About 13% of the people in the United States are older than 65 years. Women live longer than men, although the exact reason for this difference is not known. The older population is expected to grow as more “baby boomers” approach late adulthood during this decade. Most patients on adult acute care units are older than 65 years; many of these patients are discharged for home health services. Over 90% of patients in long-term care (LTC) facilities are older than 65 years. Therefore nurses and other health care professionals need to know about the special needs of older adults to care for them in a variety of settings.

This chapter describes the major health issues associated with late adulthood in community and inpatient settings. The care of older adults (sometimes referred to as elders) with specific acute and chronic health problems is discussed as appropriate throughout this text. Nursing Focus on the Older Adult charts and Considerations for Older Adults headings highlight the most important information. A brief review of major physiologic changes of aging are listed in the Assessment chapter of each body system unit.

Overview

Late adulthood can be divided into four subgroups:

• 65 to 74 years of age: the young old

• 75 to 84 years of age: the middle old

• 85 to 99 years of age: the old old

• 100 years of age or older: the elite old

The fastest growing subgroup is the old old, sometimes referred to as the advanced older adult population. Members of this subgroup are sometimes referred to as the “frail elderly,” although a number of 85 to 95 year olds are very healthy and do not meet the criteria for being frail. Frailty is a clinical syndrome in which the older adult has unintentional weight loss, weakness and exhaustion, and slowed physical activity, including walking. Frail older adults are also at high risk for adverse outcomes (Rocchiccioli & Sanford, 2009).

The vast majority of older adults live in the community at home, in assisted-living facilities, or in retirement or independent living complexes. Men older than 65 years are less likely to live alone than women of that age. Of all older adults, 5% reside in LTC facilities (mostly nursing homes) and another 10% to 15% are ill but are cared for at home. Older adults from any setting usually experience one or more hospitalizations in their lifetime. About half of all older adults will be admitted at some time during their life for short-term stays in a skilled unit of a LTC facility, usually for rehabilitation or complex medical-surgical follow-up care.

Other institutions also have an increase in aging adults. For example, men older than 50 years are the fastest growing group of prisoners today. Like the rest of the older population, older prisoners have multiple chronic health problems. However, these problems are complicated by a history of alcohol and substance abuse and poor nutrition that require deliberate management strategies. Nurses who work in these settings need to develop expertise in care of older adults.

The number of homeless people older than 60 years is also growing. The inability to pay for housing and family/partner relationship problems are primary factors that contribute to this trend. Most homeless adults have one or more chronic health problems, including mental/behavioral health disorders. Chapter 4 discusses issues related to the homeless population in more detail.

Health Issues for Older Adults in Community-Based Settings

Health is a major concern for many older adults. Health status can affect the ability to perform ADLs and to participate in social roles. A failure to perform these activities may increase dependence on others and may have a negative effect on morale and life satisfaction. When older adults lose the ability to function independently, they often feel empty and worthless. Loss of autonomy is a painful event related to the physical and mental changes of aging.

Older adults may also experience a number of losses that can affect a sense of control over their lives, such as the death of a spouse and friends or the loss of social and work roles. Nurses need to support their self-esteem and feelings of independence by encouraging them to maintain as much control as possible over their lives, to participate in decision making, and to perform as many tasks as possible.

Like younger and middle-aged adults, older adults need to practice health promotion and illness prevention to maintain or achieve a high level of wellness. Teach them the importance of promoting wellness and strategies for meeting this outcome (Chart 3-1).

Chart 3-1

Patient and Family Education: Preparing for Self-Management

Lifestyles and Practices to Promote Wellness

Health-Protecting Behaviors

• Have yearly influenza vaccinations (after October 1).

• Obtain a pneumococcal vaccination. (A routine revaccination may be necessary.)

• Have a tetanus immunization, and get a booster every 10 years.

• Wear seat belts when you are in an automobile.

• Use alcohol in moderation or not at all.

• Avoid smoking; if you do smoke, do not smoke in bed.

• Install and maintain working smoke detectors and/or sprinklers.

• Create a hazard-free environment to prevent falls; eliminate hazards such as scatter rugs and waxed floors.

• Use medications, herbs, and nutritional supplements according to your health care provider’s prescription.

• Avoid over-the-counter medications unless your physician directs you to use them.

Health-Enhancing Behaviors

• Have a yearly physical examination; see your health care provider more often if health problems occur.

• Reduce dietary fat to not more than 30% of calories; saturated fat should provide less than 10% of your calories.

• Increase your dietary intake of complex carbohydrate and fiber-containing food to five or more servings of fruits and vegetables and six or more servings of grain products daily.

• Increase calcium intake to between 1000 and 1500 mg daily; take a vitamin D supplement every day if not exposed daily to sunlight.

• Allow at least 10 to 15 minutes of sun exposure two or three times weekly for vitamin D intake; avoid prolonged sun exposure.

• Exercise regularly three to five times a week.

• Manage stress through coping mechanisms that have been successful in the past.

• Get together with people in different settings to socialize.

• Reminisce about your life through reflective discussions or journaling.

Common health issues and problems that often affect older adults in the community include:

• Decreased nutrition and hydration

• Decreased mobility

• Stress and loss

• Accidents

• Drug use and misuse

• Mental health/behavioral health problems (including substance abuse)

• Elder neglect and abuse

Decreased Nutrition and Hydration

The minimum nutritional requirements of the human body remain consistent from youth through old age, with a few exceptions. Older adults need an increased dietary intake of calcium, vitamin D, vitamin C, and vitamin A because aging changes disrupt the ability to store, use, and absorb these substances. A sedentary lifestyle and reduced metabolic rate require a reduction in total caloric intake to maintain an ideal body weight. Malnutrition or nutrition-related problems can occur in older adults when these needs are not met.

Many physical aging changes influence nutritional status or the ability to consume needed nutrients. Diminished senses of taste and smell often result in a loss of desire for food. Older adults have less ability to taste sweet and salt than to taste bitter and sour. This aging change may result in an overuse of table sugar and salt to compensate. Some older adults consume numerous desserts and other sweet foods, which can cause them to become overweight or obese. Teach older adults how to balance their diets with healthy food selections. Remind them to substitute herbs and spices to season food and vary the textures of food substances to feel satisfied.

Tooth loss and poorly fitting dentures from inadequate dental care or calcium loss can also cause the older adult to avoid important nutritious foods. Unlike today, dental preventive programs were not readily available or stressed as being important when today’s older adults were younger. Older people with dentition problems eat soft, high-calorie foods such as ice cream and mashed potatoes, which lack roughage and fiber. Unless the person carefully chooses more nutritious soft foods, vitamin deficiencies, constipation, and other problems can result. The extensive use of prescribed and over-the-counter (OTC) drugs, including herbal supplements, may affect appetite, food tolerances, and food absorption and use.

Reduced income, chronic disease, fatigue, and decreased ability to perform ADLs are other factors that contribute to inadequate nutrition among older adults. “Fast food” is often inexpensive and requires no preparation. However, it is usually high in fat, carbohydrates, and calories but lacking in healthy nutrients. Older adults can become overweight or obese when they consume a diet high in fast food.

Other older adults may reduce their intake of food to near-starvation levels, even with the availability of programs such as food stamps, food banks, and Meals on Wheels. Many senior centers and homeless shelters offer meals, as well as group social activities. The lack of transportation, the necessity of traveling to obtain such services, and the inability to carry large or heavy groceries prevent some older adults from taking advantage of food programs. Others are too proud to accept free services.

Inadequate nutrition may also be related to loneliness. Older adults may respond to loneliness, depression, and boredom by not eating, which can lead to under-nutrition. Many who live alone lose the incentive to prepare or eat balanced diets, especially if they do not “feel well.” Men who live at home alone are especially at risk for not eating enough calories to maintain their weight. Other factors associated with under-eating include being hospitalized before starting home health care, having a primary care provider who is not a female family member, and having a low level of education (Volkert et al., 2010).

Today more baby boomers and older adults recognize that healthy diet and plenty of hydration improve health and help restore body tissues. As a result, the organic food industry is rapidly expanding as some individuals try to make the best possible food choices. Organic foods, though, are typically more expensive than non-organic foods, and some older adults cannot afford them. Organic foods are also not readily available in all parts of the country.

Nursing Safety Priority

Action Alert

Perform nutritional screening for older adults in the community who are at risk for inadequate nutrition—either under-nutrition or obesity. Ask the individual about unintentional weight loss or gain, eating habits, appetite, prescribed and over-the-counter drugs, and current health problems. Determine contributing factors for older adults who have or are at risk for poor nutrition, such as transportation issues or loneliness. Based on these data, develop and implement a plan of care in collaboration with appropriate members of the health care team. Chapter 63 describes nutritional assessment and management of nutrition problems in detail.

Some older adults are at risk for geriatric failure to thrive (GFTT)—a complex syndrome including under-nutrition, impaired physical functioning, depression, and cognitive impairment (Rocchiccioli & Sanford, 2009). However, drug therapy, chronic diseases, major losses, and poor socioeconomic status can cause these same health problems. Be sure to consider these factors when screening for GFTT. For those at risk for or who have GFTT, collaborate with the older adult and family to plan referral to his or her primary care provider for extensive evaluation. Early supportive intervention can help prevent advanced levels of deterioration.

People older than 65 years are also at risk for dehydration because they have less body water content than younger adults. In severe cases, they require emergency department visits or hospital stays.

Nursing Safety Priority

Action Alert

Older adults sometimes limit their fluid intake, especially in the evening, because of problems associated with mobility, prescribed diuretics, and urinary incontinence. Teach older adults that fluid restrictions make them susceptible to dehydration and electrolyte imbalances (especially sodium and potassium) that can cause serious illness or death.

Incontinence may actually increase because the urine becomes more concentrated and irritating to the bladder and urinary sphincter. Teach older adults the importance of drinking 6 to 8 glasses of water a day plus other fluids as desired. Remind them to avoid excessive caffeine and alcohol because they can cause dehydration. Chapter 13 discusses fluid and electrolyte imbalances in detail.

Decreased Mobility

Exercise and activity are important for older adults as a means of promoting and maintaining health (Fig. 3-1). Physical activity can help keep the body in shape and maintain an optimal level of functioning. Regular exercise has many benefits for older adults in community-based settings. The advantages of maintaining appropriate levels of physical activity include:

• Decreased risk for falls

• Increased muscle strength and balance

• Increased mobility

• Increased sleep

• Reduced or maintained weight

• Improved sense of well-being and self-esteem

• Decreased depression symptoms

• Improved longevity

• Reduced risks for diabetes, coronary artery disease, and dementia

A study by Weeks et al. (2008) found that past life experience, life transitions, and future health concerns affect the participation of older adults in physical activity. For example, women who worked outside the home and/or reared multiple children stated that they did not have the time or energy to exercise when they were young. Others thought that their current health status prevented them from engaging in exercise. Some older adults worried that increasing their activity level might increase their risk for hip fracture or arthritis.

Weeks et al. (2008) also found that when compared with seniors living independently, nursing home residents had a very low level of physical activity. The researchers suggested that nursing home staff members need to be trained in how to promote resident exercise at least twice a week. Nurses who work in nursing homes must collaborate with physical and occupational therapists to plan this training and implement a regular exercise program.

Assess older adults in any setting regarding their history of exercise and any health concerns they may have. For independent older adults, remind them to check with their health care provider to implement a supervised plan for regular physical activity. Teach all older adults about the value of physical activity.

For people who are homebound, focus on functional fitness, such as performing ADLs. For those who are not homebound, teach the importance of other types of exercise. Resistance exercise, for example, maintains muscle mass. Aerobic exercise, like walking, improves strength and endurance. One of the best exercises is walking at least 30 minutes, three to five times a week. The person may walk for 30 continuous minutes or walk 3 times a day for 10 minutes. During the winter, indoor shopping centers and other public places can be used. In addition, many senior centers and community centers offer exercise programs for older adults.

Swimming is also recommended but does not offer the weight-bearing advantage of walking. Weight bearing helps build bone, an especially important advantage for older women to prevent osteoporosis (see Chapter 53). Teach older adults who have been sedentary to start their exercise programs slowly and gradually increase the frequency and duration of activity over time, under the direction of their health care provider.

NCLEX Examination Challenge

Health Promotion and Maintenance

Which statement by an older adult regarding her diet indicates a need for further teaching by the nurse?

A “I need to eat more calories to help me keep warm this winter.”

B “I plan to eat more dairy foods like milk and yogurt every day.”

C “I’m going to have dinner with my friends more often.”

D “I plan to eat more raw fruits and whole grain foods every day.”

Stress and Loss

Stress can speed up the aging process over time, or it can lead to diseases that increase the rate of degeneration. It can also impair the reserve capacity of older adults and lessen their ability to respond and adapt to changes in their environment.

Although no period of the life cycle is free from stress, the later years can be a time of especially high risk. Frequent sources of stress for the older population include:

• Rapid environmental changes that require immediate reaction

• Changes in lifestyle resulting from retirement or physical incapacity

• Acute or chronic illness

• Loss of significant others

• Financial hardships

• Relocation

How people react to these stresses depends on their personal coping skills and support networks. The loss of roles experienced by older adults often limits the availability of external support networks. For instance, losses leave many older adults without friends for support and help. As a result, many must rely solely on their personal resources to maintain their mental health/behavioral health. A combination of poor physical health and social problems leaves older adults susceptible to stress overload, which can result in illness and premature death.

The ways in which people adapt to old age depend largely on the personality traits and coping strategies that have characterized them throughout their lives. Establishing and maintaining relationships with others throughout life is especially important to the older person’s happiness. Even more important than having friends is the nature of the friendships. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis.

Some older adults have chosen to return to work at least on a part-time basis to increase their income and socialize with other people. If an individual retired between the ages of 55 and 65 years and lives into his or her 80s, funds can deplete; additional income is needed to meet basic needs, including money for prescription drugs. Although U.S. government Medicare Part A pays for inpatient hospital care, older adults pay for Medicare Part B to reimburse for 80% of most outpatient services, Medicare Part D for prescription drugs, and often a private Medi-Gap insurance (like United or Blue Cross/Blue Shield) to cover the costs not paid for by Medicare. The premiums for these insurances are very expensive and still require that older adults pay out-of-pocket copayments for health care services and prescription drugs.

Fortunately, most older adults are relatively healthy and live in and own their own homes. Physical and/or mental health problems may force some to relocate to a retirement center or an assisted-living facility, although these facilities can be very expensive. Others move in with family members or apartment buildings funded and designated for seniors. Older adults usually have more difficulty adjusting to major change when compared with younger and middle-aged adults. Being admitted to a hospital or nursing home is a particularly traumatic experience. Older adults often suffer from relocation stress syndrome, also known as relocation trauma. Relocation stress syndrome is the physical and emotional distress that occurs after the person moves from one setting to another. Examples of physiologic behaviors are sleep disturbance and increased physical symptoms, such as GI distress. Examples of emotional manifestations are withdrawal, anxiety, anger, and depression. Chart 3-2 lists nursing interventions that may help decrease the effects of relocation.

Chart 3-2

Best Practice for Patient Safety & Quality Care

Minimizing the Effects of Relocation Stress in Older Adults

• Provide opportunities for the patient to assist in decision making.

• Carefully explain all procedures and routines to the patient before they occur.

• Ask the family or significant other to provide familiar or special keepsakes to keep at the patient’s bedside (e.g., family picture, favorite hairbrush).

• Reorient the patient frequently to his or her location.

• Ask the patient about his or her expectations during hospitalization or assisted-living or nursing home stay.

• Encourage the patient’s family and friends to visit often.

• Establish a trusting relationship with the patient as early as possible.

• Assess the patient’s usual lifestyle and daily activities, including food likes and dislikes and preferred time for bathing.

• Avoid unnecessary room changes.

• If possible, have a family member, significant other, staff member, or volunteer accompany the patient when leaving the unit for special procedures or therapies.

Family members and facility staff need to be aware that older adults need personal space in their new surroundings. Older adults need to participate in deciding how the space will be arranged and what they can keep in their new home to help offset potential feelings of powerlessness. Suggest that the patient or family bring in personal items, such as pictures of relatives and friends, favorite clothing, and valued knickknacks, to assist in making the new setting seem more familiar and comfortable. This same intervention can be carried out in a hospital setting.

Accidents

Accidents are very common among older adults; falls are the most common. Motor vehicle crashes increase as well because of physiologic changes of aging or chronic diseases like Alzheimer’s or arthritis.

Fall Prevention

Most accidents occur at home. Teach older adults about the need to be aware of safety precautions to prevent accidents, such as falls. Incapacitating accidents are a primary cause of decreased mobility and chronic pain in old age. Some people develop fallophobia (fear of falling) and avoid leaving their homes.

Home modifications may help prevent falls. Collaborate with family and significant others when recommending useful changes to prevent older adult injury. Safeguards such as handrails, slip-proof pads for rugs, and adequate lighting are essential in the home. Avoiding scatter rugs, slippery floors, and clutter is also important to prevent falls. Installing grab bars and using non-slip bathmats can help prevent falls in the bathroom. Raised toilet seats are also important. Remind older adults to avoid going out on days when steps are wet or icy and to ask for help when ambulating. To minimize sensory overload, advise the older adult to concentrate on one activity at a time.

Changes in vision, touch, and motor ability can create challenges for older adults in any environment. For example, presbyopia (farsightedness that worsens with aging) may make walking more difficult; the person is less aware of the location of each step. In addition, the older adult may have disorders that affect visual acuity, such as macular degeneration, cataracts, glaucoma, or diabetic retinopathy. Teach the person to look down at where he or she is walking and have frequent eye examinations to update glasses or contact lenses to improve vision. Drug therapy or surgery may be needed to correct glaucoma or cataracts.

A reduced sense of touch decreases the awareness of body orientation (e.g., whether the foot is squarely on the step). The decreased reaction time that commonly results from age-related changes in the neurologic system may also impair the ability to recognize or move from a dangerous setting. Chronic diseases can affect mobility and sensation in the older adult as well, such as peripheral neuropathy and arthritis. If needed, encourage the use of visual, hearing, or ambulatory assistive devices. High costs and a fear of appearing old sometimes prevent older adults from obtaining or using hearing aids, eyeglasses, walkers, or canes.

Once an older person has been identified as being at high risk for falls, choose interventions that help prevent falls and possible serious injury. For those in the community, tai chi exercise is very helpful to improve balance and functional mobility, as well as to decrease the fear of falling, especially among older women (Wooten, 2010). Tai chi is described in Chapter 2.

Driving Safety

Motor vehicle crashes are the most common cause of injury-related death in the young-old population, those between 65 and 74 years of age. Increased national concerns about this growing problem have prompted many states to require more frequent testing for older drivers. As one ages, reaction time and the ability to multitask decrease. Sleep disturbances, especially insomnia, are also common in older adults but are not part of normal aging. Some crashes occur because the person falls asleep while driving.

The older the person, the more likely he or she will have chronic diseases and the drugs needed to manage them. These health problems and treatments can contribute to motor vehicle crashes. For instance, drugs used for hypertension can cause orthostatic hypotension (low blood pressure when changing body position from a supine to sitting or standing position).

Physicians and other health care professionals play a major role in identifying driver safety issues. Yet, many are reluctant to intervene because older patients feel they will lose their independence if they cannot drive. They may also be angry and resistant to the idea of giving up perhaps their only means of transportation. As an alternative, health care professionals can recommend driving refresher courses and suggest that high-risk driving conditions, like wet roads, be avoided. Newer vehicles have some safety features to help older adults, such as large-print digital readouts for speed and other data. Chart 3-3 lists additional ways to improve older adult driver safety.

Chart 3-3

Best Practice for Patient Safety & Quality Care

Recommendations for Improving Older Driver Safety