Persons with new chronic conditions often continue to work and perform their usual routine. Later, and with increasing age, the effects of the limitations caused by the condition become noticeable (Figure 15-1). The person may receive assistance and rehabilitation in the home or in a designated rehabilitation center when the disabilities are first significant or during exacerbations in the limitations. As the limitations increase further, the person at home may move to the home of another and receive informal help or into an institutional setting where formal help is available.

FIGURE 15-1 Percentage of Medicare enrollees age 65 and over who are unable to perform certain physical functions, by sex, 1991 and 2007. (Redrawn from Federal Interagency Forum on Aging-Related Statistics: *Older Americans 2010: Key indicators of well-being*, Washington DC, 2010, U.S. Government Printing Office.)

The most common chronic condition in persons over 65 is hypertension, followed by arthritis (Figure 15-2). Yet for the older adult, the presence or absence of a condition is not as important as its affect on function. The effect may be as little as an inconvenience or as great as an impairment of one’s ability to live independently (Figure 15-3).

FIGURE 15-2 Chronic health conditions among the population age 65 and over, by sex, 2007-2008. (Redrawn from Federal Interagency Forum on Aging-Related Statistics: *Older Americans 2010: Key indicators of well-being*, Washington DC, 2010, U.S. Government Printing Office.)

Working with those with chronic health conditions means that the gerontological nurse has the opportunity to decrease mortality of older adults and minimize the potentially disabling effects of chronic disease, that is, to be instrumental in decreasing morbidity. This chapter provides a snapshot of the most common chronic conditions the nurse will see in persons who depend on him or her for care and proposes strategies to promote healthy living regardless of the limitations with which one lives. We neither cover all possible conditions nor do we provide comprehensive medical management of these disorders. However, certain disorders are encountered frequently enough in late life to merit special attention. These include specific medical diagnoses and conditions in body systems. Other conditions such as those of the eyes and skin are addressed in Chapters 6 and 11.

It is anticipated that this chapter will enable the nurse to develop and implement strategies to promote healthy aging in the presence of the chronic disease.

Theoretical Frameworks for Chronic Disease

Chronic Illness Trajectory

While there are many conceptual models from which chronic illness can be viewed, the trajectory model originally conceptualized by Anselm Strauss and Barney Glaser (1975) and later Corbin and Strauss (1992) has long aided health care providers to understand the realities of chronic illness and its effect on individuals. According to this theoretical approach, chronic illness can be viewed from a life course perspective or along a trajectory trace. In this way, the course of a person’s illness can be viewed as an integral part of their lives rather than an isolated event. The nurse’s response is then holistic rather than isolated. Woog (1992) divided Glaser and Strauss’ model into eight phases for the purpose of identifying goals and developing interventions. The trajectory may include a preventive phase (pretrajectory), a definitive phase (trajectory onset), a crisis phase, an acute phase, a stable phase, an unstable phase, a downward phase, and dying phase (Table 15-1). The shape and stability of the trajectory is influenced by the combined efforts, attitudes, and beliefs held by the elder, family members and significant others, and the involved health care providers. Key points of the model are based on the theoretical assumptions listed in Box 15-1.

BOX 15-1 Key Points in the Chronic Illness Trajectory Framework

• The majority of health problems in late life are chronic.

• Chronic illnesses may entail lifetime adaptations.

• Chronic illness and its management often profoundly affect the lives and identities of both the individual and the family members or significant others.

• The acute phase of management is designed to stabilize physiological processes and promote recovery.

• Other phases of management are designed primarily to maximize and extend the period of stability in the home with the help of family and by visits to and from health care providers and other members of the rehabilitation and restoration team as appropriate.

• A primary care nurse is often in the role of coordinator of the multiple resources that may be needed to promote quality of life along the trajectory.

• The nurse has multiple opportunities to promote the health of persons during the chronic phase.

TABLE 15-1

THE CHRONIC ILLNESS TRAJECTORY

PHASE	DEFINITION
1. Pre-trajectory	Before the illness course begins, the preventive phase, no signs or symptoms present
2. Trajectory onset	Signs and symptoms are present, includes diagnostic period
3. Crisis	Life-threatening situation; acute threat to self-identity
4. Acute	Active illness or complications that require hospitalization for management
5. Stable	Controlled illness course/symptoms
6. Unstable	Illness course/symptoms not controlled by regimen but not requiring or desiring hospitalization
7. Downward	Progressive decline in physical/mental status characterized by increasing disability/symptoms
8. Dying	Immediate weeks, days, hours preceding death
Examples of goals that nurses might establish include the following: 1. To assist a client in overcoming a plateau by increasing adherence to a regimen so that he or she might reach the highest level of functional ability possible within limits of the disability. 2. To assist a client in making the attitudinal and lifestyle changes that are needed to promote health and prevent disease. 3. To assist a client who is in a downward trajectory to be able to maintain sense of self and receive expert palliative care. 4. To assist with advance care planning to assure wishes are met. 5. To assist the client who is in an unstable phase to gain greater control over symptoms that are interfering with his or her ability to carry out everyday activities.

See Woog P: The chronic illness trajectory framework: the Corbin and Strauss nursing model, New York, 1992, Springer.

The person’s perceptions of both needs met and functional limitations are paramount to predicting movement along the illness trajectory (Corbin & Strauss, 1992). By using this approach, the gerontological nurse may have the biggest impact on promoting the health of the person with a chronic condition.

Cardiovascular Disease

In 2009 the National Heart, Lung and Blood Institute reported that as of 2006 17.6 million persons in the United States had some form of cardiovascular disease (CVD). It is the leading cause of death for all persons over 65 and living in the United States with the exception of Asian Americans, for whom it is second (National Heart, Lung and Blood Institute [NHLBI], 2010). It is also the primary diagnosis of persons admitted to long-term care facilities and acute care hospitals (Auerhahn, et al., 2007). The high rate of CVD in later life is caused from a combination of genetics, normal changes with aging, risk factors such as smoking, and environmental factors such as pollution and stress, and in some cases, discrimination and racism (Box 15-2). Treatment approaches, mortality, and morbidity are highly variable by ethnicity, gender, and socio-economic group.

BOX 15-2 Risk Factors for Cardiovascular Disease

• Age (>55 years for men; >65 years for women)

• Family history of premature CHD (<55 years for men; <65 years for women)

• Microalbuminuria or estimated GFR <60 mL/min

• Hypertension *

• Cigarette smoking

• Central obesity (BMI ≥30)*

• Physical inactivity

• Dyslipidemia *

• Diabetes, IGT, or IFG *

CHD, Coronary heart disease; GFR, glomerular filtration rate; BMI, body mass index; IGT, impaired glucose tolerance; IFG, impaired fasting glucose.

^*Components of metabolic syndrome.

Cardiovascular diseases derive from damage to the blood vessels or to the heart wall or from prolonged effects on either. Hypertension, coronary heart disease (CHD), and heart failure (HF) are reviewed in this section with an emphasis on health promotion. For a more detailed examination of these conditions, the reader is referred to gerontological nursing and geriatric medicine texts that are disease-based.

Hypertension

Hypertension (HTN) is the most common chronic cardiovascular disease encountered by the gerontological nurse. Both the definition of and the guidelines for treatment of HTN are provided by the Joint National Committee of the Detection, Evaluation, and Treatment of High Blood Pressure (JNC)*. According to JNC, HTN is diagnosed any time the diastolic blood pressure reading is 90 or higher or the systolic reading is 140 or higher on two separate occasions (JNC 7, 2003) (Table 15-2). However, the average of three readings is recommended for older adults due to age-related variability. Blood pressure, especially systolic blood pressure, increases with age, and an elevation of 140 mm Hg or more is a much more important risk indicator than a diastolic elevation in persons over age 50. Contrary to prior knowledge, it was found that the parameters for the diagnosis of HTN did not change with age (Box 15-3). The current blood pressure goal of all persons is less than 140/90 and equal to or less than 130/80 for persons with diabetes (JNC 7, 2003). The U.S. Prevention Task Force has recommend that persons with blood pressure readings of <120/80 be screened every two years and once a year for those with SBP of 120-139 or DBP 80-90 (U.S. Preventive Services Task Force [USPSTF], 2007a).

BOX 15-3

Key Points of the JNC 7

• For persons older than age 50, SBP is more important than DBP as a CVD risk factor.

• Starting at 115/75 mm Hg, CVD risk doubles with each increment of 20/10 mm Hg throughout the BP range.

• Persons who are normotensive at age 55 still have a 90% lifetime risk for developing HTN.

• Those with SBP 120-139 mm Hg or DBP 80-89 mm Hg should be considered prehypertensive and require health-promoting lifestyle modifications to prevent CVD.

• Thiazide-type diuretics should be the initial drug therapy either alone or combined with other drug classes unless compelling reasons are present.

• Certain high-risk conditions are compelling indications for other drug classes, e.g., diabetes.

• Most patients will require two or more antihypertensive drugs to achieve goal BP.

• If BP is >20/10 mm Hg above goal, initiate therapy with two agents; one usually should be a thiazide-type diuretic.

SBP, Systolic blood pressure; DBP, diastolic blood pressure; CVD, cardiovascular disease; BP, blood pressure; HTN, hypertension.

Adapted from JNC 7: USHHS Pub No 03-5233, 2003. Available at www.nhlbi.nih.gov. JNC 8 is expected to be published in Fall 2011.

TABLE 15-2

BLOOD PRESSURE CLASSIFICATION

CLASSIFICATION	BLOOD PRESSURE
Normal	<120 systolic and <80 diastolic
Prehypertension	120-139 systolic or 80-89 diastolic
Stage 1 HTN	140-159 systolic or 90-99 diastolic
Stage 2 HTN	>160 systolic or >100 diastolic

HTN, Hypertension.

All persons with hypertension should be screened for diabetes.

As of 2007, over 74 million Americans were thought to have HTN. The prevalence is highest among African Americans at all ages and lowest among Mexican Americans (NHLBI, 2010). Although the genetic predisposition cannot be controlled, many risk factors for both the disease and complications are modifiable (Box 15-4).

BOX 15-4 Modifiable Factors that Increase the Risk for Essential Hypertension

• Cigarette smoking, tobacco use or exposure

• Excessive alcohol intake

• Sedentary lifestyle

• Inadequate stress/anger management

• High-sodium diet

• High-fat diet

A common problem related to the measurement blood pressure disorders in the older adult is “white coat syndrome,” wherein the blood pressure readings in the office are higher than they would otherwise be. Management is also difficult due to the frequency of postural or orthostatic hypotension, and postprandial hypotension. As a result, it may be necessary to include ambulatory blood pressure monitoring and positional measurement in the diagnostic evaluation. The subsequent evaluation includes the determination of contributing factors and end-organ damage. Only when all of the information is available can a holistic plan of care be developed.

Promoting Healthy Aging; Implications for Gerontological Nursing: Hypertension

Both pharmacological and non-pharmacological interventions that promote a healthy lifestyle have been found to be effective in controlling HTN and minimizing the complications that can significantly interfere with quality of life. The universal use of thiazide-type diuretics (e.g. chlorothiazide) was recommended when the evidence was conclusive that this would improve both mortality and morbidity of persons with HTN. It is expected that in most cases more that one type of antihypertensive medications will be needed based on concurrent co-conditions, such as diabetes and race. Pharmacological guidelines, including adjustments by race, can be found in the JNC 7 report supported by the National Heart, Lung and Blood Institute (www.nhlbi.nih.gov).

By reducing or eliminating modifiable risk factors, hypertension can be controlled or prevented leading to healthier aging (Table 15-3). With few exceptions (e.g., late-stage dementia), maintaining blood pressure control is recommended regardless of the overall disease state. This means reducing the pulse pressure and keeping the blood pressure less than 140/90 mm Hg for otherwise healthy adults and less than 130/80 mm Hg for persons with diabetes.

TABLE 15-3

BENEFITS OF CONTROLLING BLOOD PRESSURE

	AVERAGE PERCENT REDUCTION IN RISK FOR NEW EVENTS
Stroke decreased	30%-40%
Myocardial infarction decreased	20%-25%
Heart failure decreased	50%

TABLE 15-5

COMPARISON OF ARTERIAL AND VENOUS INSUFFICIENCY OF THE LOWER EXTREMITIES

CHARACTERISTICS	ARTERIAL	VENOUS
Pain	Sudden onset with acute; gradual onset with chronic Exceedingly painful Claudication relieved by rest Rest pain relieved by dependency (with total occlusion, no position will give complete relief)	Deep muscle pain with acute deep vein thrombosis Relieved by elevation
Pulses	Absent or weak	Normal (unless arterial disease is also present)
Associated changes in leg and foot	Thin, shiny, dry skin Thickened toenails Absence of hair growth Temperature variations (cooler if no cellulitis is present) Elevational pallor Dependent rubor Atrophy or no change in limb size	Firm (“brawny”) edema Reddish brown discoloration with postphlebitic syndrome Evidence of healed ulcers Dilated and tortuous superficial veins Swollen limb Increased warmth and erythema with acute deep vein thrombosis
Ulcer location	Between toes or at tips of toes Over phalangeal heads On heels Over lateral malleolus or pretibial area over metatarsal heads, on side or sole of foot	Primarily the medial malleolus and the lower leg
Ulcer characteristics	Well-defined edges Black or necrotic tissue Deep, pale base Non-bleeding	Uneven edges Ruddy granulation tissue Superficial Bleeding

There is considerable evidence regarding the importance of diet. Healthy eating habits and weight loss have been found to irrefutably lower blood pressure (Table 15-4). Even modest reductions in sodium intake and weight may make a significant difference. A healthy diet includes control of cholesterol, sodium, and calories. It is now recommended that all persons limit their daily sodium intake to less than 2400 mg/day. Teaching people how to read food labels can be a first step. An evidence-based DASH diet is available from the National Heart, Lung and Blood Institute at www.nhlbi.nih.gov (see Chapter 14). When combined with the appropriate medications, the long-term complication of heart disease can be reduced (Box 15-5).

BOX 15-5 Minimizing the Risk for Heart Disease

Maintain:

Blood pressure ≤130/80

Total cholesterol <200

LDL <100

HDL >40

Triglycerides <150

LDL, Low-density lipoprotein; HDL, high-density lipoprotein.

TABLE 15-4

RELATIONSHIP BETWEEN LIFESTYLE CHANGE AND REDUCTION IN SYSTOLIC BLOOD PRESSURE

LIFESTYLE CHANGE	APPROXIMATE REDUCTION IN SBP
Weight reduction	Decrease of 5-20 mm Hg per 10-lb loss
Adopt the DASH diet	Decrease of 8-14 mm Hg
Lower sodium intake	Decrease of 2-8 mm Hg
Increase physical activity	Decrease of 4-9 mm Hg
ETOH in moderation	Decrease of 2-4 mm Hg

SBP, Systolic blood pressure; DASH, Dietary Approaches to Stop Hypertension; ETOH, alcohol.

Unfortunately, less is known about the appropriate management of hypertension for persons over age 85 or those who are medically fragile, such as many residing in long-term care settings or those with advanced dementia. A careful risk-benefit analysis should be done related to treatment effects, side effects, and both short-and-long term outcomes in such situations. For someone with a limited life expectancy, the significant side effects of some medications and limitations in food choices may result in an unnecessary decrease in quality of life.

Coronary Heart Disease

The beating heart, like other muscles, needs oxygen and nutrients to survive. Despite all the blood that passes through it, the muscle depends on the coronary arteries for oxygenation. While not an expected change of aging, the incidence of CHD rises significantly with age, most often as a result of prolonged hypertension. CHD includes both atherosclerotic coronary artery disease (CAD) and ischemic heart disease, conditions that either completely or partially obstruct the flow of oxygenated blood to the heart.

While 425,000 deaths in 2006 were attributed to CHD, the death rate has declined dramatically in the past 20 years. While this rate has declined for persons of all races, it remains highest among African Americans and lowest among Asian Americans (NHLBI, 2010) (Figure 15-4). The incidence in men exceeds the incidence in women until after menopause, at which time the rate in women accelerates. It has been found that 70% of persons over age 70 had ≥50% atherosclerotic obstruction in at least one coronary artery on autopsy (Auerhahn, et al., 2007).

FIGURE 15-4 Coronary death rates by ethnicity. Age adjusted to the 2000 standard population. Coronary heart disease: ICD-10 codes I11,I20-I25. (Data from National Vital Statistics System—Mortality [NVSS-M], NCHS, CDC. Redrawn from www.cdc.gov/nchs/hphome.htm. Focus area No. 12.)

Etiology

Narrowed or blocked arterial lumina probably result from a complicated interaction of processes that may begin before birth. The walls of the normally pliable artery thicken and stiffen with age as a result of cross-linking. There are changes in lipid, cholesterol, and phospholipid metabolism. Although many of these changes are associated with normal aging, the sequela can be life threatening when coupled with pathophysiological conditions, such as hypertension.

Blockage may be from atherosclerosis, referred to as hardening of the arteries caused by the accumulation of lipid-laden macrophages within the arterial wall and the formation of plaques (Figure 15-5). The plaques reduce the capacity for oxygenation of the surrounding tissue. With complete obstruction, ischemic pain and tissue necrosis occur, and death may follow. With only partial blockage, the pain may be intermittent and experienced as angina. In severe cases of complete blockage, the result is acute myocardial infarction (AMI) and tissue necrosis. Risk factors for an AMI are both intrinsic and extrinsic and therefore somewhat modifiable (Figure 15-6).