Elder care
Dispelling common myths about aging
Here are some common misconceptions about aging and facts to help dispel them.
Myth: Most older people are senile or demented.
Senility is a vague term commonly used inappropriately to refer to disease-related dementias. Most people age 65 and older aren’t mentally disturbed or suffering from dementia. Significant, progressive, cognitive impairments are consequences of disease and affect less than 5% of people ages 65 to 74 and about 25% of people older than age 85.
Myth: Most older people feel miserable and depressed.
Studies of happiness, morale, and life satisfaction reveal that most older people are just as happy as they were when they were younger. According to the National Institutes of Health, only about 20% of the population age 65 and older suffer from some form of depression.
Myth: Older people can’t work as effectively as younger people.
Studies show that older workers produce more consistent output and have less job turnover, fewer accidents, and less absenteeism than younger workers.
Myth: Older people experience a decline in intellectual ability and can’t learn new skills.
Older adults are capable of learning new things, but the speed at which they process information is slower. Healthy older adults show no decline and sometimes show improvement in such cognitive skills as wisdom, judgment, creativity, and common sense. Most show a slight and gradual decline in other cognitive skills, such as abstraction, calculation, and verbal comprehension.
Myth: Most older people are sick and need help with daily activities.
In fact, 80% of older people are healthy enough to carry on their normal lifestyles. About 15% have chronic health conditions that interfere with their daily lives. Only 5% or less require maximum assistance with activities of daily living, either at home or in a care agency.
Myth: Older people are set in their ways and can’t change.
People tend to become more stable in their attitudes as they age, but they still adapt to many social changes and changes in lifestyle. In fact, older people may be required to change more frequently than they did when they were younger because of major events in their lives.
Understanding the older population
♦ People ages 65 and older need health care more often than people in any other age group.
♦ Older adults account for more than one-third of all hospital stays and over one-third of the country’s total personal health care expenditures.
♦ Because so much of the health care population is older, it’s important to understand some general concepts about this important group.
Societal attitudes and beliefs
♦ As a group, older adults in our society are stereotyped.
– Aging is a natural process, but the changes associated with it are rarely viewed as natural or positive.
– Health care professionals commonly describe such changes as “losses,” such as a loss of tissue elasticity or a decrease in blood flow.
– In general, society regards aging as a series of inevitable, negative events that a person must tolerate.
– In addition, health care professionals often mention age-related changes and disease conditions in the same breath.
♦ Some of the myths, misconceptions, and negative stereotypes about older people stem from cultural values and beliefs.
– A youth-oriented society values intelligence, strength, self-reliance, and
productivity — characteristics rarely attributed to older adults.
productivity — characteristics rarely attributed to older adults.
– Many people perceive older adults as senile, sick, and incapable of making worthwhile contributions to society.
– Portrayals of elderly people in movies, television, advertisements, and other media compound this sense.
♦ Such images perpetuate stereotypes and can reinforce negative ideas about aging.
♦ Health care workers aren’t immune to perpetuating these errors, and the quality of health care that older adults receive can be affected as well. (See Dispelling common myths about aging.)
♦ Stereotyping can influence the planning and implementation of care. For example, a nurse might regularly delay her response to an older patient’s call bell.
Age-related adjustments and transitions
♦ The aging process is accompanied by role changes and transitions. Some roles—spouse, employee—may be lost, while new roles—widow, volunteer —may arise.
♦ Such changes require role adjustment. Factors that influence role adjustment include age, sex, beliefs, attitudes, income, health, culture, and past experiences.
Role changes
♦ With aging, changes in the marital role may occur.
– After retirement, the division of labor and household management may change.
– One spouse may become the primary caregiver if the other becomes ill.
– If a spouse dies, social relations for the survivor may change.
♦ As a result, spouses may need to renegotiate household roles as well as leisure and social activities.
♦ Gradual erosion of the independentadult role is linked to the aging person’s growing need for assistance.
Retirement
♦ Retirement brings a major role change because it alters the way a person manages time and daily activities.
♦ Retirement alters identity, power, status, and friendships.
♦ The retiree may need to find new relationships and activities.
♦ Retirement may be viewed as the beginning of old age.
♦ A person’s income, health, and desire to retire predict satisfactory adjustment to retirement.
Multiple losses
♦ Aging comes with major physical, psychological, and sociologic losses as well as a reduced ability to adapt to and compensate for stressors.
♦ Loss of loved ones, income, and perhaps decent transportation and housing, added to multiple or chronic diseases and their resulting limitations, can increase the older adult’s sense of vulnerability and deplete coping resources.
♦ Older adults may lose a sense of control because of such factors as physical decline, status and role changes, negative cultural attitudes and mass media portrayals, and crime victimization.
Loneliness
♦ Any loss—such as death of a spouse, retirement, poor health, or inactivity —that creates a deficit in intimacy and interpersonal relationships can lead to loneliness.
♦ Loneliness can provoke or aggravate physical symptoms, sleep disturbances, and shortened survival.
♦ Older adults need caring, personal contact, as well as confidants in their own and other age groups.
♦ It takes a satisfying relationship with frequent contact to prevent loneliness. However, some older people choose to be alone.
Depression and suicide
♦ Depression increases in likelihood and intensity with age.
♦ Changes in neurotransmitters, multiple losses, and decreased internal and external resources contribute to its occurrence.
♦ Depression may include complaints of physical symptoms and sleep disturbance. It may also occur in early stages of dementia, making depression the most common psychiatric problem among older adults.
♦ Risk factors for depression include:
– a recent major loss
– feelings of rejection by or isolation from family or friends
– feelings of hopelessness
– absence of an identifiable role in life
– loss of a partner or sexual function
– disability.
♦ With depression comes an increased risk of suicide.
♦ The suicide rate for older men is seven times that for older women.
♦ Risk factors for suicide include:
– alcoholism
– bereavement (especially within 1 year after a loss)
– loss of health
– loss of role
– living alone
– children having married and moved away.
Fear of death
♦ While some older people avoid the topic, many older adults think and talk about death, and many have less fear of death than of dependency, pain, and loss of function and control.
♦ Fear of death may involve such concerns as separation from loved ones and questions about divine judgment and afterlife.
♦ However, fear of the process of dying, the ultimate loss of self, and the unknown may lead to denial.
♦ Denying death can keep a person from valuing life, and it can negate the positive developmental process of preparing for death.
Variables affecting data collection
♦ Data collection may take place in a variety of settings, including:
– an acute care facility
– a physician’s office
– the patient’s home
– a senior center
– an adult day care center
Age-related changes affecting mobility
The following major physical changes in five body systems affect the mobility of older people.
Musculoskeletal
♦ Changes in joint surfaces, ligaments, tendons, and connective tissues
♦ Decreased bone density (increases vulnerability for fractures)
♦ Decreased number and size of muscle fibers
♦ Atrophy of muscle tissue; replaced with fibrous tissue
Pulmonary
♦ Loss of elastic lung recoil
♦ Increased airway resistance
♦ Reduced vital capacity
♦ Decreased chest wall compliance
♦ Decreased gas exchange
Cardiovascular
♦ Increased blood pressure
♦ Decreased stroke volume
♦ Decreased cardiac reserve (ability to respond to stress)
Neurologic
♦ Reduced nerve conduction speed
♦ Decreased rate and magnitude of reflex response
♦ Decreased sensory activity
♦ Decreased myoneural transmission
♦ Decreased muscle contraction speed
♦ Increased postural sway (contributes to balance problems)
Skin
♦ Decreased subcutaneous adipose tissue
♦ Decreased elasticity of connective tissue
♦ Loss of sweat and sebaceous glands
Adapted with permission from Stone, J.T., et al. Clinical Gerontological Nursing, 2nd Ed., Philadelphia: Elsevier, Inc., 1998.
– a long-term care facility.
♦ The setting and the patient’s age don’t affect the specific methods used to collect data, but other factors may affect the overall atmosphere of trust, caring, and confidentiality, including these:
– the time needed for data collection
– the patient’s energy level
– the environment
– the patient’s consent
– language or communication deficits
– the patient’s attitude
– cultural factors
– the nurse’s attitude about aging.
Time and energy level
♦ Be sure to allow enough time for the examination.
♦ Older adults possess a wealth of information but may process information more slowly than a younger adult.
♦ The patient may need extra time, or even several shorter sessions, if such problems as fatigue or discomfort limit the amount of time he can participate meaningfully.
Deficits
♦ Sensory deficits, such as hearing and vision losses, are common in older people.
♦ Other impairments, such as musculoskeletal or neurologic deficits, may be present. (See Age-related changes affecting mobility.)
♦ All of these can significantly interfere with accurate data collection.
Language
♦ When talking with an older patient, tailor the language you use to that individual.
♦ Consider the patient’s educational level, culture, and other languages spoken.
The patient’s attitude
♦ Try to determine the patient’s attitude toward his body and health.
♦ An older person may have a distorted perception of his health problems, dwelling on them needlessly or dismissing them as normal signs of aging.
♦ He may ignore a serious problem because he doesn’t want his fears confirmed.
♦ If an older patient is seriously ill, the subjects of dying and death may come up during the health history interview.
– Listen carefully to what the patient says about dying, and ask about his religious affiliation and spiritual needs; many older people find comfort in their religious beliefs and practices.
– Ask the patient whether he has or wants help with an advance directive.
♦ The health history can serve as a life review for an older person by allowing him to recount his history in a purposeful, systematic manner.
The nurse’s attitude
♦ Communicating with an older adult may challenge you to confront your personal attitude about aging and older people.
♦ Any prejudices revealed will probably interfere with efforts to communicate because older people are especially sensitive to others’ reactions and can easily detect negative attitudes and impatience.
♦ You should examine your feelings and decide in advance how you’ll handle them.
Nutritional status
♦ In many ambulatory care settings, nutritional assessment consists mainly of obtaining a 24-hour dietary recall and comparing it to standard dietary guidelines. This obtains, at best, a cursory review of food intake over a limited time period.
♦ In the acute care setting, nutrition assessments are usually a part of the nurse’s admission assessment and are rather superficial, sometimes being limited to food preferences and allergies. The physician orders the diet, while daily food intake is documented on flow sheets and the dietitian is consulted as needed.
♦ Few data collection instruments are specific to older people.
– A nutritional component is included as part of the assessment and care screening Minimum Data Set for nursing home residents.
– The Nutrition Screening Initiative (NSI), a joint venture of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging, includes screening methods and interventions to prevent and remedy nutritional deficiencies specifically in older adults.
♦ The NSI is widely used in outpatient settings. This program begins with a self-administered questionnaire that highlights areas of known risk for nutritional deficiencies.
♦ Further screening explores the known risk areas using the mnemonic device DETERMINE:
– Disease
– Eating poorly
– Tooth loss or mouth pain
– Economic hardship
Preventing dehydration in older patients
To maintain adequate hydration, an older patient needs 1,000 to 3,000 ml of fluid daily. Less than 1,000 ml daily may lead to constipation, which can contribute to urinary incontinence. It may also result in more concentrated urine, which predisposes the patient to urinary tract infections. Follow these guidelines to make sure the patient is adequately hydrated.
Monitoring
♦ Monitor intake and output. Ensure an intake of at least 1,500 ml of oral fluids and urine output of 1,000 to 1,500 ml per 24 hours.
♦ Check skin turgor and mucous membranes.
♦ Monitor vital signs, especially pulse rate, respiratory rate, and blood pressure. An increase in pulse and respiratory rates with decreased blood pressure may indicate dehydration.
♦ Monitor laboratory test results, such as serum electrolyte, blood urea nitrogen, and creatinine levels; hematocrit; and urine and serum osmolarity. Check for signs of acidosis.
♦ Weigh the patient at the same time daily, using the same scale and with the patient wearing the same type of clothes.
♦ Auscultate bowel sounds for any increase in activity. Monitor stools for character: Hard stools may indicate dehydration; loose, watery stools indicate loss of water.
♦ Be aware of diagnostic tests that affect intake and output (for example, laxative or enema use, which cause fluid loss), and replace any lost fluids.
Providing fluids
♦ Provide fluids often throughout the day, for example, every hour and with a bedtime snack.
♦ Provide modified cups that the patient can handle; help those who have difficulty.
♦ Offer fluids other than water; find out the types of beverages the patient likes and the preferred temperatures (for example, ice cold or room-temperature drinks).
♦ Monitor coffee intake; coffee acts as a diuretic and may cause excessive fluid loss.
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