Illness and lack of sleep can also cause people to eat more than usual, and antidepressants can stimulate the appetite, cause water retention or slow metabolism. Joint pain, decreased mobility and activity intolerance can also contribute to an inactive lifestyle, and lead to overweight or obesity (Newman 2009). Obesity, in particular, creates a cycle of disadvantage for those who are trying to maintain a healthy lifestyle. Obesity in older age is often related to a decrease in energy expenditure, with hormonal changes causing an accumulation of fat, and metabolic changes that decrease a person’s ability to regulate appetite (Newman 2009). In addition, environmental and social factors include concerns about safe places to walk, a lack of recreational spaces, safety fears because of neighbourhood hazards, and the tendency to eat out or from vending machines, for those without someone to share mealtimes (Newman 2009). Being overweight or obese can exacerbate arthritis and osteoarthritis by increasing the load on knee and hip joints, causing deterioration of the cartilage. Arthritis is the most chronically disabling condition, particularly for those over age 75, but joint and mobility problems also affect those under age 75 (AIHW 2008). Although mobility in joints should be maintained by stretching and strengthening exercises, these may cause pain that often prevents older persons with even mild levels of joint deterioration from continuing to be active (Newman 2009).

Maintaining physical activity is one of the greatest challenges of ageing. Although joint pain and a lack of muscle strength can be a deterrent to regular exercise it is important to help maintain joint mobility. Combined with pain management techniques, regular exercise can help sustain quality of life throughout the older years. Strength training and Tai Chi are particularly effective for older persons to help with balance and muscle integrity. Strength and balance, together with safe home and environmental modifications, can help prevent falls, which are the most common cause of injuries in older adults (Comans et al 2009). Physical activity also provides social opportunities, whether through interactions at a gym or other facility, walking or cycling groups. Maintaining 30 minutes of exercise a day helps prevent physical deterioration and prevent lifestyle-related diseases in all adults. International studies have shown that this level of exercise has been responsible for reducing coronary artery disease, some cancers, type 2 diabetes, obesity, osteoporosis and injury from falls (Kolt et al 2009). Regular activity also improves quality of life and psychological function, reduces the risk of dementia, and facilitates independent living (Kolt et al 2009).

Most countries have introduced national guidelines for 30 minutes of exercise per day for all adults, including older people. Because older people are at risk of physical inactivity, New Zealand has also introduced the ‘Green Prescription’, which is an activity prescription provided by primary care providers, including nurses (Elley et al., 2003 and Kolt et al., 2009; NZ Ministry of Social Policy 2001; Sinclair & Hamlin 2007). Prescribing the exercise regime helps motivate a person to achieve the requisite level of activity by drawing attention to the benefits of exercise at the primary care visit, then intermittent telephone support by exercise professionals from the Regional Sports Trust. The program has already been deemed effective in terms of maintaining physical fitness, and it has proven cost effective (Dalziel et al., 2006, Elley et al., 2003, Elley et al., 2004 and Kerse et al., 2005). Researchers are now instituting a 12-month trial that will add a prescription for the over 65s, encouraging the participants to add a minimum level of steps to their daily exercise, measured through a pedometer-based study. Evaluation of the trial is expected to show even greater benefits for heart health, quality of life and functional status (Kolt et al 2009).

Many older people have mental health issues, the most common of which are Alzheimer’s disease and other forms of dementia. Dementia is a brain syndrome caused by abnormal accumulation of proteins around the neurons of the brain. These clump together, interfering with brain cell function and connections, eventually leading to cell death (Alzheimer’s Australia 2008). The disease results in an impaired level of arousal affecting at least three areas of mental activity. These can include language, memory, visuo-spatial skills, personality or emotional state, and cognitive functions such as planning, abstraction or judgement (Alzheimer’s Australia 2008; Flood & Buckwalter 2009). Memory loss tends to be the first sign of dementia, and this can cause enormous stress as the person tries unsuccessfully to retrieve something elusive from their memory (Alzheimer’s Australia 2008). For those with Alzheimer’s disease the memory loss is followed by language dysfunction and problems with spatial orientation (Alzheimer’s Australia 2008). Dementia can be caused by Alzheimer’s disease or other factors, such as vascular disease, HIV infection, neurological disease, chronic alcoholism or head trauma (Flood & Buckwalter 2009). Alzheimer’s disease often has no genetic cause but, like other dementias, it can be instigated by conditions that cause vascular damage, such as type 2 diabetes, hypertension, high cholesterol and smoking (Alzheimer’s Australia 2008).

Dementia is the most significant cause of disability at older ages, but it can also affect people under age 65 (Alzheimer’s Australia 2008). It is a progressive, incurable condition that is highly disabling as it affects activities of daily living and can lead to the need for long-term high-level care (Chang et al 2009). The condition is more prevalent in over 85s, with older females having higher rates because they tend to live longer than males. But with the increase in life expectancy for both women and men, it is an important population health issue (Nepal et al 2008). Even moderate dementia can cause severe impairments in judgement and the ability to function independently, which renders the condition a major cause of stress for both the person suffering and their carers. It is also a major expense for the health care system and for family members who absorb the expenses of caregiving, either in the home or when institutional care is required. Caregivers also have to deal with the challenges of mobility and communication difficulties that accompany dementia, especially when these cause difficult behaviours (Moniz-Cook et al 2008). Some people with dementia develop psychotic symptoms and aggressive behaviours. Often this is a response to being placed in an alienating environment, or because of the frustration of not being able to communicate their needs. Although anti-psychotic drugs are frequently prescribed to older adults with dementia, recent research suggests that the potential benefits of their use are outweighed by their adverse effects. Recommendations suggest that further research be undertaken into non-pharmacological methods of treating behavioural problems in dementia and that health professionals need to be up-skilled in managing the complexity, co-morbidity and severity of people with dementia (Banerjee 2009).

Other mental health issues affecting older people include anxiety and depression, which can be a cause or a consequence of loneliness or social isolation. Depression can also be caused by functional and sensory impairment, incontinence, loss of mobility and/or pain (Dening & Milne 2009). The depressed person typically shows persistent symptoms of being sad, anxious, loss of interest or feelings of guilt, worthlessness and hopelessness (Dahle & Ploeg 2008). The condition often impacts on physical health through disrupted eating and sleeping patterns, which cause malnutrition and decreased energy as well as difficulties in concentrating (Dahle & Ploeg 2008). Depression is an interesting phenomenon in older people, thought to arise from the cumulative effects of chronic stressors and negative life events, including both health- and non-health-related events. However, depression may also arise as a response to behaviour patterns established in earlier life stages that trigger stressors. This works like a feedback loop, in that stressors trigger depressive symptoms, which continue to elicit behaviours such as antagonistic interpersonal interactions that generate more stressors. Once this self-perpetuating loop is set in motion, it may endure for years, because of relatively stable personality and interaction patterns among older adults.

Coping strategies are an important concern for those dealing with the changes associated with ageing, or those helping others deal with these changes. Self-efficacy, believing in one’s ability to overcome difficulties, is crucial to positive coping. A sense of humour can reinforce self-efficacy, especially if social support is also available (Marziali et al 2008). Cultural considerations also play a part in coping with ageing. Some families may not encourage help-seeking because of a cultural value of self-sufficiency, while others may be more inclined to seek assistance early for any difficulties. Because of wide variation in family responses, it is important that nurses interacting with older persons and their families reinforce the need for ‘personhood’ and person-centred care, especially for those with dementia (Adams & Moyle 2007:159). Person-centred care places the emphasis on relationships rather than whatever medical condition might be present. This type of approach can help reframe caregiving in terms of empowerment, diversity and choice, rather than predetermined assumptions of a person’s needs, many of which are influenced by their environment (Price 2009). Trying to cope with depression is a pervasive challenge for those in long-term care (Dahle and Ploeg, 2008 and Dening and Milne, 2009). When a person moves into long-term care they often lose touch with friends and distant family members, who may have remained in touch while they lived at home. The sense of loss of all that is familiar can lead to a loss of control over a person’s life, and their sense of the future. This underlines the importance of place and the difficulties of displacement, especially for older persons who have lived in relatively stable environments throughout their lives.

People develop ways of adjusting to the challenges of their lives in a variety of ways. Some of these differ by gender, or other factors, but some differ according to the environmental or circumstantial aspects of their lives. ‘Place’ holds a pre-eminent position in the lives of many older adults, beyond the space where they live. The place or setting where people grow old usually has meaning for them, in that it shapes the intimate relations between people, and the broader processes of social relations that comprise society (Wiles 2005). As they go through the many transitions of ageing, their places, whether these are homes or institutional environments, are constantly being negotiated as a kind of personal geography. This includes where they live, how they move about and how they experience and understand their surroundings (Wiles 2005).

The most visible influence of place on health is in rural–urban comparisons. Ageing in the city has unique challenges. Independent-living older people with the financial means to be selective often gravitate to inner-city living, where services such as the medical practitioner, pharmacist, physiotherapist, grocer or newsagent are readily available. Safety and accessibility are the most important issues for these people, so the features they look for if they are choosing a neighbourhood are well-maintained footpaths, lighting, safe traffic conditions and shelter. Other independent-living people may wish to remain in their more suburban homes. Their environmental concerns may be focused on transportation, and ensuring there is someone to monitor their health and wellbeing, especially if they live alone.

Rural people have even greater needs for safety, access to services and health monitoring because of distance, and the sparse distribution of services. Few people are able to live alone throughout their entire older years in their home because of the isolation. Like people in urban areas, safety and access to services are paramount. Rural living also carries a higher risk for families caring for older people. This is related to a lack of transportation and assistance to move older family members when they need care, a lack of emergency or specialist services, or the type of supports for various disabilities that may be available in the cities or regional areas. In addition, carers usually have no access to respite services in rural or remote areas. Their burden is multiplied when they have to move older family members into residential aged care, which may be at a great distance from home (National Rural Health Alliance [NRHA] 2009).

Many older adults experience ‘displacements’ through multiple relocations; from their own home to the residence of a family member and sometimes back and forth between the homes of family members. They may also experience relocations between residential facilities, health care institutions and their usual residence. Each of these moves adds stress to older adults’ lives, especially if they have been forced by illness or family circumstances to leave a home in which they have spent a substantial portion of their lives. For some, the stress is exacerbated by the unpredictability of the move, either because of its location or duration, or because it signals that the family has become scattered, and there may be no one to take care of them. Relocation stress is influenced by several factors: the person’s characteristics prior to the move, their attitude towards moving, their preparation for the move, their physical and cognitive status and the extent to which they feel they have control over the move.

At some point, most people experience a loss of place in both the material and emotional sense. Some have an extended period of grieving, which can be a very intense personal experience. Besides losing the material comforts of their home, they may also be grieving for the symbolic meaning of their sanctuary, the place where they have established and sustained the family. Home is often a source of satisfaction in having provided a protective environment for loved ones. It is where possessions and personal touches mark significant family moments and memories. Dislocation from the family home because of financial peril causes extraordinary stress for some people, and brings with it concerns about becoming homeless, or dependent on institutionalised care. Some people also worry about losing their home if it will leave their children financially liable, or in difficult circumstances following their death.

The relationship of personal geographies to health and wellbeing has implications for both home and community care. Home care may violate a person’s sense of personal space by the intrusion of caregiving devices and external caregivers, or it may be readily accommodated and help define a person’s sense of place. These reactions are variable. Models of shared care involving one or more outsiders and someone in the family setting may be received differentially, depending on the older person’s connection with others, and how they choose to negotiate the relationships involved in both care and domestic living (Sebern 2005). The nurse–client relationship is often pre-eminent. Older people attending general practice or other primary health care (PHC) settings typically rely on nurses for advice and support for their self-management of chronic conditions. Nurses also provide the first line of support for caregivers, particularly in the context of home visiting. Home visiting nurses may be the most trusted health professional in an older person’s network of support because of their skill in bridging the gap between the formal and informal health care context. This requires a respectful attitude, diplomacy, and a commitment to working in partnership with the older person and/or family to identify strengths and needs in the home that will provide protection from harm, and promote health and wellbeing. Most nurses approach home visiting by tailoring their communication, assessment, health education and advocacy skills to individual needs and preferences.