Older Adults and Their Care

COURSE PRICE: $39.00

CONTACT HOURS: 6

This course will expire or be updated on or before December 1, 2014.

ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.

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Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.


Older Adults and Their Care

By Nancy Evans, BS

Nancy Evans is a health science writer and editor with more than three decades of experience in healthcare publishing. She served as senior editor at Mosby/Times Mirror, senior editor in the health sciences division of Addison-Wesley, and senior medical editor at Appleton & Lange. A breast cancer survivor since 1991, she has written and spoken extensively on breast cancer issues. Nancy co-produced the HBO documentary film Rachel's Daughters: Searching for the Causes of Breast Cancer. She is also the co-producer of Children and Asthma, a KQED documentary film, and the documentary, Good Food, Bad Food: Obesity in American Children.

COURSE OBJECTIVE:  The purpose of this course is to provide information for healthcare providers on the demographics of aging, age-related changes in health status, medication use and misuse, assessment of geriatric patients, supporting family caregivers, elder abuse, and end-of-life care and hospice.

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

  • Summarize the goals of care for the older adult.
  • List the most important age-related physical and psychosocial changes.
  • Discuss the altered effects of drugs on older people and their implications for care.
  • Describe the assessment of physical and psychosocial function in the older adult.
  • Identify factors that distinguish between reversible confusion and dementia.
  • Explain strategies for supporting family caregivers.
  • State the risk factors and signs of elder abuse.
  • Describe the principles of hospice and palliative care.

We have entered the aging century. …Not only will greater numbers of people have chronic diseases, such as heart failure or cancer, but also many will develop disabling geriatric conditions, such as dementia, difficulty walking, falling, or incontinence.
—KAO & LANDEFELD (2010)

The graying of America has a lot of people worried—not just seniors themselves, but public policy makers and health professionals. Caring for people age 65 and older can be complicated. Just as children are not small adults, older people are not just gray-haired 35 year olds. They’re different inside and out.

Age-related changes affect the function of every body system, even in the healthiest people 65 and older. Heart output declines. Calcium migrates from bones and teeth into blood vessels. Cataracts dim vision. Hearing fades. Lung, liver, and kidney functions slow. Wear and tear on joints makes pain an unwelcome companion. However, these changes do not automatically equate with disability. Regular exercise, a healthy diet, and social and intellectual stimulation can help prevent or delay disease and disability.

Normal age-related changes may be accompanied by chronic health problems such as diabetes or heart disease. Combined, these factors increase the complexity of care. But early diagnosis and effective management of chronic conditions can enable older adults to enjoy their later years as functional, active, independent members of their community.

Management of most chronic conditions means that one or more medications are prescribed for regular use. Although medications may relieve symptoms, improve the quality of life, and in some cases increase the lifespan, they are not without risk. For example, research has shown that taking four or more prescription drugs is an independent risk factor for falls. And a fall can catapult an independent older adult into the ranks of the frail elderly.

Most health professionals who care for older adults are not geriatricians or geriatric nurse specialists but primary care providers. Some may never have had a formal course in geriatrics. In many cases, the care provider is much younger than the patient and may be from a different racial or ethnic background. This makes patient-provider communication challenging, but it also offers an opportunity for mutual learning.

This course can serve as an introduction to essential information for providing competent, compassionate care to older people. It describes the demographics of aging in America, including health disparities, and focuses on common age-related changes in older people, medication use and misuse, and functional assessment. In addition, it discusses supporting family caregivers, preventing elder abuse, and planning end-of-life care.

DEMOGRAPHICS OF AGING

How old is old? What does it mean to be old?

As the first wave of the 77 million baby boomers born between 1946 and 1964 moves beyond their sixtieth birthdays, they are seeking answers to those and many other questions about growing older. Public health professionals and policy makers are seeking ways to prepare for a society in which the number of people over 65 will nearly double in the next twenty years. By 2030, 1 in 5 Americans will be over 65 years of age. People in this age group today are the greatest consumers of healthcare services in the United States.

Many people in their sixties and seventies lead active, independent lives, enjoying sports, travel, and hobbies, sometimes in addition to full-time employment. However, some experts suggest that baby boomers’ health is declining, based on the findings of the Health and Retirement Study (National Institute on Aging, 2007). This study of 20,000 Americans over age 50 found that those born between 1949 and 1954 reported having more pain, chronic health conditions, and alcohol and psychiatric problems than people who were the same age twelve years earlier.

A major reason cited for declining health among older adults is the epidemic of obesity, which affects about one third of people ages 65 to 74. Obesity increases the risk of type 2 diabetes and osteoarthritis, both of which diminish quality of life, and in the case of osteoarthritis, compromise mobility.

According to the Agency for Healthcare Research and Quality (2008), three quarters of Americans age 65 and older have two or more chronic conditions. Those with access to healthcare seek treatment for early symptoms of chronic conditions and invest in “active control strategies,” which can often improve their health and prevent further decline and disability (Wrosch & Schulz, 2008).

Growing older doesn’t mean living in a nursing home. In fact, the number of nursing home residents has declined to less than 8% of Americans ages 75 and older. Today’s seniors have a range of choices for housing and care, depending on their socioeconomic status and their health. These choices include aging in place (staying in their own homes by modifying them and arranging for home healthcare services as needed) and moving to a retirement community or an assisted living or life care facility. In addition, some older people who can no longer live alone move in with their children or other relatives.

Nearly two thirds of people over age 65 will need long-term care at home, through adult day healthcare, or in an assisted-living facility or nursing home. Nationally, the median annual rate for a one-bedroom/single-occupancy unit in an assisted-living facility is $39,132. Nursing home care is even more expensive, and many Americans are financially unprepared for this type of care. The median annual rate for a private nursing home room is $77,745 (Genworth, 2011). When savings run out, those who need nursing home care must enroll in Medicaid, which can bankrupt individuals and might eventually bankrupt the healthcare system.

Attitudes about Aging

People’s beliefs and attitudes about aging can affect how they age. Researchers found that people who held negative beliefs about aging and health in 1975 were more likely to have had heart attacks or strokes 30 years later. Those who had more positive beliefs about growing older were more likely to have better health habits (eating a balanced diet, maintaining a healthy weight, and not smoking) and fewer cardiovascular events (Levy et al., 2009).

A large Australian study found that beliefs about control, social support, and physical exercise affected functional health in midlife and old age. Those who believed they had some control over what happened in their life and how their actions could influence desired outcomes such as good health reported fewer and less severe symptoms, faster recovery from illness, and higher functional status. People with positive social relationships and interaction were healthier than those who were isolated. Being socially active and engaged tended to result in a healthier lifestyle, including regular physical exercise (Lachman & Agrigoroaei, 2010).

Health Disparities in Aging

Today’s Americans enjoy longer life than previous generations, although life expectancy at age 65 is lower than that of other industrialized countries (Federal Interagency Forum on Age-Related Statistics, 2008). The United States ranks forty-second in life expectancy among industrialized countries. The average life expectancy in the United States is 78.1 years, but there are gender and racial disparities. White women have the longest life expectancy at 81 years, compared with black women at 76.9 years. The average life expectancy for white men is 76 years, compared with black men at 70 years (CDC, 2008a).

Disparities in health and life expectancy are related largely to socioeconomic inequities such as education, income, and environment, all of which affect life-long health. People with more education tend to accumulate more wealth, enjoy better living and working conditions, and engage in more healthful behaviors. People with less than a high school education generally have lower incomes, more hazardous work and living environments, and are more likely to lack health insurance.

Communities of color are disproportionately affected by socioeconomic inequities: poorly funded schools, inadequate housing, high-crime neighborhoods, and low-paying jobs with lack of opportunity for advancement. As Steven Schroeder (2007) points out, “[B]etter health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans.” He cites the example of smoking, which kills nearly half a million Americans each year: “Smoking is increasingly concentrated in the lower socioeconomic classes and among those with mental illness or problems with substance abuse.”

MODELS OF CARE

Care of the older adult should be individualized and based on life expectancy and the patient’s values, goals, and preferences. Interventions appropriate for a healthy, active 65-year-old woman may be quite different than those for a frail woman of 85 who lives in a nursing home. For example, annual or biennial mammography screening should be recommended for the 65 year old but may be inappropriate for the 85 year old with congestive heart failure and diabetes whose life expectancy is less than five years.

Many health problems (e.g., falls) common to people over 65 can be prevented, many (e.g., hypertension) can be effectively treated, and many (e.g., visual impairment, hearing loss, mobility problems) can be compensated for with assistive devices. Overarching goals of healthcare in people over 65 include:

  • Maintaining self-care
  • Preventing complications of aging or of existing conditions
  • Delaying decline
  • Achieving the highest possible quality of life

Policy Issues

Many provisions of the healthcare reform legislation (Patient Protection and Affordable Care Act)signed into law in 2010 are intended to benefit older Americans and their families, particularly those in low-income populations (National Senior Citizens Law Center, 2010). Designed to make healthcare more affordable and accessible, the law expands access to long-term care and improves the quality and coordination of care. In addition, it will provide education and training for the healthcare workforce. However, the volatile political climate is likely to result in ongoing changes to how healthcare services are provided.

While such political controversy continues, healthcare systems must change to better meet the needs of seniors with multiple chronic conditions. For example, hospitals in Michigan are designing special emergency rooms for seniors with softer lighting and non-glare flooring. The beds and stretchers will have extra padding. Patients can consult with a senior ER social worker and receive discharge instructions in large print. One large hospital has a geriatric outpatient clinic that includes a depression center and a cognitive disorders clinic on site (Burden, 2010). One major reason for these changes is to prevent hospital readmissions, for which Medicare reimbursement is ending.

New Models of Care

Healthcare researchers are studying innovative models of care that will improve the quality of care and increase patient/family satisfaction as well as lower healthcare costs. Three new models of care address the needs of older patients with multiple chronic conditions: the Geriatric Resources for Assessment and Care of Elders (GRACE); Guided Care; and the Program of All-Inclusive Care for the Elderly (PACE). These three models share some common elements:

  • Comprehensive assessment of patient needs
  • Evidence-based planning and monitoring of care
  • Support for patient and family caregiver active involvement in care
  • Coordination of all professionals involved in care of the patient—all tailored to the patient’s goals and preferences
    (Osterweil, 2010)

Nurses are involved in all three of these models, and those with advanced preparation in geriatric care have the potential to be leaders in improving care for older adults. “Nursing is positioned perfectly to be the driver of care for older adults,” Tara A. Cortes, RN, PhD, FAAN, told Nursing.com. She noted that nurses already are experts at managing care, providing education, looking at patients holistically, and working in interdisciplinary teams, all crucial components of geriatric care (Domrose, 2010).

In the GRACE model, developed for low-income older adults, there are two teams: a support team and a larger interdisciplinary team. The support team consists of a nurse practitioner and a social worker who meet with each patient at his or her home to conduct an initial comprehensive geriatric assessment. Based on their findings, the interdisciplinary team (which includes a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) develops an individualized care plan. Then the support team meets with the patient’s primary care doctor to develop a care plan, which they then work with the patient to implement. Over a 3-year period, the GRACE model achieved improved outcomes (reduced emergency room visits and hospital admissions) and cost reduction (Boult & Wieland, 2010).

An innovative model for elder care in rural communities uses specially trained Emergency Medical Services (EMS) technicians to evaluate seniors for falls, depression, or medication management problems. EMS technicians work in collaboration with primary care physicians, the county health department, social services, and aging services. When seniors seek emergency care, EMS responders first deliver appropriate medical care and then screen for other unmet health needs that would only be apparent during a home visit. Following the EMS screening, if the patient agrees to a follow-up visit, a case manager will visit the patient and discuss topics such as vaccinations, nutrition, activities of daily living (ADLs), memory issues, and use of alcohol and other drugs. Although three fourths of the people initially screened in the study refused a follow-up visit, more than 90% of those who agreed to a second visit reported satisfaction and received important referrals for needed services (Shah et al., 2010).

AGE-RELATED CHANGES IN HEALTH STATUS

Aging is both universal and individual. The physical changes of aging are universal, but the pace at which they occur is highly individual, depending on genes, age, sex, race, environment, and lifestyle. Some people look and feel old at 60 or earlier, while others remain youthful in health, appearance, and outlook at 70 and beyond. The challenge for health professionals is to distinguish between normal age-related changes and symptoms of a disease or disorder that requires preventive or therapeutic action. For example, is forgetfulness in a particular patient just part of growing older, a sign of depression or stress, or the beginning of dementia?

Structural Changes

MUSCULOSKELETAL CHANGES

Musculoskeletal changes significantly alter the posture and appearance of older adults, usually beginning in the fifth decade of life. Thinning of vertebral disks shortens the trunk of the body and diminishes height each year, making arms and legs appear longer by comparison. Calcium leaches from bones (resorption), resulting in osteoporosis, a condition much more common in women than in men, increasing the risk of fracture. At the same time, muscles and cartilage atrophy and weaken, leading to kyphosis, a curvature of the spine, which further decreases stature and requires a “chin-up” posture to make eye contact with others. Loss of muscle mass (sarcopenia) results primarily from disuse of skeletal muscle—in other words, inactivity. Disuse leads to disability.

Resorption of bone also affects the jaw and therefore the fit of dentures, an issue for more than one fourth of all older adults and nearly 40% of those with family income below the poverty line. Some older people do not wear their dentures because they are uncomfortable, which not only changes their appearance and self-image but interferes with their speech and compromises their nutritional intake because they are unable to chew.

Wear and tear on cartilage (ligaments, tendons, and joints) reduces flexibility and increases the risk of tears. The synovial fluid that lubricates joints decreases with age, resulting in slower and sometimes painful movement. However, regular exercise such as walking and resistance training as well as doing household chores such as vacuuming, sweeping, gardening, and washing the car help preserve flexibility and strength and delay or prevent musculoskeletal deterioration.

INTEGUMENTARY CHANGES
Skin

Ultra-violet (UV) light from the sun (and from tanning booths) is a major cause of wrinkles because it damages elastin, the fibers in the skin that make it resilient. Gravity also plays a role in wrinkles, causing skin to sag, as does cigarette smoking.

Aging skin becomes more delicate and more easily damaged. Collagen levels and subcutaneous fat diminish, thinning the skin and increasing the risk of tears and bruising. Skin cells take longer to renew themselves, so wound healing takes longer than in younger people.

Dry skin is common among older people. Heating and air conditioning can make the problem worse because they remove moisture from the air. Heavy use of soaps, antiperspirants, deodorants, perfumes, or very hot baths or showers also can increase skin dryness, as can sun exposure, dehydration, and stress. Moisturizers help relieve dryness, but they must be applied often.

Skin cancer is the most common form of cancer in the United States. The two most common types of skin cancer—basal cell and squamous cell carcinomas—are highly curable if diagnosed and treated in their early stages. However, melanoma, the third most common skin cancer, is more dangerous (CDC, 2010).

The vast majority of melanomas are caused by exposure to UV light or sunlight. The U.S. Preventive Service Task Force advises clinicians to be aware that fair-skinned men and women age 65 or older and people with atypical moles or more than 50 moles, are at greater risk for developing melanoma. Clinicians need to look for skin abnormalities when conducting physical examination for other purposes (CDC, 2010). Skin cancers are seldom painful until they are very advanced, so older patients may be unaware of lesions on their back or on other areas of the body not easily seen.

Hair and Nails

Hair changes in older adults vary according to race, sex, and hormonal influences. Dark hair turns gray or even white and becomes thinner as melanin production in hair follicles diminishes and growth slows. The texture of hair may also change with age; fine, straight hair may become coarser and somewhat curly. Hair loss is more noticeable in men and may begin well before age 40. Although women may lose hair, it occurs much later and more slowly. Body hair on both men and women is also thinner and sparser.

Fingernails and toenails tend to harden and thicken with age and may develop vertical striations in the nail plate. Yellowish or dark nails may indicate a fungal infection.

HEAT STRESS

Extreme heat poses a threat to older people due to age-related impairment and loss of sweat glands, the principal component of the body’s normal evaporative cooling system. Even healthy older people are more prone to heat stress and heat stroke than younger people. Those with cardiovascular disease or hypertension are at the highest risk not only because of their disease but also because their medications impair the body’s ability to regulate its temperature. Overweight people are at higher risk for heat-related illness because they retain more body heat.

According to CDC (2009), “Heat stroke is the most serious heat-related illness and can cause death or permanent disability if emergency treatment is not provided. Body temperatures can rise to 106° F within 10 or 15 minutes. Warning signs of heat stroke may include the following:

  • Extremely high body temperature (above 103° F)
  • Red, hot, and dry skin (no sweating)
  • Rapid, strong pulse
  • Throbbing headache
  • Dizziness
  • Nausea

Heat exhaustion is a milder form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement of fluids. Warning signs of heat exhaustion may include:

  • Heavy sweating
  • Paleness
  • Muscle cramps
  • Tiredness
  • Weakness
  • Headache
  • Nausea or vomiting
  • Fainting
  • Cool and moist skin
  • Fast and weak pulse
  • Fast and shallow breathing

(CDC, 2009)

BODY COMPOSITION CHANGES

Body composition changes over time. Weight and fat mass increase during middle age (the so-called middle-age spread) and continue to about age 74 (Kyle et al., 2001). After age 74, seniors generally lose weight, stature, fat-free mass (also called lean body mass), and body cell mass. As lean body mass declines, the proportion of body fat increases. Older adults also experience a decrease in total body water. This means that water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life.

Decreased body cell mass results in decreased total body potassium (TBK). Low potassium levels over time can result in confusion, fatigue, cardiovascular dysrhythmias, kidney damage, and other serious, even life-threatening effects (Huether & McCance, 2008).

Tissue changes alter not only appearance but also the body’s response to temperature changes. With aging, subcutaneous fat decreases, particularly around the eyes and in the forearms, accentuating the bony structures. Without that insulating layer of subcutaneous fat, the older person has a heightened sensitivity to cold. Therefore, a room temperature that feels comfortable to a younger family member may feel cold to an older person, particularly someone who is less active.

HYPOTHERMIA

Keeping older people warm is more than a comfort measure; it is essential to their health and well-being. Accidental or inadvertent hypothermia can lead to confusion and disorientation, amnesia, cardiac arrhythmias, loss of consciousness, irreversible coma, and death. Those people who cannot generate enough heat to maintain normal core body temperature through shivering are at greatest risk for developing hypothermia. Patients who are confined to bed or to a wheelchair are particularly vulnerable. According to CDC (2006), “Older persons with preexisting medical conditions such as congestive heart failure, diabetes, or gait disturbance are at increased risk of hypothermia because their bodies have a reduced ability to generate heat and because they are less likely to recognize symptoms of hypothermia and seek shelter from the cold.”

Signs and symptoms of hypothermia include:

  • Shivering
  • Sensation of cold, exhaustion, and numbness
  • Confusion and disorientation, slurred speech
  • Amnesia
  • Pallor or flushed skin
  • Decreased hand coordination

Older adults undergoing surgery are also at risk for hypothermia related to medications such as muscle relaxants, narcotics, vasodilators, anesthetics, and room-temperature parenteral fluids.

Functional Changes

CARDIOVASCULAR CHANGES

Age-related cardiovascular changes include a slight decrease in maximal heart rate (the number of beats per minute) and a decrease in stroke volume during maximal exercise (amount of blood pumped out of the heart with each beat). These changes reduce cardiac output, the total amount of blood pumped out of the heart each minute. Illness, excitement, activity, or stress may cause rapid heart rate (tachycardia), which in an older person takes longer to return to the baseline level than in a younger person.

Cardiovascular function helps determine the ability to live independently. A primary criterion in assessing cardiovascular function is VO2 max, the maximum amount of oxygen that can be consumed by the body per minute during physical activity. The minimum level of VO2 max for independent living is 18 ml/kg/min (milliliters per kilogram of body weight per minute) for men and 15 ml/kg/min for women (Shephard, 2009). Regular aerobic exercise can help older adults increase their VO2 max as much as 10% to 20%, compensating for the loss of muscle mass and strength of normal aging.

As mentioned earlier, the migration of calcium from bone into blood vessels stiffens arteries, leading to atherosclerosis, some degree of which is present in most older adults. Stress testing may be necessary to distinguish between normal age-related changes and the presence of cardiovascular disease.

Atherosclerosis affects blood flow to the heart, liver, kidneys, and other organs. Vessel walls weaken and may swell under pressure, even in individuals without hypertension. Regular exercise and a low-fat diet help to delay or prevent the onset of cardiovascular disease in older adults.

RENAL CHANGES

Renal and urologic changes associated with aging have major effects on the physical and psychosocial well-being of older adults. The kidneys are the major organs that regulate blood and fluid volume (balancing intake and output of fluids) throughout the body. In addition, the kidneys filter waste products from the blood, which are then excreted in the urine. At the same time, the kidneys conserve nutrients such as glucose, amino acids, and electrolytes for resorption into the bloodstream.

The kidneys’ filtering process occurs within the nephrons, the functional units of the kidneys. In a young adult, each kidney contains more than a million nephrons, through which the body’s entire blood supply circulates approximately 12 times an hour. However, the number of nephrons decreases with age, and by age 70, a person may have only one third or one half as many nephrons. In the absence of illness, this number is still sufficient to maintain appropriate fluid balance, which is why some people are able to lead a normal life with only one functioning kidney.

Age-related vascular rigidity and decreased cardiac output reduce renal blood flow and the glomerular filtration rate (GFR), lengthening the time required to excrete waste products such as nitrogen. The biologic half-life of medications is affected by kidney function. This can translate into slower elimination of certain medications such as streptomycin and result in toxic effects for older patients.

Aging also reduces the resorption of glucose, leading to increased levels of glucose in the urine (glycosuria). Decreased resorption of bicarbonate and sodium can upset the sodium-potassium ratio, resulting in hyperkalemia (elevated potassium levels). Signs and symptoms of hyperkalemia include muscle weakness or paralysis, tingling of the lips and fingers, restlessness, intestinal cramping, and diarrhea.

Sudden or large changes in fluid volume increase the risk of hypervolemia (abnormal amount of blood volume) or hypovolemia (abnormally low amount of blood). Acute losses of fluid or chronic fluid deficits can result in renal insufficiency in older adults.

UROLOGIC CHANGES

Urologic changes are closely related to changes in the renal system. Age-related loss of muscle tone and decreased contractibility of the bladder can cause excessive urination at night (nocturia) and increased frequency of urination. These same factors may also cause urinary retention, thereby increasing the risk of bacterial growth and infection. Urinary tract infections (UTIs) are more common in women because of their shortened urethra and its proximity to the anus, which increases the risk of fecal contamination.

Some degree of age-related urinary incontinence (any involuntary leakage of urine) is common in older people, particularly among the frail elderly. There are three principal types of incontinence: urge incontinence, stress incontinence, and overflow incontinence. Urge incontinence is generally caused by uninhibited bladder contractions (detrusor overactivity) that lead to leakage of urine. In men, this condition often is accompanied by urethral obstruction from benign hypertrophy of the prostate (BPH). Urethral obstruction is common in older men but rare in older women. Bladder stones or tumors can also cause bladder contractions and sudden-onset urge incontinence, especially if urination is painful or if there is blood in the urine (hematuria). Cystoscopic examination and urinalysis may be necessary to determine the cause.

Stress incontinence is urinary loss related to laughing, standing, coughing, or lifting heavy objects. Overflow incontinence (urinary frequency, nocturia, and frequent dribbling) is related to detrusor underactivity, which may be caused by sacral lower motor nerve dysfunction (“neurogenic bladder”).

Urethral obstruction is common in older men and causes dribbling after voiding, urge incontinence as described above, or overflow incontinence due to detrusor underactivity. Applying suprapubic pressure while voiding may help empty the bladder. If that proves ineffective, intermittent catheterization is indicated.

Urinary incontinence also may be caused by factors unrelated to the renal and urologic system. These include delirium, excess fluid intake, medications, psychological factors, restricted mobility, and stool impaction and are discussed later under functional assessment of the older adult.

RESPIRATORY CHANGES

Respiratory changes in older adults are not completely understood but include loss of elasticity in the lungs and stiffening of the chest wall. Respiratory muscle strength and endurance also decrease but can be increased with exercise (Huether & McCance, 2008). These changes reduce ventilatory reserves and decrease the older adult’s exercise tolerance. Aging also impairs immune function, increasing asymptomatic low-grade inflammation and the risk of infection. These changes elevate the risk of pneumonia. In addition, older people are at increased risk for respiratory depression from medications, particularly from opioid analgesics. This risk is highest among patients with COPD, liver or renal failure, and those with adrenal insufficiency.

ENDOCRINE CHANGES

The endocrine system undergoes many changes during aging, and these changes affect other body systems and processes. This discussion is limited to the thyroid gland and the gonadal (sex) hormones.

Age-related changes in the thyroid gland affect almost all body functions and include the following:

  • Decreased secretion and plasma levels of triiodothyronine (T3), especially in men
  • Increasingly common hypothyroidism
  • Decreased secretion of thyroid-stimulating hormone (TSH)
  • Decreased responsiveness of plasma TSH concentration to thyrotropin-releasing hormone (TRH), especially in men

Hypothyroidism (deficiency in circulating thyroid hormone [TH]) is a common disorder, affecting about 5% of people over 60 (Fitzgerald, 2008). Mild or early hypothyroidism may be underdiagnosed in older people because many of its clinical manifestations are also signs of aging: dry skin, low basal metabolic rate, cold intolerance, slightly lower body temperature, and constipation. Other characteristics of hypothyroidism may include lethargy, fatigue, muscle cramps, headache, anemia, hyponatremia (abnormally low levels of sodium in the circulating blood), and lack of mental alertness. Deficiency in TH increases production of TSH (Thyroid-stimulating hormone) and can lead to goiter.

Correcting hypothyroidism in people over 60 requires a lower dose of replacement TH than in younger people. Replacement should be initiated slowly, particularly in those with coronary artery disease, to prevent angina and myocardial infarction.

Hyperthyroidism, or thyrotoxicosis (abnormally high levels of T4 or T3), may be caused by Graves’ disease, an autoimmune disease, or by toxic multinodular goiter, thyroid adenomas, thyroid carcinoma, or amiodarone. Hyperthyroidism is characterized by an accelerated metabolic rate, heat intolerance, sweating, protruding eyeballs, irritability, restlessness, anxiety, and tremors.

Androgen and estrogen secretions diminish with aging. Declining estrogen levels result in atrophy of the ovaries, uterus, and vaginal tissue in older women. Older men may develop firmer testes and hypertrophy of the prostate gland. These changes, together with other physical and psychosocial changes, may decrease sexual capacity. However, libido continues in both women and men. Although sexual activity may occur less often, it still can remain satisfying.

One of the ageist stereotypes that exist among care providers and institutions is that older people are no longer sexual beings. Although serious illness or physical or mental health problems can take precedence over sexual needs, older people remain sexually active.

AGING AND HIV/AIDS

Stereotypes about aging and sexuality also may cause health professionals to overlook the possibility of HIV/AIDS among older patients and may put seniors at risk for transmission of the disease. According to the Centers for Disease Control and Prevention (2008c), people over 50 in the United States account for:

  • 15% of new HIV diagnoses
  • Nearly one fourth of persons living with HIV
  • Nearly one fifth of all AIDS diagnoses
  • More than one third of all deaths of persons with AIDS

Since Viagra and other drugs for erectile dysfunction entered the marketplace in the late 1990s, rates of HIV/AIDS and gonorrhea increased more rapidly in middle-aged and older heterosexual adults than in people under age 40 (Jena et al., 2010).

Medicare and Medicaid now reimburse for HIV infection screening for beneficiaries of any age who voluntarily request the service. However, physicians and other healthcare workers may fail to ask patients about unprotected sex or to offer voluntary HIV testing. The result can be delayed diagnosis of HIV/AIDS in seniors because symptoms can mimic those of normal aging, such as fatigue, weight loss, forgetfulness, and/or confusion.

Most sexually active older couples do not use condoms because they are unconcerned about pregnancy. But unless a couple is monogamous, unprotected sex increases the risk of infection with HIV or other sexually transmitted diseases from multiple sexual partners.

GASTROINTESTINAL CHANGES

Gastrointestinal changes begin in middle age and continue throughout life, affecting not only nutritional intake but also quality of life. Gastrointestinal function begins in the mouth, and aging takes its toll on teeth, gums, and salivary glands. Years of use wear down tooth enamel and dentin, increasing the risk of cavities. Periodontal (gum) disease leads to tooth loss and the need for dentures or dental implants. Dentures can limit the choice of food, and ill-fitting dentures make eating painful. Aging and some medications decrease salivary secretions, which makes food more difficult to chew and swallow.

Gastric motility and volume decrease with age. Secretion of bicarbonate and gastric mucus decline and the acidity of gastric juices diminishes, leading to insufficient hydrochloric acid and delayed gastric emptying. Nutrients such as proteins, fats, minerals, and carbohydrates (particularly lactose) are absorbed more slowly. The effects of these changes can be offset by small frequent meals rather than “three squares a day.”

Constipation is often deemed an age-related problem. However, several factors may contribute to constipation in older adults. These factors include long-established bowel habits, current diet, inadequate fluid intake, and inactivity or immobility.

The liver, pancreas, gallbladder, and bile ducts are also part of the gastrointestinal system. In healthy older adults, the altered function of these organs generally does not interfere with digestion. Even though the liver decreases in size and weight, liver function remains within normal range. Decreases in liver blood flow can have a negative effect on the oxidative metabolism of certain medications. Although pancreatic secretion decreases with age, there is generally no obvious dysfunction. Gallbladder and bile duct function remain largely unchanged except in the presence of gallstones, the incidence of which increases in older people.

SENSORY CHANGES

Sensory changes in later life affect how we perceive and experience the world and can have enormous impact on independence, safety, and quality of life. All five—vision, hearing, taste, smell and touch—diminish in acuity as we age.

Vision changes generally begin in middle age, and most adults need glasses or contact lenses for reading by age 50. Older adults also may experience increased sensitivity to glare, impaired night vision, and reduced color discrimination. People age 40 or older are also at risk of serious eye conditions that can lead to low vision or blindness if not diagnosed or treated early. The most common of these conditions are age-related macular degeneration (AMD), glaucoma, cataracts, and diabetic retinopathy.

To prevent or delay serious eye disease, the American Academy of Ophthalmology recommends that people age 65 or older have an annual comprehensive eye examination.

Hearing changes related to aging also can have a major impact on independence, safety and quality of life. More than one third of people over 65 and half of those over 85 suffer some hearing loss (NIDCD, 2011). Diabetes appears to be an independent risk factor for hearing impairment (Bainbridge et al., 2008). In later life the eardrum thickens, decreasing its ability to transmit sounds. Age-related changes in the inner ear can also affect balance. These include a decline in number of hair cells in the inner ear and changes in the bony structures of the inner ear.

The number of taste buds declines with age, as does the sense of smell, diluting the intensity of flavors and possibly leading to loss of appetite. Taste and smell changes related to aging can reduce the pleasure of eating and can silence an early warning system. For example, “Taste allows us to detect sour milk; smell alerts us to the smoke of a fire or a natural gas leak” (NIDCD, 2011).

Some medications can also alter both taste and smell. A reduced ability to taste is called hypogeusia. The rare inability to detect any tastes is called ageusia; perceived loss of taste usually reflects a loss of smell. Loss of taste may be due to upper respiratory infections, head injury, middle ear surgery, or radiation therapy for cancers of the head and neck.

Abnormalities with taste and smell may also indicate one of several health problems, including obesity, diabetes, hypertension, malnutrition, Parkinson’s disease, Alzheimer’s disease, and the brain disorder Korsakoff’s psychosis.

Touch changes during aging decrease an individual’s awareness of vibrations, pain, pressure, and temperature. These changes are caused by both internal and external factors and can affect both physical and mental health.

  • Internal factors include circulatory and neurological deterioration, confusion or dementia, and immobility. Chronic diseases such as diabetes increase the risk of peripheral neuropathy and loss of sensation, particularly in the feet.
  • External factors affecting touch include nutrition, medications, alcoholism, brain surgery, and personal losses. Older people who live alone and those with limited incomes may have more than one nutritional deficiency, either related to lack of appetite, mobility problems, or lack of financial resources. Excessive alcohol consumption also leads to deficiencies in thiamin and other nutrients.

Coupled with vision impairment, peripheral neuropathy can prevent older people from noticing foot infections or discolorations. Peripheral neuropathies also lead to falls and gait disorders, which can contribute to loss of autonomy and independence.

The inability to interpret temperature sensation increases the risk of thermal injuries (burns, hypothermia, frost bite). Diminished pressure sensation can result in pressure ulcers in patients unable to change position frequently. Reduced hand sensitivity may cause older people to drop objects such as glassware or other breakable items, and cleaning up the breakage may lead to injury.

THE NEED FOR TOUCH

Although the sense of touch changes in later years, the human need for touch—for physical contact, for a sense of closeness with another human being—remains throughout life. The need for touch can increase during times of stress and illness. Many older people, especially those who are institutionalized, suffer from touch deprivation. They experience impersonal touch during procedures but lack meaningful touch with others. As Phillips (1981) explains:

Touching in Western culture is reserved for close friends and significant others. As a person ages, more and more of the people who have provided touch input are lost through death. Older people tend not to replace the lost people in their lives. As a result, fewer people provide touch stimulation, and the very old person may be virtually untouched.

Attitudes about being touched are very individual, influenced by culture, education, and life experiences. Some people simply don’t like to be touched. Therefore, care providers need to determine how best to offer appropriate touch to give reassurance, gain attention, and provide a greater sense of safety and security.

SLEEP CHANGES

Sleep alterations are common among older adults. According to the National Institute of Neurological Disorders and Stroke (2007), older people tend to sleep more lightly and for shorter time spans, but they generally need about the same amount of sleep as they did earlier (7 to 8 hours a night). Many older people experience insomnia, which includes difficulty in falling asleep and/or staying asleep, periods of wakefulness during the night, waking very early in the morning, or combinations of any of the above.

Sleep deprivation is a more serious problem for older adults than for younger people. Experimental research shows that sleep deprivation may impair immune function, memory, and physical performance. Extreme sleep deprivation can cause hallucinations and mood swings.

There are five phases of sleep: Stages 1 (dozing), 2 (light sleep), 3 (deep sleep), 4 (deepest sleep), and 5 (periods of deep sleep with rapid eye movements [REM] during which people dream). A normal sleep cycle includes four or five REM periods during the night, which together account for about one fourth of the total night’s sleep. With age, the percentage of REM sleep remains about the same, but there is a marked reduction in stage 3 and 4 sleep, plus an increase in wakeful periods.

Other factors that can interfere with sleep in older people include nocturia, muscle cramps or other pain, anxiety, medications, caffeine, alcohol, smoking, and thyroid disorders. Medications prescribed to promote sleep (e.g., benzodiazepines) increase sleep time and decrease the time needed to fall asleep and the periods of wakefulness. When the sleep medications are stopped, however, individuals may experience withdrawal symptom, including nightmares.

Antidepressants decrease REM sleep, which may improve symptoms of some depressions and worsen others. However, antidepressants increase the risks of falls. Therefore, interventions to relieve insomnia in older people should begin with non-pharmacologic measures such as regular exercise, exposure to bright light in the morning, and avoiding caffeinated beverages.

Psychosocial Changes

The physical changes of aging can have major effects on an individual’s psychological and social well-being.

LOSS

Aging involves a succession of losses, concluding with the ultimate loss—loss of self. Losses can include:

  • Loss of physical strength and abilities
  • Loss of mental abilities (confusion, dementia)
  • Loss of relationships, when companions or friends die
  • Loss of self-esteem
  • Loss of body image
  • Loss of independence
  • Loss of control over life plans and lifestyle

Moving to a long-term care facility involves multiple losses: loss of independence, self-esteem, familiar surroundings and social networks, and control over life plans and lifestyles. Many residents are at risk for what one author (Thomas, 2004) called the three plagues of living in a nursing home: loneliness, helplessness, and boredom. Experiencing multiple losses can also cause depression. Care providers and family caregivers need to be alert for signs of depression and the three plagues in older people so that therapeutic measures can be implemented. (For more information on depression, see “Functional Assessment of the Older Adult” below.)

CHANGES IN LIFE ROLES

Death or sudden illness in a spouse can result in a dramatic role change for the other spouse. For example, a husband’s illness may shift the burden of managing family finances to the wife, who must also take on the role of caregiver. Many family caregivers are older adults themselves, which puts them at risk for developing both physical and mental health problems in addition to any ongoing conditions. The Family Caregivers Alliance (FCA) is advocating that this be reflected in Medicare history-taking questionnaires by adding the question: “Are you currently providing assistance to a family member or friend who has a health condition?” This provides an opportunity to assess the health needs of the caregiver and community support (FCA, 2010).

MEDICATION USE AND MISUSE

About 1 in 3 older persons taking at least five medications will experience an adverse drug event each year, and about two thirds of these patients will require medical attention. Approximately 95% of these reactions are predictable and about 28% are preventable.
—PHAM & DICKMAN (2008)

Older people consume more medications than any other age group. Although medications may improve the quality of life and health, they also hold the potential for misuse, overuse, and life-threatening complications.

Physician-prescribed drugs are only one component of medication use by older people. Self-prescribed OTC medications and/or vitamin and herbal supplements also play a part, and alcohol use can further complicate the situation. Patients self-prescribe with OTC products and/or alcohol because they seek relief from symptoms that physician-prescribed medications do not offer—relief from chronic pain, stress, anxiety, depression, loneliness, or all of the above.

Drug Interactions and Adverse Events

Polypharmacy is the use of multiple medications by a patient. This often includes using too many forms of medication or the inappropriate use of multiple drugs, which creates a significant risk for adverse drug events. For instance, any senior taking four or more prescription drugs is at high risk for falling, which can lead to frailty and loss of independence. Patients who see several physicians for different ailments are at higher risk for adverse drug events related to drug interaction, as are those who use multiple pharmacies to fill their prescriptions or who order their prescriptions by mail.

Chronic health conditions such as heart disease, hypertension, and diabetes among older people affect the number of drugs they are prescribed. For example, because diabetes increases the risk of heart disease, many people are being treated for both conditions. These same people may also take OTC nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve their arthritis pain, antacids for indigestion, and antihistamines for allergies. The potential for interaction among these various drugs is significant, and patients and caregivers need to be aware of this risk.

One analysis of adverse drug events that led to emergency department (ED) visits showed that the three drugs most often implicated in these events were warfarin (Coumadin), insulin, and digoxin. Researchers found that the risk for ED visits for adverse events due to these three medications was 35 times greater than for medications generally considered to be potentially inappropriate for people over 65 (Budnitz et al., 2007).

Managing Drug Regimens

Ideally, each patient’s complete medication profile would be monitored by a single health professional such as a clinical pharmacist. Electronic medical records (EMRs) in some HMOs now make that possible, but the use of EMRs by private physicians in the United States is surprisingly limited.

MEDICATION REVIEW

Experts recommend periodic review of all medications that an older patient is taking, using the “brown-bag” approach. This means that the patient brings all medications—prescription and OTC—to the care provider’s office and reviews with the physician or nurse the purpose of each drug, any side effects experienced, and whether it is necessary to continue taking each one. This type of review can sometimes mean dropping one or more medications from the regimen.

Medication review is also an opportunity to evaluate how well the patient (or family caregiver) is managing the regimen and whether he or she understands the potential for interactions among drugs and between drugs and food and/or alcohol. For example, patients who are taking statins (Lipitor, Zocor, Mevacor, and others) to lower cholesterol may not know to avoid grapefruit and grapefruit juice because it can raise circulating levels of the drug to potentially toxic levels. Similarly, patients taking warfarin need to know that food containing high levels of vitamin K (broccoli, spinach, cabbage, and other green vegetables) can interfere with the blood-thinning effects of warfarin. Vitamin E and the popular herbal supplement gingko biloba also act to enhance the effects of warfarin.

AIDS TO MANAGING DRUG REGIMENS

There are various forms and other devices to help older patients and/or their caregivers manage their drug regimens. A sample form for keeping track of medications is shown in the FDA brochure Medicines in My Home (see “Resources” below).

Day-of-the-week pill boxes can also be helpful if the regimen is not too complex. Electronic aids and services for self-management of medication by older adults include those at http://www.mypillbottle.org and http://www.medsfile.com; however, these require that either the patient or the caregiver have a computer and the skills required to use it.

Inappropriate Medications

Health professionals who are not geriatricians need to familiarize themselves with the Beers criteria, which identify potentially inappropriate medications for people age 65 and older (see below). Nurses and other care providers should also be aware of the Beers criteria to monitor patients’ medication use. Although the Beers criteria are used extensively, almost one fourth of older adults have been prescribed at least one medication on this list (Zwicker & Fulmer, 2008).

THE BEERS CRITERIA
The Beers Criteria identify potentially inappropriate medications for individuals age 65 or older.*
ALWAYS POTENTIALLY INAPPROPRIATE †
* Medications identified as potentially inappropriate on the basis of the updated Beers criteria, 2003 (Fick et al., 2003). Severity was defined by the combination of the likelihood that an adverse event might occur and the clinical significance of that outcome should it occur (Beers, 1997).
High Severity
  • Amiodarone
  • Amitriptyline
  • Chlorpropamide
  • Disopyramide
  • Doxepin
  • Guanadrel
  • Guanethidine
  • Indomethacin
  • Ketorolac
  • Meperidine
  • Methyldopa
  • Methyltestosterone
  • Mineral oil
  • Nitrofurantoin
  • Orphenadrine
  • Pentazocine
  • Thiordazine
  • Ticlopidine
  • Trimethobenzamide
  • Amphetamines (except methylphenidate)
  • Anorexants
  • Anticholinergics and antihistamines (chlorpheniramine, diphenhydramine, hydroxyzine, cyproheptadine, promethazine, tripelennamine, dexchlorpheniramine)
  • Barbiturates (except phenobarbital)
  • Gastrointestinal antispasmodics (dicylomine, hyoscyamine, propantheline, belladonna alkaloids, clidnium-chlordiazepoxide, diazepam, flurazepam, quazepam, halazepam, clorazepate)
  • Long-acting benzodiazepines (chlordiazepoxide, diazepam, flurazepam, quazepam, halazepam, clorazepate)
  • Muscle relaxants and antispasmodics (methocarbamol, carisoprodol, chlorzooxazone, metaxalone, cyclobenzaprine)
Low Severity
  • Cimetidine
  • Clonidine
  • Cyclandelate
  • Dipyridamole (short-acting)
  • Doxazosin
  • Ergot mesyloids
  • Estrogens (oral only)
  • Ethacrynic acid
  • Isoxsuprine
  • Propoxyphene
† Short-acting nifedipine, short-acting oxybutynin, and dessicated thyroid are also considered always potentially inappropriate, but they are excluded from analyses because of the inability to distinguish between long-acting (nifedipine, oxybutynin) or synthetic (t-thyroxine) formulations.
POTENTIALLY INAPPROPRIATE IN CERTAIN CIRCUMSTANCES
High Severity
  • Fluoxetine (used daily)
  • Longer half-life nonsteroidal anti-inflammatory agents (NSAIDs) (long term use of full-dosage naproxen, oxaprozin, piroxicam)
  • Short-acting benzodiazepines (lorazepam >3 mg, oxazepam >60 mg, alprazolam >2 mg, temazepam >15 mg, triazolam >0.25 mg)
  • Stimulant laxatives (long-term use of bisacodyl, cascara sagrada, castor oil except in presence of opiate analgesic use)
Low Severity
  • Digoxin (>0.125 mg/d, except when treating atrial arrhythmias)
  • Ferrous sulfate (>325 mg/d)
  • Reserpine (>0.25 mg)

Prescribing physicians also need to consider the slowed metabolism and excretion of drugs in older patients—not only the choice of drugs but the dosage and timing of administration. Because older adults experience a decrease in total body water and a relative increase in body fat, water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life.

Alcohol and Drugs

Alcohol use in older adults is highly variable, from those who enjoy an occasional glass of wine or beer to those who regularly use or abuse alcohol. Alcohol abuse is not always obvious, but health professionals should be aware that the problem exists and is often overlooked in older people. Patients should be cautioned to avoid alcohol when taking medications because it can interfere with drug metabolism and potentiate the effects of many drugs (e.g., benzodiazapines).

Some experts recommend that all older patients be screened for possible alcohol abuse. The CAGE screening test (see below) is simple to use; two positive answers indicate the need for further assessment.

CAGE SCREEN FOR ALCOHOL USE

  • C — Have you ever felt you should cut down on your drinking?
  • A — Have people annoyed you by criticizing your drinking?
  • G — Have you ever felt bad or guilty about your drinking?
  • EEye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Source: National Institute on Alcohol Abuse and Alcoholism, 2008.

Signs of an alcohol or medication-related problem can include memory problems after having a drink or taking medicine, loss of coordination, changes in sleeping habits, unexplained bruises, irritability, sadness, depression, failing to bathe or wear clean clothes, difficulty concentrating, and unexplained chronic pain (FDA, 2009).

Health Literacy and Patient Teaching

The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care, partly because half of all patients leave their office visits without having understood what the physician said.
—THOMAS BODENHEIMER, MD (2006)

Health literacy—the collective skills needed to obtain and use health information to make appropriate healthcare decisions—is a critical element in self-management of medications for patients of all ages. According to AHRQ (2008), only 12% of adults in the United States have adequate health literacy to manage their own health. Only slightly more than half of those surveyed in one study could read instructions on a prescription label and determine the right time to take medication. These limitations are more prevalent among the poor, the old, and those with limited education, the same populations most likely to have one or more chronic conditions that require a high degree of self-management.

Inadequate health literacy is an independent risk factor for all-cause mortality and cardiovascular death among older adults living in the community (Baker et al., 2007). Research has shown that errors in the medication process cause the death of one person every day and injure more than a million people a year in the United States (IOM, 2000).

Although there are a number of screening tests to measure health literacy, screening can be time-consuming for busy practitioners and embarrassing for patients. One physician uses an informal screening test when working in the clinic: She hands the patient an empty pill bottle and says, “This is not your medication, but if it were, tell me how you would take it” (Marcus, 2007).

Physical and Mental Impairments

Sensory and motor impairments can affect an older person’s ability to self-manage a complex drug regimen. Impaired vision increases the risk of errors in drug use or timing of administration or in noting expiration dates. Joint pain or weakness may make it difficult for patients to handle small tablets, open child-proof caps on medication containers, or administer eye drops. Large capsules or tablets can be difficult for older adults to swallow and may cause choking.

Cognitive problems such as Alzheimer’s and other dementias also contribute to mismanagement of medication regimens. Responsibility for managing medications falls to family caregivers when the patient is at home. However, if the patient goes to adult daycare, the medication list and instructions must go along. Some medications, such as anticholinergics, are contraindicated in people with cognitive deficits because they can increase confusion and make memory problems worse.

Cost of Medications

The soaring cost of medications among older patients with chronic health conditions is a major reason for nonadherence to prescription drug regimens. Even with Medicare Part D reimbursement, the high cost-sharing expense makes medications unaffordable for some seniors (Kennedy et al., 2011).

To cope with high out-of-pocket costs for drugs, many seniors use such cost-cutting measures as choosing generic drugs rather than brand-name drugs, asking their providers for free samples, or ordering drugs over the Internet or from Canada. Others take less than the recommended dosage (e.g., cutting pills in half) to make the medications last longer. Some are forced to choose between groceries and medications, a lose-lose solution.

Prescribing physicians should be aware of medication costs and design drug regimens that carry the lowest possible out-of-pocket costs without compromising treatment effectiveness. Social workers, nurses, and clinical pharmacists can often assist in designing these regimens to reduce the financial hardship on older patients who need medications.

FUNCTIONAL ASSESSMENT OF THE OLDER ADULT

The goal of functional assessment is to determine how well older patients can care for themselves, manage their living environment, and move about in the world. Approximately one quarter of people over 65 have difficulties with activities of daily living (ADLs) or with instrumental activities of daily living (IADLs). ADLs include bathing, dressing, eating, transferring from bed to chair, continence, and toileting. IADLs include driving or managing other transportation, shopping, cooking, using the telephone, managing finances, taking medications, doing housecleaning, and laundry.

Half of people over 85 have difficulties with ADLs, indicating the need for long-term care either at home or in a residential care facility. Those who have problems with IADLs are more likely to have cognitive impairment than those who can still perform IADLs independently.

Once an assessment is completed, a plan of care can be developed that specifies the type of support services and equipment that might be appropriate, including home care and/or modification of the home, or possible placement in assisted living or other long-term care facility. Those who need assistance only with IADLs may continue to live independently with the help of family caregivers; perhaps a financial/legal consultant (accountant, attorney, or family member with durable power of attorney); a cleaning service; and someone to drive, shop, and run errands.

The Initial Assessment

The first step in assessment is to establish a trusting relationship. Make sure the patient is comfortable and take time to get acquainted before launching into assessment questions. Be sure the room is well-lighted, quiet, and warm. If the patient has brought a family member or friend, acknowledge that person but focus on the patient rather than the companion. Although the companion may assist in communication during the assessment, it is important that the patient feel that the discussion is between the two of you and that you are not addressing the (usually younger) companion.

The following recommendations are essential for communicating effectively with older patients:

  • Face patients directly so they can see your lips move when you speak; this is particularly important if the patient has a hearing problem.
  • Speak in a clear, slow, lower pitch, and a slightly louder voice.
  • Encourage questions from the patient and, if present, the companion.
  • Ask only one question at a time and allow time for the responses. Even healthy older adults may take a little longer to process the question and frame a response.
  • Tailor your communications to the individual’s learning style and incorporate language the patient uses into your questions, avoiding complex medical terminology and abbreviations.
    (Curry et al., 2005)

During your initial conversation and history taking, assess patients’ current knowledge and attitudes about healthcare and health behaviors. For example: How do they rate their own health? What do they do to maintain or improve their health? Do they think that feeling sick is just part of getting old? Or do they believe that their health problems can be treated successfully?

People often continue health habits and practices adopted years earlier that may no longer be effective or adequate to deal with age-related changes or chronic disease. Those without symptoms may tend to ignore recommendations for screenings such as mammography and colonoscopy.

Also assess the patient’s ability to adapt to change. Some people are inflexible in their attitudes and beliefs. Are patients open to changing their way of life to adapt to age-related problems they haven’t recognized? For example, do they know that the dishes they just washed still have bits of food clinging to them? Do they see the dribbled food stains on their clothes? Do they realize that it’s time to surrender their driver’s license?

Failure to admit problems such as these indicates an unwillingness and/or inability to make needed changes. This is where a trusted health professional may be able to assist them in making changes, whereas a relative or friend might be considered a “meddler.” Once trust is established, patients are more amenable to changes that will help ensure their safety and health.

Assess whether patients have the necessary resources to self-manage health. Can they afford the medications the doctor has prescribed or do they need financial assistance? Are they socially engaged with other seniors who can share health information? Are they sufficiently mobile to participate in an exercise class? How are they coping in today’s world? For example, do they use a computer (or are they willing to learn) to access health information?

Assessing Physical Function

Assessment of physical function in the older adult includes some of the same elements of any assessment: weight, height, vital signs, and body mass index (BMI). In addition, functional assessment may include vision and hearing screening tests; balance and gait assessment; assessment of oral health; assessment of skin for bruises, wounds, and other signs of skin breakdown; and questions about nutrition and incontinence.

VISION

Adequate vision is essential to safety and quality of life and vision changes with age. Visual impairment is an independent risk factor for falls. Age-related visual impairment is most often corrected by prescription eyeglasses or by contact lenses. Patients should be aware that eyeglasses need to be cleaned daily, rinsing with water or special eyeglass solution and wiping each lens with a soft cloth.

Improved lighting (brighter but using frosted bulbs and lampshades to reduce glare) can also compensate for visual impairment. For example, a 70 year old needs twice as much light to read or sew as a 35 year old.

Anyone with a family history of eye disease or who has diabetes and/or hypertension is at high risk of serious eye diseases. All people over 65 should have an annual examination by an ophthalmologist or optometrist to screen for these conditions and treat as necessary. Serious vision impairment and even blindness can result from untreated eye conditions such as cataracts, glaucoma, or age-related macular degeneration (AMD).

The incidence of serious eye diseases varies among racial groups. The leading cause of blindness among white Americans is AMD. Among African Americans, the leading causes of blindness are cataract and glaucoma. Among Hispanics, glaucoma is the most common cause of blindness.

A study of more than 4,600 Latinos showed that they developed visual impairment and blindness at the highest rate of any ethnic group in the country. Of Latinos age 80 and older, nearly 20% became visually impaired during the four years of the study and nearly 4% became blind in both eyes. Latinos are more likely to develop diabetic retinopathy than non-Hispanic whites. More than half of all eye disease in Latinos is undiagnosed and undetected (National Eye Institute, 2010).

AGE-RELATED MACULAR DEGENERATION (AMD)

Age is the primary risk factor for AMD. Because women live longer than men, AMD is more prevalent among women. Aside from age, gender, and race, other risk factors for AMD include smoking, obesity, and family history.

Warning signs of AMD include:

  • Lines or edges that appear wavy or distorted
  • Blurry faces or difficulty seeing colors
  • Dark or empty spaces that block the center of your vision
  • Difficulty reading fine print or reading road signs from a moving vehicle
  • Difficulty seeing at a distance or during twilight hours
HEARING

Hearing impairment can limit social interaction, increase the risk of depression, and compromise safety. If the patient reports difficulty in hearing or understanding conversations, watching TV, or watching movies, use of the whisper test can quickly confirm the need for referral to an audiologist for more precise testing and prescription of an amplification device (hearing aid). To perform the whisper test, stand 6 to 12 inches behind the patient and whisper several short sentences. If the patient cannot hear and understand you, an audiology referral is in order.

Some types of hearing loss can be corrected by hearing aids worn in or behind the ear. These devices amplify sounds but may prove annoying in crowded rooms or public places because it can be difficult to separate what you want to hear from other sounds. Research shows that hearing aids for both ears are advisable (but may not be covered under some health plans). If hearing loss cannot be corrected with conventional hearing aids, cochlear implants may help some people.

According to the National Institute on Deafness and Other Communication Disorders (2008), before investing in a hearing aid, people with hearing problems should see an otolaryngologist, who may refer them to an audiologist for hearing assessment. Adults who do not see a physician before getting a hearing aid must sign a waiver.

Older adults with profound, uncorrectable hearing loss can benefit from a TTD/ TTY phone line and other signaling devices that use flashing lights rather than sound (alarm clocks, smoke alarms, doorbells). These adaptations not only help people with hearing loss stay connected with family and friends but they also are critical safety measures for those living alone. Other assistive devices include amplifiers for telephones and earphones for watching TV.

MOBILITY, STRENGTH, AND GAIT

Assessing mobility, strength, and gait is essential in determining the older patient’s risk for falling. One simple means for assessing mobility, strength, and gait is the Timed Up and Go (TUG) test. Ask the patient to rise from a sitting position without the use of hands, walk 10 feet, turn around, walk back, and sit down. Those who complete the TUG test in less than 10 seconds are probably normal. Anyone who is unable to do this in less than 14 seconds is at increased risk for falls.

The speed of walking, length of stride, and type of gait are also indicators of increased fall risk. Slower gait, smaller steps, and irregular gait can signal neurologic disorders that predispose the patient to falls. For example, slow gait may be caused by muscle weakness, inactivity, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), or angina. Short steps may be a sign of Parkinson’s disease. Unsteady frontal gait may be a sign of cerebrovascular disease or normal pressure hydrocephalus.

Falls and Traumatic Brain Injury (TBI)

Falls are one of the greatest threats to senior health, and they can be life threatening. Each year, one third of people over 65 suffer a fall, and one third of these falls cause injuries requiring medical treatment. Even low-level falls (e.g., slipping while stepping off a curb or on a tile floor) can be life threatening in people over 70. These people are 3 times more likely to die from such injuries as younger people (Spaniolas et al., 2010). Fall-related injuries, particularly those requiring hospitalization, are the most frequent cause of developing new or worsening disability (Gill et al., 2010).

PREVENTING FALLS

Patients and families need to know how to prevent falls. The CDC recommends the following four essentials:

  • Encourage exercises that improve balance and coordination, such as Tai Chi.
  • Make the home or other environment safer.
  • Ask the healthcare provider to review all medications.
  • Take the patient in for a vision check.

To make the home safer, remove tripping hazards such as throw rugs from stairs and floors; place often-used items within easy reach so that a step stool is not needed; install grab bars next to the toilet and in the tub or shower; place non-stick mats in the bathtub and on the shower floor; add brighter lighting and reduce glare by using lampshades and frosted bulbs; and add handrails and lights on all staircases.

Seniors should wear shoes that offer good support and have thin, non-slip soles. They should avoid wearing slippers and socks (without shoes) and going barefoot.

Source: CDC, 2008b.

Fractures—of the hip, arm, leg, and ankle bones—are the most common injuries sustained in falls, but some falls result in traumatic brain injury (TBI). In 2005 half of all deaths due to unintentional falls were caused by TBIs. A sudden bump or jolt to the head of an older person can easily tear cerebral blood vessels and lead to long-term cognitive, emotional, and/or functional impairments. Any older person taking blood-thinning medication (warfarin/Coumadin) should be seen immediately by a healthcare provider if they have a bump or blow to the head, even if they do not have any of the symptoms of TBI (CDC, 2008b).

SYMPTOMS OF TRAUMATIC BRAIN INJURY (TBI)

Symptoms of Mild TBI

  • Low-grade headache that won’t go away
  • Having more trouble than usual remembering things, paying attention or concentrating, organizing daily tasks, or making decisions and solving problems
  • Slowness in thinking, speaking, acting, or reading
  • Getting lost or easily confused
  • Feeling tired all of the time, lack of energy or motivation
  • Change in sleep pattern—sleeping much longer than before, having trouble sleeping
  • Loss of balance, feeling light-headed or dizzy
  • Increased sensitivity to sounds, lights, distractions
  • Blurred vision or eyes that tire easily
  • Loss of sense of taste or smell
  • Ringing in the ears
  • Change in sexual drive
  • Mood changes like feeling sad, anxious, or listless, or becoming easily irritated or angry for little or no reason

Symptoms of Moderate or Severe TBI

  • A headache that gets worse or doesn’t go away
  • Repeated vomiting or nauseas
  • Convulsions or seizures
  • Inability to wake up from sleep
  • Dilation of one or both pupils
  • Slurred speech
  • Weakness or numbness in the arms or legs
  • Loss of coordination
  • Increased confusion, restlessness, or agitation

Source: CDC, 2008b.

Assistive Devices

Although most gait disorders in older adults cannot be treated medically or surgically, they sometimes can be compensated for by the use of ambulatory assistive devices such as canes, crutches, and walkers. These devices improve the patient’s balance and ability to bear weight. However, not all seniors are candidates for ambulatory assistive devices. For example, those with serious impairments in cognition, judgment, vision, or upper body strength may not be able to use one of these devices safely.

Patients who are candidates for canes, crutches, or walkers should be assessed to determine whether they need assistance for balance or weight bearing while walking. Canes are used primarily by those who need support only on one side; a cane widens the base of support and thereby increases balance.

People needing bilateral upper-extremity support for walking need to have crutches or a walker. Crutches also offer full weight-bearing support. Two types of crutches are available: axillary crutches and forearm crutches. Axillary crutches are generally used by people who have experienced a fracture or other temporary condition restricting normal ambulation. Forearm crutches, also called Canadian or Lofstrand crutches, are used by those who need ongoing bilateral upper-extremity support with some weight bearing. Forearm crutches allow freedom of hand movement without removing the crutches from the forearms.

Walkers improve balance by increasing the patient’s base of support and lateral stability, and supporting the patient’s weight. However, they can be difficult to maneuver through doorways and should not be used on stairs. Walkers also contribute to poor posture as the patient must bend forward while walking. Standard walkers are the most stable type of walker, having four legs with non-skid rubber tips.

Walkers are also available with front wheels only or with four wheels. Front-wheeled walkers are generally used by someone with a faster gait or who finds it difficult to lift a standard walker. Four-wheeled walkers provide a larger base of support but should not be used by someone who needs weight-bearing support, because full body weight could cause the walker to roll away and cause a fall.

All ambulatory assistive devices should be fitted to the individual patient, who will likely need training in using the device. Referral to a physical therapist can be helpful in the process of assessing each patient’s needs and determining which assistive device would be most appropriate (Van Hook et al., 2003).

NUTRITION

Older adults generally require fewer calories because they are not as physically active as they once were and their metabolic rates slow down. Nevertheless, their bodies still require the same or higher levels of nutrients for optimal health outcomes. Malnutrition is not synonymous with thinness. Some obese persons are also malnourished: they consume more than enough calories but insufficient nutrients essential to good health.

Functional assessment of nutrition in the older adult involves both physical and psychological factors as well as the type and quantity of food eaten. Is the patient able to bite, chew, and swallow properly? Edentulous patients may be greatly restricted in the types of food they can chew, either because they don’t or won’t wear their dentures or because the dentures do not fit properly, perhaps because of recent weight loss. Infected teeth or missing teeth also interfere with eating well, particularly fresh fruits and vegetables.

Do patients have sufficient financial, educational, visual, and neurologic resources to shop and prepare nutritious, well-balanced meals? Have they lost interest in food because the food at the long-term care facility is not appealing? Have they recently lost or gained a significant amount of weight (5% or more in 30 days, 10% or more in 180 days)?

Older adults at greatest risk for nutritional deficiencies are those with less education, low income, or who live alone or in long-term care facilities.

Chronic disease (including depression or dementia), use of three or more prescribed or OTC medications, and age over 80 years old further increase the risk of nutritional deficiencies. Residents in long-term care are at particular risk for malnutrition, especially protein-calorie malnutrition. An estimated 12% to 50% of long-term care residents are malnourished, increasing the risk of digestive, lung, and heart problems; pneumonia; and other serious infections. Malnutrition can also cause blood clots, pressure ulcers, and poor wound healing, and can worsen mental confusion and dementia.

THE DETERMINE SCREEN

Warning signs for poor nutrition include:

  • Disease
  • Eating poorly
  • Tooth loss/mouth pain
  • Economic hardship
  • Reduced social contact
  • Multiple medicines
  • Involuntary weight loss/gain
  • Needs assistance in self-care
  • Elder years, above age 80

Source: AAFP, 2005.

Protein

Older people need more of certain nutrients such as protein, calcium, and vitamin D than younger adults in order to maintain muscle strength and bone health. For example, research indicates that older adults should aim for a protein target (in grams) of half their body weight (in pounds) to protect muscle strength. In other words, someone weighing 140 pounds should have 70 grams of protein daily. Protein is particularly important for women, because it is more difficult for women than for men to replace age-related lost muscle mass as they age (Smith et al., 2008).

One study showed that seniors who consumed adequate or high levels of dietary protein and participated in resistance training not only strengthened skeletal muscles but also improved their oral glucose tolerance (Iglay et al., 2007). However, older adults tend to eat less protein because it’s easier and cheaper to fix a meal with more carbohydrates (toast and jelly rather than a scrambled egg). Meat and fish, dairy and eggs, beans, tofu, and veggie burgers are all good sources of protein.

Vitamin D and Calcium

Calcium and vitamin D are essential for bone health and reducing the risk of falls. Many older adults don’t get enough of either in their diets. Vitamin D insufficiency is highly prevalent among older adults (Barnard & Colón-Emeric, 2010) and is associated with increased risk of cardiovascular disease, depression, cognitive deficits, and mortality (Anderson et al., 2009; Stewart & Hirani, 2010; Milaneschi et al., 2010).

All of us get vitamin D from the sun, but in northern climates, especially in the winter, sun exposure is limited. Food sources of vitamin D include vitamin D–fortified dairy milk or soy milk; fish such as salmon, mackerel, and sardines; and some fortified cereals. However, it may be difficult to get enough vitamin D from food, so supplements are recommended.

Several studies have shown that daily vitamin D supplements (700–800 IU) in the diets of people in their seventies and eighties reduced the risk of falls and fractures (Bischoff-Ferrari et al., 2005; Broe et al., 2007). The International Osteoporosis Foundation recommends 800–1,000 IU per day for older adults and suggests that 2,000 IU may be needed by those who are obese, have osteoporosis, or have limited sun exposure (Dawson-Hughes et al., 2010).

Calcium deficiency in older adults is not uncommon because many have lactose intolerance and thus avoid milk and other dairy products. Experts recommend 1200 mg of calcium for both men and women age 50 and older. Sources of calcium other than dairy products include greens such as bok choy, broccoli, Chinese/napa cabbage, kale, okra, turnip and collard greens, and fortified foods (tomato, orange, and other fruit juices, and certain cereals). However, calcium supplements probably are necessary to reach the recommended amount in the diet. Caffeine interferes with the absorption of calcium, so calcium supplements should be taken at least two hours before or after consuming caffeinated food or beverages (chocolate, coffee, tea, soft drinks).

Folate, Niacin, and Zinc

Malnourished older adults may also be deficient in folate, niacin (vitamin B3), and zinc (Anderson et al., 2009). Folate is essential to the synthesis of new cells. Gastrointestinal problems such as irritable bowel syndrome may interfere with folate absorption. Alcoholics have a high risk of folate deficiency because alcohol damages the gastrointestinal tract. The RDA of folate for older adults is 400 micrograms daily. Food sources include green leafy vegetables, dried beans and peas, liver, and orange juice, as well as bread, cereals, and other grains that are fortified with folic acid.

Niacin promotes nervous system function and acts as a coenzyme in energy metabolism. Deficiency in niacin can cause pellagra, characterized by dermatitis, diarrhea, and dementia; untreated, it can result in death. The RDA for niacin is 14 mg. Excess niacin can cause liver damage, gastric ulcers, low blood pressure, nausea, and vomiting. Food sources for niacin include all protein foods and whole grains, enriched breads, and cereals.

Zinc is a trace metal that promotes tissue growth and wound healing, protects immune function, provides vitamin A transport, and supports the sense of taste. Zinc deficiency can cause hair loss, diarrhea, delayed wound healing, taste abnormalities, and mental lethargy. Too much zinc can cause anemia, elevated LDL cholesterol, lowered HDL cholesterol, diarrhea, vomiting, impaired calcium absorption, fever, renal failure, muscle pain, and dizziness. The RDA for zinc is 11 mg for older men and 8 mg for older women. Food sources for zinc include oysters, red meat, poultry, dried peas and beans, nuts, whole grains, fortified breakfast cereals, and dairy products.

Vitamins B6, B12, and E

Vitamins B6 and B12 protect the nervous system, including memory and reasoning ability. They also decrease levels of homocysteine, which may reduce the risk of heart disease and Alzheimer’s disease. A large study by Swedish researchers found that higher levels of vitamin B12 decreased the risk of developing Alzheimer’s disease (Hooshmand et al., 2010). Deficiency of these vitamins can result in unsteady gate, muscle weakness, slurred speech, and psychosis.

Unfortunately, absorption of B6 and B12 is impaired in older people due to age-related changes in the digestive system; therefore, supplementation is necessary. The recommended daily allowance (RDA) of vitamin B6 is 1.7 mg for older men and 1.5 mg for older women. The RDA of B12 is 2.4 micrograms for women and men.

Vitamin E includes a family of eight antioxidants, but alpha-tocopherol is the only form of vitamin E considered active in the body. The RDA for vitamin E is 15 mg for both men and women. The upper tolerable limit of vitamin E is 1,000 mg per day. Research on vitamin E’s benefits has produced conflicting results, however some studies have shown that vitamin E reduces the risk of heart attack and death from cardiovascular disease. A Dutch study of more than 5,000 people showed that those with the highest vitamin E intake were the least likely to develop dementia or Alzheimer’s disease (Devore et al., 2010). Vitamin E may also have visual benefits, decreasing the risk of cataract formation and macular degeneration.

Other studies indicate that vitamin E may improve immune function. For example, a large trial in nursing home residents found that daily supplementation with 200 IU of synthetic alpha-tocopherol for one year significantly lowered the risk of contracting upper respiratory tract infections, especially the common cold, but did not affect lower respiratory tract (lung) infections (Meydani et al., 2004).

Vitamin E deficiency is linked with physical decline in older adults (Bartali et al., 2008), including impaired balance and coordination (ataxia), peripheral neuropathy, and muscle weakness. Older adults with these symptoms should be screened for vitamin E deficiency. Food sources of vitamin E include vegetable oils (walnut, sunflower, cottonseed, safflower, canola) nuts, whole grains, and green leafy vegetables.

ASSESSING SKIN

Skin assessment in older persons is focused on monitoring for dryness, pruritis, signs of skin breakdown such as pressure ulcers, lesions such as bruising that could indicate abuse or unreported falls, and possible skin cancers (basal or squamous cell carcinomas or melanoma).

Clinicians need to be vigilant in inspecting both hands and feet of older adults, particularly people who have diabetes or vision or mobility problems (including obesity), which may make them unable to trim their nails and properly care for their feet. These individuals need regular care by a podiatrist, who can prevent or treat irritations and infections.

Very thin patients, those who are poorly nourished, and those who are confined to bed or a wheelchair are at greatest risk for developing pressure ulcers on bony prominences; shoulders, lower back, heels, hips, and buttocks should be carefully inspected at least once a day. In male patients, the underside of the scrotum should be examined for pressure and irritation. Avoid massaging skin on bony prominences because it can increase the risk of pressure ulcers.

Inspect the skin for brown actinic keratosis precancerous lesions, commonly found on the face, neck, and upper extremities. Untreated, these lesions may progress to squamous cell carcinomas, which are reddish dome-shaped lesions. They may be found around the ear or on the head or neck. Basal cell carcinomas are the most common type of skin cancer, particularly in light-skinned individuals, appearing as a pearly papule with an ulcerated center; as an open sore that bleeds, oozes, or crusts for more than 3 weeks; or as a reddish patch on the chest, shoulders, arms, or legs. These cancers can be successfully treated if diagnosed early. Dark brown or black lesions may be melanoma, which can metastasize quickly and may prove fatal. Any suspicious lesions should be referred to dermatology for diagnosis.

During the physical examination, look for signs of possible abuse. Injuries may be found on many areas of the body, especially the face, throat, neck, chest, abdomen, and genitals. Note any bruises, burns, or wound patterns that resemble teeth marks, hand prints, belts, or cigarette tips. Note any pain or tenderness from touching. Be alert for puncture wounds, fractures, and dislocations, scars on the vulva or rectum, or any unexplained vaginal or anal bleeding, particularly in older people. Be aware that women may wear a glove or sock to conceal a scalded hand or foot. Women who show signs of physical abuse should also be screened for STIs, including chlamydia, human papilloma virus, gonorrhea, and syphilis.

DOCUMENTING SUSPECTED ABUSE

To be admissible in a court of law, medical documentation should include the following:

  • Photographs of the injuries, taken during the initial examination
  • Body maps, which document the extent and location of the injuries
  • Description of the patient's demeanor (crying, angry, agitated, upset), including a record of the patient's comments about how the injuries occurred (the patient's own words should be set off in quotation marks or identified by such phrases as “the patient states” or “the patient reports”)
  • Any description in which the patient identifies the abuser, such as “my boyfriend kicked me”
  • The time of day when the patient is examined and, if possible, how much elapsed time since the injuries occurred (e.g., “patient says that last night her husband punched her”)
  • Legible handwriting (too often, doctors’ or nurses’ poor handwriting on medical records makes the documentation inadmissible as evidence)

Source: Isaac & Enos, 2001.

When assisting patients in bathing themselves, avoid hot water and offer a mild cleansing agent that minimizes irritation and dryness of the skin. Minimize the force and friction applied to the skin. The frequency of bathing should be individualized according to need and/or patient preference. Minimize environmental factors leading to skin drying, such as low humidity (less than 40%) and exposure to cold. Dry skin should be treated with moisturizers.

Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, provide underpads or briefs made of materials that absorb moisture and present a quick-drying surface to the skin. Topical agents that act as barriers to moisture can also be used.

URINARY INCONTINENCE

Urinary incontinence becomes more prevalent among both men and women as they age. The precise incidence of incontinence is unknown because shame and embarrassment make patients hesitant to talk with their physicians about it. Many physicians don’t screen for it, either sensing the patient’s embarrassment or because of limited time. However, when a health professional asks, “Do you have any problems with leakage of urine?,” those who experience incontinence will generally acknowledge it.

Screening for incontinence is essential because non-pharmacologic therapeutic measures can reduce or eliminate the condition, preventing complications such as skin breakdown, urinary tract infections, and withdrawal from social activities, which can lead to isolation.

Incontinence can be transient (potentially reversible) or chronic. Age-related changes in the urinary tract are only one of several factors contributing to incontinence. Potentially reversible factors include those summarized in the mnemonic DIAPPERS:

  • Delirium, which is the primary cause of incontinence in hospitalized patients (Those affected may not recognize the need to urinate or be unable to find a toilet or urinal. Once the delirium is resolved, so is the incontinence.)
  • Infection in the urinary tract (UTI) that leads to urgency and incontinence
  • Atrophic urethritis and vaginitis
  • Pharmaceuticals (as well as alcohol and caffeine)
  • Psychological factors (such as depression)
  • Excess urinary output (caused by diabetes, use of diuretics, or excess fluid intake, especially of alcohol and caffeinated beverages)
  • Restricted mobility, because the patient is unable to reach the toilet in time to avoid leakage (Restoring or improving mobility can resolve the incontinence. Otherwise a bedside commode or urinal should be provided.)
  • Stool impaction (Can cause temporary confusion, leading to incontinence of both urine and stool. Removing the impaction generally restores continence.)

People with diabetes are at high risk for incontinence due to neuropathy that affects pelvic nerves. Other high-risk groups include those with Parkinson’s or stroke-related neurologic problems, women with relaxed pelvic muscles, and men who have had prostate surgery. By observing how long it takes from intake to urinary output, caregivers can intervene at the appropriate time for toileting. Controlling UTIs also helps prevent incontinence.

Preventing incontinence is based on keeping the bladder empty by frequent toileting, bladder retraining, and in some cases, catheterization. However, limiting fluid intake (except in the evening) can cause dehydration, requiring other measures. Review of medications may identify one or more drugs that contribute to incontinence (see below); if it is not feasible to discontinue the drug(s), substituting another drug may help reduce incontinence.

MEDICATIONS ASSOCIATED WITH INCONTINENCE
Anti-hypertensives
  • Prazosin (Minipress)
  • Terazosin (Hytrin)
  • Doxasosin (Cardura)
  • Alphamethyldopa (Aldomet)
  • Reserpine (Diupres, Hydropres)
Anti-seizure medications
  • Thioridazine, chloropromazine (Thorazine)
  • Haloperidor (Haldol)
  • Clozapine (Clozaril)
Anti-anxiety and muscle relaxant drugs
  • Benzodiazepines (Valium, Xanex, Klonopin)
Diuretics (water pills)
  • Furosemide (Lasix) or hydrochlorothiazide (Diuril)
Drugs that cause incomplete bladder emptying
  • Hyoscyamine (Cystospaz, Urised, Donnatal, Levbid, Levsin)
  • Oxybutinin (Ditropan)
  • Benztropine (Cogentin)
  • Trihexyphenidyl (Artane)
  • Pindolol (Pindolol)
  • Disopyramide (Norpace)
Drugs that increase stress incontinence
  • Any drug that includes a side effect of producing a chronic cough (e.g., anti-hypertensive drugs such as Vaseretic, Vasotec, Lotensin, Monopril, Zestril).

Research indicates that behavioral modification should be the first-line therapy for incontinence in older patients. Pelvic floor exercises are helpful for stress incontinence, while bladder training is helpful for urge incontinence. Both modalities are helpful when the patient has both types of incontinence (Dumoulin & Hay-Smith, 2008). Drug treatment for stress incontinence is limited, although some experts recommend a trial of topical estrogen for women with symptomatic atrophic urethritis. Surgery is considered a last resort, particularly in very elderly women, although the success rate is 75% to 85% even in older women (Johnston et al., 2010).

Stress incontinence is a particular problem for any older woman with a cough, either chronic or temporary. The patient will likely need protection for her clothing to prevent the odor of stale urine. Wearing a panty liner or sanitary pad should be tried before selecting bulkier incontinence garments. Frequent careful cleaning of the genital area can prevent odor and skin breakdown. If the patient is unable to clean herself, the care provider must do so.

When confusion and incontinence occur together, controlling the confusion may also help prevent incontinence. However, research suggests that patients who are taking medications for dementia (e.g., cholinesterase inhibitors) should not also take medications for incontinence (e.g., anticholinergic drugs) because the interaction of these two types of drugs can hasten functional decline (Sink et al., 2008). This finding has major public health implications because an estimated one third of people with dementia also take a drug for incontinence.

Assessing Psychosocial Function

Socially isolated older persons are difficult to find. Like other vulnerable older persons, they tend to be invisible.
—GUSMANO & RODWIN (2006)

As the late Bette Davis said, “Getting old is not for sissies.” Whether life changes are slow or sudden, the result often affects both physical and mental health. For example, death, injury, or serious illness of a partner can alter living circumstances, social support, and economic security. These changes can lead to isolation, depression, and suicide among vulnerable elders.

ISOLATION

Social isolation can be hazardous to health, particularly in older adults. One in 3 Americans lives alone, and 1 in 4 of those are typically older women who live in poverty and report poor health. These women are at higher risk for institutionalization and loss of independence—as well as heart disease, memory problems, depression, and suicide—than someone living with a spouse or other companion.

Living alone does not always mean being lonely or isolated, but health professionals need to be aware of the possibility. Risk factors for social isolation include low self-esteem, a history of abuse or homelessness, depression, chronic pain, incontinence, and mobility problems.

Research shows that having social networks and participating in social activities protects cognitive function and reduces dementia incidence, particularly among older women (Ertel et al., 2008; Crooks et al., 2008). Measures to increase social engagement include referral to a support group, telephoning or emailing friends, or adopting a pet. Another strategy would be to contact a volunteer visitation organization (such as Little Brothers-Friends of the Elderly in Boston and other cities or New York’s DOROT) that matches older adults who live alone with volunteer visitors.

Institutionalized elders may also be socially isolated because of their health problems or because they have no family to visit them. As mentioned earlier, loneliness is one of the three plagues of living in a nursing home. Volunteer visitation and pet therapy can also help reduce isolation among these elders.

DEPRESSION

Depression is a widely under-recognized and undertreated medical illness in older adults. Estimates of major depression in older people living in the community range from 1% to 5%, but the rate may rise as high as 42% among those in long-term care facilities (Blazer, 2003; Djernes, 2006). “Depressive disorder is not a normal part of aging. Emotional experiences of sadness, grief, response to loss, and temporary blue moods are normal. Persistent depression that interferes significantly with ability to function is not” (National Institute of Mental Health, 2010a).

Depression can be immobilizing and can interfere with normal sleep, nutritional intake, thinking and concentration, and quality of life. Therefore, depression contributes indirectly to a decline in physical and mental health. In fact, a number of studies have shown that depression is an independent risk factor for falls.

Recognizing the symptoms of depression in older people and referring them for appropriate treatment may greatly improve their quality of life. Symptoms include:

  • Sleep disturbance and fatigue
  • Changes in physical activity, ranging from slowing down to agitation or hyperactivity
  • Loss of interest in living
  • Hopelessness about the future
  • Changes in appetite and/or weight
  • Inability to concentrate or make decisions
  • Complaints about poor memory and concentration
    (Fiske et al., 2009)

Treatment for depression may include behavioral therapy, cognitive behavioral therapy, problem-solving therapy, brief psychodynamic therapy (also called insight-oriented therapy), life review (also called reminiscence therapy); however, these therapies are used too infrequently with older adults (Fiske et al., 2009).

Antidepressant medications may also be used but, unless accompanied by some form of psychotherapy, may not be effective (O’Connor et al., 2009.). In addition, antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs), increase the risk of falls (Kerse et al., 2008). If antidepressant medications are prescribed, care providers need to redouble efforts to prevent falls. Strategies include exercises to strengthen lower leg muscles and balance retraining, as well as home assessment and modification as needed.

SUICIDE

Depression is one of the conditions most commonly associated with suicide. According to the National Institute of Mental Health (2010b), older Americans are disproportionately likely to die by suicide. The rate of suicide among people age 65 and older is higher than the national average. The incidence of suicide is highest among non-Hispanic white men, and guns are the most frequently used method. Among females, the incidence of suicide is highest among Asian Pacific Islanders. Suicide is most common among older adults who are divorced or widowed.

Risk factors for suicide in people age 65 or older include:

  • Male gender
  • Chronic or terminal illness
  • Social isolation
  • Financial strain
  • Bereavement
  • Depression
  • Alcohol or drug abuse
  • History of other suicide attempts
  • Family history of suicide
  • Preoccupation with suicidal talk and plans

Preventing suicide depends on early recognition of suicidal intent and treating physical and psychiatric conditions, reducing social isolation, enhancing self-esteem, and helping people find meaning or satisfaction in life. Health professionals and family caregivers need to pay attention to statements such as “I’d be better off dead” or “I don’t want to live.” These suggest a need for counseling by a mental health professional.

Feeling helpless, hopeless, and worthless can lead to thoughts of suicide and, in some cases, committing suicide. “People who feel helpless need empowerment. People who feel worthless need to experience their own value to the folks who matter in their lives. People who feel hopeless need to see beyond today” (Hamilton, 2008).

CONFUSION AND COGNITION

Who among us has not been confused at one time or another? Losing our sense of direction when traveling in an unfamiliar city, waking up in the hospital after a serious car accident, becoming disoriented after hearing the news of a death in the family—all can cause confusion.

When we are young, or even middle-aged, confusion is considered temporary and reversible. In older adults, however, confusion is too often regarded as the first step on the road to dementia and “senility.” As Wolanin (1981) wrote, “Diagnosis often becomes prognosis, as health professionals use stereotypes for shaping their planning.” Labeling confusion as cognitive impairment can have life-altering effects on patients and affect their treatment socially, legally, medically, and psychologically.

Some forms of confusion may be temporary or reversible, while others may be irreversible or indicative of chronic confusion and dementia, including Alzheimer’s disease.

Gradual onset of confusion may be reversible if it is related to a treatable or correctible condition such as nutritional deficiency, hypothyroidism, vision or hearing impairment, or depression. Careful assessment is needed to avoid misdiagnosis and thereby perpetuate the confusional state. Health professionals need to assume that confusion may be reversible, particularly confusion of sudden onset, and seek the possible causes.

CAUSES OF REVERSIBLE CONFUSION
Systemic Problems
  • Hypoxia
  • Hypoglycemia
  • Hyperglycemia
  • Dehydration and fluid/electrolyte imbalance
  • Hypercalcemia
  • Hypocalcemia
  • Hypothyroidism
  • Hyperthyroidism
  • Hypothermia
  • Hyperthermia
  • Hypotension
  • Drug related intoxications
  • Pernicious anemia
  • Pellagra (niacin deficiency)
  • Stress
  • Fecal impaction
Mechanical Problems
  • Obstruction to cerebral blood flow
  • Increased intracranial pressure
  • Brain cell death or loss
Sensoriperceptual Problems
  • Sensory deprivation related to vision or hearing impairment
  • Sensory overload in noisy, crowded settings
  • Lack of variety, lack of personal contacts, and lack of meaning, especially in institutional settings
  • Relocation/transfer from familiar surroundings to unfamiliar surroundings

CASE

Agnes Miller, age 86, is a widow who has lived alone successfully for years in her small apartment. She slipped and fell in her kitchen, fracturing her hip. The fall also broke her glasses and dislodged her hearing aid, which slid out of reach under the kitchen table. Unable to reach the telephone, Agnes lay on the floor and shouted for help, hoping that a neighbor would hear her. It was a cold day and all windows were closed, so nearly 24 hours passed before someone heard her and dialed 911.

Paramedics whisked Agnes off to the hospital, leaving her broken glasses on the kitchen table and failing to notice her hearing aid underneath. Arriving in the ED, Agnes was weak, disoriented, and had difficulty hearing and responding to questions. She had been without food or water and was shivering and in pain. After her condition was stabilized with IV fluids and warm blankets, she was prepped for surgery to repair her hip.

A few days later she was moved to a long-term care facility, still without her glasses or her hearing aid. Her medical record indicated “confusion” and “disorientation.” Fortunately, a nurse at the long-term care facility was able to communicate with Agnes and learned about the missing glasses and hearing aid. By contacting Agnes’s neighbor, she was able to get the hearing aid and order new glasses. Over the next week or two, Agnes once again became alert, responsive, and communicative.

Researchers have found that the brain’s ability to selectively focus (called visual attention) while screening out irrelevant or distracting information diminishes with age. Instead of remembering only the important information, the brain also remembers the unimportant information. For example, searching for car keys on a cluttered table is more difficult than seeing them without the clutter. This phenomenon may account for some aspects of confusion in the elderly (Schmitz et al., 2010).

Delirium

Delirium is an acute confusional state of rapid onset characterized by clouding of consciousness, disorientation, memory impairment, incoherent speech, and perceptual disturbance. Delirium can be caused by serious illness such as an infection, coronary ischemia, hypoxemia, fever, hypothermia, toxic-metabolic conditions, medication interactions, use of restraints, use of intravenous lines or urinary catheters, intracranial lesions, trauma, sensory deprivation, alcoholism, or stress.

Delirium is not unusual in older adult hospitalized patients, and it may progress to chronic confusion. According to Johnston and colleagues (2010), about one fourth of patients with delirium have dementia and about 40% of hospitalized people with dementia experience delirium.

Mild Cognitive Impairment (MCI)

Impairments in financial skills and judgment are often the first functional changes demonstrated by patients with incipient dementia.
—TRIEBEL ET AL. (2010)

Mild cognitive impairment is a transitional state between the normal cognitive changes of aging and the development of Alzheimer’s disease (AD) or other dementia. Two subtypes of MCI have been established. Amnestic MCI is characterized by memory problems. Nonamnestic MCI affects cognitive functions other than memory, such as language, attention, critical thinking, reading, and writing. Experts estimate that MCI may affect more than 20% of the population over age 65. People diagnosed with MCI are at increased risk of developing AD or other dementias.

Researchers at the Mayo Clinic found that MCI was more prevalent in men than in women, and more than twice as many of the study participants had the amnestic form of MCI. Prevalence of MCI was higher among those with the APOE e4 gene, a known risk factor for late onset Alzheimer’s. More years of education was associated with decreased prevalence of MCI. Being single was associated with higher prevalence of MCI compared with being currently or formerly married (Petersen et al., 2010).

In 2001, the American Academy of Neurology (AAN) established the following criteria for an MCI diagnosis:

  • An individual’s self-report of memory problems, preferably confirmed by another person
  • Measurable, greater-than-normal memory impairment detected with standard memory assessment tests
  • Normal general thinking and reasoning skills
  • Ability to perform normal daily activities

Ongoing research on MCI suggests that earlier treatment with drugs approved for AD may slow its progression to AD. A 3-year, placebo-controlled clinical trial of more than 750 patients with amnestic MCI showed that donepezil (Aricept) reduced the risk of developing AD during the first year (Petersen et al., 2005). However, by the end of the three-year study, the risk was the same as those in the placebo group. Nevertheless, delaying the progression to AD by a year represents a significant reprieve for both patients and caregivers in terms of maintaining function and quality of life as well as reducing healthcare costs.

SCREENING FOR COGNITIVE IMPAIRMENT

The Mini–Mental State Examination (MMSE) is one of a number of screening tools for cognitive impairment and dementias. It measures an individual’s reality orientation, registration abilities, attention and calculation skills, recall, language, and visuoconstruction (seeing and copying designs) abilities.

The highest possible score is 30 points. Those who score less than 25 need further evaluation for possible AD or other dementias, depression, delirium, or schizophrenia. Those who score 20 or less generally have one of these disorders.

MINI–MENTAL STATE EXAMINATION
Category Points Questions
1. Orientation to time and place 10 The patient is asked to provide information on the time (e.g., year, season, month, date, and day of week). (1 point each)
The patient is asked to provide information on the present location (e.g., state, county, city, hospital, floor). (1 point each)
2. Registration 3 The patient is asked to repeat three named prompts. (1 point each)
3. Attention and calculation 5 The patient is asked to spell WORLD backwards. (points given up to first misplaced letter, e.g., 2 points for “DLORW”)
4. Recall 3 The patient is asked to recall the three objects memorized in “registration” above.
5. Language 2 The patient is asked to name two objects when they are displayed (pencil and watch). (1 point each)
6. Repetition 1 The patient is asked to speak back a phrase (“No ifs, ands, or buts”). (1 point)
7. Complex commands 6 The patient is asked to follow complex commands, which may involve drawing a shown figure. (6 points)

Alzheimer’s Disease (AD) and Other Irreversible Dementias

No matter who you are, how old you are, what you’ve accomplished, what your financial situation is—when you’re dealing with a parent who has Alzheimer’s, you feel powerless. And as the disease unfolds, you feel ever more powerless because you don’t know what to do or what to expect.
—MARIA SHRIVER (2010)

Alzheimer’s disease is an age-related, irreversible brain disorder that gradually erases memory, thinking, understanding, and sense of self. Over time, as neurons die in widespread areas of the brain's cerebral cortex, mild sporadic memory loss evolves into severe cognitive dysfunction as well as behavior and personality changes and, eventually, loss of physical function. The course of AD and the rate of decline vary from person to person. On average, clients with AD live for 8 to 10 years after diagnosis but may live as long as 20 years.

Although the risk of developing AD increases with age, AD and other dementia symptoms are not a part of normal aging but the result of diseases that affect the brain. In the absence of disease, the human brain can function well into the tenth decade of life.

Alzheimer’s disease is one of a group of disorders called dementias, which are characterized by progressive cognitive and behavioral changes. Symptoms commonly appear after age 60, beginning with loss of recent memory, followed by faulty judgment and personality changes. People in the early stages of AD often think less clearly and may be easily confused.

In progressive stages of the disease, people with AD may forget how to manage ADLs. In the late stages, people with AD are unable to function on their own and become completely dependent on others for their everyday care. Finally, they become bedfast and succumb to other illnesses and infections. Pneumonia is the most common cause of death in AD.

CAUSES AND PREVENTION

Alzheimer’s disease has no single, clear-cut cause and therefore no sure means of prevention. Scientists believe that AD results from the interaction of genetic, environmental, and lifestyle factors over many years, causing changes in brain structure and function.

A number of factors can contribute to declines in cognitive function:

  • Increasing age
  • Hypertension
  • Diabetes
  • Stroke or transient ischemic attacks (TIAs)
  • Presence of infarcts or white-matter lesions
  • Low mood (depression)
  • Higher body mass index (BMI)
  • Traumatic brain injury
  • Head injury in early adulthood
  • Chronic stress
  • Smoking more than two packs of cigarettes per day
  • Exposure to lead and other metals (aluminum, methylmercury, iron, zinc, copper)
  • Pesticides
  • Extremely low-frequency electromagnetic fields
    (Bolin et al., 2006; Zawia & Basha, 2005; Basha et al., 2005; Hendrie et al., 2006; Rusanen, et al., 2011)

Factors that protect cognitive function include:

  • Higher levels of education
  • Higher socioeconomic status (SES)
  • Emotional support
  • Social engagement
  • Better baseline cognitive function
  • Better lung capacity
  • More physical exercise
  • Moderate alcohol use
  • Use of vitamin supplements, especially B12

Preventing AD would save untold suffering of patients and families and billions of dollars for the healthcare system. Research studies to identify factors that increase or decrease the risk of developing AD are a first step toward making primary prevention a reality. For example, lifestyle choices related to diet and exercise that reduce the risk of diabetes, hypertension, stroke, and obesity could also reduce the risk of AD. Avoiding tobacco products is also important. A large study in Sweden showed that smoking more than two packs of cigarettes per day doubled the risk of developing AD (Rusanen et al., 2010). Reducing human exposure (particularly among children and workers) to lead and other metals, pesticides, and electromagnetic fields could also reduce future incidence of AD.

DIAGNOSIS, CARE, AND TREATMENT

Alzheimer's disease remains a diagnosis of exclusion, ruling out other conditions that may cause similar symptoms, such as stroke, hypothyroidism, depression, nutritional deficiency, brain tumor, Parkinson's disease, or inappropriate medications. Conclusive diagnosis of AD is still only possible at autopsy. However, researchers have reported some success in identifying proteins called biomarkers in the blood and spinal fluid that can provide earlier probable diagnosis of the disease. Combined with more accurate neuropsychological testing and neuroimaging techniques such as positive emission tomography (PET) scans and magnetic resonance imaging (MRI), these advances enable clinicians to more accurately predict who will develop AD.

Care and treatment of the person with AD will change over time as the disease progresses. Care planning should begin at the time of diagnosis and should involve the patient and the family. The plan includes:

  • Cholinesterase inhibitor therapy to temporarily improve cognition or slow the rate of cognitive decline
  • Management of co-morbid conditions, especially sensory deficits
  • Treatment of behavioral symptoms and mood disorders
  • Support and resources for patient and caregiver
  • Discussion of advance directives
  • Compliance with state-mandated reporting requirements for driving impairment and elder abuse
    (Cummings et al., 2002)

The box below presents suggestions for creating and maintaining a supportive environment when caring for a person who has dementia.

CREATING A SUPPORTIVE ENVIRONMENT

  1. Make change very slowly. Carefully prepare the person for any change in medications, nutrition, therapy, personnel, or location.
  2. Keep the patient active as long as possible. Daily exercise, outdoors if possible, helps maintain physical and emotional function.
  3. Maintain a routine. A dependable world and a structured life are reassuring.
  4. Provide social stimulation without overload. Encourage and maintain communication through every possible channel.
  5. Avoid crowds and large spaces without boundaries. Try to prevent sensory overload and provide easily visible boundaries and interior landmarks.
  6. Monitor nutrition, attention to mouth and teeth, and footwear. Help with eating and oral hygiene to reduce the risk of infection. Comfortable, well-fitting shoes with nonslip soles help prevent falls.
  7. Keep activities and conversations simple. Avoid complexity; it creates confusion and anxiety.
  8. Provide positive input. Praise and compliments for any achievement help maintain self-esteem and encourage self-participation in activities of daily living.
  9. Provide reality checkpoints: calendars with large days and dates, clocks with large numbers marking the hours, and reminders of special events such as birthdays, anniversaries, and holidays.
  10. Support bowel and bladder control. A consistent toileting routine helps preserve function and control. Use clothing with simple fasteners like Velcro or pants with elastic waistbands.
  11. Support family caregivers. Commend their efforts, refer them to support groups and respite care, and assist them in creating a helping network.
  12. Provide information and referrals for legal assistance such as drawing up advance directives for end-of-life care.

Source: Wolanin & Phillips, 1981.

Until it becomes necessary to institutionalize the patient, the primary caregiver will most likely be the spouse (usually the wife) or a child (usually a daughter). That caregiver and other family members involved need education and support to help manage the care as the patient’s symptoms and needs change.

Patients receiving collaborative care from an interdisciplinary team or primary care providers working with the patient’s family caregiver have been shown to exhibit fewer behavioral and psychological symptoms of dementia than receiving usual care. Family caregivers also benefited, showing significant reduction in distress and improvement in depression. Researchers reported that these improvements “were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics” (Callahan et al., 2006).

When talking with older patients, especially those with dementia, health professionals and family caregivers should use a respectful, adult communication style rather than the baby talk that many well-intentioned caregivers use. Avoid a high-pitched, sing-song voice; terms like “sweetie,” “honey,” and “dearie”; and saying things like “Are we ready for our bath?” This style of communication can cause dementia patients to be uncooperative and resistant to care (Williams, 2008). Resistance to care includes pushing away, grabbing things, crying and screaming, and hitting and kicking.

FUNCTIONAL ASSESSMENT

Caring for someone with AD should include periodic assessment of the person's ability to function as the disease progresses. Researchers at Duke University developed the Functional Dementia Scale (see below) to help caregivers monitor functional abilities and plan appropriate interventions.

FUNCTIONAL DEMENTIA SCALE
Source: Moore, 1983.
Patient:
Observer:
Position or relation to patient:
Facility:
Date:
(Circle one rating for each item)
1 = None or little of the time, 2 = Some of the time, 3 = Good part of the time, 4 = Most or all of the time
Question Rating Task
1. 1 2 3 4 Has difficulty completing simple tasks on own, e.g., dressing, bathing, doing arithmetic.
2. 1 2 3 4 Spends time either sitting or in apparently purposeless activity
3. 1 2 3 4 Wanders at night or needs to be restrained to prevent wandering
4. 1 2 3 4 Hears things that are not there
5. 1 2 3 4 Requires supervision or assistance in eating
6. 1 2 3 4 Loses things
7. 1 2 3 4 Appearance is disorderly if left to own devices
8. 1 2 3 4 Moans
9. 1 2 3 4 Cannot control bowel function
10. 1 2 3 4 Threatens to harm others
11. 1 2 3 4 Cannot control bladder function
12. 1 2 3 4 Needs to be watched so doesn't injure self, e.g., careless smoking, leaving the stove on, falling
13. 1 2 3 4 Destructive of materials around self, e.g., breaks furniture, throws food trays, tears up magazines
14. 1 2 3 4 Shouts or yells
15. 1 2 3 4 Accuses others of doing self bodily harm or stealing possessions (when you are sure the accusations are not true)
16. 1 2 3 4 Is unaware of limitations imposed by illness
17. 1 2 3 4 Becomes confused and is not oriented to place
18. 1 2 3 4 Has trouble remembering
19. 1 2 3 4 Has sudden changes of mood, e.g., gets upset, angry, or cries easily
20. 1 2 3 4 If left alone, wanders aimlessly during the day or needs to be restrained to prevent wandering

SUPPORTING FAMILY CAREGIVERS

Two thirds of older people who need long-term and end-of-life care rely on family and friends for assistance. Almost one third supplement family care with help from paid providers. Family caregivers also bear an enormous burden in caring for a loved one at the end of life. They play a major role in actual care and in decision making about care provided by others.

Care provided by family and friends can make the difference between living at home and going to a nursing home or other long-term care facility. Likewise, reducing the burdens of caregiving can delay the need for nursing home care. Respite care, caregiver support groups, and skills training interventions can further reduce caregiver burden.

The caregiver experience holds a host of emotions, ranging from sadness, resentment, anger, and a sense of inadequacy, to deep gratitude for being able to care for the loved one. Physical exhaustion, inadequate sleep, disrupted routines, and endless responsibility can lead to mental health problems such as anxiety and depression. Nurses and other healthcare providers need to be aware of signs of depression or other mental health problems in caregivers and recommend that they take time to seek treatment.

Demands on caregivers’ time are significant. Most caregivers are women—wives, daughters, or other women, many of whom are juggling childcare, jobs, and other responsibilities. Many women are forced to work fewer hours outside the home, pass up a job promotion, switch from full-time to part-time employment, or even quit their jobs or retire early to provide care for an older loved one. These changes can affect women’s lifetime income, retirement security, and their own needs for long-term care.

Physical health is also impaired by caregiving. Problems such as coronary heart disease, hypertension, poor immune function, cancer, and increased risk of mortality can result (Christakis & Allison, 2006). Middle-aged or older women may not have the training or physical stamina necessary to lift, move, or turn terminally ill loved ones. Without professional help, this puts them at serious risk of physical injury. Clinicians need to anticipate this risk and offer assistance with physically strenuous aspects of care.

Caring for an older person at home inflicts financial stress on families of even moderate means. Paying for medications, purchasing consumable supplies, or modifying the home environment to prevent falls or to accommodate a wheelchair can create a financial hardship for families. Some may spend as much as 10% of their annual income on caregiving as well as sacrificing their savings. Minority and low-income caregivers bear the greatest burden because they are less likely to be able to afford paid home care assistance or to enjoy a respite from their caregiving responsibilities. Even though the Medicare hospice benefit relieves some of the financial burden of end-of-life care, families can still face severe economic consequences and personal sacrifices.

LEGAL AND ETHICAL CONSIDERATIONS

Getting legal affairs in order—drawing up advance directives, powers of attorney, wills, or trusts—is important for all adults, regardless of health status. For those diagnosed with AD or other dementia, legal affairs should be taken care of as soon as possible after diagnosis, while the patient is able to participate in decisions. This helps ensure that one's wishes are respected in end-of-life care and disposition of property after death. Otherwise, families will need to make difficult decisions without knowing the patient's wishes.

Referral to the local chapter of the Alzheimer's Association can help families find attorneys who specialize in elder law or estate planning. This referral should not be made abruptly but as a suggestion, emphasizing the universal need for such a plan.

Advance Directives

An advance directive specifies a person’s preferences for care in the event that he or she is unable to communicate those wishes—for example, in the advanced stages of AD. A living will is one type of advance directive. In an advance directive, the person can also name a representative to see that his or her wishes concerning care are carried out. This is sometimes called a durable power of attorney for healthcare.

Physicians should have copies of advance directives available or be able to refer families to a source for the appropriate forms. Federal law requires hospitals to inform patients that they have a right to complete an advance directive (the Patient Self-Determination Act), but advance directives are regulated by state law and may differ from state to state.

Health professionals who see evidence of cognitive impairment in a patient should ask the spouse, partner, or other family member whether anyone has been designated to act on the patient’s behalf in managing his or her financial affairs, such as paying bills. This requires a general power of attorney, which does not include healthcare decisions. Designating a trusted family member or friend as a general power of attorney helps ensure that the patient’s financial affairs will be handled appropriately rather than exploited, a common type of elder abuse. If the patient has no family or friends, an attorney or an officer of a bank may serve this role.

A patient who has no spouse, partner, or other family member to fulfill this role may need both a guardian and a conservator, both of whom are appointed by the court. The guardian is responsible for the health and safety of the patient, and the conservator is responsible for controlling the financial affairs of the patient.

Family Caregiver Alliance can provide state-specific information and appropriate forms for advance directives (see “Resources” below).

CPR vs. DNAR Orders

Do-not-attempt-resuscitation orders (DNAR) (formerly known as “do-not-resuscitate orders”) have been renamed to emphasize the minimal likelihood of successful cardiopulmonary resuscitation (CPR). Patients and families need to understand not only the unlikely success of resuscitation but also the risks involved, which include fractured ribs, damaged internal organs, and neurologic impairment. Although the patient (or family) must ultimately decide about whether to attempt CPR, healthcare providers need to explain that withholding CPR does not equate with letting someone die. Rather, as one physician suggested, a DNAR order should be considered an Allow Natural Death order, “which is the right thing to do in many cases” (Borenstein, 2008).

The DNAR order should be readily available in the event of an emergency to ensure that the patient’s wishes will be honored. It should be posted prominently, either on the head or foot of the bed, or if the patient is at home, on the refrigerator. The specifics of the order should also be carefully documented in the patient’s chart. Some patients prefer the additional safeguard of wearing a bracelet or necklace to alert care providers that a DNAR order is in force.

Physician Orders for Life-Sustaining Treatment (POLST)

Several states have adopted an advance directive form developed in Oregon and known as POLST, which stands for Physician Orders for Life-Sustaining Treatment (2005). This simple form, to be completed and signed by both patient and a physician or nurse practitioner, specifies the patient’s preferences concerning measures such as antibiotics, artificial nutrition (including tube feeding) and hydration, CPR, comfort measures, and mechanical ventilation/respiration.

The form is printed on bright-colored paper and stays with the patient during transfers from one care setting to another. Patients at home keep the POLST form on the refrigerator or where emergency responders can easily find it. Long-term care facilities retain POLST forms in residents’ charts. Information about POLST programs in each state is available online at http://www.polst.org.

Artificial Nutrition and Hydration (ANH)

People with advanced Alzheimer’s disease or other dementias eventually forget how to feed themselves or even how to eat. These patients should be considered terminal, and care providers need to help families understand that forgoing artificial nutrition and hydration is not “killing” or “starving” the patient. People with advanced dementia are unlikely to benefit from tube feeding, either in terms of survival or quality of life. On the contrary, tube-fed patients with dementing illnesses have higher incidence of lung infections and agitation, which requires physical restraints and sedation, resulting in painful skin breakdown.

Despite evidence that feeding tubes cause more harm than help to the patient with advanced dementia, the practice continues. Research has shown that some nursing homes promote the idea of ANH for financial reasons. “System-wide [reimbursement] incentives favor use of tube feeding and may influence substitute decision-makers, bedside clinicians, gastroenterologists and administrators regardless of patient preferences or putative medical indications” (Finucane et al., 2007).

Reporting Unsafe Driving

Families are usually the first to notice unsafe driving behaviors in their older loved one but often find it difficult to convince the person to stop driving. Whether the problem is vision impairment, dementia, or some other health condition, there often comes a time when an older adult is no longer a safe driver.

Some patients willingly stop driving; others are reluctant to give up the independence that driving represents, thereby creating a significant threat to personal and public safety. Those who refuse to quit driving even though they pose a hazard must be prevented from driving by other means, either by hiding the car keys or disabling the car. If family members can’t convince the impaired driver to stop driving, their physician needs to intervene.

Although many states encourage physicians and other health professionals to report people with conditions that may affect their ability to drive safely, only six states have mandatory reporting requirements for physicians to report specific conditions such as seizure disorders and AD, among other disorders: California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania. Health professionals need to know the reporting requirements in the state where they practice (AMA, 2010).

In Florida, any physician, person, or agency knowing of a licensed driver's (or applicant's) mental or physical disability to drive is authorized to report this to the Department of Highway Safety and Motor Vehicles. “Such reports are confidential and used only to determine the qualifications of the individual to operate a motor vehicle on Florida's highways. No civil or criminal action may be brought against any physician, person, or agency for providing this information” (Florida DHSMV, 2003).

ELDER ABUSE

Abuse of older adults is a well-kept secret in the United States. Abuse may be physical, emotional, financial, sexual, or by neglect or abandonment. The actual prevalence of elder abuse is unknown; experts suggest that only 1 in 5 cases of abuse are reported. However, prevalence was recently reported at more than 11% in people over 60 (Acierno et al., 2010).

TYPES OF ELDER ABUSE
Source: Administration on Aging, 2010.
Physical Inflicting physical pain or injury on a senior, e.g., slapping, bruising, or restraining by physical or chemical means
Emotional Inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts, e.g., humiliating, intimidating, or threatening
Sexual Non-consensual sexual contact of any kind
Neglect Failure by those responsible to provide food, shelter, healthcare, or protection for a vulnerable elder
Exploitation Illegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else’s benefit
Abandonment Desertion of a vulnerable elder by anyone who has assumed responsibility for care or custody of that person
Self-neglect Failure of a person to perform essential self-care tasks, which failure threatens his/her own health or safety

Most known perpetrators of abuse and neglect are family members, usually an adult child or a spouse (Hildreth et al., 2009). Most abuse happens in the elder’s own home. However, abuse also occurs in long-term care facilities. One recent study showed that nursing homes have the highest rates of all types of abuse, while paid home care had high rates of verbal abuse and assisted-living facilities had high rates of neglect (Page et al., 2009).

Financial exploitation is a serious risk for elders with any degree of cognitive impairment. Unscrupulous individuals, including family members, friends, attorneys, and financial advisors, have taken advantage of older people with impaired judgment and financial acumen. Many older people have lost their homes and their life savings because of financial exploitation. The Internet has increased the opportunity for scam artists to prey on elders who may be cognitively impaired.

Risk Factors

People with Alzheimer’s disease or other cognitive impairment as well as people with disabilities are at higher risk than other older adults. Caring for a person with AD can cause stress, depression, feelings of isolation, financial worries, and substance abuse, any or all of which can lead to elder abuse. Violent behavior by the patient may also lead to physical abuse by the caregiver. Respite care for the patient and support group and counseling for the caregiver can help prevent elder abuse. In severe cases, it is usually necessary to separate the patient from the caregiver, initiate legal action, and find a safe facility for the patient.

A study of 600 women ages 50 to 64 found that more than 5% experienced some form of abuse by their partners within the two years prior to the study. Women on public assistance reported even higher proportions of intimate partner violence (IPV), as did those who had a recent history of homelessness (Somanti & Shibusawa, 2008). Women over 80 are the most frequent victims of abuse.

Risk factors for elder abuse include:

  • Lack of social support and isolation
  • Cognitive impairment, including Alzheimer’s or other dementias
  • Mental health problems of abusers or victims
  • Physical frailty
  • Abuse of alcohol or other drugs by abusers or victims
  • Polypharmacy or inappropriate use of medications

Screening and Reporting

Health professionals should be alert to any indication of elder abuse. Signs of physical abuse include bruises, skin wounds, burns or fractures, and lack of explanation for falls and injuries. Physical signs of neglect include severe weight loss, dehydration, poor personal hygiene, and pressure ulcers (bedsores).

Home care workers and prehospital care providers (paramedics) also need education on the signs and symptoms of elder abuse and neglect. In Maryland, one fourth of prehospital care providers surveyed defined elder abuse as a social problem, not a medical problem. One third of respondents indicated that they would suspect dementia, depression, or other reasons rather than abuse for a report of sexual assault in an elderly patient (Rinker, 2009).

The University of Maine Center on Aging (2007) developed a brief protocol for screening older patients for domestic abuse and violence. The center recommends that all patients 60 years old and older be routinely screened at least once a year for elder mistreatment. The protocol consists of a brief introduction followed by six questions:

  1. Has anyone close to you called you names or put you down recently?
  2. Are you afraid of anyone in your life?
  3. Are you able to use the telephone any time you want to?
  4. Has anyone forced you to do things you didn’t want to do?
  5. Has anyone taken things or money that belong to you without your OK?
  6. Has anyone close to you tried to hurt you or harm you recently?

Patients should have the opportunity to respond to the questions in a confidential setting outside the presence of the patient’s family, caregiver, or the person who brings the patient to the appointment.

Nurses and physicians in all settings where older people receive care need to be aware of the possibility of elder abuse as well as their legal requirements for reporting the abuse to the appropriate government agencies. Anyone can and should report suspected elder abuse to the local adult protective services agency. State reporting numbers are available at the National Center on Elder Abuse website (see “Resources” below).

END-OF-LIFE CARE AND HOSPICE

Americans are reluctant to talk about death or to express their wishes about end-of-life care. But avoiding these subjects imposes a costly ignorance, which can mean less than optimal care and diminished quality of life for those who are dying and for their families. According to the National Hospice and Palliative Care Organization (NHPCO), three fourths of Americans do not know that hospice care can be provided in the home. The vast majority do not realize that the Medicare hospice benefit guarantees comprehensive high-quality care at little or no cost to terminally ill Medicare beneficiaries and their families.

Many people think hospice care means “giving up,” that it will shorten survival. However, research suggests the opposite—the mean survival was 29 days longer for hospice patients than for non-hospice patients. For hospice patients with congestive heart failure, lung cancer, and pancreatic cancer, the survival was significantly longer than for non-hospice patients with the same conditions (Connor et al., 2007).

When the patient asks, “How long do I have?” the physician often cannot answer with certainty. One study showed that only 20% of physicians’ estimates of survival time were even approximately accurate (Christakis & Lamont, 2000); more than half were overly optimistic. An estimated 1 in 10 patients who enter hospice care are discharged alive by their own choice. Columnist Art Buchwald entered hospice after refusing dialysis for kidney failure—and left five months later to go home and write another book. He died nearly a year later.

Health professionals can help patients and families understand what palliative care and hospice care can offer before serious or life-threatening conditions occur. That understanding will enable them to plan for eventual care needs, including advance directives.

Palliative Care

The Center to Advance Palliative Care (2009) states:

The goal of palliative care is to relieve the pain, symptoms, and stress of serious illness—whatever the prognosis. Palliative care is available to those undergoing curative treatments even at the early stages of a serious and complex illness.

Palliative care’s focus on communication in addition to pain and symptom management occurs long before the end of life. These are quality of life conversations that allow physicians to explore their patients’ values and goals. Patients facing serious illness may live for years. This is why palliative care is necessary for patients with chronic illnesses who want to remain in control of their lives and destiny.

Palliative care for those with life-limiting illness ideally begins at the time of diagnosis. Many people who do not fear death do fear the process of dying, the prospect of pain and suffering, and being a burden to their families. Research by the National Hospice and Palliative Care Organization (2010) shows that the top priorities for a loved one with terminal illness are:

  • Someone to be sure that the patient’s wishes are honored
  • Choice among the types of services the patient can receive
  • Pain control tailored to the patient’s wishes
  • Emotional support for the patient and family

Hospice Care

All the abovementioned priorities are available in hospice care, which is a delivery system for palliative care services. Hospice is considered the gold standard for end-of-life care. The central belief of hospice is that each person is entitled to a pain-free death with dignity and that families are entitled to the support necessary to allow that to happen.

Hospice care is based on an interdisciplinary team approach. Many hospices employ physicians and nurses with special expertise in pain management and symptom relief. Bereavement and spiritual counselors are also available to help the dying and their families explore their needs and preferences as they come to terms with death. The team develops an individualized care plan to meet each patient’s needs for pain management and symptom control. When the patient is cared for at home, hospice staff is on-call 24 hours a day, 7 days a week.

The hospice team includes:

  • The family
  • A physician
  • A nurse, who usually serves as a case manager and coordinates care with other disciplines
  • Counselors, including psychologists and clergy
  • A social worker
  • Home health aides
  • Trained volunteers

Many people mistakenly think that hospice refers to a place. Although there are some residential hospice facilities, most hospice care takes place in the patient’s home or the home of a loved one, and less frequently in hospitals and nursing homes.

Hospice care is far less expensive than other types of end-of-life care (e.g., aggressive chemotherapy). Hospice patients are more often able to die at home. According to the National Hospice and Palliative Care Association, three fourths of the people who choose hospice care die at home, in a nursing home, or other residential facility.

ACCESSING HOSPICE CARE

Hospice is not just for people with cancer. Any patient who is diagnosed with terminal illness is eligible for hospice care. In fact, more than half of those admitted to hospice in 2008 had a non-cancer diagnosis, such as heart disease, kidney disease, emphysema, Alzheimer’s or other dementia, HIV/AIDS, or an unspecified condition.

To access the Medicare hospice benefit, the patient’s doctor must certify that the patient likely has six months or less of life remaining. If the patient lives more than six months, the benefit can be extended for an unlimited number of 60-day periods based on the physician’s recertification that the patient is likely to die within the next six months.

The patient must agree to forgo disease treatments such as chemotherapy and radiation. This requirement is one reason some people avoid hospice until the last days or weeks of life and continue with aggressive, expensive treatment, which may make little or no difference in survival time and may diminish the quality of life in the process.

Hospice services covered by Medicare are listed below. In addition, many private healthcare plans and Medicaid in 46 states and the District of Columbia cover hospice services.

HOSPICE SERVICES COVERED BY MEDICARE

Medicare covers these hospice services and pays nearly all of their costs:

  • Doctor services
  • Nursing care
  • Medical equipment (such as wheelchairs or walkers)
  • Medical supplies (such as bandages and catheters)
  • Drugs for symptom control and pain relief (patients may need to pay a small copayment)
  • Short-term care in the hospital
  • Short-term respite care (patients may need to pay a small copayment)
  • Home health aide and homemaker services
  • Physical and occupational therapy
  • Speech therapy
  • Social worker services
  • Dietary counseling
  • Bereavement services for patients and families (up to 13 months after a patient’s death)
  • Any other covered Medicare services needed to manage pain and other symptoms, as recommended by the hospice team
VETERANS HOSPICE AND PALLIATIVE CARE BENEFITS

Veterans benefits include palliative care and hospice care, but some veterans may not know or understand about these benefits (Running, 2009). Although local VA medical centers have the flexibility to address end-of-life care according to veterans’ needs, national policy and standards stipulates that each VA facility have the following resources and services:

  • A designated hospice contact person who is part of an integrated network for local and national communications and information dissemination
  • Provision of needed hospice services in all settings
  • Inpatient hospice beds or access to them in the community
  • An interdisciplinary palliative-care consultation team
  • Assistance with referrals to community hospices in its service area
  • Tracking of hospice and palliative care services provided to veterans in all settings

Health professionals need to be aware that veterans dying in the VA system may have a higher degree of social isolation, lack of family support, or lower income than those outside the system. In addition, military training may have created in them an attitude of stoicism and a barrier to admitting pain or requesting pain medication. On the other hand, being in a hospice with other veterans offers a camaraderie that can be comforting.

Showing respect for a veteran and acknowledging service to the country is a first step in establishing a relationship. Simply asking, “What branch of the service were you in?” can be a key assessment question. Other factors that influence experiences at the end of a veteran’s life include age, whether enlisted or drafted, rank, and combat or POW experience (NHPCO, 2005). Not all veterans have served in combat; those who have may have witnessed horrific events.

CONCLUSION

Caring for America’s aging population presents enormous challenges to healthcare providers and the entire healthcare system. Their health care needs are every bit as specialized as those of America’s children. Given the uncertainty of what the healthcare system will look like over the next decades, it is impossible to predict just how those needs will be met.

Three fourths of Americans over age 65 have two or more chronic illnesses. Graying baby boomers will only intensify this burden. Chronic illness and the ongoing epidemics of cancer and HIV/AIDS point to exponential escalation in the demand for geriatric care.

As the healthcare system continues to change, self-care and prevention remain paramount elements in the health of older people. Nurses and other healthcare providers have a critical role in educating patients about what they can do to improve or maintain their health and independence, to prevent the complications of aging, and to achieve the highest possible quality of life. This course lays the groundwork for providing competent, compassionate care to older people—the kind of care we all want for ourselves.

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RESOURCES

Alzheimer’s Association
http://www.alz.org

American Society on Aging
http://www.asaging.org/index.cfm

Area Agencies on Aging
http://www.n4a.org/

Assist Guide Information Services (AGIS): Eldercare, long-term care, and caregiving information
http://www.agis.com/

Caring from a Distance
http://www.cfad.org

Centers for Disease Control and Prevention: Preventing Falls: What Works
http://www.cdc.gov/ncipc/preventingfalls/

DOROT
http://www.dorotusa.org

Eldercare Locator
http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx

Environmental Protection Agency’s Aging Initiative: Resources to protect the environmental health of older people
http://www.epa.gov/aging

Family Caregiver Alliance
http://www.caregiver.org

FDA: Medicines in My Home (brochure)
http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/UCM201466.pdf

Growth House: Educational materials on end-of-life care, palliative medicine, and hospice care
http://www.growthhouse.org

Life Before Death Project: Self-help guide to planning end-of-life care
http://www.lifebeforedeath.com/qualityofdeath/index.shtml

Little Brothers—Friends of the Elderly
http://www.littlebrothers.org

National Association of Professional Geriatric Care Managers
http://www.caremanager.org/

National Center on Elder Abuse
http://www.elderabusecenter.org
1-800-677-1116

National Hospice and Palliative Care Organization
http://www.nhpco.org

National Institute on Aging
http://www.nia.nih.gov

National Resource Center on LGBT Aging
http://www.lgbtagingcenter.org/index.cfm

National Respite Network
http://www.archrespite.org/home

A Place for Mom: Free senior care referral service
http://www.aplaceformom.com

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