Only one in six cases of elder abuse are reported, although nearly all states have enacted mandatory reporting laws and have services available to provide assistance (Halphen and Sadowsky, 2009). Although legal definitions vary from state to state, the NCEA defines neglect as “the refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Neglect may also occur if the person who has fiduciary responsibilities fails to pay for items or necessary home care services or, on the part of the in-home service provider, to provide the necessary care (NCEA, n.d., p 2). Older persons can make independent choices with which others may disagree. Their right to self-determination can be taken from them if they are declared incompetent. According to the Older Americans Act, financial exploitation is the “illegal or improper act or process of an individual, including a caregiver, using the resources of an older individual for monetary or personal benefit, profit or gain” (Area Agency on Aging, n.d., p 1).

During the assessment process, nurses will want to be aware of contradictions between injuries and the explanation of their cause, co-dependency issues between client and caregiver, and substance abuse by the caregiver. The local social services agency or area agency on aging can help with information on reporting requirements. Nurses can play a key role in reducing elder abuse.

The Patient Self-Determination Act of 1991 requires those providers receiving Medicare and Medicaid funds to give clients written information regarding their legal options for treatment choices if they become incapacitated. A routine discussion of advanced medical directives can help ease the difficult discussions faced by health care professionals, families, and clients (Emanuel, 2008). The nurse can help an individual complete a values’ history instrument. These instruments ask questions about specific wishes regarding different medical situations (Messinger-Rapport, Baum, and Smith, 2009). “Your Life Your Choices: Planning for Future Medical Decisions: How to Prepare a Personalized Living Will” (Pearlman et al, n.d.) is a valuable resource to help people by using scenarios and information to guide people through the process of developing advance medical directives. There are two parts to the advanced directives. The living will allows the client to express wishes regarding the use of medical treatments in the event of a terminal illness. A durable medical power of attorney is the legal way for the client to designate someone else to make health care decisions when he or she is unable to do so. A do-not-resuscitate order (DNR) is a specific order from a physician not to use cardiopulmonary resuscitation. State laws vary widely regarding the implementation of these tools, so it is important to consult a knowledgeable source for information. It is also important to involve the family, and especially the designated decision maker or agent, in these discussions so that everyone is clear about the client’s choices (Emanuel, 2008).

It is important to understand that the hosts (men and women) may respond differently to environmental factors. For example, Clougherty (2010) reports that women and girls are affected more than men and boys by air pollution. Both gender (a social construct) and sex (a biological construct) are factors that make identification of the impact of environmental hazards on men and women more complex. Social and environmental factors influence adults’ choices of health behaviors. Understanding how these factors impact health outcomes will require additional research and policy analysis (Angel and Angel, 2006; USDHHS, Healthy People 2020, 2010). Conducting gender analysis as part of research would help clarify if environment is influencing separate social and biological differences between men and women.

Governmental programs are in place to improve environmental health. The Centers for Disease Control and Prevention (CDC) Environmental Hazards and Effects Program (EHEP) is designed to prevent and control disease or death and to promote health and quality of life that result from interactions between people and their environments. The program uses indicators that can be used to assess and monitor progress on goals to improve the environmental health. It is incumbent on community health nurses to decrease the burden of disease resulting from an unhealthy environment (Levin P et al, 2008).

Life expectancy is a measure that is often used to gauge the overall health of a population. Although the United States spends more money per capita on health than any other country, other developed countries have a longer life expectancy for both genders. As illustrated in Figure 30-1, in the United States, life expectancy for men (75.2 years) ranked 25th out of 37 countries and territories and 23rd for women (80.4 years) (MMWR, 2008).

In 2007, both American men and women could expect to live longer than they did in 1990. Overall, American men gained 3.5 years of life and women could expect to live 1.6 years longer. Mortality from heart disease, stroke, and cancer has continued to decline in recent years and was substantially lower in 2006 than in 1950, decreasing overall by 46%. Specifically, the age-adjusted rates for heart disease declined by 66%, cerebrovascular disease by 75%, and the overall death rates for cancer declined 16% (NCHS, 2009). However, mortality from chronic respiratory disease and unintentional injury has not seen this decline (Miniño et al, 2009; NCHS, 2009).

Life expectancy and mortality rates also vary among ethnic/racial groups in the United States. The gap in life expectancy between white adults and African-American adults persists but has narrowed since 1990 (NCHS, 2009). The age-adjusted death rate was 1.3 times greater, infant mortality rate 2.4 times greater, and maternal mortality rate 3.4 times greater for the African-American population than for the white population. Life expectancy for the white population exceeded that for the African-American population by 5.0 years (Heron et al, 2009).

When healthy years of life are increased, longer life spans are generally considered desirable. However, increasing prevalence of chronic diseases and other conditions associated with aging can increase functional limitations and affect quality of life. Moreover, being male or female leads to different socialization, expectations, and lifestyles that affect and interact with health in very complex ways (Azad and Nashtar, 2005; Chandra and Minkovitz, 2006; Chang et al, 2006; Brittle and Bird, 2007).

Of particular concern is the high prevalence of adults with risk factors such as tobacco use, high cholesterol, obesity, and insufficient exercise habits, which are associated with chronic disease. Cholesterol levels have been dropping, in particular for

In 1988 the CDC created the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). Chronic illness has become a public health problem of great proportions. The most common and costly chronic diseases are heart disease, diabetes, stroke, cancer, and arthritis. Chronic disease is the leading cause of preventable deaths, disability, and decreased quality of life. The costs accounted for more than 75% of the nation’s $1.4 trillion medical care spending in 2007 (NCCDPHP, 2007). Many models have been developed to guide the delivery of care to people with chronic illness. A complex health care system and community model was developed with the funding of the Robert Wood Johnson Foundation. This model is Wagner’s Chronic Care Model (CCM).

The CCM identifies the essential elements of a health care system that encourages high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed clients who take an active part in their care and providers with resources and expertise (Model Elements, 2007). The CCM continues to be implemented and evaluated today. Using electronic health records, provider reminders for key evidence-based care components, interprofessional teams communicating regularly, and community health classes to educate people with chronic diseases are ways the CCM is being implemented.

Family remains an important source of support for people with chronic disease. A recent review of programs whose purpose was to increase effective family support showed that programs that train families in supportive communication techniques have improved both health behaviors and client symptom management (Rosland and Piette, 2010).

More than one in three, or an estimated 81.1 million, American adults have one or more types of cardiovascular disease (CVD). The leading cause of death for African Americans, American Indians or Alaska Natives, Hispanics, and whites in the United States is heart disease. It is the leading cause of death for both men and women. Heart disease was responsible for 26% of deaths in 2006 (Heron, 2007). In 2010 the cost of heart disease to the United States was estimated to be $316.4 billion (Lloyd-Jones et al, 2010). In response to the high incidence and mortality rates of heart disease, the American Heart Association (AHA) has the following goal: “By 2020, to improve the cardiovascular health of all Americans by 20 percent while reducing deaths from cardiovascular diseases and stroke by 20 percent” (AHA, 2010a).

Approximately 23 of the Healthy People 2020 objectives focus on cardiovascular disease. Reaching these objectives means intervening with all ethnicities in the United States. However, there continues to be gaps in knowledge and awareness for heart disease, particularly in women. In a 2009 survey of 2300 women age 25 or older, 60% of white women were aware that heart disease was the leading cause of death for women. However, only 43% of African-American women, 44% of Hispanic women, and 34% of Asian women knew the major cause of death for their gender. Knowledge of heart attack signs and symptoms have not increased since 1997 among all women surveyed, and only 53% of the women surveyed said they would call 911 if they thought they were having a heart attack (Mosca et al, 2010).

High blood pressure, or hypertension, is estimated to occur in one in three U.S. adults and, because hypertension does not have symptoms, one third of these people do not know they have the disease. Uncontrolled hypertension leads to heart attack, stroke, kidney damage, and a host of other complications. Only 77.6% of people with hypertension are aware they have the disease. Hypertension is controlled in 44.1% of people with the disease, 67.9% are under current treatment, and 55.9% do not have it controlled (AHA, 2010b). Although these numbers are not optimal, blood pressure control improved significantly from 1999 to 2006; however, racial, ethnic, and socioeconomic differences have not shown significant improvement (McWilliams et al, 2009). Both men and women have racial and ethnic differences in hypertension. Of non-Hispanic white males, 34.3% have hypertension compared with 43% of African-American males and 25.9% of Mexican-American men. Of African-American females, 44.8% have hypertension while 31.6% of Mexican-American women and 31.1% of non-Hispanic white women have hypertension (AHA, 2010). In a study conducted in New York City, the single most important factor for lack of blood pressure control was lack of a routine place of medical care (Angell et al, 2008).

Pazoki et al (2007) conducted a study on an intervention that focused on increasing physical activity in women in a community-based healthy heart program. This study included 335 healthy women from 25 to 64 years old and showed that a community-based lifestyle modification program significantly increased time spent in either moderate or vigorous physical activity, significant decreases in systolic blood pressure, and a significant increase in post-test healthy heart knowledge over the control group.

Strokes have decreased in the United States since the 1950s. However, the estimated prevalence of stroke in 2006 was 6.4 million (about 2.5 million males and 3.9 million females). This has decreased from 7 million in 2002. African Americans have almost twice the risk of first-time strokes as whites. Mexican Americans also have an increased incidence of stroke over non-Hispanic whites. Stroke is responsible for about 1 in 18 deaths. Since women live longer than men and strokes increase with age, more women are likely to die from stroke than men. In 2011, 60.6% of the stroke deaths were women (AHA, 2011).

Healthy People 2020 retained Objective 12-7 from Healthy People 2010 to reduce stroke deaths to 48 in 100,000. Community-based programs and policy regarding stroke care from initial signs and symptoms to after treatment have been developed by the AHA (Jones et al, 2008). Collaboration between health care institutions, community leaders, emergency medical services, and support groups within the community is needed for programs to be effective. Nurses can direct efforts toward smoking, since the incidence of ischemic stroke is twice as high in smokers as in adults who do not smoke (AHA, 2010).

Diabetes is a serious public health challenge for the United States. Of the 23.6 million people with diabetes, 12 million, or 11.2% of all men 20 years and older, have diabetes. Of all U.S. women more than 20 years old, 11.5 million, or 10.2%, have diabetes (CDC, 2008). In the United States, diabetes is an epidemic with 1 in 12 to 13 adults reportedly having diabetes, costing the nation approximately $174 billion each year. It is also estimated that for every three people who have diabetes, there is another who does not know he or she has it. Age-adjusted diabetes was diagnosed in 6.6% of non-Hispanic, 7.5% of Asian Americans, 10.4% of Hispanics, and 11.8% of non-Hispanic African Americans (CDC, 2008). The many complications associated with diabetes include heart disease, stroke, hypertension, retinopathy, kidney disease, neuropathies, amputations, and dental disease (NIDDK, National Diabetes Information Clearinghouse, 2008).

At least 18 of the goals of Healthy People 2020 are related to diabetes. There is a tremendous need in the community to strive to limit the toll this disease takes on the person and the community. Social and economic factors related to health and well-being need to be addressed.

Primary prevention includes educating adults about nutrition and the risks of obesity, smoking, and physical inactivity. Community interventions addressing healthy eating, exercise, and weight reduction can also benefit adults at risk for diabetes. Secondary prevention includes screening for diabetes with finger-stick blood glucose tests or glucose tolerance tests. Screening is also accomplished by thorough history and physical examination. Tertiary prevention targets activities aimed to reduce the complications of the disease.

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