Older Adult Care
COURSE PRICE: $45.00
CONTACT HOURS: 8
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Course Availability: Expires September 6, 2017. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. 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 healthcare. Medical Disclaimer Legal Disclaimer Disclosures
Older Adult Care
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare healthcare professionals to address the needs of their older adult patients by understanding aging-related demographic trends, changes in health status and assessment of older adults, medication use and misuse, recommended interventions, support of family caregivers, elder abuse, and end-of-life care.
Upon completion of this course, you will be able to:
- Describe the current demographic characteristics, healthcare conditions, and health disparities in older adults.
- Summarize the goals of care for the older adult.
- Discuss the major age-related physiologic, psychosocial, and cognitive changes impacting the health of older adults.
- Review treatment and prevention recommendations related to age-related changes.
- Identify the key elements in the functional assessment of the older adult.
- Describe the risk factors and assessment strategies for falls in older adults.
- Discuss the risks, safety, and management of medications for older adults.
- Explain strategies for supporting family caregivers of elders.
- Review the risk factors and signs of elder abuse.
- Clarify the principles and goals of end-of-life care.
TABLE OF CONTENTS
- Goals of Care for the Older Adult
- Physiologic Changes of Aging
- Cognitive Changes of Aging
- Psychosocial Changes of Aging
- Depression and Suicide
- Functional Assessment and ADLs
- Balance and Fall Risk
- Medication Use and Misuse
- Supporting Family Caregivers
- Legal and Ethical Considerations
- Elder Abuse
- End-of-Life Care
The graying of America has the attention of many—not only seniors themselves, but public policy makers and health professionals. Caring for people age 65 and older can be complicated and requires specialized knowledge of this demographic group.
Older adults in the United States are faced with many obstacles, including the challenges of the aging process, societal norms and expectations, changes in financial and caregiving resources, and environmental challenges (Leland et al., 2012).
Age-related changes affect the function of every body system, even in the healthiest older people. Heart output declines. Calcium migrates from bones and teeth into blood vessels. Cataracts may dim vision. Hearing fades. Lung, liver, and kidney functions slow. Wear and tear on joints makes pain an unwelcome companion.
Normal age-related changes may be accompanied by chronic health problems such as diabetes or heart disease. Management of many such chronic conditions may include one or more medications 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 a fall injury, which can catapult an independent older adult into the ranks of the frail elderly.
Combined, these factors increase the complexity of care. 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. Early diagnosis and effective management of chronic conditions can enable older adults to enjoy their later years as functional, active, and independent members of the community.
Caring for older adults requires a multidisciplinary approach and may include a primary care provider or geriatric nurse practitioner who coordinates care with other team members, including physical and occupational therapists, pharmacists, nurses, and other health professionals.
Demographics of Aging
As the first wave of the 77 million “baby boomers” born between 1946 and 1964 move beyond their sixtieth birthdays, they are seeking answers to many 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.
This change in the growth in the number and proportion of older adults will make history in the United States. Because of the longer lifespan and aging population of baby boomers, it is estimated that by 2030 one in five Americans will be over 65 years of age (CDC, 2013a). People in this age group today are the greatest consumers of healthcare services in the United States.
Many people in their sixties, seventies, and beyond lead active, independent lives, enjoying sports, travel, and hobbies, many times in addition to part- or full-time employment. However, living with and managing a chronic disease is common in adults over age 65. The risk of developing chronic diseases increases as a person ages, with the root causes of many of these diseases often starting early in life.
Incorporating healthy behaviors from an early age and getting recommended screenings can substantially reduce a person’s risk of developing chronic diseases. Research has shown that people who do not use tobacco, participate in regular physical activity, and eat a healthy diet may significantly decrease the risk of developing heart disease, cancer, diabetes, and other chronic conditions (CDC, 2013a).
Current data on health-related behaviors among people aged 55 to 64 years do not indicate a positive future for the health of older adults. More than a quarter of all Americans and two out of every three older Americans have multiple chronic conditions, and treatment for this population accounts for 66% of the country’s healthcare budget. 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 (CDC, 2013a).
Aging and Long-Term Care
Aging and living with chronic diseases can affect a person’s ability to perform essential self-care activities. Older adults may have trouble with the instrumental activities of daily living (IADLs), such as managing money, shopping, preparing meals, and taking medications as prescribed. As functional ability—physical, mental, or both—declines, people may also lose the ability to perform the more basic activities of daily living (ADLs), such as taking care of personal hygiene, feeding themselves, getting dressed, and toileting. As functional changes occur (e.g., after a stroke or fall), it can be advantageous to work with a physical or occupational therapist to incorporate a rehabilitation plan to address strengthening exercises, adaptive strategies, and assistive devices (if needed).
Loss of the ability to care for oneself safely and appropriately means further loss of independence and can often lead to the need for care in an institutional setting. 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 $42,000. Nursing home care is even more expensive, and many Americans may be financially unprepared for this type of care. The median annual rate for a private nursing home room is $87,600 (Genworth, 2014).
Growing older does not always translate to 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 one’s own home by modifying it and arranging for home healthcare services as needed) and moving to a retirement community or an assisted-living or life-care facility. In addition, older people who can no longer live alone may move in with their children or other relatives.
Attitudes about Aging
People’s beliefs and attitudes about aging can directly affect their psychological well-being. Researchers found that people who held negative beliefs about aging and health reported lower life satisfaction, lower self-esteem, lower self-efficacy, and lower meaning-focused coping as they aged. They also reported higher pessimism about aging and higher work strain than those who feel younger relative to their chronological age (Mock & Eibach, 2011).
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 (Bryant et al., 2012).
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. The United States ranks 42nd 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 a life expectancy of 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, 2013b).
The health status of Hispanics, Asian Americans, African Americans, American Indians/Alaska Natives, Native Hawaiians/Pacific Islanders, and other minority population groups at all ages has historically lagged behind that of non-Hispanic whites. For a variety of reasons, older adults in these groups may experience the effects of health disparities more than younger people. Language barriers, low health literacy, reduced access to healthcare, low socioeconomic status, and differences in cultural norms are major challenges to promoting health in the ever-increasing diverse aging population (CDC, 2013a).
The 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 have more stable incomes, 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.
GOALS OF CARE FOR THE OLDER ADULT
Overarching goals of healthcare in people over 65 include:
- Maintaining self-care. This goal is one of the primary objectives for keeping an older adult independent, healthy, and able to manage any chronic conditions in their home environment with relatively few resources. Once self-care becomes difficult, additional challenges may arise, such as recognizing the need for help, finding resources, dependence on a caregiver, and a loss of independence.
- Preventing complications of aging or of existing chronic conditions. The goal for managing chronic conditions is to regularly assess a patient’s current status for any changes or complications that might require new interventions or changes in treatment. To address this goal, communication with the healthcare team is important, as well as educating the patient and family to verify understanding and importance of management goals.
- Delaying decline. Older adults should be carefully monitored for any decline. Goals may include addressing strength and physical abilities as well as promoting and reinforcing healthy behaviors and appropriate self-care strategies.
- Achieving the highest possible quality of life. Each individual will have personal goals that are important to their quality of life. These may be based on the values and beliefs of each person. Care providers should address each individual’s goals on a personal basis. A discussion about quality of life is important to address with the patient each time there is a change in health status.
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 years 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 and who may be unable to deal with the rigors of treating a malignancy if it is discovered.
Many health problems (e.g., falls) common to people over age 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 and/or rehabilitative interventions.
Fall risks and other potential safety concerns should be evaluated at each healthcare visit to assess any newly developing changes in status. Nurses, physical therapists, occupational therapists, and other rehabilitation specialists can address a person’s ability to manage in the home or living environment at the highest possible level of independence and can also identify any environmental safety risks (such as loose rugs, uneven steps, clutter, etc.), appropriate adaptive equipment or durable medical equipment (DME), or assistive devices that might be needed.
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 (HHS, 2014). 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 provides education and training for the healthcare workforce. However, the changing political climate is likely to result in ongoing modifications to how healthcare services are provided.
Healthcare systems are making changes to better meet the needs of seniors with multiple chronic conditions. For example, hospitals are designing special rooms for seniors with softer lighting, non-glare flooring, and beds and stretchers with extra padding. Patients may be able to consult with a geriatric social worker and receive discharge instructions in large print. One major reason for these changes is to prevent hospital readmissions, for which Medicare reimbursement standards are changing.
Models of Care
Traditional healthcare delivery models do not always have mechanisms in place for coordinating care across settings, which is a frequent occurrence for older adults with chronic illness—for example, a patient with a new stroke is admitted to the hospital for acute care, discharged to a rehabilitation or care facility for intermediate care, and finally returned to the home setting with the assistance of home-based care.
Outcomes for current models of care that are being studied and implemented include the following best practices:
- Improve the quality of care and increase patient/family satisfaction
- Lower healthcare costs by reducing hospital readmission rates and emergency department visits
- Coordinate transitions of care or changes in the level, location, or providers of care
Two examples of models of care that address the needs of older adult patients with multiple chronic conditions include the Geriatric Resources for Assessment and Care of Elders (GRACE) and Guided Care. These models share some common elements:
- Comprehensive assessment of patient needs
- Evidence-based planning and monitoring of care
- Support for patient and family active involvement in care
- Coordination of all professionals caring for the patient
- All care tailored to the patient’s goals and preferences
(Li et al., 2014)
Nurses, therapists, social workers, and care coordinators are involved in these models, and those with advanced preparation in geriatric care have the potential to be leaders in improving care for older adults. Successful models of care include multiple interventions simultaneously from multidisciplinary team members with the overarching goals of improving communication among care providers, better patient and caregiver education, and coordination of social and healthcare services.
The GRACE model was developed for low-income older adults to improve the quality of geriatric care, reduce excess healthcare use, and prevent long-term nursing home placement. It utilizes two distinct teams—a support team and a larger multidisciplinary team—and a staged process to develop and implement an individualized plan for each patient.
- 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 multidisciplinary team (which includes a geriatrician, pharmacist, physical therapist, occupational therapist, speech-language pathologist, mental health social worker, and community-based services liaison) develops an individualized care plan, which is shared with the patient’s support team.
- The support team then meets with the patient’s primary care provider to finalize the patient’s care plan.
- The final step involves the support team working with the patient and his or her family or caregiver to implement the plan.
Researchers determined that the GRACE model achieved improved outcomes, including improved quality of life measures, reduced emergency room visits, and hospital admissions with overall cost reduction (Li et al., 2014).
GUIDED CARE MODEL
The Guided Care model involves nurses who work in partnership with physicians and others in primary care (pharmacists, therapists, social workers) to provide patient-centered, cost-effective care to patients with multiple chronic conditions. Nurses conduct in-home assessments, facilitate care planning, teach self-management strategies, monitor conditions, provide care coordination, and facilitate access to community resources. When studied, the Guided Care model reduced the number of skilled nursing facility and hospital admissions as well as emergency department visits (Li et al., 2014).
KEY STRATEGIES TO REDUCE HOSPITAL READMISSIONS
- Engage key stakeholders: patient, caregivers, hospital and skilled nursing staff, primary care providers, rehabilitation specialists, and home health workers
- Assess risk and develop a comprehensive transition plan throughout the hospitalization
- Enhance the safe management of medications
- Place an emphasis on daily communication among the multidisciplinary team focused on a coordinated transition
- Standardize transition plans, procedures, and forms
- Send discharge summaries directly to the primary care provider and/or the next care setting at discharge
- Provide easy-to-understand discharge plans to patients and caregivers and ensure patient understanding through teach-back methods
- Ensure timely follow-up and coordination of support after the patient leaves the care setting
Source: Li et al., 2014.
RISK FACTORS FOR HOSPITAL READMISSION
Researchers identified five key risk factors associated with hospital readmission in low-income older adults. These include:
- Living alone
- Poor or low satisfaction with primary care provider
- Not having Medicaid
- Receiving a new assistive device within the past 6 months
- Having a nursing home stay in the preceding 6 months
Source: Iloabuchi et al., 2014.
PHYSIOLOGIC CHANGES OF AGING
Aging is both universal and individual. The physiologic 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 years or younger, while others remain youthful in health, appearance, and outlook at 70 years 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.
Beginning by around the fifth decade of life, musculoskeletal changes may significantly alter the posture, overall appearance, and/or function of older adults. Thinning of intervertebral disks can lead to shortening of the trunk of the body, subtly alter the alignment of vertebrae, and slowly diminish height over time, potentially making arms and legs appear longer by comparison.
Calcium is progressively leached (resorbed) from bones, frequently resulting in osteopenia or osteoporosis—both much more common in women than in men—which may increase the risk of fracture. At the same time, muscles and cartilage atrophy and weaken, which may lead to postural deviations such as increased thoracic kyphosis (a pronounced curvature of the thoracic region of the spine), which can further decrease stature and necessitate the adoption of a “chin-up” posture to make eye contact with others.
Loss of muscle mass (sarcopenia) results primarily from disuse of skeletal muscle, as frequently may occur with age-related inactivity (Bonder & Dal Bello-Hass, 2009). On average, muscle mass and strength may reduce by 30% to 50% between the ages of 30 and 80 years, with the main cause being reduced numbers of total muscle fibers as well as atrophy of type II muscle fibers. This type II atrophy leads to a progressive loss of skeletal muscle size and strength, resulting in decreased functional abilities, with the most prevalent muscle loss in the lower limbs of older adults. Moreover, muscle strength continues to be lost at an average rate of 12% to 14% per decade after age 50 years (Milanovic et al., 2013).
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.
Loss of muscle mass and muscle strength can ultimately contribute to a loss of balance and coordination and—if not effectively addressed—to the inability to perform activities of daily living, disability, and eventual loss of independence.
Assessment of musculoskeletal function in an older adult includes general observation of posture, stance, and walking. Observations focus on whether a patient is favoring one side of the body or another while walking. The Timed Up-and-Go Test provides a quick assessment of an older adult’s overall mobility and function (see under “Balance and Fall Risk among Older Adults” later in this course). For patients with existing disabilities, an inquiry is made to assure the patient has been evaluated in physical therapy for the correct fitting and teaching of the proper use of existing and assessment for any new assistive devices.
Osteoporosis can be assessed by additional questioning of the patient regarding any back pain, joint pain, and loss of height. Bone mineral density (BMD) testing can also be completed, with results comparing the patient’s bone mass to individuals in their age range, or previous results if the patient has had a previous baseline BMD test (Mauk, 2014).
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. Exercise has well-documented musculoskeletal benefits, including increased strength, bone density, flexibility, and endurance, as well as decreasing the risk of falls for older adults (Miller et al., 2010). Studies have shown that older individuals may be able to achieve significant strength gains through properly designed resistive strength-training regimens (Sherk et al., 2012). Additional strategies such as gentle yoga and tai chi can provide support to enhance strength, balance, and flexibility as a person ages (Bonder & Dal Bello-Hass, 2009).
The current physical activity recommendations for adults consist of at least 30 minutes of moderate-intensity activity at least five days per week, as well as strengthening exercises at least two days per week. These guidelines are identical to the guidelines for generally fit older adults who do not suffer from any limiting health conditions. In addition to physical activity and strengthening, it is recommended that older adults incorporate activities that increase balance into their exercise routines (Costello et al., 2011).
Frequently, a patient with physical limitations due to musculoskeletal changes will be referred to a rehabilitation specialist. Based on this evaluation, the physical and/or occupational therapist is able to create an individualized treatment plan that includes the patient’s goals for treatment and addresses the individual physical limitations. Exercise is frequently a key component of physical rehabilitation and involves specific movements focused on maintaining and improving strength, endurance, and balance (Brown & Flood, 2013).
(Also see below under “Balance and Fall Risk in Older Adults.”)
SKIN, HAIR, AND NAILS
Ultraviolet (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. Regular exposure to the sun and UV light also places adults at higher risk for skin cancer.
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, 2013c).
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.
Because of the amount of sun exposure received by hands during normal daytime activities, concern has been raised about the increased use of UV or LED light to cure “gel” nails or nail polish, either in a salon or at home. LED lights have been shown to pose less of a risk, but using either a topical sunscreen or purpose-made protective gloves with only the nails exposed can provide a barrier while the products are curing (Shipp et al., 2014).
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 with age.
Fingernails and toenails tend to harden and thicken with age and may develop vertical striations in the nail plate. Yellowish or dark nails may also indicate a fungal infection.
Skin assessment in older persons is focused on monitoring for dryness, pruritus, 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 the 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. Massaging skin on bony prominences can increase the risk of pressure ulcers.
Assessment includes inspecting 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 three 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.
Clinicians also assess for skin abnormalities when conducting a physical examination for other purposes (CDC, 2013c). 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.
“ABCDE” SIGNS FOR SKIN LESIONS
These ABCDE signs can be followed for assessing suspicious skin lesions:
- Asymmetry: when one half of a mole is different than the other
- Border: irregular or uneven
- Color: irregular, with patches of black, brown, red, blue, or white
- Diameter: larger than 1/4 inch or 6 mm
- Evolving: any change in size, shape, color, or texture, or any new symptoms such as itching, bleeding, or crusting
Source: Mayo Clinic, 2014a.
Adequate nutrition and hydration is essential to skin health. Older adults with skin conditions should be encouraged to see a dietitian for recommendations. (See also “Nutritional Changes” below for additional recommendations.)
Skin ulcers and pressure sores should be evaluated and treated promptly, since skin breakdown can progress quickly. The skin should be well protected, moisturized, and inspected daily for any changes. Wound care and dressings for any pressure ulcer care should be monitored by the healthcare team, with careful assessment for any infection and evidence of wound healing.
Any skin lesions that are larger than 6 mm or those with any of the “ABCDE” signs (see above) should be referred to a dermatologist for potential biopsy. Treatment of skin lesions varies and may include cryotherapy, radiotherapy, surgery, and topical treatment.
Older adults should be taught to inspect their feet on a regular basis. Corns, ingrown toenails, and fungus should be treated by a podiatrist. If existing foot or nail problems are present, a regular inspection by a podiatrist (annually or more frequent if needed) is recommended (Mauk, 2014).
When assisting in strategies for self-care and bathing, patients should avoid hot water and use a mild cleansing agent that minimizes irritation and dryness of the skin. Patients should also use a gentle motion and minimize the force and friction applied to the skin. The frequency of bathing should be individualized according to need and/or patient preference.
Patients should also minimize environmental factors that may lead to skin drying, such as low humidity (less than 40%) and exposure to cold. Dry skin should be treated with gentle moisturizers that do not contain perfumes, dyes, or alcohol.
Patients and caregivers should be taught how to minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, underpads or briefs made of materials that absorb moisture and present a quick-drying surface to the skin can be recommended. Topical agents that act as barriers to moisture can also be used (e.g., Eucerin, Vanicream, Aquaphor).
The best treatment for skin cancer is prevention. All adults should protect themselves from sun exposure by wearing sunblock and protective clothing (e.g., long sleeves, hat, sunglasses) and by seeking shaded areas when outdoors. Most skin cancers, if detected early, are treatable. Regular full-body skin exams are recommended for all older adults on an annual basis (Mauk, 2014).
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 years. 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 (Tabloski, 2014).
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 both heat and 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.
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.
Heat stroke is a serious heat-related illness and can cause death or permanent organ damage if immediate treatment is not provided. Body temperatures can rise to 104 °F within 10 or 15 minutes (Mayo Clinic, 2014b). 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
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
- Muscle cramps
- Nausea or vomiting
- Cool and moist skin
- Fast and weak pulse
- Orthostatic hypotension
- Rapid and shallow breathing
(Mayo Clinic, 2014b)
Heat cramps are the mildest form of heat-related illness. Signs and symptoms of heat cramps usually include:
- Heavy sweating
- Muscle cramps
Many of the symptoms of heat stress are similar to symptoms of age-associated diseases or may mimic the symptoms of drug-drug interactions. Careful assessment of symptoms, patient history, medications, and chronic conditions will help distinguish symptoms that are related to heat stroke or heat exhaustion. Blood tests may be taken to check for low sodium or potassium as well as muscle damage, and urine tests may be needed to check kidney function. Imaging tests may be indicated if organ damage is suspected (Mayo Clinic, 2014b).
Heat stroke should be recognized as an urgent and life-threatening condition. Older adults with signs and symptoms of heat stroke should immediately seek emergency care. The body temperature should be measured, with the goal of reducing the temperature until reaching between 101 °F and 102 °F. Cooling can be performed by specialized cooling blankets; cool, wet wraps; or immersion in a cool tub or shower. Intravenous fluids may also be administered in order to hydrate the patient and correct any electrolyte imbalances.
Milder forms of heat-related conditions such as heat cramps and heat exhaustion may be treated with self-care by recommending that the patient drink cool water or sports drinks (containing electrolytes), placing the patient in a cool or air-conditioned location, and promoting rest until symptoms subside. If symptoms do not subside within one hour, the patient should be advised to seek medical attention (Mayo Clinic, 2014b).
Older adults can take precautions to prevent heat-related illnesses with the following strategies:
- Wear loose-fitting, lightweight, light-colored clothing
- Stay out of the sun during peak hours (10 a.m.–2 p.m.) and use protective clothing, including hats
- Seek the shade or a cooler place indoors with air conditioning on high heat-index days (temperature above 91 °F)
- Rest and drink plenty of fluids (avoiding alcohol)
- Allow the body to adjust to the heat
- Avoid strenuous activity when the temperature is hot
- Take breaks and stay well hydrated if activity is unavoidable
(Mayo Clinic, 2014b)
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 a wheelchair are particularly vulnerable. According to the CDC (2013d), “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.”
Diagnosis of hypothermia may be apparent based on the patient’s symptoms and physical condition or exposure that caused the hypothermia. Rectal temperature readings may be needed in order to detect accurate body temperature. Blood tests may also be needed to check for any organ damage or to rule out other conditions (Mayo Clinic, 2014c). Signs and symptoms of hypothermia include:
- Sensation of cold, exhaustion, and numbness
- Confusion, disorientation, and slurred speech
- 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. Many of the symptoms of hypothermia are similar to symptoms of age-associated diseases or may mimic the symptoms of drug-drug interactions. Careful assessment of symptoms, patient history, medications, and chronic conditions will help distinguish symptoms that are related to hypothermia.
If an older adult is suspected of having hypothermia, self-care measures may include the following:
- Relocate to a warm environment
- Remove wet clothing
- Cover with warm blankets (paying close attention to covering the head)
- Drink warm beverages
- Apply warm compresses to the neck, chest, and groin areas (do not apply warm compresses to the extremities)
These measures can be taken in order to start warming the patient prior to professional medical attention.
Depending on the severity of the patient’s hypothermia, immediate medical interventions to treat hypothermia may include the following:
- Blood rewarming (using a dialysis or heart bypass machine)
- Infusion of warmed intravenous fluids
- Airway rewarming (using warmed, humidified oxygen by mask or nasal cannula)
- Warmed irrigation (peritoneal or lung)
To prevent hypothermia, older adults should take the following precautions during cold weather exposure:
- Wear protective clothing, including a warm coat, hat, scarf, and gloves or mittens
- Avoid strenuous activities that would cause sweating while exposed to the cold
- Dress in layers and stay dry
- Take breaks from exposure to the cold to warm up
(Mayo Clinic, 2014c)
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.
The cardiorespiratory system is also vulnerable to decline, and significant decreases in aerobic capacity have been found after the age of 40 years, averaging a 30% decrease in capacity by age 65 (Milanovic et al., 2013).
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. 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.
Several conditions related to the cardiovascular system are common in older adults. The most common include congestive heart failure (CHF), hypertension, coronary artery disease (CAD), stroke, myocardial infarction (MI), and peripheral vascular disease (Mauk, 2014).
Older adults should have regular assessment of blood pressure and heart function. As people age, the systolic blood pressure may have a tendency to rise. Blood pressure readings of over 160/90 indicate hypertension in older adults and require intervention. However, because of the increased risk for stroke, recent changes in the recommendations for older adults indicate that they should be evaluated and treated if readings approach a systolic reading of 140 or above. A diagnosis of hypertension should be based on several readings at various times of the day (Mauk, 2014).
A cardiac stress test may be necessary to distinguish between normal age-related changes and the presence of cardiovascular disease. Additional testing may include electrocardiogram (ECG) and angiogram or cardiac catheterization to evaluate symptoms or if blockage is suspected.
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. 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 (ACSM, 2014).
Lifestyle modifications (see below) may help control blood pressure and improve cardiac function. In addition, medications may be prescribed to treat hypertension and cardiovascular conditions in older adults. For hypertension, the goal of medical treatment for older adults is to lower the blood pressure to 120/80 mm Hg or below. Thiazide diuretics or beta-blockers are often used to control hypertension, however it is not uncommon for patients to need a combination of medications to achieve adequate control. For cardiovascular conditions, beta-blockers and calcium channel blockers are often prescribed to decrease the oxygen demands on the heart (Mauk, 2014).
Lifestyle modifications may help older adults control blood pressure and prevent cardiovascular problems. Strategies that may help older adults include the following:
- Limit alcohol to one drink per day
- Limit sodium intake
- Stop smoking
- Maintain a low-fat diet
- Undertake regular daily aerobic exercise (30 minutes/day)
- Maintain (or lose) weight (even a 10-pound weight loss can decrease risk)
Older adults are encouraged to work closely with their healthcare providers to achieve good control of their blood pressure, since it is a risk factor and contributes to many other serious cardiovascular conditions such as heart disease and stroke (Mauk, 2014).
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 red blood cell production, blood pressure, fluid volume (intake and output of fluids), and electrolyte balance 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 increase in blood volume) or hypovolemia (abnormal decrease in blood volume). Acute losses of fluid or chronic fluid deficits can result in renal insufficiency in older adults.
Assessment of patient renal function is recommended on a regular basis but is most important to consider when adding new medications or prior to exposure to contrast media for diagnostic tests. Blood pressure should be monitored regularly as well as any medications used in the management of hypertension in older adults. Patients with diabetes are also at increased risk for kidney failure. Creatinine clearance is an important indicator of kidney function and should be assessed prior to making a decision about new medications or drugs that are cleared through the kidneys. Additional blood tests that evaluate kidney function include GFR and blood urea nitrogen (BUN) (Touhy & Jett, 2014).
Symptoms of kidney failure are due to the build-up of waste products in the body that may cause patients to experience weakness, shortness of breath, lethargy, and confusion. Inability to remove potassium from the bloodstream may lead to abnormal heart rhythms and sudden death. Initially, there may be no symptoms of kidney failure.
Treatment of the underlying cause of kidney failure may return kidney function to normal. In older adults especially, efforts to control blood pressure and diabetes may be the best way to prevent chronic kidney disease and progression to kidney failure. Kidney function may gradually decrease over time. If the kidneys fail completely, the only treatment option available for an older adult may be dialysis.
Preservation of kidney function can be maintained by carefully monitoring and treating any chronic condition, such as hypertension and diabetes. Older adults also need to carefully monitor their fluid intake and make adjustments in response to medication effects or other influences on the fluid and electrolyte balance. Patients who are on medications that are excreted by the kidney should have kidney function tests on an annual basis (or more frequently if needed) to monitor any side effects.
Those working with older adults in the healthcare setting should be aware that the stress from surgery, fever, or other acute illness can put an older adult at increased risk for kidney damage or kidney failure (Touhy & Jett, 2014).
Urologic Changes and Incontinence
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 four principal types of incontinence: urge, stress, overflow, and functional (Tabloski, 2014).
- 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 prostatic hyperplasia (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”).
- Functional incontinence occurs when the patient has either physical or psychological factors that impair the ability to get to the toilet (e.g., a patient who is wheelchair-bound or has dementia) (Tabloski, 2014).
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 (Tabloski, 2014).
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 about it. Many clinicians do not 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.
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 (Tabloski, 2014). Drug treatment for stress incontinence is limited, although some experts recommend a trial of topical estrogen for women with symptomatic atrophic urethritis.
|Source: Tabloski, 2014.|
|Scheduled voiding regimens||
|Pelvic floor muscle strengthening||
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 (Fox et al., 2011). This finding has major public health implications because an estimated one third of people with dementia also take a drug for 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 table below); if it is not feasible to discontinue the drug(s), substituting another drug may help reduce incontinence.
|Anti-anxiety and muscle relaxant drugs||
|Diuretics (water pills)||
|Drugs that cause incomplete bladder emptying||
|Drugs that increase stress incontinence||
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 adrenal insufficiency.
Patients with respiratory illnesses such as pneumonia may experience new onset of symptoms such as:
- Chest pain
- Productive cough
- Shortness of breath
Assessment and diagnosis may be made through chest x-ray, blood tests, and sputum culture. A physical exam, swallow test, lung auscultation, and pulmonary function test are also common assessments for respiratory conditions (Mauk, 2014).
Respiratory conditions such as COPD and pneumonia may be treated with oxygen therapy. In addition, a patient who has difficulty swallowing may need to take precautions when eating. Antibiotics may be needed to treat bacterial pneumonia. Adequate fluid intake is also important when faced with respiratory illnesses. Intravenous fluids may be indicated, depending on the condition of the patient (Mauk, 2014).
Adults over the age of 65 are advised to receive a pneumonia vaccine as well as annual vaccination for influenza. Older adults at risk for aspiration should take precautions when eating to prevent aspiration pneumonia, and caregivers should watch for signs and symptoms of difficulty, including coughing while eating (Mauk, 2014).
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.
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, which may make sexual intercourse painful. 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 exists 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 adults remain sexually active.
Erectile dysfunction (ED) is defined by the inability to achieve and sustain a sufficient erection for sexual intercourse. The incidence of ED increases with age, but many options for treatment are available (Mauk, 2014).
Assessment of endocrine function includes a physical exam, patient history, blood tests to check hormonal levels, and assessment of patient symptoms. Sexual function may be assessed with a physical exam and patient-reported signs and symptoms (Mauk, 2014). In addition, libido may be affected by nonphysiologic causes including depression, stress, and other emotional concerns.
Endocrine conditions, such as hypothyroidism, may be treated with medications to replace the hormones that are deficient in the body. Correcting hypothyroidism in people over 60 requires a lower dose of replacement thyroid hormone than in younger people. Replacement should be initiated slowly, particularly in those with coronary artery disease, to prevent angina and myocardial infarction.
Treatment options for ED in men include oral medications, vacuum pump devices, penile implants, and drugs injected into the penis. Many oral medications are contraindicated in patients who have baseline cardiac conditions, since they can increase their risk for myocardial infarction. Women may want to explore vaginal creams, gels, and lubricants to increase comfort during intercourse (Mauk, 2014).
Patients who are experiencing changes in endocrine function should have regular assessments, especially with existing chronic conditions that involve glandular functions (e.g., diabetes, thyroid problems, and prostate changes). Maintaining a healthy lifestyle, good nutrition, and close monitoring of blood tests to be aware of any changes are important.
For men, causes of ED may be many, including diabetes, hypertension, thyroid disorders, alcoholism, and depression. Lifestyle changes to decrease risk factors for ED include the following:
- Smoking cessation
- Healthy weight
- Proper nutrition
- Alcohol in moderation
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. The prevalence of HIV disease among older adults is increasing because more people are now living into their sixties with HIV managed as a chronic condition. In high-income countries, approximately 30% of all adults living with HIV are aged 50 and over (Rueda et al., 2014).
Since Viagra and other drugs for erectile dysfunction entered the marketplace in the late 1990s, rates of HIV/AIDS and gonorrhea have 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.
Sexually active older couples may 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 (GI) 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 square meals 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, inadequate dietary fiber and/or 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.
Patients with GI symptoms may be evaluated with a variety of assessment techniques including physical exam, patient history, and blood and diagnostic tests. Upper and lower GI diagnostic exams with endoscopy can evaluate the esophagus, stomach, and duodenum. Patients should be encouraged to report any new GI symptoms to their healthcare team for early assessment and intervention (Mauk, 2014).
Lifestyle and dietary modifications as well as medications may be indicated for treatment of constipation. Adequate fluid intake, routine bowel habits, good nutrition, and regular exercise can all contribute to improvement of constipation. Stool softeners may be indicated for patients who have limited mobility or are at risk for constipation due to medications.
Older adults can prevent GI problems and constipation by maintaining a healthy diet and adequate fluid and fiber intake. Patients who are on medications that put them at higher risk for constipation (e.g., calcium and iron) may need to take countermeasures to prevent constipation (Mauk, 2014).
Sensory changes in later life affect how people perceive and experience the world and can have an enormous impact on independence, safety, and quality of life. All five senses—vision, hearing, taste, smell, and touch—diminish in acuity with age.
Vision changes generally begin in middle age, and most adults need glasses or contact lenses for reading because of presbyopia by age 50. Older adults also may experience increased sensitivity to glare, dry eyes, 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 (ARMD), glaucoma, cataracts, and diabetic retinopathy (Tabloski, 2014). Approximately 2 million adults ages 40 and older have ARMD, over 2.5 million have glaucoma, over 24 million adults have cataracts, and over 7 million have diabetic retinopathy. The incidence of serious eye diseases varies among racial groups. The leading cause of blindness among white Americans is ARMD. Among African Americans, the leading causes of blindness are cataract and glaucoma. Among Hispanics, glaucoma is the most common cause of blindness (NEI, 2012).
Adequate vision is essential to safety and quality of life. Visual problems can lead to a loss of ability to perform IADLs (e.g., self-care, driving, navigating in the home), social isolation, depression, and a decrease in quality of life. Visual impairment also increases the risk of falls, which in turn may cause fractures requiring hospitalization and rehabilitation (Tabloski, 2014).
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; Tabloski, 2014). Diabetes appears to be an independent risk factor for hearing impairment (Tabloski, 2014). 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 the number of hair cells in the inner ear and changes in the bony structures of the inner ear.
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, the clinician stands 6 to 12 inches behind the patient and whispers several short sentences. If the patient cannot hear and understand, an audiology referral is recommended (Tabloski, 2014).
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 individuals to detect sour milk, and smell serves as a warning sign for 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.
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, and 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.
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 the table. 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.
Anyone with a family history of eye disease or who has diabetes and/or hypertension is at high risk of serious eye diseases. 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.
AGE-RELATED MACULAR DEGENERATION (ARMD)
Age is the primary risk factor for ARMD. Because women live longer than men, ARMD is more prevalent among women. Aside from age, gender, and race, other risk factors for ARMD include smoking, obesity, increased exposure to ultraviolet light, light-colored eyes, hypertension or cardiovascular disease, poor intake of antioxidants and zinc, and family history (Tabloski, 2014).
Warning signs of ARMD include:
- Lines or edges that appear wavy or distorted
- Blurry faces or difficulty seeing colors
- Dark or empty spaces that block the center of vision
- Difficulty reading fine print or reading road signs from a moving vehicle
- Difficulty seeing at a distance or during twilight hours
Age-related visual impairment (presbyopia) 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.
The treatment of low vision can include conditions such as macular degeneration, glaucoma, diabetic retinopathy, and normal age-related vision loss. Dealing with visual loss can make it difficult to complete daily tasks. Some activity tips to promote productive aging with older adults with low vision may include:
- Color contrasting various areas for easier identification of transitions or hazards in the home
- Maintaining good lighting in pathways and stairways
- Using labels and various other organizational methods to identify small items
- Keeping commonly used items in easy-to-access locations
- Avoiding moving quickly into a dark room or lighted area; giving the eyes time to adjust to changing light levels
- Using large-print books, checkbooks, or magnifying glasses for reading
Some types of hearing loss can be corrected by hearing aids worn in or behind the ear. These devices amplify sounds but may prove to be a challenge in crowded rooms or public places because it can be difficult to separate what one wants to hear from other sounds. In most cases, hearing aids for both ears are advisable. If hearing loss cannot be corrected with conventional hearing aids, cochlear implants may be indicated for some patients (Tabloski, 2014).
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.
Older adults should continue to practice health habits to preserve their sight and hearing. A few preventive measures include the following:
- Protect the eyes from sunlight with sunglasses (wrap-around style).
- Eat a healthy balanced diet (especially high in fresh fruits, vegetables, and antioxidants).
- Protect the ears from loud noises by wearing protective devices.
- Participate in eye and hearing screening exams in order to monitor and detect any changes with early interventions.
THE NEED FOR TOUCH
Although the sense of touch changes in later years, the human need for touch—for physical contact and 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.
Research has shown that simple interventions that include touch, such as back rubs, hand and foot massages, and touch therapy, can have a positive effect on the quality of life of older adults who have dementia (Tabloski, 2014).
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.
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 do not or will not 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 (Tabloski, 2014).
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 over-the-counter medications, and age over 80 further increase the risk of nutritional deficiencies. Older adults who live alone or in long-term care are at particular risk for malnutrition, especially protein-calorie malnutrition. Malnutrition can also cause blood clots, pressure ulcers, and poor wound healing and can worsen mental confusion and dementia (Tabloski, 2014).
THE DETERMINE SCREEN
The warning signs for poor nutrition can be assessed using the mnemonic DETERMINE. They include:
- 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: Tabloski, 2014.
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.
Protein intake of 1.5 grams per kg (body weight) per day (about 20% to 25% of total daily calories) is currently the recommendation for older adults (Touhy & Jett, 2014). Meat, fish, dairy, eggs, beans, and soy products are all good sources of protein. Protein is particularly important for women because it is more difficult for women than for men to replace age-related lost muscle mass (Tabloski, 2014).
Vitamin D and Calcium
Calcium and vitamin D are essential for bone health and reducing the risk of falls. Many older adults do not get enough of either in their diets. Vitamin D insufficiency is highly prevalent among older adults and is associated with increased risk of bone loss, fracture risk, and other chronic conditions (Tabloski, 2014).
A primary source of vitamin D is from exposure to sunlight, 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.
The current daily recommendation for vitamin D is 700–800 IU for adults in their seventies and eighties. The International Osteoporosis Foundation recommends 800–1,000 IU per day for frail 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 as sources of calcium. Experts recommend 1,200 mg of calcium for both men and women age 50 and older (Tabloski, 2014). 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 (Tabloski, 2014). 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 recommended dietary allowance (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. Deficiency of these vitamins can result in unsteady gate, muscle weakness, slurred speech, and psychosis (Tabloski, 2014).
Absorption of B6 and B12 is impaired in older people due to age-related changes in the digestive system; therefore, supplementation is necessary. The RDA for vitamin B6 is 1.7 mg for older men and 1.5 mg for older women. The RDA for 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 (NIH, 2013). Vitamin E may also have visual benefits, decreasing the risk of cataract formation and macular degeneration.
Vitamin E deficiency is linked with physical decline in older adults (NIH, 2013), 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, and canola), nuts, whole grains, and green leafy vegetables.
Care should be taken if older adults are taking high-dose supplements of vitamin E (>1,000 mg/day), since this can put them at risk for bleeding and stroke. The effects are even stronger if the patient is taking anticoagulation or the herb ginkgo biloba (Tabloski, 2014).
“MYPLATE” FOR OLDER ADULTS
“MyPlate for Older Adults” was introduced in 2011 by Tufts University to correspond with the federal government’s “MyPlate” dietary recommendations and to place an emphasis on the unique physical and nutritional needs of older adults. “MyPlate for Older Adults” features images of fruits and vegetables that are convenient, affordable, and readily available for older adults. Unique components include icons for regular physical activity and an emphasis on adequate fluid intake, which are particularly important to older adults.
The following foods, fluids, and physical activities are represented on “MyPlate for Older Adults”:
- Bright-colored vegetables such as carrots and broccoli
- Deep-colored fruit such as berries and peaches
- Whole grains and cereals such as whole wheat bread, brown rice, and barley
- Low- and nonfat dairy products such as yogurt and low-lactose milk
- Dried beans, nuts, fish, poultry, lean meats, and eggs
- Vegetable oils such as olive oil; soft spreads low in saturated and trans fat
- Spices to replace salt
- Fluids such as water and fat-free milk
- Regular activity such as walking, resistance training, and household chores
Source: Tufts University, 2011.
Sleep alterations are common among older adults. Older adults tend to sleep more lightly and for shorter time spans, but they generally need about the same amount of sleep as they needed as a young adult (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 (Tabloski, 2014).
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 (stages) of sleep: 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 (Tabloski, 2014).
Other factors that can interfere with sleep in older people include:
- Sleep apnea
- Restless leg syndrome
- Muscle cramps or other pain
- Thyroid disorders
Assessment of sleep is important to the overall care of older adults. Assessment of the onset, duration, and severity of symptoms along with any previous treatments for sleep issues should be determined. Risk factors for sleep disturbances should be identified, including the following:
- Personal or family history of sleep issues (e.g., sleep apnea)
Older adults may want to keep a sleep diary to record their evening activities, nighttime routine, and quality of sleep. Assessment of the sleep diary may indicate areas that can be addressed in order to improve sleep habits and quality of sleep. A review of medications, herbal supplements, caffeine, nicotine, and alcohol intake is also important, since some medications and substances can interfere with sleep routines (see above). A diagnostic sleep study may also be indicated if the patient has symptoms of obstructive or central sleep apnea (Mauk, 2014).
A regular nighttime routine is important to maintaining adequate sleep. Healthy sleep hygiene includes keeping a regular sleep and wake schedule, limiting exercise and stimulants in the early evening, and keeping a quiet, comfortable sleep environment.
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 sleep medications are stopped, however, individuals may experience withdrawal symptoms, including nightmares.
The increased use of electronic devices on a regular basis may also have an effect on sleep. The use of electronic readers, smartphones, and computers in the evening hours exposes people to artificial light and stimulates mental activity that affects the brain’s ability to “shut down” for sleep.
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 adults should begin with nonpharmacologic measures such as regular exercise, exposure to bright light in the morning, and avoiding caffeinated beverages.
Patients diagnosed with sleep apnea may need to sleep with a continuous positive airway pressure (CPAP) device and should keep a regular routine of use. Regular maintenance of the machine and evaluation of its effectiveness are also important considerations.
Adequate sleep can be maintained with good sleep habits and a healthy lifestyle. Attention to new medications and changes in daily routine are important to consider if a patient notices changes or new onset of insomnia. Older adults may want to also explore mind-body techniques such as guided imagery or other relaxation techniques to promote onset of sleep.
COGNITIVE CHANGES OF AGING
It is not uncommon to have fleeting moments of confusion at one time or another. People may lose sense of direction when traveling in an unfamiliar city, be confused when waking up in the hospital after a serious car accident, or become disoriented after hearing the news of a death in the family.
Most times, at a young age, or even when middle-aged, confusion is considered temporary and reversible. In older adults, 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 (AD).
Reversible Forms of Confusion
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 (Tabloski, 2014).
|Source: Tabloski, 2014.|
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, especially patients who have had anesthesia with surgery or who have an existing diagnosis of dementia (Touhy & Jett, 2014).
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 (Touhy & Jett, 2014).
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.
|1. Orientation to time and place||10||
|3. Attention and calculation||5||
|7. Complex commands||6||
Mild Cognitive Impairment (MCI)
Mild cognitive impairment is a transitional state between the normal cognitive changes of aging and the development of Alzheimer’s disease or other dementias. 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 18% of the population over age 65. People diagnosed with MCI are at increased risk of developing AD or other dementias (Petersen et al., 2014).
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., 2014).
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 three-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., 2014). 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.
Additional non-pharmacologic strategies that have been studied and shown to be helpful include cognitive training and aerobic exercise. However, to date the studies have involved small sample sizes and need to be replicated (Petersen et al., 2014).
Alzheimer’s Disease (AD)
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 (Touhy & Jett, 2014).
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.
Risk factors for AD include the following:
- Advanced age
- Family history of dementia
- 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
- Lack of physical activity
- Sleep apnea
- Low levels of vitamin D
(Touhy & Jett, 2014; Rusanen et al., 2011)
Factors that protect cognitive function include:
- Higher levels of education
- Higher socioeconomic status (SES)
- Healthy diet
- Intellectually challenging activities
- Active social lifestyle
- Regular physical exercise
(Touhy & Jett, 2014)
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.
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
Care and treatment of the person with AD changes over time as the disease progresses. Care planning should begin at the time of diagnosis and 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 comorbid 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
(Touhy & Jett, 2014)
The progressively lowered stress model (see box below) presents one option for creating and maintaining a supportive environment when caring for a person who has dementia.
PROGRESSIVELY LOWERED STRESS (PLST) MODEL
- Evaluate for any loss of functional abilities and support by assistive devices as needed.
- Establish a caring and respectful relationship with the patient and family.
- Assess and respond to patient cues of anxiety and avoidance when faced with stimuli and overwhelming activities.
- Provide education and feedback to caregivers to understand primary cause of behaviors and to observe for both verbal and nonverbal cues.
- Identify any triggers related to patient discomfort or stress.
- Make environmental modifications to address the safety of the patient.
- Evaluate and make changes to care routines as the patient experiences functional changes.
- Encourage as much patient control as possible (i.e., offer choices, do not force activities).
- Maintain a predictable daily routine and stable environment (daily activities and caregivers should be familiar).
- Provide ongoing support, care, and resources for caregivers and family members.
Source: Adapted from Touhy & Jett, 2014.
Until it becomes necessary to institutionalize the patient, the primary caregiver will most likely be the spouse or a child. The caregiver and other family members involved need education and support to help manage care as the patient’s symptoms and needs change.
Patients receiving collaborative care from an interdisciplinary team including physicians, nurses, social workers, and rehabilitation specialists working with the patient’s family caregiver have been shown to exhibit fewer behavioral and psychological symptoms of dementia than those receiving traditional care. Family caregivers also benefited, showing significant reduction in distress and improvement in depression.
COMMUNICATING WITH PATIENTS WITH COGNITIVE IMPAIRMENT
When talking with older adult patients, especially those with dementia, health professionals and family caregivers should use a respectful, adult communication style. Suggestions for communicating with patients who have cognitive impairment include the following:
- Make an introduction by stating your name and why you are there; shake hands
- Find common ground
- Be personal
- Use humor
- Allow the patient to choose the topic of conversation
- Use a general opening (i.e., “How is your day today?”)
- Follow the patient’s lead
- Give instructions one step at a time
- Speak slowly while facing the person
- Allow time for response
- Reduce other distractions
- Provide clues to the instructions (e.g., if asking the patient to sit, have the chair in front of them and pat the seat of the chair)
- Clarify time orientation of the patient (i.e., get into the place and time of the patient)
- Recognize any themes to what the patient is saying (fear, sadness, happiness)
Support Continued Communication
- Treat the patient with respect and dignity
- Limit making corrections (do not try to bring the person into reality; go to where they are)
- Use multiple ways of communicating (touch, gestures, images)
- Understand the life history and experiences of the patient (career, family, hobbies)
- Adjust for hearing or vision loss
Source: Touhy & Jett, 2014.
FUNCTIONAL ASSESSMENT OF AD
The Reisberg Functional Assessment Staging (FAST) Scale is a 16-item scale designed to parallel the progressive activity limitations associated with AD. Stage 7 identifies the threshold of activity limitation and indicates a life expectancy of 6 months or less.
|Stage||Function or Activity|
|Source: Adapted from AGS, 2014.|
|Stage 1||No difficulty in function reported by patient or others|
|Stage 2||Complains of forgetting location of objects; subjective work difficulties|
|Stage 3||Decreased job functioning evident to coworkers; difficulty in traveling to new locations|
|Stage 4||Decreased ability to perform complex tasks (e.g., following a recipe) or handling finances|
|Stage 5||Requires assistance in making self-care decisions, (e.g., choosing proper clothing)|
|Stage 6||Decreased ability in ADLs (e.g., dressing, bathing)|
|Substage 6a||Difficulty understanding how to put on clothing|
|Substage 6b||Unable to bathe properly; may develop fear of bathing|
|Substage 6c||Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)|
|Substage 6d||Urinary incontinence present|
|Stage 7||Loss of speech, locomotion, and consciousness|
|Substage 7a||Ability to speak only limited vocabulary (1–5 words a day)|
|Substage 7b||All intelligible vocabulary lost|
|Substage 7c||Not able to ambulate|
|Substage 7d||Unable to smile|
|Substage 7e||Unable to hold head up|
Additional forms of dementias include vascular dementia, Parkinson’s dementia, dementia with Lewy bodies, and frontotemporal dementias. The various forms of dementia have different symptom patterns and brain abnormalities. Accurate diagnosis of the type of dementia is important, as each one is treated and managed differently (Touhy & Jett, 2014).
Vascular dementia is the second most common type of dementia. This type of dementia is typically caused by decreased blood flow to parts of the brain due to a series of small strokes or infarcts that block arterial blood flow to the brain. Symptoms of this type of dementia may be very similar to AD, with memory less affected (Touhy & Jett, 2014).
Parkinson’s dementia occurs at least one year after the onset of Parkinson’s symptoms. Lewy bodies (abnormal protein deposits) form inside the nerve cells of the brain and cause cognitive symptoms (Touhy & Jett, 2014).
DEMENTIA WITH LEWY BODIES
Lewy body dementia has a pattern of decline similar to AD, including loss of memory and judgment. Unusual behaviors may be the presenting symptom (i.e., hallucinations, suspiciousness). Patients with Lewy body dementia may experience fluctuations in cognitive symptoms on a daily basis. Muscle rigidity and tremors are also common (Touhy & Jett, 2014).
Frontotemporal dementia involves damage to the frontal and parietal parts of the brain. Symptoms include a change in the patient’s personality, unusual behaviors (impulse control), and difficulty with language skills. Pick’s disease (characterized by Pick’s bodies in the brain) is one form of frontotemporal dementia (Touhy & Jett, 2014).
PSYCHOSOCIAL CHANGES OF AGING
The physiologic changes of aging can have major effects on an individual’s psychological and social well-being. 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.
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. Experiencing multiple losses can also cause depression and isolation. Care providers and family caregivers need to be alert for signs of depression in older adults so that therapeutic measures can be implemented.
Changes in Life Roles
Death or sudden illness in a spouse can result in a dramatic role change for the other spouse. For example, one partner’s illness may shift the burden of managing family finances to the other, 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.
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
- History of abuse or homelessness
- Low income
- Chronic pain
- Mobility problems
Measures to increase social engagement include referral to wellness programs (offering physical activities, social outings, and nutrition support) and other support groups, telephoning or emailing friends, or adopting a pet.
Institutionalized elders may also be socially isolated because of their health problems or because they have no family to visit them. Volunteer visitation and pet therapy can also help reduce isolation among these elders.
DEPRESSION AND SUICIDE
Depression is a widely under-recognized and undertreated illness in older adults. Estimates of major depression in older people living in the community range from 1% to 5%. “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” (NIMH, 2014).
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 and screening for 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 favorite activities
- Hopelessness about the future
- Changes in appetite and/or weight
- Inability to concentrate or make decisions
- Complaints about poor memory and concentration
- Thoughts of suicide
(NIMH, 2014; Tabloski, 2014)
One tool to assess for depression is the Geriatric Depression Scale (see box below).
GERIATRIC DEPRESSION SCALE (GDS, SHORT FORM)
Choose the best answer for how you felt over the past week.
- Are you basically satisfied with your life? yes/no
- Have you dropped many of your activities and interests? yes/no
- Do you feel that your life is empty? yes/no
- Do you often get bored? yes/no
- Are you in good spirits most of the time? yes/no
- Are you afraid that something bad is going to happen to you? yes/no
- Do you feel happy most of the time? yes/no
- Do you often feel helpless? yes/no
- Do you prefer to stay at home, rather than going out and doing new things? yes/no
- Do you feel you have more problems with memory than most? yes/no
- Do you think it is wonderful to be alive now? yes/no
- Do you feel pretty worthless the way you are now? yes/no
- Do you feel full of energy? yes/no
- Do you feel that your situation is hopeless? yes/no
- Do you think that most people are better off than you are? yes/no
Score 1 point for each bolded answer.
Cut-off: normal 0–5; above 5 suggests depression.
Source: Sheikh & Yesavage, 1986.
Intervention for Depression
Treatment for depression may include the following recommendations:
- Behavioral therapy
- Cognitive-behavioral therapy
- Problem-solving therapy
- Brief psychodynamic therapy (also called insight-oriented therapy)
- Life review (also called reminiscence therapy)
- Light therapy
(NIMH, 2014; Tabloski, 2014)
Antidepressant medications may also be used but, unless accompanied by some form of psychotherapy, may not be effective. In addition, antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs), increase the risk of falls (Tabloski, 2014).
If antidepressant medications are prescribed, care providers may need to take extra safety measures in order to prevent falls from occurring, including removing/minimizing trip hazards in the home, installing safety bars in bathrooms and/or near the bed, and increasing the level of direct supervision and/or physical assistance as needed. If falls or balance issues become a concern, consultation with a physical therapist may be indicated.
Depression is one of the conditions most commonly associated with suicide. According to the National Institute of Mental Health (2014), 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 Asians/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
- Alcohol or drug abuse
- History of other suicide attempts
- Family history of suicide
- Preoccupation with suicidal talk and plans
Feeling helpless, hopeless, and worthless can lead to thoughts of suicide and, in some cases, committing suicide. 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.
FUNCTIONAL ASSESSMENT AND ACTIVITIES OF DAILY LIVING
Many people over age 65 have difficulties caring for themselves, managing their living environment, and moving about in the world. This impacts their functional performance in what are referred to as activities of daily living (ADLs) or instrumental activities of daily living (IADLs) (see table below). Difficulties with ADLs, or basic self-care tasks, may indicate the need for long-term care either at home or in a residential care facility. Those who have problems with IADLs, or the complex skills needed to live independently, are more likely to have cognitive impairment than those who can still perform IADLs independently (Tabloski, 2014).
|Activities of Daily Living (ADLs)||Instrumental Activities of Daily Living (IADLs)|
The goal of a functional assessment is to determine how well older adult patients can perform these activities. Patient assessment and evaluation of functional performance includes a review of comorbid diseases, medications, weight-bearing status, and cardiac limitations. Assessment of home safety, self-care abilities, and driving abilities are also important considerations for any frail older adult.
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; a financial/legal consultant (accountant, attorney, or family member with durable power of attorney); a cleaning service; and/or someone to drive, shop, and run errands.
Elements of the Assessment
Assessment of physical function in the older adult includes some of the same elements of any assessment, including the following:
- Weight and height
- Vital signs
- Body mass index (BMI)
- Vision and hearing screening tests
- Balance and gait assessment
- Oral health
- Assessment of skin for bruises, wounds, and other signs of skin breakdown
- Bowel and bladder function
“FANCAPES” ASSESSMENT MODEL
FANCAPES is a model for the comprehensive physical assessment of the frail older adult. It stands for fluids, aeration, nutrition, communication, activity, pain, elimination, and socialization. This model of assessment focuses on the patient’s basic needs and ability to function independently. Assessment questions may include:
- What is the patient’s current fluid status?
- Is the patient able to drink adequate fluids throughout the day?
- Does the patient have barriers or circumstances that would affect fluid intake or balance (e.g., swallowing problems, diuretic use, cognitive impairments, kidney function)?
- What is the patient’s oxygen exchange (goal is O2 saturation of at least 96%)?
- What is the patient’s respiratory rate at rest, while talking, and during activity?
- Do breath sounds indicate any signs of pneumonia?
- What is the patient’s usual food intake?
- Is the patient able to chew and swallow well?
- Is the patient on any special diet?
- Can the patient communicate their needs well?
- Does their caregiver understand them well?
- What is the patient’s level of hearing?
- Is the patient able to speak and be understood (any aphasia)?
- What is the patient’s literacy level?
- Is the patient able to meet their basic needs (ADLs)?
- How much assistance do they need and with what activities?
- Is the patient able to meet higher level needs for activities (e.g., social outings, attending church)?
- What is the patient’s level of coordination, balance, dexterity, and strength?
- Is the patient experiencing any level of pain (physical, psychological, or spiritual)?
- Is the patient able to express pain and their needs for pain relief?
- How does the patient normally treat their pain?
- Does the patient have cultural barriers to pain expression?
- Is the patient having any problems with bladder or bowel function?
- Are their environmental barriers to adequate toileting (e.g., location of bathroom from bedroom)?
- Does the patient need any assistive devices in the bathroom (e.g., toilet seat riser, bedside commode)?
S—Socialization and Social Skills
- Is the patient able to negotiate relationships within their family and social circles?
- Does the patient have a sense of self-worth within their world?
- Is the patient involved in hobbies or interests outside of their home environment?
Source: Touhy & Jett, 2014.
Occupational therapists in particular have specialized knowledge and skills that address the limitations that older adults experience with the performance of ADLs and IADLs. The occupational therapy process in the effective treatment of the older adult begins with a thorough evaluation that identifies why the individual is seeking services and the areas of occupation that are causing problems for the individual. Various standardized assessments are used during this process (e.g., Falls Efficacy Scale, Modified Barthel Index) to help identify priorities and desired outcomes (Leland et al., 2012).
Communication with Older Adults
The first step in assessment is to establish a trusting relationship with the patient. It is important to ensure the patient is comfortable and to take time to get acquainted before launching into the assessment questions. The room should be well-lit, quiet, and warm. Other family members, friends, or caregivers should be acknowledged, but the main focus should be on the patient rather than the companion. Although a companion may assist in communication during the assessment, it is important that the patient is the primary person being addressed in the discussion.
BEST PRACTICES FOR COMMUNICATION WITH OLDER ADULTS
The following recommendations are essential for communicating effectively with older patients:
- Providers should make the assessment face-to-face, allowing the patient to see their lip movement when speaking; this is particularly important if the patient has a hearing problem.
- Voice tone should be clear, slow, lower pitch, and slightly louder than usual.
- The provider should verify understanding by asking for questions from the patient and, if present, a caregiver or companion.
- One question should be asked at a time, allowing sufficient time for patient responses. Even healthy older adults may take a little longer to process a question and frame a response.
- Communication should be modified to match the individual’s learning style and incorporate language the patient uses, avoiding complex medical terminology, acronyms, and abbreviations.
- If the patient has cognitive impairment, assessment questions should be verified with the assistance of the healthcare proxy or primary caregiver.
(Touhy & Jett, 2014)
During the initial conversation and history taking, it is important to assess the patient’s 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 screening exams such as mammography and colonoscopy.
The patient’s ability to adapt to behavior changes should also be assessed. 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 may not yet have recognized? Are they able to see well enough to make self-assessments of their feet? Have they modified their home environment for safety? Do they realize that it may be 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.
Assessment should address whether patients have the necessary resources to self-manage health. Can they afford the medications their primary care provider 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?
Alice is a widowed 83-year-old still living in her own home. She is in to the clinic today to have her blood pressure checked after starting a new medication for hypertension. She has been prescribed atenolol 50 mg daily, with original instructions to start by taking 25 mg in the evening for the first week, followed by 25 mg in the morning and evening on the second week. She has been taking the atenolol for three weeks now and is here for an evaluation.
Her nurse is Molly, who greets her with a smile and a warm handshake in the lobby of the clinic. Molly then introduces herself and asks how Alice is today. Alice responds that she is fine. As Alice and Molly walk together into the exam room, Molly notices that Alice seems a little unsteady on her feet, reaching out to the wall as she walks. Once they arrive to the exam room, Molly has Alice sit for a few minutes prior to taking her blood pressure reading. This is the perfect time to establish rapport and make a few observations.
Molly notices that Alice seems winded as she sits and has a couple of bruises on her legs that look fresh. Molly asks to see Alice’s medication bottle and goes on to ask how things are going with taking the new medication. Alice states that things are “going OK” and that she is “hoping to get used to the medication.” Molly picks up on the fact that she does not seem sure of herself and adds the question, “What has been happening since you started the atenolol?” Alice says that she is “more tired, has less energy, and has even felt a little faint.” Remembering the bruises, Molly goes on to inquire if Alice has had a fall recently? Alice states, “Well, it was nothing. I am clumsy and fell after getting up from a nap one afternoon.”
Molly suspects that perhaps Alice’s blood pressure and pulse are too low as a result of the medication. When she takes Alice’s blood pressure, the reading is 88/52 and her pulse is 56. Molly asks Alice how many pills she is taking, and Alice replies two pills in the morning and one pill in the evening.
Molly then goes on to verify the dose of medication, and says to Alice, “The atenolol dose that you should be taking is one pill in the morning and one a night.” Alice looks confused and says, “I thought I was supposed to start with one pill in the morning and then add a second pill the next week in the morning and at night. Did I make a mistake?”
Molly reassures Alice and says, “It’s okay. Taking a new medication is confusing sometimes, but the extra medication is probably why you are feeling tired, weak, and have had a fall recently.” Alice nods in understanding and asks, “Oh, well what do I need to do now?” Molly goes over the schedule of taking one pill in the morning and one pill at night and asks if she has a family member who can help organize her pills and check her blood pressure 2 to 3 times a week at home. Alice replies that her daughter lives close to her and that she could come over and help her with this.
Molly also suggests that perhaps Alice’s daughter can pick her up today and give her a ride home, since her blood pressure is quite low. Molly instructs her to drink adequate fluids and have someone check on her later in the day. Alice should not take her evening dose of atenolol this evening and should then check her blood pressure in the morning. Molly also discusses Alice’s risk for falls and instructs her to take care when going from a lying or sitting position to standing, since she may experience dizziness.
As Alice leaves her appointment, Molly walks out with her to meet her daughter and to make sure that she is safe to transfer home. She also schedules a phone call for the next day to check on Alice’s status as well as a re-check in one week to learn the status of her blood pressure and pulse.
Ambulation and Mobility
Being able to ambulate safely within their homes and communities is often a crucial factor in older adults’ ability to continue living an independent lifestyle. Community ambulation refers to an individual’s ability to successfully complete ambulation over uneven terrain and in community venues such as medical offices, supermarkets, pharmacies, banks, department stores, post offices, etc.
The Functional Independence Measure states that a patient must be able to safely walk a minimum of 46 meters (150 feet) in order to be classified as an independent ambulator. However, it has more recently been argued that an individual must be able to ambulate at least 600 meters (about 650 yards) in order to be able to independently access common community situations (Andrews et al., 2010).
COMMON ASSISTIVE DEVICES FOR AMBULATION
While many mobility issues in older adults cannot be treated medically or surgically, they sometimes can be compensated for by the use of ambulatory assistive devices. There are a number of assistive devices available that may be of assistance to older adults with mobility impairments. Assistive mobility devices offer a wide range of levels of support based on a patient’s individual needs. When fitted correctly and used properly, assistive devices may increase base of support, improve stability with standing or walking, and increase activity and independence level.
- Standard/straight cane: Lightweight and inexpensive, generally crafted from wood or aluminum. A cane may help improve stability in a patient who does not need the upper extremity to bear weight.
- Offset cane: This type of cane distributes the patient’s weight over the cane’s shaft. An offset can is often indicated for patients who require their upper extremity to bear weight at times (i.e., due to gait problems caused by pain from knee or hip osteoarthritis).
- Quadripod cane (“quad” cane): A four-legged cane that provides a larger base of support. This type of cane can stand freely if the patient needs to use upper extremities for other tasks momentarily and may be useful for some patients with hemiplegia. For safe and proper use, all four points of the cane must contact the ground at the same time.
- Crutches: Useful for patient who must use their upper extremities for purposes of both weight-bearing and propulsion. Due to the significant energy requirements for their use, as well as the level of arm and/or shoulder strength needed, crutches are infrequently indicated for the majority of older adults, particularly frail elders. If crutches are indicated:
- Axillary crutches are cost-effective but can be difficult to use and may cause brachial plexus and/or axillary artery compression if fitted or used incorrectly.
- Lofstrand (forearm) crutches have proximal forearm cuffs and distal hand grips, allowing bilateral upper extremity support with occasional weight bearing. This allows the patient’s hands to be free without needing to drop the crutch during certain functional activities.
- Platform crutches provide a horizontal platform on which the forearms rests and bears weight (instead of the hand). Platform crutches are potentially beneficial for patients with elbow contractures or with weak/painful hands or wrists.
- Standard walker: The most stable walker. However, since the patient must completely lift the walker off ground with each step, it results in a slower gait. This may be challenging for frail older patients with decreased upper body strength.
- Front-wheeled walker (two-wheeled walker): Less stable than a standard walker but maintains more natural gait pattern. This is an alternative for older adults who cannot lift a standard walker.
- Four-wheeled walker (rollator): Potentially useful for higher-functioning patients who do not require a walker to serve weight-bearing purposes. This type of walker is easy to propel but not generally appropriate for patients with significant balance or cognitive impairment because it may roll forward unexpectedly. They often come with seats and baskets but must be used with caution. Brakes should always be engaged and the rollator positioned against a wall or other solid object before the patient sits.
Selection of an appropriate assistive device for mobility is contingent on a patient’s strength, endurance, balance, cognitive status, and environmental demands. All ambulatory assistive devices should be fitted to the individual patient, who will likely need training in using the device. 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.
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. It is important to bear in mind that a wheelchair may be the safest mobility option for patients who can no longer ambulate safely or who have severe lower extremity weakness that does not respond to therapeutic interventions (Bradley & Hernandez 2011).
Safe Driving and Transportation
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 cannot 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 a small number of states have mandatory reporting requirements for physicians to report specific conditions such as seizure disorders and AD, among other disorders. These include California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania. Health professionals need to know the reporting requirements in the state where they practice (AMA, 2010).
Strategies for managing an older adult’s transportation needs for shopping, medical appointments, social events, etc., may include the following:
- Asking a friend or neighbor for a ride
- Visiting a local driver’s licensing agency for an evaluation of driving skills
- Using taxis and public transportation
- Attending a CarFit event
- Avoiding driving during the evenings or rush hour
Adapting or modifying the home environment of older adults may be required in order to mitigate identified hazards and facilitate greater participation in daily activities, exercises to enhance mobility (particularly balance, strength, and gait training), and promotion of the safe performance of daily activities. The occupational therapist plays an important role in home safety, which may include physical interventions, environmental modifications, and behavioral adaptations.
Specific interventions that promote independence and safety may include the following:
- Removal of throw rugs
- Decreasing clutter
- Repairing furniture that is not sturdy
- Reducing electrical cords and keeping them out of pathways
- Seeking out community-based programs like Rebuilding Together or Habitat for Humanity to assist with home repair or implementation of adaptive equipment (e.g., ramps, grab bars)
- Getting professional assistance for cleaning/housekeeping and lawn care
- Arranging for Meals on Wheels or assistance from other community agencies or faith-based groups
BALANCE AND FALL RISK AMONG OLDER ADULTS
Falls are one of the greatest threats to the health of older adults, 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 three times more likely to die from such injuries as younger people. Fall-related injuries, particularly those requiring hospitalization, are the most frequent cause of developing new or worsening disability (Touhy & Jett, 2014).
Falls are the leading cause of emergency department visits by older adults and the number one cause of hospital admissions due to trauma. The estimated average cost of a hospital admission due to a fall is $20,000. By 2030, it is estimated that up to $54 billion will be spent on healthcare costs due to falls (Schubert, 2011).
Screening and Assessment
Screening for potential balance impairments and risk of falls is an important component of the functional screening of an older adult, particularly if a patient has a prior history of falls, medications, or comorbid conditions that may affect balance or equilibrium.
Older adults should be assessed for any factors that may place them at greater risk for falls, including:
- Age (>85 years)
- Gender (female)
- Race (white, non-Hispanic)
- Chronic disease (osteoarthritis, Parkinson’s disease, cardiovascular disease)
- Acute illness (influenza, infections)
- Previous history of falls
- Gait and mobility impairment
- Vision and hearing deficits
(Faber et al., 2010)
There are a number of valid and reliable screening tools employed for the purposes of determining an individual’s risk for falls. The following table outlines common screening and assessment tools used by rehabilitation professionals to assess physical function and fall risk. Initial screening tests identify baseline function and patients with functional decline with an increased risk for falls. Assessment tools are used to evaluate patients with existing or high risk factors for falls and/or to assess progress of a rehabilitation plan.
|Instrument||Type (Screening or Assessment)||Time to Administer||Equipment|
|Source: Modified from Faber et al., 2010.|
|Timed sit-to-stand test||S||<10 min||Stopwatch, chair|
|Berg balance scale||S or A||<20 min||Stool, stopwatch, ruler|
|Functional reach test||S||<5 min||Tape measure, platform for foot position|
|Limits of stability test||A||20–30 min||Computer software|
|Computerized dynamic posturography||A||20–30 min||Computerized dynamic posturography system|
|Dynamic gait index||S or A||15 min||Staircase, shoebox, two cones, tape measure, tape|
|Tinetti balance assessment||A||20 min||Armless chair, pencil|
|Timed up-and-go (TUG) test (see below)||S or A||<5 min||Chair, measuring tape, stopwatch|
|Expanded timed up-and-go test||S or A||<5 min||Chair, measuring tape, stopwatch|
|Four-square step test||S or A||<5 min||Four canes, stopwatch|
Assessing mobility, strength, and gait is essential in determining the older patient’s risk for falling and experiencing difficulty in meeting other physical needs. 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.
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 within a normal range. Anyone who is unable to do this in less than 14 seconds may be at increased risk for falls.
Prevention and Intervention
Patients and families need to know how to prevent falls. The CDC recommends the following four essentials for prevention:
- 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 (for side effects and interactions).
- Take the patient in for a vision check.
Additional precautions that can make the home safer and prevent falls include:
- Removing tripping hazards such as throw rugs from stairs and floors
- Placing often-used items within easy reach so that a step stool is not needed
- Installing grab bars next to the toilet and in the tub or shower
- Placing non-stick mats in the bathtub and on the shower floor
- Adding brighter lighting and reducing glare by using lampshades and frosted bulbs
- Adding handrails and lights on all staircases
- Wearing shoes that offer good support and have thin, non-slip soles
- Avoiding wearing slippers and socks (without shoes) and going barefoot
EXERCISE INTERVENTION STRATEGIES
Physical therapists may employ a number of intervention strategies and approaches in the delivery of therapeutic exercise for the purposes of improving balance and reducing fall risk in older adults. Some of these strategies include:
- Multifactorial intervention: May be interdisciplinary in nature; any program or protocol that includes assessment of and interventions for more than one fall risk factor.
- Single-factor intervention: Focuses primarily on the risk factor associated with falling (i.e., only balance training activities, strengthening exercises, or home safety education).
- Multicomponent exercise program: Incorporates multiple components; may include performance, balance/postural control, walking, and/or cardiovascular endurance activities.
- Single-component exercise program: Contains one modality of exercise (i.e. balance, strengthening, or endurance).
- Balance training program: Specifically designed to target and progressively improve static and dynamic balance.
- Moderate-challenge balance exercise programs: Incorporates two of the three modes of balance exercises: 1) movement around the individual’s center of mass, 2) utilizing narrowed base of support, and 3) minimal upper extremity support.
- High-challenge balance program: Incorporates all three modes of balance exercises (see above).
- Structured exercise intervention/program: Scripted; composed of specific components (warm-up, balance, gait training, etc.) delivered in a consistent manner over time; designed to be progressive and challenging.
- Best practice programs: Exercise programs, often offered at senior centers and wellness facilities, composed of evidence-based activities.
- Evidence-based programs: Have been translated and tested in the community setting in randomized controlled trials and deemed effective in reducing risk of falling. Highly scripted, target specific populations, and include specific implementation instructions.
Source: Schubert, 2011.
Violet is an 82-year-old retired professor who lives independently in her own home. Violet has a prior history of spinal stenosis and underwent a lumbar fusion five years ago. As a consequence of the surgery, she has residual L-sided foot drop (for which she wears an ankle-foot orthosis [AFO] during the day) and persistent pain. She underwent post-operative physical and occupational therapy and currently walks with a single-point cane. Since her surgery, Violet has required assistance with cleaning her house and gardening but has remained independent in ADLs, including bathing, dressing, and light meal preparation. Violet is able to drive independently.
In the past six months, Violet has fallen several times in her home. One of these incidents resulted in a fractured rib. Today, she is seeing her primary care provider, who is concerned about her increased incidence of falls and their potential consequences to Violet’s independence. Violet wears glasses and does not report any dizziness, lightheadedness, or other cardiac-related symptoms. Her medications include atenolol, trazodone, and aspirin.
In the initial interview, Violet states that she sometimes has problems climbing the eight steps into the main level of her house and is sometimes not able to ascend the stairs without holding on to the rail for support. She states that she generally uses her cane when she goes out but does not always do so when she is at home. Violet states that she would like to feel steadier on her feet and stop having falls so that she can continue to live independently in her home. The primary care provider makes a referral to physical therapy for a functional mobility evaluation.
The physical therapist completes an initial evaluation of Violet’s functional status, which reveals the following pertinent information:
- Range of motion, gait, and strength are assessed. Violet states that she has not been wearing her AFO as often as she should because it has been hurting her leg lately.
- Violet’s straight cane is too long for her height, causing her to hold her arm at an unnatural angle to grasp the cane.
- Violet is able to maintain balance with her feet together on a foam surface for ~3 seconds without wearing her AFO and for ~10 seconds while wearing her AFO.
- Violet displays mild to moderate difficulty ascending stairs, mild difficulty descending stairs, and use of one handrail for support.
Together, the physical therapist and Violet develop the following goals in order to address both her current functional deficits and her long-term personal objectives:
- Violet will be independent and compliant with a home program that addresses static and dynamic balance, gait training, proper use of assistive devices, lower extremity strengthening, and safety awareness.
- Violet’s cane will be readjusted to the proper length for her height in order to allow more comfortable and safe use.
- Violet will wear her L-sided AFO with 100% compliance during the day in order to normalize her gait pattern and to optimize her safety with ambulation and when negotiating stairs.
- Violet will successfully ascend and descend eight stairs with one handrail, using a step-to gait pattern with no losses of balance.
- Violet will demonstrate consistently safe ambulation over all surfaces (including soft, uneven, or sloped surfaces) without loss of balance, using her AFO and cane 100% of the time.
- Violet will successfully navigate her home and community environment without loss of balance or falls for a period of 30 days, using her straight cane correctly and with 100% compliance.
- While wearing her AFO and using her straight cane, Violet will successfully ascend/descend 12–14 stairs using one handrail with no hesitation or loss of balance.
The physical therapist recommends a plan of care to address Violet’s current deficits and to allow her to return to the highest possible level of physical function. The plan includes:
- Outpatient physical therapy twice weekly for a period of six to eight weeks
- Assistive device fitting and compliance training
- Static and dynamic balance training
- Household and community safety awareness training
- Structuring and tailoring of an overall, long-term functional mobility plan
- Recommendation for a follow up with the orthotist to have Violet’s AFO checked and re-fitted
Falls and Traumatic Brain Injury
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). Adults aged 65 years or older have the highest rates of hospitalization due to TBI, with a high risk of death as a result of TBI (CDC, 2014). 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, 2014).
SYMPTOMS OF MILD TBI
- Low-grade headache that will not 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 such as 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 does not go away
- Repeated vomiting or nausea
- 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
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.
—Touhy & Jett, 2014
Older people consume more medications than any other age group. Although medications may improve 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 (Touhy & Jett, 2014).
Drug Interactions and Adverse Events
Polypharmacy is defined as taking more than five medications at the same time (Touhy & Jett, 2014). 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.
The medication classes responsible for over 67% of emergency hospitalizations in adults over age 65 include warfarin (Coumadin), insulin, oral anti-platelet agents, and oral hypoglycemic agents (Budnitz et al., 2011).
Managing Drug Regimens
Medication management is an important daily function that should be assessed regularly. If a patient is managing multiple medications (especially new medications), assessment should include a review of dosage, timing, and side effects. Ideally, each patient’s complete medication profile is monitored by a single health professional such as a clinical pharmacist.
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, herbal, supplements, 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 (Touhy & Jett, 2014). 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 ginkgo biloba also act to enhance the effects of warfarin.
AIDS TO MANAGING DRUG REGIMENS
Older adults frequently have arthritis, cognitive changes, or vision impairment; therefore special aids or strategies may be needed, such as a hand-held magnifier, easy open caps, larger organizer boxes, and instructions or reminders written in large print. Occupational therapists can assist patients to formulate a plan to organize and find the best medication aids to meet each individual’s needs.
There are various forms, calendars, 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” at the end of this course.)
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 pill reminder applications (apps) available for use with mobile devices; however, these require that either the patient or the caregiver have a mobile device and the skills required to use it.
Carol is an 80-year-old widowed woman who currently takes prescribed medications, including low-dose aspirin, a beta-blocker, a thiazide diuretic, and warfarin. Her over-the-counter medications include a multivitamin, vitamin C, vitamin E, calcium tablets, and Bayer PM for sleep. She occasionally takes Tums for an upset stomach and either aspirin or acetaminophen for a headache. She reports that she has recently developed constipation and has also been taking a laxative.
She arrives to see her primary care provider for her annual exam. The nurse, Sharon, has asked Carol to bring in all of her medications so that they can review all of her prescriptions, supplements, and OTC medications together. As the nurse greets her and asks how she is doing, Carol states that she is “feeling washed out, very tired, but not sleeping well lately.” Because of the fatigue, she has not been able to do her daily 30-minute walk.
During her visit with Sharon, Carol has her medication bottles as well as OTC and supplement bottles with her. For each medication, Carol is asked to identify what the medicine is, how she takes it, and the reason she is taking it. Carol is able to recall all medications and indications. She can’t remember exactly when she started taking the vitamin E, but states that a friend of hers told her that it was good for her heart, so she decided to start taking it. After all, she says, “It’s just a vitamin.”
Sharon also asks Carol about her usual diet for a day. Carol states that she ate the following items the previous day:
- Breakfast: grapefruit juice, blueberry muffin, coffee with cream
- Lunch: grilled cheese and tea
- Snack: glass of milk with two cookies
- Dinner: cheese with crackers, a glass of wine, broiled chicken, peas, carrots, mashed potato with butter, chocolate ice cream
- Bedtime snack: coffee-flavored yogurt
Sharon reviews all of this information and goes on to provide feedback and education with Carol based on her nursing assessment. Sharon feels that Carol’s recent symptoms of constipation may be a side effect of the beta-blockers as well as her intake of calcium (from her diet of cheese, yogurt, and ice cream as well as taking of Tums). Long-term use of beta-blockers can also cause depression and may be affecting Carol’s ability to exercise.
Carol’s use of the sleep aid may be causing a hangover effect, with her symptoms of lack of energy. She may also be experiencing hypokalemia from the thiazide diuretic. Sharon reinforces eating foods that contain potassium, such as bananas, oranges, apricots, or prune juice.
They also discuss the fact the grapefruit juice may be increasing the absorption of some of her medications, causing toxicities. Also, because Carol is taking an anticoagulant, they discuss when she last had her international normalized ratio (INR) checked. They review symptoms of bleeding, such as blood in the urine or stool. Sharon spends time educating Carol on the interactions of other supplements and OTC items that should be avoided in patients who take warfarin. This includes items that contain aspirin (the Bayer PM) and vitamin E (which prolongs bleeding).
Regarding sleep, Sharon discusses Carol’s caffeine intake and recommends that she avoid caffeine in the afternoon and evening hours. They talk about drinking decaffeinated tea and coffee instead, as well as trying a warm glass of milk prior to bedtime to induce a sleep effect.
Sharon discusses all of these factors with Carol’s primary care provider. Carol is scheduled for an INR as well as a check of her electrolytes, with a follow-up visit to go over results scheduled in a week.
Potentially inappropriate medications may be prescribed for older adults, leading to drug-related problems and adverse drug events. To reduce such outcomes, health professionals can make use of the American Geriatric Society’s Beers Criteria, which identify potentially inappropriate medications for people age 65 and older. These criteria are divided into three categories:
- Potentially inappropriate medications and classes to avoid in older adults
- Potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate
- Medications to be used with caution in older adults
(AGS, 2012; see also “Resources” at the end of this course)
Prescribing physicians must consider the slowed metabolism and excretion of drugs in older patients—not only in the choice of drugs but in 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.
Physical and Mental Impairments
Sensory and motor impairments can affect an older adult patient’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.
Alcohol and Recreational Drug Use
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., benzodiazepines).
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 (Touhy & Jett, 2014; Tabloski, 2014).
Some experts recommend that all older patients be screened for possible alcohol abuse. The SMAST-G screening test (see below) is simple to use; two positive answers indicate the need for further assessment (Tabloski, 2014).
SHORT MICHIGAN ALCOHOLISM SCREENING TEST—GERIATRIC VERSION (SMAST-G)
- When talking with others, do you ever underestimate how much you drink? (Yes or No)
- After a few drinks, have you sometimes not eaten or been able to skip a meal because you did not feel hungry? (Yes or No)
- Does having a few drinks help decrease your shakiness or tremors? (Yes or No)
- Does alcohol sometimes make it hard for you to remember parts of the day or night? (Yes or No)
- Do you usually drink to relax or calm your nerves? (Yes or No)
- Do you usually take a drink to take your mind off your problems? (Yes or No)
- Have you ever increased your drinking after experiencing a loss in your life? (Yes or No)
- Has your doctor or nurse ever said they were worried or concerned about your drinking? (Yes or No)
- Have you ever made rules to manage your drinking? (Yes or No)
- When you feel lonely, does having a drink help? (Yes or No)
Scoring 2 or more “yes” responses is indicative of an alcohol problem.
Source: Regents of the University of Michigan, University of Michigan Alcohol Research Center. Adapted from Tabloski, 2014.
Baby boomers approaching older age present a unique problem for the healthcare system. Older adults with situational or life-long recreational drug habits will be more common. Recreational drugs used by the baby boomer generation include marijuana, cocaine, amphetamines, as well as abuse of prescription pain medications. This generation is more likely to use recreational and prescription drugs for situational problems, such as loss of work, isolation, changes in health status, retirement, and loss of adequate income (O’Malley, 2012).
Currently, very few validated tools have been created to screen older adults for drug abuse. However, signs and symptoms may include the following:
- Memory loss
- Depressed mood
- Poor hygiene
- Poor nutrition
- Changes in blood pressure
- Pain in upper abdomen
- Sleep disturbance
- Loss of appetite
- Weight loss
- Family dysfunction
Health Literacy and Older Adults
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. One of the most vulnerable populations at risk for low health literacy is the elderly. As the U.S. population ages, understanding how age and health literacy are related will be of increased importance within the healthcare system.
- Older adults use more medical services than any other group (CDC, 2011).
- They may need to often manage complicated medication administration schedules, frequent medical appointments, and medical insurance documentation.
- Along with the physiological and psychological changes of aging, this group may also experience cognitive decline, chronic illness, and social isolation, which may have a negative impact on health literacy.
- Reading is a major factor that influences health literacy. Increased age is associated with lower reading skills, which may be affected by visual and hearing acuity and cognitive changes.
- The elderly may have fewer social contacts and opportunities to learn about health-related issues that would provide access to the latest updates and resources. They may depend on different communication strategies such as radio or television for sources of medical information and updates rather than the Internet, journal articles, or electronic media.
Effectively assessing health literacy within the clinical setting can be a challenge. Researchers who looked at simplifying the process of a health literacy assessment discovered that a tool using one question—”How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”—was the most effective in identifying those patients with low health literacy (Dickens & Piano, 2013).
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 (Tabloski, 2014).
To cope with high out-of-pocket costs for drugs, many seniors use such cost-cutting measures as skipping doses, going off their medication for a time, or purchasing their medications from unreliable sources online or abroad. Others take less than the recommended dosage (e.g., cutting pills in half) to make the medications last longer (Tabloski, 2014).
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 adult patients who need medications.
The Centers for Medicare and Medicaid (2014) have recommendations on how healthcare professionals can help older adults with limited or low income to manage the cost of drugs, including:
- Discuss switching to less-expensive brands or generic brands.
- Help search for a medication assistance program for the specific drug needed.
- Inquire about government programs that offer assistance with premiums and other drug costs.
- Determine whether patients qualify for extra help through Medicare and the Social Security system.
- Provide resources for national and community-based charitable programs (such as the National Patient Advocate Foundation).
(See also “Resources” at the end of this course.)
SUPPORTING FAMILY CAREGIVERS
An estimated 25 million family caregivers in the United States provide care for a frail elderly person (spouse, parent, or sibling), ranging from help with daily activities to 24-hour care. Such caregivers may experience added stress, anxiety, and depression from the heavy responsibilities and isolation of caregiving. Asking for respite care, attending support groups, continuing hobbies, and participating in regular exercise are helpful strategies that caregivers can employ to address the stress of caregiving (Tabloski, 2014).
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 an older adult remaining at home and going to a nursing home or other long-term care facility. Likewise, reducing the burdens on caregivers can delay the need for nursing home care. An important consideration is to educate caregivers about community resources available to help balance the stress of caregiving. Connecting family caregivers to local senior centers, facilities offering respite care, churches, caregiver support groups, and skills training interventions can further reduce caregiver burden. Resources can be located by working with the local Area Agency on Aging, Family Caregiver Alliance, or Eldercare Locator (see “Resources” at the end of this course).
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 and emotional health is also impaired by caregiving. Problems such as depression, anxiety, poor physical health, poor immune function, and increased risk of mortality can result (Touhy & Jett, 2014). Risk factors for caregiver burden include the following:
- Advanced age of the caregiver
- Insufficient resources
- Poor baseline health of the caregiver
- Caring for a loved one with dementia
- History of a difficult relationship between the caregiver and patient
(Touhy & Jett, 2014)
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.
TIPS FOR CAREGIVERS
- Seek education and support about the disease or medical condition of your loved one.
- Find a healthcare provider who specializes in the condition.
- Plan for the future (i.e., legal and financial planning).
- Ask for help from friends and other family members when needed.
- Talk about your needs with someone you trust.
- Take time to focus on stress relief and relaxation strategies (i.e., hobbies, exercise, meditation).
- Maintain a sense of humor.
- Find support in religious or spiritual beliefs.
- Set realistic goals.
Source: Touhy & Jett, 2014.
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 dementias, 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.
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 or healthcare proxy.
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.
Having an advance directive in place is important for all adults, young or old. An advance directive outlines the person who is responsible for making healthcare decisions (only in the case that the patient is unable) as well as the kind of medical treatment the patient wishes or does not wish to have. Advance directives can also outline specific instructions for end-of-life care and organ donation. Once the advance directive is outlined, copies should be placed in the medical record and given to the patient’s family members as well as others who may be involved in the care of the patient. A person who is named as the durable power of attorney for healthcare should also have a copy of the advance directive.
Health professionals who see evidence of cognitive impairment in a patient should ask the spouse, partner, or other family members 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 (Tabloski, 2014). A patient who has no spouse, partner, or other family member to fulfill this role may also need 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.
The Family Caregiver Alliance can provide state-specific information and appropriate forms for advance directives (see “Resources” at the end of this course).
CPR Versus DNAR Orders
Do-not-attempt-resuscitation orders (DNAR) (also known as “do-not-resuscitate [DNR] 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 whether to attempt CPR, healthcare providers need to explain that withholding CPR does not equate with letting someone die. Rather, a DNAR order should be considered in the context of the complex medical situations that can occur. A decision to withhold CPR should take into consideration the patient’s wishes (as outlined in the living will) and the resulting quality of life.
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 (Tabloski, 2014).
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” (Touhy & Jett, 2014). 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. (See “Resources” at the end of this course for POLST programs in your state.)
Artificial Nutrition and Hydration (ANH)
People with advanced age, multiple comorbidities, progressing or life-limiting illness, Alzheimer’s disease, or other dementias may eventually experience a loss of interest in eating or drinking or forget how to feed themselves or even how to eat. These changes may cause distress, especially for family members and caregivers and may lead to a discussion about artificial nutrition and hydration (ANH).
ANH should be discussed with the patient’s wishes and expected outcomes in mind. Older adults who feel strongly that they do not want to have tube feedings should specify this wish in their living wills. ANH is considered a medical treatment and can be accepted or rejected as a patient decision. Evidence no longer supports the use of ANH for patients who are at end of life or in advanced stages of dementia (Tabloski, 2014).
Elder abuse occurs when harm or distress is caused to an older person within the context of a relationship where there is an expectation of trust (Mauk, 2014). Elder abuse is connected with adverse health outcomes as well as an increased risk of mortality. Elder abuse is difficult to track. There is no national reporting system, and statistics are unreliable and outdated. In addition, older adults may be hesitant to report abuse out of fear. However, estimates indicate that over one million older adults experience some form of abuse annually (Mauk, 2014).
Elder abuse can take many forms, including physical, sexual, emotional, financial, caregiver neglect, and abandonment. Nurses and other healthcare providers should regularly screen for elder abuse and recognize any unusual symptoms or patient responses that may indicate abuse.
|Source: National Institute on Aging, 2011.|
|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. Most abuse happens in the elder’s own home. However, abuse also occurs in long-term care facilities.
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 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
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.
Assessment and Screening
Health professionals should be alert to any indication of elder abuse. During the physical examination, it is important to look for physical signs of possible abuse or neglect. These may include bruising, malnutrition, burns, scars, and fractures. Signs of sexual abuse may include trauma to the vulva or rectum or any unexplained vaginal or anal bleeding. Clinical findings of neglect may include dehydration, malnutrition, decubitus ulcers, and contractures.
Assessment and interview of the patient separate from the caregiver may be needed to confirm any suspicion of abuse or neglect (Tabloski, 2014). Office or emergency department visits provide a safe and confidential environment. 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.
Screening questions for elder abuse may be used with patients. Questions for routine screening include the following:
- Do you feel safe where you live?
- Who prepares your food?
- Does someone help with your medications?
- Who takes care of your checkbook?
- Does anyone at home hurt you?
- Do they scold or threaten you?
- Do they touch you without your consent?
- Are you afraid of anyone in your life?
- Are you alone a lot?
- Are you able to use the telephone any time you want to?
- Has anyone forced you to do things you didn’t want to do?
- Has anyone taken things or money that belong to you without your permission?
- Has anyone ever failed to help you take care of yourself when you needed help?
(Stanford School of Medicine, 2014)
Nurses, physicians, and other clinical providers in all settings where older people receive care also need to be aware of their legal requirements for reporting 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” at the end of this course).
People are often 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.
Life ends for everyone; this is a fact. As older adults approach the end of their lives, they may be relatively healthy or they may be dealing with a chronic or incurable illness. Preparing older adults and their families to plan and anticipate making decisions regarding end-of-life care and treatment is important, especially in the event that the older adult is not able to make decisions for themselves.
Older adults should plan and discuss their preferences with significant others, family, and healthcare providers to communicate their wishes through planning advance directives, a living will, and appointing a healthcare power of attorney. Advance directives are designed to communicate the type of care patients want when they cannot speak for themselves. A healthcare power of attorney is someone appointed by the patient to make treatment decisions on their behalf. (See also above under “Legal and Ethical Considerations.”)
Palliative care incorporates multiple strategies to relieve physical and emotional suffering and to enhance quality of life. Palliative care can be requested in the early phases of a life-limiting or debilitating illness and coexist with life-sustaining treatment. For patients with chronic illnesses, palliative care may continue for years.
Hospice care is designed to optimize the end-of-life experience. Hospice care empowers patients and families to be active participants and make personal decisions about the dying process. Hospice care incorporates physical, emotional, psychosocial, and spiritual needs at the end of life. Bereavement services are also included and may continue for up to a year after the patient’s death.
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.
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.
The Center to Advance Palliative Care (2014) states:
Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.
Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.
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. Goals for palliative care support patient and family needs during this time by providing:
- A way to honor the patient’s wishes
- Choices among the types of services the patient can receive
- Pain control tailored to the patient’s wishes
- Emotional support for the patient and family
NURSING AND REHABILITATION THERAPY GOALS
Palliative care includes team members from medicine, nursing, social work, pharmacy, chaplaincy, rehabilitation, and other disciplines. The goal of palliative care is to achieve the best possible quality of life for patients and their families. Nursing interventions may include the following:
- Pain management
- Symptom management (e.g., oxygen to ease breathing)
- Spiritual care
- Emotional support (e.g., mind-body techniques for anxiety)
- Home equipment needs (e.g., assistive devices, safety features, and other equipment)
- Home care and medication management
- Referral to social work, community resources, and other identified needs
In cases where individuals are not deemed likely to make a recovery from an illness or condition, rehabilitation specialists may be a primary resource within the interdisciplinary team. Consultation with a physical therapist may be indicated for issues of functional mobility that may be present, ongoing, or worsening. Interventions for palliative care patients are often similar in nature to treatments provided to traditional patient populations, however, it is important to remember that performance and functional improvements/progress may be adversely affected by co-existing disease processes (Cruz, 2013).
The Palliative Performance Scale (PPS) is a valid and reliable tool that can assist therapists in the identification of changing patient care needs in response to disease fluctuations. It consists of five domains: ambulation, activity level, self-care, intake, and level of consciousness. While it is generally not likely that palliative patients will achieve or maintain independent status in these domains, therapists do have the opportunity to maximize patient performance and functional capabilities through compensatory techniques, patient education, and modification of a patient’s home or living environment (Cruz, 2013).
Due to the often-fluctuating nature of functional status in palliative patients, it is important that interventions focus on an ameliorative, as opposed to a curative, approach to functional limitations. Goals should ideally be realistic, meaningful, and patient-collaborative and should maximize the patient’s level of function and dignity (Cruz 2013).
Physical therapy interventions may include:
- Pain management
- Home safety evaluations/strategies
- Training and fitting in durable medical equipment (DME)
- Patient positioning
- Breathing techniques and energy conservation
- Transfer and gait training
- Balance training
- Transition discharge planning
Hospice care is intended for people who are nearing the end of life. The focus of hospice care is not to cure or treat the underlying disease but to provide the highest quality of life possible for whatever time remains. 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 services are provided by a team of healthcare professionals who create a holistic plan of care that addresses pain and comfort as well as physical, psychological, social, and spiritual needs of both the patient and the entire family. Many hospice programs 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 generally includes:
- Nurse, who usually serves as a case manager and coordinates care with other disciplines
- Physical therapist and/or occupational therapist
- Counselors, including psychologists and clergy
- Social worker
- Home health aides
- Trained volunteers
For patients and families who are investigating hospice care, helpful questions they may ask include the following:
- How is the hospice program certified?
- What services does the program offer to the patient as well as the family?
- What is the cost? Do benefits cover hospice care (Medicare and private insurance usually do)?
- What is the process of being accepted into the program?
- What is the setting (home or facility)?
Talking about hospice care is not easy, but it often helps to encourage patients and families to start the discussion early so that choices and initial decisions can be made before a crisis occurs. The fact is that many people enter hospice only in their last few days instead of their last months. Hospice care is designed to give patients the best quality of life during the time when they need it most.
ACCESSING HOSPICE CARE
Hospice is not just for people with cancer. Any patient who is diagnosed with a terminal illness is eligible for hospice care. In fact, many patients admitted to hospice have a non-cancer diagnosis, such as heart disease, kidney disease, emphysema, Alzheimer’s or other dementia, HIV/AIDS, and other degenerative conditions.
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 (HHS, 2013).
Cancer patients must agree to forgo active 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 most 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 make a small copayment)
- Short-term care in the hospital
- Short-term respite care (patients may need to make a small copayment)
- Home hospice aide and homemaker services
- Physical therapy
- 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
Source: HHS, 2013.
Robert is an 82-year-old man with advanced chronic obstructive pulmonary disease (COPD) and a history of congestive heart failure. Robert has been receiving care at home with a home agency coordinating nursing care and physical therapy services for the past six weeks. He is now deteriorating and no longer able to complete his originally established physical therapy program due to declining pulmonary function and decreased physical strength. He is homebound, dependent on steroids, and receives constant oxygen therapy. His primary caregiver is his wife, Diane, who is 80 years old and has osteoarthritis and is in need of a hip replacement. They also have two children who live close by, work full time, and visit weekly.
Because Robert’s condition has deteriorated, his primary care physician has indicated that he is now in the end stage of his illness, with a prognosis of six months or less. Robert has dyspnea at rest, bone pain, decreased functional ability, extreme fatigue, and cough. The home care nurse initiates a conversation with Robert and Diane about enrolling in hospice care in the home. They discuss the fact that hospice services are available and can provide Robert and Diane with coordinated care in the home environment. Robert and Diane agree that this is a good idea.
A hospice care team is assigned to Robert and includes his primary care provider along with an interdisciplinary team consisting of a nurse, home health assistant, and social worker. The nurse meets with Robert first to address physical needs, including pain management, comfort measures, and assistance with ADLs in the home. The home health assistant arrives daily to assist Robert with bathing and self-care. The social worker meets with Robert and Diane to address any resources that they may need as they plan for end of life, including an advance directive and DNAR order.
A few months later, as Robert’s condition declines, Diane is no longer able to manage his care in the home, and he is transferred to a hospice facility for the last weeks of his life. He receives round-the-clock symptom management and comfort care as well as support from the hospice chaplain. This allows Diane to be available emotionally as her husband experiences his last days. Robert dies peacefully and comfortably surrounded by his family three weeks later.
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. Although local VA medical centers have the flexibility to address end-of-life care according to veterans’ needs, national policy and standards stipulate 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
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 country can be a first step in establishing a relationship. Simply asking, “What branch of the service were you in?” may 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.
Caring for America’s aging population presents unique challenges to healthcare providers and the entire healthcare system. The health care needs of older adults 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. Knowledge, skills, and tools to assist in the assessment and management of the multiple aspects of caring for older adults are important considerations for the various healthcare provider roles.
As the healthcare system continues to change, self-care and prevention remain paramount in the health of older people. Nurses, rehabilitation therapists, and other healthcare providers have a critical role in educating patients and their caregivers about what they can do to improve or maintain their health and independence, to ameliorate 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.
Costs for Medicare Drug Coverage (medicare.gov)
Eldercare Locator (eldercare.gov)
Medicines in My Home (U.S. Food and Drug Administration)
National Center on Elder Abuse: State Resources
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