medicine, National Academy Press, Special report.

Spector, R. (2012). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Prentice-Hall.

Upadhyaya, R. C., & Kautz, D. D. (2009). Appreciating diversity and enhancing intimacy. In K. Mauk (Ed.), Introduction to gerontological nursing. Boston: Jones & Bartlett.

C R I T I C A L T H I N K I N G E X E R C I S E S

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 stereotyp-

ing 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 nutri- tion 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?

http://www.aoa.gov/AoARoot/Aging_Statistics/minority_aging/Index.aspx

http://www.americanbar.org/groups/public_education/resources/law_issues_for_consumers/patient_self_determination_act.html

http://privacyruleandresearch.nih.gov

ROLE AND FUNCTION OF FAMILIES Families play a significant role in the lives of most older per- sons. 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

Family Influences

Elizabeth C. Mueth, MLS, AHIP

Original author: Vicki L. Schmall, PhD; Revisions by Elizabeth C. Mueth, MLS, AHIP.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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 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

98 PART II Influences on Health and Illness

provided in the home environment. Community services gen- erally 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 popula- tion 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 per- sons 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. 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 noninstitution- alized 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 com- prise 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 counter- parts, 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, accord- ing to 2010 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 mar- riages, 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 per- sons 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 sup- port in caring for their aging parents. Although 90% of insti- tutionalized 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 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 inter- pret this as a lack of commitment to career. “Family respon- sibilities 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

CHAPTER 6 Family Influences 99

limitation of the law is that family members with a differ- ent 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.

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 fam- ilies face include changes in living arrangements, nursing facil- ity 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 iso- lated 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 allow-

ing a person to be as independent as possible and creating a more secure environment. They may wonder whether they should force a 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 func-

tional 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

CULTURAL AWARENESS CULTURAL ATTITUDES TOWARD OLDER ADULTS

Blacks Greater respect for older adults and their role in the family compared with whites. Value placed on kinship and extended family bonds.

Whites Less respect for older adults and their role in the family. Tendency for men and women to share more equally in family; democratic family structure. Aging parents expected to be self-sufficient and not overly dependent on adult children.

East Asians High level of respect for older adults. Hierarchic family roles and ascribed status (related to age and gender). Oldest son assuming responsibility for aging parents as part of filial duty.

Hispanics More overt respect for older adults than whites. Tendency toward a more patriarchal family structure. Aging parents invited to live in household that consists of ex- tended family members.

Native Americans (540 federally recognized tribes)

High level of respect for older adults and their years of accumulated wisdom and knowledge; sought after for advice.

MYTHS AND THE REALITY OF AGING

Myth In the past, three-generation households were the most com- mon living arrangement.

Reality Co-residence of three generations has never been the domi- nant living arrangement in the United States. Most house- holds consisted of nuclear, not extended, families.

Myth Most older persons want to live with their children. Reality Most older persons, as long as they can manage indepen-

dently, prefer to live in households separate from their children. “Intimacy at a distance” is preferred both by older persons and their adult children.

Myth Older persons are often abandoned by their families. Reality The family is still the top provider of support and caregiving to

older persons. Even when bedridden or home-bound, older per- sons are twice as likely to be cared for by a relative at home than by professionals in an institution. Extended family members, for example, nieces, nephews, or grandchildren, often help when older persons do not have spouses or adult children. Also, broth- ers and sisters often play an important role in the lives of older persons who are widowed or who have never married.

Myth Families use nursing facilities as a “dumping ground” for frail older family members.

Reality Most persons in care facilities are greatly impaired and need comprehensive care. Older persons who do not have children and live alone are the most vulnerable to nursing facility placement. Approximately half of all nursing facility residents are single women or widows without close family. Families do not sud- denly “dump” and abandon their older family members in care facilities. The reality is that most families use nursing facilities as a last resort, only after they have exhausted other alternatives.

Myth If family-oriented services are made readily available, fami- lies will be less likely to provide caregiving.

Reality Policy makers sometimes fear that requests for services will be overwhelming if respite and adult day care programs are subsi- dized; yet studies show that caregivers, in general, are willing to pay for what they can afford and are modest in their use of services.

100 PART II Influences on Health and Illness

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 resis- tance, 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?

• Are the requirements of community agencies—financial dis- closure, application process, interviews—overwhelming to my family member? Depending on the answers to these questions, it may be help-

ful 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 obser- vations. Indicate that you know it must be hard to experience change. If your father views government-supported ser- vices 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 arrange- ment rather than a long-term commitment. Some fami- lies 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 think about moving from his or her home is strongly influ- enced 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 infor- mation 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).

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

BOX 6-1 HARTFORD INSTITUTE FOR GERIATRIC NURSING AT NEW YORK UNIVERSITY

From Hartford Institute for Geriatric Nursing. (2014). <http://www. hartfordign.org> Accessed 08/24/2014.

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: • 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

http://www.hartfordign.org

http://www.hartfordign.org/spotlight

CHAPTER 6 Family Influences 101

spas. Nonetheless, the attraction of CCRCs is health care for life. This type of community typically allows residents to live inde- pendently 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 com- bined (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 older person makes the decision. The difficulty of the deci- sion 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 fami- lies 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 fami- lies 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).

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 dis- cussed 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 hesi- tate 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 com- plete plan exists. When a person has been diagnosed with Alzheimer disease or a related disorder, it is critical that the

BOX 6-2 SHOULD I MOVE MY PARENTS INTO MY HOME?

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.

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?

BOX 6-3 QUESTIONS TO CONSIDER WHEN MOVING FROM INDEPENDENT LIVING TO A SUPERVISED LIVING FACILITY

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.

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 prox-

imity 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?

http://http://www.caring.com/articles/moving-in-aging-relative-or-parent

102 PART II Influences on Health and Illness

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 check- book, preparing 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 deci- sion, 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 devel- opmental stage ultimately ends in death. Thus, end-of-life deci- sions 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, caregiv- ers could mention that they have completed some of the same planning for themselves (Auer, 2008) (Table 6-2).

A useful tool to help with end-of-life planning is “Five Wishes,” an easy to use legal document written in everyday lan- guage. 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

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. 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”

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)

http://www.aoa.gov

http://www.aarp.org

http://www.ahcancal.org

http://www.cms.gov

http://www.caremanager.org

http://www.caregiveraction.org

http://www.where-to-turn.org

CHAPTER 6 Family Influences 103

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 profes- sionals, 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 over-

whelming responsibility exists and cannot be shared. 3. It is complex. Complex treatment regimens must be bal-

anced 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 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, turn- ing 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 coun- try’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 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 transpor- tation to specific appointments to get them used to the idea. Families may need assistance in assessing a person’s driving

ability and how to best carry out a recommendation that their relative should limit or discontinue driving. Health care profes- sionals play a critical role in discussing the issue of driving with older persons. Some older persons view health care profession- als 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.

Family Caregiving Family caregiving is primarily provided by the adult children of the older person. Often, the varying levels of participation

http://Helpguides.com

104 PART II Influences on Health and Illness

among siblings may cause stress within the family. It is impor- tant for the nurse to recognize the types and levels of family caregiving (Willyard, Miller, Shoemaker, & Addison, 2008): Routine Care—regular assistance that is incorporated into the

daily routine of the caregiver Back-up Care—assistance with routine activities that is pro-

vided only at the request of the main caregiver Circumscribed Care—participation that is provided on a regu-

lar 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 care- giving 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 sud- denly 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 func- tional 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).

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 dis- ease.” 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 care- giving. 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 particu- larly helpful to long-distance caregivers. A care manager can evaluate an older person’s situation and needs, establish an inter- face with health care providers and arrange for needed services, monitor the older person’s status and compliance with treat- ment 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 per- sonal care).

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

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.

http://www.aarp.org

http://seniordriving.aaa.com

http://www.nhtsa.gov/Senior-Drivers

http://www.ama-assn.org

CHAPTER 6 Family Influences 105

because of unrealistic expectations or lack of knowledge and time. When caregiving is combined with other family responsi- bilities, the caregiver may feel that he or she does not have suf- ficient 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 hos- pital 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-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 com- promised. 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 pro- viding 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. 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 respon- sibility. In addition, the person may “perk up” in response to a visit by a rarely seen family member and may not display the

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 bedrid- den. 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 bedrid- den. 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 ser- vices 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 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.

http://LongTermCare.gov

106 PART II Influences on Health and Illness

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 expe- riences. 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 caregiver. They also need to know that local caregivers often have to compromise with the older person and accept imperfect solutions to problems.

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 informa- tion 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.

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 spring- board 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 talk- ing to others and joining the support group.

Most caregivers do not have the opportunity for extensive edu- cation or training before assuming their role. Often, education

programs from rehabilitation services or brochures and book- lets 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 get- ting 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 care- giving generally affect not only caregivers and care receivers but also other family members. Anger and family dissension

From Alzheimer’s Association. (2013). Take care of yourself. <www.alz. org> Accessed March 9, 2013.

TABLE 6-4 MANAGING STRESS

10 Symptoms of Caregiver Stress Denial Anger Social

withdrawal Anxiety

Depression Exhaustion Sleeplessness

Irritability Lack of concentration Health problems

I know Mom is going to get better. If he asks me that one more time, I'll scream. I don't care about getting together with the neighbors

any more. What happens when he needs more care than I can

provide? I don't care any more. I'm too tired for this. What if she wanders out of the house or falls and

hurts herself? Leave me alone! I was so busy that I forgot we had an appointment. I can't remember the last time I felt good.

10 Ways to Manage Stress 1. Understand what is happening as soon as possible 2. Know what community resources are available. 3. Become an educated caregiver. 4. Get help from family, friends, community resources. 5. Take care of yourself (diet, exercise, plenty of sleep). 6. Manage your level of stress through relaxation techniques, or talk to your

doctor. 7. Accept changes as they occur, and be prepared for changing needs. 8. Make legal and financial plans. 9. Give yourself credit, not guilt. 10. Visit your doctor regularly.

http://www.alz.org

CHAPTER 6 Family Influences 107

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 communi- cate 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 life- time; yet using appropriate techniques may reduce stress for everyone. The benefits of such 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 enjoy- able for the both of us.

5. Using community services. Many caregivers need informa- tion about the range of community services, the types of help that are available, how to access services, and care facil- ity options.

6. Long-term planning. This includes making legal and finan- cial 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 emo- tional health. Although the factors that affect feelings of pow- erlessness 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 con- sequences for older persons, caregivers, and other family members.

• Help caregivers solve problems. The ability to solve prob- lems in 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 prac- tice 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 dif- ferently the next time in applying the skills.

It is important to discuss the barriers caregivers may con- front in the real world and ways to overcome these barriers. For example, professionals often talk about the importance of care- givers 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 impor- tant 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 something that looks like it will be complicated or dif- ficult to understand. Materials should be written in plain lan- guage 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 infor- mation and understanding (Schmall, 1994). Sometimes, other family members “listen” more readily to information in a hand- out 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 informa- tion 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 specifi- cally 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) care- giver support (Alzheimer’s Association, 2013a).

108 PART II Influences on Health and Illness

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 will match their needs and abil- ities (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 avail-

ability 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 receiv- ers 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 required to prepare and transport care receivers may limit use of adult day programs.

• Program inflexibility and bureaucracy. Program inflexibil- ity may contribute to caregivers’ low usage of respite care. These are issues the nurse may need to address when work-

ing with a caregiver who hesitates or refuses to use a respite pro- gram. 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 caregiv- ing 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 primar- ily 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 social- izing, rest, and exercise experience more favorable outcomes than caregivers who spend the time primarily in obligatory activities such as doing 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).

Support Groups In many communities, caregiver support groups have devel- oped. Some support groups are oriented to specific diseases such as 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 care- giver’s experience. Discovering that they are not alone may pro- vide 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

CHAPTER 6 Family Influences 109

BOX 6-4 VIDEO RESPITE: AN INNOVATIVE CAREGIVER RESOURCE

From Video Respite. (2013). <http://www.videorespite.com/> Accessed October 9, 2013.

“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 breaks to take a short rest, to have time alone, to attend to personal matters, to make tele- phone calls, or to do household chores without interruption. Video Respite, devel- oped 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 involve- ment 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 partici- patory 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 exam- ple, songs and routines such as reciting the Pledge of Allegiance; city and coun- try 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 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 memo-

ries 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.

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 per- sons 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 per- sons 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 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 ser- vices; however, it does offer considerable promise in providing caregivers with an opportunity for respite time.

http://www.videorespite.com/

110 PART II Influences on Health and Illness

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 care- giving, other family members are important in providing sup- port. 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 poten- tial 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.

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 meet- ing. The first meeting is held without the older person to discuss ideas and feelings, raise concerns, and identify needed informa- tion. 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 con- cerns, who hold differing values and outlooks in regard to the sit- uation, 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 resent- ments 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 dis- cussion, 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 facili- tation skills. The 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 emo- tions to common interests and can handle many difficult situa- tions. 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 follow- ing 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 pref- erences, 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 will- ing and able to do, and encourage everyone to be honest about their limitations. Sharing information about other responsibilities may help others understand the reasons sup- port 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.

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, par- ticularly 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

CHAPTER 6 Family Influences 111

to others by love and friendship and function as a family to each other. These relationships often extend into caregiving. The fol- lowing 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 nec- essary 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 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 care- giver, 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 situa- tion, 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 reevalu- ate 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 even- tually 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.

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 per- son’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 ill- ness 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 his- tory 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 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, par- ents, 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 alli- ances, 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?

112 PART II Influences on Health and Illness

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 con- flict for the people who bear them? For example, family mem- bers 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 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 knowl- edgeable 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 ar- ranged 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 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 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 be- lieved 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 fami- lies 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:

CHAPTER 6 Family Influences 113

• 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 depen- dence 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 exag- gerating the dependence? Is anyone overprotecting or forc- ing dependency? Providing caregiving to a family member may be more dif-

ficult if the caregiver has been the dependent person in the relationship. 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 reas- sessment, 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 uncom- fortable 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 degenera- tive disease such as Alzheimer disease. Waiting for a situation to worsen reduces the options. Although planning does not pre- vent 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 philoso- phies, 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, fam- ilies 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 want to make decisions for you?” or “If you could no longer care for yourself at home, even with the help of community ser- vices, 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 prefer- ences will be known and honored.

Helping Family Members Communicate Their Concerns Honestly and Positively Open, honest communication helps build and maintain rela- tionships, but such communication is not easy if family com- munication has been about “game playing.” Adult sons or

114 PART II Influences on Health and Illness

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 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 prob- lem. 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 differ- ent to a person from “You should . . . .” When done correctly, “I” messages come across as “speaking from the heart.” “I” mes- sages 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 lis- tens, acknowledges, and accepts these feelings.

It is helpful if family members try to imagine how a situa- tion 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 con- sideration or what is happening. A person who is excluded from decision making is more likely to become angry, demanding, help- less, or withdrawn. Plans also are more likely to backfire.

Involvement in decision making provides greater assur- ance 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 impair- ment may be unable to remember discussions or agreements made. However, the person often feels a sense of being involved in what is 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 carry- ing 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 talk- ing 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 decisions and caregiving. These emotions may include grief,

CHAPTER 6 Family Influences 115

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 percep- tion 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 care- givers “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 resent- ment. For example, family members who feel guilty about moving a relative into a care facility are more likely to be criti- cal of staff, overprotective of their 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, inflexi- ble, 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 gener-

ally 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 criti- cal 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 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 author- ity 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 rela- tionships 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 physi- cally ill. Caregivers should ask, “What happens if my family member enters a care facility or dies? Will I have been so wrapped up in caregiving that I will be ‘used up’ and with- out 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 increas- ing independence. However, with older adult caregiving,

116 PART II Influences on Health and Illness

the prognosis generally involves decline and increasing dependence, not recovery. In addition, it is generally dif- ficult 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 consid- eration 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 deterio- rates 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 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 per- son’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 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 poten- tial options will be evaluated. These may include financial con- straints 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 posi- tions 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 over- whelmed 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 alter- natives 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.

Some families find that writing down the plan and indicating who has agreed to do which tasks by when help reduce disagree- ments. A written plan also may be useful later when the plan is reevaluated.

CHAPTER 6 Family Influences 117

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 help- ful 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, flex- ibility is a key to high-quality decision making.

Step 6. Reassessing It is important that the family makes plans for assessing the out- comes of the decision by asking, “How well is the plan work- ing?” and then adjusting the plan as necessary.

Decision making is seldom easy. It is influenced by many fac- tors such as the specific decision being faced, the personalities of family members, the quality of family relationships and commu- nication, 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.

SUMMARY Providing high-quality care to older adults requires recogniz- ing 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 impor- tant 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 recogniz- ing the family’s limitations in providing support and caregiving.

K E Y P O I N T S • Families are significant in the lives of older persons and pro-

vide 80% of the support to older adults. • Common dilemmas and decisions families face in later life

involve changes in living arrangements, nursing facility place- ment, 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 dif- ficult 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 respon- sible for implementing it.

• Caregiving tends to be more stressful if the care receiver has a dementing illness, behavioral problem, or emotional distur- bance 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 per- sonal 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 solv- ing, decision making, and applying skills.

• Respite is most effective when a caregiver begins to use it early to 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 pro- vide the needed care, and the nature and degree of caregiver stress.

• Strategies and considerations for nurses working with fami- lies 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 mem- bers. 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.

118 PART II Influences on Health and Illness

C R I T I C A L T H I N K I N G E X E R C I S E S 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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Willyard, J., Miller, K., Shoemaker, M., & Addison, P. (2008). Making sense of sibling responsibility for family caregiving. Qualitative Health Research, 8(12), 1673.

Yang, Y., & Grimm, G. (2013). Caring for elder parents: A comparative evaluation of family leave laws, Journal of Law, Medicine, and Ethics, 41(2), 501.

http://www.divorcesource.com/ds/main/u-s-divorce-rates-and-statistics-1037.shtml

http://www.videorespite.com/

120

Socioeconomic and Environmental Influences

Jennifer J. Yeager, PhD, RN

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

Each person is a unique design of genetic inheritance, life expe- riences, education, and environment. Social status, economic conditions, and environment influence our health and response to illness. This chapter discusses the socioeconomic and envi- ronmental conditions that influence the way older adults inter- act with the health care system.

Socioeconomic factors such as income, level of educa- tion, 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 pro- tection 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 socioeco- nomic status (Krause, 1997). The environment also influences safety and well-being. Therefore, it is imperative that health care professionals understand the socioeconomic and environ- mental 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 hous- ing, 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 con- tinued 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 increas- ingly older population; notable examples are prescription drugs and cardiac disease. Adults over the age of 65 average twice as many physician visits than persons younger than 65 (O’Hara & Caswell, 2013).

L E A R N I N G O B J E C T I V E S 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.

Original author: Carol Will, RN, MA; Revised by: Sue E. Meiner, EdD, APRN, BC, GNP.

http://evolve.elsevier.com/Meiner/gerontologic

CHAPTER 7 Socioeconomic and Environmental Influences 121

Older adult health care consumers often depend on the health care professional for advocacy. To be an effective advo- cate, the nurse must understand the factors that shape the older consumer’s perceptions of environment, socioeconomic status, and access to health care.

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, psycho- logical, 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 understand- ing cohorts, the nurse develops a greater understanding of older adults’ value systems. For example, persons who reached matu- rity 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 produc- tive 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 profes- sionals for services, thereby becoming more conscious of pre- ventive 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 pursued further educational oppor- tunities. 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 circum- stances 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, experi- enced 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 pri- marily for the war effort. Signs and billboards urged people

to sign up or to purchase war bonds. Windows of houses dis- played 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 serv- ing 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 unob- tainable otherwise. With the help of veterans’ benefits, they pur- chased houses for little or no money as down payment. Having experienced the trauma of war, this group developed an appe- tite 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.

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 dis- cussed 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 tomogra- phy (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

122 PART II Influences on Health and Illness

is a benefit package for retired individuals, survivors of partici- pants, and those with disabilities. Funds for Social Security are derived from payroll taxes, and benefits are earned by accumu- lating credits based on annual 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 receiv- ing 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 grad- ual steps from 65 to 67 (Table 7–1). For those who wish to delay retirement, the benefit increases by a certain percentage depend- ing 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).

Very poor older adults depend on another federal govern- ment 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.

Ages 55 to 64 Those in the preretirement age cohort of 55 to 64 are gener- ally 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 eco- nomic picture of this age cohort. In February of 2010, the job- less 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 work- ers 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 fam- ilies 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 disabil- ity 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 con- tinues to 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’ ben- efits 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).

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

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

TABLE 7–1 AGE TO RECEIVE FULL SOCIAL SECURITY BENEFITS

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.

Benefits for eligible veterans include the following: • Disability compensation • Pension • Education and training • Home loan guaranties • Life insurance • Burial benefits • Health care benefits

BOX 7–1 VETERANS’ 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.

http://www.socialsecurity.gov

http://www.ssa.gov/pubs/retirechart.htm

http://www.va.gov/opa/publications/benefits_book/2013_Federal_Benefits_for_Veterans_English.pdf

CHAPTER 7 Socioeconomic and Environmental Influences 123

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 house- hold chores.

Ages 85 and Older This group is the fastest growing segment of our popula- tion (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 medica- tion (DeNavas-Walt et al., 2013; Federal Interagency Forum on Aging-Related Statistics, 2012).

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 invest- ments 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 hous- ing 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 invest- ments 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 periodi- cally and can be found by checking with the U.S. Census Bureau at http://www.census.gov/ or with the AOA at 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 inad- equate. A worn out wardrobe and lack of transportation may cause the older adult to avoid social contact, leading to isola- tion. 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).

PERCENT DISTRIBUTION

GENDER AND AGE GROUP 1980 1990 2000 2008 2010

All Persons 65 years and older 100 100 100 100 100 65 to 74 years old 61 58 53 52 54 75 to 84 years old 30 32 35 34 32 85 years and older 9 10 12 15 14

Men 65 years and older 100 100 100 100 100 65 to 74 years old 66 63 58 56 58 75 to 84 years old 28 30 34 32 32 85 years and older 7 7 9 11 10

Women 65 years and older 100 100 100 100 100 65 to 74 years old 59 55 49 48 51 75 to 84 years old 32 34 36 34 33 85 years and older 10 12 15 17 16

TABLE 7–2 POPULATION 65 YEARS OR OLDER BY GENDER AND AGE GROUP: 1980 TO 2008

From U.S. Census Bureau. (2012). The 2012 statistical abstract: <http://www.census.gov/population/www/socdemo/educ-attn.html> Accessed 04/30/14.

http://www.census.gov/

http://www.aoa.gov/

http://www.census.gov/population/www/socdemo/educ-attn.html

124 PART II Influences on Health and Illness

Education Education has been shown to have a strong relationship to health risk factors (Brown, 1995). The level of education influ- ences earning ability, information absorption, problem-solving ability, value systems, and lifestyle behaviors. The more edu- cated person often has greater access to wellness programs and preventive health options (Land, Guralnik, & Blater, 1994).

The educational level of the older population has increased steadily between 1970 and 2012, reflecting increased manda- tory 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 sub- jects of interest. Seeking educational opportunities in later life has many benefits for older adults. Lifelong learning promotes

intellectual growth, increases self-esteem, and enhances social- ization. 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 impor- tant 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.

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.)

Recession 50

Aged 65 and older

Under age 18P er

ce nt

Aged 18 to 64 5

A Year 19

59 19

65 19

70 19

75 19

80 19

85 19

90 19

95 20

00 20

05 20

12 200 40 60 80 100

Hispanic Black only Asian only

White only, not Hispanic

Hispanic Black only Asian only

White only, not Hispanic

Hispanic Black only Asian only

White only, not Hispanic

Poverty level

Under 18 years

Low-income population, 2006

18-64 years

65 years and over

PercentB

100%–less than 200%

Below 100%

27 2733

1412 1610

17 28 2120

33 31

23 25

12 23

12 129

Older adults often have short-term memory deficits or limited vision or hear- ing 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, video-

tape and audiotape, and photos and pictures. • With written material, use large print and clear black letters on a contrast-

ing 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.

BOX 7–2 PATIENT TEACHING STRATEGIES

http://www.roadscholar.org/

CHAPTER 7 Socioeconomic and Environmental Influences 125

Health Status The health status of older adults influences their socioeco- nomic 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 noninstitutional- ized 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 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 indi- vidual’s ability to perform ADLs and instrumental activities of daily living (IADLs). ADLs include six personal care activi- ties: (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 per- form one or more ADLs. The term IADLs refers to the follow- ing 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 nec- essary 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, medi- cal care, home care assistance, and nursing facility care, some of which may not be covered by insurance programs. In addi- tion, 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 equip- ment 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.

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 pro- gram 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 eli- gibility 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 inves- tigate several insurance companies to find the best coverage for the least cost.

Many older adults have automobiles that have reached maxi- mum depreciation. These automobile owners may still be car- rying 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 premi- ums from several companies. Completion of a defensive driv- ing 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 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 aver- age 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 pro- vide 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

http://www.aarpdriversafety.org/

126 PART II Influences on Health and Illness

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

Part B is medical insurance coverage. Most Medicare recipi- ents 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 ser-

vices 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; how- ever, 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 Advan- tage plans (“Medicare Advantage Plans,” n.d.) were intro- duced 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 Part C. These programs provide comprehensive care through a variety of health care delivery models, includ- ing 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 depart- ments 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 infor- mation 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 poli- cies in a language that most people can understand (please see: 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 neighbor- hoods 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

http://www.medicare.gov

http://www.medicare.gov/Publications/Pubs/pdf/02179.pdf

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Institutional-Care/Nursing-Facilities-NF.html

http://www.aarp.org/health/health-insurance/

https://www.medicare.gov/

CHAPTER 7 Socioeconomic and Environmental Influences 127

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 com- pared 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 cul- tivate 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 population numbers from 1950 to 2050).

In a study of how age and gender affect the perception of quality of support, Lynch (1998) found that men appear to per- ceive spousal support as the most positive, whereas women per- ceive 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 out- number 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 protector. A woman feels responsible for her family’s com- fort 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 emo- tional 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 posi- tion. 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 coun- seling, support groups, or 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 entitle- ments are available to older Americans, and these affect their socioeconomic status. Entitlement programs require the ben- eficiary 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 commu- nity 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 hous- ing 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

500

400

300

200

100

Total population

N um

be r

in m

ill io

65 years and over

Year Projected

19 50

19 60

19 70

19 80

19 90

20 00

20 10

20 20

20 30

20 40

20 50

75 years and over65–74 years

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.)

128 PART II Influences on Health and Illness

the rent and the housing authority pays the rest. Eligibility stan- dards 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 donation is requested for each meal. If older adults are home- bound, home delivered meals are available in many communities.

Energy assistance is also available. This program is admin- istered 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).

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 avail- able, 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 neces- sarily 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 hous- ing, 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 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).

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 danger- ous. 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, hous- ing, and safety issues as they relate to the environment of the older person are discussed in the following sections.

65–74 years

65–74 years 65–74

years

55–64 years

55–64 years 55–64

yearsUnder 18

Under 18

75� 75� 75�

18–54 years 18–54 years

1950 2004 2050 Projected

Under 18

18–54 years

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.)

CHAPTER 7 Socioeconomic and Environmental Influences 129

Geographic Location of Residence Geographic factors influence individuals differently. Climate is important to older adults because they are susceptible to tem- perature extremes. Those who live in cold climates need ade- quate heat and clothing; those in temperate areas need cooling systems during warm seasons. Because older adults are con- cerned 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 frighten- ing 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 transporta- tion. However, the social supports obtained through churches, friends, 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 indepen- dence. In 2009, 33 million older adults still had their drivers’ licenses (“Older adult drivers,” 2013). In some areas, an auto- mobile is necessary for transportation to shopping areas, medi- cal 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 transporta- tion 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 transporta- tion is available in its area. Obstacles preventing public trans- portation 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).

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 gen- eration 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’ abili- ties 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 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 man- ager 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 fur- nished rooms with limited cooking facilities and communal bathrooms. Tenants are traditionally single persons with limited incomes, mental illness, or substance abuse problems. Typically,

Conservator—manages an older person’s financial resources. An annual re- port 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 prin- cipal) 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 princi- pal to the court.

BOX 7–3 DEFINITIONS

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.

130 PART II Influences on Health and Illness

they have few contacts with other tenants and no family to pro- vide 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 light- ing, 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 por- table 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 older adults take in boarders to help with expenses and house- hold chores. The boarder is often a younger person who can do the “heavy” housework.

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 rec- reational vehicle as a second home. The real nomads are those who travel all 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 hous- ing (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 house- keeping 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, house- keeping, 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 domicili- ary care) provide a home to a small number of older adults

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 ulti- mately participated. Nine participants wore a personal emergency response system (PERS) device.

Method In-person interviews were conducted every few months over an 18-month pe- riod. 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 de- vice 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 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 con- fident living at home alone. Nurses come in contact with older women dur- ing 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.

CHAPTER 7 Socioeconomic and Environmental Influences 131

( 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 professionals and trained personnel who provide needed assistance. The services on the premises generally include meals, personal laundry services, and a hair salon. Activity pro- gramming 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 his- torical 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, low- ered 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 Coalition for the Homeless, 2009). Women are increasing in numbers among the homeless older adult com- munities. 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).

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 identi- fied needs such as clean water, healthful food, adequate rest and

10%

20%

30%

40%

50%

60%

70%

80%

90%

Own Rent Nursing home/ retirement community

Other

55-64 65-74 75-84 85+

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 retire- ment study, Washington, D.C.: U.S. Department of Health and Human Services.)

132 PART II Influences on Health and Illness

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, adap- tations, and safety. Many are free or available at minimum cost. The federal government also provides materials on housing options through the Consumer Information Center.

Criminal Victimization Elder victimization frequently goes unreported. Often, the per- petrator 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).

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.

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 oper- ated 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 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 psy- chosis, 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 of- fers 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 as- sist 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.

The types of crimes most often committed against older adults include the following: Financial/Material exploitation: illegal or improper use of funds, prop-

erty, 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 Neglect: intentional or unintentional failure to fulfill obligations Abandonment: desertion

BOX 7–4 TYPES OF CRIMES COMMITTED AGAINST OLDER ADULTS

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.

• Victimization rates are higher among older men than among older women. However, the rates of personal larceny with contact such as purse snatch- ing 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 house- hold 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 resi- dents in cities compared with suburban or rural older adults.

• Older renters are more likely than owners to experience both violence and personal theft. However, older homeowners are more likely than renters to be victims of household crime.

BOX 7–5 OLDER ADULT CRIME VICTIMS

From U.S. Department of Justice. (1994). Elderly crime victims: National crime victimization survey. Annapolis Junction, MD: Bureau of Justice Statistics Clearinghouse.

http://www.victimsofcrime.org/library/crime-information-and-statistics/elder-victimization

http://www.ncea.aoa.gov/FAQ/Type_Abuse/index.aspx

CHAPTER 7 Socioeconomic and Environmental Influences 133

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).

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.

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 seal- ing, or a burglar alarm system should be installed. Other older adults respond to appeals and advertising seen on the televi- sion, 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 clothespins (Bekey, 1991). Illegal tele- marketing 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 vulner- able 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 word- ing 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 con- fused, disoriented, fearful, or angry. When trying to assist older adult victims, the nurse should give the impression of nonhos- tile 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 com- posure. 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

• 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

• 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 in- formation about the products or services that are being sold

BOX 7–6 CONSUMER FRAUDS PERPETRATED MOST AGAINST OLDER ADULTS

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 reluc- tant 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.

4. Older adults often have concerns about maintaining a comfortable lifestyle on a fixed income, affording good medical and long-term care, and provid- ing for spouse and children.

5. Chronic illness leads many older adults to consider medical remedies of- fered by health fraud promoters.

6. Many older adults believe it is impolite to hang up on a caller or turn some- one away at the door.

BOX 7–7 REASONS OLDER ADULTS ARE VICTIMS OF FRAUD

134 PART II Influences on Health and Illness

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 pro- grams 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 profession- als working with older adults to report suspected abuse. In other states, reporting is voluntary. The local department of social ser- vices 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 pro- grams 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 through- out 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.

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 pro- cess 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 devel- ops 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 impor- tant 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 advo- cate 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 com- petency 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.

Socioeconomic Influences • Assess older adults’ outside sources of income. Many supplemental poli-

cies 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 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 fro-

zen. 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.

HOME CARE

http://www.aarp.org/

CHAPTER 7 Socioeconomic and Environmental Influences 135

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, pros- perity 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 commu- nity resources. The nurse should be aware of housing options, nutrition programs, transportation opportunities, respite pro- grams, 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 sup- port systems for the maximum positive effect on the health and well-being of older adults.

Advocates for older persons, whether the older adults them- selves or professionals in the field of aging, can help make socio- economic and environmental factors a positive influence on older adults.

To provide maximum benefits to aging health care consum- ers, 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.

K E Y P O I N T S • Socioeconomic factors such as income level, income sources,

insurance coverage, benefits and entitlements, and educa- tional 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 avail- ability 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 mainte- nance 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 under- stand 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 qual- ity 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 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 trans- portation affect the security and safety of older adults. Aging and outdated homes and appliances, worn furni- ture, 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 facili- ties, and nursing facilities. Each option provides a differ- ent level of service to help older adults maintain maximum independence.

• Perceived victimization in older adults may result in increased suspicion and eventual withdrawal and iso- lation, 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 pro- grams 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.

136 PART II Influences on Health and Illness

C R I T I C A L T H I N K I N G E X E R C I S E S 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 percep- tion 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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http://www.victimsofcrime.org/library/crime-information-and-statistics/elder-victimization

http://www.medicare.gov/nursing/alternatives/pace.asp

http://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/how-medicare-advantage-plans-work.html

http://www.census.gov/prod/www/statistical-abstract-04.html

http://assets.aarp.org/rgcenter/ppi/econ-sec/fs224-economic.pdf

138 PART II Influences on Health and Illness

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

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 1 (800) 723–0560

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

139

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 dis- ease 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 second- ary 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 prob- lems such as fractures, myocardial infarctions, and cerebro- vascular accidents (Moser & Watkins, 2009; Parker et al., 2012;

Thompson et al., 2007). Appropriate screening with mam- mography, 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 participa- tion 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 medi- cations (Anderson et al., 2011).

Many factors put older adults at risk for having ineffective health maintenance (Table 8-1). Theoretically, reasons and deci- sions 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 physi- cal health, function, cognition, age, gender, and other relevant

Health Promotion and Illness/Disability Prevention

Sue E. Meiner, EdD, APRN, BC, GNP and Dr. Jean Benzel-Lindley, PhD, RN

Previous author: Barbara Resnick, PhD, CRNP, FAAN, FAANP.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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

140 PART II Influences on Health and Illness

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.

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 fore- thought. 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 expectan- cies, which are the beliefs that a certain consequence will be produced by personal action. The theory of self-efficacy sug- gests 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, individ- ualized 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, spir- itual, and intellectual health (O’Donnell, 2009). The promo- tion 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 ful- filled by health care providers. Disease prevention focuses on protecting as many people as possible from the harmful con- sequences of a threat to health (e.g., through immunizations).

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 pre- vent 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 suc- cessful primary prevention helps avoid the suffering, cost, and burden associated with injury or disease, it is typically consid- ered 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 dis- ease that occurs commonly and has significant risk of a nega- tive outcome without treatment. Screening tests for cancer are

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.

• Increasing physical activity • Smoking control • 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

BOX 8-1 AREAS OF HEALTH PROMOTION MOST RELEVANT TO PHYSICAL FITNESS OF OLDER ADULTS

CHAPTER 8 Health Promotion and Illness/Disability Prevention 141

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 established disease; attempts are made to restore the person to highest function, minimize the negative effects of dis- ease, and prevent disease-related complications.

Quaternary prevention involves limiting disability caused by chronic symptoms while encouraging efforts to maintain func- tional 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.

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 technol- ogy” within health promotion programs, agencies, and organiza- tions. 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 indi- vidual’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 multidis- ciplinary scientific designs and studies from epidemiologic, educational, and psychosocial sciences. The PRECEDE phase, which stands for predisposing, reinforcing, and enabling con- structs in education/environmental diagnosis and evaluation, examines life quality, health goals, and health problems. The PROCEED phase, which stands for policy, regulatory, and orga- nizational constructs in educational and environmental devel- opment, 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 devel- oping and deciding the context in which health behaviors will be modified. Three basic categories are older adults’ charac- teristics 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, addi- tional 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 nurs- ing 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 gen- erally 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.

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 cor- onary 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 medica- tion 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 activ- ity (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 guide- lines 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, mam- mography, Pap test, and most recently, colorectal cancer screen- ing (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 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 prob- lems, and have better cognitive status are more likely to par- ticipate in primary and secondary health-promoting activities.

142 PART II Influences on Health and Illness

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, lim- ited income of many older adults.

Ethnic and cultural factors may have a negative effect on health care–seeking behaviors. The cultural diversity issue is complex and varies from one location to another throughout the United States (see Chapter 5). The diversity among com- munities 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 impe- tus for additional protective or preventive services limits pro- gram 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 con- cerning 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 pur- pose 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).

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 elimi- nate disparities, create social and physical environments that promote health, and optimize quality of life across the entire life span.

DISEASE PREVENTION

Primary Preventive Measures Primary prevention refers to some specific action taken to opti- mize 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.

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 vacci- nation every 10 years. All older adults should receive a vacci- nation against pneumococcal infection at or immediately after

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).

CHAPTER 8 Health Promotion and Illness/Disability Prevention 143

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, dia- betes 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 differ- ent 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 prescrip- tion counterparts. Increased focus has been placed on medica- tions 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 opti- mization 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 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 recom- mended 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.

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

144 PART II Influences on Health and Illness

The USPSTF also provides guidelines regarding screening for cardiovascular disease, osteoporosis, diabetes, and obesity (USPSTF, 2008). Some evidence supports screening for osteo- porosis, 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.

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

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 Decreased risk of congestive heart failure

Health complications: gastrointestinal, cardiac, dermatologic, cognitive, and neurologic; impairment of nutritional state

Risk of depression 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

CHAPTER 8 Health Promotion and Illness/Disability Prevention 145

include arthritis, osteoporosis, stroke, Parkinson disease, and uri- nary or fecal incontinence. For additional information regard- ing tertiary measures of prevention, see the specific disorders in Part 6.

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 evo- lution 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 pre- vention 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 essen- tial 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 find- ing 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 oppor- tunities to spread information regarding illness prevention and health promotion (see the Evidence-Based Practice box).

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 par- ticipate 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 hy- pertension 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 ses- sions 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 preven- tion and maintenance behaviors. At the end of the 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 pro- gram 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 op- portunities 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 par- ticipants 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 ses- sions. Three individuals (15%) attended 0 sessions. Consistently, 12 to 14 partici- pants attended each session. Reminder calls were needed for approximately 50% of the participants for the first few weeks of the study and then attendance stabi- lized. 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 improve- ment in cholesterol intake (p = 0.09) were seen. No changes in time spent in mod- erate level physical activity, sodium intake, medication adherence, or self-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 im- provements 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 screen- ing, 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.

146 PART II Influences on Health and Illness

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 capi- tol. 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 edu- cation 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 When assessing an individual, the nurse must look at poten- tial health hazards to identify risk factors for illness or injury. Contributing risk factors include habits, lifestyle patterns, per- sonal and family medical histories, and environmental condi- tions. 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 exami- nation. 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 func- tional 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 descrip- tion and subjective and objective assessments. Within each of these patterns, 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 cogni- tive, 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 explora- tion 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, with- drawal from previous activities, self-destructive actions, excessive grieving, and increased dependency on others. Assess changes in eating, sleeping, and physical activity pat- terns. 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 communica- tion and interactions with other people, as well as meaning- ful 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 unsatisfac- tory relationships, and identify attempts to change patterns and outcomes.

Objective: Examine the family or friend dynamics of interde- pendent, 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 impor- tance the older adult places on these behaviors.

Subjective: Determine the level of understanding of any treat- ments or therapy required for management of health deficits or activities, including the possible sources of reimburse- ment and concerns about costs; include assessment of per- formance 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

CHAPTER 8 Health Promotion and Illness/Disability Prevention 147

the patient resides. Assessment should include information about prior health promotion activities (e.g., mammogra- phy, 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 real- istic 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 approxi- mately how much is eaten during a 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 success- fully 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 spe- cific 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 defi- cits 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 patient’s ability to comprehend. Also note the ability to read, hear the spoken word, smell, and distinguish tactile sensa- tions 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 influ- ences 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 environ- mental factors will affect their self-efficacy to perform 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, medica- tions, 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 over- all 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.

148 PART II Influences on Health and Illness

Activity or Exercise Pattern 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 physi- cal 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 activi- ties, 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 activi- ties such as bathing, dressing, toileting, and feeding, if pos- sible. 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 pat-

terns 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 dis- tribution of sleep hours within a 24-hour period. Inquire about episodes of insomnia and deterrents to sleep such as pain; anxiety; depression; use of pharmacologic agents such as caffeine, over-the-counter agents that may cause arousal, alcohol, and prescribed medications such as some treat- ments for depression; lack of exercise; and inappropriate sleep hygiene. Identify the time and circumstance for regu- lar 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 behav-

ioral 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 excre-

tory 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; exter- nal genitalia and pelvic examinations may be indicated. Note daily intake of food, particularly amount of dietary fiber, and assess 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 recommen- dations. Internet addresses for these and other information cen- ters 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 indi- vidual 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.

Implementation Implementation may begin by adopting a proactive stance toward an action plan for health promotion of the older

CHAPTER 8 Health Promotion and Illness/Disability Prevention 149

individual. Seeking activities, locations, and means for dis- seminating 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 screen- ings may be incorporated into programs that provide vacci- nations 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 sup- port. However, changes may 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 appropri- ate and realistic revised goals and realistic steps to achieve them.

SUPPORTING EMPOWERMENT OF OLDER ADULTS Nurses can provide a bridge between the theory of health pro- motion 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 qual- ity 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 individ- uals, small groups, and larger groups where older adults congre- gate. 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 nurs- ing 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 for- mally in health promotion classes and informally during health care visits. The education should provide current recommenda- tions for health promotion activities (e.g., when to get a mam- mogram) and help older patients decide what health behaviors they want to engage in. This type of individualized approach has the advantage of being 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 promo- tion increases adherence to positive health behaviors such as smoking cessation and exercise.

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

150 PART II Influences on Health and Illness

SUMMARY This chapter discussed the practices of health promotion, health protection, and disease prevention in the older adult popula- tion. In addition to the use of a social–ecologic model, several models of interpersonal health promotion activities were pre- sented. 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 per- son’s participation in a health promotion program. The third model is the PRECEDE/PROCEED Model. This multidisci- plinary 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 com- plex 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 dis- cussed. 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 coun- seling 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 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 func- tional 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 individual- ized 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.

K E Y P O I N T S • 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 inju- ries, (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 com- plete health assessment using the functional health pat- terns framework; this should incorporate an individualized approach for each patient.

• Using the nursing process in health promotion activities pro- vides 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 pri- mary, secondary, tertiary, and quaternary prevention activi- ties will help them achieve their optimal quality of life.

C R I T I C A L T H I N K I N G E X E R C I S E S 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?

CHAPTER 8 Health Promotion and Illness/Disability Prevention 151

2. Several nurses have volunteered to give flu shots to older adults at a senior center. When the line to receive the injec- tions 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 appro- priate 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/

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153

Health Care Delivery Settings and Older Adults

Marie H. Thomas, RN, PhD, FNP-C, CNE

C H A P T E R

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 knowl- edge, skills, and abilities to care for older adults during hospital- ization and beyond.

L E A R N I N G O B J E C T I V E S 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.

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.

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.

http://evolve.elsevier.com/Meiner/gerontologic

154 PART II Influences on Health and Illness

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 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.

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, cerebrovascu- lar 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 pro- foundly 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.

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 ill- ness, and impaired functional status, requires astute care plan- ning 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 hospitaliza- tion, 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, physi- cally, 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 pro- motion and preservation of health. The value placed on technol- ogy fosters a task orientation that may detract from the holistic focus required for the care of older adults. Acute care 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 medica- tions) 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 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 hos- pital falls include both intrinsic and extrinsic factors. Intrinsic factors include age-related physiologic changes and diseases, as

CHAPTER 9 Health Care Delivery Settings and Older Adults 155

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 unfamil- iarity 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 approx- imately 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 pre- sentation, 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 uri- nary 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 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, dis- infection 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 disabil- ity. Immobilized patients are vulnerable to rapid loss of muscle strength, reductions in orthostatic competence, urinary inconti- nence 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 eye- glasses. 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 cre- ativity on the part of the nursing staff.

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

BOX 9-1 ENVIRONMENTAL MODIFICATIONS

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.

• 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 • 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

156 PART II Influences on Health and Illness

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 cus- tomize 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, phle- botomists, and physical therapists) have a documented compe- tency 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 adults are in an unfamiliar envi- ronment, 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 inter- preted as a classic sign of illness or as a complication of their ill- ness. 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 geri- atric 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 recruit- ing 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 acute care setting is often at high risk for falls and conse- quent 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, appro- priate 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).

Critical Care and Trauma Care 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 homeo- static mechanisms are altered with age so that the abilities to gen- erate 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

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 symptom-

less 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.

CHAPTER 9 Health Care Delivery Settings and Older Adults 157

individuals are at particular risk for delirium because of impaired physical and mental defenses (Monkhouse, 2013) (Table 9-1).

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 malnourished on admission or acquire nutritional defi- cits 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 emer- gency surgery or for medical reasons have a mortality rate of up to 67% (Monkhouse, 2013). Clinical recognition of the phar- macokinetic 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) expe- rienced 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 cir- cumstances 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 fail- ure. 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 deple- tion 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 environmen- tal 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 sup- ports the fact that older adults are at greater risk for compli- cations and higher mortality even when injuries are not severe (Legome & 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 func- tional 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 indi- cates those at risk for increased mortality and institutionaliza- tion. Frail individuals have a limited capacity to respond to internal and external stressors (Hubbard & Woodhouse, 2010).

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 pro- grams, 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.

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 ill- nesses and treatments on older adults. They must also be aware

TABLE 9-1 CHANGES IN COGNITIVE STATUS

DELIRIUM DEMENTIA DEPRESSION

Onset Sudden and acute Insidious, subtle, gradual; difficult to pinpoint

May be sudden or gradual, depending on course; may pinpoint date

Duration Brief; often clears within 1 month or when underlying disorder is resolved

2 to 20 years Weeks to years; variable

Awareness Clouded state of consciousness; disoriented Alert and aware Directed inward; self-absorbed Mood/behavior Easily distracted; incoherent speech;

difficulty with attention and concentration; hallucinations and illusions; disturbed sleep–wake cycle; increased or decreased psychomotor activity; fluctuation of symptoms: lucid at times but often worse at night

Personality changes; emotionally labile; may become easily agitated, with catastrophic reactions

Often aware of cognitive problems; apathetic, with feelings of hopelessness or worthlessness; vague somatic complaints

Task performance Often unable to carry out tasks; difficulty following directions

Tries hard to carry out activities; gradual loss of abilities

Able but makes little effort

Mental function Disorganized thinking; fluctuating impairments in memory, coherence, orientation, and perception

Impairments in memory, abstract thinking, judgment, and language; loss of common knowledge

Selective memory loss: “I don’t know” answers on cognitive tests

158 PART II Influences on Health and Illness

of available community resources. Home health remains one way to help the older adult who has a physical or cognitive impair- ment stay in the home. Because of changes in reimbursement for federal programs that provide services for older adults and lim- ited funds for state programs, home health nurses are challenged to use interventions that are both effective and cost efficient.

FACTORS AFFECTING THE HEALTH CARE NEEDS OF NONINSTITUTIONALIZED OLDER ADULTS

Functional Status Functional status is a term used to describe an individual’s abil- ity 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, func- tional 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 abil- ity 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 func- tional 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 set- ting or require a supervised care setting (Monkhouse, 2013).

Cognitive Function Cognitive impairment, which often affects an individual’s func- tional status, is another eligibility criterion used by various community programs. Cognitive status is assessed on admis- sion 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 limi- tations. For example, individuals with deficits in memory, lan- guage, abstract thinking, and judgment have great difficulty executing ADLs or IADLs (e.g., shopping, paying bills, prepar- ing 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 cri- teria 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 cogni- tive 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 cog- nitive impairment is an example of someone who qualifies for home health care.

Housing Options for Older Adults 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

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 • 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

BOX 9-2 SERVICES FOR OLDER INDIVIDUALS

CHAPTER 9 Health Care Delivery Settings and Older Adults 159

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 finan- cial 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).

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).

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.

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/>.

http://www.aarp.org/home-garden/housing/

160 PART II Influences on Health and Illness

The type of services needed, the availability of the services, the cost of the services, and the requirements to qualify for the ser- vices are determined by a home health agency.

Community services are categorized into formal and infor- mal services. Home health care is a short-term, formal service that provides assessment, observation, teaching, certain techni- cal 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 home- maker 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 ser- vices. Community resources, formal and informal, must meet the client’s needs (see Cultural Awareness box).

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 pro- vided appropriately. In other situations, case management ser- vices 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 indi- viduals 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 individu- als 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 ser- vice administration. The OAA requires that each AAA desig- nate 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 pro- vided through the OAA and the AAAs include information and referral for medical and legal advice; psychological counseling; preretirement and postretirement planning; programs to pre- vent 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 ser- vices 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

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 pre- dominantly Mexican Americans and 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 sacri- fices 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 so- cial 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 in- surance, 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 prob- lem 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-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).

CHAPTER 9 Health Care Delivery Settings and Older Adults 161

senior centers is provided primarily through the OAA and agen- cies 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 super- vision 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.

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 dif- ficult 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 per- sons 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 volun- teers, 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 Homemaker services include such things as houseclean- ing, 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 agen- cies, 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 quali- fications for the positions.

Nutrition Services Nutrition services provide older adults with inexpensive, nutri- tious meals at home or in group settings. Home-delivery pro- grams 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 supple- ments 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 supervi- sor. 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 transporta- tion 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 (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 con- tact (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 organiza- tions 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 moni- toring systems that allow older persons to obtain immediate assistance in emergent situations, for example, after a fall or

162 PART II Influences on Health and Illness

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.

HOME HEALTH CARE Home care consists of multiple health and social services deliv- ered to recovering, chronically ill, or disabled individuals of all ages in their place of residence. There are three main catego- ries of home care providers, known as home care organizations (National Association for Home Care and Hospice [NAHC], 2013). Medicare-certified agencies include hospice and free- standing 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 ser- vices 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 bedrid- den) 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 cri- teria 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 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 crite- ria 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 guide- lines and payment methods for home health, and each covers different home health services (CHAMPVA, 2013).

Managed care companies have various methods for approv- ing services related to home health care. The admission assess- ment 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 refer- ring physician. The home health agency stays in close commu- nication 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 physi- cal 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 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 por- tion of their business. Owners of a for-profit entity are stock- holders in the corporation.

Facility-Based Agencies A facility-based home care agency is a department or compo- nent 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 ser- vices 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

CHAPTER 9 Health Care Delivery Settings and Older Adults 163

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 agen- cies 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 affili- ated with existing home care agencies to provide options for patients who were going home with existing health care needs. The Affordable Care Act (2011) made changes to Medicare reim- bursement, 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 allo- cation 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 repre- sentation of the home care agency as a service of the facility.

Visiting Nurse Associations A visiting nurse association (VNA), or community nursing ser- vice, 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 com- munity 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 paren- teral 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 dis- ease (COPD), unstable diabetes, kidney or liver disease with subsequent transplantation, or recent strokes;

• Have chronic mental illnesses such as depression, schizo- phrenia, or other psychoses;

• Need assistance with medical regimens to prevent readmis- sion 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 com- fort 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 rea- sons 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).

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 coor- dinated care throughout a patient’s lifetime to maximize health

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, co- morbidity, 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-on-wheels] pat- terns 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 situa- tion, 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.

164 PART II Influences on Health and Illness

outcomes. A PCMH service includes preventive services; treat- ment of acute and chronic illness; and assistance with end-of-life issues. This care model promotes improved access and commu- nication; 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 reimburse- ment 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 9-4 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 combi- nation 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 prehos- pitalization screening, at the time of admission to the hospital, after a client’s condition has changed, or as a client is being dis- charged. What really matters is that the client be assessed for home care needs before he or she leaves the hospital.

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 increas- ingly 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 thera- pists, 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 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

Plan • Gather data on admission. • Identify goals for discharge. • Identify specific functional problems. • Validate that a problem exists. • 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 9-3 PLAN, DO, CHECK, ACT CYCLE 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 • Intravenous chemotherapy • Multiple medications or a major medication change • Ventilator dependence • Low-air-loss bed or other complex medical equipment

CHAPTER 9 Health Care Delivery Settings and Older Adults 165

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 assign- ments are made according to geographic areas, the client’s spe- cial needs, or the nurse’s specialty.

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 through- out 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 subcu-

taneous) 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 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 pre- sentation 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 cul- tural 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 rec- ommendations to the primary physician. The home care nurse also works cooperatively with community resources and gov- ernmental 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 threat- ening 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 neigh- borhoods, will ensure the nurse’s safety. In a recent position paper, The Joint Commission endorsed the role of the home health care nurse in managing patients in noninstitutional set- tings and preventing admissions and readmissions to the insti- tutional 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 medica- tions 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 cer- tified 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 cer- tain 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 caregiv- ers 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 thera- pist 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

166 PART II Influences on Health and Illness

• Assisting with dressing and ambulation • Light housekeeping

OASIS Outcome and Assessment Information Set (OASIS) is an assess- ment 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 qual- ity 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 ser- vices, and resumption of services. Surveyors who monitor agen- cies 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.

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 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 regu- lations as are hospice programs.

In Canada, the term palliative care is pervasive, and hos- pice 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 coun- try 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 dis- ease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiri- tual 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 pro- cess. 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 initia- tives, federal funding, and financial support from private foun- dations are available for research and innovative programs regarding end-of-life issues. As 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 spiri- tual care; certified nursing assistant services; additional thera- pies, as needed (e.g., physical, occupational, and speech therapy); inpatient care related to difficulty in managing symptoms;

CHAPTER 9 Health Care Delivery Settings and Older Adults 167

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 main- tain 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 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 interdis- ciplinary 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 commit- ment 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 pro- vides family caregivers with release time from the daily care of the client. This type of respite care is usually limited to 5 consec- utive 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 fol- lowing 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 receiv- ing 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 recerti- fied as terminally ill at the beginning of each period. Hospice clients may change their 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 cov- ered. 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 con- tinues to pay covered costs necessary to treat unrelated condi- tions 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 geo- graphic 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, free- standing 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 hos- pice team will assist the family in choosing an alternative to home-based hospice care. The transition between locations of care should be seamless with the assistance of the hospice team.

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 col- lection 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 devel- opmentally disabled persons, persons permanently impaired from traumatic injuries, and chronically ill younger persons.

168 PART II Influences on Health and Illness

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.

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 admit- ted 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, rehabili- tative, social, and spiritual care is usually provided. All nursing facilities must function under the federal regulations set forth by the OBRA. Some facilities are 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 institution- alization 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).

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 nurs- ing facility becomes necessary when the person’s physical and mental 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 nurs- ing facilities tends to be hierarchic and bureaucratic, alterna- tive 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 medi- cal 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

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

TABLE 9-3 CONTINUUM OF SETTINGS IN WHICH LONG-TERM CARE IS PROVIDED 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 • 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

BOX 9-5 FACTORS AFFECTING THE NEED FOR NURSING HOME ADMISSION

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.

CHAPTER 9 Health Care Delivery Settings and Older Adults 169

social and psychological health of nursing facility residents, in addition to the traditional medical concerns. Residents’ subjec- tive 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).

Sometimes, nursing facility personnel do not fully under- stand 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.

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 resi- dent rights in the nursing facility (IOM, 1986). Emphasis on resident rights was directly related to a revised view that res- idents 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 with- holding of life-sustaining treatments

• A grievance process whereby residents and families can chal- lenge 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 resi- dent rights. Ideally, this effort will be the operational philosophy for all nursing facilities.

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 inde- pendence. Each situation must be evaluated individually, and the legalities may be complicated (NHPCO, 2012).

Resident Assessment Interdisciplinary functional assessment of residents is the cor- nerstone 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 utili- zation 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 informa- tion; cognitive, communication and hearing, and vision pat- terns; physical functioning and structural problems; mood, behavior, and activity pursuit patterns; psychosocial well-being; fecal and urinary continence; health conditions; disease diagno- ses; oral, nutritional, and dental status; skin condition; medica- tion 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.

The specific method used to complete the RAI varies from facility to facility. Some facilities assign one nurse to com- plete 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, and the RAI are completed at 5 or 14 days, 30 days, 60 days, and 90 days and with any significant change.

BOX 9-6 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

170 PART II Influences on Health and Illness

Both licensed vocational or practical nurses and RNs may contribute to the RAI. However, only an RN can sign the docu- ment and function as the RN assessment coordinator (RAC). The RAC signs and certifies the completion of the assess- ment, not the accuracy of the assessment data (CMS, 2012b). Contributions to the RAI are also made by the dietary supervi- sor, social worker, recreational therapist, medical records clerk, and physical and occupational therapists.

The overall goal of the RAI is to provide an ongoing, com- prehensive 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 over- all health and quality of life. Skin care programs in the nurs- ing 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, pediculo- sis, 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 con- sidered an indicator of poor quality of care, although research and current knowledge of pressure ulcer etiology does not sup- port this view as totally accurate. Aggressive and appropriate preventive measures are initiated to address each resident’s spe- cific 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 depart- ment staff plus a physical therapist, occupational therapist, and

dietitian. On 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, posi- tioning devices, vitamin and nutritional supplements, skin lubri- cants, 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, devel- oped 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 regula- tions concerning the required frequency of the nurse’s clinical staging and routine assessment of pressure ulcers. Most facili- ties 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 facil- ity 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 consul- tant 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 incon- tinence increases. This common health problem has financial, physical, and 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 break- down, UTIs, and an increased risk of falling and consequent hip fracture. Urinary incontinence is one of the most psycho- logically 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 uri- nary incontinence. Clinical programs in nursing facilities are directed at prevention, treatment, and management of incon- tinence. Prevention is aimed at reducing the risk of develop- ing urinary incontinence among at-risk residents of nursing facilities. Preventive measures include assessment of individual patterns of elimination so that anticipatory assistance with toi- leting may be provided, aggressive staff response to residents’ requests for assistance in toileting, and arrangement of the

• 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

BOX 9-7 PROBLEM AREAS OF THE RESIDENT ASSESSMENT PROTOCOL SUMMARY

CHAPTER 9 Health Care Delivery Settings and Older Adults 171

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, blad- der training, pelvic muscle exercises, and biofeedback proce- dures (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 cog- nitive 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.

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 indwell- ing 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 inad- equate intake and those causing increased nutritional require- ments (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, hospi- talization, 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, cer- tain medications, and chronic medical disorders. Culture, reli- gion, and personal choice also affect how and what a person eats. A resident’s appetite is affected by 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 interven- tions 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 maintain- ing adequate caloric intake and effective identification of resi- dents 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 assis- tant (a CNA with 30 hours of formal training beyond CNA with a focus on direct restorative care and delegated formalized ther- apy 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 interven- tions directed at supplemental nutritional support. In addition to the strategies already described, changes in therapeutic diets and the use of nutritional products (e.g., Ensure), vitamin sup- plements, 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 admin- istration of medications through oral, intravenous, intramuscu- lar, subcutaneous, and enteral routes. In the nursing facility, the

172 PART II Influences on Health and Illness

licensed nurse is often responsible for the administration, docu- mentation, storage, ordering, cart stocking, and destruction of many medications. In some states, medication aides are used to administer medications. The RN is responsible for monitor- ing 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 nurs- ing 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 resi- dent’s medical record, and the nurse has numerous structured opportunities to monitor for these medication-related prob- lems. These opportunities include routine interactions with residents while administering medications and assessment at quarterly care-planning conferences, monthly reviews of psy- chotropic 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 ben- zodiazepines, hypnotics, sedatives, anxiolytics, and antipsy- chotics, 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 facil- ity (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 ongo- ing instruction to each resident (or the resident’s legal repre- sentative) regarding the initiation of new drug therapy and changes in the dosages of medications. If a resident is cogni- tively 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, includ- ing 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 phy- sician, physical therapists, occupational therapists, speech and language pathologists, and facility interdisciplinary team mem- bers, including the nurse, social services representative, activity

coordinator, and 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 rehabilita- tion 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 commu- nication, 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 spe- cialties. 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 amputa- tion), and training with new adaptive equipment are therapeutic components of these programs. (2) The less intensive rehabili- tation 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 pro- grams are provided by specially trained certified nursing assis- tants or facility nursing staff. These programs are established, revised, and supervised by the physical and occupational thera- pists 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 pre- vention of unnecessary loss of function.

Facilities must provide the required rehabilitation services or obtain them from an outside source. The needs of the individ- ual 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 stan- dard precautions and transmission-based precautions, as out- lined 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 con- trol program designed to provide a safe, sanitary, and comfortable

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environment; its purpose is to help prevent the development and transmission of disease. Facilities must have policies and proce- dures for investigating, controlling, and preventing infections. Records of incidents and corrective action taken related to infec- tions 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 immo- bilized, 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 vaccina- tions available as appropriate are also in place.

According to OSHA, employees at risk for exposure to blood- borne pathogens must receive free information and training on employment and annually thereafter. Employers must make the 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 mem- bers representing each department meets either monthly or quarterly to review data describing the prevalence and inci- dence 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 respon- sible 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 con- sulting 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, anti- septics, and germicides.

Mental Health General topics related to mental health and aging are described in Chapter 27. Among the aged and institutionalized popula- tion, mental health issues of particular concern include a vari- ety of behavioral problems that may jeopardize the safety of the resident or other residents (e.g., wandering, kicking, or hit- ting). Because the residents live in a community setting, behav- ioral problems are not just an issue for the affected resident.

The aberrant behavior of one resident has an effect on other residents.

Residents manifesting behavioral problems commonly have dementia-related illnesses. More than 60% of nursing facility residents have some degree of cognitive deficit. These deficits fre- quently 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 stimu- lation. 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 help- ing 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 facili- ties provide hospice training for staff. Hospice programs may also provide care to residents in the nursing facility (see Chapter 18).

MANAGEMENT ASPECTS OF THE NURSING FACILITY

The Nursing Department The nursing department is the largest department in the nurs- ing facility. The director of nursing is responsible for managing the entire nursing staff. This consists of RNs, licensed voca- tional 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, restor- ative 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

174 PART II Influences on Health and Illness

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, opportu- nities, 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 profes- sional skills as clinicians, teachers, and managers. They are part of an interdisciplinary team 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 evaluat- ing 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 con- trol, 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 func- tion in a highly regulated industry. Funding for innovative pro- grams 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 facili- ties. 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 treat- ment 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 maintain- ing 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.

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 advan- tages. Long-term continuity cannot be provided when CNAs and licensed nurses change group assignments frequently. Staff do not form attachments to residents, and residents, par- ticularly 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 docu- mentation 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 disad- vantage 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 practic- ing in the nursing facility is challenged to work effectively with licensed vocational or practical nurses and CNAs, incorporat- ing 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 develop- ment. The baccalaureate level nurse is the best prepared to fill these positions and significantly affect the quality of care and the quality of life of many residents.

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 diver- sity 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 house- keeping services, transportation, 24-hour security, an emer- gency call system, health checks, medication administration, and minor medical treatments (Assisted Living Provider Type

CHAPTER 9 Health Care Delivery Settings and Older Adults 175

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 oppor- tunities 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 contin- ues 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 desig- nation given to freestanding facilities or units within nursing facil- ities that specialize in the care of people with Alzheimer disease and other types of dementia-related illnesses. Behavioral manifes- tations of 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 cri- teria 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 bar- riers to freedom of movement (e.g., door alarms and outside fencing to facilitate safe wandering). Program features empha- size 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 manifes- tations. It is not a work setting that everyone can enjoy. Nurses who work with these special resident populations are in a posi- tion to provide valuable consultation regarding persons with Alzheimer disease to nurses practicing in other settings, includ- ing 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 set- tings. With increased political awareness of the rising costs of the Medicare and Medicaid programs, the prospect of sig- nificant savings provided by subacute care is an attractive one. Insurance companies are looking to less costly settings to pro- vide patient care. It is estimated that subacute care could even- tually replace almost 50% of current acute care hospital lengths of stay.

Subacute care is an industry category rather than a reim- bursement or regulatory category. Professional organizations have developed guidelines for the clinical and business develop- ment 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 nurs- ing facility to provide care. To care for such clients, the nurs- ing 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.

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 endeav- ors, obtaining the financial resources can be the most dif- ficult 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 walk- ing and feeding these pets. Aviaries containing tiny birds pro- vide 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).

176 PART II Influences on Health and Illness

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 cerebrovas- cular accident on February 25. Her hospitalization consisted of a stay in an acute care facility followed by an 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, hy- perventilation, 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, hos- pital 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 care- giver 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, ensure medica-

tion 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 be-

havior 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 in- creasing 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 con- tinue. 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 inde- pendently 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 pri- mary 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 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 recommenda- tion 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 psychi- atric 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 im- age 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 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 home- maker encouraged Mrs. T to make greater accomplishments because she re- fused 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.

CHAPTER 9 Health Care Delivery Settings and Older Adults 177

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 with- out being required to participate in staff evaluations. The nurse practitioner must also have the full support of the facility medi- cal 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 cur- rently employ them on a full-time basis. The major employ- ment 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 resi- dents 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.

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, includ- ing 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, nurs- ing 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 cre- ative in a highly regulated industry is a significant challenge. Professional nurses who conceptualize their practice as includ- ing 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 per- sonal autonomy.

SUMMARY Although nursing is a recognized specialty, most nurses work- ing 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 learn- ing 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 alterna- tive 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 nontradi- tional alternatives must be developed for use by various health care personnel. The reimbursement structure is currently chal- lenged, and will clearly continue to be, to accommodate these developments.

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.

178 PART II Influences on Health and Illness

K E Y P O I N T S • 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 maxi- mizing 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 ter- minal diagnosis (may involve a small copayment at the discre- tion 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 has evolved to support complex treat- ments 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 addi- tion, 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 pres- ence 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, nutri- tion, 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 programs for residents, nursing education pro- grams, and the use of nurse practitioners.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 dis- order. He is alert and interested in his care, but he has a hearing deficit. On teaching him about his cardiac medi- cations, you notice that he often gets confused about the dosing schedules, names, and side effects of each medi- cation. Offer several strategies to help him remain inde- pendent 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 com- plications of long-term diabetes and feels that she is no

longer able to care for her mother. No other family mem- bers 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 advanta- geous to him during his recovery?

CHAPTER 9 Health Care Delivery Settings and Older Adults 179

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181

Nutrition

Kathleen M. Rourke, PhD, MSN, RD, RN

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

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 accord- ing 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 alter- native medical therapies, including consumption of herbal teas, vitamin therapy, and a variety of touch therapies such as mas- sage 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 nutri- tion 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 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 supple- ment 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.

L E A R N I N G O B J E C T I V E S 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

182 PART III Wellness Issues

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 miss- ing 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 pop- ular category, particularly after the terrorist attacks on September 11, 2001, when purchases of donuts and pastries increased signifi- cantly (Balon, 2002; Comforted but unfattened, 2002).

Food is much more than fuel for the body; food in our soci- ety 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 • 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 • 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 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.

*These dietary practices are generalizations; not all of these religions follow these guidelines.

CHAPTER 10 Nutrition 183

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 emo- tional 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 practitio- ner 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 recom- mendations 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 dis- covered. 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, bring- ing 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 ther- apy 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 sig- nificance food plays in the vast majority of the population.

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 tech- nology, these individuals who helped automate this country are not only living longer but are also hearty souls capable of over- coming many adversities. The other very large cohort of the aging population (individuals 65 years and older) are the “baby boom- ers” who are expected to number more than 89 million individu- als 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 under- stated. 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 age group), this aversion to technology is much less pro- nounced. 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 popula- tion 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

184 PART III Wellness Issues

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 abil- ity 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 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 pres- ently 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 increas- ingly prevalent, especially in older U.S. women (McGuire, Strine, Vachirasudiekha et al., 2008; Stadler & Teaster, 2002).

PHYSIOLOGIC CHANGES IN AGING THAT AFFECT NUTRITIONAL STATUS Aging produces physiologic changes; however, assumptions about the aged are often generalizations without merit. A dis- tinction 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 determi- nants 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 mobil- ity, predisposing aging adults to falls and affecting (although minimally) metabolism and bone strength. Exercise is effec- tive in maintaining skeletal muscle mass, and it enhances func- tional 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 per- forming, or be unable to perform, ADLs related to eating. They may be unable to shop for groceries, prepare food, or eat with- out 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 recep- tors, 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 nutri- ents, and the ability to eliminate waste products via the kidneys (Keithley, 1996). Changes in the oral cavity include tooth loss or ill-fitting dentures, mouth dryness, and decreased esopha- geal motility. Medications may exacerbate dryness in the oral cavity, whereas obesity or osteoporosis may affect gastro- esophageal 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 hos- pitalizations caused by dehydration among older adult patients. Dehydration among community-dwelling seniors or those housed in long-term care set- tings is widespread. Older people are susceptible to fluid loss and electro- lyte 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 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 in- formation 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 ad- mitted through emergency departments were discharged back to community

CHAPTER 10 Nutrition 185

Older adults are at risk of dehydration caused by a decreased intake of fluids, loss of sodium, and increased fluid losses. Physiologically, the decreased intake may be related to altered thirst; older adults may not feel thirsty even when hypovole- mic and often do not compensate for fluid losses during illness. Confusion, depression, and dementia also contribute signifi- cantly 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 dehy- dration 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 discom- fort. 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 gastro- intestinal 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.

PSYCHOSOCIAL AND SOCIOECONOMIC FACTORS RELATED TO MALNUTRITION Poverty is a significant problem for older Americans, particu- larly 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 esti- mated 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 limita- tion 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 com- pletely 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 depres- sion 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 pro- grams 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 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 nutri- tional assessment.

NUTRITIONAL SCREENING AND ASSESSMENT

Nutritional Screening Nutritional screening is an abbreviated assessment of nutri- tional risk factors that identifies patients who are in need of a more comprehensive assessment and nutritional interven- tions. A variety of tools have been developed to conduct nutri- tional 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).

settings. The most common characteristics for an older adult hospitalized pa- tient 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 “resi- dence 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 edu- cation 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.

186 PART III Wellness Issues

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 fac- tors associated with nutrition and health. A score of 3 or more indicates moderate to high nutritional risk and triggers the need for a more 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).

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

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.)

CHAPTER 10 Nutrition 187

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 and stabiliza- tion in light meal preparation.” The focus of the OASIS proj- ect 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 signifi- cantly increase the costs of hospitalization and care (Feldblum et al., 2008). Charney and Marian (2005) report that the preva- lence 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 mal- nutrition and its complications, especially in older adults.

Standards developed by the TJC require nutritional screening of all hospitalized and home care patients who receive

FIGURE 10-1, Cont'd

188 PART III Wellness Issues

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.)

Level II Screen Complete the following screen by interviewing the client directly and/or by referring to the client chart. If you do not routinely perform all of the described tests or ask all of the listed questions, please consider including them but do not be con- cerned if the entire screen is not completed. Please try to conduct a minimal screen on as many older clients as possible, and please try to collect serial measurements, which are extremely valuable in monitoring nutritional status. Please refer to the manual for additional information.

Anthropometrics Measure height to the nearest inch and weight to the nearest pound. Record the values below and mark them on the body mass index (BMI) scale to the right. Then use a straight edge (e.g., paper, ruler) to connect the two points and circle the spot where this straight line crosses the center line (body mass index). Record the number below. Healthy older adults should have a body mass index between 22 and 27; check the appropriate box to flag an abnormally high or low value.

Height (in): Weight (lb): Body mass index (weight/height2):

Please place a check by any statement regarding body mass index and recent weight loss that is true for the client.

Body mass index �22 Body mass index �27 Has lost or gained 10 pounds (or more) of body weight in the past 6 months

Record the measurement of midarm circumference to the nearest 0.1 centimeter and of triceps skinfold to the nearest 2 millimeters.

Midarm circumference (cm): Triceps skinfold (mm): Midarm muscle circumference (cm):

Refer to the table and check any abnormal values:

Midarm muscle circumference �10% Triceps skinfold �10% Triceps skinfold �95%

L E

V E

L II S

C R

E E

N N

A M

E :

D A

T E

Note: midarm circumference (cm) – {0.314 � triceps skinfold (mm)} � midarm muscle circumference (cm)

For the remaining sections, please place a check by any statements that are true for the client.

Laboratory Data Serum albumin below 3.5 g/dL Serum cholesterol below 160 mg/dL Serum cholesterol above 240 mg/dL

Drug Use Three or more prescription drugs, over-the-counter medications, and/or vitamin and mineral supplements daily

CHAPTER 10 Nutrition 189

Significant weight loss over time Significantly low or high weight-for-height Significant reduction in serum albumin Significant changes in functional status Significant and inappropriate food intake Significant reduction in midarm circumference Significant increase or decrease in skinfold Osteoporosis or osteomalacia Folate or vitamin B12 deficiency

Clinical Features Presence of (check each that applies): Problems with mouth, teeth, or gums Difficulty chewing Difficulty swallowing Angular stomatitis Glossitis History of bone pain History of bone fractures Skin changes (e.g., dry, loose, nonspecific lesions, edema)

Eating Habits Does not have enough food to eat each day Usually eats alone Does not eat anything on one or more days each month Has poor appetite Is on a special diet Eats vegetables two or fewer times daily Drinks milk or eats milk products once or not at all daily Eats fruit or drinks fruit juice once or not at all daily Eats breads, cereals, pasta, rice, or other grains five or fewer times daily Has more than one alcoholic drink per day (if a woman); more than two drinks per day (if a man)

Living Environment Lives on an income of less than $6000 per year (per individual in the household) Lives alone Is housebound Is concerned about home security Lives in a home with inadequate heating or cooling Does not have a stove and/or refrigerator Is unable or prefers not to spend money on food (�$25 to $30 per person spent on food each week)

Clients in whom you have identified one or more major indicators of poor nutritional status require immediate medical attention; if minor indicators are found, ensure that they are known to a health professional or to the client’s own physician. Clients who display risk factors of poor nutritional status should be referred to the appropriate health care or social service professional (e.g., dietitian, nurse, dentist, case manager).

Concurrent syndromes Alcoholism Cognitive impairment Chronic renal insufficiency Multiple concurrent medications Malabsorption syndromes

Symptoms Anorexia, nausea, or dysphagia Early satiety Change in bowel habits Fatigue or apathy Memory loss

Physical signs Poor oral or dental status Dehydration Poorly healing wounds Loss of subcutaneous fat or muscle mass Fluid retention

Laboratory tests Reduced levels of serum albumin, transferrin, prealbumin, or ascorbic acid Folate, iron, or zinc deficiency Dehydration-related laboratory phenomena

Functional Status Usually or always needs assistance with (check each that applies): Bathing Dressing Grooming Toileting Eating Walking or moving about Traveling (outside the home) Preparing food Shopping for food or other necessities

Mental/Cognitive Status Clinical evidence of impairment (e.g., Folstein �26) Clinical evidence of depressive illness (e.g., Beck Depression Inventory �15, Geriatric Depression Scale �5)

Minor IndicatorsMajor Indicators

Inappropriate food intake Poverty Social isolation Dependency or disability Acute or chronic diseases or conditions Chronic medication use Advanced age

Risk Factors

Men Women Percentile 55–65 yr 65–75 yr 55–65 yr 65–75 yr Arm circumference (cm) 10th 27.3 26.3 25.7 25.2 50th 31.7 30.7 30.3 29.9 95th 36.9 35.5 38.5 37.3 Arm muscle circumference (cm)

10th 24.5 23.5 19.6 19.5 50th 27.8 26.8 22.5 22.5 95th 32.0 30.6 28.0 27.9

Triceps skinfold (mm) 10th 6 6 16 14 50th 11 11 25 24 95th 22 22 38 36 From: Frisancho AR. New norms of upper limb fat and muscle areas for

assessment of nutritional status. Am J Clin Nutr 1981; 34:2540–2545.

FIGURE 10-2, Cont'd

190 PART III Wellness Issues

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 assess- ment as follows: • 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 influ-

ence 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 per day; chewing or swallowing difficulties; gas- trointestinal problems or symptoms that affect eating; oral health and denture use; history of diseases or surgery; activ- ity 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 por- tions. 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 pat- terns, 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 cate- gory such as calcium 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 com- promising the patient’s sense of privacy about food intake and diet.

Anthropometrics Height and weight are the mainstays of anthropometric mea- surements. 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 anthro- pometry, 1988):

Knee Heightasan Estimateof Stature

Stature for men knee heig= ×2 02. hht in centimeters cm age

Stature for women

[ ]( ) × +

= ( . ) .

0 04 64 19

1 833 0 24 84 88

×( ) ×( )+

knee height in cm age. .

• 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

BOX 10-1 NUTRITIONALLY AT-RISK PATIENTS

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.

CHAPTER 10 Nutrition 191

In comparing weight and height, the nurse may use instru- ments 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 mislead- ing. 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).

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 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 anthro- pometric 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 prac- titioner to evaluate not only bone density at several sites but to also evaluate body fat in a minimum amount of time (gen- erally less than 20 minutes) with minimum radiation expo- sure (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 may indicate severe depletion.

Prealbumin is a carrier protein for retinol-binding pro- tein 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.

*Those older than age 69 should use the ranges for individuals in their 60s. Reprinted with permission from Health after 50. (1999). Johns Hopkins Medical Letters, 7(1), 5.

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

192 PART III Wellness Issues

Total lymphocyte count (TLC) is sometimes used as a nutri- tional marker. In severe or prolonged malnutrition, immune proteins are depleted and the TLC is decreased.

NUTRITIONAL GUIDELINES FOR ALL AGES Healthy eating is important for all Americans, regardless of age. Nutritional guidelines are published by a number of organiza- tions. 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 individ- ual’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 cardiovascu- lar disease, cancer, macular degeneration, and Alzheimer dis- ease, and many studies support a negative correlation between fruit and vegetable intake and obesity, diabetes, and hyperten- sion (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, cardiovas- cular disease, macular degeneration of the eye, and other dis- eases (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

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)

http://hnrca.tufts.edu/wp-content/uploads/81059_TuftsMyPLate.pdf

CHAPTER 10 Nutrition 193

of fruits and vegetables daily and a movement to a more plant- based diet (USDA-DHHS, 2005, Box 10-2).

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 con- sume 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 defi- ciency or in combination with folate or vitamin B

12 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, 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 identi- fied in the minimum data set (MDS) and resident assessment pro- tocols (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 allow- ances (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 regard- ing the roles of nutrients in the body and in health, a partner- ship 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 recom- mended dietary allowances for nutrients as well as the upper tol- erable limits and risk for toxicity for each nutrient for both age categories and gender categories (Institute of Medicine, 2004).

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 require- ments 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 indi- vidual. 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 advis- able 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, B

6 , folate, and B

12 ), calcium, phos-

phorus, magnesium, iron, zinc, iodine, and selenium. The label must also specify calories based on serving size and indicate the number of servings. In addition, the label specifies the per- centage 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).

• 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 ul- traviolet band radiation (i.e., sunlight): Consume extra vitamin D from vita- min 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 appropri- ate management of other health 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 steam- ing 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.

BOX 10-2 DIETARY GUIDELINES FOR AMERICANS, 2005, PERTAINING TO ADULTS AND OLDER ADULTS

194 PART III Wellness Issues

TABLE 10-2 DIETARY REFERENCE INTAKES FOR OLDER ADULTS VITAMINS AND ELEMENTS

VITAMIN A (MICROGRAM [MCG])

VITAMIN C (MILLIGRAM [MG])

VITAMIN D (MCG)

VITAMIN E (MG)

VITAMIN K (MCG)

THIAMIN (MG)

RIBOFLAVIN (MG)

NIACIN (MG)

VITAMIN B6 (MG)

FOLATE (MCG)

RDA or AI1

Age 51–70 Male 900 90 10* 15 120* 1.2 1.3 16 1.7 400 Female 700 75 10* 15 90* 1.1 1.1 14 1.5 400 Age 70+ Male 900 90 15* 15 120* 1.2 1.3 16 1.7 400 Female 700 75 15* 15 90* 1.1 1.1 14 1.5 400

Tolerable Upper Intake Levels Age 51–70 Male 3000 2000 50 1000 ND ND ND 35 100 1000 Female 3000 2000 50 1000 ND ND ND 35 100 1000 Age 70+ Male 3000 2000 50 1000 ND ND ND 35 100 1000 Female 3000 2000 50 1000 ND ND ND 35 100 1000

VITAMIN B12 (MCG)

PANTOTHENIC ACID (MG)

BIOTIN (MCG)

CHOLINE (MG)

BORON (MG)

CALCIUM (MG)

CHROMIUM (MCG)

COPPER (MCG)

FLUORIDE (MG)

IODINE (MCG)

RDA or AI1

Age 51–70 Male 2.4 5* 30* 550* ND 1200* 30* 900 4* 150 Female 2.4 5* 30* 425* ND 1200* 20* 900 3* 150 Age 70+ Male 2.4 5* 30* 550* ND 1200* 30* 900 4* 150 Female 2.4 5* 30* 425* ND 1200* 20* 900 3* 150

Tolerable Upper Intake Levels Age 51–70 Male ND ND ND 3500 20 2500 ND 10000 10 1100 Female ND ND ND 3500 20 2500 ND 10000 10 1100 Age 70+ Male ND ND ND 3500 20 2500 ND 10000 10 1100 Female ND ND ND 3500 20 2500 ND 10000 10 1100

ELEMENTS AND MACRONUTRIENTS

IRON (MG)

MAGNESIUM (MG)

MANGANESE (MG)

MOLYBDENUM (MG)

NICKEL (MG)

PHOSPHORUS (MG)

SELENIUM (MCG)

VANADIUM (MG)

ZINC (MG)

RDA or AI1

Age 51–70 Male 8 420 2.3* 45 ND 700 55 ND 11 Female 8 320 1.8* 45 ND 700 55 ND 8 Age 70+ Male 8 420 2.3* 45 ND 700 55 ND 11 Female 8 320 1.8* 45 ND 700 55 ND 8

Tolerable Upper Intake Levels Age 51–70 Male 45 350 11 2000 1 4000 400 1.8 40 Female 45 350 11 2000 1 4000 400 1.8 40 Age 70+ Male 45 350 11 2000 1 3000 400 1.8 40 Female 45 350 11 2000 1 3000 400 1.8 40

ENERGY2 (KCAL)

PROTEIN3 (G)

CARBOHYDRATES4 (G)

TOTAL FAT5,6 (% KCAL)

N-6 PUFA (G)

N -3 PUFA (G) TOTAL FIBER (G)

DRINKING WATER, BEVERAGES, WATER IN FOOD (L)

RDA or AI1

Age 51–70 Male 2204 56 130 14⁎ 1.6* 30* 3.7*

CHAPTER 10 Nutrition 195

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 interac- tions 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.

NURSING DIAGNOSES ASSOCIATED WITH NUTRITIONAL PROBLEMS Nursing diagnoses are derived from an assessment of the patient during a comprehensive health history and physical examina- tion, 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 nutri- tional problem and diagnoses that commonly have a nutritional component.

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

ENERGY2 (KCAL)

PROTEIN3 (G)

CARBOHYDRATES4 (G)

TOTAL FAT5,6 (% KCAL)

N-6 PUFA (G)

N -3 PUFA (G) TOTAL FIBER (G)

DRINKING WATER, BEVERAGES, WATER IN FOOD (L)

Female 1978 46 130 11⁎ 1.1* 21* 2.7* Age 70+ Male 2054 56 130 14* 1.6* 30* 2.6* Female 1873 46 130 11* 1.1* 21* 2.1* AMDR7 10-35% 45-65% 20-35% 5-10% 0.6-1.2%

ELECTROLYTES POTASSIUM (G) SODIUM (G) CHLORIDE (G)

RDA or AI1

Age 51–70 Male 4.7 1.3* 2.0* Female 4.7 1.3* 2.0* Age 70+ Male 4.7 1.2* 1.8* Female 4.7 1.2* 1.8”

Tolerable Upper Intake Levels Age 51–70 Male

2.3 3.6

Female 2.3 3.6 Age 70+ Male

2.3 3.6

Female 2.3 3.6

TABLE 10-2 DIETARY REFERENCE INTAKES FOR OLDER ADULTS—CONT'D

1Recommended dietary allowances (RDAs) are in bold type and adequate intakes (AIs) are in ordinary type followed by an asterisk (*). 2Values 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, 1838 kcal. 3The RDA for protein equilibrium in adults is a minimum of 0.8 gram per kilogram (g/kg) body weight for reference body weight. 4The RDA for carbohydrate is the minimum adequate to maintain brain function in adults. 5Because 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. 6Values for mono- and polyunsaturated fats and cholesterol not established as “they have no role in preventing chronic disease, thus not required in the diet.” 7AMDRs for intakes of carbohydrates, proteins, and fats expressed as % of total calories.

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).

196 PART III Wellness Issues

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 nutri- tion, 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 sati- ety 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 dis- order. Dysphagia after a stroke may be successfully treated with swallowing exercises and retraining. Referral to a speech thera- pist 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 care- fully 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.

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

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.

TABLE 10-4 SAMPLE OF DRUG–NUTRIENT INTERACTIONS*

DRUG EFFECT

Analgesic Acetaminophen Decreased drug absorption with food; overdose associated with liver failure Aspirin Absorbed directly through stomach; decreased drug absorption with food; decreased folic acid,

vitamins C and K, and iron absorption

Antacid Aluminum hydroxide Decreased phosphate absorption Sodium bicarbonate Decreased folic acid absorption

Antiarrhythmic Amiodarone Taste alteration Digitalis Anorexia, decreased renal clearance in older persons

Antibiotic Penicillins Decreased drug absorption with food, taste alteration Cephalosporin Decreased vitamin K Rifampin Decreased vitamin B6, niacin, vitamin D Tetracycline Decreased drug absorption with milk and antacids, decreased nutrient absorption of calcium,

riboflavin, vitamin C caused by binding Trimethoprim/sulfamethoxazole Decreased folic acid

Anticoagulant Coumarin Acts as antagonist to vitamin K

Anticonvulsant Carbamazepine Increased drug absorption with food Phenytoin Decreased calcium absorption; decreased vitamins D, K, and folic acid; taste alteration; decreased

drug absorption with food

Antidepressant Amitriptyline Appetite stimulant Clomipramine Taste alteration, appetite stimulant Fluoxetine (selective serotonin reuptake inhibitor [SSRI]) Taste alteration, anorexia

Antihypertensive Captopril Hydralazine

Taste alteration, anorexia Enhanced drug absorption with food, decreased vitamin B6

Labetalol Methyldopa

Taste alteration (weight gain for all beta-blockers) Decreased vitamin B12, folic acid, iron

Antiinflammatory All steroids Increased appetite and weight, increased folic acid, decreased calcium (osteoporosis with long-term

use), promotes gluconeogenesis of protein

Antiparkinsonian Levodopa Taste alteration, decreased vitamin B6 and drug absorption with food

Antipsychotic Chlorpromazine Thiothixene

Increased appetite Decreased riboflavin

Bronchodilator Albuterol sulfate Theophylline

Appetite stimulant Anorexia

Cholesterol Lowering Cholestyramine Decreased fat-soluble vitamins (A, D, E, K); vitamin B12; iron

Diuretic Furosemide Decreased drug absorption with food Spironolactone Increased drug absorption with food Thiazides Decreased magnesium, zinc, and potassium

Laxative Mineral oil Decreased absorption of fat-soluble vitamins (A, D, E, K), carotene

Platelet Aggregate Inhibitor Dipyridamole Decreased drug absorption with food

Potassium Replacement Potassium chloride Decreased vitamin B12 Tranquilizer Benzodiazepines Increased appetite

*Not intended to be an exhaustive or all-inclusive list. Always check pharmacology references before administering medications. 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.

198 PART III Wellness Issues

foods, for example, following a cerebrovascular accident or with myasthenia gravis, amyotrophic lateral sclerosis, and multiple scle- rosis. Enteral nutrition is also used when the upper gastrointesti- nal 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 gastros- tomy [PEG], or radiology-assisted gastrostomy), or directly into the jejunum (jejunostomy or percutaneous endoscopic jejunos- tomy). For decompression of the stomach and simultaneous feed- ing 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 com- plex carbohydrate), modified protein (peptide), and elemental (amino acid) formulas. Some enteral formulas have added solu- ble or insoluble fiber. Disease-specific formulas are also available for the dietary treatment of diseases, for example, reduced pro- tein for patients receiving renal dialysis, increased lipid percent- age 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 for- mulas are considerably more expensive than standard formu- las 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 nutri- tion support benefit from $4.20 for every $1 invested in nutri- tion support management (Journal of the American Dietetic Association [ADA], 1995). Transition to an oral diet 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 ade- quate nutrients to maintain health. Diseases and conditions typ- ically 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 cath- eter, 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 vari- ous health care settings or at home. Nurses educate home care patients about the use and care of their access devices, admin- istration 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.

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, fail- ure 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 bio- logic, 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 commu- nity 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, malnutri- tion, 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 fail- ure 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 nutri- tion, as necessary, a thorough diagnostic evaluation is warranted.

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 Risk for Ineffective Gastrointestinal Perfusion

BOX 10-3 NURSING DIAGNOSES ASSOCIATED WITH NUTRITIONAL PROBLEMS

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.

CHAPTER 10 Nutrition 199

SUMMARY Food has strong cultural, spiritual, religious, and social connota- tions, which were recognized by physicians, statesmen, and schol- ars 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 proper- ties of food and nutrients are major areas of research, including the area of epigenetics. Nurses must understand the role of vita- mins 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 compre- hensive 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 nutri- ents. Parenteral nutrition is a life-saving measure; in addition, research has shown that nutrients provided via the gastrointesti- nal 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 col- laborates with the physician, the dietitian, the pharmacist, and other members of the health care team to promote the nutri-

tional health of patients.

K E Y P O I N T S • Appropriate food intake for health maintenance was recog-

nized 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 poor-

est 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 mem- bers of the health care team to formulate a comprehensive and coordinated nutritional care plan.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 gro- cery 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 fol- lowing 24-hour intake:

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 supple- ment 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 suc- tion cups, or padded utensils). An occupational therapist should evaluate the patient and provide assistive devices.

8. Instruct caregivers and homebound older adults on any treatments that pro- vide nutritional support (e.g., enteral nutrition).

9. Ensure that appliances (such as stoves and microwave ovens) are function- ing safely. Assess older adults’ functional ability to use appliances safely.

HOME CARE

http://MyPlate.gov

200 PART III Wellness Issues

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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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202

Sleep and activity are two universal, dichotomous functions of all human beings. Sleep is a natural, periodically recurring, physi- ologic state of rest for the body and mind; sleep is a state of inac- tivity 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 accord- ing to personal choice, lifestyle, and health status. This chapter considers age-related changes in sleep and activity and the role of the nurse in assisting older individuals to adapt to those changes.

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 wake- fulness center. The thalamus, limbic system, and reticular acti- vating 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.

Stage 1 of NREM sleep is the lightest level of sleep. During stage 1, an individual can be easily awakened. Sleep progres- sively deepens during stages 2 and 3 until stage 4, the deep- est 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

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C H A P T E R

L E A R N I N G O B J E C T I V E S 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.

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.

Sleep and Activity

Jennifer J. Yeager, PhD, RN

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CHAPTER 11 Sleep and Activity 203

reduced, an individual may experience difficulty concentrat- ing, 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 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 electro- encephalography (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 night- time 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 morn- ing 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., postopera- tive 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 pos- sible overuse of hypnotic or over-the-counter (OTC) medica- tions (Kryger et al., 2004).

Age-Related Changes in Sleep Many older adults experience changes in sleep, which are con- sidered “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).

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 approxi- mately 90%. However, this percentage drops to 75% for older adults (Hoffman, 2003).

Nocturnal awakenings contribute to an overall decrease in the average number of hours of sleep. The frequency of noc- turnal awakenings increases with age; older adults may wake up four or more times per night. The interruptions of sleep con- tribute 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 noc- turnal 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.

STAGES TYPE OF SLEEP SELECTED CHARACTERISTICS

NREM Sleep (Four Stages) Stage 1 Light sleep Easily awakened Stage 2 Medium deep sleep More relaxed than in stage 1 Slow eye movements Fragmentary dreams Easily awakened Stage 3 Medium deep sleep Relaxed muscles Slowed pulse Decreased body temperature Awakened with moderate stimuli Stage 4 Deep sleep Restorative sleep Body movement rare Awakened with vigorous stimuli REM Sleep Active sleep Rapid eye movement Increased or fluctuating pulse,

blood pressure, and respirations Dreaming occurs

TABLE 11-1 NORMAL STAGES OF SLEEP

NREM, non–rapid eye movement; REM, rapid eye movement. 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.

BOX 11-1 AGE-RELATED CHANGES IN SLEEP

• Increased sleep latency • Reduced sleep efficiency • Increased nocturnal awakenings • Increased early morning awakenings • Increased daytime sleepiness

204 PART III Wellness Issues

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 sleepi- ness 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 car- diovascular disease (Chasens, Sereika, & Burke, 2009). Daytime sleepiness may also be caused by medication side effects (e.g., antiarrhythmics, clonidine, selective serotonin reuptake inhibi- tors [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 supple- mented 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. 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 for- mation (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 pro- ductive 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 per- son’s quality and amount of sleep. For older adults, environ- ments 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 quality of sleep. Not only are these environments unfa- miliar, 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 inva- sive procedures such as Foley catheterization, intravenous line placement, venipuncture, mechanical ventilation, and discom- fort 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 medica- tions 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 nurs- ing interventions address (1) the scheduling of procedures and care activities to avoid unnecessary awakenings, (2) modifi- cation 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 inter- fere with the enjoyment of activities. Sources of noise include personnel, roommates, visitors, equipment, and routine activi- ties 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 environmen- tal noise in institutions involves cooperation among employees from other departments, visitors, and nurses.

• Talking and calling out by residents • Talking by staff • Television • Intercoms, bells, alarms • Equipment (e.g., linen carts, floor cleaning equipment)

BOX 11-2 SOURCES OF NIGHTTIME NOISE IN NURSING FACILITIES

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.

CHAPTER 11 Sleep and Activity 205

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 institu- tional setting for glare, brightness, and uneven levels of illumi- nation. Selectively dimming the institution’s lights at night may promote better sleep. However, safety concerns must be con- sidered. 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 night- time reduction in core body temperature related to reduced metabolic rate and reduced muscle activity. Being too warm will also disrupt sleep, but some older adults sleep better if simple measures are used to keep them warm. The ambient tempera- ture 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, qual- ity, 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 mea- sures 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, comfort- able chairs may be a solution. Reclining chairs with soft cush- ions 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 indi- viduals and thus promote sleep. If being out of bed is not fea- sible, modifying the bed with extra pillows to support painful limbs and promote comfortable body positioning or using spe- cial mattresses (e.g., air or water 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 move- ment 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 popu- lation. 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 depres- sion, 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 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 resi- dence, from their house or apartment to the home of their chil- dren 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, engen- ders 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 contrib- utes 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

206 PART III Wellness Issues

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 inter- ests 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 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 bever- ages 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 anal- gesics 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 pro- motes 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 cul- ture 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 pros- tatic 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 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) caus- ing 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 non- pharmacologic interventions for insomnia are also available. Tranquilizers and sedatives decrease activity and calm the recip- ient. 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, anti- histamines, 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 benzo- diazepines 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], 2012). Age-related changes in the clearance of benzodiazepines increase the risk of prolonged sedation. Complications of benzodiazepine use include day- time 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 medica- tion, 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 reten- tion; and, paradoxically, confusion, agitation, restlessness, and insomnia. As another example, TCAs may be slightly sedating but may also cause insomnia and nightmares.

CHAPTER 11 Sleep and Activity 207

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 awak- ening (Table 11-2). OTC medications that interfere with sleep include nasal decongestants containing amphetamine-like sub- stances and analgesics containing caffeine. Many prescription medications have side effects that affect sleep.

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).

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 treat- ment 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, noc- turnal 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 evalu- ation. 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, appro- priate interventions follow naturally (Rowe, 2003). Medications such as sedatives or antipsychotics should be avoided 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 sleepi- ness 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 epi- sodes 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

TABLE 11-2 EXAMPLES OF MEDICATIONS THAT DISTURB SLEEP

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.

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 Daytime sleepiness Antipsychotics (haloperidol,

risperidone), long-acting benzodiazepines, cold remedies containing antihistamines, atenolol, diltiazem, nifedipine, ranitidine, cimetidine

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 substi- tute 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 promo-

tional materials and package information. 8. Check any warnings on the label or package, and check for 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!

BOX 11-3 TIPS FOR OLDER ADULTS USING HERBAL AND HOMEOPATHIC REMEDIES

From Miller, C.A. (1996). Alternative healing products. Geriatric Nursing, 17(3), 145-146.

208 PART III Wellness Issues

in women. Complications related to sleep apnea include cardiac disease, hypertension, stroke, obesity, headaches, irritability, depression and anxiety, sexual dysfunction, daytime sleepi- ness and difficulty with memory, thinking, and concentration. Persons with sleep apnea are also at increased risk for automo- bile 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 head- aches, poor memory and concentration, and moodiness. Risk factors associated with CSA include heart failure, hypothyroid- ism, 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 main- tain open nasal passages. Continuous positive airway pressure (CPAP) treatment may be beneficial for those with CSA, espe- cially 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 ton- sils, large tongue or uvula, narrow airway, and deviated septum (Olson, Moore, Morgenthaler et al, 2003). Additionally, smok- ing, hypertension, and cardiac risk factors increase the likeli- hood 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 max- illary advancement surgery, or nasal surgery) (Goldberg, 2012).

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 cardiovascu- lar and cerebrovascular diseases, as well as use of opioid drugs. Prevalence may be as high as 20% and increases with age; it

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 fa- tigue associated with grooming, dressing, 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 him- self 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. Explore with patient motivators to lose weight; reinforce as needed. Teach about the USDA’s food guidance system, MyPlate (http://www.choosemy-

plate.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 mo-

bility 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 dis-

tress 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 activ- ity 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. Discuss with patient plans for discharge, and explore alternative living arrange-

ments, including residence on a first-floor apartment, especially if mobility is impaired.

http://www.choosemyplate.gov/

CHAPTER 11 Sleep and Activity 209

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 disrup- tion of sleep. Some older adults are unaware of their leg move- ments; 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), anti- convulsants, 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 antidepres- sants 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).

Getting a Good Night’s Sleep Whether sleep is disturbed by the environment, diet, medica- tions, lifestyle changes, or sleep disorders, the first step in devel- oping interventions to improve the amount and quality of sleep is taking a thorough sleep history. Supplementing the sleep his- tory 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, inter- ventions to improve sleep usually begin with basic sleep hygiene measures.

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 awak- ens. 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

• 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

BOX 11-4 SLEEP HISTORY COMPONENTS

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 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 conse- quence 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.

210 PART III Wellness Issues

has slept a total of 6 hours. Information about a person’s typical bedtime rituals or practices should also be obtained.

The older adult is likely to seek additional help in achiev- ing satisfaction with sleeping habits. If the older adult is too tired or fatigued to perform normal activities, the sleep prob- lem 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 exer- cise and activity pattern provide additional information about sleep habits. In general, strenuous activity should be avoided at least 2 hours 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 medi- cations, 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, pulmo- nary disease, or musculoskeletal problems (Spieker & Motzer, 2003). Common problems that cause pain and discomfort in bed include COPD; rheumatologic problems such as osteopo- rosis; 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 pri- mary sleep disorders. Patients are asked to spend the night so that a sleep study can be administered. This often includes poly- somnography, 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 clini- cal 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 cer- tain 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 bed- time 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 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., environ- ment, pain, or equipment such as a Foley catheter) that pre- dispose 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

CHAPTER 11 Sleep and Activity 211

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 impor- tant to promote their sense of security.

Other Therapies to Promote Sleep In addition to sleep hygiene measures, other nonpharmaco- logic 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 relax- ation 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 ther- apy attempts to reestablish the 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 activi- ties 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 min- utes (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 ques- tions about sleep habits, bedtime routines and rituals, medica- tions, 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 edu- cating 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).

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 demen- tia 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 con- siderations 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 activi- ties 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, relo- cation 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 sup- plement the care provided by family members and friends, or relo- cation 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 qual- ity 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 pro- motion of more restful sleep (Schoenborn, Vickerie, & Powell- Griner, 2006). Exercise preserves mobility and reduces the risk of falls by promoting muscle strength and joint flexibility.

212 PART III Wellness Issues

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, prayer, reading, watching TV, listening to music, snacks).

Offer a bedtime snack or beverage. Enable bedtime reading or listening to music. Assist with aspects of personal hygiene at bedtime (e.g., a bath). Encourage prayer or meditation.

Verbalizations about the quality and quantity of sleep (e.g., statements of difficulty falling asleep, frequent awakenings; 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.

Bibliography for the development of protocol from Jenike, M.A. (1989). Geriatric psychiatry 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. From Foreman, M.D. & Wykle, M. (1995). Nursing standard-of-practice protocol: Sleep disturbances in elderly patients. Geriatric Nursing, 16, 238.

CHAPTER 11 Sleep and Activity 213

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 seg- ments of at least 10 minutes’ duration. To measure the appro- priate 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 condi- tions 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 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 con- tinue 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 influ- enced 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 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 vol- unteer in community organizations, return to school for the joy of learning, or even start second careers. Nurses are empa- thetic 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 facil- ity will have different options for activities. New social networks can be established. The nurse’s role during relocation is to sup- port efforts to become accustomed to new situations and oppor- tunities 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 activi- ties 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 par- ticipation. The activity preferences of each resident are assessed on admission. The individualized care plan includes activities that are appropriate for 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).

214 PART III Wellness Issues

Loss of Spouse The loss of a spouse disrupts both joint activities and those activ- ities 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 activi- ties, 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 develop- ment 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 participate in activities that were once enjoyed. Caregivers gradually assume more responsibility for monitor- ing behavior, performing basic personal care tasks, and provid- ing 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 con- straints caused by aging or other diseases, and safety concerns.

Activities for older adults with dementia should be mean- ingful (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 par- ticipants. 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

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).

CHAPTER 11 Sleep and Activity 215

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 (Alzheimer’s Association, 2012b).

As cognitive impairment increases, the older adult with dementia requires more supervision and assistance with per- sonal care activities such as bathing, dressing, grooming, toi- leting, 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 inde- pendence and preserve functional ability, nurses should encour- age 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 impor- tant 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 set- ting, 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 demen- tia, an 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 promo- tion 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 iden- tify 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.

Exercise Walking programs (indoor, outdoor) Dancing (balloon, square, line) 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 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)

BOX 11-5 EXAMPLES OF ACTIVITIES IN LONG-TERM CARE FACILITIES

1. Assess risk factors (e.g., environment, pain, or equipment such as a Foley cath- eter) that would predispose homebound older adults to sleep disturbances.

2. Review all medications to identify those that may interfere with home- bound 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.

HOME CARE

216 PART III Wellness Issues

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.

K E Y P O I N T S • 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 fac- tors, 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 diag- nostic studies in a sleep laboratory may be used to supple- ment 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, 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 regu- larly, adequate hydration before and after exercise, and suit- able 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 accom- panied 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 recom- mendations 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 recommenda- tions do you give her? What precautions do you include in your recommendations?

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http://www.dovepress.com/complex-sleep-apnea-syndrome-peer-reviewed-article-PPA

http://www.webmd.com/sleep-disorders/guide/insomnia-symptoms-and-causes

http://www.who.int/dietphysicalactivity/physical-activity-recommendations-65years.pdf?ua=1

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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 acci- dents, 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.

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

http://evolve.elsevier.com/Meiner/gerontologic

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.

C H A P T E R

12 Safety

Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C and Deb Bagnasco Stanford, MSN, RN, CCRN

L E A R N I N G O B J E C T I V E S 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.

http://evolve.elsevier.com/Meiner/gerontologic

CHAPTER 12 Safety 219

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 physi- ologic 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 occur- rences 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 sus- tain 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 place- ment in 40% of the population seeking institutionalization.

Falling has numerous antecedents and consequences that can be identified and managed. Most clinical research demon- strates 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 improve- ments, and behavioral modification. Clinical research findings demonstrate variability in the effectiveness of these interven- tions. Not all falls are preventable; therefore, goals for individu- als who fall frequently are fall reduction, prevention of serious injury, and modification of significant risk factors.

It is also important to note that because falls are multifac- torial, not all individuals fall as a result of the same anteced- ents. 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 pres- ent, and both can be modified through education and behav- ioral modification. Thus, because falls tend to be multifactorial in this age group, care must be taken to perform a comprehen- sive 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 pro- cess, which is distinct from diseases and the adverse effects of medications. It is important to tell older adults that the etiol- ogy 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 inter- ventions (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.

Definition of Falling 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 situ- ation. 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

General Care • 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.

BOX 12-1 GENERAL FALL PREVENTION GUIDELINES

• “I think I slipped.” • “I don’t remember what happened.” • “I was in a hurry.” • “I tripped.” • “I lost my balance.”

BOX 12-2 COMMON EXPLANATIONS FOR FALLING GIVEN BY OLDER ADULTS

220 PART III Wellness Issues

from standing upright into a seat or onto the floor. Injuries such as bruising, sprains, strains, or fractures may result from mini- mal height drops.

History taking should be detailed enough for the examiner to envision the details leading to the fall. Refer to the later sec- tion “Evaluation of Clients Who Fall” for specific questions to ask during history taking (Tideiksaar, 2009).

Meaning of Falling to Older Adults Falling, in a broad sense, is a concept that holds negative conno- tations 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 limita- tions 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 con- dition. 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 fall- ing, 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 associ- ated 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 flexibil- ity 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 prob- lem 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 con- duction, including a loss of high-tone frequencies, called pres- bycusis. 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 suscep- tible 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 cognizant of environmental condi- tions 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 get- ting 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 support- ive 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

CHAPTER 12 Safety 221

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 ambu- lation aids; joint range of motion; and modalities such as ice, hot packs, and physical therapy.

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, depend- ing 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 physi- cally 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 pro- mote autonomy, it is important to allow older patients to con- tinue 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 poste- rior 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 walk- ing 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 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.

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 fall- ing 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 eval- uation 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 condi- tions 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 indi- viduals 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 bal- ance 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 fall- ing.” The workup seeks to identify the underlying cause so that it can be treated, thus ultimately preventing or reducing recur- rent falling. One aim of fall management is the reduction of risk factors to promote safety while still respecting patient auton- omy. Because falling is individually determined and not always preventable or predictable, it is important to avoid classifying

• 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 • Carotid hypersensitivity • Carotid stenosis • Delirium*

BOX 12-3 TREATABLE CAUSES OF FALLING IN OLDER ADULTS

*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.

222 PART III Wellness Issues

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 sig- nificance 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 sym- metry, and path. Important areas of balance assessment include sitting and standing balance, turning, and the ability to sit with- out loss of balance. The Tinetti Gait and Tinetti Balance instru- ments 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 assis- tive aids or physical therapy, older individuals require medical workups for treatable causes of gait and balance abnormalities (Table 12-1).

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 impair- ment 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 criti- cal 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 modi- fication (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 this situation, teaching individuals to count the steps (i.e., keeping a mental tally of the number of steps ascend- ing or descending), and reinstalling handrails that meet indi- viduals’ 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.

Floor Surfaces Floors that have been waxed or polished are common slippery surfaces that are a safety risk for older adults, especially per- sons 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.

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

TABLE 12-1 TREATABLE CAUSES OF GAIT AND BALANCE ABNORMALITIES

FIGURE 12-1 Steep stairs with handrail missing on the right. (Courtesy of Deanna Gray-Miceli.)

CHAPTER 12 Safety 223

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, car- peting 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 ide- ally 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 great- est 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 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).

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 seri- ous 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 geronto- logic nurse 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 pro- gram. 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).

BOX 12-4 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

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.

TABLE 12-2 BEHAVIORAL INTERVENTIONS TO PREVENT SERIOUS INJURY

224 PART III Wellness Issues

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 behav- iors 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 con- scious attempts, whenever a behavior is performed, to change or alter it. Much of what the nurse teaches must be remem- bered for later action; the use of notes and tape recorders as daily reminders may help.

Disease or condition modification to reduce the risk of seri- ous 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 associ- ated 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 interven- tions, 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 non- serious, 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 intrin- sic 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).

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 spe- cific 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 associ- ated 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 ill- nesses. These types of falls have key symptoms that may be elicited on history taking; physical examination findings and diagnostic tests 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 her- alding 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 pur- pose, possibly with a desire to do harm. Older patients with significant depression or suicidal ideation may throw them- selves 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).

Fall Consequences Physical Injury The incidence of fall-related injuries spans from trivial trauma such as skin tears and sprains to serious injury such as hip frac- tures, internal bleeding, or subdural hematomas. Each year thou- sands 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

• Multifactorial • Extrinsic (environmental) • Intrinsic (illness or disease related) • Intentional • Isolated • Cluster • Premonitory • Prodromal

BOX 12-5 FALL CLASSIFICATION

CHAPTER 12 Safety 225

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 impair- ment, 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 promi- nences 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 psy- chological 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 signifi- cant consequence of falling may be fear of falling again or fear

of being able to get up independently after a fall. Both these con- ditions have been researched more extensively than other psy- chological 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 hypoth- esis 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.

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 respon- dent 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 cabi- nets, or hurrying to answer the telephone. This tool is based on

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

BOX 12-6 THE MULTIFACTORIAL AND INTERACTING CAUSES OF FALLS

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.

BOX 12-7 FEAR OF FALLING (FOF) ISSUES

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.

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 (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 impair- ment, increased age, and certain chronic diseases) residences.

226 PART III Wellness Issues

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 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 indi- vidual 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 imme- diately before a fall. The acronym SPLATT helps in further eval- uation (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 symp- toms 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).

Physical Examination The physical examination of an individual who falls includes a focused examination based on the patient’s presenting com- plaints in addition to the sensory, cardiovascular, musculoskel- etal, and neurologic systems. Many treatable causes of falling may be identified on physical examination. Sensory input origi- nates from visual, auditory, tactile, cardiovascular, and motor response systems. Sensory inputs from vision and hearing, proprioception of the distal lower extremities, and the periph- eral 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 per- fusion 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 inves- tigations have found that poor ankle dorsiflexion affects the abil- ity to right oneself during the phases of a fall (Tideiksaar, 2009). Manual muscle strength testing identifies weakness in particu- lar 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.

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 bal- ance. 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 bal- ance 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 cor- related 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).

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

TABLE 12-3 KEY SYMPTOMS TO ELICIT DURING HISTORY TAKING FROM PATIENTS WHO HAVE FALLEN

CHAPTER 12 Safety 227

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 spe- cific 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 seri- ous injury.

Several aids for monitoring and preventing falls are avail- able. 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 informa- tion is extremely useful in determining antecedents and conse- quences of falling. Fall diaries are inexpensive or may be created by the nurse simply by using a pen, paper, and ruler (Box 12-8).

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 particu- lar 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 pro- cess of aging, along with the effects of disease, results in changes that affect the host. One aim of injury prevention is to alter fac- tors that impinge on the host by maximizing patient health and functional status, reducing unnecessary medications, and alter- ing risk-taking behaviors. These combined efforts will reduce the risk of unintentional injuries. Alterations in environment through the elimination of environmental hazards will reduce

Instructions: Client is seated in a hard, armless, chair. The following maneuvers are tested:

1. Sitting balance 0 � Leans or slides in chair 1 � Steady and safe

2. Arise 0 � Unable without help 1 � Able, but uses arm to help 2 � Able without use of arms

3. Attempts to arise 0 � Unable without help 1 � Able, but requires more than one attempt 2 � Able to arise in one attempt

4. Immediate standing balance (first 5 seconds) 0 � Unsteady (e.g., staggers, moves feet, marked trunk sway) 1 � Steady, but uses walker or cane or grabs another object for support 2 � Steady without walker, cane, or other support

5. Standing balance 0 � Unsteady 1 � Steady, but has a wide stance (i.e., medial heels �4 inches apart) or uses a cane, walker, or other support 2 � Narrow stance without support

6. Nudge (with subject at maximum position with feet as close together as possible. Examiner pushes lightly on client’s sternum three times with palm of the hand). 0 � Begins to fall 1 � Staggers, grabs, but catches self 2 � Steady

7. Eyes closed (with subject at maximum position as in #6) 0 � Unsteady 1 � Steady

8. Turn 360° 0 � Discontinuous steps 1 � Continuous steps 0 � Unsteady (e.g., grabs, staggers) 1 � Steady

9. Sit down 0 � Unsafe (e.g., misjudges distance, falls into chair) 1 � Uses arms or does not use a smooth motion 2 � Safe, smooth motion

/ 16 Balance score

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 pro- viders. Journal of the American Geriatrics Society, 52(9), 1522- 1526. doi:10.1111/j.1532-5415.2004.52416.x.)

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 infor-

mation 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. 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 sched- uled appointment.

BOX 12-8 DESIGNING A FALL DIARY

228 PART III Wellness Issues

accidental injuries that occur in older patients’ homes. Improved technology through research seeks to alter the transfer of energy and thus 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 sur- faces designed to absorb the impact of a falling body and redis- tribute 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 seri- ous 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 con- tinuing 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 activi- ties 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.

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).

Physical Modifications • Cushion the landing surface. • Use specialized tile that absorbs the impact of falls. • Pad the floor. • 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.

BOX 12-9 FALL AND INJURY PREVENTION STRATEGIES

NURSING CARE PLAN 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, respira- tions 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. 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.

CHAPTER 12 Safety 229

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 tempera- tures 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 ther- mometer 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 accord- ingly. 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). 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 care- less 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 instruc- tional 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 fol- lowing 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 com- bustible 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 geo- graphic 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 pre- vent blocking the exit of fire and smoke. If proper cleaning is not done regularly, the resulting 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 sug- gest 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).

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 ex- amination 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 arrhyth-

mia occurred, resulting in the fall; monitor vital signs, especially blood pres- sure and apical pulse

4. A neurologic assessment and inquiry about a postfall headache 5. Checking of the environment for any spills or hazards that 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 emer-

gency department for radiography and evaluation

230 PART III Wellness Issues

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 for- getfulness. 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 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 pre- vent 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 shut- off must be operable. The equipment housing and the electri- cal 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 fami- lies to keep fire extinguishers, smoke detectors, and carbon monoxide detectors in their homes. Home fire drills are rec- ommended 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).

Common fire hazards in the home are flammable liquids (e.g., gasoline, acetone, and paint thinner), combustible liq- uids (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): 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 condi- tion 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 installa- tion of a carbon monoxide detector in all home safety pro- grams. Box 12-11 lists ways to prevent carbon monoxide in the home.

Chemical Injuries Inadvertent skin exposure or ingestion of household chemi- cals, 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

• Maintain smoke alarms. • Develop and practice a fire escape plan. • Have home fire sprinklers installed. • 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.

BOX 12-10 SAFETY TIPS TO PROTECT THE HOME FROM FIRE

Adapted from United States Fire Administration. (2008). Fire safety facts for people 50-plus. Emmitsburg, MD: USFA.

CHAPTER 12 Safety 231

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 venti- lation during mixing and storage is mandatory for most chemi- cals 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 cor- rect reading 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 caus- tic 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 dial- ing 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 inef- fective. 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 Food handling, preparation, and consumption behaviors asso- ciated 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 truck- ing industry. These foods are shipped from unknown loca- tions, where pesticides and other sprays may have been used. Therefore, washing fruits, vegetables, and hands before begin- ning 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, bac- teria 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).

• 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 feel- ing 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.

BOX 12-11 CARBON MONOXIDE POISONING: PREVENTION GUIDELINES

From Centers for Disease Control and Prevention. (2005). Carbon monoxide poisoning: prevention guidelines. Atlanta, GA: Department of Health and Human Services.

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 col- lected 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 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.

232 PART III Wellness Issues

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 sur- faces after cleaning with soap and water. Cleaning procedures should be done after each different type of food is prepared (CDC, 2010).

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, cli- matic 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 physi- ologic changes, placing the older individual at risk for inability to manage extreme temperatures. The hypothalamus is respon- sible for regulating the body temperature. Although no signifi- cant age-related changes occur in this organ, the hypothalamus depends on the sensory functions to transmit sensory informa- tion. These sensory functions undergo changes with aging, and older persons may be unable to effectively manage changes in temperature.

Hypothermia 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, hypother- mia follows exposure to low temperature or immersion acci- dents 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 hypo- thermia 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 respi- ration 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 medi- cal 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 • 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, flat- tening of the T or P waves, and atrial fibrillation. Death is usu- ally the result of lethal arrhythmias or respiratory arrest (Kare & Shneiderman, 2001). Peripheral vasoconstriction occurring with hypothermia may also lead to increases in kidney perfu- sion and a subsequent increase in urine output referred to as cold diuresis.

CHAPTER 12 Safety 233

Diagnostic Findings The most objective finding for the diagnosis of hypothermia is a measured core temperature of less than 95 ° F (35 ° C). In addi- tion to physical findings, individuals may manifest changes in their acid–base balance. Initially the individual hyperventilates, which leads to respiratory alkalosis. As the hypothermia pro- gresses, the metabolic rate drops, and metabolic and respiratory acidosis ensues. As a result of these stresses on the body, glu- cose 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 radi- ography 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 exter- nal 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 with- out 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 irri- gation. 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 thermo- regulatory mechanism in which patients have a core body tem- perature 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 usu- ally 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 temper- ature exceeds the core temperature, the body’s thermoregula- tory 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 perspi- ration. This form of heat dissipation is achieved via the convec- tion 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 thermo- regulatory mechanism.

Risk Factors Risk factors leading to hyperthermia are either physiologic or environmental but usually work in combination. Older indi- viduals 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 condi- tions with a sedentary lifestyle, disabilities, poor hydration, and prescription medications that impair the ability to tolerate heat (e.g., diuretics, antihypertensives, neuroleptics, and anticholin- ergics) may also hasten the development of heat stroke (Kare & Shneiderman, 2001). Additional factors that cause or predis- pose 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 manifes- tation 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 com- plete neurologic and physical assessments in older persons with hyperthermia. The main objective is to bring the temperature down immediately. Interventions used to decrease body tem- perature 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 • Decreasing the room temperature • Placing ice packs on the groin and axillae together with cool-

ing blankets The nurse should use protective cream on the older adult to

prevent skin burns from the cooling blanket and provide a light- weight gown and bed coverings for the individual. Bed rest should be maintained to decrease muscle activity and subsequent heat

234 PART III Wellness Issues

production. Antipyretic medications may be administered, as ordered, to facilitate patient comfort. It is also essential to admin- ister 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.

DISASTERS Natural and human-generated disasters have become more publicized over the past decade. Floods, tornadoes, earthquakes, hurricanes, and other severe weather phenomena have fre- quently 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 medi- cal problems or died during Hurricane Katrina were frail older adults. To provide guidelines for responding to disasters involv- ing 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.

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 ele- ment 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, dress- ings 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 instruc- tions by home care nurses. The nurse should provide and col- lect 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 mate- rial 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 disposal should be made through the local health department or hospital.

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 out- side 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.

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 activi- ties. 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 percep- tion, susceptibility to glare, and the general slowing of reflexes and cognitive processing (Touhy & Jett, 2012).

Because driving is a complex skill that involves rapid cogni- tive and psychomotor coordination and because many older

CHAPTER 12 Safety 235

adults have age-related changes, have illnesses, or are taking medications that slow their responses to road conditions, auto- mobile 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 influ- ence 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 pro- fessionals 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 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 deter- mine 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 acci- dents 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.

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 indepen- dent component of a functional assessment (Gallo, Rebok, & Lesikar, 1999). When a functional assessment strongly indi- cates 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 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).

BOX 12-12 MOST COMMONLY CITED REASONS FOR PEDESTRIAN ACCIDENTS

From Automobile Association of America. (1993). Pedestrian safety for the older (65+) adult. Motorist 14, May-June 1993.

• 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 pick- ing 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 intersection.

• “Walk” or a green signal does not give sufficient time to allow older per- sons to cross safely.

236 PART III Wellness Issues

ABUSE AND NEGLECT With the estimated number of older adults suffering mistreat- ment 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 vio- lence, 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 follow- ing categories: • Low risk for abuse • Self-neglect • Neglect • Abuse

A scale to rate the potential for abuse or neglect helps nurs- ing 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 caregiv- ers (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).

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, emo- tional, or social needs (e.g., nutrition, hygiene, clothing, shel- ter, 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, con- trolling 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 per- sonal benefit, profit, or gain (e.g., forgery, misuse or theft of

money or possessions, use of coercion or deception to sur- render 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 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 care- givers 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 dis- tress 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 environ- ment and to the global challenges of caring for victims and per- petrators 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.

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

http://www.cdc.gov/ncipc

CHAPTER 12 Safety 237

K E Y P O I N T S • 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 sen-

sory impairment, cognitive impairment, unsafe living envi- ronments (e.g., poor lighting, staircases and walkways in poor repair or without hand rails, lack of grab bars in bath- rooms, 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 exer- cise 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 haz- ards, 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 mainte- nance and repair of heating sources in the home and detec- tion 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 essen- tial to the safe use of fans and all other electrical equipment in the home.

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 fac- tors (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 crimi- nal entering a home and taking the weapon away from an older person, which often has fatal consequences.

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, sea- sonal safety issues with hyperthermia and hypothermia, disas- ters, 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 pri- mary care, into each clinic or office visit. The most challenging step to promoting safety in the homes of older adults is the pre- vention of injuries and illnesses from environmental hazards.

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 fac- tors 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 environ- ment for the older adults based on the identified risks and hazards.

5. Emphasize the value of physical therapy in assessing the home setting; de- termine 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 but- tons 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 ex- tremely 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 care- givers. If abuse or neglect is suspected, follow the reporting laws of the given state.

HOME CARE

238 PART III Wellness Issues

• Foodborne illnesses may be prevented through care- ful cleaning of all foods before cooking and cleaning of the food preparation area before, during, and after meal preparation.

• With aging, thermoregulatory mechanisms undergo physi- ologic changes, placing the older individual at risk for inabil- ity to manage extreme temperatures.

• 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 thermo- regulatory mechanism in which the core body temperature is greater than 105 ° F (40.6 ° C).

• Anhidrosis (lack of perspiration) is the most common mani- festation 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 rela- tive. 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 fall- ing 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 con- sidering a restraint?

2. A 75-year-old woman, hospitalized on a medical–surgical unit, shares a room with another older adult. You see her sit- ting 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 environ- mental 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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241

Sexuality and Aging

Jennifer J. Yeager, PhD, RN

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

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 per- sons, 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 circum- stances (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 assess- ing and managing sexuality in the various care settings in which older adults reside are discussed. Finally, this chapter proposes the application of the nursing process to older adults’ need for sexuality and intimacy.

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 profes- sionals carry out few interventions to facilitate older adults’

L E A R N I N G O B J E C T I V E S 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.

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242 PART III Wellness Issues

expression of sexuality. One reason for this is that society con- tinually equates sexuality with sexual intercourse. However, according to the World Health Organization, sexuality is a cen- tral 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 spiri- tual 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 part- ner does not necessarily mean that the woman does not have continuing sexual needs. It is imperative health care profession- als 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 provid- ers, although men do prefer to speak with their physician while women have no preference (Farrell & Belza, 2012).

At times, such interventions might include increasing socialization for older women to assist them with finding new partners. Older adults may be reluctant to begin dating, feel- ing 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 preva- lence 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; how- ever, 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 close- ness 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.

When older adults are not able to participate in sexual rela- tionships with others, the nurse’s use of touch is fundamental in preventing touch deprivation. Therapeutic touch is an alter- native 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 opportu- nity 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 embarrass- ing 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.

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 facili- ties, 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 inti- mately 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 inti- macy (Benbow & Beeston, 2012; Katz, 2013).

Older adults face many barriers to sexual expression. The NSHAP found that low desire (43%), lack of vaginal lubrication

CHAPTER 13 Sexuality and Aging 243

(39%), and anorgasmia (39%) were the greatest barriers among women. Among men, erectile difficulty (37%) was the most prev- alent 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, 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).

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 pro- viders 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 dysfunc- tions include sexual desire disorders, sexual arousal disorders, erectile dysfunction, premature ejaculation, orgasm disorders, and sexual pain disorders.

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 func- tion, 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 pre- ejaculatory 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 endocri- nologists 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 globu- lin (SHBG) concentrations gradually increase as a function of age, making less free testosterone. Testosterone levels dimin- ish 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 physio- logic changes, aging men may still experience orgasmic pleasure (Messinger-Rapport et al., 2003).

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 struc- tural abnormalities of the penis, the adverse effects of drugs, psychological disorders, and vascular, neurologic, and endo- crine 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 irri- tation 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

244 PART III Wellness Issues

testosterone, elevated prolactin, and, indirectly, decreased estro- gen. 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 sexually active women older than the age of 65 experience dyspareunia. Causes of dyspareunia include inadequate vaginal lubrication, irritation and dry- ness 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 dyspa- reunia, vaginal infections, or vaginal mucosal irritation. It may be triggered by fear of losing control or of being hurt during intercourse (Kaiser, 2000b).

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).

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).

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 immunodefi- ciency syndrome (AIDS) in less than 12 months in older adults compared with younger persons. The estimated 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 infec- tions 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 post- menopausal, so having the man wear a condom is not a concern.

Cardiac Conditions Congestive heart failure Myocardial infarction Angina Arrhythmias Hypertension

Endocrine Conditions Diabetes mellitus Hypothyroidism

Genitourinary Conditions Prostatitis Cystitis and urethritis 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

BOX 13–1 CONDITIONS THAT AFFECT SEXUAL FUNCTION

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.

CHAPTER 13 Sexuality and Aging 245

• 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 deci- sions 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 pro- gression 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 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

TABLE 13–1 DRUGS AFFECTING SEXUALITY

DRUG CLASS EXAMPLE EFFECT ON SEXUALITY

Dopamine agonists Levodopa Increased desire Ropinirole hydrochloride (Requip) Pramipexole dihydrochloride (Mirapex) Pergolide mesylate (Permax) Diuretics Thiazide diuretics

Furosemide (Lasix) Incontinence

Bumetanide (Bumex) Spironolactone (Aldactone) Anticholinergics Tolterodine tartrate (Detrol) Impaired ejaculation Metoclopramide (Reglan) Diphenhydramine (Benadryl) Furosemide Note: Many drugs have anticholingeric properties. Antipsychotics Phenothiazines Inhibited erection Atypical antipsychotics Inhibited ability to ejaculate, even when the capacity for erection

remains Sedatives–hypnotics Zolpidem tartrate (Ambien) Depressed sexual arousal Temazepam (Restoril) Antidepressants Tricyclic antidepressants

Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors

Inhibited sexual desire

Lack of orgasm Antihypertensives Angiotensin-converting enzyme inhibitors

Alpha-blockers Beta-blockers Calcium channel blockers

Erectile dysfunction

Incontinence Inhibition of orgasm Alcohol Erectile dysfunction Increased subjective desire and pleasure

Decreased physiologic arousal Antianxiety medications/

benzodiazepines Lorazepam (Ativan) Decreased sexual desire Alprazolam (Xanax) Inhibition of orgasm

Anticonvulsants Phenytoin (Dilantin) Decreased desire Carbamazepine (Tegretol) Erectile dysfunction

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.

246 PART III Wellness Issues

incontinence and impotence, both affecting a male’s sexual- ity. 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 distur- bances. Factors associated with dementia that may affect sexual functioning include failure to recognize a partner, misiden- tification of a partner, delusions, hallucinations, personality changes, and disinhibition (Lesser, Hughes, & Kumar, 2005). One behavior common among patients with dementia is hyper- sexuality, 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).

ENVIRONMENTAL AND PSYCHOSOCIAL BARRIERS TO SEXUAL PRACTICE One of the most difficult problems encountered when interven- ing to assist older adults with meeting their needs for sexual- ity 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 mem- bers 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 life- style 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 rela- tionships. Health care professionals working with cognitively impaired older adults need to determine whether the individ- ual 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 person’s sexual expression (Rheaume & Mitty, 2008).

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 homosexu- als. As they age, compared with their heterosexual counterparts, lesbian, gay, bisexual, and transgender (LGBT) individuals feel socially isolated, fear discrimination from health care provid- ers, 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 lesbi- ans 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 rela- tionship with these older adults without the interference of personal feelings. Homosexual patients’ partners should be encouraged to participate in the sexual assessment and plan- ning 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.

CHAPTER 13 Sexuality and Aging 247

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 experi- ence. 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 con- ditions 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.

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 pri- mary 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 uncom- fortable 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), nurses may take a number of steps to create a nonthreat- ening 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 review- ing medications and medical conditions that may contribute to a sexual dysfunction, as discussed earlier. In addition, the nurse

• 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?

BOX 13-2 QUESTIONS ON SEXUALITY

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. • 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?

TABLE 13-2 EVALUATING SEXUAL RISK IN OLDER ADULTS

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.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm

248 PART III Wellness Issues

should review the older adult’s early experiences, if he or she is will- ing 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.

The nurse should also obtain information on sexual prefer- ences. This should be followed by an assessment of the environ- ments 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 pri- vacy 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 special- ized 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.

Among older adults, an added risk factor is possible cognitive impairment, which may hinder patients’ decision-making abili- ties. Before a sexual relationship commences, it may be appro- priate for the nurse to meet with both patients individually and together to discuss their intentions and expectations regard- ing 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 compe- tent 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 cog- nitive 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 diag- noses are appropriate for older adults experiencing actual

• Total serum testosterone • Dihydrotestosterone • Estradiol • Mean gonadotropin-releasing hormone • Serum luteinizing hormone • Serum prolactin • Prostate-specific antigen • Complete blood cell count • Complete metabolic panel • Thyroid-stimulating hormone

BOX 13–3 LABORATORY TESTS TO GUIDE SEXUAL ASSESSMENT

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.

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.

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 assess- ment, 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 antihyper- tensive medication

■■ 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 impo-

tence 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).

CHAPTER 13 Sexuality and Aging 249

or potential 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 sat- isfaction 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 transi- tions, 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 acquir- ing sexually transmitted diseases (STDs), or impaired rela- tionship with the significant other (see Nursing Care Plan on Ineffective Sexuality Patterns).

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).

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 accept- able to the patient.

2. The patient verbalizes his or her sexual concerns and dis- cusses them with his or her significant other.

3. The patient explores alternative sexual activities and prac- tices 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 associ- ated with aging. Teaching and reassurance by the nurse that some changes are a normal part of aging helps patients under- stand their bodies and feel comfortable learning how to com- pensate for these changes (see Patient/Family Teaching boxes). Teaching regarding coital positioning for couples with physi- cally disabling conditions is often a necessary intervention (Figure 13–1).

When sexual intercourse is not the preferred method of inti- macy 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 abil- ity of older adults to be intimate with one another. Touch is

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-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 reas-

surance, 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 interests.

250 PART III Wellness Issues

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 relation- ships, 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).

If an older adult is concerned about his or her family’s feel- ings regarding a sexual relationship, further counseling should be provided and should include the family, when possible.

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: • 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 pe-

nis. Some discomfort may be experienced, so the use of alternative posi- tions 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 or-

gasm, 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 plan to resume foreplay or use this time to touch or talk.

• Rectal sphincter contractions may be experienced, but these do not inter- fere with orgasm.

CHAPTER 13 Sexuality and Aging 251

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 rela- tionships. 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 maintain- ing the dignity of these older adults. Ignoring the behavior or punishing the older adult does not curtail the behavior. A thor- ough 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 envi- ronment, 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 situa- tion in which they may injure themselves.

In the community setting, adaptive equipment such as hos- pital 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 part- ner. See Box 13-5 for strategies that may enhance sexual func- tion in older patients.

• 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, treat- ments, 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.

BOX 13–4 ACTIONS TO PREVENT SPREAD OF HUMAN IMMUNODEFICIENCY VIRUS AMONG OLDER ADULTS

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.

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 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.

BOX 13–5 STRATEGIES TO ENHANCE SEXUAL FUNCTION IN OLDER ADULTS

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.

http://www.hivoverfifty.org/tip.html

http://www.aidsaction.org

http://www.consultgerirn.org/topics/sexualiity_issues_in_aging/want_to_know_more

252 PART III Wellness Issues

Staff education about the sexuality and intimacy of older adults should include recognition of cues, desires, and inter- est 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 train- ing should include normal changes associated with older men and women and how to compensate for specific physical dis- abilities. 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 effec- tive technique to gain understanding of the effect of the staff and family’s personal values on older adults.

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 medica- tions, 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 transmis- sion of HIV and other sexual diseases among older adults (Huffstetler, 2006). These medications may be effective in treating erectile dysfunction in older men when appropri- ately 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 prac- tices 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 sat- isfactory 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, includ- ing the procurement of artificial aids and teaching, should be documented.

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, hetero- sexual, 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.

K E Y P O I N T S • 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 train- ing 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.

1. Assess sexual patterns in homebound older adults who have chronic conditions.

2. Provide information regarding sexual positions or sexual function to accom- modate 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 part- ners to discuss sex-related fears, concerns, and feelings.

4. Explain pathologic conditions that may affect older adults’ sexual re- sponses, 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.

HOME CARE

CHAPTER 13 Sexuality and Aging 253

• 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 ful- filling 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 teach- ing 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 1. A 73-year-old female patient confides that she is embar-

rassed 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 after- noon 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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255

Pain

Jacqueline Kayler DeBrew, PhD, MSN, RN and Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C

C H A P T E R

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 expec- tation 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 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).

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 asso- ciated 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 defini- tion 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 agree- ment that pain is (1) a complex phenomenon derived from sensory stimuli or neurologic injury and modified by indi- vidual memory, expectations, and emotions (Leo & Huether, 2010; Sternbach, 1978) and (2) usually associated with injury or a pathophysiologic process that causes an uncomfortable

L E A R N I N G O B J E C T I V E S 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.

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.

http://evolve.elsevier.com/Meiner/gerontologic

256 PART IV Common Psychophysiologic Stressors

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 associated with negative images and stereotypes.

The AGS Panel on Persistent Pain identified four catego- ries of pain that encompass most syndromes (Box 14-1) (AGS, 2002):

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 non- pharmacologic 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 mecha- nisms. 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 anal- gesia 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 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 under- treated (AGS, 2002; Robinson, 2010; Shoefield, 2010).

Stereotyping older persons as having less pain because of their age contributes to less frequent pain assessment and con- sequently 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 anal- gesic drugs despite the fact that they are more likely to experi- ence the side effects of analgesic medications. Research groups

BOX 14-1 PATHOPHYSIOLOGIC CLASSIFICATION OF CHRONIC PAIN

From American Geriatrics Society Panel on Chronic Pain in Older Persons. (1998). Clinical practice guidelines. Journal of the American Geriatrics Society, 46, 635.

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 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

CHAPTER 14 Pain 257

do not want comorbid conditions confounding the findings of a single medication or treatment.

Consequences of Unrelieved Pain 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 activi- ties 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 recog- nized. 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 nurs- ing care.

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 manage- ment while attempting to control the acute pain (Campbell, Andrews, Scipio et al., 2009).

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 expec- tation 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 (affer- ent pathways) to the spinal cord. A painful stimulus (e.g., a pin- prick) 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 stimula- tion flows to the brain through a series of relay neurons.

When the pain stimulus or signal reaches the CNS, it is eval- uated and interpreted in the limbic system, reticular formation, thalamus, hypothalamus, medulla, and cerebral cortex. The brain’s interpretation is based on both physical and psychologi- cal 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 neurotransmitter, facilitates transmission of the stimulus from the afferent (peripheral) neuron across the syn- apse to the spinothalamic tract neuron. Uninhibited by medica- tions 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 inter- pretation 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 effec- tively. 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

258 PART IV Common Psychophysiologic Stressors

(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 experi- enced 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 com- plexity of pain assessment and management in the older adult is also a contributor (McCleane, 2008).

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 profession- als, 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 pre- vent 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 exacerba- tion 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 facil- ities 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 networks (Robinson, 2010).

The nurse’s lack of knowledge regarding adequate pain assess- ment is viewed as a barrier as well. Nurses should be knowledge- able 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 moder- ate 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 inter- ventions for the situation.

The STCP is based on the assumption that behaviors associ- ated 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 psychoso- cial and environmental needs. Intervention trials are pharmaco- logic 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, Noonan et al., 2006).

Serial Trial Intervention

Behavior change identification

Serial assessment

Physical � �

� �

If behavior continues

If behavior continuesAffective

Target Proceed to 2

Target Trial: Nonpharmacological comfort

Proceed to 3

Proceed to 4

Consultation OR Trial: Psychotropic

Repeat consult OR Repeat serial trial intervention

Proceed to 5Trial: Analgesics

Serial treatment

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.)

CHAPTER 14 Pain 259

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 long- standing chronic pain (Herr, 2002). Otherwise, disease progres- sion 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.

Pain assessment should include a thorough history and a phys- ical 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 con- sultation is indicated (AGS, 2002; Linton & Lach, 2007).

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 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.

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?

260 PART IV Common Psychophysiologic Stressors

Some of the following are general principles on pain assess- ment 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 evi-

dence 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 sub- stantial 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 caregiver reports and input.

• Seek specialist consultation for patients with debilitating psychiatric problems, substance abuse problems, or intrac- table pain.

• Monitor patients with chronic pain by recording pain inten- sity, medication use, response, and associated activities in a pain log or diary.

• Reassess all patients with chronic pain regularly for improve- ment, deterioration, positive or negative effects of medica- tions, 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, incor- porating his or her cultural beliefs and practices when assessing and managing pain.

Pain Assessment Tools Pain assessment tools assist health care professionals in objec- tively 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.

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 experi-

encing 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.

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 interven- tions (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.

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 dem- onstrate an altered presentation of common acute illnesses, including “silent” myocardial infarctions and “painless” intraab- dominal 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 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 physi- cal assessment books recommend using the mnemonic “P, Q, R, S, T, U” to assist in remembering how to ask questions regard- ing 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

CHAPTER 14 Pain 261

includes an evaluation for autonomic, sensory, or motor defi- cits; 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 impor- tant 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 assessment of factors that contribute

FIGURE 14-2 Daily pain diary. (From McCaffery, M. & Pasero, C. [1999]. Pain: Clinical manual (2nd ed.). St. Louis, MO: Mosby.)

262 PART IV Common Psychophysiologic Stressors

to or help alleviate pain. Functional status can be significantly improved through aggressive pain management. It is impor- tant 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 activi- ties?” 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.

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, effec- tive, 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 con- servative, 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 (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

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)

TABLE 14-2 FUNCTIONAL PAIN SCALE

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.

Interventions for increased

pain

Phase One Provide: (either/or) 1. Analgesic (non-opioid) 2. Other therapies 3. If pain persists go to next phase

Phase Two Provide: (either/or)

1. Mild opioid (or non-opioid) 2. Adjuvant therapies 3. Other therapies 4. If pain persists go to next phase

Phase Three Provide: (either/or)

1. Stronger opioid 2. Adjuvant therapies 3. Other therapies 4. If pain persists re-evaluate plan

FIGURE 14-3 Incorporation of analgesics in the treatment of older adults experiencing cancer pain.

CHAPTER 14 Pain 263

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/).

Nonopioid Analgesics Analgesics are used as a first-line approach to pain manage- ment. Acetaminophen (Tylenol), ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve) are examples of nonopioid analgesics. These drugs block pain by inhibiting pain recep- tion 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 moder- ate 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 analge- sic 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 espe- cially 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 indiges- tion. Indigestion may be reduced with antacid use or food con- sumption 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 Opioids are usually prescribed for patients with mild to moder- ate pain that is poorly tolerated or cannot be adequately man- aged 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, cli- nicians 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).

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, con- stipation, and urinary retention, especially in individuals with prostatic hypertrophy. Older adults are more sensitive to seda- tion 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 titra- tion 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 preexist- ing 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 constipa- tion, the Oncology Nursing Society recommends the following (Woolery et al., 2008): • Increase fluid intake. • 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. 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

http://www.who.int/cancer/palliative/painladder/en/

264 PART IV Common Psychophysiologic Stressors

few days of starting the opioid, a new opioid should be tried (AGS, 2002) (Table 14-3).

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 reju- venation offered by sleep. Nurses should monitor for respiratory

PATIENT/FAMILY TEACHING What Can You Do for Constipation?

Opioid analgesics cause constipation in most people. The following sug- gestions 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.

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

NURSING CARE PLAN Prostate Cancer with Bone Metastases

Clinical Situation Mr. K is a 77-year-old retired telephone company executive who has been ad- mitted 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 through- out 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 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 un- able to walk outside his home or for distances longer than 25 feet without rest- ing. 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 receiv- ing 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 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 opi-

oids, 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 to space ac-

tivities with periods of rest. Evaluate the environment to determine the need for equipment for ambulation

or other activities.

CHAPTER 14 Pain 265

depression (<8 breaths per minute or oxygen saturation of <90% [AGS, 2009]), especially during rapid, high-dose escala- tions. Table 14-4 identifies analgesics that should be avoided in older adults.

Adjuvant Medications Adjuvant medications, defined as medications without intrin- sic analgesic properties, are helpful in treating certain types of chronic pain. Adjuvant medications include anticonvulsants, antidepressants, and some sedatives. The treatment of under- lying 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 posther- petic 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 in this category include zonisamide (Zonegran), tiagabine (Gabitril), pregabalin (Lyrica), and milnacipran (Savella). Anticonvulsants may cause blood dyscrasias; there- fore, 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 continu- ously 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 anticho- linergic 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 pros- tatic 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 trans- mission pathways (AGS, 2009).

Adjuvant medications alter or modulate the perception of pain. They may be used alone or with other pain medica- tions (Touhy & Jett, 2012). It is important that the nurse notify patients and their family members when these adjuvant medi- cations are being used to treat the patient’s pain. Clinical expe- rience 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 nonpharmaco- logic pain management therapies works well in older adults. Individually, most of the nondrug therapies work well only with mild pain. With moderate pain, drug therapy must com- plement 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

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.

NONOPIOIDS ORAL DOSE (MILLIGRAMS) OPIOIDS

DOSE (MILLIGRAMS)

Acetaminophen 650 Codeine 32–60 Aspirin 650 Hydrocodone 5 Choline salicylate 1000 Oxycodone 3–5 Magnesium

salicylate 1000

Sodium salicylate 1000

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.

TABLE 14-4 DRUGS TO AVOID IN PAIN MANAGEMENT OF OLDER ADULTS

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.

266 PART IV Common Psychophysiologic Stressors

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 prac- tices (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 botani- cals, 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/complementaryan- dalternativemedicine/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 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 var- ious 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, memo- ries, pet therapy, projects such as games or puzzles. This is usu- ally used with mild pain, but it can be used in conjunction with pain medication.

Exercise Exercise and physical therapy prevent stiffness, maintain func- tion, 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 subcutane- ously 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 cowork- ers (2009) found that peripheral nerve stimulation was effec- tive 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 medi- cation requirements, choices of nonpharmacologic interven- tions, 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 and family caregivers is essential to the successful implementation of pain management regimens. This applies to both pharmacologic and nonpharmacologic pain relief measures.

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 nurs- ing facilities is a large problem. Older adults suffer many painful chronic illnesses such as arthritis and cancer. When

http://nccam.nih.gov/health/whatiscam

http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/herbsvitaminsandminerals/capsicum

CHAPTER 14 Pain 267

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 pro- vides a list of helpful 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

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

BOX 14-2 WEBSITES

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 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.

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. 3. The nurse should assess factors that may influence effective pain con-

trol 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.

HOME CARE

http://www.aahpm.org

http://www.painmed.org

http://www.americangeriatrics.org

http://www.ampainsoc.org

http://www.hospicecare.com

http://www.nho.org

http://www.pain.com

http://www.seniorhealthcare.org

http://www.pain.com

http://www.ConsultGeriRN.org

268 PART IV Common Psychophysiologic Stressors

K E Y P O I N T S • Pain often remains under-recognized and undertreated in

older adults, mainly because of limited gerontologic pain research. Therefore, nurses must have a special understand- ing 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 com- municate 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, exami- nation for signs of trauma; musculoskeletal system exami- nation; 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 assess- ment 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 therapies include methods using cold, or heat; relaxation or distraction; imagery; TENS; and hypno- sis. For the pain management to be effective, the nurse must continually assess a patient’s response to pain when employ- ing 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 inter- val or a change in the drug prescribed for pain management?

REFERENCES Agency for Health Care Policy and Research (AHCPR). (1994). Manage

ment of cancer pain. Clinical Practice Guidelines No. 9. US Dept. of Health & Human Services. Rockville, MD. US Public Health Service.

American Geriatrics Society (AGS). (2002). The management of per- sistent pain in older persons. Journal of the American Geriatrics Society, 50(S224), S205.

American Geriatrics Society. (2009). 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, 57(1331).

Aronoff, G. (2002). Drawing the line between pain management and addiction. Psychopharmacol Update, 12(9), 1.

Bishop, T., & Morrison, R. (2007). Geriatric palliative care- part 1: pain and symptom management. Clinical Geriatrics, 15(1), 25–32.

Campbell, L. C., Andrews, N., Scipio, C., Flores, B., Feliu, M. H., et al. (2009). Pain coping in Latino populations. The Journal of Pain, 10(10), 1012–1019, Oct.

Clair, A. A. (2008). Therapeutic uses of music with older adults (2nd ed). Baltimore, Md: Health Professional Press.

Davis, G. C., & White, T. L. (2008). A goal attainment pain manage- ment program for older adults with arthritis. Pain Management Nursing, 9(4), 171.

Ferrel, B. R., & Ferrel, B. A. (1995). Pain in the elderly. In D. B. McGuire, C. H. Yarbo, & B. R. Ferrel (Eds.), Cancer pain management. Boston, MA: Jones & Bartlett.

Gloth, F. M., 3rd, Scheve, A. A., Stober, C. V., Chow, S., & Prosser, J. (2001). The functional pain scale: reliability, validity & respon- siveness in an elderly population. Journal of the American Medical Directors Association, 2(3), 110–114, May-June.

Hartford Institute for Geriatric Nursing. (2012). Pain assessment for older adults. Retrieved from: www.consultgerirn.org/uploads/File/ trythis/try_this_7.pdf, Accessed on April 20, 2014..

Herr, K. (2002). Chronic pain: challenges and assessment strategies. Journal of Gerontological Nursing, 2, 20.

Herr, K., Bjororo, K., & Decker, S. (2006). Tools for assessment of pain in nonverbal older adults with dementia: a state of the science re- view. Journal of Pain and Symptom Management, 31, 170.

Herr, K., Bursch, H., Ersek, M., et al. (2010). use of pain behavioral as- sessment tools in the nursing home: Expert consensus recommen- dations for practice. Journal of Gerontological Nursing, 36, 18.

Hoffart, M. B., & Keene, E. P. (1998). The benefits of visualization. American Journal of Nursing. 98(12), 44.

International Association for the Study of Pain. (2010). Position Statement: IASP Pain Terminology.

Jansen, M. P. (2008). Pain in older adults. In M. P. Jansen (Ed.), Managing pain in the older adult, New York.

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Jett, K. (2012). Pain and comfort. In Jett Touhy & Hess Ebersole (Eds.), Toward Healthy Aging: Human needs & nursing response. (8th ed)St. Louis: Mosby/Elsevier.

Kouroukli, I., Dionissios, N., Panareto, V., Zompolas, V., Papastergiou, D., Sanidas, G., et al. (2009). Peripheral subcutaneous stimulation for the treatment of intractable postherpetic neuralgia: two case re- ports and literature review. Pain practice: the official journal of World Institute of Pain, 9(3), 225–229.

Kovach, C. R., Logan, B. R., Noonan, P. E., et al. (2006). Effects of the se- rial trial intervention on discomfort and behavior of nursing home residents with dementia. American Journal of Alzheimer's Disease and Other Dementias, 21, 147.

Leo, J., & Huether, S. E. (2010). Pain, temperature regulation, sleep, and sensory function. In K. McCance & S. Huether (Eds.), Pathophysiology. (ed 3.) St Louis: Mosby.

Linton, A. D., & Lach, H. W. (2007). Matteson & McConnell’s geronto logical nursing: concepts and practice. St Louis: WB Saunders.

McCaffery, M. (2000). Pain: nursing management of the patient with pain (ed 3). Philadelphia: Lippincott.

McCaffery, M., & Pasero, C. (1999). Pain: clinical manual (ed 2). St Louis: Mosby.

McCance, K. L., & Huether, S. E. (2010). Pathophysiology: the bi ologic basis for disease in adults and children (ed 6). St Louis: Mosby.

McCleane, G. (2008). Pain perception in the elderly patient. Clinics in Geriatric Medicine, 24(2), 203–211.

Merskey, H. & Bogduk, N. (Eds.), (1994). Classification of chronic pain. (p. p xi (ed 2). Seattle: IASP Press.

Natan, B., Ataneli, M., Admenko, A., & Har Noy, R. (2013). Nurse as- sessment of residents’ pain in a long term care facility. International Nursing Review, 60(2), 251–257.

Park, J., & Hughes, K. (2012). Nonpharmacological approaches to the management of chronic pain in community dwelling older adults: a review of empirical evidence. Journal of the American Geriatrics Society, 60(3), 555–568.

Reid, M. C., Bennett, D. A., Chen, W. G., Eldadah, B. A., et al. (2011). Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them. Pain Medicine, 12(9), 1336–1357 Sep.

Robinson, P. (2010). Pharmacological management of pain in older persons. The Consultant Pharmacist, 25(suppl a), 11.

Shoefield, P. (2010). “It’s your age”: The assessment and management of pain in older adults. Continuing Education in Anaesthesia, Critical Care & Pain, 10, 93.

Sternbach, R. A. (1978). Clinical aspects of pain. In R. A. Sternbach (Ed.), The psychology of pain (p. 223). New York: Raven Press.

Touhy, T. A., & Jett, K. (2012). Ebersole & Hess’ Toward healthy ag ing: human needs & nursing response (8th ed.). St. Louis: Mosby/ Elsevier.

Woolery, M., Bisanz, A., Lyons, H., Gaido, L., Yenulevich, M., et al. (2008). Putting evidence into practice: evidenced-based interven- tions for the prevention and management of constipation in pa- tients with cancer. Clinical Journal of Oncology Nursing, 12(2), 317–337.

World Health Organization. (1990). Cancer pain relief and palliative care. Geneva: The Organization.

270

Infection

Jennifer J. Yeager, PhD, RN

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 dis- criminate 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 func- tion may be mediated by psychological and behavioral factors. Awareness of the impact of mood, activity level, stress, and

nutrition on the capacity of this system to provide optimal pro- tection 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.

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 mecha- nism include Clostridium difficile infection from a commode or

Previous authors: Martha Hains Bramlett, PhD, RN, Teresa M. Garrison, BSN, MSN; Sue E. Meiner, EdD, APRN, BC, GNP; and Dianne Thames, RN, DNS.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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.

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CHAPTER 15 Infection 271

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 dis- ease. The portal of entry may be penetration of the skin, direct contact, ingestion, or inhalation. Any disruption or penetra- tion 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., sur- gery 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 poison- ing, and hepatitis A are examples of diseases that occur through ingestion. Pathogens must be able to survive the low pH and the enzymes of the gastric acid secretions to establish infection. People with reduced gastric acidity (because of disease or medi- cations) 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 pen- etrate 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 blood- stream, respectively. Genetic, constitutional, and other non- specific factors in the host determine whether a pathogen will succeed in causing infection and clinical disease.

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 respon- sible 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).

Cell-mediated immunity is the ability of the host to dif- ferentiate between self and nonself. Diminished cell-mediated

immunity in older adults is generally associated with dimin- ished 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 autoantibod- ies. This predisposes older adults to an increase in autoim- mune 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” 2013). With aging, the skin becomes more fragile and prone to break- down or abrasion, thus disrupting the defensive mechanisms and providing a portal of entry for bacteria.

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 defi- cits; 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

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 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

BOX 15-1 AGE-RELATED CHANGES IN THE IMMUNE SYSTEM

272 PART IV Common Psychophysiologic Stressors

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 thor- ough assessment of their dietary intake done prior to beginning nutritional supplementation. When adequate amounts of vita- mins 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) nutri- ents 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 suscepti- bility to infectious disease. Restoring nutritional balance, espe- cially protein balance, can improve older adults’ immune status (Nowson, 2007).

Iron and Trace Element Deficiency The effects of iron deficiency on immunocompetence and sus- ceptibility 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 neutro- phils, macrophages, and B and T cells. In addition, iron defi- ciency contributes to a delayed responsiveness to antigens.

Zinc is thought to be associated with immune function. A 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 rela- tively recent, and our understanding of the nature of these relationships is constantly changing. Therefore, the clinical rel- evance 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 con- sideration. 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 depres- sion (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 include immunosuppressants and immunoenhancers. Many drugs given for therapeutic purposes have an immunosuppres- sant effect. Some of these drugs include corticosteroids, cyclo- sporine, and chemotherapeutics for cancer. Corticosteroids such as prednisone, are given for a variety of reasons, including treatment of autoimmune processes (e.g., rheumatoid arthri- tis). Individuals receiving corticosteroids, those taking cyclo- sporine 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 vari- ability 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 medi- cations. Patients should be advised to discuss all herbal supple- mentation with their health care provider.

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 likeli- hood of autoimmune processes. However, whether such auto- immune processes are actually age related is still being debated (Kane et al, 2009).

Individuals with diminished immune function are suscep- tible to numerous infections. Some of the more common infec- tions 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 pre- scribing the appropriate antibiotic or antiviral medication. See Box 15-2 for examples of autoimmune diseases.

Influenza and Pneumonia Pneumonia and influenza are ranked as the seventh lead- ing 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 drop- lets 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 reha- bilitation activities.

CHAPTER 15 Infection 273

The most effective measure to control influenza is the vac- cination of persons at high risk. Influenza vaccination is a Medicare-covered benefit for older adults, yet only approxi- mately 68% of the population 65 years or older is vaccinated. Every adult over the age of 65 should receive the influenza vacci- nation annually, unless they have had a serious reaction to a pre- vious 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, care- ful hand washing, and the use of barrier precautions when han- dling bodily substances, especially respiratory secretions.

About 50% of pneumonia cases result from viral infection. Community-acquired pneumonia results from bacterial infec- tion, most often from Streptococcus pneumoniae, and pneu- mococcal pneumonia results from Streptococcus pneumoniae. Early recognition and treatment of bacterial pneumonia leads to recovery, although antibiotic resistance is becoming a prob- lem. The pneumococcal vaccine is recommended for everyone over the age of 65; in 2008, 67% of older adults were vaccinated (“Pneumonia Fact Sheet,” 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 micro- organisms 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 pros- tate 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 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 divid- ing 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 rheuma- toid 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 identify- ing 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,

BOX 15-2 EXAMPLES OF AUTOIMMUNE DISEASES

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.

Systemic Diseases Rheumatoid arthritis Scleroderma Systemic lupus erythematosus (SLE)

Vascular Diseases Autoimmune hemolytic anemia Idiopathic thrombocytopenic purpura

Diseases of Other Organs Goodpasture syndrome Insulin-dependent diabetes mellitus Myasthenia gravis Ulcerative colitis

274 PART IV Common Psychophysiologic Stressors

headache, and dizziness. 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, lim- ited 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 myo- carditis), 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 func- tional 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 char- acterized 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 popu- lation. A liver biopsy is essential for confirming the diagnosis and assessing for disease activity and the presence of cirrhosis (Czaja, 2008).

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 infec- tions 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 resid- ing 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 pro- gresses 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 partici- pating 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.

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 organ- ism is present and the normal flora of the bowel are disturbed. C. difficile produces toxins, which cause hemorrhaging and cel- lular 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 han- dling 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 dis- ease, 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 per- form a meticulous 15-second hand washing with an antimicro- bial 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 indi- cated through culture and sensitivity.

CHAPTER 15 Infection 275

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 peni- cillin. 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 vanco- mycin. 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 nurs- ing homes (Wachtel & Fretwell, 2007). MRSA may also be trans- mitted via contaminated equipment, especially in burn units. Risk factors for acquiring MRSA are insulin-dependent diabe- tes 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.

NURSING MANAGEMENT

Assessment With such a spectrum of possible infections, clinical assess- ment 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, red- ness, swelling, or inflammation may be reduced with infec- tions. 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.

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 ele- vated 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, infec- tion 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 obser- vation is needed to detect subtle symptoms. Changes in the behavior of patients (e.g., increased malaise or fatigue, espe- cially 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 immunosuppres- sion 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 his- tory of previous episodes of infection, including the timing, nature, and severity of the infection, is important. Infections in older adults 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 infor- mation 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 antiin- flammatory 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 infec- tions. In addition, information on the use of alcohol, tobacco, and other drugs, as well as exposure to toxic substances, should be obtained.

Subjective Take history: • Previous infections • Predisposing illnesses • Medications • Vaccinations • Living environment • Lifestyle factors (e.g., smoking, activity level, and chemical 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

BOX 15-3 ASSESSMENT OF INDIVIDUALS AT HIGH RISK FOR INFECTION

276 PART IV Common Psychophysiologic Stressors

Knowledge about a patient’s lifestyle may provide invalu- able 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 sup- port system should be acquired, and indicators of life stressors should be elicited. A classic life stressor is bereavement, espe- cially 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 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 result- ing 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 dif- ficulties 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.

The diagnosis “Risk for Infection” is applicable to those at risk for developing an infection and those with existing infec- tions. The presence of an infection indicates the immune system is already challenged. This increases the likelihood of a second- ary infection. For instance, it is not unusual for an individual with viral influenza to later develop a secondary bacterial infec- tion of pneumococcal pneumonia.

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 con- sume 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 associ- ated with the individual at risk for infection because social sup- port 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, mainte- nance of immune status, and health practices determines the goals for patient teaching.

In setting nutritional goals, nurses might find a consulta- tion with a registered dietitian appropriate. They must con- sider 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 defi- cits, an appropriate goal might be to participate in 15 minutes of moderate exercise 3 times a week. The exact target 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 immu- nity 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 patho- gens 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 contamina- tion 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, teach- ing 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 atten- tion 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.

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

CHAPTER 15 Infection 277

Nutritional Interventions Other measures may be taken to strengthen the immune system to better enable patients to resist infection. As previously men- tioned, optimal nutritional status is important. Although all nutritional needs for healthy older adults may be met through normal dietary intake, many older adults have dietary deficien- cies. In patients with cancer, the nutritional deficits may be extreme. After assessment, efforts should be made to resolve detected deficiencies. In institutional settings, dietary supple- ments and frequent meals may be supplied. Food may be pre- pared 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 bal- anced, 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 psy- chosocial 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 move- ments, 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 psychoso- cial variables are explored, new treatment modalities are devel- oped. Modalities currently being explored include biofeedback, therapeutic touch, and hypnosis.

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

EVIDENCE-BASED PRACTICE 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 medi- cations for comorbid conditions.

Method In this feasibility study, patients were randomly assigned to receive either pla- cebo 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 pla- cebo were more likely to have diarrhea. One patient from the placebo group had Clostridium difficile–positive toxin. This study was too small to make generaliza- tions 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 medica- tion 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 tak- ing 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 military veterans. Journal of Clinical Pharmacological Therapy, 33, 663-668.

NURSING CARE PLAN Pneumococcal Pneumonia

Clinical Situation Mrs. C is an 80-year-old woman admitted to the hospital for treatment of pneu- mococcal 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 former neighbors, who live across town, are unable to visit because of the distance and because of their own de- bilities. 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

Continued

278 PART IV Common Psychophysiologic Stressors

NURSING CARE PLAN Effects of Chemotherapy

Clinical Situation Ms. M is a 68-year-old woman who is receiving chemotherapy after a modi- fied 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) main- tenance 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. 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.

Deficient Knowledge, related to influenza and pneumococcal vaccination be- cause 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) spend- ing time each week with others and (2) voicing satisfaction with social contacts.

The patient will identify the advantages of the influenza and 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 de-

pressed immune status and should limit her exposure to additional patho- gens. 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. Assess the patient’s level of stress to determine whether an easily accessible,

low-exertion relaxation program is indicated. (A relaxation program may pro- vide 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 im- munization (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 recu- peration 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 adminis-

tration after her illness.

NURSING CARE PLAN—CONT'D

CHAPTER 15 Infection 279

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 immu- nocompromised individuals. However, any improvement in immune status, or even maintenance, may allow older patients to live better lives (see the Nursing Care Plan boxes).

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 mor- tality associated with infection in this age group, immuniza- tions and interventions specific to various body systems should be implemented for those identified as susceptible to infection.

K E Y P O I N T S • 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 1. Your neighbor is a 72-year-old woman whose husband died

last year. Since his death, she has become sedentary and with- drawn. 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 get- ting 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?

1. Assess nutritional and dietary status to ensure proper immune function- ing 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 in- fluenza 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 infec- tions. Instruct older adults and caregivers about ways to protect the older adults from infection from themselves 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, re- spiratory equipment, and other devices used in home care-related treatment.

10. Develop a plan for alternative care in case a caregiver develops an infection.

HOME CARE

REFERENCES Administration on Aging. (2012). A profile of older Americans:2012.

Retrieved from, http://www.aoa.gov/AoARoot/Aging_Statistics/ Profile/index.aspx.

Agrawal, A., Sridharan, A., Prakash, S., & Agrawal, H. (2012). Dendritic cells and aging. Retrieved from, Expert Review of Clinical Immunology, 8(1), 73–80. http://www.medscape.com/ viewarticle/755539.

Akincigil, A., Olfson, M., Walkup, J. T., Siegel, M. J., Kalay, E., Amin, S., & Crystal, S. (2011). Diagnosis and treatment of depres- sion in older community-dwelling adults: 1992–2005. Journal of the American Geriatrics Society, 59, 1042–1051. http://dx.doi. org/10.1111/j.1532-5415.2011.03447.x.

Czaja, A. (2008). Clinical features, differential diagnosis and treatment of autoimmune hepatitis in the elderly. Drugs and Aging, 25(3), 139–219.

Goldman, L., & Ausiello, D. (2004). Cecil textbook of medicine (ed 22). Philadelphia: W.B. Saunders.

Eliopoulos, C. (2005). Immunity. In C. Eliopoulos (Ed.), Gerontological nursing. Philadelphia: Lippincott.

Frasca, D., & Blomberg, B. B. (2011). Aging affects human B cell re- sponses. Journal of Clinical Immunology, 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. (2009). Essentials of clinical geriatrics (6th ed.). New York: McGraw-Hill.

McCance, K., Huether, S., Brashers, V., & Rote, N. (2010). Pathophysiology: the biologic basis for disease in adults and children (ed 6). Philadelphia: Elsevier/Mosby.

Newson, P. (2007). Presentation of illness in the elderly patient. Nurs Residential Care, 9(5), 218–221.

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http://dx.doi.org/10.1111/j.1532-5415.2011.03447.x

http://dx.doi.org/10.1007/s10875-010-9501-7

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280 PART IV Common Psychophysiologic Stressors

Nowson, C. (2007). Nutritional challenges for the elderly. Nutrition and Dietetics, 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/pneu- monia-fact-sheet.html.

Porth, C. M. (2004). Pathophysiology: concepts of altered health state (ed 7). Philadelphia: Lippincott Williams & Wilkins.

Safdar, N., Barigala, R., Said, A., & McKinley, L. (2008). Feasibility and tolerability of probiotics for prevention of antibiotic-associated diarrhoea in hospitalized US military veterans. Journal of Clinical Pharmacy and Therapeutics, 33, 663–668.

Span, P. (2013, August 7). Suicide rates are high among the elderly. Retrieved on January 24, 2014 from, The New York Times. http:// newoldage.blogs.nytimes.com/2013/08/07/high-suicide-rates- among-the-elderly/?_php=true&_type=blogs&_r=0.

Townsend, M. C. (2008). In Essentials of psychiatric mental health nursing. (ed 4). Philadelphia: FA Davis.(pp. 581–609).

United States Census Bureau. (2014). State & county quickfacts. Retrieved on January 24, 2014 from, http://quickfacts.census.gov/ qfd/states/00000.html.

Wachtel, T., & Fretwell, M. (2007). Practical guide to the care of the geri- atric patient (3rd ed). Philadelphia: Mosby/Elsevier.

Wallace, M. (2008). Essentials of gerontological nursing. New York: Springer Publishing Company.

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http://newoldage.blogs.nytimes.com

http://quickfacts.census.gov/qfd/states/00000.html

281

CHRONICITY Chronic disease affects the physical, psychological, and social aspects of the lives of individuals and families. A person’s life- style, 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 dis- ease and chronic illness. Often these terms are used interchange- ably 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 dys- function 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; how- ever, it is often the illness experience that we can most influence.

Just as the terms chronic disease and illness are complex, defin- ing 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.

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 defini- tion addresses the total experience of the individual and the family. The following definition better defines the illness expe- rience 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 disabil- ity. (Curtin & Lubkin, 1995)

Chronic Illness and Rehabilitation

Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C

Original author: Teresa M. Garrison, MSN, BSN; Revised by Pamala D. Larsen, PhD, CRRN, FNGNA.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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

282 PART IV Common Psychophysiologic Stressors

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 treat- ing individuals with chronic conditions account for more than 75% of our nation’s medical care costs each year (CDC, 2013a).

The continuing increase in the prevalence of chronic con- ditions is caused by many factors. Primary among them are lifesaving and life-extending technologies not previously avail- able, an expanding population of older adults, and as a result, increasing life expectancy. Individuals who would have suc- cumbed to an acute illness in the past now recover, age, and live with a chronic 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 preven- tive 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 ill- ness. The current U.S. health care system was largely developed in the two decades after World War II. It was designed to pro- vide 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 obstruc- tive 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 dis- satisfaction 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 com- pared with 13.2% predicted for 2010 (Administration on Aging [AOA], 2013). With aging, the chances of having a chronic con- dition increase. The State of Aging and Health in America (CDC & Merck Company, 2007) reported that 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 par- ticularly 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 increas- ing functional ability, preventing complications, promoting the highest quality of life, and, when the end stage of life occurs, pro- viding 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 dis- eases continue to predominate (Table 16-3). Hospitalizations resulting from injuries, particularly in women (e.g., hip frac- tures), 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.

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 individ- ual and his or her family. However, the educational background of most health care professionals is one that fits with the medi- cal model and does not consider the different illness perceptions and illness behaviors of individuals. We have been taught that

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

TABLE 16-1 PERCENTAGE OF DEATHS FROM LEADING CAUSES AMONG PERSONS AGES 65 AND OVER: UNITED STATES, 2005

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.

http://www.cdc.gov/nchs/fastats/deaths.htm

CHAPTER 16 Chronic Illness and Rehabilitation 283

patients have diseases and the degree of their pathology dic- tates 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 ill- ness behavior and its meaning, became concerned that research- ers have “reduced sickness to something divorced from meaning in order to avoid the heard and still unanswered technical ques- tions 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 physi- cal 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 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 posi- tion 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 pro- viders in providing culturally competent care. The website of the Transcultural Nursing Society (www.tcns.org) provides infor- mation 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 of quality of life exist, but most include physical, psychological, and social components; disease and

DIAGNOSIS NO. OF DISCHARGES (IN THOUSANDS)

Women (ages 65–74) Heart disease 406 Cancer 160 Pneumonia 112 Stroke 105 Diabetes 48 Osteoarthritis 169 Injuries 109

Men (ages 65–74) Heart disease 519 Cancer 151 Pneumonia 101 Stroke 105 Diabetes 48 Osteoarthritis 100 Injuries 70

TABLE 16-2 DISCHARGES IN NONFEDERAL SHORT-STAY HOSPITALS, BY GENDER, AGE, AND SELECTED FIRST-LISTED DIAGNOSIS (AGES 65–74), 2006

From Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey. (2008). Health, United States. Atlanta, GA: The Agency.

DIAGNOSIS NO. OF DISCHARGES (IN THOUSANDS)

Women (ages 75–84) Heart disease 570 Cancer 126 Pneumonia 140 Stroke 134 Diabetes 44 Osteoarthritis 119 Injuries 222

Men (ages 75–84) Heart disease 496 Cancer 114 Pneumonia 248 Stroke 141 Diabetes 29 Osteoarthritis 69 Injuries 94

TABLE 16-3 HOSPITAL DISCHARGES AND BY DIAGNOSIS (AGES 75–84), 2006

From Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey. (2008). Health, United States. Atlanta, GA: The Agency.

http://www.tcns.org

284 PART IV Common Psychophysiologic Stressors

treatment-related symptoms; and spirituality. However, no consensus on the definition exists. The following defini- tion, 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 ill- ness. 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 abil- ities 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 inter- ventions. 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 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 influ- ence nonadherence. These factors include (1) individual char- acteristics, (2) psychological factors, (3) social support, (4) prior health behaviors, (5) somatic factors, (6) regimen characteris- tics, (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 behav- iors are mixed. Park and Skurnik (2004) suggested that a vari- ety of factors may interfere with the ability of the older adult to adhere to a treatment plan. However, in general, develop- mental 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 treat- ment 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 gener- ated 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 par- ticipating 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 nurs- ing 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 com- ponents 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 resi- dents. 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.

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.

CHAPTER 16 Chronic Illness and Rehabilitation 285

The cost of today’s health care requires that nurses be aware of specific needs of older adults when structuring their therapeu- tic regimens. Regimens should emphasize activities that build endurance and self-reliance and that facilitate self-care and qual- ity 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 dif- ferent 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. 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 frame- work to assist nurses in (1) gaining insight into the chronic

illness experience of the patient, (2) integrating existing lit- erature about chronicity into their practice, and (3) provid- ing 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 differ- ent 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 stud- ies 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 expe- rience 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 per- spective 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 perspec- tive 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 fami- lies need to be considered. Several are mentioned in the follow- ing 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.

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Stigma Stigma is defined as “a mark of shame or discredit or an iden- tifying mark or characteristic” (Merriam Webster, 2013), and it may be a significant factor in many chronic illnesses and dis- abilities. 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 dis- ability, 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 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 activi- ties, 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 prob- lems 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 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 cir- cumstances of the disability. Developmental changes, life transi- tions, 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 estab- lish new relationships. The nurse may also explore interventions that meet spiritual needs. The nurse may refer and encour- age 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 psy- chosocial 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 imper- fections 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 atti- tude toward new roles and the ability to obtain a feeling of inde- pendence 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 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

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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 fami- lies. Ongoing support by health care professionals is crucial for them to find enough strength to continue coping.

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 nonprescrip- tion 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 breath- ing exercises, guided imagery, and visualization. These tech- niques 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 activ- ity, 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

maintaining chronically ill older adults on the continuum of wellness. Inactivity may result from functional loss, and as activ- ity 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 complica- tions 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 communica- tion 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 part- ners 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 nonjudgmen- tal 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 ill- ness. 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 dif- ficulty of balancing caregiving with activities such as personal time or social activities (Figure 16-1). The primary family care- giver often receives little help from siblings or children and con- siders institutionalization only when he or she is physically or emotionally exhausted.

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 exac- erbations in the trajectory of the illness cause uncertainty. Anticipation of these phases may also produce stress. Some chronic conditions develop slowly, and planning for crisis peri- ods 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

288 PART IV Common Psychophysiologic Stressors

stress. The patient’s functional ability and the type and amount of care needed affect caregiver stress. Ongoing care or the per- ception that ongoing care is needed may be physically and psy- chologically 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 care- giving 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 bal- ance of caregiving and caring for one’s self. Personal activities may include work outside the home. Many caregivers experi- ence 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 irre- versible. 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 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, knowl- edge 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 com- munity social service agencies, local church members, visit- ing 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 infor- mation 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.

Caring for older adults with chronic conditions requires long-term adaptation on the part of family members. To con- tinue in a caregiving role, a family member caregiver needs ongoing support by all involved health care professionals (see Chapter 6).

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 pro- motes 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

FIGURE 16-1 A daughter–caregiver assisting her mother down the hallway of her home. (Courtesy of Rod Schmall, West Linn, OR.)

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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 rela- tionships, 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 dou- bles 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 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 toler- ate 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 reha- bilitation units. Outpatient rehabilitation therapy services may be available to older adults in their homes.

Reimbursement Issues Medicare becomes available to older adults at age 65 regard- less of whether they continue to work. Part A, or basic cover- age (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 insur- ance plans are available to cover the “Medigap,” or the 20% of ser- vice cost not reimbursed under Medicare guidelines. Medicare is a fee-for-service delivery system. Medicare also contracts with

health maintenance 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 agen- cies 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 legisla- tion by advocating for the needs of older adults with disabili- ties 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 subse- quent 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 pro- grams and services provided by state and local governments, and in the provision of goods and services provided by private

FIGURE 16-2 A patient receiving therapy in a rehabilitation set- ting. (Courtesy of Loy Ledbetter, St. Louis, MO.)

290 PART IV Common Psychophysiologic Stressors

companies and commercial facilities (ADA, 2013). However, the ADA did not eliminate the discrimination inherent in the cur- rent 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).

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 dis- abled (www.ncd.gov).

Enhancement of Fitness and Function The goal in caring for older adults with disabilities is to main- tain or improve function. Maintaining mobility, even when hos- pitalized, 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 activi- ties 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 decon- ditioning 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 sus- tain 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 impor- tant in older adults. These include endurance training; which are exercises to increase breathing and heart rate; strength train- ing, which builds muscles and increases muscle strength; bal- ance exercises, which improve standing and gait; and 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 assess- ment may help older adults, their families, and health care providers identify problem areas and plan appropriate interven- tions 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 con- trol, (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 reha- bilitation 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 com- plex problems need specific assessments of their abilities and 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 physi- cal 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, feel- ings 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 func- tion, 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

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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 disabilities, and preventing further disease, all while striving for optimal health.

Determining reasons why an older adult participates in reha- bilitation 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 stud- ies have found that fitness, health, independence, and socializa- tion 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.

As Calloway stated, “nurses have been leaders in health pro- motion since the time of Florence Nightingale, whose pioneer- ing 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 physi- ologic effects of aging and their effect on rehabilitation. For example, a cardiac rehabilitation program should focus on exer- cise training, 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, reha- bilitation goals and candidacy for prosthetics should be deter- mined 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 institu- tional 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 contin- ued 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 pro- fessionals 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 signifi- cance to the condition. An individual faced with a long rehabili- tation 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 medica- tion 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 con- stant 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 ill- ness, and records of findings are examples. Organizing medica- tions and treatments might include establishing a schedule for medications or treatments such as catheterization, toileting, or home dialysis. Organizing for working with health care profes- sionals might include establishing a means to make and keep appointments, preparing for a visit, and obtaining the informa- tion needed to improve self-care.

FIGURE 16-3 Older adults in exercise class, practicing health promotion. (Courtesy of Ursula Ruhl, St. Louis, MO.)

292 PART IV Common Psychophysiologic Stressors

The nurse should help older adult patients maximize finan- cial resources by interpreting insurance coverage and making referrals to community agencies. Most assistive devices, hand- rails, canes, walkers, and hearing aids are paid for out-of-pocket. The nurse should encourage patients to shop around, ask ques- tions, 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 moni- toring equipment, adaptive equipment, and supplies needed to maintain health. The NCD periodically reviews Medicare and Medicaid benefits packages to ensure inclusion of assistive tech- nologies 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 maintain- ing 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 facili- tate 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 provid- ers. 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 impor- tant 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 home- like 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.

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.

CASE STUDY

Mrs. W is a 75-year-old woman admitted to a skilled nursing facility for reha- bilitation 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 mas- ters 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 assis- tance 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 in- cludes 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.

K E Y P O I N T S • Health care providers need to understand the unique ill-

ness 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 psy- chosocial, 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 func- tional ability.

• Health promotion incentives that are important to older adults are fitness, health, independence, and socialization.

CHAPTER 16 Chronic Illness and Rehabilitation 293

C R I T I C A L T H I N K I N G E X E R C I S E 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 ill- ness. She is reluctant to seek help because she does not want

to prolong her life if it means a loss of quality. Make a judg- ment about where she fits within the illness trajectory, and explain how a nurse can be of assistance.

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CHAPTER 16 Chronic Illness and Rehabilitation 295

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 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 www.stroke.org

http://www.apdaparkinson.org

http://www.arthritis.org

http://www.ncd.gov

http://www.nia.nih.gov

http://www.stroke.org

296

Cancer

Jennifer J. Yeager, PhD, RN

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

Cancer risk increases with aging, as do multiple comorbidi- ties 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 can- cers 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 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).

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 can- cers. 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 approx- imately 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 diag- nosing 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

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.

L E A R N I N G O B J E C T I V E S 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.

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CHAPTER 17 Cancer 297

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 preva- lence 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 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 demon- strate 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).

Racial and ethnic group age cohorts demonstrate differ- ent patterns of cancer incidence. Older Japanese immigrant women demonstrate a lower incidence of breast cancer com- pared with second- and third-generation Japanese women born in America. Age is an important factor, especially when envi- ronmental 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 deter- mining 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 scien- tific 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

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

TABLE 17-1 CANCER INCIDENCE RATES (NUMBER OF NEW CASES EACH YEAR)

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)

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., 2006-2010. Retrieved May 1, 2014, from http://www.cancer.org/acs/groups/content/@research/documents/ document/acspc-041785.pdf.

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

BOX 17-1 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.

http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-041785.pdf

298 PART IV Common Psychophysiologic Stressors

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, employ- ment, adequate housing, good nutrition, preventive health prac- tices, 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 dif- ferences, particularly differences between developing and devel- oped 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.

The leading cancers among Caucasian men are prostate, lung, colorectal, and urinary bladder cancers; melanoma; and non–Hodgkin lymphoma. Caucasian men have a higher uri- nary 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 high- est 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.

Cancer incidence rates vary considerably among the sub- groups 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 cer- tain 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 can- cers; and among Vietnamese, lung, liver, and prostate cancers. Stomach cancer rates among Korean men and liver cancer rates among Vietnamese men are higher than 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 pan- creas. 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 inci- dence rates for stomach, cervix, uterine, liver, and gallbladder cancer. American Indians have the highest gallbladder cancer

TYPE AFRICAN AMERICAN CAUCASIAN ABSOLUTE DIFFERENCE RATE RATIO

All types 651.5 551.4 100.1 1.18 Prostate 248.5 156.7 91.8 1.59 Lung/bronchus 107.6 79.3 28.3 1.36 Urinary/bladder 20.4 40.6 –20.2 0.50 Skin melanoma 1.1 28.5 –27.4 0.04

TABLE 17-3 CANCER INCIDENCE RATES OF AFRICAN AMERICAN AND CAUCASION MALES

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.

TYPE AFRICAN AMERICAN CAUCASION ABSOLUTE DIFFERENCE RATE RATIO

All types 398.9 423.6 –24.7 0.94 Colon/rectum 54.5 43.2 11.4 1.26 Breast 117.6 130.6 –13.1 0.90 Lung/bronchus 54.6 54.9 –0.3 0.99

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.

http://www.cancer.org/acs/groups/content/@nho/documents/document/cffaa20092010pdf.pdf

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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.)

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 bio- logically 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 condi- tions of famine and malnutrition might have a life expectancy different from a cohort that did not experience childhood mal- nutrition. Both biologically programmed life span and envi- ronmentally 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 postreplicat- ing 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 involve accelerated replication, or hyper- proliferation. 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 abnor- malcy as it replicates. Aberrant cell growth is related to failure of growth control mechanisms, which leads to less cell regu- lation 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 promot- ing 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 pro- moting 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 imme- diately after initiation, promotion is thought to be most suc- cessful when it involves repeated exposure to an initiated cell. Prevailing thought is that initiation is irreversible, whereas pro- motion is reversible. This belief has been demonstrated clini- cally in tobacco smokers: once the exposure to the promoter (tobacco) is withdrawn, the incidence of cancer is reduced.

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 abnor- malities. 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 loca- tion of the cancer cells from one organ or part of the body to another that is not directly connected.

Initiation Promotion Reversible

Progression – Transformation – Clonal progression – Metastasis

Irreversible

FIGURE 17-1 Stages of cancer growth.

300 PART IV Common Psychophysiologic Stressors

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 exces- sive 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 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, research- ers hope to develop drugs that target those specific genes to stop the cancer’s growth. Also, identifying the genes respon- sible 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 treat- ment 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 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): • 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 pro- gression 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 dif- ficult to repair it.

• Oncogene activation might be increased in older persons, resulting in decreased regulation of cell growth and the 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 boundar- ies. Although it appears difficult to undo or reverse the cellular damage sustained in younger years, prolonged exposure to pro- moting agents is, nonetheless, needed for the initiated cells to be

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

CHAPTER 17 Cancer 301

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 sun- burns 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 con- tained in foods are being examined for their effects on the pro- motion 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 halt- ing, the cancer process. In addition, evaluation of environmen- tal risk factors may lead to specifically targeted education and screening programs among selected high-risk cohorts.

COMMON MALIGNANCIES IN OLDER ADULTS

Lung Cancer Lung cancer is the most common type of cancer and the lead- ing 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 sev- eral 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 demonstrat- ing a dose–response relationship; that is, the risk of lung cancer increases with the quantity of cigarettes smoked. The great- est 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 sub- stances such as asbestos, chromium, nickel, arsenic, soot, tar, or radon. Radiation exposure from occupational, medical, and envi- ronmental sources is also a risk factor. Air pollution contains sev- eral 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 dis- eases are chronic and diminish the quality of life for those persons living with the disease (American Lung Association, 2004).

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 symp- toms. Because symptoms often do not appear until the disease is advanced, early detection is difficult. When used in combi- nation, chest radiographic studies and cytologic examination of sputum cells help detect small tumors. Both tests are expen- sive, requiring special facilities and personnel. The Mayo Lung Project, conducted between 1972 and 1982, examined the ben- efits of screening for lung cancer and determined that although screening programs achieved earlier diagnoses and longer sur- vival times, no significant reduction in mortality was demon- strated (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 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 aggres- sive 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

302 PART IV Common Psychophysiologic Stressors

and smoking. However, adenocarcinoma may occur in nonsmok- ers. 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 carci- noma grows fast and spreads quickly. NSCLC does not respond well to chemotherapy. Results are improved with surgical resec- tion, 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, increas- ing 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 develop- ing 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 fac- tors 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 contra- ceptives, 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 dis- ease 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 develop- ing breast cancer. 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 circa- dian 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 sur- vival 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, 2008).

Previously widely accepted reasons for this disparity centered around dif- ferences in survival status based on socioeconomic status and the overrepre- sentation 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 can- cer 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 con- trolled. 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 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)

CHAPTER 17 Cancer 303

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 inher- ited 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 del- eterious 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 prac- tices. 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).

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 opportu- nities for women to learn about BSE and consistent reinforce- ment 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 mani- fest 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 mam- mography screening every year for women after age 40, along with a clinical breast 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 metas- tasizes 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 combina- tion) 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 treat- ment of choice, if performed, breast reconstruction is an option, depending on personal preference and the extent of the disease.

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 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 pro- viders 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 interven-

tion strategies for each of the at-risk groups to influence their early detec- tion behaviors.

• Use the media to increase knowledge and promote positive early detection practices among older women from culturally diverse backgrounds.

304 PART IV Common Psychophysiologic Stressors

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 sur- vival rates are not a predictor of treatment success. Risk factors, cancer stage, and treatment choice all play into the success of any given therapy.

Prostate Cancer One in six men will develop prostate cancer during their life- time. 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 pros- tate 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 inter- rupted urine flow, difficulty, or inability to begin urine flow, dif- ficulty 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, addi- tional 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 antigen (PSA) testing are the two primary screening tests for prostate cancer in the United States. However, neither screen- ing 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 vac- cine 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 radi- cal 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, fol- lowing 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 effec- tive. The objective of hormone therapy is to reduce circulating androgens in the body or to prevent androgens from reach- ing 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-suppressing drugs. All forms of hormone therapy have similar side effects: reduced libido, impotence, shrinking of the sex organs, hot flashes, breast ten- derness, 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, immunosup- pression, 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 pro- hibitive ($93,000 per dose, with three doses required); addition- ally, 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).

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Colorectal Cancer Colorectal cancer is the third most common cancer, account- ing 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 diag- nosis for colorectal cancer is 69; the median age at death is 74 (ACS, 2013b).

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 obstruc- tion. 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 ear- lier. 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 sigmoidos- copy 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.

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 recur- rence. 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 pene- trated 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 stan- dard chemotherapy which targets all rapidly dividing cells, tar- geted 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 com- bination 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).

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 asymp- tomatic persons at risk is feasible in many common malignan- cies, 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 identifica- tion 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

306 PART IV Common Psychophysiologic Stressors

adults, screening asymptomatic persons at risk for cancer may be the most promising way to reduce the number of cancer deaths in older adults.

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, screen- ing 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 guide- lines 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 choos- ing 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 fac- tors 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 frame- work 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 deci- sions require weighing quantitative information such as risk of cancer death and likelihood of beneficial and adverse screen- ing outcomes, as well as qualitative factors such as individual patients’ values and 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 like- lihood 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 sig- nificant. 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 out- comes 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 geriat- ric parameters into the treatment of their patients.

The International Society of Geriatric Oncology (SIOG) cre- ated a task force to review the evidence on the use of a com- prehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted. Several bio- logic and clinical correlates of aging were identified. Strong evi- dence 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. 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 under- standing 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 implica- tions, 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 unim- portant cancers increase as people age; therefore, older patients are frequently diagnosed with these types of cancer.

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• Older people have more cognitive and physical condi- tions 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.

• 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 list- ing 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 sur-

vival 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 grow- ing and less malignant neoplasms, which leads to the appear- ance 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 recommen-

dations for screening require individual consideration. In addi- tion 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 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 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 pre- menopausal 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 radia- tion therapy.

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 sociodemo- graphic characteristics on unwillingness to participate in colorectal cancer (CRC) screening.

Design Cross-sectional, disproportionally allocated, stratified, random-digit-dial tele- phone questionnaire of noninstitutionalized households.

Setting New York City, New York; Baltimore, Maryland; San Juan, Puerto Rico.

Subjects Ethnically diverse sample of 454 adults ≥ 50 years of age.

Measures Health status, cancer screening effectiveness, psychosocial factors (e.g., per- ceptions of pain, fear, trust), and CRC screening intentions using the Cancer Screening Questionnaire, which addresses a range of issues related to willing- ness 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% con- fidence 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 knowl- edge, addressing fears and mistrust, and normalizing CRC screening as a ben- eficial 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.

http://www.ahrq.gov/clinic/uspstfix.htm

308 PART IV Common Psychophysiologic Stressors

Nurses working with older adults should examine the role of cancer screening and the potential benefits for the popu- lation assigned to their care. The decision to screen or not to screen should be an active one, made after thoughtful consid- eration 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 individu- alized health teaching about cancer risk and detection. Older persons may lack an awareness of the risks of cancer associ- ated 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 per- sons 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

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 ther- apy. Cancer therapies may be directed at a cure, or elimination of the disease; control, or minimization of the disease; or pallia- tion, 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 physi- ologic 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 spe- cific 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.

Laser light can focus a narrow beam on specific tissues at exact locations and depths. At this time, lasers are used primar- ily on lesions of the skin and on endothelial lesions in the lin- ings 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; how- ever, research indicates older adults are subject to treatment bias based on age. Health care providers often fail to recom- mend 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, treat- ment 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

Method The researchers sought to determine whether a group of symptoms as de- scribed 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 symp- toms and their effect on quality of life.

Findings All four symptoms were present for 6 of the 17 study participants. Three symp- toms 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 par- ticipants. The symptom that had the greatest negative effect on quality of life was fatigue. Even 2 years after finishing treatment, these women still experi- enced 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 con- cluded. Discussing methods to address these symptoms in breast cancer sur- vivors 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.

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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 rela- tives 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 mas- tectomy when lumpectomy was an option. She remembered her mother’s complications related to older methods of cobalt radi- ation therapy, a delivery method for external beam radiation therapy that has now 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 diag- nose 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 loca- tion 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 place- ment of treatment-related devices such as implanted access devices, shunts, or drains. In addition, surgery may be indi- cated 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 mul- tiple 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 opera- tions. Greater insight into the pathophysiology of cancer and the development of additional therapies has led to more sophis- ticated surgical techniques. Early detection of smaller tumors has also contributed to the decline in the number of radical pro- cedures. Less radical 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, nutri- tional, 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 complica- tions 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 pre- operative assessment to identify risks, older patients may be offered appropriate supportive therapies that minimize compli- cations. Although age alone is not a determinant of surgical risk, data indicate that older adults are less likely to receive surgi- cal therapy compared with younger persons (Farrow, Hunt, & Samet, 1996).

Postoperative priorities should include preventing respira- tory 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 thromboembo- lism. 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 develop- ment of delirium. Bowel 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 foun- dation 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 ther- apy 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, recur- rent 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), approxi- mately half of all cancer patients receive radiation therapy in the course of their treatments today.

310 PART IV Common Psychophysiologic Stressors

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 disfig- urement than some extensive surgeries. Radiation also allows simultaneous treatment to multiple metastatic sites (Davis & Lindley, 2004).

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 exter- nal or internal techniques. External beam therapy, which is radiation from a source at a distance from the body, is admin- istered primarily by linear accelerators and mostly in an outpa- tient 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 predeter- mined period. Rotation of either the target site or the radia- tion beam makes it possible to deliver a high dose to the tumor, while only part of the dose reaches the surrounding noncancer- ous tissue.

The response of older adults to radiation therapy has not been well evaluated. Several initial reports suggest that no dif- ference 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 per- sons (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 fac- tors (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 com- pensating for temporary dysfunction in a single organ or in mul- tiple 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 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 neces- sary. 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 thera- pies, chemotherapy is systemic. Although single-agent chemo- therapy 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 chemo- therapy 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 combina- tion 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 che- motherapeutic agents by drug classification and mechanism of action.

Pharmacokinetics Pharmacokinetics refers to the activity of drugs in the body, including absorption, distribution, metabolism, and excre- tion. For oral chemotherapeutic agents, age-related changes in the digestive tract appear to have little effect on the absorp- tive capacity of the intestine. The exception may be with leu- covorin, 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 demon- strated (Vestal, 1997). The liver is the main site of metabolism for many chemotherapeutic agents. Liver size 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 impair- ment in drug metabolism is likely related to underlying liver damage, including exposure to environmental toxins or alco- hol. Chemotherapeutic agents primarily metabolized by the liver include anthracyclines, mitoxantrone, mitomycin C, and the vinca alkaloids. Biliary excretion of drugs such as anthracy- clines, mitomycin C, and the vinca alkaloids seems to be unaf- fected by age (Balducci, Mowrey, & Parker, 1992; Egorin, 1993). Only the age-related decline in kidney function has been dem- onstrated to have clinical consequences for drug dosing. Toxic drug levels have been demonstrated for agents that are primar- ily excreted by the kidney—methotrexate, bleomycin, carbo- platin, 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 che- motherapeutic 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,

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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 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

312 PART IV Common Psychophysiologic Stressors

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 mem- brane 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).

Biologic Therapy Biologic therapy is the use of agents (living organisms, sub- stances 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 stim- ulate 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 prolifera- tion of lymphocytes; although ILs are naturally occurring cyto- kines 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 chemo- therapy or continuation of treatment that might otherwise be stopped because of low WBC or RBC counts. Monoclonal anti- bodies 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 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, amifos- tine (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 tis- sues such as the breast, prostate, and endometrium may be treated with the use of endocrine therapy. This type of ther- apy 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.

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 folli- cles. 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,

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 limita- tions before his diagnosis of cancer. His oncologist prescribes a chemotherapy regimen of cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), and etopo- side (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) sec-

ondary to chemotherapy Risk for Injury, bleeding caused by bone marrow depression (thrombocytope-

nia) 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.

CHAPTER 17 Cancer 313

intensity of the dose, and duration of the therapy. In most cases, side effects are reversible.

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 transplantation may lead to prolonged and severe myelosup- pression 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 medi- cations 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 trans- fusions 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 mil- limeter (cells/mm3). The most common cause of thrombo- cytopenia 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 antiinflammatory drugs (NSAIDs), pen- icillin and cephalosporin antibiotics, phenothiazines, and anti- depressants. Platelet counts should be monitored carefully, and patients should be instructed to use precautions during periods of thrombocytopenia. Precautions should be aimed at prevent- ing 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 mem- branes 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 undergo- ing 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

■■ 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 re- main above 50,000 cells/mm3.

Instruct the patient and family to: • Avoid trauma:

• 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.

314 PART IV Common Psychophysiologic Stressors

cancer: Surgery interrupts the normal protective barrier of the skin; chemotherapy and radiation therapy cause slough- ing and interruption of the integrity of the mucous mem- branes; 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 per- sons 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 neu- tropenic and at increased risk for infection. When the neutro- phil count is less than 500 cells/mm3, the risk for infection is severe (NICE, 2012).

Nursing care focuses on prevention. Patients and their fami- lies 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 hematopoi- etic 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 epigas- tric 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 chemothera- peutic agents cause nausea and vomiting, and those that have high emetic potential do not cause equal distress in all per- sons. Considerable variation exists among patients and types of agents. Antiemetic management has changed with the devel- opment of better pharmacologic agents. Before the develop- ment of these agents, an estimated 10% of patients refused chemotherapy because of actual or feared nausea and vomiting (Rhodes, Watson, & Johnson, 1985). Because many older adults likely have friends or family members who were treated with older therapies, nurses should reassure patients that manage- ment 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 vomit- ing, for example, increased taste threshold and decreased gas- trointestinal 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; how- ever, delayed nausea and vomiting are more common and more severe in older persons and are less well managed by pharma- cologic 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, includ- ing dehydration. Older adults are less tolerant of dehydration compared with younger persons and may manifest acute con- fusion in response. Dehydration may create a metabolic crisis necessitating resuscitation with intravenous fluid administra- tion. 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 imbal- ances may aggravate cardiac problems and precipitate drug toxicity if a patient is taking medication to manage a car- diac 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-HT

3 ) receptor antagonists, neuroki-

nin 1 (NK 1 ) receptor antagonists, corticosteroids, benzomide

analogs, phenothiazine derivatives, butyrophenones, and ben- zodiazepines (Navari, 2007).

Nursing care should begin with an in-depth emetic his- tory 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. 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).

Chemotherapy-Induced Oral Mucositis Chemotherapy-induced oral mucositis is caused by the destruc- tion 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 muco- sitis, 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

CHAPTER 17 Cancer 315

available mouthwashes contain alcohol. Safer mint-flavored normal saline or hydrogen peroxide products are available at specialty pharmacies. Viscous lidocaine, topical morphine solu- tion, 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 inflamma- tion. 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 nutri- tional depletion with age.

Anorexia Many patients receiving cancer treatments complain of a general loss of appetite. Contributing factors include chemo- therapeutic 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 con- tribute 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 pat- terns 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 malnu- trition. 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.

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 high- est 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.

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.

316 PART IV Common Psychophysiologic Stressors

Assessment of diarrhea includes the number of stools per day, their consistency, and their color. Older patients may be reluctant to 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; other- wise, 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.

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 sta- tistics 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 per- son’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, quality is a very—if not the most—important consideration.

Determining quality of life goes beyond evaluating the sever- ity of symptoms (such as nausea, pain, or fatigue) to consid- ering the degree of functional status reflected in the person’s ability to perform daily tasks of living. Quality of life is a mul- tidimensional 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, psy- chological 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, psycho- social well-being is most important (Dibble, Padilla, Dodd & Miaskowski, 1998).

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 thera- peutic strategies that result in a more normal life. Older adults may need special quality-of-life consideration when choos- ing 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 statisti- cally 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 plan- ning, and management of depression.

Some measure of a person’s quality of life has been included in most studies evaluating treatment modalities or chemothera- peutic agents. Historically, these studies focused on measures of functional status, primarily assessing the ability of patients

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CHAPTER 17 Cancer 317

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).

Depression 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 stud- ies 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 diagno- ses, 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

Psychologic Issues Search for meaning Self-enhancement

QUALITY OF LIFE

Sociocultural Issues Impact on family Social support

Cultural perspective

Ethical Issues Functional Status

Activities of daily living Independent activity

Economic IssuesSpirituality

FIGURE 17-2 Quality of life as a multidimensional concept.

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 termi- nally ill patients in a home-based hospice program and (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

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.

distress (pain, nausea, shortness of breath, and restlessness). Significant correla- tions 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.

http://palliative.info/resource_material/PPSv2.pdf

318 PART IV Common Psychophysiologic Stressors

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 psy- chological 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 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 depres- sion. 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, psy- chotherapy, 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 func- tional ability, loss of self-esteem, and loss of control. The losses associated with cancer may overlap other losses frequently expe- rienced 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 pro- viding 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 allow the diagnosis of cancer to reach conscious awareness.

The information about the diagnosis is allowed into the aware- ness 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 dif- ferent paces as they realize the impact of the diagnosis on their lives. The diagnosis of cancer often leads to a confusing and con- flicting 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 ongo- ing 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 bene- fits of treatment. Interventions may be necessary when a patient and family are so threatened by the diagnosis that they are inca- pable 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 associ- ated 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 physi- cal 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 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 some- thing 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.

CHAPTER 17 Cancer 319

• 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 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 uncom- fortable 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 availabil- ity 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 per- ceive 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 neces- sary to relocate an older adult during cancer treatment. When an older adult is relocated to live with family or in a residen- tial care facility, he or she needs assistance with developing and maintaining social 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 impor- tance 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 agen- cies or support groups. Both cancer patients and their fami- lies 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 hospice, including consumer guides, fact sheets, historical perspectives, and other background information. The website offers information from the leg- islative, 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 pallia- tive 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 clini- cal oncology from the Journal of Clinical Oncology, ASCO’s Annual Meetings, and ASCO’s “Meet the Experts” events.

http://www.aarp.org/families/grief_loss

http://www.nahc.org/haa

http://www.nhpco.org

http://www.asco.org

320 PART IV Common Psychophysiologic Stressors

• 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 presen- tations, 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. 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

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 out- lined 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 pallia- tive 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 mis- leading 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.

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 screening is a life-

long 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 ther- apy, 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.

HOME CARE

K E Y P O I N T S • 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 atten- tion 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 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.

http://www.cancer.net

http://www.cancer.gov

http://www.cancer.org

http://www.nationalbreastcancer.org

http://www.prostatefoundation.org

http://www.lungusa.org

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C R I T I C A L T H I N K I N G E X E R C I S E S 1. You are asked to make a 30-minute presentation at a

senior center on the benefits and risks of cancer screen- ing in older adults. Prepare a topical outline for the presentation.

2. The director of oncology services asks you to develop a pro- cedure for functional assessment of older adults with cancer.

Develop the procedure and include any functional assess- ment 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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324

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 employ- ment into retirement, from a lifelong home to a smaller home or senior 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 transi- tions, especially those focused on death and dying; the meaning that these changes may have for older persons and their fami- lies; 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 nurs- ing care of older persons and their families throughout this process.

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 relation- ship. 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

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.

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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.

Loss and End-of-Life Issues

Cindy R. Morgan, RN, MSN, CHC, CHPN and Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

CHAPTER 18 Loss and End-of-Life Issues 325

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.

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 per- sons 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 con- fusion, and withdrawal. Individual coping styles, the existence of support systems, the ability to maintain some sense of con- trol, and the griever’s health status and spiritual beliefs all influ- ence 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 survi- vor (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 compan- ion who often is one’s best friend, sexual partner, and partner in decision making and household management, as well as a con- tributing 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 affect- ing the adjustment of many surviving spouses (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 expe- rienced, 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 neg- ative 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 bereave- ment 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.

• 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 reac- tions 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 emo- tional 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.

326 PART IV Common Psychophysiologic Stressors

Physical Symptoms Physical symptoms are commonly associated with acute grief responses. Tearfulness, crying, loss of appetite, feelings of hollow- ness in the stomach, decreased energy, fatigue, lethargy, and sleep difficulties are common symptoms of grief. Other physical sen- sations 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 regard- ing 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 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 deter- mined 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 suffer- ing 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 addi- tion 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 cre- ating 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 mean- ing, 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 in the spirit. Meaning in life is highly individu- alized, 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 mean- ingful 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, how- ever, the grief experience may precipitate a crisis in their beliefs and values. Gender, social class, ethnicity, and culture may influ- ence one’s spiritual response to grief (D’Avanzo, 2008; Doka & Davidson, 1998) (see Cultural Awareness box).

PATIENT/FAMILY TEACHING 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 in- tense 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.

CULTURAL AWARENESS Loss and End-of-Life Issues

In some cultures, people believe that particular omens may warn of approach- ing death (e.g., some Native American and Mexican American groups be- lieve the appearance of an owl and messages in dreams foreshadow death). Research indicates that the desire to be told of one’s impending death var- ies 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 consider- ations 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 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.

CHAPTER 18 Loss and End-of-Life Issues 327

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 advo- cated. 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 gen- erally 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 abnor- mal 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 working with compli- cated 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’ appar- ent 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 pro- cess both because it cannot be expressed and because social sup- port is not available. Doka (1997, 2002) described four major situations that cause disenfranchised grief: (1) when a relation- ship 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 circum- stances 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 satis- factory 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 grief reaction trig- gered 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 physi- cal 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

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 vio- lently (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 spe- cific 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 expen- sive jewelry and money, and wrapped in new blankets. Some Navajo believe that the structure in which the person died must be burned.

Often interrelated with religious beliefs and practices, culture influences funeral and burial or cremation practices, as well as what is expected of be- reaved family members (e.g., who grieves, for how long, and culturally appro- priate 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.

328 PART IV Common Psychophysiologic Stressors

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 eco- nomic 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.

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 soci- ety (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.

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 per- sons. 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 expres- sion of grief often contribute to unresolved grief. The third task, adjusting to an environment in which the deceased is miss- ing, 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.

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 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

TABLE 18-1 PSYCHOLOGICAL FACTORS INFLUENCING GRIEF RESPONSES

Modified from Rando, T.A. (Ed.) (1986). Loss and anticipatory grief. Lexington, MA: Lexington Books. Used with permission of Therese A. Rando, PhD.

CHAPTER 18 Loss and End-of-Life Issues 329

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 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 sur- vivors 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, 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 mean- ing in a person’s life after the death of a loved one is an impor- tant 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), research- ers 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)construc- tions until, over time, they become more focused on positive meaning reconstruction. For instance, persons might vacillate between positive reappraisal of the situation and negative rumi- nation 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 nurses are often tempted to try to do so. Nurses should assist and support bereaved persons through the grieving process, rec- ognizing 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 clini- cal 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 rein- vest 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).

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 volun- teers may provide grief counseling, whereas therapy should be

330 PART IV Common Psychophysiologic Stressors

Assessment Date Assessed by ID# Patient / Deceased Name Bereaved Name

Comments

I. Kinship

a) spouse/partner of patient or deceased

b) parent/parental figure of patient or deceased

II Caregiver

a) family member or friend who has taken primary responsibility for care

III. Mental Health a) significant mental illness (eg major depression, schizophrenia, anxiety disorder)

b) significant mental disability (eg developmental, dementia, stroke, head injury)

IV. Coping

a) substance abuse / addiction (specify)

b) considered suicide (no plan, no previous attempt)

c) has suicide plan and a means to carry it out OR has made previous attempt

d) self-expressed concerns regarding own coping, now or in future

e) heightened emotional states (anger, guilt, anxiety) as typical response to stressors

f) yearning/pining for the deceased OR persistent disturbing thoughts/images > 3 months

g) declines available resources or support

h) inability to experience grief feelings or acknowledge reality of the death > 3 months

V. Spirituality / Religion

significant challenge to fundamental beliefs / loss of meaning or faith / spiritual distress

VI. Concurrent Stressors

a) two or more competing demands (eg single parenting, work, other caregiving)

b) insufficient financial, practical or physical resources (eg income, no childcare, illness)

c) recent non-death losses (eg divorce, unemployment, moving, retirement)

d) significant other with life-threatening illness / injury (other than patient/deceased)

VII. Previous Bereavements

a) unresolved previous bereavement(s)

b) death of other significant person within 1 year (from time of patient’s death)

c) cumulative grief from > 2 OTHER deaths over past 3 years

d) death or loss of parent/parental figure during own childhood (less than age 19)

VIII. Supports & Relationships

a) lack of social support/social isolation (perceived or real - eg housebound)

b) cultural or language barriers to support

c) longstanding or current discordant relationship(s) within the family

d) relationship with patient/deceased (eg abuse, dependency)

IX. Children & Youth

a) death of parent, parental figure or sibling

b) demonstration of extreme, ongoing behaviours/symptoms (eg sep anxiety+, nightmares)

c) parent expresses concern regarding his/her ability to support child’s grief

d) parent/parental figure significantly compromised by his/her own grief

X. Circumstances Involving the Patient, the Care or the Death

a) patient/deceased less than age 35

b) lack of preparedness for the death (as perceived or demonstrated by bereaved)

c) distress witnessing the death OR death perceived as preventable

d) violent, traumatic OR unexplained death (eg accident, suicide, unknown cause)

e) significant anger with OTHER health care providers (eg “my GP missed the diagnosis”)

f) significant anger with OUR hospice palliative care program (eg “you killed my wife”)

XI. Protective Factors Supporting Positive Bereavement Outcome a) internalized belief in own ability to cope effectively

b) perceives AND is willing to access strong social support network

c) predisposed to high level of optimism/positive state of mind

d) spiritual/religious beliefs that assist in coping with the death

Aug-08

Bereavement Risk Assessment Tool © Victoria Hospice Society 2008

Risk Indicators and Protective Factors

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.)

http://www.victoriahospice.org/health-professionals/clinical-tools

CHAPTER 18 Loss and End-of-Life Issues 331

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 read- justment 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 rela- tionship. 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 profes- sionals present to offer details and descriptions of the death or explanations of puzzling situations that family members may not understand. Having information about the death and the events preceding and following the death is impor- tant 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 expres- sion. 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 per- sons 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 sad- ness among older persons.

• Assist the survivor in living without the deceased. The nurse needs to assess the survivor’s daily living situation and iden- tify 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 com- munity resources and teaching of practical skills are necessary to meet this need. In general, survivors should be advised to postpone 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 diffi- cult 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

First learned of the impending death

Able to get on with the rest of your life

1 2 3 4 5 6 7 8 9 10

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.)

332 PART IV Common Psychophysiologic Stressors

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 impor- tant that nurses, with a clear understanding of the range of normal grief responses, communicate acceptance and reas- surance 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 them- selves in their grief responses. Nurses may need to explain the wide range of responses and assist mourners with allow- ing one another to grieve in their own ways.

• Provide continuing support for the survivor. Although nurses’ interactions with bereaved persons may be brief or intermit- tent, referrals may be made for outside support. This sup- port 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, evalu- ate 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, how- ever, 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 success- fully worked through a loss—big or small—and has reflected on the experience has valuable insight into the grieving pro- cess. 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.

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 fac- tors: (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 per- sons 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, con- cerns about quality of life, and fear of dying suddenly and not being found (Lloyd-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 adap- tation 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

CHAPTER 18 Loss and End-of-Life Issues 333

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 con- ducted, however, because older adults have widely varied expe- riences 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 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 previ- ous 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 identi- fied 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 instru- mental in helping older persons cope with these fears. Assessing patients’ desires for religious and spiritual assistance is particu- larly 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 com- petencies 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 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 per- sons. 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 iso- lation 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 qui- etly. This attitude also fosters social isolation. Thus, social isola- tion, 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 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

334 PART IV Common Psychophysiologic Stressors

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), pneu- monia 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 func- tional 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) determin- ing 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 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 sleepless- ness, 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 per- sons 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 prob- lems for older persons are discussed in this section.

Age-related changes in the integumentary and vascular sys- tems, coupled with alterations in nutrition, elimination, and

mobility, quickly lead to skin breakdown. Loss of the subcuta- neous fat layer and a decrease in sebaceous gland activity cause the skin to become thin and dry, which makes it more suscep- tible 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 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 impac- tion, and sometimes diarrhea. Although health care profession- als 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 con- fusion 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 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

CHAPTER 18 Loss and End-of-Life Issues 335

and discomfort need to be heeded and validated by the nurse. Nonpharmacologic interventions for pain relief, for example, therapeutic touch, massage, acupressure, relaxation, and visual- ization, need to be used, whenever possible.

Age-related changes in pharmacokinetics and pharmaco- dynamics 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 moni- tored. 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 inabil- ity to sleep. Although medication may be appropriate in some instances, it needs to be prescribed with caution and moni- tored 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 fol- lowed by appropriate treatment aimed at that cause.

Nursing Care Excellent nursing care of dying older persons begins with exam- ination of a nurse’s own feelings about death and values regard- ing 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 greater probability for survival receive more attention com- pared 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 experi- ences. 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 spiri- tual 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 care- givers 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 (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.

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 meet- ing those needs.

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 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 indi- vidually 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 aspi- rin 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

http://www.nationalconsensusproject.org/guideline.pdf

http://www.hospicecare.com

336 PART IV Common Psychophysiologic Stressors

For each of the following statements, circle the response that is most nearly true for you at this time.

1. I feel that I have found a significant meaning or meanings for leading my life.

Strongly disagree Disagree Uncertain Agree Strongly agree

2. Even though there may be a purpose in my life, I do not try to do much about it.

Strongly disagree Disagree Uncertain Agree Strongly agree

3. I have a belief or beliefs about life that gives my living significance.

Strongly disagree Disagree Uncertain Agree Strongly agree

4. Something seems to stop me from doing what I really want to do.

Strongly disagree Disagree Uncertain Agree Strongly agree

5. I do not value what I am doing in my life.

Strongly disagree Disagree Uncertain Agree Strongly agree

6. The things that are the most important to me dominate my activities.

Strongly disagree Disagree Uncertain Agree Strongly agree

7. In thinking of my life, it is hard for me to see a reason for my being here.

Strongly disagree Disagree Uncertain Agree Strongly agree

8. Basically, I am living the kind of life I want to live.

Strongly disagree Disagree Uncertain Agree Strongly agree

9. In life, I have no goals or aims at all.

Strongly disagree Disagree Uncertain Agree Strongly agree

10. My personal existence is purposeful and meaningful.

Strongly disagree Disagree Uncertain Agree Strongly agree

11. Life seems to be completely routine.

Strongly disagree Disagree Uncertain Agree Strongly agree

12. Facing my daily tasks is a source of pleasure and satisfaction.

Strongly disagree Disagree Uncertain Agree Strongly agree

Meaning Framework Question

Is there something or things so important to you in your life that they give your life meaning?

Yes No

If no, please describe your life situation at this time.

If yes, please list those things that are currently important to you and that give your life meaning.

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.)

CHAPTER 18 Loss and End-of-Life Issues 337

patients and family caregivers regarding pain medication, and close communication with the prescriber for changes in medica- tion as needed. Attention needs to be given to a patient’s emo- tional state because psychosocial factors and emotional pain may accentuate physical pain (Wiech & Tracey, 2009).

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 condi- tions. 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 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 impair- ment, immobility, and sleep disturbances (Cavalieri, 2002).

Dyspnea, or shortness of breath, is another common symp- tom feared by both patients and caregivers. Common causes include hypoxemia, poor handling of secretions, anxiety, bron- chospasm, 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 analge- sics may be sufficient to improve dyspnea. Morphine, which is often the most effective medication for decreasing dyspnea, also

To share and come to terms with the unavoidable future

To perceive meaning in death

To maintain respect in the face of increasing weakness

To maintain independence To feel like a normal person, a part of

life right to the end To preserve personal identity

To talk To be listened to with understanding To be loved and to share love To be with a caring person when dying

To be given the opportunity to voice hidden fears

To trust those who care for him or her To feel that he or she is being told

the truth To be secure

To obtain relief from physical symptoms

To conserve energy To be free of pain

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.)

Interventions for increased

pain

Phase One Provide: (either/or) 1. Analgesic (non-opioid) 2. Other therapies 3. If pain persists go to next phase

Phase Two Provide: (either/or)

1. Mild opioid (or non-opioid) 2. Adjuvant therapies 3. Other therapies 4. If pain persists go to next phase

Phase Three Provide: (either/or)

1. Stronger opioid 2. Adjuvant therapies 3. Other therapies 4. If pain persists re-evaluate plan

FIGURE 18-5 Incorporation of analgesics in the treatment of older adults.

338 PART IV Common Psychophysiologic Stressors

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 suf- ficient 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 consid- eration with catheter placement. For the dying patient with decreased mobility and problems with skin integrity, the ben- efits 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 with- drawal 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 effec- tive, 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 neu- tral topics (Craun, Watkins, & Hefty, 1997). The technique of validation, based on empathic understanding of the emotion and messages behind the confusion, is effective in communi- cating 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 appropri- ate (see Nutritional Considerations box). Palliative care physi- cians 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 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.

Good communication skills are essential in dealing with dying persons and their families, although a lack of effec- tive 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 clari- fying 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 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 sup- port 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 ther- apy interventions such as forgiveness therapy for older termi- nally 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 character- istics that invoke memories of previous unresolved losses that

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 com- plications 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.

CHAPTER 18 Loss and End-of-Life Issues 339

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 recog- nize 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 sig- nificant change from the turn of the last century, when approxi- mately 75% 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 per- sons 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 (treat- ment 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 dif- ferent goals and different reimbursement systems than hos- pitals. 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 facil- ity setting.

Hospice care was founded on the philosophy of compassion- ate, 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 ide- ology 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 qual- ity of life on a day-to-day basis. During the dying process and the bereavement period, physical, emotional, social, and spiri- tual 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 quality of life of patients and their families facing the prob- lem associated with life-threatening illness, through the pre- vention 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 pallia- tive 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 hos- pice 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 com- pleted advance directives, and professional–patient communi- cations 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 conse- quences of life-prolonging treatments versus no treatment may undermine the older person’s ability to make 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 direc- tives 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 hos- pital. 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 docu- mented. The overall numbers of formal advance directives remained low: HCPOA, 20.6%; living will, 26.9%. When necessary, the health care team did

340 PART IV Common Psychophysiologic Stressors

Nurses caring for very ill older adults need to understand the 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.

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.

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 home- bound 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 pos- sible 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.

HOME CARE

From Dobbins, E. (2007). End-of-life decisions: Influence of advance directives on patient care. Journal of Gerontological Nursing 33(10), 50-56.

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 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 un- able. 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.

K E Y P O I N T S • Grief is the acute reaction to one’s perception of loss, mourn-

ing 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 man- ifests itself in physical symptoms, psychological responses, changes in socialization patterns, and spiritual issues con- cerning 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, examin- ing defenses and coping styles, identifying pathologic condi- tions, and making appropriate referrals.

• Sociocultural and religious background, physical and func- tional status, social isolation and loneliness, and the mean- ingfulness 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 delivering excellent physical care, using good communica- tion skills, conducting a life review, and educating and sup- porting family caregivers.

CHAPTER 18 Loss and End-of-Life Issues 341

• Hospice programs help dying persons live as fully as pos- sible 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 1. A 70-year-old woman is admitted to the hospital unit with

COPD. She lives alone in a retirement community. Her chil- dren 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 mul- tiple 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 anticipa- tory grief process?

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344

Laboratory and Diagnostic Tests

Jennifer J. Yeager, PhD, RN

Diagnostic testing in older adults takes on a different meaning than testing in younger adults. The nurse must realize that labo- ratory 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 over- all 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.

COMPONENTS OF HEMATOLOGIC TESTING Blood is composed of cells (erythrocytes and leukocytes), spe- cialized 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 extracel- lular fluid (Thibodeau & Patton, 2003).

Previous authors: Tamara R. Tripp, AD, BSN, MSN, and Susan A. Moore, PhD, RN.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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

CHAPTER 19 Laboratory and Diagnostic Tests 345

TABLE 19-1 HEMATOLOGY TEST

NAME ADULT NORMALS OLDER ADULT NORMALS SIGNIFICANCE OF DEVIATIONS

Red blood cells (RBCs) 4.2–6.1 million/unit Unchanged with aging Low: hemorrhage, anemia, chronic illness, renal failure, pernicious anemia

High: high altitude, polycythemia, dehydration Hemoglobin 12–18 grams per deciliter

(g/dL) Values may be slightly

decreased Low: anemia, cancer, nutritional deficiency, kidney disease

High: polycythemia, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), high altitudes, dehydration

Hematocrit 37%–52% Values may be slightly decreased

Low: anemia, cirrhosis, hemorrhage, malnutrition, rheumatoid arthritis

High: polycythemia, severe dehydration, severe diarrhea, COPD White blood cells (WBCs) (total) 5.0–10.0 thousands/cubic

millimeter (mm3) Unchanged with aging Low: drug toxicity, infections, autoimmune disease, dietary deficiency

High: infection, trauma, stress, inflammation Neutrophils 55%–70% Unchanged with aging Low: dietary deficiency, overwhelming bacterial infection, viral

infections, drug therapy High: physical and emotional stress, trauma, inflammatory disorders

Eosinophils 1%–4% Unchanged with aging Low: increased adrenosteroid production High: parasitic infections, allergic reactions, autoimmune disorders

Basophils 0.5%–1% Unchanged with aging Low: acute allergic reactions, stress reactions High: myeloproliferative disease

Monocytes 2%–8% Unchanged with aging Low: drug therapy (predisposition) High: chronic inflammatory disorders, tuberculosis, chronic ulcerative

colitis Lymphocytes 20%–40% Unchanged with aging Low: leukemia, sepsis, systemic lupus erythematosus, chemotherapy,

radiation High: chronic bacterial infection, viral infections, radiation, infectious

hepatitis Folic acid 5–25 nanograms per

milliliter (ng/mL) Unchanged with aging Low: malnutrition, folic acid anemia, hemolytic anemia, alcoholism,

liver disease, chronic renal disease High: pernicious anemia

Vitamin B12 160–950 picograms per milliliter (pg/mL)

Unchanged with aging Low: pernicious anemia, inflammatory bowel disease, atrophic gastritis, folic acid deficiency

High: leukemia, polycythemia, severe liver dysfunction Total iron-binding capacity

(TIBC) 250–460 micrograms per

deciliter (mcg/dL) Unchanged with aging Low: hypoproteinemia, cirrhosis, hemolytic anemia, pernicious

anemia High: polycythemia, iron deficiency anemia

Iron (Fe) 60–180 mcg/dL Unchanged with aging Low: insufficient dietary iron, chronic blood loss, inadequate absorption of iron

High: hemochromocytosis, hemolytic anemia, hepatitis, iron poisoning Uric acid 4–8.5 mg/dL May be slightly increased Low: lead poisoning High: gout, increased ingestion of purines, chronic renal disease,

hypothyroidism Prothrombin time (PT) 11–12.5 seconds (sec) Unchanged with aging High: liver disease, vitamin K deficiency, warfarin ingestion, bile duct

obstruction, salicylate intoxication Partial thromboplastin time (PTT) 60–70 sec Unchanged with aging Low: early stages of disseminated intravascular coagulation,

metastatic cancer D-dimer <0.5 mcg/mL (<0.5 mg/L

SI units) Unchanged with aging High: deep vein thrombosis, disseminated intravascular coagulation,

pulmonary embolism, recent surgery, sepsis High: coagulation factor deficiency, cirrhosis, vitamin K deficiency,

heparin administration Platelets 150,000–400,000/mm3 Unchanged with aging Low: hemorrhage, thrombocytopenia, systemic lupus erythematosus,

pernicious anemia, chemotherapy, infection High: malignancy, polycythemia, rheumatoid arthritis, iron deficiency

anemia

Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby.

346 PART V Diagnostic Studies and Pharmacologic Management

Red Blood Cells Red blood cells (RBCs), or erythrocytes, are nonnucleated bicon- cave disks that carry molecules of hemoglobin. Hemoglobin allows the transport and exchange of oxygen and carbon diox- ide. The average life span of an erythrocyte is 120 days. Although aging does not affect the life span of an erythrocyte, replen- ishment 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 diox- ide 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 unno- ticed 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 symp- tomatology 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. Overproduction of RBCs is known as polycythemia. This may occur secondarily as a result of hypoxia caused by chronic pul- monary 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 hemato- crit 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 for- eign 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, antime- tabolites, 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, aspi- rin, 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 pros- taglandins, which contribute to activation of the inflammatory response (McCance & Huether, 2008). The monocyte, the larg- est 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 & Patton, 2003).

Aging does not appear to affect the function of neutro- phils, 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 leu- kocytes, eosinophils, and basophils, have not been shown to be affected by aging.

CHAPTER 19 Laboratory and Diagnostic Tests 347

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 malig- nancies 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 macro- cytic 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, antima- larials, 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 con- sumption to folic acid levels, it is important for the gerontologic nurse to assess nutritional intake, including alcohol consump- tion habits. Elevated levels of folic acid may be seen in people with pernicious anemia, who do not have an adequate amount of vitamin B

12 to metabolize folic acid. Therefore, the folic

acid levels should be tested in conjunction with assessment of vitamin B

12 levels (Pagana & Pagana, 2010).

Vitamin B12 Vitamin B

12 , or cobalamin, is a water-soluble vitamin that is

part of the B-complex group of vitamins. Vitamin B 12

defi- ciency is present in nearly a quarter of older adults. Common causes of deficiency include malabsorption secondary to gas- tric bypass, pancreatic disease, ileal resection or inflamma- tion, and prolonged use of certain medications such as proton pump inhibitors, colchicine, cholestyramine, histamine 2 (H

2 )

blockers, or metformin. Strict vegetarian or vegan diets may also lead to vitamin B

12 deficiency (Bryan, 2010; Orton, 2012).

Malabsorption of vitamin B 12

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 preva- lence of pernicious anemia increases significantly with aging (Chatta & Lipschitz, 1999).

Vitamin B 12

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 B

12 intake (Grodner, Long, & DeYoung, 2004). Vitamin B

12 defi-

ciency 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 B

12 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 col- lects iron and transports it to the bone marrow for incorpo- ration into hemoglobin. Increased TIBC and transferrin levels may indicate iron deficiency anemia; decreased levels may indi- cate 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 intes- tine and transported to the plasma (Pagana & Pagana, 2010). Iron is necessary for controlling protein synthesis in the mito- chondria 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 defi- ciency 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 sig- nificantly 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 pres- ence 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 body, causing painful, inflamed joints. Thiazide diuretics, caffeine, low-dose aspirin, and antiparkinso- nian 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 throm- bin in the first step of the clotting cascade. Clotting is neces- sary 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

348 PART V Diagnostic Studies and Pharmacologic Management

performing (McCance & Huether, 2008). An increased PT is seen in liver disease, vitamin K deficiency, bile duct obstruction, and salicylate intoxication. Some medications, including, allopuri- nol, cephalothins, cholestyramine, clofibrate, and certain anti- biotics, 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 decreas- ing 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 provid- ers 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 tradition- ally reported in seconds and includes a value called the interna- tional normalized ratio (INR). INR is a mathematic “correction” of the results of the one-stage PT and was created to standard- ize results caused by variation in laboratory reagents. The INR should be between 2.0 and 3.0 for most 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).

Partial Thromboplastin Time Partial thromboplastin time (PTT) refers to the measurement of the common pathway of clot formation. Heparin may inac- tivate prothrombin, so the PTT is a good indicator of the ade- quacy 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 symp- toms of thrombus, embolus, or disseminated intravascular coagulation. Results are interpreted when combined with clini- cal information 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, infec- tions, 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 inter- pret 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 develop- ment 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 consid- ered to be 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 trans- fusions 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, how- ever, must recognize that older adults who take iron supple- ments have changes in bowel habits and stool color, which may not necessarily indicate the presence of occult blood. When pre- paring older adults for fecal occult blood testing, it is important to instruct them to stop iron supplements 3 days before testing.

COMPONENTS OF BLOOD CHEMISTRY TESTING Blood chemistry testing involves electrolytes, glucose, and vari- ous other blood components. Although many of these tests are

NUTRITIONAL CONSIDERATIONS

Vitamin K is used in emergency situations to counteract the increased co- agulation times that sometimes occur when patients are receiving warfarin (Coumadin). The nurse should be aware that foods high in vitamin K may af- fect 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.

CHAPTER 19 Laboratory and Diagnostic Tests 349

done in groups, others may be ordered individually to determine the presence or absence of a particular disorder. Current termi- nology labels these chemical analyses into groups with names such as “basic metabolic profile” and “complete metabolic pro- file,” 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 elec- trolyte 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 The test for sodium (Na+) measures the amount of sodium in circulating blood, but it is actually an index of body water defi- cit or excess. Sodium regulation is important for the mainte- nance 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 kid- neys (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 neces- sary for maintaining the extracellular fluid balance (osmolarity).

TABLE 19-2 BLOOD CHEMISTRY

TEST NAME ADULT NORMALS OLDER ADULT NORMALS SIGNIFICANCE OF DEVIATION

Sodium 136–145 milliequivalents per liter (mEq/L)

Unchanged with aging Low: decreased intake, diarrhea, vomiting, diuretic administration, chronic renal failure, congestive heart failure (CHF), peripheral edema, ascites

High: increased intake, Cushing syndrome, extensive thermal burns Potassium 3.5–5 mEq/L Unchanged with aging Low: deficient intake, burns, diuretics, Cushing syndrome, insulin

administration, ascites High: excessive dietary intake, renal failure, infection, acidosis,

dehydration Chloride 98–106 mEq/L Unchanged with aging Low: overhydration, CHF, vomiting, chronic gastric suction, chronic

respiratory acidosis, hypokalemia, diuretic therapy High: dehydration, Cushing syndrome, kidney dysfunction, metabolic

acidosis, hyperventilation Calcium 9–10.5 milligrams per

deciliter (mg/dL) Tends to stay the same or decrease Low: renal failure, vitamin D deficiency, osteomalacia, malabsorption

High: Paget disease of the bone, prolonged immobilization, lymphoma Phosphorus 3–4.5 mg/dL Slightly lower Low: inadequate dietary ingestion, chronic antacid ingestion,

hypercalcemia, alcoholism, osteomalacia, malnutrition High: renal failure, increased dietary intake, hypocalcemia, liver disease Magnesium 1.3–2.1 mEq/L Decreases 15% between third and

eighth decade Low: malnutrition, malabsorption, alcoholism, chronic renal disease

High: renal insufficiency, ingestion of magnesium-containing antacids or salts, hypothyroidism

Fasting glucose 70–105 mg/dL Increase in normal range after age 50 Low: hypothyroidism, liver disease, insulin overdose, starvation High: diabetes mellitus, acute stress response, diuretic therapy,

corticosteroid therapy Postprandial

glucose Less than 140 mg/dL

2 hours (hr) after meal Less than 160 mg/dL 2 hr after meal Low: hypothyroidism, insulin overdose, malabsorption

350 PART V Diagnostic Studies and Pharmacologic Management

The occurrence of hyponatremia (a low sodium level) increases with age. The majority of cases are related to the kid- neys’ inability to excrete free water because of decreased basal levels of renin and aldosterone. Vague symptoms such as mal- aise, 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 pseudohyponatre- mia. In these cases, the osmolarity remains normal or high as a result of excess amounts of other osmolites in blood, for exam- ple, 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 rea- sons for a given condition, for example, restrictions in mobility, visual disturbances, urinary incontinence, and swallowing dis- orders. 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.

TABLE 19–2 BLOOD CHEMISTRY—Cont'd

TEST NAME ADULT NORMALS OLDER ADULT NORMALS SIGNIFICANCE OF DEVIATION

High: diabetes mellitus, malnutrition, Cushing syndrome, chronic renal failure, diuretic therapy, corticosteroid therapy

Amylase 60–120 Somogyi units/dL Slightly increased in elderly High: acute pancreatitis, perforated bowel, acute cholecystitis, diabetic ketoacidosis

Glycosylated hemoglobin (Hb A1c)

2.2%–4.8% Unchanged with aging Low: hemolytic anemia, chronic renal failure High: newly diagnosed diabetes, poorly controlled diabetes, nondiabetic

hyperglycemia Total protein 6.4–8.3 grams per deciliter

(g/dL) Unchanged with aging Low: liver disease, malnutrition, ascites

High: hemoconcentration Albumin 3.5–5 g/dL Decreases slightly with aging Low: malnutrition, liver disease, overhydration High: dehydration Blood urea nitrogen

(BUN) 7–22 mg/dL May be slightly higher Low: liver failure, overhydration, malnutrition

High: hypovolemia, dehydration, alimentary tube feeding, renal disease Creatinine 0.7–1.5 mg/dL Decrease in muscle mass may cause

decreased values Low: debilitation, decreased muscle mass High: reduced renal blood flow, diabetic neuropathy, urinary tract

obstruction Creatinine

clearance 87–107 milliliters per

minute (mL/min) Values decrease 6.5 mL/min/decade

of life due to a decline in glomerular filtration rate (GFR)

Low: impaired kidney function, CHF, cirrhosis High: high cardiac output syndromes

Cholesterol (total) >200 mg/dL Increases until about middle age but decreases thereafter (or can Increase abruptly in women)

Low: malabsorption, malnutrition, cholesterol-lowering medication, pernicious anemia, liver disease, myocardial infarction

High: hypercholesteremia, hyperlipidemia, hypothyroidism, uncontrolled diabetes mellitus

High-density lipoprotein (HDL)

>45 mg/dL Unchanged with aging Low: familial low HDL, liver disease, hypoproteinemia High: familial HDL lipoproteinemia, excessive exercise

Low-density lipoprotein (LDL)

60–180 mg/dL Increases with aging after menopause Low: hypolipoproteinemia

High: hypothyroidism, alcohol consumption, chronic liver disease, Cushing syndrome

Alkaline phosphatase

30–120 units/L Slightly higher Low: hypothyroidism, malnutrition, pernicious anemia High: cirrhosis, healing fracture, Paget disease

Acid phosphatase 0.13–0.63 units/L Unchanged with aging Low: thrombosis High: heparin administration, cirrhosis, prostate cancer Aspartate

transaminase (AST)

0–35 units/L Values slightly higher Low: acute renal disease, diabetic ketoacidosis, chronic renal dialysis High: myocardial infarction, hepatitis, cirrhosis, multiple trauma, acute

hemolytic anemia Creatine kinase

(CK) 30–170 units/L Unchanged with aging High: diseases or injury affecting heart muscle, skeletal muscle, and brain

Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby.

CHAPTER 19 Laboratory and Diagnostic Tests 351

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 extra- cellular fluid. The majority of potassium is found within the cell, and minute amounts in the extracellular fluid. This extracellular amount 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 potas- sium and should be used with caution. Many medications such as potassium-sparing diuretics, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor block- ers (ARBs) used in conjunction with potassium supplements, may cause hyperkalemia in older adults. In addition, nonste- roidal 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).

Potassium, like sodium, maintains cell osmolarity, muscle function, and the transmission of nerve impulses, and it regu- lates 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 main- tains the normal level of calcium in blood, but the resulting bone loss secondary to calcium leaching may lead to osteoporo- sis (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 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 kid- neys 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

EMERGENCY TREATMENT Abnormal Laboratory Values: Potassium

Hypokalemia • If asymptomatic, may repeat test before treatment. • Monitor for possible cardiac arrhythmias (e.g., sinus bradycardia, atrioven-

tricular 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. • 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.

352 PART V Diagnostic Studies and Pharmacologic Management

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 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.

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 A 1c

HbA 1c

). This is a blood test that checks the amount of glucose bound to hemoglobin. Test is used to diagnose diabetes and monitor therapy. It pro- vides 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: 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 con- trol of blood sugar.

2. Random blood sugar. This test measures blood glucose with- out fasting. Wide variance in blood glucose levels may indi- cate a problem. Hypoglycemia may cause central nervous system (CNS)

changes such as confusion, which is related to brain cell star- vation. 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 amy- lase from the pancreas. Elevated amylase levels also may be seen in nonpancreatic disorders such as perforated ulcer and perfo- rated or necrotic bowel or secondary to medications. Decreased amylase levels may be found with chronic pancreatitis, pancre- atic 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, and diarrhea may occur when this conver- sion 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 nutri- tional 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 medica- tions, 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 albu- min 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 prealbu-

TABLE 19-3 DIAGNOSING AND CLASSIFICATION OF DIABETES

HbA1c, Glycohemoglobin; mg/dL, milligrams per deciliter. Taken from American Diabetes Association. (2013). Standards of medical care in diabetes—013. Diabetes Care, 36(Suppl 1), S11-S66.

HbA1c

FASTING BLOOD GLUCOSE

ORAL GLUCOSE TOLERANCE TEST

Diabetes ≥6.5% ≥125 mg/dL ≥200 mg/dL Prediabetes 5.7–6.4% 100–125 mg/dL 140–199 mg/dL Normal ≤5% ≤99 mg/dL ≤139 mg/dL

CHAPTER 19 Laboratory and Diagnostic Tests 353

min level may be useful in evaluating an older adult’s response to nutritional supplements (Manning & Shenkin, 1995).

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 par- allel decrease occurs in mean muscle mass and actual creati- nine 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 exam- ple, 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:

Creatinineclearance milliliters per minute mL

Age i

/ min[ ]( ) =

−140 nn years Weight in kilograms kg Serum creatinine mg dL

( ) × [ ]( ) × (72 % / ))

(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:

MDRD GFR SCr

age if female if bla

− = ( ) ×( ) ( ) 186

0 742 1 210

1 154

0 203

. . . cck( )

Neither method of calculating GFR is without varia- tion; 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, espe- cially 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 the major lipid associated with cardiovascular dis- ease. 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 evalu- ate 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 degrada- tion. 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):

LDLcholesterol Total cholesterol HDL cholesterol Triglycerid

= − − ee level÷( )5

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 estab- lished 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.

354 PART V Diagnostic Studies and Pharmacologic Management

Brain Natriuretic Peptide 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 spe- cific 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 dia- stolic heart failure (Prahash & Lynch, 2004).

Alkaline Phosphatase Alkaline phosphatase (ALP) is an enzyme found in many tis- sues, although it has its highest concentrations in the liver and bone. Testing for ALP is used to identify liver and bone dis- orders (Pagana & Pagana, 2010). Testing of the alkaline phos- phatase level in older adults is often used in the biochemical assessment of Paget disease (Lyles, 1999) and other bone dis- eases (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 deter- mining 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 kid- neys. It is 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 pyra- zinamide (Rajagopalan & Yoshikawa, 1999).

Creatine Kinase Creatine kinase (CK) is present in cardiac and skeletal mus- cles 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 circulat- ing blood, and the level rises with damage to skeletal muscle. CK levels rise and peak at specific intervals during myocar- dial 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 mus- cles, brain, liver, kidneys, and RBCs. As with CK, LDH may be isolated into five isoenzymes (CK only has three). These iso- enzymes 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 detect- ing heart injury compared with other tests. These indices appear 2 to 8 hours after a decrease in the oxygenation of cardiac muscle caused 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 worsen- ing angina or acute coronary syndrome without ST elevation.

Thyroid Function Tests Testing of thyroid function includes the assessment of two hor- mones secreted by the thyroid gland: thyroxine (T

4 ) and triiodo-

thyronine (T 3 ). Thyroid function tests are a means of screening

for hypothyroidism or hyperthyroidism and for monitoring the effectiveness of thyroid-suppression or hormone replacement therapy. T

4 and T

3 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, radia- tion therapy or thyroid surgery, or certain medications (e.g., lith- ium). 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).

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 pros- tate 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 asso- ciated 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.

CHAPTER 19 Laboratory and Diagnostic Tests 355

COMPONENTS OF URINE CHEMISTRY TESTING Urine chemistry testing includes testing for the presence of pro- tein, 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 infec- tion (UTI) or kidney disease.

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

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.

TEST NAME ADULT NORMALS OLDER ADULT NORMALS SIGNIFICANCE OF DEVIATIONS

Thyroxine (T4) 4–12 micrograms per deciliter (mcg/dL)

Slightly decreased Low: hypothyroidism, malnutrition, renal failure, cirrhosis

High: hyperthyroidism, hepatitis Triiodothyronine (T3) 75–220 nanograms per deciliter

(ng/dL) Slightly decreased Low: hypothyroidism, pituitary insufficiency,

protein malnutrition, renal failure, liver diseases

High: hyperthyroidism, hepatitis, hypoproteinemia

Thyroid-stimulating hormone (TSH) 2–10 microunits/mL Unchanged with aging Low: pituitary dysfunction, hyperthyroidism High: primary hypothyroidism

TABLE 19-5 URINE CHEMISTRY

TEST NAME ADULT NORMALS OLDER ADULT NORMALS SIGNIFICANCE OF DEVIATIONS

Color Yellow; amber Same Straw colored urine indicates dilution. Appearance Clear Same Cloudy urine may indicate presence of pus, casts, blood, and bacteria. Specific gravity 1.005–1.030 Values decrease with aging Low: overhydration, renal failure, diuresis, hypothermia High: dehydration, water restriction, vomiting, diarrhea pH 4.6–8.0 Same Acidic urine: diarrhea, metabolic acidosis, diabetes mellitus, respiratory

acidosis, emphysema Alkaline urine: respiratory alkalosis, metabolic alkalosis, vomiting, gastric

suctioning, diuretic therapy, urinary tract infection (UTI) Protein 1–8 milligrams per

milliliter (mg/mL) Same Positive: diabetes mellitus, congestive heart failure (CHF), systemic lupus

erythematosus, malignant hypertension Glucose Negative Same Positive: diabetes mellitus, Cushing syndrome, severe stress, infection,

drug therapy Ketones Negative Same Positive: uncontrolled diabetes mellitus, starvation, excessive aspirin

ingestion, high-protein diet, dehydration Blood Negative Same Positive: renal trauma, renal stones, cystitis, prostatitis Leukocyte esterase Negative Same Positive: possible UTI Bacteria Negative May be seen in older adults without

symptoms; evaluate for pyuria and symptoms

Positive: UTI

Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby.

356 PART V Diagnostic Studies and Pharmacologic Management

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 overaccumula- tion 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 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 methe- namine. 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 oxa- late stones; alkaline urine is associated with calcium carbon- ate, 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 abnor- mal 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.

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 oxygen- ation 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 alterna- tive 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).

TEST NAME ADULT NORMALS

OLDER ADULT NORMALS

SIGNIFICANCE OF DEVIATIONS

pH 7.35–7.45 Same Low: respiratory or metabolic acidosis

High: respiratory or metabolic alkalosis

PaO2 80–100 mm Hg Decreases 25% between 30 and 80 years old

Low: cardiac or respiratory disease

PaCO2 35–45 mm Hg Same Low: respiratory alkalosis

High: respiratory acidosis

O2 saturation 95%–100% 95% Low: impaired gas exchange

HCO3 – 21–28 mEq/L Same Low: metabolic

acidosis High: metabolic

acidosis

TABLE 19-6 ARTERIAL BLOOD GASES

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. Adapted from Pagana, K.D. & Pagana, T.J. (2010). Mosby’s diagnostic and laboratory test reference (10th ed.). St. Louis, MO: Elsevier Mosby.

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, de- fined 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.

CHAPTER 19 Laboratory and Diagnostic Tests 357

Oxygen Oxygen (i.e., partial pressure of oxygen in arterial blood [PaO

2 ]) 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 (CO

2 ) 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 PaO

2 should be considered

in the context of a patient’s age. The PaO 2 decreases approxi-

mately 25% between the ages of 30 and 80 years (Cavalieri

et al., 1992). The following formula for arterial oxygen satu- ration may be used in calculating age-appropriate PaO

2 levels

(Cavalieri et al., 1992):

PaO mm Hg Age2 100 1 0 325( )= −( )( ). .

pH of the Blood pH measures the hydrogen ion (H−) concentration in the blood- stream. 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 vom- iting, diarrhea, lung function, endocrine function, and kidney function (see Table 19-6).

Carbon Dioxide Carbon dioxide (CO

2 ) in blood exists in the form of bicar-

bonate (HCO3−); therefore, the CO 2 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 (O

2 sat %) measures how much of the hemo-

globin 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.

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 pulmo- nary 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 ventricu- lar arrhythmias and seizures. This level should be determined

EVIDENCE-BASED PRACTICE 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 antibiot- ics 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 in- continence 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 speci- mens were considered by the nursing assistants to have a strong smell.

About half of those specimens (15) were found to be positive for bacteri- uria. 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 pres- ent 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.

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 dehydra- tion, 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.

358 PART V Diagnostic Studies and Pharmacologic Management

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.

SUMMARY Aging today is vastly different from aging in previous genera- tions. Health care researchers and scientists have traditionally used young or middle-aged men for studies, generalizing find- ings 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 over- all 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 labora- tory 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 promot- ing 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 man- agement 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.

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 mid- night the night before until the procedure).

HOME CARE

K E Y P O I N T S • 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 osmo- larities 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 unreli- able 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 thy- roid 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 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?

CHAPTER 19 Laboratory and Diagnostic Tests 359

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361

OVERVIEW OF MEDICATION USE AND PROBLEMS

Demographics of Medication Use Drugs have an important role in the management of condi- tions and the maintenance of well-being in older adults. At least 94% of community-dwelling adults aged 65 to 74 take medi- cations. 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 condi- tions 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 pharmacody- namics, 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.

Pharmacologic Management

Jennifer J. Yeager, PhD, RN

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.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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.

http://evolve.elsevier.com/Meiner/gerontologic

362 PART V Diagnostic Studies and Pharmacologic Management

What 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 sec- tion explores pharmacokinetic changes that occur with aging. A summary of important age-related physiologic alterations that affect pharmacokinetics is presented in Table 20-1.

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 gas- tric acid, slowed gastric emptying, and decreased gastrointes- tinal 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 (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 rela- tive amounts of total body water, fat content, and protein bind- ing. 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 toxic- ity, 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 compo- sition 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, albu- min 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 reactions (oxidation, reduction, demethylation, or hydroly- sis via the cytochrome P [CYP] 450 enzyme system) or phase II

TABLE 20-1 AGE-RELATED CHANGES IN PHARMACOKINETICS

VARIABLE CHANGE EXAMPLE

Absorption Gastric pH Acid secretory capacity Gastrointestinal blood flow or

gastric motility

Increased Decreased Diminished

Calcium carbonate: decreased dissolution Calcium carbonate: decreased dissolution Analgesics: delayed onset of effect, naproxen, salicylates; increased free concentration

Distribution Plasma albumin Diminished Meperidine: increased free concentration caused by decreased binding to red blood cells Protein affinity Diminished Propranolol: reduced unbound fraction Alpha-1-acid glycoprotein Increased Psychotropics: increased distribution into fat; potential accumulation Body fat Increased Long-acting benzodiazepines, tricyclic antidepressants, beta-blockers, narcotic analgesics: higher concentrations

from decreased metabolism

Metabolism Size of liver Decreased Long-acting benzodiazepines, tricyclic antidepressants, beta-blockers, narcotic analgesics: higher concentrations

from decreased metabolism Hepatic blood flow Decreased Long-acting benzodiazepines, tricyclic antidepressants, beta-blockers, narcotic analgesics: higher concentrations

from decreased metabolism

Renal Function Glomerular filtration rate Decreased Allopurinol, cephalosporins, chlorpropamide, ciprofloxacin, digoxin, histamine 2 (H2)-receptor blockers: higher

concentrations due to reduced renal clearance Renal plasma flow Decreased Allopurinol, cephalosporins, chlorpropamide, ciprofloxacin, digoxin, H2-receptor blockers: higher concentrations

caused by reduced renal clearance

From Hammerlein, A., Derendorf, H., & Lowenthal, D.T. (1998). Pharmacokinetic and pharmacodynamic changes in the elderly: Clinical implications, Clin Pharmacokinet 35(1):49.

CHAPTER 20 Pharmacologic Management 363

reactions (glucuronidation, acetylation, conjugation, or sulfation). Recent research has demonstrated that aging does not appear to affect phase II processes. Furthermore, although some isoen- zymes (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 pri- marily 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 cre- atinine level is commonly used as a screening test for renal func- tion; 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 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 calcula- tion; the CG slightly underestimates GFR and is easier to calcu- late (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 pharmacoki- netics rests primarily on careful patient monitoring to assess the adequacy of drug level to achieve the desired effect and iden- tify 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., war- farin) 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, recep- tors on cell surfaces, carrier molecules and protein transport- ers 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 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 phar- macodynamics, some drugs and drug classes are less likely to be tol- erated 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 propoxy- phene, doxazosin, diphenhydramine, and amitriptyline. A sepa- rate study 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).

http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf

364 PART V Diagnostic Studies and Pharmacologic Management

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 depart- ment 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 per- ceived 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 cog- nition, 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 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 per- spective so that a more appropriate intervention can be imple- mented. When other options are not advisable, it is generally important to honor the patient’s wishes. Patient-centered ther- apeutic management considers the patient’s beliefs and goals’ regarding quality of life to be tantamount to those of the pro- vider 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, polyphar- macy, 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 metabo- lism via the CYP450 hepatic enzyme system. Some drugs have the ability to induce or inhibit the activity of various CYP iso- zymes, which results in increasing or decreasing biotransfor- mation 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 oppos- ing or antagonistic actions. For example, in the patient who has both asthma and hypertension, a BB given to control hyperten- sion may oppose the actions of a beta-agonist given to dilate bronchi. Some drug–drug interactions 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.

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 exam- ple, 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 respon- sible 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).

Drug–disease interactions may exacerbate patients’ con- ditions or hinder healing. These drugs are generally contra- indicated in patients with coexisting underlying disease. For

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

TABLE 20-2 COMMON DRUG–DRUG INTERACTIONS IN OLDER ADULTS

NSAIDs, Nonsteroidal antiinflammatory drugs.

CHAPTER 20 Pharmacologic Management 365

example, 13% of African American men and 20% of African American women are carriers of a gene that may cause a defi- ciency 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.

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 of the drugs they are taking: prescription, OTC, and comple- mentary and alternative medications. It may be helpful to provide the patient with a list of acceptable OTC drugs for common prob- lems 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).

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 medica- tions 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 prescriptions filled at more than one pharmacy (Emmons, 2008). Additional contributors to polypharmacy include the use of OTC and alternative medicines or supple- ments 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 contraindi- cated when taken together.

FOOD DRUG POTENTIAL EFFECT

Caffeine Theophylline Increased potential for toxicity 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

TABLE 20-3 COMMON DRUG–FOOD INTERACTIONS IN OLDER ADULTS

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.

IF YOU HAVE

GENERALLY AVOID OVER- THE-COUNTER MEDICINES CONTAINING EXAMPLES BECAUSE

SAFER ALTERNATIVES

Asthma or lung disease Ephedrine Epinephrine Extra theophylline Pseudoephedrine Caffeine

Bronkaid Primatene Bronkaid Sudafed NoDoz,

May cause insomnia, nervousness, irregular heartbeats, especially when taking prescription asthma medicines

Ask your doctor

DeWitt’s pills Aspirin/salicylates (if you have

aspirin allergy) Ecotrin May cause allergic reaction (e.g.,

wheezing, itching, hives) Acetaminophen

NSAIDs (if you have aspirin allergy) Nuprin Blood clots (and are taking

blood thinners) Aspirin/salicylates Ecotrin, Vanquish, Alka-

Seltzer, Pepto-Bismol May cause bleeding Acetaminophen

NSAIDs Nuprin May cause bleeding Heart problems (high blood

pressure, heart failure, abnormal heartbeat)

Sodium, salt Phenylpropanolamine Ephedrine Epinephrine/pseudoephedrine Caffeine

Alka-Seltzer, antacids Dexatrim Bronkaid Primatene, Sudafed NoDoz

May worsen your condition Acetaminophen, nasal sprays, nonmedicated throat lozenges

Diabetes Liquid or syrups containing alcohol or sugar

Emetrol, many cough or cold syrups

May alter blood sugar Sugar-free, sugarless, or alcohol-free liquids

Phenylpropanolamine Dexatrim, Acutrim May increase blood sugar Nonmedicated nose sprays, throat lozenges

Ephedrine Bronkaid Epinephrine Primatene Aspirin/salicylates Ecotrin, Pepto-Bismol May decrease blood sugar if taking

oral diabetes pills to lower sugar Acetaminophen

Seizures Aspirin/salicylates May change levels of prescription seizure medicines

Acetaminophen

Antihistamines (depressant medicine)

Benadryl, Unisom May add to drowsiness caused by prescription seizure medicines

Ask your doctor

Theophylline Bronkaid May change levels of prescription seizure medicine

Stomach ulcers Aspirin/salicylates Ecotrin May worsen your ulcers Acetaminophen NSAIDs

Theophylline Nuprin Bronkaid May have more side effects from

theophylline if taking certain prescription ulcer medicines

Ask your doctor

TABLE 20-5 A LIST OF SAFE OVER-THE-COUNTER MEDICATIONS

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.

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 pro- poxyphene, digoxin, and amitriptyline. The average individual health care expen- ditures were $9,292 in 2001.

Implications A review of health care providers’ prescriptions given to older 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.

CHAPTER 20 Pharmacologic Management 367

Although only advanced practice nurses can prescribe medi- cations, 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 mil- lion ADEs and 7000 deaths occur in the United States each year secondary to medication errors. Older adults are dispro- portionately 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 mil- lion for adults age 65 or older (Jenkins & Vaida, 2007).

The definition of medication error adopted by many author- itative 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 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 pro- fessional, 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; compound- ing; 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 medi- cation 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 medica- tion 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 hos- pital 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, contrain- dications, 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 professional practice, healthcare products, procedures, and sys- tems, including prescribing; order communication; product label- ing, 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 mis- interpreted (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 docu- mentation (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 medi- cation errors (IOM, 2007). Strategies to reduce errors include use of bar coded medication labels, error tracking, and public educa- tion. 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).

COMMONLY USED MEDICATIONS

Psychotropics Psychotropic medications, which include antipsychotics, anti- depressants, sedative–hypnotics, and anxiolytics, are often pre- scribed 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 resi- dents to have a psychiatric diagnosis along with dementia. Some general problems with psychotropic prescribing reported in

368 PART V Diagnostic Studies and Pharmacologic Management

older adults include (1) overprescribing of anxiolytics and hyp- notics, often at doses that are too high and for extended peri- ods; (2) underprescribing of antidepressants and maintenance of subtherapeutic doses that may cause side effects without providing maximum therapeutic benefit; and (3) both under- prescribing and overprescribing of antipsychotics, which poten- tially denies benefit to some and causes side effects without therapeutic benefit in others. Of particular concern is the prac- tice 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 sec- ondary to medication side effects or secondary to medical con- ditions such as dementia, thyroid abnormalities, or depression, proper diagnosis and treatment of underlying causes of insom- nia or anxiety may decrease the inappropriate use of these medi- cations. 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 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 exces- sive sedation, impaired memory, decreased psychomotor perfor- mance, 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, uri- nary 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 benzodiaz- epines. Similarly, when sleep-hygiene and other nonpharmaco-

logic interventions for insomnia fail, short-term treatment with benzodiazepine receptor agonists (BZRAs), pyrazolopyrimi- dines, 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 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 nonsedat- ing, 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 som- nolence. Additionally, TCAs possess anticholinergic side effects that may create problems for many older adults.

Selective serotonin reuptake inhibitors (SSRIs) are the anti- depressants 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 anxi- ety and increase appetite; therefore, if the patient suffers from depressive symptoms of anxiety, insomnia, and lack of appe- tite, then mirtazapine may be an appropriate choice to help the patient sleep while also increasing appetite and reducing anxi- ety. A patient exhibiting depressive symptoms such as increased sleepiness, decreased affect, and decreased socialization may benefit from a more stimulating antidepressant such as sertra- line or venlafaxine. Thus, the side effect profile of an antidepres- sant may be used to identify the most appropriate drug for a patient’s depressive symptom pattern.

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 anti- psychotic prescription include schizophrenia, paranoid states, and psychosis.

Antipsychotics may cause excessive sedation, which may impair 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.

CHAPTER 20 Pharmacologic Management 369

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 manage- ment 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).

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 evidence-based clinical guidelines to guide the management of hypertension. The drugs recommended for the management of hypertension are also used in the manage- ment 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

DRUG AVOID IN OLDER ADULTS

ANTICHOLINERGIC SIDE EFFECTS IN OLDER ADULTS SEDATION

ORTHOSTATIC HYPOTENSION

Tricyclics: Tertiary Amines Amitriptyline √ ++++ ++++ ++ Clomipramine √ +++ +++ ++ Doxepin √ ++ +++ ++ Imipramine √ ++ ++ +++ Trimipramine √ ++ +++ ++

Tricyclics: Secondary Amines Amoxapine √ +++ ++ + Desipramine √ + + + Nortriptyline √ ++ ++ + Protriptyline √ +++ + +

Phenethylamines Venlafaxine (Effexor) 0 0 0

Tetracyclics Maprotiline √ ++ ++ +

Triazolopyridines Trazodone (Desyrel) + ++ ++

Aminoketones Bupropion (Wellbutrin) ++ ++ ++

Selective Serotonin Reuptake Inhibitors Fluoxetine (Prozac) 0/+ 0/+ 0/+ Paroxetine (Paxil) 0 0/+ 0 Sertraline (Zoloft) 0 0/+ 0 Citalopram (Celexa) 0/+ 0/+ 0/+ Escitalopram (Lexapro) 0/+ 0/+ 0/+ Fluvoxamine (Luvox) 0/+ 0/+ 0

Miscellaneous Nefazodone (Serzone) 0/+ ++ + Mirtazapine (Remeron) ++ +++

TABLE 20-6 ANTIDEPRESSANTS: COMPARATIVE PROFILES

Data from Drug facts and comparisons (59th ed.). (2005). St. Louis, MO: Facts & Comparisons. +++, Strong; ++, moderate; +, weak; 0, none.

370 PART V Diagnostic Studies and Pharmacologic Management

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 deter- mined 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 confer renal protection, which is particularly benefi- cial 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 hyperten- sion 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.

The main concerns with the use of antihypertensive medica- tions in older adults are an increased risk of orthostatic hypo- tension 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 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.

DRUG SEDATION EXTRAPYRAMIDAL SYMPTOMS

ANTICHOLINERGIC EFFECTS

ORTHOSTATIC HYPOTENSION WEIGHT GAIN

Phenothiazines, Aliphatic Chlorpromazine +++ ++ ++ +++ Promazine ++ ++ +++ ++ Triflupromazine +++ ++ +++ ++ Piperazine Fluphenazine + ++++ + + Perphenazine ++ ++ + + Trifluoperazine + +++ + +

Piperidines Mesoridazine +++ + +++ ++ Thioridazine +++ + +++ +++ Thioxanthenes Thiothixene + +++ + ++

Phenylbutylpiperidines Haloperidol + ++++ + + Pimozide + +++ ++ +

Dihydroindolones Molindone ++ ++ + ++ Ziprasidone ++ ++ + ++ + Loxapine + ++ + +

Novels (Atypical Agents) Clozapine +++ 0 +++ +++ ++++ Olanzapine ++ + ++ ++ ++++ Quetiapine ++ 0 0/+ ++ +++ Risperidone + ++ 0/+ ++ +++ Quinolinone Aripiprazole ++ 0 0/+ + +++

TABLE 20-7 ANTIPSYCHOTIC AGENTS

Data from Drug facts and comparisons (59th ed.). (2005). St. Louis, MO: Facts & Comparisons. +++, Strong; ++, moderate; +, weak; 0, none.

CHAPTER 20 Pharmacologic Management 371

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 antihyperten- sive therapy is essential in maintaining the health of older adults and reducing complications and hospitalizations.

In addition to drugs used in the management of hyperten- sion 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 infec- tions (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 adjust- ments may be needed for certain antibiotics such as fluo- roquinolones. 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 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 reclas- sified to nonprescription status (e.g., nonsteroidal antiinflam- matory 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, oppor- tunities 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 educa- tion 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 nonpre- scription 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 contraindica- tions 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 med- icines. The use of dietary supplements is an established 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 cardiovas- cular problems; glucosamine–chondroitin for joint problems; and saw palmetto for prostate problems. Additional frequently used supplements identified in a separate 6-year retrospective

TABLE 20-8 COMPELLING DIAGNOSES FOR PRESCRIBING SPECIFIC ANTIHYPERTENSIVE DRUG CLASSES

ACEI, Angiotensin-converting enzyme inhibitor; ALDOANT, aldosterone antagonist; ARB, angiotensin II receptor blocker; BB, beta-blocker; CCB, calcium channel blocker. 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.

RECOMMENDED DRUGS

COMPELLING INDICATION DIURETIC BB ACEI ARB CCB ALDOANT

Heart failure √ √ √ √ √ After myocardial infarction √ √ √ High coronary disease risk √ √ √ √ Diabetes √ √ √ √ √ Chronic kidney disease √ √ Recurrent stroke prevention √ √

372 PART V Diagnostic Studies and Pharmacologic Management

review of supplement use in older adults include ginkgo biloba, black cohosh, borage, evening primrose, flaxseed oil, dehydro- epiandrosterone (DHEA), grapeseed extract, hawthorn, and St. John’s wort (Wold, Lopez, Yau et al., 2005). A particularly trou- bling 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 scien- tific research and authoritative information the National Center for Complementary and Alternative Medicine (NCCAM) was established under the umbrella of the National Institutes of Health (NIH). NCCAM provides information to health care professionals as well as to the lay public on its website at http:// nccam.nih.gov.

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 non- adherence 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), com- plex 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 contrib- utors 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 phar- macy 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 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 progress- ing 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 medica- tion from another. Stiffness of joints coupled with decreased hand strength or tremors may make it difficult to open medica- tion bottles. Swallowing difficulties are exacerbated by large tab- lets. 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 coor- dinate with certain times of the day (e.g., at bedtime). Keeping up with complicated schedules, particularly when they con- flict 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 nonad- herence. Prevention begins with an assessment of risk factors. A simple checklist may be used to help identify areas of primary concern.

http://nccam.nih.gov

CHAPTER 20 Pharmacologic Management 373

• 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 open- ing 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 cer- tain medications as inappropriate? Each item checked indicates a potential contributor to non-

adherence. 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 nonadher- ence, so it is a mistake to assume that the patient takes medica- tion as prescribed or recommended. In clinic settings, the nurse should have the patient bring in all prescription and OTC medi- cations 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 his- tory,” 2009). When reviewing medications, the nurse should ask the patient how each drug is taken and compare this informa- tion 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 nonad- herence, 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 individual- ized 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 prescrip- tions filled at the same pharmacy each time because this pro- vides 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 patient should determine the answers to the following questions: • Is a documented and appropriate indication for each medi-

cation 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?

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.

3. Teach the side effects and interactions of all over-the-counter medica- tions to homebound older adults and their caregivers.

4. Collaborate with social workers to identify community resources for fi- nancial assistance with pharmaceutical needs.

5. Use laboratory parameters to monitor overuse and underuse of medica- tions, 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 medi- cation 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 writ- ing prescriptions.

HOME CARE

374 PART V Diagnostic Studies and Pharmacologic Management

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; blad- der 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 cogni- tive 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 medica- tions are opioids, benzodiazepines, and stimulants, which may result in ataxia, falls and accidents, and cognitive impairments such as attention and memory problems (Fontaine, 2003).

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 com- bines substance abuse and dependence into a single category: addictions and related disorders. The DSM-5 requires two cri- teria be met for diagnosis.

Difficulty in Identification of Abuse The physiologic, psychological, and sociologic changes associ- ated with aging make the identification and treatment of addic- tions and related disorders in older adult patients difficult. Age-related psychological and sociologic changes and symp- toms 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 hesi- tant 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 psy- chiatric comorbidities. Patients with later onset alcohol depen- dence tend to have a milder clinical picture and fewer medical problems because of the shorter exposure to alcohol. They are more affluent, include 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 assess- ment 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).

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

FIGURE 20-1 Loneliness and hopelessness may be manifesta- tions of alcohol abuse. (Courtesy of Ursula Ruhl, St. Louis, MO.)

CHAPTER 20 Pharmacologic Management 375

certain substances to mask negative feelings about themselves; they may eventually attribute some of their positive personal- ity characteristics to substances. Examples of such substances include alcohol and benzodiazepines (e.g., diazepam). Patients who are prescribed benzodiazepines by a physician for a lim- ited 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 addic- tions 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 prescrip- tion 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 atti- tudes about substance abuse behaviors that are passed from one 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., pov- erty, 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.

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 strate- gies for abuse of alcohol, prescription and nonprescription medi- cations, 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).

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.

Peripheral neuropathy Diminished proprioception Alcoholic liver disease (hepatitis or cirrhosis) Alcoholic pancreatitis Gastrointestinal bleeding 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

BOX 20-1 MEDICAL MANIFESTATIONS OF SUBSTANCE ABUSE IN OLDER ADULTS

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.

376 PART V Diagnostic Studies and Pharmacologic Management

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) parox- ysmal 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 atti- tudes regarding addictions and related disorders in the older adult population. Many health care providers overlook the pos- sibility 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 values and choices.

Inherent changes in tissue and organ function are highly vari- able and individual. Hence the response to medication is just as variable and as unpredictable in this population. The guiding prin- ciples are to “start low and go slow” when prescribing medications; change or add only one medication at a time; review each medica- tion to see whether the patient is still taking it; and determine the dose, frequency, and time (see Evidence-Based Practice box).

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

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)

BOX 20-2 PSYCHOLOGICAL MANIFESTATIONS OF SUBSTANCE ABUSE IN OLDER ADULTS

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 seg- ment of life, an already strained substance abuse treatment system will be over- whelmed. 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-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.

CHAPTER 20 Pharmacologic Management 377

1. Do you enjoy having a drink now and then? 0

2. Do you feel you are a normal drinker? (By normal, we mean do you

drink less than or as much as most other people and you have not

gotten into any recurring trouble while drinking?) 2

3. Have you ever awakened the morning after some drinking the night

before and found that you could not remember a part of the evening? 2

4. Do either of your parents or any other near relative, or your spouse, or

any girlfriend or boyfriend ever worry or complain about your drinking? 1

5. Can you stop drinking without a struggle after one or two drinks? 2

6. Do you feel guilty about your drinking? 1

7. Do friends or relatives think you are a normal drinker? 2

8. Are you able to stop drinking when you want to? 2

9. Have you ever attended a meeting of Alcoholics Anonymous (AA)? 5

10. Have you gotten into physical fights when you have been drinking? 1

11. Has your drinking ever created problems between you and either of

your parents, another relative, your spouse, or girlfriend or boyfriend? 2

12. Have any of your family members ever gone to anyone for help about

your drinking? 2

13. Have you ever lost friends because of your drinking? 2

14. Have you ever gotten into trouble at work or at school because of

drinking? 2

15. Have you ever lost a job because of drinking? 2

16. Have you ever neglected your obligations, school work, your family,

or your job for 2 or more days in a row because you were drinking? 2

17. Do you drink before noon fairly often? 1

18. Have you ever been told you have liver trouble? Cirrhosis? 2

19. After heavy drinking have you ever had severe shaking, heard voices,

or seen things that really weren’t there (e.g., delirium tremens [DTs])? 2 (DTs: 5)

20. Have you ever gone to anyone for help about your drinking? 5

21. Have you ever been a patient in a psychiatric hospital or on a

psychiatric ward of a general hospital where drinking was part of

the problem that resulted in hospitalization? 2

22. Have you ever been seen at a psychiatric or mental health clinic,

or gone to any doctor, social worker, or clergy for help with any

emotional problem, where drinking was part of the problem? 2

23. Have you ever been arrested for drunk driving, driving while intoxicated,

or driving under the influence of alcoholic beverages or any other

drug? (If YES, how many times?) 2 each

24. Have you ever been arrested, or taken into custody, even for a few

hours, because of other drunken behavior as a result of either alcohol

or another drug? (If YES, how many times?) 2 each

*Interpretation: Standard MAST—0 to 3 points probable normal drinker; 4 points borderline

score; 5 to 9 points 80% associated with alcoholism/chemical dependence; 10 or more

points 100% associated with alcoholism.

YES NO

MAST*

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.)

378 PART V Diagnostic Studies and Pharmacologic Management

NURSING MANAGEMENT

Interventions Multidisciplinary interventions are appropriate for all indi- viduals 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 ther- apy, intensive outpatient or inpatient treatment, and residen- tial treatment. Brief therapy is usually provided by a trained professional in a community drug treatment center. Goal set- ting, 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 down- sizing and closing because third-party reimbursement is rap- idly 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) 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 neces- sary before complementary and alternative therapies can be rec- ommended 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 sup- port. 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 indi- vidual or family group sessions. Finally, outpatient support is

YES NO

BMAST*

1. Do you feel that you are a normal drinker? 2

2 2. Do friends think that you are a normal drinker?

3. Have you ever attended an AA meeting? 5

4. Have you ever lost friends, girlfriend or boyfriend because of drinking? 2

5. Have you ever gotten into trouble at work because of drinking?

6. Have you neglected your obligations, family, or work for 2 or more

days in a row because you were drinking?

7. Have you ever had DTs, heard voices, or seen things that were not

there after heavy drinking?

8. Have you ever gone to anyone to help stop your drinking?

9. Have you ever been in a hospital because of drinking?

10. Have you ever been arrested for drunk driving or driving after drinking?

*Alcoholism is indicated by a score of greater than 5. Test scores are determined by tallying

values for answers that are on a progressive scale of 0, 2, and 5.

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.)

CHAPTER 20 Pharmacologic Management 379

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.

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 not- withstanding, 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 prob- lems related to alcohol abuse as they moved into older adult- hood. Older adults who have used alcohol in the past without abuse or addiction may experience problems with alcohol con- sumption as changes occur in their bodies as a result of normal aging (e.g., decreased liver function or changes in body compo- sition) (Morris, 2001).

Assessment Older adults who abuse alcohol may display symptoms of anxi- ety, nervousness, memory impairment, depression, blackouts, confusion, weight loss, and falls. In addition, physical exam- ination 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, cirrhosis, com- promised hepatic function, osteomalacia as a result of com- promised 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 elec- trolytes, glucose, and magnesium, as well as electrocardiogra- phy (ECG) (Videbeck, 2004).

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 screen- ing tools may help the nurse determine the amount and fre- quency of alcohol consumption. Input from family and friends should also be obtained. Family and friends may deny the prob- lem; 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 intoxica- tion 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 coor- dination, 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 provid- ing 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, tran- sient visual, tactile, or auditory hallucinations or illusions, psy- chomotor 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 impor- tant to assess older patients for the possibility of alcohol with- drawal if agitation, hallucinations, anxiety, or seizures develop 2 or 3 days after hospitalization (see Emergency Treatment box).

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

TABLE 20-9 AGE- AND ALCOHOL-RELATED CHANGES IN BODY SYSTEMS OF OLDER ADULTS

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.

380 PART V Diagnostic Studies and Pharmacologic Management

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 precau- tions (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 with- drawal 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 nonprescrip- tion medications (Tables 20-10 and 20-11), (2) various meth-

ods 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 sobri- ety. 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 edu- cation to help identify triggers to avoid relapse and strategies for dealing with triggers (Fontaine, 2003; Mahgoub, 2009).

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 topi- ramate may alter the 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 treat- ment plan for sobriety, and outpatient support. Safe detoxifi- cation 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 absti- nence 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).

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 4. Administration of prescribed medications such as benzodiazepines, beta-

blockers, clonidine, and anticonvulsant drugs

SUBSTANCES INTERACTING WITH ALCOHOL MECHANISM POSSIBLE EFFECT(S)

I. Antihistamines, antidepressants, opioid analgesics, sedative-hypnotics, antianxiety agents, antipsychotic drugs

Additive Enhanced CNS depressant effects

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

TABLE 20-10 SELECTED SIGNIFICANT ALCOHOL–DRUG INTERACTIONS

From McKenry, L.M. Mosby’s pharmacology in nursing (22nd ed.). 2005. St. Louis, MO: Mosby.

CHAPTER 20 Pharmacologic Management 381

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 polyphar- macy is high (Figure 20-4). Prescription drugs commonly used by independent older people are cardiovascular medications, benzodiazepines, diuretics, cathartics, antacids, thyroidal medi- cations, and anticoagulants. Opioid and benzodiazepine depen- dence 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 dis-

cussing medications. Therefore, it is imperative that the nurse assess for prescription medication abuse in older adults.

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 screen- ing 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, 2003; Neushotz & Fitzpatrick, 2008).

Interventions The interventions for prescription drug abuse are similar to the interventions associated with alcohol abuse. First, if prescrip- tion 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 inter- actions resulting from prescribing a new medication that is

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.

FIGURE 20-4 Older adults’ concurrent use of many prescrip- tion medications may lead to polypharmacy. (Courtesy of Loy Ledbetter, St. Louis, MO.)

382 PART V Diagnostic Studies and Pharmacologic Management

contraindicated because of an existing prescription. The nurse should document any signs of withdrawal, provide an environ- ment 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 metha- done, 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 medi- cation use and the effects of medication misuse on the body.

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; how- ever, 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, dif- ficulty concentrating, restlessness, decreased heart rate, and increased appetite (APA, 2013).

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 cloni- dine. Clonidine is an antihypertensive that blocks the neuro- logic 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).

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 medi- cation or technique should be recommended. Furthermore, the nurse must 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 edu- cation 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).

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.

FUTURE TRENDS Current figures indicate 1% of older adults use illicit drugs; how- ever, 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

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; ad- equate 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.

CHAPTER 20 Pharmacologic Management 383

1. How soon after you wake up do you smoke your first cigarette? Within 5 min 3

6–30 min 2

31–60 min 1

After 60 min 0

2. Do you find it difficult to refrain from smoking in places where it

is forbidden? Yes 1

No 0

3. Which cigarette would you hate most to give up? The first one in

the morning 1

Any other 0

4. How many cigarettes per day do you smoke? 10 0

11–20 1

21–30 2

31 3

5. Do you smoke more frequently during the first hours after

waking than during the rest of the day? Yes 1

No 0

6. Do you smoke if you are so ill that you are in bed most of the

day? Yes 1

No 0

Comments to Different Degrees of Dependence

POINTS % SMOKERS COMMENTS

0–1 20 Very low dependence

Few and light withdrawal symptoms

Seldomly need help to give up

2–3 30 A big group of smokers

A certain degree of dependence

Difficult withdrawal symptoms can occur

Often manages to give up by themselves

Medicines can be of help

4–5 30 A big group of smokers

Over average dependence

Withdrawal symptoms common

Medicines often very helpful

Risk for smoking related disorders is real

6–7 15 Strong dependence and withdrawal

Likelihood to give up smoking poor

High risk for smoking related disorders

Medicines important, possibly combinations

Higher dose, longer duration may be needed

Support treatment important

Depression and high alcohol intake common

8–10 5 Small group with extreme dependence

Chances to give up are very small

Handicapping withdrawal symptoms

Support treatments and medicines essential,

preferably over long time and in high dose

Most will have smoking related disorders

Anxiety, depression, pain and alcohol dependence

common

The Fagerström Test for Nicotine Dependence

384 PART V Diagnostic Studies and Pharmacologic Management

medication for nonmedical reasons?” has been shown to accu- rately identify individuals using drugs in the outpatient setting; however, a trial has not been conducted in older adults (Smith, Schmidt, Allensworth-Davies, & Saitz, 2010).

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 medi- cation 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 con- sequences. It is essential that nurses identify addictions and related disorders in older adults and examine their own atti- tudes about addictions and related disorders in this popula- tion. Early identification and intervention are essential for preventing misdiagnosis and ineffective, costly treatments. Nurses should recognize that older adults who abuse sub- stances 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.

K E Y P O I N T S • 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, polyphar- macy, 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 essen- tial in planning alternative medication regimens and pre- venting 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 neces- sary 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.

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

TABLE 20-12 CLINICALLY SIGNIFICANT PHARMACODYNAMIC DRUG INTERACTIONS WITH SMOKING

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.

1. Obtain a prescription medication inventory, including the physician sources of all prescriptions.

2. Mail-order prescription suppliers send large quantities of drugs to home- bound 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 administra- tion 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 pre- dispose homebound older adults to addictions and related disorders.

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.

HOME CARE

CHAPTER 20 Pharmacologic Management 385

• Psychological changes, primarily a result of the numerous losses 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, transporta- tion, 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 popula- tion are alcohol, prescription medications, nonprescription medications, nicotine, and caffeine.

• The nurse should assess older adult patients for key medi- cal 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 dis- orders in older adult patients include assessing for signs of withdrawal, administering appropriate medications to pro- vide safe detoxification, providing a safe environment, edu- cating patients regarding harmful effects, and encouraging patients to participate in AA, NA, or individual, family, or group therapy.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 assess- ment 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 sub- stance 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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388

Cardiovascular Function

Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C

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 dis- ease cost more than $300 billion, including health care services, medications, and lost productivity (CDC, 2013a). Risk fac- tors for cardiovascular disease include high cholesterol levels, hypertension, diabetes mellitus, tobacco use, physical inactivity, obesity, alcohol use, age, and heredity (CDC, 2013a). As an indi- vidual ages, the chances of comorbid conditions increase. The reality is that atherosclerosis, the underlying cause of the major- ity of clinical cardiovascular problems, is typically present for years before the onset of a clinical 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.

AGE-RELATED CHANGES IN STRUCTURE AND FUNCTION Aging alters the cardiovascular system both structurally and physiologically. However, increasing evidence suggests that life- style 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 pres- sure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure; and the muscle contrac- tion, muscle relaxation, and ventricle relaxation phases are elon- gated (Banasik, 2013b; Beers & Berkow, 2000; Larsen, 2009). An S

4 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).

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.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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.

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CHAPTER 21 Cardiovascular Function 389

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 adrener- gic stimulation. Common aging changes that are reflected by electrocardiography (ECG) include a notched P wave, a pro- longed P–R interval, decreased amplitude of the QRS complex, and a notched or slurred T wave (Banasik, 2013b).

Vessels Calcification of vessels occurs, making them tortuous. The elas- tin 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 contractil- ity 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.

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, hyperten- sion, heart failure, arrhythmias (particularly heart blockage), val- vular 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 inci- dence of morbidity and death from ischemic heart disease and stroke. Health promotion and disease prevention are discussed in Chapter 8.

Blood Pressure High blood pressure, or hypertension, is a major modifiable risk factor that contributes to the incidence of coronary artery dis- ease (CAD) and stroke. It also contributes to the development of congestive heart failure (CHF), renal failure, and PVD. It is esti- mated that one in three adults have high blood pressure. Data collected by the National Center for Health Statistics in the 2010 to 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 preva- lent 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 nor- motensive 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

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)

BOX 21-1 RISK FACTORS FOR CARDIOVASCULAR DISEASE

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.

390 PART VI Nursing Care of Physiologic and Psychologic Disorders

of hypertension in persons aged 55 years or older (Emerson, 2013). This has changed the theory of treating older persons more cau- tiously 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 choles- terol 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 opti- mal. 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 believed to provide some protec- tion 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 consid- ered 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 pres- sure 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 non- smoker. Smoking cessation should be encouraged at every encounter. The 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 exer- cise 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 fac- tors (e.g., by 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, cardiomyopa- thy, 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

CHAPTER 21 Cardiovascular Function 391

(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, visu- alization, 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 fac- tors 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, shar- ing their meals, and dividing tasks of shopping, meal prepara- tion, and clean-up are other popular concepts. This way, older patients can maintain balanced diets and enjoy the companion- ship of peers.

Hormone Usage Before menopause, estrogen is believed to have a protective effect by helping to maintain adequate levels of HDL choles- terol 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 corre- sponds 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 com- plications of hypertension has not decreased. These complica- tions 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 con- tained 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 health- ier lifestyle, starting in childhood and youth, may prevent and reverse abnormal blood pressure patterns.

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 pre- vent 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 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.

Sample/Setting Five hundred participants from a telemetry unit were randomly assigned to an intervention group (247 subjects) or a control group (253 subjects).

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 vari- ables 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 informa- tion 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.

EVIDENCE-BASED PRACTICE Repetition in Patient Teaching Is Beneficial

392 PART VI Nursing Care of Physiologic and Psychologic Disorders

• 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 treat- ment 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], angio- tensin 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 dispro-

portionately to DBP because of increased arterial stiffness and rigidity. In the past, it was argued that hypertension was a normal process of aging and did not require therapy. However, data from the Framingham Heart Study confirm that car- diovascular risk escalates dramatically in older adults. The addition of risk factors such as smoking, glucose intolerance, hypercholesterolemia, and left ventricular hypertrophy signifi- cantly 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 thick- ening of the arterial wall. Rigidity in the brachial artery leads to ineffective compression of the brachial artery with a sphyg- momanometer. Pseudohypertension may be suspected without evidence of target organ damage despite elevated blood pres- sure 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 sphygmomanom- eter 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) medica- tions 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 anti- inflammatory drugs (NSAIDs) may adversely affect the action of some medications for hypertension. NSAIDs have been found to cause elevated blood pressure in 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 hyperten- sion. 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 pres- sure (JNC 7, 2003).

The pathophysiology of hypertension is complex because various environmental, structural, renal, hormonal, and homeostatic mechanisms contribute to blood pressure mainte- nance, 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 thick- ening, 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 hyper- trophy occurs as an adaptation to longstanding hypertension and may lead to CHF. Once this occurs, there is a 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 expe- rience fatigue, dizziness, headaches, vertigo, and palpitations. In severe hypertension, the patient may experience throbbing occipital headaches, confusion, visual loss, focal deficits, epi- staxis, 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

CHAPTER 21 Cardiovascular Function 393

• 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 second- ary 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 exam- ination. The following tests should be included: hemoglobin and hematocrit to exclude anemia or polycythemia; urinaly- sis 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 possi- bly, echocardiography to assess left ventricular function and hypertrophy.

The physical examination should include examination of the neck (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 modifi-

cations should be employed. Older adults respond to modest sodium reduction and weight loss.

2. Select an appropriate agent with consideration for comor- bidity. 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 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 hydrochlorothia- zide) 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 min- imal in older adults. Table 21-1 provides the classifications of antihypertensive drugs, their adverse effects, and the nursing implications.

Diuretics The thiazide diuretics hydrochlorothiazide and chlorthalidone continue to be the most commonly prescribed antihyperten- sive 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 hypo- tension or hypokalemia. Patients should be carefully moni- tored 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 cardio- protective. 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 stim- ulates the release of aldosterone. These drugs decrease mortality in older adults with decreased left ventricular function and pre- serve renal function in those with diabetes mellitus. Side effects of these drugs include rash, cough, taste disturbance, neutro- penia, 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 cause orthostatic hypotension in older adults. These drugs typically have vasodilator effects such as headache, flushing,

394 PART VI Nursing Care of Physiologic and Psychologic Disorders

TABLE 21-1 CLASSIFICATION OF ANTIHYPERTENSIVE DRUGS, ADVERSE EFFECTS, AND NURSING IMPLICATIONS

ANTIHYPERTENSIVE DRUG ADVERSE EFFECTS NURSING IMPLICATIONS

Diuretics Thiazides Chlorothiazide (Diuril) Hyperglycemia Patients with diabetes may require an increase in insulin. Chlorthalidone Hydrochlorothiazide (Microzide, Hydrodiuril) Polythiazide (Renese)

Hypokalemia Hypomagnesemia Hyponatremia Hyperuricemia

Encourage patients to restrict sodium intake and eat foods high in potassium.

Check baseline and later levels of LDL and HDL, cholesterol, and triglycerides.

Indapamide (Lozol) Metolazone (Zaroxolyn)

Hypercholesterolemia Sexual dysfunction Photosensitivity

Report dry mouth, muscle weakness, cramps, drowsiness, and loss of appetite, which may be indicative of electrolyte imbalance.

Hypersensitivity to sulfonamides Be cautious in sunlight.

Loop Diuretics Bumetanide (Bumex) Fluid electrolyte imbalance Observe for signs of dehydration and acid–base imbalance. Furosemide (Lasix) Torsemide (Demadex)

Diuresis leading to hypovolemia, hypotension, and shock

Monitor blood pressure to detect signs and symptoms of shock.

May cause thromboembolism in older patients Observe for signs and symptoms of thromboembolism.

Potassium-Sparing Diuretics Amiloride (Midamor) Hyperkalemia Monitor serum potassium levels. Triamterene (Dyrenium) May cause breast pain and amenorrhea in women Potassium supplements should be discontinued when these

drugs are added to a sulfonamide diuretic regimen. May cause renal calculi

Impotence, sexual dysfunction Triamterene should be given cautiously to patients taking

indomethacin.

Aldosterone Receptor Blockers Eplerenone (Inspra) Hyperkalemia Monitor electrolytes. Spironolactone (Aldactone) GI bleeding or ulceration Use K diuretics sparingly. Do not give NSAIDs.

Beta-Blockers Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol (Zebeta)

Cardiac effects, including bradycardia and heart block

Dizziness and fainting

Report bradycardia and episodes of dizziness and syncope. Do not administer drugs to patients with heart failure or

advanced degrees of heart block. Metoprolol (Lopressor) Metoprolol extended release (Toprol XL)

Fatigue, weakness, lethargy, depression, disorientation, and hallucinations

Observe patient for any changes in physical and mental status.

Check LDL and HDL, triglyceride, and cholesterol levels. Instruct patients to avoid abrupt discontinuation of the drug.

Nadolol (Corgard) Sexual dysfunction

Propranolol (Inderal) Nausea, vomiting Propranolol long-acting (Inderal LA) Bronchospasm in patients with asthma Timolol (Blocadren) May mask hypoglycemia May aggravate peripheral vascular insufficiency

Beta-Blockers with Intrinsic Sympathomimetic Activity Acebutolol (Sectral) Penbutolol (Levatol)

Fatigue, dizziness, headache, urinary frequency Avoid abrupt discontinuation of medication. Monitor weight, blood sugar, and vital signs.

Pindolol May mask hypoglycemia or hyperthyroidism Constipation, diarrhea Insomnia Safety concerns Bradycardia, edema, weight gain, hypotension,

syncope, atrioventricular block

Diarrhea, nausea, hyperglycemia, abnormal vision, dyspnea

Combined Alpha- and Beta-Blockers Carvedilol (Coreg) Labetalol (Normodyne, Trandate)

Fatigue, dizziness, postural hypotension, muscle weakness, diarrhea or constipation

Avoid driving during initial administration. Take with food. Report any new cough that continues.

Report any unusual swelling of extremities.

CHAPTER 21 Cardiovascular Function 395

TABLE 21-1 CLASSIFICATION OF ANTIHYPERTENSIVE DRUGS, ADVERSE EFFECTS, AND NURSING IMPLICATIONS—Cont'd

ANTIHYPERTENSIVE DRUG ADVERSE EFFECTS NURSING IMPLICATIONS

ACEIs Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik)

Tickle in throat or hacking cough Hyperkalemia Rash Reversible renal failure in patients with proteinuria

or renal artery stenosis Dizziness, headache, diarrhea, and fatigue Impaired sense of taste and sexual dysfunction

rare

Observe patients for cough. Check electrolytes for increase in potassium. Observe for rash. Check for increase in BUN or serum creatinine levels. Observe for signs of dizziness, headache, and diarrhea.

Angiotensin II Antagonists Candesartan (Atacand) Eprosartan (Teveten) Irbesartan (Avapro) Losartan (Cozaar)

Dizziness, cough, upper respiratory infection, diarrhea, fatigue, and headache

Edema, flushing, palpitations, and dizziness

Monitor renal function. Instruct patient to avoid alcohol, barbiturates, and narcotics. Adjust insulin and antidiabetes medications, which potentiate

hydrochlorothiazide, headaches, and dizziness. Potentiated by grapefruit juice.

Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan)

Safety concerns May increase angina or myocardial infarction

Avoid beta-blockers, digitalis, and diuretics. Do not crush. Monitor liver studies in older patients.

Calcium Channel Blockers Nondihydropyridines Diltiazem extended release (Cardizem CD,

Cardizem LA, Dilacor XR, Tiazac) Verapamil immediate release (Calan, Isoptin) Verapamil extended release (Calan SR,

Isoptin SR) Verapamil-COER (Covera-HS, Verelan PM)

Headache, dizziness, flushing, and weakness Bradycardia Edema Nausea Constipation (especially with verapamil) Gingival hyperplasia

Monitor heart rate. Monitor blood pressure during dose adjustment. Check laboratory results to assess liver and kidney function.

Dihydropyridines Amlodipine (Norvasc) Felodipine (Plendil) Isradipine extended release (DynaCirc CR) Nicardipine sustained release (Cardene SR) Nifedipine long-acting (Adalat CC, Procardia XL)

Edema, fatigue, palpitations, dizziness, abdominal pain, GI upset, flushing

Drowsiness

Monitor for hepatic dysfunction, CVD, and/or aortic stenosis.

Nisoldipine (Sular)

Alpha1-Blockers Doxazosin (Cardura) Prazosin (Minipress) Terazosin (Hytrin)

Syncope with first dose, dizziness, fatigue, edema, rhinitis, tinnitus, epistaxis, sexual dysfunction, polyuria, urinary incontinence, ataxia, leukopenia, neutropenia, arrhythmia, somnolence, rash, red eyes, dry mouth

Impaired liver function, dose changes. Check orthostatic blood pressure. Limit ETOH. Pregnancy.

Central Alpha2-Agonists and Other Centrally Acting Drugs Clonidine (Catapres) Clonidine patch (Catapres-TTS) Methylodopa (Aldomet) Reserpine Guanfacine

Dry mouth, drowsiness, dizziness, weakness, constipation, rash, myalgia, urticaria, nausea, insomnia, agitation, orthostatic hypotension, impotence, arrhythmias

Severe coronary disease. Recent MI. CVD, renal failure. Taper. Do not stop abruptly.

Direct Vasodilators Hydralazine (Apresoline) Minoxidil (Loniten)

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. 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.

http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm

396 PART VI Nursing Care of Physiologic and Psychologic Disorders

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).

NURSING MANAGEMENT

Assessment The majority of patients with hypertension are asymptomatic. Symptoms that do occur are variable, depending on the pro- gression 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 blad- der 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 hyperten-

sion, 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 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 signifi-

cant 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 pharmaco- logic) interventions. An explanation of the physical exami- nation 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 ham- pered 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 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 regard- ing the disease process; signs and symptoms of hypertension; treatment regimen; medications and their actions and side effects, including sexual dysfunction; and the need for fre- quent 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 health- ier 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 modifica- tion. Positive reinforcement should be provided, whenever possible.

CHAPTER 21 Cardiovascular Function 397

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 com- plications. 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 regi- men. Documentation includes accurate records of blood pres- sure, weight, exercise, and activity patterns; 24-hour dietary intake; cholesterol levels; and any blood pressure monitoring results outside the clinical encounter.

Coronary Artery Disease CAD, or ischemic heart disease, refers to a broad group of con- ditions that partially or completely obstruct blood flow to the heart muscle. Obstruction of coronary arteries may result in isch- emia (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 character- ized 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, throm- bus 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 cho- lesterol levels, hypertension, and diabetes mellitus. Promoting healthy lifestyles in younger and older individuals is an impor- tant 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 mortal- ity 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 myocar- dium. The classic symptom is chest pain during activity that is relieved with rest or nitroglycerin. MI is caused by total disrup- tion 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).

Because symptoms of angina or MI may be vague and atypi- cal of textbook symptoms, older adults may not recognize their seriousness and may not seek medical attention as soon as they 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 pre- cipitate 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 permeabil- ity 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 cal- cium. 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

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

398 PART VI Nursing Care of Physiologic and Psychologic Disorders

superior in assessing cardiac chamber size and ventricular function.

• Myocardial imaging (using thallium), multiple-gated acquisi- tion cardiac pool imaging, or digital subtraction angiography to evaluate myocardial perfusion or ventricular abnormalities.

• 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 iden- tify 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 coex- isting diseases such as arthritis, PVD, and chronic obstruc- tive 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 condi- tions such as musculoskeletal or CNS impairments.

Pharmacologic Treatment Treatment is directed toward restoring the balance between myocardial oxygen demand and oxygen supply for the preven- tion of CAD. Pharmacologic agents play a major role. Normal changes with aging (e.g., alterations in body mass, water com- position, liver size, renal system, and plasma protein concen- tration) 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 arter- ies 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; how- ever, tolerance 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 pre- vent 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 bradycar- dia, 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 clini- cal 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 myo- cardial 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, flushing, dizzi- ness, 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 inci- dence 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 contrain- dicated 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 bleed- ing. Older adults have an increased risk for bleeding with fibri- nolytics. 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 for- mation 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 anticoag- ulation 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).

CHAPTER 21 Cardiovascular Function 399

Antihyperlipidemics Antihyperlipidemics are used to lower serum lipid levels by pre- venting 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 smok- ing 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 saphe- nous 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 Age-related physiologic changes, long duration of adverse life- style behaviors, and the presence of other conditions in older adults may complicate the progress and treatment of CAD; how- ever, 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 atten- dance at cardiac rehabilitation if they are referred. Women typically are 10 years older than men when diagnosed with car- diac disease and experience worse outcomes than men (Tecce, Dasgupta, & Doherty, 2003).

NURSING MANAGEMENT

Assessment Assessment of an older adult with CAD begins with a complete health history and physical examination. Complaints of dys- pnea, 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).

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,

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, palpita-

tions, 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

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.

400 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 • 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 plan- ning process; however, older adults should be consulted to deter- mine 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 reduc-

tion 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; precipitat- ing 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.

Cardiovascular, respiratory, renal, and neurologic assess- ments should be conducted on a regular basis to detect prog- ress and prevent complications. Diagnostic testing, especially of potassium levels because older patients are prone to hyper- kalemia, 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 con- cern about emergency measures such as resuscitation or life support. The nurse should be sensitive to these needs and initi- ate discussion with the patient, family, and physician to estab- lish 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 func- tioning. 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 main- tenance 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 evalu- ate 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 dis- comfort 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 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, sur- vivors 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 sched- ules. Women have been documented as showing the poorest adherence to the program (Touhy & Jett, 2012). The interdis- ciplinary 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 coun- seling (AHA, 2012).

Visiting nurse programs provide education, support, and supervised activities in the home environment if older patients

CHAPTER 21 Cardiovascular Function 401

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 asso- ciations 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 com- munity 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 nurs- ing facility with complaints of fatigue, weakness, and vertigo. Staff at the nurs- ing 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 en- zymes were tested. Creatinine phosphokinase (CPK) levels were normal, but lactate dehydrogenase was elevated. She was diagnosed with an inferior myo- cardial 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 pe- riodic bouts 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 mil- liliters per hour (mL/hr).

The patient will tolerate activity, as evidenced by stable vital signs; absence of pain, weakness, fatigue, and vertigo; and 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 sensa-

tions 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. 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.

402 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 junc- tions 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 cha- otic 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 fill- ing (Ball et al, 2014).

Atrial fibrillation may occur during intense emotional stress, 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 car- diomyopathy; 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 epi- sodes 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 classi- fication 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, isch- emia, enhanced vagal tone, electrolytes, and effects of drugs (e.g., digoxin and BBs).

Symptoms of arrhythmia are weakness, fatigue, forgetful- ness, palpitations, dizziness, hypotension, bradycardia, and syncope, all of which predispose older patients to falls and inju- ries. 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 sig- nificant 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 hypo- kalemia. 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 correc- tion 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.

CHAPTER 21 Cardiovascular Function 403

NURSING MANAGEMENT

Assessment Older adults should be assessed for a history of CAD, heart failure, hypertension, cardiac valve disease, and current medi- cations (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 fac- tors, 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 measure- ment of heart rate. Apical and radial rates should be compared to assess peripheral perfusion. Electrolyte, hemoglobin, and hema- tocrit values should be assessed for imbalances and anemia.

Diagnosis Nursing diagnoses common for an older patient with arrhyth- mia 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 ADLs and adequate heart rate, sustain cardiac output, and pre- vent 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, dizzi- ness, and palpitations to the nurse for comparison with electri- cal 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 activ- ity 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 reduce cardiac output and place patients at a higher risk for faint- ing and falls. Interventions to prevent injury include (1) having the patient sit for 3 to 5 minutes before an activity and (2) pro- tecting 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, shav- ing 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

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., con- tact 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. 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 pace-

maker 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 nurs- ing: 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.

PATIENT/FAMILY TEACHING Pacemaker

404 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 main- tain 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 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 stand- ing 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 auto- nomic 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.

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, medi- cations, 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 posi- tion, 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, phenothi- azines, sildenafil, sympatholytics, sympathomimetics (with prolonged use), tricyclic antidepressants, vasodilators, and vin- cristine (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 • 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 hypoten- sion include the following: 1. The patient will remain free of injury. 2. The patient will verbalize and correctly demonstrate mea-

sures 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 ortho- static 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, non- skid surfaces, and an uncluttered living space minimize injuries. In long-term care settings, low beds are sometimes used for cog- nitively 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 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.

CHAPTER 21 Cardiovascular Function 405

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 vaso- vagal 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 prodromal period is present, and during this time, the older adult may feel dizzy or flushed, expe- rience 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 con- sciousness 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 recog- nized 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 ven- tricular 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 usu- ally seen as a regular tachycardia with a wide QRS complex, often up to rates of 300 beats/min. Again the problem is inad- equate ventricular filling during diastole, leading to signifi- cantly 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 brady-

cardia is symptomatic (Beers & Berkow, 2000). Structural prob- lems of the heart such as aortic stenosis, cardiomyopathy, and acute MI may also cause syncope.

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 con- sciousness. 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 arter- ies 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 ven-

tricular 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 requir- ing 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

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 arrhyth- mias. 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.

406 PART VI Nursing Care of Physiologic and Psychologic Disorders

Older adults should be able to identify the cause of their syn- cope and methods of prevention, including methods of pre- venting injury if syncope occurs.

Valvular Disease Valvular disease occurs when the cardiac valves do not com- pletely 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 atrium to the ventricle during diastole. With time, the left atrium becomes accustomed to increasing volumes and pres- sure, 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 ven- tricle from the aorta during diastole, leading to volume over- loads 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 ventricu- lar systole. The prolapse is normally benign but may progress to severe regurgitation with ventricular dilation.

Rheumatic fever is the most common cause of valvular dis- ease, 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 pro- lapse 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 degen- erative process.

Individuals with valvular disease may be asymptomatic for many years, but with the deterioration of the valves and hypertro- phic 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 palpi- tations. Atrial fibrillation is often associated with mitral disorders from distention of the left atria, and symptoms of angina are more common with aortic disorders because of decreased cardiac output. Symptoms of valvular disease may be difficult to recog- nize in older adults because symptoms may mimic those of CAD, which is common in the older adult population.

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 enlarge- ment. 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 endocar- ditis. For patients with valvular disorders resulting from degen- erative 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.

BOX 21-4 EXAMPLES OF CLINICAL MANIFESTATIONS OF VALVULAR HEART DISEASE

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, J.L., Homeier, B.P., & Beers, M.H. (2005). The Merck manuals online medical library: Palpitations. <http://www.merckmanu- als.com/professional/palpitations.html> Accessed April 2014.

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

http://www.merckmanuals.com/professional/palpitations.html

CHAPTER 21 Cardiovascular Function 407

Valvular surgery on older adults has steadily increased during the past decade and has increased the quality of life for older adults (Segal, 2003b).

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 dis- ease. 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 cardiovas- cular 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: • 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 treat- ment 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 evi-

denced 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 evi- denced 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 spe- cific fears, and stable vital signs.

4. The patient will correctly explain the disease process, thera- peutic plan, and preventive precautions.

Intervention Cardiovascular and respiratory assessments should be con- ducted on a regular basis to detect progress and to prevent com- plications. 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 maxi- mize thoracic excursion; and 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 toler- ance; 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 precau- tions 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 perfor- mance. 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 sub- jected to extensive diagnostic tests and blood studies, which should be explained to the patient and family to alleviate anxi- ety. 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, hemor- rhage, 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 con- fusion 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 alleviate episodes of delirium.

Recovery from valvular surgery is generally complete within 6 to 8 weeks; however, recovery may be delayed in older adults

408 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 rec- ommended, 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 failure. Hospitalizations for heart fail- ure 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 car- diac output to meet the body’s metabolic demands (Touhy & Jett, 2012). CHF is not a disease in itself, but it has several pre- cipitating factors. Some of these contributing factors include age, hypertension, CAD, rheumatic heart disease, valvular heart disease, arrhythmias, renal disease, diabetes mellitus, thyro- toxicosis, MI, cardiomyopathy, pulmonary embolism, infection, anemia, liver disease, emotional stress, and other factors related to biologic, socioeconomic, iatrogenic, and lifestyle consider- ations (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 stiff- ness and peripheral resistance, reduced ventricular compliance,

and reduced maximum aerobic capacity. In older adults, the inability to maintain function because of pulmonary and sys- temic 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.)

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 mil- liliter (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 hospi- talization 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 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 nec- essary 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.

EVIDENCE-BASED PRACTICE Assessing Heart Failure Admissions

CHAPTER 21 Cardiovascular Function 409

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).

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 criti- cal. 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.

Diastolic CHF The goal is to reduce ventricular filling pressure and control symp- toms. 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.

DRUG CLASSIFICATION ADVERSE REACTIONS PRECAUTIONS

ACEIs Captopril (Capoten) Enalapril (Vasotec) Lisinopril (Zestril) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik)

Cough, skin rash, hypotension, taste disturbance, angioedema

Monitor renal function. Avoid sudden changes in position.

Aldosterone Antagonist Spironolactone (Aldactone) GI bleeding, sexual dysfunction, fever,

urticaria, confusion, ataxia Monitor for fluid and electrolyte imbalance.

Monitor renal and hepatic levels.

Beta-Blockers Bisoprolol (Zebeta) Carvedilol (Coreg) Metoprolol (Lopressor) Metoprolol extended release (Toprol-XL)

Bradycardia, shortness of breath, fatigue, dizziness, depression, diarrhea, pruritus, rash, arthralgia

May mask symptoms of hyperthyroidism and hypoglycemia

Monitor heart rate. Monitor for signs of hyperglycemia.

Diuretics Thiazides Hydrochlorothiazide (Hydrodiuril, Esidrix) Metolazone (Zaroxolyn)

Electrolyte depletion, hypovolemia, hyperglycemia, gastric irritation

Monitor electrolytes, especially potassium. Monitor urine output.

Loop Diuretics Furosemide (Lasix) Bumetanide (Bumex) Ethacrynic acid (Edecrin) Torsemide (Demadex)

Electrolyte depletion, anorexia, diarrhea, malaise, mental confusion, ototoxicity

A dramatic increase occurs in urine output

Monitor electrolytes, especially potassium. Monitor hearing.

Cardiac Glycosides Digoxin (Lanoxin) Altered color perceptions, visual

disturbances, confusion, headache, muscle weakness, nausea, anorexia, arrhythmias, bradycardia

Monitor potassium levels. Use with caution in patients with IHSS. Half-life may be longer in the elderly leading to increased risk of

toxicity (Kennedy & Ignatavicius, 2006). Monitor vital signs.

Sympathomimetics Dopamine (Intropin)

Dobutamine (Dobutrex) Amrinone (Inocor)

Headache, tachycardia, arrhythmias, hypertension

Headache, nausea, hypotension Headache, anorexia, hepatotoxicity,

thrombocytopenia, hypotension

Contraindicated in patients with IHSS or sensitivity to any sulfite.

Contraindicated in patients with IHSS or hypersensitivity to metabisulfite. Use with caution in patients with CAD or recent MI. Contraindicated in patients with metabisulfite hypersensitivity.

TABLE 21-2 SELECTED MEDICATIONS FOR CONGESTIVE HEART FAILURE

CAD, Coronary artery disease; GI, gastrointestinal disease; IHSS, idiopathic hypertrophic subaortic stenosis; MI, myocardial infarction. 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.

410 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 asso- ciated with pulmonary and systemic vascular congestion. Loop diuretics are the most commonly prescribed and pro- vide predictable and controllable diuresis in severe heart fail- ure. 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 indi- cators 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 hos- pitalization 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 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 predis- pose 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 gen- eral population of the same age. Valvular disease that is sur- gically 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

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 ven- tricle failure is caused by increased pulmonary pressure that results from left ventricle failure. This prevents the right ventricle from pumping adequately, which causes general- ized 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 circula- tory 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 hypertro- phied. The heart may be able to activate compensatory mechanisms to minimize clinical symptoms, but this com- pensation 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).

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 auscul- tation, 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).

CHAPTER 21 Cardiovascular Function 411

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

Planning and Expected Outcomes Expected outcomes are aimed at maximizing myocardial func- tion 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 reduc- tions 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 evi- denced 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 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 moni- tor 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 posi- tion. 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

BOX 21-5 NEW YORK HEART ASSOCIATION FUNCTIONAL 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.

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 Fatigue with a low exercise tolerance Edema that worsens in a dependent position and subsides with rest and eleva-

tion; 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

BOX 21-6 CONGESTIVE HEART FAILURE

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.

http://www.merckmanuals.com/professional/geriatrics/drug_therapy_in_the_elderly/drug-related_problems_in_the_elderly.html

412 PART VI Nursing Care of Physiologic and Psychologic Disorders

encourage the older patient to take slow deep breaths during dys- pneic 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 symp- toms 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 con- siderations. 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 individu- als. 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 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 emer- gency 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 ir-

regular; 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 “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 lim-

its, 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. 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 advan-

tage 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. 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.

CHAPTER 21 Cardiovascular Function 413

Peripheral Artery Occlusive Disease Peripheral artery occlusive disease (PAOD) is any distur- bance 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 distur- bances 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 choles- terol 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 forma- tion of thrombi and aneurysms.

Arteriosclerosis obliterans is a chronic occlusive disease of the arteries caused by plaque formation. As the lumen nar- rows, 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 tis- sues 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 steno- sis. Thromboemboli tend to block arteries at bifurcation points of the femoral and popliteal arteries. Impaired blood flow and ischemia occur at sites distal to the occlusion.

As the atheromatous plaque progresses, the medial layer of the wall calcifies and loses elasticity, which weakens the arte- rial 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 rup- tures. Aneurysms commonly occur in large arteries such as the abdominal aorta. Multiple aneurysms may develop in the pop- liteal artery. Thrombi may form within the aneurysm and circu- late 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, thick- ened 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 insuf- ficiency 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 throm- bosis. A pulsating mass may be palpated in the abdominal area with 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 guide- lines (Kuznar, 2004).

Doppler ultrasonography detects and measures the veloc- ity 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 special- ized catheter inserted into the brachial or femoral artery, and a series of radiographic studies trace the dye through the arte- rial 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 pro- phylactic 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 cath- eter. The catheter is advanced under fluoroscopy to the athero- sclerotic lesion 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 athero- sclerosis and gangrene of the extremities necessitate amputa- tion of the limb.

414 PART VI Nursing Care of Physiologic and Psychologic Disorders

Prognosis Pharmaceutical agents are not particularly effective in the treat- ment 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).

NURSING MANAGEMENT

Assessment Assessment of an older adult with PAOD begins with a com- plete 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.

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 tempera- ture 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.

4. The patient will correctly describe the disease process and treat- ment 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, reg- ular 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.

Prevention is the key to the management of PAOD. Control risk factors: Stop smoking; lose weight; control hypertension and dia-

betes 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 tem- perature with a thermometer or elbow, but do not use your toes. After bath- ing, 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, 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 prob- lems. 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.

PATIENT/FAMILY TEACHING Peripheral Artery Occlusive Disease (PAOD)

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, diabe-

tes 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) Muscle tone

BOX 21-7 ASSESSMENT OF OLDER ADULTS WITH PERIPHERAL ARTERY OCCLUSIVE DISEASE

CAD, Coronary artery disease; PAOD, peripheral artery occlusive disease.

CHAPTER 21 Cardiovascular Function 415

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 weak- ness 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 occupa- tion 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 interven- tion such as sclerotherapy and ligation may be required.

Deep vein thrombosis (DVT) is a common and serious dis- order 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 individu- als 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 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 ultra- sonography, plethysmography, venous duplex ultrasonography, and contrast venography. Doppler ultrasonography measures

NURSING CARE PLAN Peripheral Artery Disease

Clinical Situation Mrs. A, a 72-year-old woman, is complaining of a decreased activity level be- cause 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; respi-

ratory 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. 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., re-

ducing 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. Identify available community resources.

416 PART VI Nursing Care of Physiologic and Psychologic Disorders

venous obstruction and reflux of blood by changes in the fre- quency 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 sur- gical strategies to enhance blood flow and prevent clot formation.

Palliative measures are important for maintaining com- fort. 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 prevent- ing 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 super- ficial venous system and the deep venous system, as well as sur- gery for venous obstruction (Crowther & McCourt, 2004).

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 treat- ment are essential in avoiding complications or death.

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, modi- fiable risk factors, and personal and family history. Objective data include skin color, hair distribution, atrophy, edema, vari- cosities, petechiae, lesions, and ulcerations. Table 21-3 provides more information for the assessment of peripheral arterial and venous disease.

Diagnosis Nursing diagnoses for an older adult with PVD include the following: • Risk for Impaired Skin Integrity, related to venous stasis and

fragility of small blood vessels • Ineffective Peripheral Tissue Perfusion, related to interrup-

tion 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 inflam-

matory 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 tem- perature, pain, color, edema, and pulses). The nurse should use a Doppler sensor if pulses seem to be absent. The affected extrem- ity should be elevated to facilitate venous circulation, and the

TABLE 21-3 DIFFERENTIATING ARTERIAL AND VENOUS INSUFFICIENCY

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.

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

CHAPTER 21 Cardiovascular Function 417

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 sev- eral 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 fac- tors to prevent the hazards of immobility. The patient and family 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 pro- gram 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 dis- comfort, which is measured by a decrease in signs and symp- toms. If skin is intact and edema is minimal, education has been successful. Documentation emphasizes accurate record- ing 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 diag- nosis but a condition caused by some other pathologic condi- tion. 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 release of oxygen from hemoglo- bin, 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) mac- rocytic 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 macro- cytic normochromic anemia, the RBCs are large but have normal amounts of hemoglobin. Vitamin B

12 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 fre- quent 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 symp- toms of anemia. Older adults may exhibit symptoms of anemia (e.g., fatigue and dizziness) but attribute these to the aging pro- cess 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 erythropoi- etin, 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 absorption of vitamin B

12 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 normochro- mic), 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 B

12 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 B

12 level is normal. The gastric analy-

sis shows no free gastric acid, and on gastroscopy the gastric mucosa appears pale and gray. The treatment is vitamin B

(cyanocobalamin) given intramuscularly for life.

418 PART VI Nursing Care of Physiologic and Psychologic Disorders

Prognosis The prognosis for anemia depends on the cause. With medica- tions and dietary changes, the prognosis is usually good.

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).

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 informa- tion 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.

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 condi- tion. 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 appropri- ate food selection and meal preparation to promote RBC for- mation. The nurse should provide a list of foods high in iron, folic acid, and vitamin B

12 to incorporate into the daily meal

plan. The physician or nurse practitioner may order supple- mental iron preparations and, if so, should assess the patient’s tolerance of the preparation. Side effects include gastrointesti- nal 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 geronto- logic 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, includ- ing 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.

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

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.

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.

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, dizzi-

ness, headache, or tinnitus)

Objective Data Pallor (of nail beds, conjunctivae, or oral mucous membranes) Tachycardia Tachypnea Syncope Systolic murmur Confusion Unsteady gait Stomatitis CHF (severe anemia) CBC values

BOX 21-8 ASSESSMENT OF OLDER ADULTS WITH ANEMIA

CBC, Complete blood cell count; CHF, congestive heart failure; NSAIDs, nonsteroidal antiinflammatory drugs.

CHAPTER 21 Cardiovascular Function 419

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.

SUMMARY CVD remains the leading cause of death in the United States. In the older adult population, it is often difficult to clearly distin- guish 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.

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 needing help and not being able to obtain it. Establishing a link with an emergency commu- nity 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 toler- ance, 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, espe- cially for those homebound older adults who live alone or are responsible for household tasks. Often, these older adult patients do not request as- sistance, 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.

HOME CARE

K E Y P O I N T S • 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 conse- quences are the most common causes of morbidity and mor- tality, 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 exacerba- tion 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 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 attrib- uted to the aging process or to a variety of chronic diseases.

• Nursing interventions (e.g., education on the role of car- diovascular 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.

420 PART VI Nursing Care of Physiologic and Psychologic Disorders

C R I T I C A L T H I N K I N G E X E R C I S E S 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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http://www.americanheart.org/presenter.jhtml?identifier=92392009

http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf

http://www.cdc.gov/heartdisease/

http://www.cdc.gov/bloodpressure/

http://content.onlinejacc.org/cgi/content/full/53/15/1343

http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm

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422

Respiratory Function

Sue E. Meiner, EdD, APRN, BC, GNP

The respiratory system is responsible for gas exchange between the environment and blood and involves two processes: ventila- tion 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 (CO

2 )-rich air is moved

out. During oxygenation, CO 2 is transferred from the vascula-

ture to the pulmonary side of the lungs and oxygen is trans- ferred 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 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 envi- ronment where oxygen and CO

2 can transfer, and chemorecep-

tors sensitive to the maintenance of oxygenation and pH levels.

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 antero- posterior diameter. Advanced cases may result in marked limi- tation 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 dif- ficult for the older person to ventilate. It requires more energy. Table 22-1 summarizes various changes in the aging respiratory system.

Muscle strength declines with age, and as respiratory muscles weaken, it becomes increasingly more difficult to exert inspira- tory 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 respira- tory 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 mus- cles of respiration such as the abdominal, sternocleidomastoid, and trapezius muscles. As the abdominal muscles become more

Previous authors: Pamela Becker Weilitz, MSN(R), CS, ANP; Lynn Ferebee, MSN, RN, FNP; and Thomas J. Hendrix, PhD, RN.

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

L E A R N I N G O B J E C T I V E S 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

CHAPTER 22 Respiratory Function 423

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 com- bination results in a relatively unchanged arterial CO

2 pressure

(PaCO 2 ). 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 struc- ture 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 walls become thinner, the alveoli enlarge because of dilation of the proximal bronchioles, but fewer cap- illaries are available for gas exchange. The increase in physio- logic 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 (PaO

2 ).

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 respira- tory mucosal surface that neutralizes viruses. The combination of decreased IgA and an increase of pooling secretions make infections more likely. With repeated respiratory tract infec- tions 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 PaO

2 is 80 to 100 mm

Hg. However, after the age of 60, the PaO 2 drops by 1 mm Hg

per year. Therefore, a PaO 2 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 PaO

2 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

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 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

A–a, Alveolar–arterial; IgA, immunoglobulin A; PaO2, partial pressure of arterial oxygen; Vt; tidal volume. Modified from Pierson, D.J. & Kacmarek, R.M. (Eds.). (1992). Foundations of respiratory care. New York: Churchill Livingstone.

424 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 (PAO

2 ) with the PaO

2 . With rapid diffusion in a healthy

adult the net difference is close to zero. This gradient nor- mally increases in older adults, most likely because of the ventilation–perfusion mismatch (Brashers, 2012).

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, PaCO

2 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 CO

2 . 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 sympa- thetic nervous system response. Therefore, careful assess- ment is crucial. The most sensitive clinical indicator for hypoxia and hypercapnia in older adults is mental status changes and complaints of occipital headaches or forget- fulness 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.

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 expira- tory 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 (FEV

1 ) 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 stiff- ness 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% reduc- tion 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 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 clo- sure. Other factors contributing to early airway closure include increased time in a supine position and shallow breathing.

TABLE 22-2 PULMONARY FUNCTION CHANGES IN OLDER ADULTS

DESCRIPTION

AVERAGE VALUE

ADULT MALE OLDER PATIENT

Lung Volume Tidal volume (Vt) Volume of air inhaled or exhaled per breath 5 to 10 (mL/kg) Decreased Inspiratory reserve volume (IRV) Volume of air inhaled in addition to normal Vt 3000 mL Decreased Expiratory reserve volume (ERV) Maximum volume of air that can be exhaled in

addition to normal Vt 1200 mL Decreased

Residual volume (RV) Volume of air left in lungs after maximum exhalation

1200 mL Increased by as much as 25%

Lung Capacity Functional residual capacity (FRC) Volume of air left in lung after a normal

exhalation (RV + ERV) 2400 mL Increased

Residual volume/total lung capacity (RV/TLC)

Ratio of RV to TLC expressed as percentage 33% Increased

Vital capacity (VC) Volume of air exhaled after maximal inhalation (IRV + Vt + ERV)

4800 mL Decreased by as much as 25%

Total lung capacity (TLC) Total volume of air in lungs after maximum inhalation (IRV + Vt + ERV + RV)

6000 mL Unchanged

CHAPTER 22 Respiratory Function 425

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 dis- tensible and more fibrous, which results in increased pul- monary artery diameter and greater thickness of the vessel wall; in turn, these increases result in increased pulmonary vascular resistance and increased pulmonary artery pres- sure. 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).

FACTORS AFFECTING LUNG FUNCTION

Exercise and Immobility Exercise has a positive effect on the respiratory and cardiovas- cular 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 involv- ing 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 second- hand smoke has also been shown to damage the lungs of

nonsmokers. Heavy smokers may demonstrate a nine times increase in the reduction of FEV

1 over normal expected reduc-

tions. Cilia, which are paralyzed by nicotine, are unable to pro- tect 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 medica- tions are also affected by smoking, which decreases clearance and increases serum drug levels. Some drugs altered by smok- ing include antidepressants, propranolol, theophylline, ami- nophylline, 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 Smoking cessation is imperative. The five components (five As) of smoking cessation consist of asking, advising, assessing, assist- ing, 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 smok- ing cessation. When speaking to older adults, the nurse should use strong, clear, and personalized language. The nurse should

• Avoidance of cigarette and secondhand smoke • Avoidance of environmental and air pollutants • Healthy diet and exercise plan • Immunizations • Avoidance of allergens • 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 respira-

tory 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)

HEALTH PROMOTION/ILLNESS PREVENTION The Respiratory System

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.

426 PART VI Nursing Care of Physiologic and Psychologic Disorders

assess older adults for their willingness to give up smoking and determine how soon they are ready to start the process. Then the 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), pro- viding supplemental educational materials, and offering appro- priate 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 nic- otine 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 reduc- tion 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 respira- tory tract infections.

Excessive weight may result in sleep apnea caused by inter- ference with normal ventilation. Hypoventilation is seen in morbidly obese persons whether awake or asleep. Fluid reten- tion is another rationale for rapid weight gain and is associated with decreased pulmonary gas exchange.

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 dis- orders, 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 dis- order 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 ampli- fied 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 hydra- tion, frequent position changes, and early mobility will decrease the risk of developing atelectasis.

RESPIRATORY SYMPTOMS COMMON IN OLDER PATIENTS Respiratory symptoms common in older patients include alter- ations 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 respi- ratory problems is a change in mental status. Because the physi- ologic 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 com- plain 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 dif- ficult for the older patient to quantify; dyspnea may therefore be dismissed, especially when no clinical evidence can be attrib- uted 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 dis- ease 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

CHAPTER 22 Respiratory Function 427

use the stairs. An older patient may simply choose the elevator or escalator and not consider reporting the shortness of breath associated with stair climbing. It is important to determine which ADLs an older patient no longer participates in and why.

The cough mechanism in older patients is altered because of the 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 sup- pressants with caution. Suppression of the cough and depression of any respiratory function could lead to retention of pulmo- nary secretions, plugged airways, atelectasis, and aspiration.

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 signifi- cant 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 phy- sician’s office, getting to the pharmacy for medications, admin- istering 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).

Respiratory disease is divided into two categories: (1) obstruc- tive pulmonary disease and (2) restrictive pulmonary disease. Obstructive lung diseases are characterized by changes in expi- ratory 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 charac- terized by decreased ability to expand the chest, impaired inhala- tion, 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 bron- chopulmonary infections, pulmonary edema, and pulmonary emboli (CDC, 2012c).

OBSTRUCTIVE PULMONARY DISEASE

Asthma Asthma is a chronic inflammatory disease that affects the air- ways and is characterized by reversible airway obstruction,

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 sub- jects 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, help- lessness, 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 epi- sode 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.

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 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 con- ditions 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.

428 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 hyperrespon- siveness; air flow limitations, including acute bronchoconstric- tion, 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, breath- lessness, 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 aller- gens or irritants such as changes in weather, odors, or stress. In older patients, asthma is often associated with viral respira- tory infections. Signs and symptoms include dyspnea, audible wheezing, palpitations, tachypnea, tachycardia, use of acces- sory muscles of respiration, pulsus paradoxus, diaphoresis, and chest hyperinflation. Initially, a patient may hyperventilate and effectively blow off increasing CO

2 . Falling PaO

2 and pH with

rising PaCO 2 are indicative of imminent respiratory failure.

The increasing PaCO 2 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 reduc- tion of impairment and risk, which may be achieved by (1) preventing chronic and troublesome symptoms such as cough- ing or breathlessness during the day, at night, or after exercise, (2) maintaining (near) normal pulmonary function, (3) main- taining normal activity levels, including exercise and atten- dance at work or school, (4) requiring infrequent use (≤2 days a week) of inhaled short-acting beta

2 -agonists (SABAs) and sat-

isfying the patient’s and family’s expectations of asthma care, (5) preventing recurrent exacerbations and minimizing

emergency department visits, and (6) providing optimal phar- macologic 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 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 toler- ated and safe when used at the recommended dosage. Most of the benefit is achieved with relatively low doses, and the poten- tial 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 corticoste- roids with long-acting beta

2 -agonists (LABAs), and the second,

most recent recommendation is to increase the dose of cortico- steroids (NHLBI, 2007). The clinical response to corticosteroids is a reduction in airway inflammation, improvement in peak expiratory flow rate (PEFR), diminished airway hyperrespon- siveness, 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 beta

2 -receptors to increase cyclic adenosine

monophosphate (cAMP). They are not recommended as a monotherapy for long-term control but, rather, are often pre- scribed 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 beta

2 -agonists are used on a long-term basis before exer-

cise, their effects last only 5 hours. An example of these medi- cations 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 contrac- tion and increased mucous secretion; they also attract and acti- vate 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 leukotriene antagonist is montelukast (Singulair) or zafirlukast (Accolate). These drugs block the leukotriene receptors, whereas zileuton (Zyflo) pre- vents leukotriene synthesis. These drugs do not reverse symp- toms during an asthma attack and should not be used as rescue medication (Workman, 2013).

CHAPTER 22 Respiratory Function 429

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 persis- tent asthma, especially if allergies are the primary trigger. The nurse should always be prepared and equipped to treat for ana- phylaxis 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, anti- cholinergics, and systemic corticosteroids. SABAs are bron- chodilators 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 can- ister per month do not have adequate control and need addi- tional antiinflammatory therapy. Daily use of SABAs is not recommended.

Anticholinergics such as ipratropium bromide (Atrovent) may provide an additive benefit to inhaled beta

2 -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 exac- erbations 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).

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 conjunc-

tion 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 corticoste- roid. 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 leu- kotriene modifier may substitute for the long-acting bron- chodilator. 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 beta

2 -agonists are used

prn. Add additional long-term control therapy with daily or increased usage.

Step 6: Daily inhaled corticosteroid plus long-acting broncho- dilator plus an oral corticosteroid. Consider an immuno- modulator for patients with allergies. Patient education, environmental control, and quick man-

agement 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 osteo- porosis that are aggravated by asthma medications. Older adults with ischemic heart disease may be more sensitive to beta

2 -

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 hyper- tension, 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 (arthri- tis, visual) or cognitive impairments could be challenging for them (NHLBI, 2007).

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 move- ment, 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 respira- tion in which it occurs, and whether it is present during a forced expiratory maneuver. Determination of the PEFR with a peak

430 PART VI Nursing Care of Physiologic and Psychologic Disorders

expiratory flow meter (PEFM) is important in determining trends of airway resistance (Figure 22-1).

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, adventi- tious breath sounds, or a combination of all of these

• Impaired Gas Exchange, related to alveolar–capillary mem- brane 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 breath- ing and chest tightness,(4) variation in PEFR of 20% or more, and (5) symptoms that worsen during exercise, with viral infec- tion, in the presence of environmental irritants such as animal fur, dust mites, mold, smoke, pollen, changes in weather, air- borne chemicals, or dust, during menses, or with strong emo- tional expression (NHLBI, 2007).

Pulmonary function tests (PFTs) are used to measure the presence and amount of airway obstruction. An FEV

1 –forced

vital capacity (FVC) ratio of less than 65% indicates obstruc- tion of air flow. Measurements of FEV

1 , FVC, and the FEV

1 –

FVC ratio before and after inhaled short-acting bronchodilators are recommended. Other diagnostic procedures include metha- choline, 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 FEV

1 , even with optimally prescribed inhaled bronchodilators.

In older patients with heartburn, coughing, nocturnal symp- toms 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 symp- toms, and (3) lung function (Table 22-3). Asthma also occurs as seasonal asthma, cough variant asthma, and exercise-induced asthma.

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 collab- orative care (7th ed.). St. Louis, MO: Elsevier.)

TABLE 22-3 CLASSIFICATION OF ASTHMA BY SEVERITY OF DISEASE BEFORE TREATMENT*

⁎ After treatment, severity is measured by the minimum medications needed to maintain good health.

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.

CHARACTERISTIC MILD MODERATE SEVERE

Frequency of exacerbations ≤2 times/week; lasting less than 1 hour >2 times/week; may last days; not frequently severe

Frequent exacerbations, often severe

Frequency of symptoms Minimal Often Continuous Exercise tolerance Minimal Diminished Poor; activity limited Frequency of nocturnal asthma ≤2 times/month >2 times/week almost nightly, chest tight in morning School or work attendance Good Fair Poor Pulmonary function: peak expiratory

flow rate (PEFR) >80% 60% to 80% <60%

PEFR variability <20% 20% to 30% >30% Spirometry Minimal airway obstruction Airway obstruction evident with

reduced expiratory flow at low lung volumes

Substantial airway obstruction with increased lung volumes and marked unevenness of ventilation

http://www.nhlbi.nih.gov/health/health-topics/topics//asthma/treatment.htm

CHAPTER 22 Respiratory Function 431

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 revers-

ible 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).

Intervention Interventions for patients with asthma include health mainte- nance, lifestyle changes, administration of medications at des- ignated time intervals, exercise, and promotion of hydration and good nutrition. Education is started at the time of diag- nosis 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 expla- nations 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 suf- ficient time for instruction, demonstration, and return demon- strations (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 avoid- ing 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 edu- cation. Continue to stress the need for regular follow-up with the primary care provider. Pictures and 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 effec- tiveness 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 pul- monale, polycythemia, hypoxemia, and respiratory insuffi- ciency. Clinical symptoms include a persistent cough, dyspnea on exertion, purulent sputum, cyanosis, crackles on ausculta- tion, tachycardia, pedal edema, unexplained weight gain, and a decreased PaO

2 with a normal or elevated PaCO

2 .

Emphysema Emphysema usually occurs between ages 60 and 70 and is char- acterized by progressive destruction of the alveoli and their supporting structures. The alveoli distal to the terminal bron- chioles become enlarged. Loss of connective tissue supporting the alveoli leads to permanent obliteration of the peripheral air- ways. 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 presen- tation 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 hemo- globin level, crackles and wheezes on auscultation, and abnor- mal PFTs with decreased VC, increased TLC, increased FRC, and decreased FEV

1 .

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 mani- fested include peripheral airway inflammation, airway fibrosis, hypertrophy of smooth muscles, hyperplasia of goblet cells and resultant mucus hypersecretion, and eventually, the destruc- tion of the lung parenchyma (Barnett, 2009). The two revers- ible 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 dif- ferentiate 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

http://www.ginasthma.org/Guidelines

432 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 pro- gressive 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 inter- vention 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).

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 spi- rometry testing. COPD is staged based on the percent of the predicted value of FEV

1 (Table 22-4).

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 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 FEV

1 and helps

relieve symptoms. Benefits to smoking cessation include reduc- tion 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 step- wise 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

TABLE 22-4 STAGING CHRONIC OBSTRUCTIVE PULMONARY DISEASE BY LEVEL OF AIR FLOW

FEV1, Forced expiratory volume in 1 second; PaO2, partial pressure of arterial oxygen. 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.

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.

CHAPTER 22 Respiratory Function 433

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 addi- tion of inhaled glucocorticosteroids is appropriate. However, chronic treatment with systemic glucocorticosteroids is not recommended.

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 beta

2 -agonists, anti-

cholinergics, and the methylxanthines. The choice of drug will depend on the patient’s response.

Beta2-Agonists These sympathomimetic drugs work by stimulating the beta

2 -receptors in the lungs, which results in bronchial dila-

tion, 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). Beta

2 -agonists should be used with cau-

tion in the older patient with ischemic heart disease. Examples of beta

2 -agonists include albuterol (Proventil, Ventolin), meta-

proterenol sulfate (Alupent, Metaprel), and pirbuterol acetate (Maxair).

Anticholinergics Inhaled anticholinergics—ipratropium bromide or oxitropium bromide—are used to treat chronic bronchitis. They work by inhibiting vagal stimulation of the lungs, preventing contrac- tion 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).

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 fre- quency 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 contain- ing killed or live inactivated viruses are recommended for older adults, and the pneumococcal polysaccharide vaccine is recom- mended 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 rest- ing PaO

2 55 mm Hg or less or saturation of arterial oxygen (SaO

2 )

88% or less with or without hypercapnia. Oxygen therapy may also be indicated if the patient’s PaO

2 is between 55 and 60 mm

Hg, the SaO 2 is 88% or less, or evidence of pulmonary hyper-

tension, peripheral edema, or polycythemia (hematocrit level >55%) exists. The primary goal of oxygen therapy is to increase baseline PaO

2 to at least 80 mm Hg and SaO

2 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.

FIGURE 22-2 Commercial spacers for metered-dose inhal- ers (MDIs): Top, AeroChamber; bottom, InspirEase. (From Dettenmeier, P. (1992). Pulmonary nursing care. St. Louis, MO: Mosby.)

434 PART VI Nursing Care of Physiologic and Psychologic Disorders

Pulse oximetry can detect desaturation before physical appear- ance of dusky skin, pale mucosa, or pale nail beds are noted (DeMeulenaere, 2007).

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).

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 pri- mary 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 respira- tion, 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 condi- tions (e.g., use over-bed light or natural sunlight). The nurse should be attentive to factors that may mask cyanosis by caus- ing vasoconstriction. These include environmental conditions (e.g., air conditioning and mist tents) and patient behaviors (e.g., smoking and taking medications causing vasoconstric- tion). Examine the usual places in which cyanosis is found, that is, the lips, nail beds, around the mouth, cheek bones, and ear- lobes. 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 ques- tionable, 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.

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, hypox-

emia or hypercapnia or both, paroxysmal nocturnal dyspnea, and orthopnea

• Risk for Infection, related to inadequate primary and sec- ondary 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 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 inter- vention, including tests and medications; and lifestyle changes such as smoking cessation, weight gain or loss, exercise, and breathing retraining (see Nursing Care Plan: COPD).

CHAPTER 22 Respiratory Function 435

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 rehabili- tation programs are designed to provide the patient with exercise training, breathing retraining, education, smoking cessation, medications, and nutrition information. The exercise compo- nent 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 incre- ments, 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

NURSING CARE PLAN Chronic Obstructive Pulmonary Disease

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 awak- ening 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 scat- tered 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 hy- giene. 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 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 respira-

tory muscle endurance Impaired Verbal Communication, related to endotracheal intubation Deficient Knowledge, about home oxygen therapy and smoking cessation, re-

lated 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 mechani- cal 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 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 ex-

pansion, 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, talk-

ing 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. 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.

436 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 pro- gram 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 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 hospital- izations 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 smok- ing 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 associ- ated 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 pro- vides a framework for cessation (Fiore et al., 2000) (Table 22-5).

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 CO

2 load, thereby increasing the work of

breathing, especially in those with CO 2 retention), eat high-

protein foods, and reduce the intake of fat (see Nutritional Considerations Box).

Breathing Retraining The goals of breathing retraining include decreasing the work of breathing, improving oxygenation, increasing the efficiency of breathing patterns, and promoting patient control of breathing. Two of the most commonly taught techniques are diaphrag- matic breathing and pursed-lip breathing (Boxes 22-1 and 22-2; Figures 22-3 and 22-4).

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 main-

tenance; 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 in-

creases the carbon dioxide (CO2) load and may increase the work of breath- ing, especially in older patients with CO2 retention

Fats—20% to 25% nonprotein calories

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.

TABLE 22-5 HOW TO HELP THE PATIENT WHO IS WILLING TO QUIT SMOKING

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.

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 22-1 DIAPHRAGMATIC 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 be at least

twice as long as inhalation). 6. Rest. 7. Repeat.

BOX 22-2 PURSED-LIP BREATHING

CHAPTER 22 Respiratory Function 437

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 exha- lation time, reduces the respiratory rate, and allows the patient to slow the breathing.

Chest Physiotherapy Chest physiotherapy (CPT) includes chest percussion, pos- tural 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 position- ing the patient in a head-down position after CPT to facili- tate 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 expe- rience increased breathlessness as a result of the mobilization of secretions and 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 exer- cises, and coughing techniques (Box 22-3). Older patients are prone to dehydration and therefore are at risk for airway plug- ging. The nurse should encourage a volume of oral fluids of 4 to 6 quarts a day, if not contraindicated by cardiovascular dis- ease; 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.

Medications Patient education regarding medications includes the pur- pose of the medication, dosage, side effects, and schedule of administration. Medications are administered by mouth, MDI

FIGURE 22-4 Pursed-lip breathing. (Courtesy of Ursula Ruhl, St. Louis, MO.)

Inhale

Exhale

FIGURE 22-3 Diaphragmatic breathing.

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 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.

BOX 22-3 EFFECTIVE COUGHING TECHNIQUES

Dettenmeier, P. (1992). Pulmonary nursing care. St Louis, MO: Mosby.

438 PART VI Nursing Care of Physiologic and Psychologic Disorders

(Box 22-4), or nebulizer. Inhaled medications are only as effec- tive 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 mechani- cal 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 periodi- cally, holding the MDI upside down, and failure to remove the cap before spraying the medication (Self, Kilgore, & Shelton, 2003).

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, concen- trators, and liquid systems. A liquid oxygen system with por- tability 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 avail- able 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 concentra- tor 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 addi- tional 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 educational materials; however, once taught, they should have a good understanding and be able to adapt these tech- niques to their lifestyle.

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 expan- sion, 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 diag- nosis 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).

Diagnostic Tests and Procedures Diagnosis is based on the clinical history and chest radiogra- phy. The initial workup includes a complete blood cell (CBC) count, carcinoembryonic antigen (CEA) level, chest radiogra- phy, computed tomography (CT), ABG measurements, PFTs, and an electrocardiography (ECG). Sputum cytology is used

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.

BOX 22-4 USING A METERED-DOSE INHALER

CHAPTER 22 Respiratory Function 439

to determine the cell type. If metastasis is suspected, addi- tional diagnostic tests include magnetic resonance imaging (MRI) of the brain, bone scintigraphy, exercise PFTs, quanti- tative ventilation–perfusion scanning, treadmill exercise test, Doppler echocardiography, and carotid Doppler ultrasonog- raphy. Fiberoptic bronchoscopy is used to obtain tissue con- firmation 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 diag- nostic testing, the stage of NSCLC involvement is determined (Table 22-6). SCLC is not staged because it is extremely aggres- sive and is always assumed to be systemic once diagnosed.

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 radi- ation 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 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 func- tional 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 tol- erate a complex medical regimen, especially with other organ involvement or underlying disease processes.

NURSING MANAGEMENT

Assessment Assessment includes the identification of risk factors for lung cancer. The clinical presentation of lung cancer may easily be mis- taken 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 physi-

ologic condition and long-term stress

Planning and Expected Outcomes Planning includes developing interventions and expected out- comes for the patient that focus on improving gas exchange, pro- moting 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.

TABLE 22-6 STAGING OF NON–SMALL- CELL LUNG CARCINOMA

Adapted from National Cancer Institute. (2014). Lung cancer. <http:/www.cancer.gov/cancertopics/types/lung> Retrieved April 2014.

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

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.

EVIDENCE-BASED PRACTICE Patient Education Needs Related to Treatment of Lung Cancer

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.

http://www.cancer.gov/cancertopics/types/lung

440 PART VI Nursing Care of Physiologic and Psychologic Disorders

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. 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 verbaliza- tion 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 discom- fort as younger patients. The nurse should help patients quan- tify 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 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 communi- cable 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, gastrec- tomy, jejunal bypass, weight more than 10% below ideal body weight, chronic renal failure, diabetes mellitus, and hematologic disorders such as leukemia, lymphomas, and other malignan- cies. 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).

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 immunocompro- mised, 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 rec- ommended 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 tra- chea. Older adults may show lower lobe nodular infiltrates with- out cavitation. Diffuse, finely nodular, uniformly distributed lesions characterize hematogenous TB. Any persistent infiltrate

CHAPTER 22 Respiratory Function 441

in older patients must 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 poten- tial 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 organ- ism load is seen within 2 weeks. Cultures will convert to neg- ative within 3 months in patients compliant with therapy. Medications include a combination of bactericidal drugs. The most common drugs are isoniazid, rifampin, ethambutol, strep- tomycin, and pyrazinamide (CDC, 2014c). Other drugs used in the treatment of TB include ethionamide, kanamycin, paraami- nosalicylic acid, cycloserine, and rifabutin. Fluoroquinolones such as ciprofloxacin are also being used to treat TB.

Monitoring of liver function on a monthly basis is recom- mended 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 rela- tively stable level 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 rede- velop 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 iso- niazid 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.

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 cavita- tion 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 fol- lowing (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 pro-

cess, 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 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 medica-

tion 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 admin- istration, 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

442 PART VI Nursing Care of Physiologic and Psychologic Disorders

she should call the doctor or nurse immediately. Patients should not drink alcohol while taking isoniazid.

Other TB drug side effects to report to the health care practi- tioner 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 wear- ing 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.

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 con- tinue to rise as the population ages (CDC, 2013a). The influ- enza 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 receiv- ing 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 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 pre- vent influenza, the use of antiviral agents such as amanta-

MEDICATION DOSAGE ADVERSE REACTIONS NURSING CONSIDERATIONS

Isoniazid Primary therapy: 5 mg/kg, po, daily up to 300 mg/

day

Anemia, hepatitis, hypersensitivity, peripheral neuritis, seizures, and systemic lupus erythematosus

Therapy lasts for 6 to 9 months and is used in conjunction with other antituberculosis medication.

Intramuscular—same as po, Instruct patient to avoid alcohol. Rifampin (Rifadin, Rofact) 10 mg/kg body weight (maximum

600 mg) Decreased effectiveness of oral

contraceptives, hemolysis, hepatic toxicity, increased metabolism of hepatically excreted drugs, induction of methadone withdrawal, renal failure, thrombocytopenia, orange body fluids, and rash

Monitor hepatic, renal, and hemolytic parameters. Give 1 hour before or 2 hours after meals. Monitor hepatic function (urine may become red-

orange in color). Instruct patient to avoid alcohol. Usually used with one other drug.

Pyrazinamide (PZA) 20 to 35 mg/kg/day up to 3 g/day Anorexia, arthralgia, gout (rare), hepatitis, hyperuricemia, nausea, renal failure (rare), and vomiting

Monitor platelet count and complete blood cell count (CBC).

Have patient take medication with meals or snack to reduce gastric irritation.

Instruct patient to report any problems with urination. Monitor liver function tests. Instruct patient regarding signs of thrombocytopenia,

such as unexplained bleeding or bruising, appearance of petechiae, and nosebleeds.

TABLE 22-7 ANTITUBERCULOSIS MEDICATIONS

g/day, Gram per day; mg/kg/day, milligram per kilogram per day; po, by mouth.

CHAPTER 22 Respiratory Function 443

dine, 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 dura- tion of some influenza strains in healthy adults when adminis- tered 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 sup- portive. The nurse should focus on symptom relief and pre- venting the spread of influenza and secondary infections. Of all influenza- related deaths, 90% occur in the older adult popula- tion (CDC, 2013a), and as such, older adults with an underlying illness may require hospitalization.

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 fol- lowing (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):

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.

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 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 pres- sure, 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 some- one 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 clini- cal picture, the resolution of symptoms, and the prevention of complications. Failure to improve may indicate the develop- ment 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, crack- les, or dullness on chest percussion should alert the nurse to possible pneumonia.

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.

EVIDENCE-BASED PRACTICE Respiratory Syncytial Virus (RSV) in Older Adults and High-Risk Adults

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.

444 PART VI Nursing Care of Physiologic and Psychologic Disorders

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-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, dehydra- tion, and a failure to thrive. The patient may require hospi- talization and admission to the intensive care unit (ICU) with subsequent intubation and mechanical ventilation. The inci- dence of pneumonia in older adults in long-term care institu- tions 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 respi- ratory 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 dehy- dration, confusion, and a respiratory rate greater than 26 breaths per minute. Other signs include tachycardia, chest dis- comfort, dyspnea, headache, nausea, vomiting, myalgia, arthral- gia, fatigue, weakness, abdominal pain, diarrhea, and anorexia (Mandell, Wunderink & Anzueto, 2007). In multiple-lobe pneu- monia, 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 pneumo- nia 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).

Health Care–Associated Pneumonia, Hospital-Acquired Pneumonia, and Ventilator-Associated Pneumonia Health care–associated pneumonia (HCAP) is new-onset pneu- monia. 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 inci- dence 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 antimi- crobial therapy (Norris, 2011).

Nosocomial Pneumonia Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeru- ginosa, and Escherichia coli most often cause nosocomial pneumo- nia. 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 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 situa- tions such as stupor, coma, cardiopulmonary resuscitation, alcohol

TABLE 22-8 CRITERIA FOR SEVERE COMMUNITY-ACQUIRED PNEUMONIA (CAP)

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. 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.

MINOR CRITERIA MAJOR CRITERIA

Respiratory rate (RR) ≥30 Uremia (BUN ≥20) Hypothermia Core temperature <36 ° C

Invasive mechanical ventilation

Multilobar infiltrate Leukopenia (WBC <4000) Hypotension requiring fluid resuscitation

Septic shock with a need for vasopressors

Confusion/disorientation Thrombocytopenia Platelets <100,000

CHAPTER 22 Respiratory Function 445

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, position- ing, feeding, and the use of a feeding tube place older patients at increased risk for aspiration pneumonia. The use of narcotic medi- cations, 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 pneumo- nia 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 iden- tify 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 present (Norris, 2011; Mandell et al., 2007).

Treatment Treatment consists of administration of the appropriate antibi- otics, hydration, good nutrition, and rest. The length of treat- ment with antibiotics may range from 10 to 14 days, depending on the causative organism. The initial management of immu- nocompetent patients with CAP emphasizes empiric treatment instead of extensive testing because of the difficulty in deter- mining 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, PaO

2 or

fractional concentration of oxygen in inspired gas (FiO 2 ) 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, pres- ence of coexisting illness, altered mental status, chronic alcohol abuse, dehydration, malnutrition, nursing facility residency, aspi- ration, history of 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 PaO

2 of 60 mm Hg or less.

Prognosis Clinical improvement usually occurs between 3 and 5 days of the initiation of treatment. Patients failing to respond to ther- apy 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.

NURSING MANAGEMENT

Assessment A history of generalized fatigue, malaise, decreased appe- tite and fluid intake, or a recent viral infection may indicate a

DEMOGRAPHICS COMORBIDITY VITALS DIAGNOSTICS OTHER

Age ≥65 Neoplastic Respiratory rate >30 pH <7.35 Altered mental status Male Cerebrovascular SBP <90 BUN >10.7 mmol/L New-onset mental confusion Nursing home resident CHF Temp either <35 ° C or >40 ° C Sodium <130 mEq/L Chronic renal Pulse >125 Hematocrit <30% Chronic liver PaO2 < 60 mm/Hg Glucose >13.9/mmol/L Radiography shows effusion

TABLE 22-9 VARIABLES USED TO CALCULATE PNEUMONIA RISK AND TO DETERMINE HOSPITALIZATION

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. 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.

446 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 per- cussion, 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, vom- iting, 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 (PaO

2 or FiO

2 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]), PaO

2 (60 mm Hg), or PaCO

2 (over 50 mm Hg)

(Mandell et al., 2007). Another sign is a rapid change in chest radiography that consist of spreading infiltrates and extrapul- monary 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 infec- tion 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 PaO

2 of 80 mm Hg by ABG anal-

ysis or an arterial oxygen saturation (SaO 2 ) 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.

Intervention Nursing management of an older patient with a bronchopulmo- nary infection includes maintenance of hydration, promotion of effective airway clearance, and proper positioning. Other inter- ventions 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 oxygen- ation. 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 transplanta- tion, 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 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 moni- tor 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

CHAPTER 22 Respiratory Function 447

because a weaker cough is common in older adults and ineffec- tive 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 pat- tern for effective breathing and use of accessory muscles of respiration.

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 his- tory 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 asymp- tomatic or have a mild respiratory illness. The signs and symp- toms of a moderate respiratory illness include a temperature over 100.4 ° F, coughing, shortness of breath, dyspnea, or hypox- emia. A severe respiratory illness includes the latter and radio- graphic 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 ill- ness confirms the diagnosis (Marthaler, Keresztes, & Tazbir, 2003). Other diagnostic tests include chest radiography, CBC, ABG analysis, pulse oximetry values, clotting profile, respira- tory 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 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 fail- ure. 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 pulmo- nary venoocclusive disease. A rise in pulmonary capillary pres- sure occurs as a result of elevated left ventricular end-diastolic filling pressure, elevated left atrial pressure, and elevated pul- monary venous pressure.

The clinical presentation of acute cardiogenic PE includes acute shortness of breath; orthopnea; frothy, blood-tinged sputum; cyanosis; diaphoresis; and tachycardia. Physical find- ings 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, reexpan- sion PE, and neurogenic PE.

Cardiogenic Pulmonary Edema Diagnostic Tests and Procedures Diagnosis is based on clinical presentation and diagnostic test- ing. ABG measurements are drawn to determine arterial PO

2 ,

arterial PO 2 saturation, and pH. A reduced oxygen tension and

saturation and a resultant acidity related to retained CO 2 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 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 (nitroglyc- erin). Morphine is also a mainstay of treatment; it reduces anxi- ety 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 rehabilita- tion 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

448 PART VI Nursing Care of Physiologic and Psychologic Disorders

may need intubation and mechanical ventilation. In addition, the placement of an arterial line and pulmonary artery cath- eter 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 con- sumption, 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 main- tenance 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 approxi- mately 30% to 60%. Comorbidity, frailty, and nosocomial infec- tions put older adults at increased risk for complications. If an older adult does not require mechanical ventilation, the prog- nosis 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).

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 pre- disposing factors, which include aspiration of gastric contents, pneumonia, thoracic injury, pulmonary contusions, smoke inhalation, multiple blood transfusions, uremia, cardiopul- monary 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 fol- lowing (Malone, 2011): • Ineffective Breathing Pattern, related to decreased energy • Impaired Gas Exchange, related to alveolar–capillary mem-

brane 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 fac- tors and respiratory muscle fatigue

• Risk for Infection, related to inadequate primary and sec- ondary 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 out- comes 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 communica-

tion 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 associated functional disability secondary to activity intoler- ance, 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 encour- aged 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

CHAPTER 22 Respiratory Function 449

drainage; frequent suctioning then becomes appropriate. The nurse should reassure the patient and family or signifi- cant 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 care- giver 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).

Interventions include supplemental oxygen, mechanical ventilation, and nursing measures to promote oxygen balance. Monitoring PaO

2 saturation helps the nurse determine which

activities deplete oxygen saturation. Interventions such as suc- tioning, 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 impor- tant 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, resolu- tion 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 ther- apies and invasive interventions. Older adults need continual reas- surance 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 addi- tional fluids. The nurse should monitor the patient’s 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 thrombo- sis 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 plate- lets, red blood cells (RBCs), and WBCs, releases vasoactive sub- stances 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 confine- ment, central venous catheter placement, neurologic disease with extremity paresis and a history of vascular disease, COPD, heart disease, diabetes mellitus, malignancy, and previous pul- monary 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 pleu- ritic chest pain, decreased PaO

2 , and S

3 or S

4 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 PaO

2 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 supraventricu- lar tachycardia if the emboli are extensive. Massive pulmonary emboli may result in electromechanical dissociation, in which electrical conduction 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 pul- monary 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 pulmo- nary 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 interna- tional normalized ratio (INR). The goal range of the INR is 2.5 to 3.0. Patients with recurrent pulmonary emboli are can- didates for Greenfield vena cava filters.

450 PART VI Nursing Care of Physiologic and Psychologic Disorders

Prognosis The prognosis for pulmonary emboli is guarded. Older adults are at increased risk for deep vein thrombosis (DVT) and pul- monary emboli because of decreased mobility. Often, the diag- nosis is made on postmortem examination.

NURSING MANAGEMENT

Assessment Assessment begins with the identification of risk factors for the development of pulmonary emboli. In older adults, dehydra- tion and immobility are leading causes. If an older patient has a history of recent fracture of a long bone or a pelvic fracture sec- ondary 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 inter-

ruption of arterial flow • Impaired Spontaneous Ventilation, related to metabolic

factors

Planning and Expected Outcomes Planning includes developing interventions and expected out- comes for the older patient that are aimed primarily at improv- ing 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. 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 treat- ment is focused on these goals, maintaining effective oxygen- ation and ventilation is paramount. The nurse should monitor tissue oxygen delivery, signs and symptoms of respiratory fail- ure, 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 pre- vent 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 adminis- tered. The nurse may use vasopressors if hypotension cannot be reversed with fluids.

The patient needs to be monitored for bleeding complica- tions 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 stock- ings 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 exer- cise and mobility. Education on anticoagulant therapy includes 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 par- tial 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 par- tially 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, mechanore- ceptor activation during obstructed efforts, chemoreflex acti- vation 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 nervous system activity. During obstructive apnea, large fluctuations in intra- thoracic pressure occur, causing changes in venous return, left

CHAPTER 22 Respiratory Function 451

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 polysomnogra- phy 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 follow- ing: 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 posi- tive airway pressure (CPAP). It provides immediate prevention of upper airway collapse and leads to correction of ABG derange- ments, improved sleep continuity, improved cognition, and reduc- tion of sleepless symptoms (Bloom et al., 2009). The most critical factor in the use of nasal CPAP is the patient’s level of compli- ance. 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 uvulopalato- pharyngoplasty (UVPP or UPPP). The goal of UVPP or UPPP is to remove obstructing tissue of the soft palate, uvula, and pos- terolateral pharynx, thereby eliminating obstruction. The pro- cedure 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 commit- ment 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.

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, pul- monary hypertension and cor pulmonale (Bloom et al., 2009).

Diagnosis Nursing diagnoses for a patient with OSAS include the follow- ing (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. 6. The patient will maintain adequate vital signs. 7. The patient will maintain adequate oxygenation and ventila-

tion 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 activ- ity. 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.

Evaluation Evaluation is based on achievement of the expected out- comes and improvement in the patient’s perception of sleep.

452 PART VI Nursing Care of Physiologic and Psychologic Disorders

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.

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 pulmo-

nary structure and function include elastic recoil and muscu- loskeletal 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 treat- ment regimens, and, most important, pulmonary hygiene and airway patency.

FIGURE 22-5 Management of sleep apnea often involves sleep- ing with a nasal mask in place. The pressure supplied by air coming from the compressor opens the oropharynx and naso- pharynx. (From Lewis, S.M., Dirksen, S., Heitkemper, M.M., et al., (2011). Medical-surgical nursing: assessment and manage- ment of clinical problems (8th ed.). St. Louis, MO: Mosby.)

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 ex- ercise within their capacity to promote thoracic muscle conditioning.

3. Monitor homebound older adult patients for smoking and exposure to sec- ondhand 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. 6. Encourage frequent small meals to reduce breathlessness associated with

eating. 7. If a patient is using home oxygen, assess the home environment for po-

tential 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 fam- ily caregivers these signs as well.

HOME CARE

K E Y P O I N T S • 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 dia- phragmatic breathing) may result in decreased breathless- ness 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 con- trol 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 ventila- tion or other technology should include the patient and family.

• Primary nursing diagnoses for the older patient with respira- tory disease focus on increasing airway clearance, decreasing breathlessness, and improving oxygenation.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 respi- ratory failure? How would you assist patients and/or family members faced with decisions of this nature?

CHAPTER 22 Respiratory Function 453

REFERENCES Agency for Health Care Research and Quality (AHCRQ). (2000). You

can quit smoking: consumer guide. Silver Springs, Md: the Agency. Andrews, P., & Habashi, N. (2010). Detecting, managing, and prevent-

ing pulmonary embolism. American Nurse Today, 5(9), 21–25. Barnett, M. (2009). An overview of assessment and management of

COPD. British Journal of Community Nursing, 14(5), 195–201. Bloom, H., Ahmed, I., Alessi, C., et al. (2009). Evidence-based recom-

mendations for the assessment and management of sleep disorders in older persons. Journal of the American Geriatrics Society, 57, 761.

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http://http:/www.cdc.gov

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455

Endocrine Function

Sue E. Meiner, EdD, APRN, BC, GNP and Dr. Jean Benzel-Lindley, PhD, RN

C H A P T E R

http://evolve.elsevier.com/Meiner/gerontologic

Previously dominated by diabetes and thyroid disease, geron- tologic 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 physiol- ogy 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, meta- bolic 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” is now discussed in terms of decreased estrogen produc- tion 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 molec- ular 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 ner- vous system (CNS) is one of the earliest measurable character- istics 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).

ENDOCRINE PHYSIOLOGY IN OLDER ADULTS Composed of ductless glands (Figure 23-1, A), which secrete 40 major hormones (Moore, Dalley, & Agur, 2010) that con- trol numerous processes throughout the body (Table 23-1), the endocrine system uses a delicate balance of chemical messen- gers 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 hor- mones 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).

L E A R N I N G O B J E C T I V E S 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.

Previous authors: Catherine Hill, DNP, RN, GNP-BC, Ann Peterson, MSN, RN, CDE, Karen Baker, MSN, RNC, and Carol Green-Nigro, MN, RN, PhD.

http://evolve.elsevier.com/Meiner/gerontologic

456 PART VI Nursing Care of Physiologic and Psychologic Disorders

Apoptosis (cell death) is a theme that has dominated cellu- lar 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: hypo- secretion, 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 sys- tems 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 somato- pause physiology without discussion of other potential super- imposed pathophysiologic states.

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

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.)

Hypothalamus

Capillaries from hypothalamus to anterior pituitary

Anterior pituitary

Corpus luteum

Positive feedback

(maintains progesterone production)

Inhibition of secretion of

releasing factors

Negative feedback (inhibits)

Follicle

Maturing oocyte

Inhibition of FSH release

Ovary

Releasing factors

FSH LH

Fertilized egg

Implanted embryo

Ovum

Progesterone

Stimulation of endometrium

Anterior pituitary

Estrogen

CRH

ACTH Cortisol

Adrenal cortex

TRH

TSH Thyroxine

ThyroidB

GnRH

FSH LH Estradiol

Ovary

� � � �

� �

CHAPTER 23 Endocrine Function 457

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, labo- ratory values to determine the endocrine decline are unique to each sex: luteinizing hormone (LH) and testosterone are of pri- mary 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, irri- tability, 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, poten- tial 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 hor- mones used in perimenopausal women (Simpson, 2012). The

NAME LOCATION FUNCTION AGING ENDOCRINE DISORDER

Thyroid Anterior aspect of neck Basal metabolic rate, growth, nutrition Obesity, hyperthyroidism, hypothyroidism, autoimmune thyroiditis, Graves disease, euthyroid sick syndrome, thyrotoxicosis, thyroid storm, multinodular toxic goiter

Parathyroid Near thyroid Calcium and phosphorus metabolism, muscular irritability

Osteoporosis, osteomalacia, Paget disease, hypocalcemia, hypercalcemia, hypophosphatemia, hyperphosphatemia, hypomagnesemia

Adrenal cortex Above each kidney Carbohydrate metabolism, salt–water balance, some sexual characteristics

Addison disease, Cushing syndrome, dehydration, hyponatremia, hypernatremia, hyperkalemia, hypokalemia

Adrenal medulla Embedded in kidney, surrounded by cortex

Sympathetic nervous system, carbohydrate metabolism

Acidosis, alkalosis

Anterior pituitary Base of brain Growth, sexual development, skin pigmentation, thyroid function, adrenocortical function (indirectly)

Hypopituitarism

Posterior pituitary Attached to anterior pituitary

Uterine contraction, water balance Dehydration, diabetes insipidus

Testes Scrotum Secondary sexual characteristics and function, metabolism

Andropause

Ovaries Pelvic cavity Secondary sexual characteristics and function, metabolism

Menopause

Pancreas Abdomen Sugar metabolism Diabetes type 1 or type 2, hypoglycemia Pineal gland Center of brain Daily biologic clocks Sleep disturbance Thymus Chest cavity Influences immune system response Immune senescence: reduced response to immunization,

cancer, monoclonal gammopathy, increased autoantibodies

Hypothalamus Brain Regulates autonomic nervous system; influences hormone production, sleep, and appetite

Kwashiorkor, obesity, hypothermia, hyperthermia, sleep disturbance

TABLE 23-1 PRINCIPAL ENDOCRINE GLANDS

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.

HYPORESPOSIVENESS HYPOSECRETION DEGRADATION CHANGES HYPERSECRETION

Increased connective tissue, pigment, and structural changes in target tissue

Plasma insulin-like growth factor T3

Thyroid hormones Cortisol Aldosterone

Norepinephrine Parathyroid hormone Atrial natriuretic peptide

Decreased receptor—ligand binding Aldosterone Inactive to active renin conversion Insulin Active renin Norepinephrine clearance Glucagon Calcitonin Arginine vasopressin Growth hormone

TABLE 23-2 AGING CHANGES IN THE ENDOCRINE SYSTEM

http://www.merckmanuals.com/professional/geriatrics.html

458 PART VI Nursing Care of Physiologic and Psychologic Disorders

2002 Women’s Health Initiative findings of increased breast cancer, heart disease, stroke, and blood clots from perimeno- pausal HR have been confirmed (Schierbeck, Rejnmark, Tofteng et al., 2012) and joined by evidence of improved metabolic syn- drome 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 con- tinue 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 mineralocor- ticoids, 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, pro- tein, and fat metabolism. The decline of DHEA with age par- allels 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 hor- mones (neurosecretion). Somatopause focuses on the neuron– hypothalamus–pituitary axis and the failure of CNS integration of the endocrine and nervous systems, which causes periph- eral 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–pituitary axis influences many age-related changes in nutrition, metabolism, body temperature, and circa- dian rhythms, circulation, salt–water balance, growth, and repro- duction. 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.

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, poly- cystic 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 inflam- matory cytokines correlating with the development of diabe- tes 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 (popula- tion 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 (includ- ing patients with 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 meta- bolic risk factors are detailed in (Box 23-1). Nutritional man- agement for metabolic syndrome should include meticulous attention to the amounts of low-saturated fats, trans fat, cho- lesterol, 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,

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 lev- els, blood pressure, and fasting glucose. Reinforce TLCs. Consider meal replacements.

Visit 4: Evaluate weight, waist circumference, LDL, HDL-C, triglyceride lev- els, blood pressure, and fasting glucose. Reinforce TLCs. Consider meal replacements. If no 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.

CHAPTER 23 Endocrine Function 459

drug therapy for elevations in blood pressure, low-density lipoprotein cholesterol (LDL-C), and glucose levels should be incorporated into the regimen.

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.

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 ves- sels (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 insulin release, and resistance to insulin-mediated glucose disposal (Nathan, Buse, & Davidson et al., 2009). As with metabolic syndrome, the most important variables asso- ciated 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 pathophysi-

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Nutrition 1. Mini Nutritional Assessment 2. Body mass index 3. Overweight: >10% over ideal 4. Obese: >20% over ideal 5. Triceps skin fold: >15 mm in

men or >25 millimeters (mm) in women

6. Lifetime weight trends 7. Thyroid function 8. Medications 9. Nutrition knowledge 10. Cultural issues 11. Comorbidities 12. Medications

1. Imbalanced Nutrition: More Than Body Requirements

1. Use calorie count and dietary log.

2. Use satiety and emotional scale.

3. Adjust seasonings, as needed (prn).

4. Introduce behavior modification techniques.

5. Provide teaching on medication and dietary recommendations of National Research Council Report for adults older than 65 years.

1. Review log and weight weekly.

2. Eat only at kitchen table. 3. Drink 8 ounces (oz) of water

before meal. 4. Limit fat, sweets, and

alcohol. Eat low-calorie snacks.

5. Control portions, eat slowly, wait 15 seconds between bites.

1. Patient is able to list dietary rules and reasons.

2. Patient demonstrates slow, steady weight loss toward goal.

3. Patient lists medication effects and dietary implications.

13. Social support network

Activity 1. Respiratory system 2. Cardiovascular system 3. Musculoskeletal system 4. Developmental status 5. Comorbidities 6. Medications 7. Cultural issues 8. Social support network

1. Activity Intolerance 2. Ineffective Health

Maintenance 3. Ineffective Coping

1. Accommodate comorbidities, sensory deficits, safety concerns, financial aspects.

2. Address motivation, lifestyle, and environmental barriers.

3. Provide role models and social support.

4. Include aerobic and strength training.

1. Assess resting vital signs and 3 minutes after activity.

2. Reduce intensity or duration of activity if pulse takes longer than 3 to 4 minutes to return within six beats of baseline.

3. Begin with active range-of- motion exercises twice a day; add isometrics. Gradually increase tolerance from 15 minutes.

1. Patient will progress to specified activity level.

2. Patient is able to verbalize and engage in health maintenance behaviors.

3. Patient will make decisions and follow through with appropriate actions.

4. Provide support, safety, and fall protection.

5. Use personal incentives such as playing with grandchildren, returning to work, or going fishing.

6. Teach primary and secondary prevention related to aging and sensory deficits.

7. Teach stress-related signs and symptoms.

TABLE 23-3 METABOLIC SYNDROME

Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.

460 PART VI Nursing Care of Physiologic and Psychologic Disorders

ology of diabetes mellitus - type 2 in contrast to type 1 diabe- tes 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 con- ditions: It affects 40% of the older adult population (Samuel, Petersen, & Shulman, 2010).

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 poly- uria, 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 clas- sic 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 infec- tions. When questioned, both men and women often attribute these changes to “aging.” Individuals are 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.

Insulin deficiency

↓ Glucose utilization by muscle and liver

↑ Gluconeogenesis Glycerol Lipolysis

↑ Glucagon

H�

Osmotic diuresis ↑ Liver FFA

↑ �-Hydroxybuterate ↑ Acetoacetate

↑ Free fatty acids (FFA)

Fatty acid oxidationHyperglycemia

Ketoacidosis

↑ Triglycerides

Shock

Hyperviscosity

Hemoconcentration

Lactic acidosisThrombosis

Prerenal azotemia

Ketonemia Ketonuria

Dehydration and hypovolemia

Loss of H2O, Na �,

K�, PO4 �

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.)

Type 1

I I

Type 2

Pancreas

Insulin-producing beta cellsBeta cells destroyed

Little or none

Normal number of receptors

• Defective insulin action • Receptor problems (rare) • Postreceptor problems (common)

Beta cells present

Variable: • Reduced • Normal • Above normal

Insulin receptors (needed for insulin

to be effective)

Insulin output

Body cells

FIGURE 23-3 Insulin defects in type 1 and type 2 diabetes mel- litus. (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.)

CHAPTER 23 Endocrine Function 461

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 pre- serve beta-cell function while controlling serum glucose levels (Figure 23-4). Five different oral drug classes are currently avail- able for use in diabetes management (Box 23-2). Some medi- cations prescribed for comorbid problems may make glucose control more difficult.

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 microvascu- lar 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.

Type 2 DM Nonketotic,

nondehydrated, not acutely ill, no

significant weight loss

Reassess every 3 months, if FPG

�240 mg/dL and HbA1C � 6.5%

Thiazolidinedione �

secretagogue

Thiazolidinedione �

biguanide

Thiazolidinedione �

secretagogue �

biguanide

Secretagogue �

biguanide

Add biguanide Add secretagogue Go to next stepAdd thiazolinedione

Reassess in 2 months, if FPG � 240 mg/dL or symptomatic

Increase secretagogue or biguanide to half the maximum effective dose

Discontinue secretagogue and initiate basal-bolus insulin therapy or

Consider adding bedtime insulin using either NPH or insulin glargine

Reassess every 3 months, if FPG � 240 mg/dL and HbA1C � 6.5%

Increase to half the maximum or to maximum effective doses

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

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.

462 PART VI Nursing Care of Physiologic and Psychologic Disorders

The nurse should ask a client about current medications, par- ticularly diuretics, beta-blockers, anticonvulsants, antihyper- tensives, 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 measure- ment and recent patterns of loss or gain, typical dietary pat- terns, changes in the sense of taste or smell, dentition, and ability to shop for and prepare foods. Because uncontrolled dia- betes 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 incontinence, constipation, and diarrhea. Stress incon- tinence, which is more common in older adults, may be intensi- fied 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 shel- ter. Older adults who live alone may eat little and be malnour- ished 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 pre- ferred 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 depres- sion 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 remem- ber 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 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 hypergly- cemia 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 feel-

ings of distress

Planning and Expected Outcomes The goal of nursing management for the older adult with dia- betes mellitus is the achievement and maintenance of desired blood glucose control, prevention of symptoms and complica- tions, and self-care management, when feasible. Expected out- comes 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.

CHAPTER 23 Endocrine Function 463

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. 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 melli- tus - 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 priori- ties. Once crises are resolved, the nurse may provide education to support diabetes management.

Education The nurse provides or coordinates education on a variety of rec- ommended 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 instruc- tions on when to contact the health care team. Teaching is facili- tated if older patients and significant others are actively involved in learning (e.g., having patients demonstrate glucose monitor- ing 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.

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, ath- erosclerosis, and hypertension. When a diet plan is established, nursing interventions are directed at supporting the dieti- tian’s recommendations through assessment of the patient’s understanding of and adherence to the plan (see Nutritional Considerations box).

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 ther- apy 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 signifi- cant other preparing the prescribed insulin dosages; observe the

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 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.

464 PART VI Nursing Care of Physiologic and Psychologic Disorders

patient actually injecting insulin; and note if the patient draws up an accurate amount of insulin, injects it into an appropri- ate site, and discards the sharp needle in a puncture-proof con- tainer. 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 appro- priate 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 regu- lar insulin.

PARAMETER METFORMIN TROGLITAZONE SULFONYLUREAS ACARBOSE

Mode of action Decreased hepatic glucose Decreased hepatic glucose Increased insulin secretion Alpha-glucosidase inhibition Increased skeletal muscle

glucose utilization Increased skeletal muscle

glucose utilization Decreased hepatic glucose

production Decreased carbohydrate

digestion and absorption from gastrointestinal tract

Glucose effects Fasting and postprandial Fasting and postprandial Fasting and postprandial Postprandial Hypoglycemia as monotherapy No No Yes No Weight gain No Possible Yes No Insulin levels Decreased Decreased Increased Decreased Side effects Gastrointestinal (self-limiting

symptoms of nausea, diarrhea, anorexia)

None; equal to placebo Potential allergic reaction if patient has sulfa allergy

Potential drug interactions (first-generation agents)

Gastrointestinal (flatulence, abdominal distention, diarrhea)

Syndrome of inappropriate antidiuretic hormone

Lipid effects Decreased Decreased Increased or decreased Decreased Starting dose for a 70-kilogram

(kg) man 500 milligrams (mg), twice daily

(bid), with meals 200 mg, once daily (qd), with

breakfast Varies with each agent:

glyburide 2.5 mg, qd; glipizide extended release (Glucotrol XL) 5 mg, qd; glyburide (Glynase) 3 mg, qd; glimeperide (Amaryl) 2 mg, qd

25 mg, three times a day (tid), with first bite of each meal

Maximum dose 850 mg, tid, with meals 600 mg, qd, with breakfast Varies with each agent: glyburide 10 mg, bid, glipizide extended release (Glucotrol XL) 20 mg, qd; glyburide (Glynase) 6 mg, bid; glimeperide (Amaryl) 8 mg, qd

100 mg, tid, with first bite of each meal

Contraindications Type 1 diabetes Type 1 diabetes Type 1 diabetes Type 1 diabetes Renal dysfunction

Hepatic dysfunction Hepatic dysfunction Inflammatory bowel

disease History of alcohol

abuse Bowel obstruction

Cirrhosis Chronic conditions associated

with hypoxia (asthma, chronic obstructive pulmonary disease, congestive heart failure [CHF])

Chronic conditions associated with maldigestion or malabsorption

Acute conditions associated with potential for hypoxia (surgery, acute myocardial infarction, CHF)

Situations associated with potential renal dysfunction (e.g., intravenous contrast media)

TABLE 23-4 COMMON ORAL MEDICATIONS FOR DIABETES MELLITUS - TYPE 2

CHAPTER 23 Endocrine Function 465

Older patients often require two insulin injections a day to adequately control blood glucose levels. Splitting the inter- mediate 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 sulfonyl- ureas are frequently used to lower blood glucose concentra- tions 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 hypoglyce- mia, which does not respond well to simple carbohydrates (Thompson, Vande, Linnebur, & Saseen, 2013). Recent stud- ies 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.

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 glu- cose 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 hypoglyce- mia prevents the more serious neuroglycopenic symptoms asso- ciated with moderate and severe hypoglycemia. Unrecognized and untreated hypoglycemia puts an individual with diabetes at risk for seizures and even death.

Emergency Identification Patients should be advised to carry medical emergency iden- tification. 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).

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 compli- cations 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 physi- ologic 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 patient’s capabilities and limitations are considered, an exer- cise 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 brace- let, 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 diabe- tes. 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 initia- tion 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

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

TABLE 23-5 HYPOGLYCEMIA LEVELS, SYMPTOMS, AND TREATMENT

466 PART VI Nursing Care of Physiologic and Psychologic Disorders

significant hyperglycemia during routine blood glucose testing and should contact the health care provider for specific instruc- tions on how to 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).

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.

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 di- gested 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

Angiopathy ? Neuropathy

Macrovascular disease

Small artery, arteriole, and microvascular

disease

Loss of sensation Muscle atrophy

Decrease in

perspiration

Painless trauma

Bone changes

Thrombosis with

large-vessel occlusion

Patchy or small areas of

gangrene

Atrophic skin

changes

Dry skin Cracks

Fissures

Ulceration

Mechanical Chemical Thermal

Deformed foot

Change in gait

New pressure

points Ulceration

Infection

Moderate-sized areas of gangrene

Infection Infection

Minor amputations

Extensive gangrene

Amputation

Diabetes mellitus

Large vessel Small vessel Autonomic Sensory Motor

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.)

care provider whenever they have questions or concerns or the treatment regi- men 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.

Sick day management is important in individuals with diabetes mellitus - type 2 because an untreated illness may lead to a complication called hyper- glycemic 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 mil- liosmoles per liter [mOsm/L] of water]). Treatment for this condition consists of insulin, intravenous fluids, and identification and treatment of the precipi- tating event (e.g., infection or cardiovascular problems) in the intensive care setting of a hospital.

CHAPTER 23 Endocrine Function 467

Foot care is the same for older adults as for other persons with diabetes. Daily inspection and cleansing of feet with non- drying 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 pre- vent 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 complica- tions 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 contrib- ute 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 to fever, erythema, warmth, discharge with ulcer- ation, 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 dis- tended 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 sig- nificant 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 treat- ment 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 achieve- ment 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 moni- toring 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 brace- lets or other emergency information. Patients may be asked to review their recent experiences with sick days and their manage- ment 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 self-care approach. The nurse may help a patient evaluate the effectiveness of self-care activities by direct exami- nation and through interview techniques.

The nurse should positively reinforce effective diabetes man- agement 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.

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 (hyper- functioning) 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 (T

3 ), 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 hyperthyroidism incidence of 2.5% to 6% in the geriat- ric 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).

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. 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).

468 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 hyperthy- roidism among older patients using amiodarone, a cardiac drug containing iodine, which deposits in tissue and delivers iodine to the circulation over long periods.

Subclinical hyperthyroidism, a condition in which an oth- erwise healthy, asymptomatic patient has a suppressed serum TSH level with normal thyroxine (T

4 ) and T

3 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 ill- ness, withdrawal from antithyroid drugs, or treatment with radioactive iodine (Cho et al., 2011).

Signs and Symptoms The classic geriatric presentation includes tachycardia, fatigue, trem- ors, 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 hyperthyroid- ism. The most common complication, occurring in 27% of geriat- ric hyperthyroid patients, is atrial fibrillation that does not convert back to sinus rhythm when a euthyroid state is achieved.

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 mil- ligrams 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 ad- mission. Hospitalization is necessary to treat the foot infection and his newly diagnosed diabetes.

■■ 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 dia-

betes 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 dia-

betes management, as evidenced by making appropriate diet selections, cor- rectly 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 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, drain-

age, 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 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, swell-

ing, 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 per- forms self-care skills and techniques.

CHAPTER 23 Endocrine Function 469

Medical Management Treatment of subclinical hyperthyroidism in older adults is con- troversial 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 regi- men needed for radioactive sodium iodine. Propranolol or other beta-blockers are frequently used to manage hyperthyroid- induced tachycardia.

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.

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 T

4 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 T

level because it corrects for abnormalities in the T 4 -binding pro-

teins. As the thyroid gland ages, it develops moderate atrophy, fibrosis, colloid nodules, and lymphocyte infiltration (Garg & Vanderpump, 2013). The production of T

4 decreases by about

30% between young adulthood and advanced age, but serum levels are usually maintained because of the body’s decreased use of T

4 as a correlate to the age-related decline in lean body mass.

Hypofunctioning thyroid states may result from defects in hor- mone production, target tissues, or receptors. When the defect

FIGURE 23-6 Simple goiter. (Courtesy of Bergman LV and Associates, Cold 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.)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

1. Weight loss trends over 3 and 6 months

2. Body mass index 3. Serum albumin and thyroid-

stimulating hormone 4. Mini Nutritional Assessment 5. MiniMental State Examination 6. Dysphagia 7. Manual dexterity 8. Financial resources 9. Dentition 10. Comorbidities 11. Medications 12. Social support 13. Cultural influences 14. Tachycardia, defined as >90

beats per minute (beats/min) 15. Fatigue

1. Imbalanced Nutrition: Less Than Body Requirements

2. Risk for Decreased Cardiac Tissue Perfusion

3. Fatigue

1. Teach disease, treatment and monitoring.

2. Teach dietary recommendations of the National Research Council Report for those older than 65 years.

3. Add 250- to 300-calorie snacks to increase body weight slowly.

4. Refer to Meals on Wheels, consultations, or other community resources as needed.

5. Monitor cardiovascular status.

1. Explain hyperthyroidism, complications, testing techniques, activity restrictions, dietary measures, medications, radioactive iodine therapy (if needed), surgery (if needed), eye care for exophthalmos (if needed).

2. Facilitate specific meal plans, procurement, preparation, and social support.

3. Monitor for pulse rate <90 beats/min, respiratory rate <22 breaths per minute, normal blood pressure, bibasilar crackles, decreased urine output, mentation changes, cool or mottled skin, distended neck veins, decreased saturation of arterial oxygen (SaO2).

1. Patient will increase intake as evidenced by gradual weight gain to normal range of body mass index.

2. Patient will maintain adequate cardiac output.

TABLE 23-6 HYPERTHYROIDISM

Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.

470 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 condi- tion is called secondary hypothyroidism. Tertiary hypothyroidism results from a defect in the hypothalamus.

Autoimmune thyroiditis is the most common cause of pri- mary 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 carbon- ate, amiodarone, and iodine. Other causes of hypothyroidism include ablation of the thyroid gland with radioiodine or sur- gery 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, incon- spicuous, 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).

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 T

4 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.

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 fre- quently in women, osteoporosis is a disease characterized by low bone mass leading to fragile bones that break easily. The geri- atric 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 for- mation; 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

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

1. Fatigue on a scale of 1 to 10 2. Onset, pattern, and

aggravating and relieving factors of fatigue

3. Effects of fatigue on activities of daily living (ADLs), instrumental ADLs (IADLs), mood, accident proneness, concentration, motivation, leisure activities, and libido

4. Depression Scale 5. MiniMental State

Examination 6. Laboratory values of

thyroid-stimulating hormone, hemoglobin, and hematocrit

1. Fatigue 1. Identify patient’s energy patterns and teach energy conservation.

2. Facilitate prioritization and delegation of tasks.

3. Teach disease pathophysiology, medication management, and monitoring.

4. Facilitate appropriate community and financial resource use.

1. Explain patient’s type of hypothyroidism, symptoms, complications, diagnostic tests, activity restrictions, dietary guidelines, lifelong therapy, and symptoms of accidental thyroid hormone overdose.

2. Work with patient to target ADLs and IADLs for patient performance, health care surrogate, and community services assistance.

1. Patient will achieve a balance of activity and rest.

2. Patient can verbalize pathophysiology, medication use, and monitoring required.

7. Comorbidities 8. Medications 9. Social support network 10. Weight as detailed in

Table 23-3

TABLE 23-7 HYPOTHYROIDISM

Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.

CHAPTER 23 Endocrine Function 471

is genetically determined, which supports the importance of family history in determining an individual’s risk.

Parathyroid hormone has also been shown to increase skel- etal 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 per- sons contributes to bone loss mediated by the aging parathy- roid gland, low daily exposure to natural sunlight, and reduced dietary intake. The primary role of calcium alone in maintain- ing 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 generally occurs in those in the sixth decade or older. Divided into primary and secondary types based on etiology, osteoporosis involves both the appen- dicular and axial skeleton. Other endocrine disorders such as parathyroid disease, Cushing syndrome, hypogonadism, alco- hol abuse, liver disease, and amenorrhea may cause secondary osteoporosis. Osteoporosis is diagnosed by dual x-ray absorp- tiometry (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 den- sitometry is frequently used on the heel; however, it is not con- sidered as reliable as DEXA scanning. A history of fractures after age 40, family history of osteoporosis, cigarette smok- ing, and low body mass index have all been shown to corre- late strongly with osteoporosis. Dorsal kyphosis, chronic back pain, and loss of height are common signs of primary osteo- porosis in older persons (Van Meirhaeghe, Bastian, Boonen et al., 2013).

Medical Management Calcium and vitamin D supplementation, exercise, and anti- resorptive 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 inter- national 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, bisphospho- nates, 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 hypertension as a comorbid condition because it decreases urinary calcium excretion, which slows bone loss.

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.

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 rel- atively high rate of sexual dysfunction exists among postmeno- pausal women (higher than men) (Cumming, Mauelshagen, & Parrish, 2010). A marked decline occurs in female sexual

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

1. Use of hormone replacement 2. Calcium and vitamin D intake 3. Exercise habits 4. Alcohol, caffeine, and protein

intake 5. Current or past use of

corticosteroids 6. History of thyroid, bowel,

kidney, or liver disease 7. Use of excessive thyroid

replacement 8. Weight as listed in Table 23-3 9. Comorbidities 10. Medications 11. Social support 12. Cultural influences

1. Ineffective Health Maintenance

1. Teach disease and medical management and dietary recommendations of the National Research Council Report for those older than 65 years.

2. Teach therapeutic lifestyle changes.

3. Ensure safety and fall awareness.

1. Teach pathophysiology, testing, medications, monitoring, complications, sources of support and information, and fall precautions.

2. Provide for supervised meal planning, encourage food label reading, and calcium and vitamin D supplementation.

3. Have patient undergo postural retraining and weight-bearing exercises.

1. Patient will have an absence of fractures, no falls, and improved bone mineral density.

TABLE 23-8 OSTEOPOROSIS

Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.

472 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 characteris- tic 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.

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 neuro- muscular 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 addi- tion, in FSD, neuroendocrine physiologic impairments inter- fere with the normal female sexual response and frequently bring about complaints of diminished sexual arousal, libido, genital sensation, and ability to achieve orgasm. Other physi- cal contributors to FSD include vaginitis, cystitis, endome- triosis, hypothyroidism, and diabetes mellitus. Drugs such as oral contraceptives, hormone replacement, antihypertensives, antidepressants, or sedatives can cause a sexual arousal disor- der as a side effect.

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 anti- psychotics 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, tes- tosterone, 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 expen- sive 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 pro- duce 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 fac- tors that may overlie physiologic ED.

Medical management of FSD includes watchful waiting, dose reduction of causative medications, testosterone replace- ment, sensate focus psychotherapy, and prescription of bupro- pion, 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, 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).

NURSING MANAGEMENT The nursing process in sexual dysfunction requires a biopsy- chosocial approach to the issues in ED and FSD, as detailed in Table 23-9.

1. Regularly assess homebound older adults diagnosed with endocrine disor- ders 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 writ- ten instructions to assist them in the learning process.

4. Instruct caregivers and homebound older adults about laboratory indica- tions 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 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 medi-

cations used to treat hormone imbalances associated with endocrine disorders.

HOME CARE

CHAPTER 23 Endocrine Function 473

SUMMARY This chapter discussed endocrine aging as an increased molecu- lar 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 cur- rent knowledge. Finally, the nursing process was applied to some of the most common endocrine diseases affecting older adults.

K E Y P O I N T S • 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 hor- mone resistance, a condition in which the tissue response to hor- mones 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 popu- lation. It is caused by improper nutrition, inadequate physi- cal activity, and obesity.

• Diabetes mellitus - type 2 is very common in the older population. • The most important variables associated with diabetes mel-

litus - 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 hypoglycemia and hyperglycemia), the patient’s learning style, and emergency identification.

• Management of serious wounds in older patients with diabe- tes 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.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

1. Genital anatomy 2. Sexual identity and sexual

behaviors 3. Sex drive 4. Fatigue 5. Emotional lability 6. Painful intercourse 7. Cultural influences 8. Partner availability 9. Available private time 10. Baseline function 11. Couple’s connectedness 12. Erectile dysfunction, ejaculatory

dysfunction, or anorgasmia 13. Depression 14. Comorbidities 15. Fears related to sexually

transmitted disease 16. Medications 17. Job or financial worries 18. Values or relationship conflicts 19. Alcohol or drug use 20. Energy level 21. Laboratory abnormalities

1. Ineffective Sexuality Pattern

1. Explore patient’s patterns of functioning.

2. Discuss relationship between sexual functioning and life stressors.

3. Reaffirm need for candid discussion between partners.

4. Intensive therapy: refer patient to appropriate therapist, counselor, or physician.

1. Permission: convey a willingness to discuss sexual matters.

2. Limited information: provide some information on likely situations and treatments.

3. Specific suggestions: offer some specific instructions based on patient’s acknowledged situation.

4. Identify and problem solve acute or chronic illness and other contributing factors.

1. Patient will achieve satisfactory sexual function.

TABLE 23-9 SEXUAL DYSFUNCTION

Data from Carpenito-Moyet, L.J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: JB Lippincott.

474 PART VI Nursing Care of Physiologic and Psychologic Disorders

• Thyroid hormone replacement should always be carefully monitored; follow-up appointments are essential for incre- mental 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 admin- ister 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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477

Gastrointestinal Function

Jennifer J. Yeager, PhD, RN

C H A P T E R

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 diges- tion, 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 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.

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 con- tribute to alterations in GI function. Misinformation about changes in GI function may lead to more complex problems because of fail- ure to seek health care or engage in appropriate preventive and treat- ment 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 absorp- tion 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 cardio- vascular 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

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.

L E A R N I N G O B J E C T I V E S 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.

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478 PART VI Nursing Care of Physiologic and Psychologic Disorders

bacterial infection and inflammation under the gum line, dam- ages bone and connective tissue. Teeth become loose, chewing becomes 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, anticho- linergics, 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 neutraliz- ing 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 pre- ventive oral care and early treatment efforts for older adults (Healthy People 2020 website, 2013).

Esophagus Age-related changes in the smooth muscle lining the esopha- gus contribute to a decrease in the strength of esophageal con- tractions 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 produc- tion of gastric acid, pepsin, bicarbonate, prostaglandins, and mucus. By 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 B

12 , calcium, and folic acid. Altered absorption and

decreased gastric acid production, combined with altered gas- tric 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 result- ing 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 sur- face. 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 con- stipation. 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 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 per- sons 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 repair or an inadequate response to regeneration of liver tissue.

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.

CHAPTER 24 Gastrointestinal Function 479

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.

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

*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. 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.

RISK CATEGORY AGE TO BEGIN RECOMMENDATION COMMENT

Increased Risk People with a single, small (<1 centimeter [cm])

adenoma 3–6 years after the initial

polypectomy Colonoscopy* If the examination is normal, the patient may

thereafter be screened per average risk guidelines.

People with a large (>1 cm) adenoma, multiple adenomas, or adenomas with high-grade dysplasia or villous change

Within 3 years after the initial polypectomy

Colonoscopy* If normal, repeat examination in 3 years; if normal then, the patient may thereafter be screened per average risk guidelines.

Personal history of curative-intent resection of colorectal cancer

Within 1 year after cancer resection

Colonoscopy* If normal, repeat examination in 3 years; if normal then, repeat examination every 5 years.

Either colorectal cancer or adenomatous polyps, in any first-degree relative before age 60 or in two or more first-degree relatives at any age (if not a hereditary syndrome)

Age 40, or 10 years before the youngest case in the immediate family

Colonoscopy* Every 5–10 years. Colorectal cancer in relatives more distant than first-degree does not increase risk substantially above the average risk group.

High Risk Family history of familial adenomatous

polyposis (FAP) Puberty Early surveillance

with endoscopy and counseling to consider genetic testing

If the genetic test is positive, colectomy is indicated. These patients are best referred to a center with experience in the management of FAP.

Family history of hereditary nonpolyposis colon cancer (HNPCC)

Age 21 Colonoscopy and counseling to consider genetic testing

If the genetic test is positive or if the patient has not had genetic testing, every 1–2 years until age 40, then annually. These patients are best referred to a center with experience in the management of HNPCC.

Inflammatory bowel disease, chronic ulcerative colitis, Crohn disease

Cancer risk begins to be significant 8 years after the onset of pancolitis, or 12–15 years after the onset of left-sided colitis

Colonoscopy with biopsies for dysplasia

Every 1–2 years. These patients are best referred to a center with experience in the surveillance and management of inflammatory bowel disease.

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

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. 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.

480 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 physi- ologic 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 spe- cific 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, assess- ment, 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 vasomo- tor function. Occasionally, stimuli from one center spill over to another and symptoms may become mixed (Figure 24-1).

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 pre- cedes 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 sur- rounding a complaint of nausea and vomiting. Data should be elicited about precipitating factors (e.g., the relationship of nausea 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 symp- toms 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 replace- ment should be a priority. Sips of fluids every 15 minutes until more can be tolerated may decrease episodes of dehy- dration. 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 ascer- tain 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, vom- iting, abdominal pain, diarrhea, and constipation. In addition, psychosocial factors such as stress, grief, pain, and concomitant illnesses may also need 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 impor- tant 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 medi- cal 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 dif- ficult, 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

Smell center

Sight center

Emetic center

Skeletal muscle

GI tract

Vestibular stimulation

CTZ

Eye

Nose

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.)

CHAPTER 24 Gastrointestinal Function 481

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 tis- sues. 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 dif- ferent site than the source of the pain but sharing the same der- matome). This type of pain is usually sharp and well localized; it may resemble somatic pain (Figure 24-2).

In assessing any type of pain, the nurse should elicit infor- mation about its duration, location, mode of onset (sudden or gradual), intensity, quality, rhythm, relationship to food, alle- viating 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 medi- cal care. Older adults are also less likely to exhibit leukocytosis (increased white blood cell [WBC] count), fevers, rebound ten- derness, 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 abdom- inal 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 nasogas- tric tube for decompression of the stomach; (3) monitoring and recording vital signs and reporting abnormal findings; (4) moni- toring intake and output accurately every hour; and (5) complet- ing an assessment on the onset of pain, presence of vomiting or diarrhea, and presence of fever and taking an accurate medical and surgical history.

Gas Belching, bloating, fullness, and flatus are some of the com- plaints 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 intes- tinal 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 con- sidered 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 mal- absorption; 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, exces- sive 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 intol- erant 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

Liver

Biliary colic

Cholecystitis, pancreatitis,

duodenal ulcer

Appendicitis

Colon pain

Heart

GERD

Peptic ulcer Renal colic

Small intestine pain, appendicitis

Ureteral colic

Pancreatitis Perforated duodenal ulcer Penetrating duodenal ulcer

Cholecystitis Pancreatitis, renal colic

Rectal lesions

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.)

482 PART VI Nursing Care of Physiologic and Psychologic Disorders

changes in dietary factors (e.g., focusing on eating more slowly and avoiding gas-producing foods) and a routine exercise plan.

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 diar- rhea, 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 (inter- mittent or continuous), associated factors (fever, weight loss, abdominal pain, vomiting, dietary or medication changes, and any systemic diseases), characteristics of the diarrhea (fre- quency, 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 func- tional 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 provid- ing emotional support as necessary. Usual water loss accom- panying 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 dehy- dration and volume depletion in older patients is important. Patients and their families need to be taught to report complica- tions 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 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 sec- ondary 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 func- tion (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 consti- pation in older adults is diet. It is usually a lack of certain foods, rather than the addition of certain foods, that leads to the prob- lem. For example, many foods such as fresh fruits and vegetables contain natural laxatives, although older adults may have dif- ficulty 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 defeca- tion. 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 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 func- tions. 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 avail- able. 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 sup- positories (bisacodyl, glycerin) may also be used, but they must

CHAPTER 24 Gastrointestinal Function 483

be retained for 20 to 30 minutes for optimal results and so may be more difficult for older patients to use.

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), neu- rologic problems (dementia, stroke, and spinal cord lesions), laxative abuse, unrecognized lactose intolerance, diabetic neu- ropathy, 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 pre- ventable 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 achiev- able 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.

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 pro- vides an explanation of the diagnostic tests used in this section.

Gingivitis and Periodontitis The gingivae, or gums, are subject to localized and systemic dis- eases, problems caused by drug therapy, poor oral hygiene, and poor nutrition. Gingivitis, an inflammation of the gums sur- rounding the teeth, may result in pain and bleeding; it may lead to periodontitis, a spreading of the inflammation to the underly- ing 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 com- promised immune systems and in those with suppressed immu- nity 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 unpleas- ant taste, burning, or itching or may be asymptotic (Duthie, Katz, & Malone, 2007).

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 deter- mine 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 rou-

tine, including regular professional dental care. 3. The patient will maintain normal body weight and nutri-

tional status.

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, 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 nor-

mal 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.

484 PART VI Nursing Care of Physiologic and Psychologic Disorders

TABLE 24-3 DIAGNOSTIC STUDIES: GASTROINTESTINAL SYSTEM

STUDY DESCRIPTION AND PURPOSE NURSING RESPONSIBILITY

Radiology Upper gastrointestinal (GI) or barium

swallow Radiography with fluoroscopy with contrast medium. Study is

used to diagnose structural abnormalities of the esophagus, stomach, and duodenum.

Explain procedure to patient, the need to drink contrast medium, and the need to assume various positions on x-ray table. Keep patient NPO (nothing by mouth) for 8–12 hours (hr) before procedure. Tell patient to avoid smoking after midnight the night before the study. After radiography, take measures to prevent contrast medium impaction (fluids, laxatives). Tell patient that stool may be white up to 72 hr after test.

Small bowel series Contrast medium is ingested and films taken every 30 minutes until medium reaches terminal ileum.

Same as for upper gastrointestinal (GI) series.

Lower GI or barium enema Fluoroscopic and radiographic examination of colon using contrast medium, which is administered rectally (enema). Double-contrast or air-contrast barium enema is test of choice. Air is infused after thick barium flows through the transverse colon.

Before the procedure, administer laxatives and enemas until colon is clear of stool evening before procedure. Administer clear liquid diet evening before procedure. Keep patient NPO for 8 hr before test. Instruct patient about being given barium by enema. Explain that cramping and urge to defecate may occur during procedure and that patient may be placed in various positions on tilt table.

After the procedure, give fluids, laxatives, or suppositories to assist in expelling barium. Observe stool for passage of contrast medium.

Ultrasonography Noninvasive procedure uses high-frequency sound waves (ultrasound waves), which are passed into body structures and recorded as they are reflected (bounded). A conductive gel (lubricant jelly) is applied to the skin and a transducer is placed on the area.

Abdominal ultrasonography Study detects abdominal masses (tumors and cysts) and is also used to assess ascites.

Instruct patient to be NPO 8–12 hr before ultrasonography. Air or gas may reduce quality of images. Food intake may cause gallbladder contraction, resulting in suboptimal study.

Hepatobiliary ultrasonography Study detects subphrenic abscesses, cysts, tumors, and cirrhosis and visualizes biliary ducts.

Same as abdominal ultrasonography.

Gallbladder (GB) ultrasonography Study detects gallstones. Same as abdominal ultrasonography. Esophageal endoscopic

ultrasonography Study detects and stages esophageal tumors. Fine-needle

aspiration can validate cancer or dysplasia. Same as upper GI endoscopy.

Computed tomography (CT) Noninvasive radiologic examination combines special x-ray machine used for CT that allows for exposures at different depths. Study detects biliary tract, liver, and pancreatic disorders. Use of contrast medium accentuates density differences.

Explain procedure to patient. Determine sensitivity to iodine if contrast material is used.

Magnetic resonance imaging (MRI)

Noninvasive procedure using radiofrequency waves and a magnetic field. Procedure is used to detect hepatic metastases and sources of GI bleeding and to stage colorectal cancer.

Explain procedure to patient. Contraindicated in patient with metal implants (e.g., pacemaker) or who is pregnant.

Virtual colonoscopy Technique combines CT or MRI with computer virtual reality software to detect colon and bowel diseases, including polyps, colorectal cancer, diverticulosis, and lower GI bleeding. Air is introduced via a tube placed in rectum to enlarge colon to enhance visualization. Images are obtained while patient is on back and stomach. Computer combines images to form two- and three-dimensional pictures, which are viewed on monitor.

Bowel preparation similar to colonoscopy (see Colonoscopy later in this table). Unlike conventional colonoscopy, no sedatives are needed and no scope is used. Procedure takes about 15–20 minutes (min).

Cholangiography Percutaneous transhepatic

cholangiography (PTC) After local anesthesia, liver is entered with long needle (under

fluoroscopy), bile duct is entered, bile withdrawn, and radiopaque contrast medium injected. Fluoroscopy is used to determine filling of hepatic and biliary ducts.

Observe patient for signs of hemorrhage or bile leakage. Assess patient’s medication for possible contraindications, precautions, or complications with the use of contrast medium.

CHAPTER 24 Gastrointestinal Function 485

Continued

TABLE 24-3 DIAGNOSTIC STUDIES: GASTROINTESTINAL SYSTEM—Cont'd

STUDY DESCRIPTION AND PURPOSE NURSING RESPONSIBILITY

Surgical cholangiography Study is performed during surgery on biliary structures such as gallbladder. Contrast medium is injected into common bile duct.

Explain to patient that anesthetic will be used. Assess patient’s medication for possible contraindications, precautions, or complications with the use of contrast medium.

Magnetic resonance cholangiopancreatography (MRCP)

Noninvasive study uses MRI technology to obtain images of biliary and pancreatic ducts.

Same as MRI.

Nuclear imaging scans (scintigraphy)

Purpose is to show size, shape, and position of organ. Functional disorders and structural defects may be identified. Radionuclide (radioactive isotope) is injected IV and a counter (scanning) device picks up radioactive emission, which is recorded on paper. Only tracer doses of radioactive isotopes are used.

Tell patient that substances contain only traces of radioactivity and pose little to no danger. Schedule no more than one radionuclide test on the same day. Explain to patient need to lie flat during scanning.

Gastric emptying studies Radionuclide study is used to assess ability of stomach to empty solids or liquids. In solid-emptying study, cooked egg white containing technetium-99 m (Tc-99 m) is eaten. In liquid-emptying study, orange juice with Tc-99 m is ingested. Sequential images from gamma-camera are recorded every 2 min for up to 60 min. Study is used in patients with emptying disorders from peptic ulcer, ulcer surgery, diabetes, or gastric malignancies.

Same as above.

Hepatobiliary scintigraphy (hepatic 2, 6-dimethyl-imidodiacetic acid [HIDA])

Patient is given intravenous (IV) injection of Tc-99 m and positioned under camera to record distribution of tracer in the liver, biliary tree, gallbladder, and proximal small bowel. Useful for identifying diffuse hepatic disease (such as cirrhosis or neoplasm), as well as for confirming acute cholecystitis.

Same as above.

Scintigraphy of GI bleeding Tc-99 m–labeled sulfur colloid or Tc-99 m labeling of the patient’s own red blood cells (RBCs) can accurately determine the site of active GI blood loss. The sulfur colloid or the patient’s RBCs are injected, and images of the abdomen are obtained intermittently.

Same as above.

Endoscopy Esophagogastroduodenoscopy

(EGD) Technique directly visualizes mucosal lining of esophagus,

stomach, and duodenum with flexible, fiberoptic endoscope. Test may use video imaging to visualize stomach motility. Inflammations, ulcerations, tumors, varices, or Mallory-Weiss tear may be detected. Biopsies may be taken and varices can be treated with band ligation or sclerotherapy.

Before the procedure, keep patient NPO for 8 hr. Make sure signed consent is on chart. Give preoperative medication if ordered. Explain to patient that local anesthetic may be sprayed on throat before insertion of scope and that patient will be sedated during the procedure.

After the procedure, keep patient NPO until gag reflex returns. Gently tickle back of throat to determine reflex. Use warm saline gargles for relief of sore throat. Check temperature every 15–30 min for 1–2 hr (sudden temperature spike is sign of perforation).

Colonoscopy Study directly visualizes entire colon up to ileocecal valve with flexible fiberoptic scope. Patient’s position is changed frequently during procedure to assist with advancement of scope to cecum. Test is used to diagnose inflammatory bowel disease, detect tumors, diagnose diverticulosis, and dilate strictures. Procedure allows for biopsy and removal of polyps without laparotomy.

Before the procedure, a bowel preparation is done. Type of preparation varies depending on physician. For example, patients may be kept on clear liquids 1–2 days before procedure. Cathartic and/or enema may be given the night before. An alternative is to give 1 gallon of polyethylene glycol (GoLYTELY, Colyte) evening before (8-ounce glass every 10 min). Explain to patient that flexible scope will be inserted while patient is in side-lying position. Explain to patient that sedation will be given.

After the procedure, be aware that patient may experience abdominal cramps caused by stimulation of peristalsis because the bowel is constantly inflated with air during procedure. Observe for rectal bleeding and signs of perforation (e.g., malaise, abdominal distention, tenesmus). Check vital signs.

486 PART VI Nursing Care of Physiologic and Psychologic Disorders

TABLE 24-3 DIAGNOSTIC STUDIES: GASTROINTESTINAL SYSTEM—Cont'd

STUDY DESCRIPTION AND PURPOSE NURSING RESPONSIBILITY

Capsule endoscopy Patient swallows a capsule with camera (approximately the size of a large vitamin) that provides endoscopic evaluation of GI tract. Most commonly used to visualize small intestine and diagnose diseases such as Crohn disease, celiac disease, and malabsorption syndrome and to identify sources of possible GI bleeding in areas not accessible by upper endoscopy or colonoscopy. Camera takes about 57,000 images during 8-hr examination. Capsule relays images to data recorder that patient wears on belt. After examination, images are downloaded to monitor.

Dietary preparation: similar to colonoscopy. The video capsule is swallowed, and the patient is usually kept NPO until 4–6 hr later. Procedure is comfortable for most patients. Eight hours after swallowing the capsule, the patient returns to have the monitoring device removed.

Peristalsis causes passing of the disposable capsule in feces.

Sigmoidoscopy Study directly visualizes rectum and sigmoid colon with lighted flexible endoscope. Sometimes, special table is used to tilt patient into knee–chest position. Test may detect tumors, polyps, inflammatory and infectious diseases, fissures, and hemorrhoids.

Administer enemas evening before and morning of procedure. Patient may have clear liquids day before, or no dietary restrictions may be necessary. Explain to patient knee–chest position (unless patient is older or very ill), need to take deep breaths during insertion of scope, and possible urge to defecate as scope is passed. Encourage patient to relax and let abdomen go limp. Observe for rectal bleeding after polypectomy or biopsy.

Endoscopic retrograde cholangiopancreatography (ERCP)

Fiberoptic endoscope (using fluoroscopy) is inserted through the oral cavity into descending duodenum; then common bile and pancreatic ducts are cannulated. Contrast medium is injected into ducts and allows for direct visualization of structures. Technique may also be used to retrieve a gallstone from distal common bile duct, dilate strictures, obtain biopsy of tumors, and diagnose pseudocysts.

Before the procedure, explain procedure to patient, including patient role. Keep patient NPO 8 hr before procedure. Ensure that consent form is signed. Administer sedation immediately before and during procedure. Administer antibiotics, if ordered.

After the procedure, check vital signs. Check for signs of perforation or infection. Be aware that pancreatitis is most common complication. Check for return of gag reflex.

Endoscopic ultrasonography

Combined use of endoscopy and ultrasonography using an ultrasound transducer attached to an endoscope. Enables visualization of the esophagus, stomach, intestine, liver, pancreas, and gallstones.

Similar to upper GI endoscopy.

Laparoscopy (peritoneoscopy)

Peritoneal cavity and contents are visualized with laparoscope. Biopsy specimen may also be taken. Done under general anesthesia in operating room. Double-puncture peritoneoscopy permits better visualization of abdominal cavity, especially liver. Technique may eliminate need for exploratory laparotomy in many patients.

Make sure signed consent form is on chart. Keep patient NPO 8 hr before study. Administer preoperative sedative medication. Ensure that bladder and bowel are emptied. Instruct patient that local anesthetic is used before scope insertion. Observe for possible complications of bleeding and bowel perforation after the procedure.

Blood Chemistries Serum amylase Study measures secretion of amylase by pancreas and

is important in diagnosing acute pancreatitis. Level of amylase peaks in 24 hr and then drops to normal in 48–72 hr. Depending on method, normal finding is 0–130 units per liter (units/L; 0–2.17 microkatal [μkat]/L).

Obtain blood sample in acute attack of pancreatitis. Explain procedure to patient.

Serum lipase Study measures secretion of lipase by pancreas. Level stays elevated longer than serum amylase. Normal finding is 0–160 units/L (0–2.66 μkat/L)

Explain procedure to patient.

Liver biopsy Percutaneous procedure uses needle inserted between sixth and seventh or eighth and ninth intercostal spaces on the right side to obtain specimen of hepatic tissue. Often done with ultrasonography or CT guidance.

Before the procedure, check patient’s coagulation status (prothrombin time, clotting or bleeding time). Ensure that patient’s blood is typed and cross-matched. Take vital signs as baseline data. Explain holding of breath after expiration when needle is inserted. Ensure that informed consent has been signed.

After the procedure, check vital signs to detect internal bleeding every 15 min × 2, every 30 min × 4, every hour × 4. Keep patient lying on right side for minimum of 2 hr to splint puncture site. Keep patient in bed in flat position for 12–14 hr. Assess patient for complications such as bile peritonitis, shock, and pneumothorax.

CHAPTER 24 Gastrointestinal Function 487

Intervention Nursing management of an older patient with gingivitis or periodontitis includes promotion of regular oral hygiene, regular preventive dental care, and maintenance of nutri- tional 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 medica- tions (e.g., acetaminophen), frequent mouth rinses, and a liquid or soft diet.

The key to treatment of gingivitis and periodontitis is pre- vention. 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 reg- ular 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 instruc- tions or explanations given to the patient. The patient’s response to recommended treatment measures should also be documented.

Dysphagia 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 ade- quate evaluation, nutrition, hydration, and safe positioning during meals to prevent aspiration. Dietary modification may be recommended following speech–language pathologist evalu- ation and modified barium swallow.

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 dyspha- gia. 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 sub- stances; 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

TABLE 24-3 DIAGNOSTIC STUDIES: GASTROINTESTINAL SYSTEM—Cont'd

STUDY DESCRIPTION AND PURPOSE NURSING RESPONSIBILITY

Miscellaneous Tests Gastric analysis Purpose is to analyze gastric contents for acidity and volume.

Nasogastric (NG) tube is inserted, and gastric contents are aspirated. Contents are analyzed mainly for hydrochloric (HCl) acid, but pH, pepsin, and electrolytes may be determined. Histalog and pentagastrin may be used to stimulate HCl acid secretion. Exfoliative cytology may be done to determine whether malignant cells are present. With fasting, normal acidity is 2.5 milliequivalents per liter (mEq/L; 2.5 millimoles [mmol]/L) and normal volume is 62 mL/hr; 30 min after Histalog or pentagastrin administration, normal acidity is 1.5 mEq/L (1.5 mmol/L) and normal volume is 110 mL/hr.

Keep patient NPO for 8–12 hr. Explain insertion of NG tube. Withhold drugs affecting gastric secretions 24–48 hr before test. Ensure no smoking morning of test (nicotine increases gastric secretion).

Fecal analysis Form, consistency, and color are noted. Specimen examined for mucus, blood, pus, parasites, and fat content. Tests for occult blood (guaiac test, Hemoccult, Hematest) are done.

Observe patient’s stools. Collect stool specimens. Check stools for blood with Hemoccult or Hematest. Keep diet free of red meat for 24–48 hr before guaiac test.

Stool culture Tests for the presence of bacteria, including Clostridium difficile. Collect stool specimen.

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.

488 PART VI Nursing Care of Physiologic and Psychologic Disorders

• 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. 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 diag-

nosis 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 informa- tion 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 fre- quent regurgitation. Optimizing nutritional status and prevent- ing 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, evalu- ation focuses on a patient’s ability to satisfactorily incorporate and adhere to the dietary recommendations and modify behav- iors and lifestyle to reduce symptoms.

Gastroesophageal Reflux and Esophagitis Gastroesophageal reflux disease (GERD) is a prevalent con- dition 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 tet- racycline, alendronate, potassium chloride, quinidine, aspirin,

ascorbic acid, nonsteroidal antiinflammatory drugs (NSAIDs), clindamycin, and theophylline. Older adults often take medica- tions 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 con- tact time between the esophageal mucosa and the gastric con- tents, as well as the acidity and quantity of gastric secretions. Additional causes of esophagitis include viral, fungal, or bacte- rial 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 pas- sage 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 aspi- ration 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 continu- ous type is least common, accounting for only about 10% of cases. Either part or all of the stomach, and even the intes- tines, 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 pos- ture (Lewis et al., 2011).

NURSING MANAGEMENT

Assessment Assessment begins with a history of symptoms and possible aggravating factors. Older patients may use terms such as indi- gestion 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 hoarse- ness, chest pain, postprandial fullness, respiratory symptoms,

CHAPTER 24 Gastrointestinal Function 489

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 gastroesopha- geal reflux include the following: 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 life- style 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 B

12 deficiency is a condition present in over 20% of

older adults. Malabsorption causes the majority of cases; how- ever, pernicious anemia accounts for about one fifth of known cases. Causes of malabsorption include gastritis, alcoholism, gastric surgery, inflammatory bowel disease, autoimmune dis- orders, and long-term use of proton-pump inhibitors (PPIs) or histamine-2 (H

2 ) blockers (Chaparro & Mauricio, 2013). In

pernicious anemia, degeneration of the parietal cells in the gas- tric mucosa leads to a decrease in production of the intrinsic factor, resulting in reduced absorption of vitamin B

12 . Vitamin

B 12

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 injec- tions of vitamin B

12 as oral vitamin B

12 is not well absorbed

(Lewis et al., 2011). However, supplementation with 1000 micrograms (mcg) cyanocobalamin orally has been shown to elevate B

12 levels, even in those with pernicious anemia. Oral

supplementation is preferred for older adults with malabsorp- tion or other causes of B

12 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).

Acute gastritis causes transient inflammation, hemorrhages, and erosion into the gastric mucosal lining. Although the cause may be undetermined, it is frequently associated with alcohol- ism, aspirin or NSAID ingestion, smoking, and severely stress- ful conditions such as burns, trauma, central nervous system (CNS) damage, chemotherapy, and radiotherapy.

Cricopharyngeus muscle (upper esophageal sphincter)

Aortic arch

Left bronchus

Diaphragm

Upper teeth

Angle of His

Stomach

Lower esophageal sphincter

Pleura

Peritoneum

Diaphragm

Peritoneal sac

Gastroesophageal junction

Positive intraabdominal

pressure

Thoracic part of esophagus with negative intrathoracic

pressure

B C

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.)

490 PART VI Nursing Care of Physiologic and Psychologic Disorders

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, vita- min deficiencies, chronic alcohol use, gastric mucosal atrophy, achlorhydria, and peptic ulceration. The continual loss of gas- tric 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 sen- sitivity 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 and the difficulty of stopping it once it has started, pre- ventive measures are routinely used to decrease hydrogen ion secretion and neutralize gastric acid. These include adminis- tration of antacids, as well as histamine blockers, sucralfate, or both.

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 sec-

ondary to acidity, or both

TABLE 24-4 GERONTOLOGIC DIFFERENCES IN ASSESSMENT: GASTROINTESTINAL SYSTEM

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.

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 decreased Constipation, fecal impaction

Pancreas

Pancreatic ducts distended, lipase production decreased, pancreatic reserve impaired

Impaired fat absorption, decreased glucose tolerance

CHAPTER 24 Gastrointestinal Function 491

• Deficient Fluid Volume, related to decreased intake, vomit- ing 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 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, avoid- ing aspirin and other NSAIDs, and seeking prompt medical atten- tion for symptoms of indigestion and epigastric pain.

Evaluation Evaluation includes documentation of achieved expected out- comes, a decrease in symptoms, and no evidence of GI hemor- rhaging 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).

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 gener- ates 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 associ- ated 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, develops ulcers. However, prolonged stress may produce a stress ulcer in anyone.

Gastric Ulcers In gastric ulcers, the level of hydrochloric acid secretion is usu- ally 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 gnaw- ing 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 duode- num, close to the pylorus. It is believed that the bacterium H. pylori migrates from the stomach to the duodenum in the pres- ence 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 pat- tern. The pain begins 2 to 4 hours after meals, and is immediately

Erosion Acute ulcer

Chronic ulcer

Scarring

Mucosa

Submucosa

Muscularis

Serosa

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.)

492 PART VI Nursing Care of Physiologic and Psychologic Disorders

relieved by food or antacids. The pain is located in the midepi- gastrium 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 duode- nal 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.

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, loca- tion, character, and especially alleviating and precipitating fac- tors. 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 stom- ach 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 out- comes for an older patient with PUD include the following: 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 smok-

ing, 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 modi- fications, and medications that may be used in the treatment plan. Lifestyle changes include cessation of smoking, cessa- tion 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 heart- burn and acid indigestion. Medications to reduce or prevent acid production (H

2 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 produc- tion 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 H

2 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 diaphore- sis 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 symp- toms. 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 pro- tozoal 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 pri- marily 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 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

CHAPTER 24 Gastrointestinal Function 493

they may remain for many years. Acute enteritis is a result of direct bacterial or viral infection or the effect of the toxins pro- duced 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 gen- eral, 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 elec- trolyte imbalances of hyponatremia and hypokalemia. Older adults are particularly at risk for dehydration and electrolyte imbalance. Prompt treatment is required.

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 poi- soning is suspected, the nurse should also question the patient regarding possible sources of contamination. Physical examina- tion includes inspection of mucous membranes and assessment of orthostatic blood pressure, temperature, and abdominal ten- derness. 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 electro-

lyte 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 elec- trolyte 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 impera- tive. 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 dehydra- tion and when to seek further medical care. Prevention of bac- terial 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 moni- toring 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 pri- marily 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.

Paralytic ileus involves decreased or absent peristalsis result- ing 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 isch- emia 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 muco- sal layer becomes necrotic, and peristalsis diminishes. Although intestinal or mesenteric ischemia is relatively rare, its high mor- tality rate and predominance in older adults make it important for nurses caring for older adults. Some degree of intestinal isch- emia 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 dis- ease, 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, gas- tric, biliary, and pancreatic secretions, along with water, elec- trolytes, and serum proteins, begin to accumulate in the area, causing an increase in intraluminal pressure. A third space

494 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 sever- ity 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 pro- duce an acute, severe abdominal pain with associated vomit- ing and diarrhea.

Abdominal distention will be present, especially if the obstruction is in the lower small intestine or colon. Percussion will elicit a tympanic sound because of the accumulation of gas and air in the bowel. Hyperactive bowel sounds are pres- ent above the site of a mechanical obstruction as the intes- tine 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 fecu- lent, depending on the level of the obstruction. Diarrhea may occur if the obstruction is not complete, allowing watery con- tents to pass. The patient may develop signs of dehydration and shock.

Complications of intestinal obstruction include perfora- tion of the bowel, chemical or bacterial peritonitis, hypovo- lemic shock, and septic shock. The increased pressure on the mucosa of the affected bowel segment may lead to bowel necro- sis, resulting in changes in the permeability of the bowel wall. Normal bacteria of the intestine may then escape into the peri- toneal cavity, causing peritonitis that may escalate to bactere- mia. Perforation of the thinned intestinal wall results in the loss of fluid into the abdominal space, chemical peritonitis, and pos- sible abscess formation. Infection and loss of fluid and electro- lytes 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.

NURSING MANAGEMENT

Assessment Assessment begins with a thorough history of the precipitat- ing event; the nurse should focus on the type and frequency of vomiting and diarrhea (e.g., profuse or fecal) and the location

D E F G

B C

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.)

CHAPTER 24 Gastrointestinal Function 495

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 char- acter 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 intesti- nal obstruction include the following: 1. The patient will maintain adequate fluid volume and electro-

lyte balance. 2. The patient will verbalize a tolerable level of discomfort. 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 overload- ing or dehydration, is important. Nasogastric or nasoin- testinal tubes are usually required for decompression, and maintenance of their patency and placement is imperative. Pain relief measures may include medication; however, nar- cotics 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, prepa- ration 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 heal- ing status is necessary.

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 diver- ticula 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 constipa- tion 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 diver- ticulosis. This is a disease of middle age and old age. The inci- dence of diverticulosis increases with age, and represents the fifth most important gastrointestinal disease in Western coun- tries 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 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, constipa- tion, 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 inflamma- tion, 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 peri- tonitis. 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 experi- ence some change in bowel habits; most complain of constipa- tion. 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 bleed- ing. Surgery may be necessary if an obstruction or perforation is suspected.

496 PART VI Nursing Care of Physiologic and Psychologic Disorders

NURSING MANAGEMENT

Assessment Assessment begins with an older patient’s history of elimination patterns and changes in these patterns such as frequency of def- ecation, 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., hemor- rhoids or bowel surgery), and family history of bowel problems

such as polyps or colon cancer are also important. With diver- ticulitis the patient may have fever and chills. A physical exami- nation 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

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 com- plaining 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 tell- ing 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 uncom- plicated 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 au- dible 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 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 elec- trolyte levels. Serum amylase was 500 units per deciliter (units/dL). Plain ab- dominal 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 consul- tation. 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 obstruc- tion or perforation. She was discharged to home on the eighth day after admis- sion. She resumed her previous medications.

■■ NURSING DIAGNOSES Deficient Fluid Volume, related to active loss of body fluid secondary to naso-

gastric tube output

Imbalanced Nutrition: Less Than Body Requirements, related to prolonged NPO status

Constipation, related to decreased mobility, daily ingestion of constipating medi- cations, 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. 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; spe-

cific 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. 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.

CHAPTER 24 Gastrointestinal Function 497

• 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.

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 con- stipation and the initiation of dietary changes. This includes teaching the patient and family about the development of diver- ticula 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 manage- ment (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 docu- sate), as necessary. Preventing constipation is of the utmost importance.

Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of complications, and main- tenance 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 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 develop- ing cancer.

The most common nonmalignant polyps are of the hyper- plastic 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.

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 examina- tion 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. 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 sig- moidoscopy 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 mem- brane inside the rectum or near the anal opening. These dila- tions are common and develop in susceptible people as a result of increase in pressure on the veins in the pelvic and rectal areas.

498 PART VI Nursing Care of Physiologic and Psychologic Disorders

Patients may be predisposed because of diarrhea or constipa- tion, 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 vary- ing 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.

NURSING MANAGEMENT

Assessment Assessment begins with an older patient’s history of constipa- tion 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 pro- lapsed 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.

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, includ- ing 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 toilet- ing 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 possibil- ity of a more serious disorder.

Evaluation Evaluation includes documentation of achievement of the expected outcomes, prevention of complications, and mainte- nance of regular bowel patterns and habits.

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, estro- gen, 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, pan- creatitis, or cholangitis (inflammation of the bile ducts).

Cholecystitis may be acute or chronic and is usually associ- ated 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, necro- sis, 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.

CHAPTER 24 Gastrointestinal Function 499

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 reliev- ers or changes of position) need to be documented. Physical examination may reveal a tender right upper quadrant and pos- sibly 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 pro-

cess, 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 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 cho- lecystitis may require hospitalization and may receive intrave- nous 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 symp- toms 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 bili- ary 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 pancre- atitis 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 pan- creas; activation of the enzymes is thought to result from reflux 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 under- stood (Evans & Draganov, 2006); however, the majority of cases are caused by chronic alcohol abuse. Additional factors in the development of chronic pancreatitis include hereditary pancre- atitis, cystic fibrosis, elevated triglycerides, cholelithiasis, and medications.

Symptoms include severe abdominal pain in the epigas- tric 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 continu- ous 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).

NURSING MANAGEMENT

Assessment Assessment begins with an older patient’s history of precipitat- ing 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

500 PART VI Nursing Care of Physiologic and Psychologic Disorders

Planning and Expected Outcomes Expected outcomes for an older patient with pancreatitis include the following 1. The patient will maintain adequate fluid volume and electro-

lyte balance. 2. The patient will obtain pain relief. 3. The patient will stabilize and maintain weight. 4. The patient will not experience complications.

Intervention Nursing management of an older patient with pancreatitis includes maintenance of fluid and electrolyte balance, establish- ing pain relief measures, and prevention of complications. This includes monitoring intravenous therapy, vital signs, intake and output, serum electrolyte values, and weight. Pain man- agement 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 pre- vention of recurrence. When pancreatitis results from alcohol abuse, teaching should focus on the need to avoid alcohol con- sumption to prevent future acute episodes. Referral and coun- seling 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 sup- port is important for patients who may need surgery.

Evaluation Evaluation includes documentation of achievement of expected outcomes, prevention of complications, prevention of recur- rence (for acute pancreatitis), and maintenance of adequate nutrition and hydration. Older adults who are addicted to alco- hol may go through withdrawal, requiring the nurse to care- fully 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, chemi- cals 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 hepatitis A. The primary mode of transmission of this organism is the fecal–oral route, commonly through inges- tion 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 rou- tine 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 individu- als may be asymptomatic or have subclinical symptoms; how- ever, 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 inflamma- tion 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 hepato- cyte, 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).

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 dis- ease 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, 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 con- valescent phase, jaundice and other symptoms disappear, and patients feel fully recovered. It is important that patients under- stand that it will take 3 to 6 months for the liver to return to its normal functioning status. Care should be taken with regard

CHAPTER 24 Gastrointestinal Function 501

to rest and drug and alcohol consumption during this phase; a relapse is possible.

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 per- form activities of daily living (ADLs) have decreased from base- line 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 knowl-

edge 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 following: 1. The patient will verbalize the causes of hepatitis, the treat-

ment 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 particu- lar 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 cer- tain 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.

TYPE A TYPE B TYPE C

Transmission Fecal–oral route (formerly called infectious hepatitis)

Parenteral; close personal contact (formerly called serum hepatitis)

Parenteral; close personal contact; primary cause of transfusion-related hepatitis

Incubation period May be spread without symptoms Spread: blood, semen, or other body fluid 2–6 weeks after exposure 6 weeks–6 months 20–90 days Risk groups Institutional populations, including daycare

centers, and travelers to endemic areas Intravenous drug use and sexual contact;

considered by the CDC to be a sexually transmitted disease

Recipients of blood or blood product transfusions

Course of disease Clinical course tends to be mild and of short duration; no residual liver disease after recovery.

Course more severe than with hepatitis A Milder course

Symptomatic usually less than 2 months 70% of adults and children older than 5 years will develop symptoms

Chronic state No 5% to 10% of patients asymptomatic or with subclinical symptoms; however, they remain contagious as long as antigen is present

40%–60%

Prevention/vaccination Yes Yes No 2 injections, 6 months apart 3–4 shots over a 6-month period Liver cancer risk None Yes (also other liver diseases like

cirrhosis) Yes

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.

http://www.cdc.gov/hepatitis/Resources/HealthProf.htm

502 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 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; how- ever, about 80% of cases in the United States are attributed to alcohol abuse.

The progressive loss of functioning liver tissue is mani- fested 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 clot- ting 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 dia- thesis in any patient with advanced liver disease, regardless of cause.

Ascites is the accumulation of serous fluid in the abdomi- nal cavity. It is the result of several factors relating to poor liver function, but the most important of these is the decreased pro- duction 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.

Neurologic Hepatic encephalopathy

Peripheral neuropathy Asterixis

Gastrointestinal Anorexia

Dyspepsia Nausea, vomiting

Change in bowel habits Dull abdominal pain

Fetor hepaticus Esophageal and gastric varices

Hematemesis Hemorrhoidal varices

Congestive gastritis

Reproductive Amenorrhea

Testicular atrophy Gynecomastia (males)

Impotence

Integumentary Jaundice Spider angioma Palmar erythema Purpura Petechiae Caput medusae

Hematologic Anemia Thrombocytopenia Leukopenia Coagulation disorders Splenomegaly

Cardiovascular Fluid retention Peripheral edema Ascites

Metabolic Potassium deficiency Hyponatremia Hypoalbuminemia

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.)

CHAPTER 24 Gastrointestinal Function 503

In addition to contributing to the development of ascites, portal hypertension and the backflow of venous blood cause severe problems with hemorrhoids, splenomegaly, and esophageal var- ices. The effect of portal hypertension on the esophageal veins is the most dangerous because these vessels are fragile and suscep- tible 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 inabil- ity 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 suc- cessful treatment. A patient with high ammonia levels will begin to exhibit changes in behavior, irrationality, agitation, combat- iveness, and muscle tremors (asterixis). If the condition remains untreated, hepatic coma ensues and has a mortality rate of 90%.

NURSING MANAGEMENT

Assessment Assessment of the patient with cirrhosis involves a careful his- tory 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 assess- ment of all body systems, especially the skin and abdomen, and respiratory and mental status is indicated. Assessment of nutri- tional 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

ADLs within current ventilatory function. 3. The patient will remain free from injuries and bleeding. 4. The patient will demonstrate resolution of cerebral dysfunc-

tion, 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 pres- sure 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 expan- sion 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 lim- ited. Mouth care should be provided before meals. The envi- ronment should be conducive to eating. Small, bland feedings may be given, especially if the patient complains of nausea. The nurse should consider the 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 individu- als with anorexia.

The nurse should encourage the patient to discuss feelings about self-esteem while maintaining a judgment-free envi- ronment at all times. The nurse should also reinforce positive abilities and traits and help the patient identify negative auto- matic 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 com- plications. 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 phar- macokinetics 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

504 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 indi- viduals. 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 pos- sibly hepatic failure, especially in older patients. Ingestion of poi- sonous 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, espe- cially with the cholestatic presentation. Hepatomegaly and other signs of liver damage may also appear. The onset of symp- toms may be immediate or several weeks to months after expo- sure 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 transplanta- tion, to death.

NURSING MANAGEMENT

Assessment In addition to the previously discussed assessments related to liver disease, it is essential that information be obtained regard- ing 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 hep- atitis 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 complica- tions of liver failure.

3. The patient will verbalize understanding of current medica- tions and their interactions.

Intervention Nasogastric suction, if required, needs to be explained and per- formed in a calm manner. The nurse should also discuss the adverse effect of certain medications with the patient and pro- vide written material as reminders to avoid these drugs. The nurse must monitor the patient carefully for signs and symp- toms 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 complica- tions 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.

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 adeno- carcinomas, 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 dyspha- gia, 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 treat- ment. 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 squa- mous cell carcinoma, risk factors include heavy alcohol con- sumption, 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 adenocarci- noma 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.

CHAPTER 24 Gastrointestinal Function 505

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 metas- tasis, results in a generally poor prognosis. The natural history of the disease includes esophageal obstruction, coughing, hic- cups, bleeding, malnutrition, cachexia, pneumonia, and death.

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 defini- tive 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. 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, pre- vention of aspiration, maintenance of comfort, and provision of emotional support. Optimizing nutritional status and pre- venting 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, assess- ment of difficulty with eating and drinking, and proper posi- tioning 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 fac- tors 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 preven- tion. 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).

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 environmen- tal and genetic factors, including diet (e.g., diets high in salt, nitrate preserved 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 gas- tric 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) lympho- mas, (2) gastrointestinal stromal tumors, (3) carcinoid tumors, and (4) rarely squamous cell carcinomas or small cell carci- nomas. 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

506 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 stom- ach (antrum) and worse for tumors that occur higher in the stomach (fundus).

NURSING MANAGEMENT

Assessment Assessment begins with a thorough history and review of symp- toms pertaining to the GI system, particularly symptoms that an older patient may not report unless asked. These include

indigestion, discomfort after eating, nausea, anorexia, vomit- ing, 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 medi- cations, 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:

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 dif- ficulty 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, tem- perature 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 sched- uled 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 in-

take of nutrients secondary to dysphagia 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 nec- essary, 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. 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.

CHAPTER 24 Gastrointestinal Function 507

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.

3. The patient will maintain adequate nutrition, as evidenced by stabilization and maintenance of weight and consump- tion of a well-balanced, high-calorie diet.

4. The patient will effectively manage pain, as evidenced by ver- balization 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 atten- tion 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 medi- cal attention. In addition, identifying those at risk and encourag- ing 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 coordi- nate with other health care team members regarding alternative care arrangements.

Colorectal Carcinoma Cancer of the colon and rectum accounts for 14% of all can- cers; 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 malignancy for both men and women. Colorectal cancer affects both genders equally, and the probability of devel- oping 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 rough- age is considered a risk factor for colorectal cancer. Genetic stud- ies 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 asymp- tomatic 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 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.

NURSING MANAGEMENT

Assessment Assessment begins with an older patient’s history of symp- toms such as diarrhea, constipation, abdominal pain, blood in stools, or melena. Generalized symptoms may have been over- looked by an older patient; these include malaise, weight loss, weakness, and fatigue. Eliciting a family history of colorec- tal 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

508 PART VI Nursing Care of Physiologic and Psychologic Disorders

Planning and Expected Outcomes Expected outcomes for an older patient with colorectal cancer include the following: 1. The patient will maintain recommended weight and ade-

quate nutrition. 2. The patient will verbalize comfort after taking an analgesic. 3. The patient will verbalize acceptance of permanent or tem-

porary body changes resulting from a colostomy.

Intervention Nursing management of an older patient with colorectal cancer depends on the stage of the disease and the treatment modali- ties 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 supple- ments such as Ensure or nighttime tube feedings may be nec- essary 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 asso- ciated 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 cur- able. 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 addi- tion, documentation of the patient’s methods of coping with the lifestyle changes imposed by the various treatment modali- ties is essential.

Pancreatic Cancer Pancreatic cancer accounts for approximately 2% of all cancer in the United States. Slightly more than 20% of affected indi- viduals survive for 1 year after diagnosis, and the 5-year sur- vival 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 environ- mental 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 infil- trate 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 rap- idly, 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 dis- ease 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.

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 termi-

nal 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.

CHAPTER 24 Gastrointestinal Function 509

Intervention 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 pro- longed use. Other nonpharmacologic measures of pain relief (e.g., diversional activities, repositioning, meditation, and mas- sage) 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 carci- noma) 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, diabe- tes, 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 metas- tasis is usually an indicator that the primary cancer is incurable. Weight loss is a common early finding in cases with metastatic liver disease. Signs 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.

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.

K E Y P O I N T S • 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 dis- ease 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 impor- tant risk factors for the development of GI cancers in older patients.

• Gastric ulcers have a higher incidence of becoming malig- nant compared with DUs.

• Intestinal ischemia should be included in the differential diagnosis of an older patient who has a history of cardiovas- cular 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.

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 home- bound 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, fre- quency, 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 maintaining hydration in the presence of GI disturbances.

8. Instruct caregivers and homebound older adults on all aspects of any treat- ments used to provide nutritional support in the absence of a functioning GI system (e.g., enteral nutrition, total parenteral nutrition, and formula supplements).

HOME CARE

510 PART VI Nursing Care of Physiologic and Psychologic Disorders

• Although 60% of polyps and cancers are visualized with flex- ible sigmoidoscopy, a colonoscopy is necessary to detect any suspected cancers in the right colon.

• Although treatment of asymptomatic gallstones is not cur- rently recommended, the rise in new therapeutic treatment options for cholecystitis should lead to a decline in morbid- ity and mortality previously associated with cholecystecto- mies in older adults.

• 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.

C R I T I C A L T H I N K I N G E X E R C I S E S 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 diag- nosis of cirrhosis of the liver. During the shift report, his pri- mary care nurse states that he has been agitated and anxious but has not exhibited any manifestations of alcohol with- drawal. 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.

REFERENCES Barker, L., & Zieve, P. (2007). Principles of ambulatory medicine (7th

ed.). Philadelphia: Lippincott, Williams & Wilkins. Berman, H., Brooks, L., & Silver, S. (2007). A rational approach to con-

stipation. Geriatrics and Aging, 10(10), 654–660. Centers for Disease Control and Prevention. (2009a). Oral cavity &

pharynx health. Retrieved April 10, 2009, from, http://www.cdc.gov/ pcd/issues/2009/jan/07_0237.htm.

Centers for Disease Control and Prevention. (2009b). Viral hepatitis. Retrieved April 10, 2009, from, http://www.cdc.gov/hepatitis/ Resources/HealthProf.htm.

Chaparro, O., & Mauricio, J. (2013). Vitamin B12 deficit and develop- ment of geriatric syndromes. Colombia Médica, 44(1), 43–47.

Chapman, J., Davies, M., Wolff, B., et al. (2005). Complicated diverticuli- tis: Is it time to rethink the rules? Annals of Surgery, 242(4), 576–583.

Davis, C. P. (2012). Viral hepatitis, Retrieved December 20, 2013 from, http://www.medicinenet.com/viral_hepatitis/.

Duthie, E., Katz, P., & Malone, M. (2007). Practice of geriatrics (4th ed.). Philadelphia: Saunders.

Eliopoulos, C. (2005). Gerontological nursing (6th ed.). St Louis: Lippincott Williams & Wilkins.

Evans, W., & Draganov, P. (2006). Is empiric cholecystectomy a rea- sonable treatment option for idiopathic acute pancreatitis? Nature Clinical Practice Gastroenterology & Hepatology, 3(7), 356–357.

Forsmark, C. (2008). The early diagnosis of chronic pancreatitis. Clinical Gastroenterology and Hepatology, 6(12), 1291–1293.

Ginsberg, D., Phillips, S., Wallace, J., & Josephson, K. (2007). Evaluating and managing constipation in the elderly. Urol Nurs, 27(3), 191–200 212.

Healthy People 2020 website. (2013). http://healthypeople.gov/2020/. Jarvis, C. (2008). Jarvis physical examination and health assessment (5th

ed.). St Louis: Saunders. Kane, R., Ouslander, J., Abrass, I., & Resnick, B. (2009). Essentials of

clinical geriatrics (6th ed.). New York: McGraw-Hill.

LeMone, P., & Burke, K. (2008). Medical surgical nursing: Critical think- ing in patient case (4th ed.). Upper Saddle River, NJ: Prentice Hall.

Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St Louis: Mosby.

McKenry, L., Tessier, E., & Hogan, M. (2006). Mosby’s pharmacology in nursing (22nd ed.). St Louis: Mosby.

Mindikoglu, A., & Miller, R. (2009). Hepatitis C in the elderly: Epidemiology, natural history, and treatment. Clinical Gastroenterology and Hepatology, 7(2), 128–134.

Nettina, S. (2009). A new look at vitamin B 12

deficiency. The Nurse Practitioner, 34(11), 18–24. http://dx.doi.org/10.1097/01. NPR.0000363588.59740.6f.

Petruzziello, L., Iacopini, F., Bulajic, M., et al. (2006). Uncomplicated diverticular disease of the colon. Alimentary Pharmacology and Therapeutics, 23(10), 1379–1391.

Pilotto, A., Franceschi, M., Maggi, S., Addante, F., & Sancarlo, D. (2010). Optimal management of peptic ulcer disease in the elderly. Drugs & Aging, 27(7), 545–558.

Price, S. A., & Wilson, L. M. (2003). Pathophysiology: Clinical concepts of disease processes (6th ed.). St Louis: Mosby.

Rubin, E., & Reisner, H. (2009). Essentials of Rubin’s pathology. Philadelphia: Lippincott Williams & Wilkins.

Shaheen, N. J. (2006). Effects of aging on the digestive system. Retrieved December 2, 2013, from, http://www.merckmanuals.com.

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.

Tazkarji, M. (2008). Abdominal pain among older adults. Geriatrics and Aging, 11(7), 410–415.

Wolfe, M. (2006). Therapy of digestive disorders (2nd ed.). Philadelphia: Saunders Elsevier.

http://www.cdc.gov/pcd/issues/2009/jan/07_0237.htm

http://www.cdc.gov/hepatitis/Resources/HealthProf.htm

http://www.medicinenet.com/viral_hepatitis/

http://healthypeople.gov/2020/

10.1097/01.NPR.0000363588.59740.6f

http://www.merckmanuals.com

511

Musculoskeletal Function

Laurie Kennedy-Malone, PhD, GNP-BC, FGSA and Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA, PhD-C

C H A P T E R

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 arthri- tis 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 musculo- skeletal 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 impair- ments 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 transpor- tation, 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).

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 elastic- ity 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 flex- ion. Changes in posture result in a shift in the center of gravity. In men, the gait becomes small stepped with a wider-based stance.

L E A R N I N G O B J E C T I V E S 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.

Previous authors: Karen Van Dyke Lamb, BS, MS, ND, CS; Marilyn Cummings, MS, RN; and Sue E. Meiner, EdD, APRN, BC, GNP.

http://evolve.elsevier.com/Meiner/gerontologic

512 PART VI Nursing Care of Physiologic and Psychologic Disorders

Women become bowlegged (genus varus), have a narrow stand- ing 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.

All the changes mentioned may cause pain, impaired mobil- ity, 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); mod- erate 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 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 tra- jectory, which may ultimately result in death. Falls may also cause a cycle of disuse. This pattern of disuse usually occurs after the indi- vidual 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

BONE REMARKS BONE REMARKS

Frontal Thicker in black men than in white men Femur Convex anterior: Native Americans Parietal/

occipital Thicker in white men than in black men; occipital

protuberance palpable in Eskimos Straight: blacks

Intermediate: whites Palate Tori (protuberances) along suture line of hard

palate, which is problematic for denture wearers

Pelvis Hip width 1.6 centimeters (cm) (0.6 inch) smaller in black women than in white women; Asian American women have significantly smaller pelvises

Incidence: Blacks: 0%

Second tarsal Second toe longer than great toe Incidence:

Whites: 24% Whites: 8% to 34% Asian Americans: up to 50% Blacks: 8% to 12% Native Americans: up to 50% Vietnamese: 31% Mandible Tori (protuberances) on lingual surface of mandible

near canine and premolar teeth, which is problematic for denture wearers

Height Melanesians: 21% to 57% Clinical significance for joggers and

athletes Most common in Asian Americans and Native

Americans; exceeds 50% in some Eskimo groups

White men 1.27 cm (0.5 inch) taller than black men and 7.6 cm (2.9 inches) taller than Asian American men

Humerus Torsion or rotation of proximal end with muscle pull White women equal to black women

Radius/ulna

Larger in whites than in blacks Torsion in blacks is symmetric; torsion in whites

usually greater on right side than on left Length at wrist variable

Composition of long bones

Asian American women 4.14 cm (1.6 inches) shorter than white or black women

Longer, narrower, and denser in blacks than in whites; bone den- sity in whites greater than in Chinese, Japanese, and Eskimos

Ulna or radius may be longer Osteoporosis lowest in black men; highest in white women Equal length: Peroneus tertius Responsible for dorsiflexion of foot Swedish: 61% Muscle absent:

Chinese: 16% Asian Americans, Native Americans, and white: 3% to 10% Ulna longer than radius:

Swedish: 16% Chinese: 48%

Blacks and Berbers: 10% to 15% (Sahara desert): 24% No clinical significance because tibialis anterior also dorsiflexes

the foot Radius longer than ulna: Palmaris longus Responsible for wrist flexion Swedish: 23% Muscle absent: Chinese: 10% Whites: 12% to 20% Vertebrae 24 vertebrae found in 85% to 93% of all people;

racial and gender differences reveal 23 or 25 vertebrae in select groups (23 vertebrae in 11% of black women; 25 vertebrae in 12% of Eskimo and Native American men)

Native Americans: 2% to 12% Blacks: 5% Asian Americans: 3% No clinical significance because three other muscles are also

responsible for flexion Related to lower back pain and lordosis

Data from Overfield, T. (1995). Biologic variation in health and illness: Race, age, and sex differences (2nd ed.). Boca Raton, FL:, CRC Press.

CULTURAL AWARENESS Biocultural Variations in the Musculoskeletal System

CHAPTER 25 Musculoskeletal Function 513

prevented through the use of regular programs of active exercise and resistive muscle strengthening (Chen, Tseng, Chang, Huang, & Li, 2013).

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) frac- tures, vertebral fractures, and clavicular fractures. Fractures are classified as open or closed by the location and type of fracture (Ensrud, 2013) (Figure 25-1).

The completed process of bone healing is termed union. After fractures occur, regenerative cells (fibroblasts and osteo- blasts) 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 frag- ments 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 • Color • Temperature • Pulse • Sensation If fracture is open and bleeding is present: • Apply pressure. • Apply sterile dressing. • Immobilize the fracture site.

Avulsion Comminuted Displaced Greenstick

Impacted Longitudinal Oblique

Pathologic Spiral Stress Transverse

Interarticular

I J K L

F G H

B C D

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 frag- ments appear to be floating. C, A displaced (overriding) frac- ture 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 perios- teum 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 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.)

514 PART VI Nursing Care of Physiologic and Psychologic Disorders

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).

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 surgi- cal repair depends on the location and type of fracture and may

include internal fixation with pins, plates, and screws, or prosthetic replacement of the femoral head (Schneider, Williams, Brancati, et al., 2013) (Figure 25-4).

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

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 perspec- tives (8th ed.). St. Louis, MO: Mosby.)

FIGURE 25-3 Buck extension. Heel is supported off bed to pre- vent 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 flex- ion 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.)

A B 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.)

CHAPTER 25 Musculoskeletal Function 515

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 pres- ence 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 immobiliza-

tion 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 indepen-

dence and recovery period needed for fracture healing

Planning and Expected Outcomes Nursing care of a patient with a hip fracture involves the periop- erative, postoperative, and rehabilitation periods. Each of these stages of treatment and recovery requires specific nursing inter- ventions and includes the following expected outcomes: 1. The patient will report minimum discomfort and an ade-

quate level of pain control. 2. The patient will remain free from postoperative complica-

tions 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 occu-

pational 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 condi- tions. During this preoperative period, the nurse’s main focus is on keeping the patient comfortable and hydrated and prevent- ing complications of immobility. Preoperatively, hip fractures may produce severe muscle spasms, causing intense pain. Pain medications, traction, or immobilization and proper position- ing are used to manage the pain. Preoperative education should include information regarding the surgical procedure, postop- erative treatments, potential complications, and expected out- comes 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 bleed- ing. Movement, circulation, and sensation of the extremity are assessed to determine impaired circulation. Mental status should be assessed and any changes noted. Postoperative delir- ium 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 poten- tial for delirium. Care planning should include familiarizing the patient with his or her surroundings, providing for safety, instituting comfort measures, decreasing anxiety, and assist- ing with maintaining a sense of independence and identity (see Evidence-Based Practice: Changes to Home Environment after Identifying the Location of Home Falls).

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, respi- ratory 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

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 ran- domized 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 com- plete 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, 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 in- dividual 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.

516 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 hemiar- throplasty are at risk for dislocation. The nurse should give the patient and family instructions on preventing disloca- tion. 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 adduct- ing the legs when lying on the nonoperated 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, com- prehensive interdisciplinary rehabilitation focuses on returning the patient to the prior level of function and preventing dis- ability (Della Rocca, Moylan, Crist et al., 2013). Specific areas of treatment are gait and transfer training, muscle strengthen- ing through active assistive exercises, teaching the use of adap- tive 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).

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 ther- apy 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 abili- ties, 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 surgi- cal site and intact skin integrity. Muscle strength, joint move- ment, 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).

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.

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:

• 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.

CHAPTER 25 Musculoskeletal Function 517

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 neuro- vascular 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.

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 notice- ably deformed, dropping downward, forward, and inward. Treatment of a clavicular fracture includes reduction of the fracture and immobilization with a sling or cast. Nursing mea- sures 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 pro- viding pain relief and protect the injured bone from becom- ing contaminated (Boyd, Benjamin, & Asplund, 2009). They maintain proper positioning of the injured area, prevent fur- ther deformity, protect realigned bones, and promote healing. Used on the lower extremities, they may also allow for earlier weight bearing.

Casting materials include plaster of Paris or synthetic mate- rials 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 physi- cian approval and should be dried thoroughly afterward. A hair dryer set at a low temperature may be used for this purpose.

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

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 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. 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.

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.

518 PART VI Nursing Care of Physiologic and Psychologic Disorders

assessment for potential areas of skin irritation or breakdown. The patient should be instructed to report any redness or dis- comfort 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.

Osteoarthritis Osteoarthritis, also known as degenerative joint disease, is a noninflammatory disease of joints that is characterized by pro- gressive 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 predis- posing factors in the development of osteoarthritis. The under- lying 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, par- ticularly 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 into contact with each other. This results in joint pain. The distal interphalan- geals, 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 sen- sation, 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 enlarge- ments, called Heberden nodes (Figure 25-7), may be seen on

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.)

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.)

A B C D

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the distal interphalangeals, and Bouchard nodes are the nodules of the proximal joints (LeBlond, Brown, & DeGowin, 2009).

NURSING MANAGEMENT

Assessment Nursing assessment of a patient with osteoarthritis begins with taking a thorough history of the problem. Data gath- ered include information about the onset, location, qual- ity, 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; medica- tions 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: 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).

The physician may also prescribe various nonsteroidal anti- inflammatory drugs (NSAIDs) and nonopioid analgesics to control the pain. Patients may initially be given OTC medica- tions and then gradually be advanced to a prescription antiin- flammatory 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 treat- ment options for more severe pain may include directly inject- ing 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 medi- cations, 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 pro- cedures 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

EVIDENCE-BASED PRACTICE Osteoarthritis and Benefits of Regular Exercise

Background Age is the most strongly associated factor in the development of osteoar- thritis. 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 osteoarthri- tis in later life.

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, out- comes, subjects involved, and interventions.

Findings The authors judged that too wide a set of variations existed in how the exer- cise regimens were conducted to allow for clear comparisons between pro- grams 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 osteoar- thritis 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.

520 PART VI Nursing Care of Physiologic and Psychologic Disorders

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 sur- gery. 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 compli- cations, and the postoperative course. After surgery the goals of nursing care are to prevent complications, relieve surgi- cal pain, and assist the patient in achieving a higher level of function and activity. Major complications after joint replace- ment 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 post- operative period include measures to prevent infection, con- trol pain, and assist with daily activities. Aseptic precautions should be taken with surgical wound dressings, urinary cath- eters, 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 com- plication. The incidence of deep infection of joint replacement sites is 0.5% to 1%. The infection may be a result of contamina- tion 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 cor- ticosteroid 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 pro- longed rehabilitation. Various prophylactic measures should be ordered to prevent DVT. These may include various lower extremity compression devices, oral or injectable anticoagu- lants, and physical therapy to mobilize the patient (Ramzi & Leeper, 2004).

Pain control during the first 24 to 48 hours may be accom- plished with intravenous or epidural administration of narcotic analgesics. Patient-controlled analgesia is frequently used to pro- vide 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.

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 proce- dure 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 out- lined 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 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 becom- ing 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

PATIENT/FAMILY TEACHING 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.

CHAPTER 25 Musculoskeletal Function 521

with spinal stenosis may develop claudication-like symptoms of burning and numbness in their lower extremities (Briggs, Kaplan, Eskander, & Franklin, 2010; Pacala & Sullivan, 2010).

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 identi- fied. 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 bilat- eral and generally worsens with prolonged standing or activ- ity. 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 walk-

ing 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 ste- nosis 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 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 toler-

ance of activity. 3. The patient will be able to incorporate a plan for lifestyle

modifications that includes