Chronic Illness and Older Adults



Chronic Illness and Older Adults


Margaret Baker and Margaret McLean Heitkemper




Learning Outcomes



1. Describe the prevention and major causes of chronic illness.


2. Explain the characteristics of a chronic illness.


3. Define ageism.


4. Explain the needs of special populations of older adults.


5. Describe nursing interventions to assist older adults with chronic conditions.


6. Describe common problems of older adults related to hospitalization and acute illness and the nurse’s role in assisting them.


7. Differentiate among care alternatives to meet needs of older adults.


8. Describe the nurse’s role in health promotion, disease prevention, and managing the special needs of older adults.



Key Terms












Reviewed by Kathleen Blais, RN, EdD, Professor Emerita, Florida International University, College of Nursing and Health Sciences, Wilton Manors, Florida; Deborah Marks Conley, RN, MSN, APRN-CNS, GCNS-BC, FNGNA, Gerontological Clinical Nurse Specialist, Nebraska Methodist Hospital and Assistant Professor of Nursing, Nebraska Methodist College, Omaha, Nebraska; and Mary A. Cox, RN, MS, Professor, Nursing, Sinclair Community College, Dayton, Ohio.


This chapter discusses issues related to chronic illness and aging. The population of older adults is growing quickly and they often have increased health care needs and problems that you need to consider.



Chronic Illness


Illness can be categorized as either acute or chronic (Table 5-1). Today the U.S. health care system faces a growing burden of chronic illness as the population ages. Chronic diseases account for 70% of all deaths in the United States.1 Chronic illness results in limitations in physical functioning, work productivity, and quality of life for nearly 1 out of 10 Americans, or about 31 million people. Older adults often live with more than one chronic illness. A significant portion of U.S. health care dollars go toward the treatment of chronic illnesses.1 The management of a chronic illness can profoundly affect the lives and identities of the patient, family, and caregiver. Table 5-2 presents the impact of some chronic illnesses.






eTABLE 5-1


GERIATRIC DEPRESSION SCALE (SHORT FORM)










































































































































Instructions: Circle the answer that best describes how you felt over the past week.
 1. Are you basically satisfied with your life? Yes No
 2. Have you dropped many of your activities and interests? Yes No
 3. Do you feel that your life is empty? Yes No
 4. Do you often get bored? Yes No
 5. Are you in good spirits most of the time? Yes No
 6. Are you afraid that something bad is going to happen to you? Yes No
 7. Do you feel happy most of the time? Yes No
 8. Do you often feel helpless? Yes No
 9. Do you prefer to stay at home, rather than going out and doing things? Yes No
10. Do you feel that you have more problems with memory than most? Yes No
11. Do you think it is wonderful to be alive now? Yes No
12. Do you feel worthless the way you are now? Yes No
13. Do you feel full of energy? Yes No
14. Do you feel that your situation is hopeless? Yes No
15. Do you think that most people are better off than you are? Yes No
  Total Score _________________
GERIATRIC DEPRESSION SCALE (GDS) SCORING INSTRUCTIONS
Instructions:  
 1. Are you basically satisfied with your life? Yes No
 2. Have you dropped many of your activities and interests? Yes No
 3. Do you feel that your life is empty? Yes No
 4. Do you often get bored? Yes No
 5. Are you in good spirits most of the time? Yes No
 6. Are you afraid that something bad is going to happen to you? Yes No
 7. Do you feel happy most of the time? Yes No
 8. Do you often feel helpless? Yes No
 9. Do you prefer to stay at home, rather than going out and doing things? Yes No
10. Do you feel that you have more problems with memory than most? Yes No
11. Do you think it is wonderful to be alive now? Yes No
12. Do you feel worthless the way you are now? Yes No
13. Do you feel full of energy? Yes No
14. Do you feel that your situation is hopeless? Yes No
15. Do you think that most people are better off than you are? Yes No
Score 1 point for each bolded answer. A score of 5 or more suggests depression. Total Score _________________


image


From The use of rating depression series in the elderly, in Poon LW, editor: Handbook for clinical memory assessment of older adults, Washington, DC, 1986, American Psychological Association.


In addition to people living longer, other societal changes have contributed to the increase in chronic illnesses, including insufficient physical activity, lack of access to fresh fruits and vegetables, tobacco use, and alcohol consumption.1




Trajectory of Chronic Illness


Chronic illnesses may have acute exacerbations in which an individual moves from a level of optimum functioning, with the illness well controlled, to a period of instability during which the individual may need assistance. Corbin and Strauss proposed a view of chronic illness as a trajectory (Fig. 5-1) with overlapping phases2 (Table 5-3). This trajectory characterizes the common course of most chronic illnesses. In addition, Corbin and Strauss identified the seven tasks of those who are chronically ill2 (Table 5-4). These tasks are discussed in the following sections.




image
FIG. 5-1 The Chronic Illness Trajectory is a theoretical model of chronic illness. The trajectory model of chronic illness recognizes that chronic illness will have many phases (see Table 5-3).


Preventing and Managing a Crisis.

Most chronic illnesses have the potential for an acute exacerbation of symptoms, which may result in further disability or death. Examples include the patient with heart disease who has another myocardial infarction or the patient with asthma who has a severe attack. A major task for both the patient and the caregiver is to learn to prevent or manage the crisis. First, the patient and caregiver need to understand the potential for the crisis to occur. Second, they need to know ways to prevent or modify the threat. This often involves adherence to a prescribed medical regimen. Patients also need to know the signs and symptoms of the onset of a crisis. Depending on the chronic illness, signs and symptoms may occur suddenly (e.g., seizure in a patient with seizure disorder) or slowly (e.g., heart failure in a patient with untreated hypertension). It is important for the patient and caregiver to develop a plan to manage a crisis that is likely to occur.










Nursing Management Chronic Illness


Diagnosis and treatment of the acute phase or acute exacerbations of a chronic illness are sometimes done in a hospital. Other phases of a chronic illness are managed in an ambulatory care setting, at home, in an assisted living facility, or in a skilled nursing facility. The course of chronic illness is often unpredictable. The management of a chronic illness can profoundly affect the lives of the patient, caregiver, and family.


An assessment of health status includes an individual’s level of daily functioning and his or her perception of relative health or illness. This health assessment includes activities of daily living (ADLs), such as bathing, dressing, eating, toileting, and transfer. It also includes instrumental ADLs (IADLs), such as using a phone, shopping, preparing food, housekeeping, doing laundry, arranging transportation, taking medications, and handling finances.


Because the majority of chronic illnesses are treated in an ambulatory care setting, it is increasingly important for patients and caregivers to understand and manage their own health. The term self-management refers to the individual’s ability to manage his or her symptoms, treatment, physical and psychosocial consequences, and lifestyle changes in response to living with a long-term disorder.4


You play an important role in the management of individuals with chronic illness. This begins with planning care, teaching the patient and caregiver regarding the treatment plan, implementing strategies for symptom management, and assessing patient outcomes.


Family caregivers (e.g., spouses, adult children, partners) often have important roles in the life of the chronically ill person. The ideal situation is one in which family caregivers work together with the patient to manage the illness. This collaboration begins under the direction of the health care team at the time of diagnosis. When the caregiver is a spouse who is also older, he or she may have a chronic illness as well, which complicates the situation.5 The stresses and needs of family caregivers are discussed in Chapter 4 and Table 4-5.



Older Adults


Demographics of Aging


In the past three decades the older adult population (those 65 years of age and older) has grown twice as fast as the rest of the population. Almost 40 million people, or 13% of the population, are age 65 or older.6 Nearly one in five U.S. residents is expected to be 65 or older by 2030. The number of Americans age 85 or older is expected to more than triple, from 5.8 million to 19 million, between 2010 and 2050.6 This dramatic increase is in part due to aging of the Baby Boomers (those born between 1946 and 1964) who began to turn 65 in 2011.


Upcoming cohorts of older adults will be better educated than previous cohorts and have greater access to technology and resources. In the United States 13% of people over age 65 are people of color, including 8% African Americans; 3% Asian/Pacific Islanders; and less than 1% American Indians, Eskimos, and Aleuts. People of Hispanic/Latino ethnicity (who may be of any race) represent 7% of the older population.1 By 2030 the proportion of older adults who are people of color will increase 160% (Latinos 202%; African Americans 114%; American Indians, Eskimos, and Aleuts 145%; and Asian/Pacific Islanders 145%), while growth in the European-American population will increase by only 59%.6


Other factors add to the overall increase in the older population. Common diseases of the early to mid-twentieth century that killed many people before they reached older age, such as influenza and diarrhea, are now less common. Declining infant mortality, new drug therapies, mechanical devices, improved surgical interventions, health promotion, and earlier detection and treatment of diseases have contributed to the increase in life span.



Evidence-Based Practice


Translating Research Into Practice



What Is the Effectiveness of Chronic Illness Strategies for Asian/Pacific Islanders?








The U.S. Census Bureau predicts life expectancy to continue to increase for both men and women. Men and women born in 1950 who reach age 65 can expect, on average, another 12.8 and 15.8 years of life, respectively.1,7 Whether this gender difference is due to differences in health behaviors (e.g., smoking, alcohol use) or occupation is not known.8


The fastest-growing segment of older Americans is people ages 85 or older. Since the 1960s, this group has increased 250%. The terms young-old adult (65 to 74 years of age) and old-old adult (85 years of age and older) describe two groups of older adults with different characteristics and needs. The old-old adult is often a woman who is widowed, divorced, or single and dependent on family for support. Many have outlived children, spouses or partners, and siblings. Old-old adults are often characterized as hardy, elite survivors. Because old-old adults have lived so long, they may have become the family icon, the symbol of family tradition and legacy.


Nearly 6% of individuals age 65 to 74 and 25% of those 85 and older live in nursing homes.8 The frail older adult is usually over age 75 and has physical, cognitive, or mental dysfunctions that may interfere with independently performing ADLs.9 (Older frail adults are discussed later in this chapter.)



Attitudes Toward Aging


Who is old? The answer to this question often depends on the respondent’s age and attitude. It is important to understand that aging is normal and is not related to pathology or disease. Age is established by a date in time and is influenced by many factors, including emotional and physical health, developmental stage, socioeconomic status, culture, and ethnicity.10


As people age, they are exposed to new and different life experiences. The accumulation of these differences makes older adults more diverse than any other age-group. As you assess older adults, consider and value their diversity and life history. Also assess their own perceptions of what it means to be an older adult. Older adults with poor health report a higher perceived age and lower sense of well-being when compared with healthy older adults. The majority of older adults report having good-to-excellent health despite having a chronic illness. Age is important, but it may not be the most relevant factor in determining appropriate care of an individual older adult patient.


Myths and stereotypes about aging are often supported by media reports of older adults who are “problematic.” These commonly held misconceptions may lead to errors in assessment and unnecessary limitations or interventions. For example, if you think that all older people are rigid in their thinking, you may not present new ideas to a patient.11 Ageism is a negative attitude based on age. Ageism leads to discrimination and disparities in the care given to older adults. If you demonstrate negative attitudes, it may be because you fear your own aging process or you are not knowledgeable about aging and the health care needs of the older adult. Therefore it is important to gain knowledge about normal aging and have increased contact with older adults who are healthy and live independently. Also, it is your role as a nurse to dispel myths of aging.



Biologic Aging


From a biologic view, aging is defined as the progressive loss of function. The exact cause of biologic aging is unknown. Biologic aging is a multifactorial process involving genetics, diet, and environment.12 In part, biologic aging can be viewed as a balance of positive and negative factors (Fig. 5-2).


image
FIG. 5-2 The aging process can be viewed as a balance between negative and positive factors.

Research is directed at increasing both the average life span and the quality of life of older adults. The hope is that new antiaging therapies will be developed to slow down or reverse age-related changes that result in chronic illness and disability. Based on numerous laboratory studies in rodents, caloric restriction (reducing dietary intake by 25% to 50%) has been consistently shown to significantly extend the life span.13 It may be that caloric restriction results in changes in body composition, metabolism, and hormones that are conducive to long life. Caloric restriction in humans is associated with decreases in the incidence of obesity, diabetes, hypertension, and cancer, all of which are associated with aging.13,14


A number of nutrients have been tested for their potential benefits in reducing the impact of aging. Examples include β-carotene, selenium, vitamin C, and vitamin E. To date, research has failed to show that large doses of these supplements prevent chronic illness, such as heart disease or diabetes.15 However, much more research is needed before it is determined whether any of these substances will delay aging or enhance the functional ability of older adults.



Age-Related Physiologic Changes


Age-related changes affect every body system. These changes are normal and occur as people age. However, the age at which specific changes occur differs from person to person and within the same person. For instance, a person may have gray hair at age 45 but relatively unwrinkled skin at age 80. In your role as a nurse, assess for age-related changes. Table 5-6 presents a list of tables where specific age-related assessment findings can be found throughout the book.


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Nov 17, 2016 | Posted by in NURSING | Comments Off on Chronic Illness and Older Adults

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