chapter 9
Nursing Care of the Aging Adult
After studying this chapter, the student should be able to:
1 Differentiate between physiological and psychosocial theories of aging.
2 Describe the changes of aging on each body system, including how these normal changes differ from disease processes.
3 Identify important techniques for effective therapeutic communications with older adults.
4 Explain how nursing care and anticipatory teaching can positively affect older adults.
5 Discuss important factors to consider when administering medications to older adults.
6 List assessment techniques and adaptations appropriate for older adults.
7 Describe specific diseases that affect each body system and effective nursing care for older adults.
http://evolve.elsevier.com/Mosby/comprehensivePN
GOVERNMENT RESOURCES FOR THE OLDER ADULT
INCOME
A Social Security (Old-Age, Survivors, and Disability Insurance [OASDI]): a federal program first adopted in 1935
1. Funded by employee and employer payroll taxes
2. Entitlement is determined by U.S. Social Security Administration; benefits are granted in accordance with:
b. Lifetime earnings record; retirement age is steadily increasing.
c. Free earnings credits for active military service.
d. Whether the required number of work credits has been earned (work credits are measured in quarters).
3. There is a specific maximum benefit amount with cost-of-living protection against inflation.
4. Minimum retirement benefits begin at 62 years of age.
5. Railroad workers have a separate retirement system; workers who have fewer than 10 years of railroad service may transfer earnings to Social Security to be counted toward Social Security benefits.
6. Federal employees are covered under the Civil Service Retirement System, the Federal Employees Retirement System, and the Thrift Savings Plan.
7. Social Security benefits are reduced according to money earned over a stated maximum annual allowable income.
8. Social Security benefits are not reduced for full-time employees over the age of 70 years.
B Supplemental Security Income (SSI); established in 1972
HEALTH
A Medicare (Title XVIII of Social Security Act): established in 1965
1. Administered by the Centers for Medicare and Medicaid Services (CMS) (www.cms.gov), a branch of the U.S. Department of Health and Human Services
2. Designed to help people over 65 years of age, certain disabled people under 65 years of age who are eligible under Social Security, and people of any age with permanent kidney failure to meet medical care costs regardless of income
3. Claims handled by major insurance companies in each state (e.g., Travelers Insurance Company in New York)
4. Pays for only limited time in long-term care
5. Do not have to be retired to receive benefits
6. Financed by employer and employee payroll taxes and self-employment tax money
7. Everyone over 65 years of age who is entitled to Social Security benefits receives hospital insurance without paying premium charges.
8. Automatic hospital insurance is provided to disabled persons who have been entitled to Social Security disability benefits for 24 consecutive months.
9. Initial enrollment period begins 3 months before the month in which the individual will become 65 years of age and continues for 4 months after individual turns 65 years of age.
10. The annual enrollment period is January 1 through March 31.
11. Premiums generally increase if people do not apply when they are eligible.
12. The deductible is applied to each benefit period.
a. Part A is designed as hospital insurance that has certain exclusions.
b. Part B covers physician services and outpatient services.
c. Part D covers prescription drug costs.
d. If subscribing to part A, the person is automatically enrolled in part B unless it is declined.
e. Part A is free; there is a cost for Part B and Part D; premiums can be withheld from the Social Security benefit.
B Medicaid (Title XIX of Social Security Act); established in 1965
a. To cover specific expenses not provided for by Medicare
b. To reduce expenses of individuals who have exhausted their Medicare benefits
c. To defray medical expenses of persons who cannot afford Medicare premiums
2. Funded by federal and state contributions
4. Funds the majority of long-term care after Medicare and personal funds are depleted
a. Qualified Medicare Beneficiary (QMB) Program
(1) Annual income must be at or below the national poverty level; 12% of older adults fall below the poverty line.
(2) Functions similar to a Medigap policy
(3) State Medicaid program helps pay
(4) Pays Medicare Part B premium
(5) Pays Medicare Part A premiums for eligible older adults and disabled persons, Medicare deductible, and coinsurance fees
b. Specified Low-Income Medicare Beneficiary (SLMB)
a. Medicare supplement insurance
b. Regulated by state and federal law
d. Lifetime maximums established
f. Policies of choice may be purchased from any insurer providing Medigap policies in the state of residency for a 6-month period from date enrolled in Medicare Part B and for those age 65 years or older.
g. Plans pay all or most medical coinsurance amounts; some policies pay for Medicare deductibles.
h. Medicare Part D, effective January 1, 2006, is optional to assist with medication cost.
b. Supplements Medicare benefits
c. Sold by insurance companies and health maintenance organizations (HMOs)
d. Difference between Medicare Select and Medigap is that specific physicians and certain hospitals must be used for nonemergency care to qualify for full benefits.
e. Federally approved in all states
HOUSING
A U.S. Department of Housing and Urban Development
1. Rent Supplement Program: rent-subsidized apartments for older adults, disabled individuals, or low-income families
2. Provides home improvement loans
3. Provides mortgage insurance
B Older adult and handicapped housing (Housing Act of 1959)
1. Provides funding to private, nonprofit organizations for renovation or building of units for the older adult and handicapped
C National Housing Act (Housing and Urban Development Act, 1968): provides funding to private corporations for construction of low- and middle-income housing
D National Housing Act of 1952: provides funding to private, profit, or nonprofit groups for nursing home construction or renovation
LEGISLATION AFFECTING THE OLDER ADULT
A Social Security: established in 1935. Some legislators predict that benefits may soon be depleted. Timelines vary but, viability of Social Security is being closely monitored.
B Medicare and Medicaid programs: developed in 1965. Programs have been through many reforms.
C Older Americans Act: first initiated in 1987 and revised in 1992. It established standards for safeguarding the rights of the older adult.
D The Omnibus Budget Reconciliation Act (OBRA) of 1990: established to improve the lives of individuals residing in nursing homes. It attached stringent guidelines for the use of physical and chemical restraints and established education and training guidelines for the staffs of long-term care facilities.
E The Patient Self-Determination Act (PSDA): established in 1991. It was developed in an effort to allow individuals to control end-of-life care.
1. Living wills: completed while the individual is well and outlines what the individual may or may not want done if unable to make decisions regarding end-of-life care
2. Health care proxy: The individual designates a person to make end-of-life care decisions for him or her should he or she become incapacitated.
NURSING ROLES AND THE CARE OF THE OLDER ADULT
A Care provider: Nurses are in the unique position to meet the health care needs of the older adult.
1. Nursing goals focus on positive outcomes to assist the older adult in attaining and maintaining an optimal state of health.
2. Nursing care focuses on prevention of acute and chronic health problems, promotion of a healthy lifestyle, and management of the symptoms of chronic health problems.
1. Nurses educate the older adult concerning health promotion and maintenance of acute and chronic health problems.
2. Nurses increase public awareness of problems affecting the older adult.
1. Nurses must assess the older adult’s need for services.
2. Area agencies on aging are the best resource regarding services for older adults in the community.
1. Nurses act as patient advocates to ensure that the rights of the older adult are preserved with regard to health care practices, treatment modalities, and end-of-life care.
2. The American Nurses Association’s Council on Gerontological Nursing has established Nursing Standards of Gerontological Practice.
3. Nurses recognize the older adult as a unique individual, shaped by life experience, family, society, religion, and culture (Box 9-1).
THEORIES OF AGING
SOCIOLOGICAL THEORIES
2. Mutual withdrawal from social interaction by older adult and society
3. Describes engagement as active occupation and devotion
4. Supports leisure as a form of activity
1. Remains active and interacts with society and its events
2. Pursues new interests, friends, and roles to substitute for lost roles
3. Supports social activity as beneficial to life satisfaction, morale, and mental health
1. Lifelong personality characteristics and coping strategies continue.
2. Sense of inferiority develops when continuity is disrupted.
D Passages: Life cycle changes can be identified, predicted, planned for, and managed.
BIOLOGICAL THEORIES
1. Stress and use deplete the body cells of repair ability. Aging results from accumulated stress and damage, not chronological age.
2. Coping mechanisms decline because of the decrease in available energy.
1. Collagen is the most abundant body protein.
2. Collagen molecules are held together by bonds.
3. Chemical reactions cause a switching of bonds between collagen molecules, resulting in structural changes characteristic of the aging process.
C Lipofuscin accumulation (one type of free radical)
1. Lipofuscin granules or age pigments are insoluble end products of cell metabolism.
2. Lipofuscins accumulate in the cell, altering the ability of the cell to function normally.
1. Aging is an autoimmune disease process.
2. Cells change, and the body does not recognize its own cells.
3. Autoimmune responses damage the cells, causing cell death.
E Cell death of genetic programming
1. Cell reproduction is programmed; “biological clock” is ticking.
2. Programming determines the rate and time at which a member of a given species ages and dies.
1. Molecules that have an extra electron are free radicals.
2. Free radicals attach to other molecules, altering function or structure, causing damage and aging.
3. Free radicals come from internal and external sources.
4. The belief is that the free radicals damage membrane function and structure. Antioxidants such as vitamins A, C, and E; carotenoids; selenium; and phytochemicals are thought to reduce free-radical activity.
PSYCHOLOGICAL THEORIES
A Freud: did not recommend psychoanalysis for the older adult population (see Chapter 6)
1. Eighth stage (65 to 100 years of age) identified as “integrity versus despair” (Table 9-1)
Table 9-1
Erikson’s Stages of Psychosocial Development in the Adult
From Morrison-Valfre M: Foundations of mental health care, ed 5, St Louis, 2013, Mosby.
2. The older adult who views his or her own life as having no meaning ends the stages of life in despair; the older adult who can review his or her accomplishments and errors derives a sense of integrity.
ROLE CHANGES
B Sufficient preparation and adequate support determine adjustment success or failure.
C Role changes that occur in the life of the older adult are predominantly crisis oriented, both sudden and gradual.
5. Friends who move away or die
6. Family members who relocate, assume new roles, have increasingly less time for relationships
7. Society’s assigned role of decreased psychological and physiological functioning
ALTERATIONS IN LIFESTYLE
EMPLOYMENT
A Society emphasizes the employed as valuable and the unemployed as useless.
B The number of older women working has increased.
C The number of older men working has decreased.
D Part-time employment is more common.
E The trend is toward early retirement, although much depends on the state of the economy at any given time.
F Serial careers are emerging in keeping with interest changes.
G More women are joining the work force at a time when men are winding down their working lives.
H The older worker possesses involuntary limitations.
I Older workers possess innumerable strengths.
RETIREMENT
A Mandatory retirement in federal employment has been eliminated.
B Mandatory retirement age may be 70 years of age in private employment, depending on occupation.
C Changes in the economy are leading to forced retirements.
D More people are taking advantage of early retirement because of incentives by companies to retire older workers either to replace them with younger workers or to simply decrease the overall size of the workforce. Pension plans are changing.
E Health problems are the primary reason for voluntary retirement.
G Tremendous anxiety may be created for some older adults.
H Some older adults derive an initial feeling of relief; however, for most it is a loss that comes at a time of meaningful productivity.
I Adjustment depends on previously established patterns of adjustment, degree of financial security, state of health, and future outlook.
J For many older adults, retirement creates an additional series of losses and problems at a time in life when coping and problem-solving abilities are fragile.
c. Creates discouragement, depression, and loneliness
d. Alters family relationships; may increase marital stress
e. May result in alcohol abuse from drinking as a reaction to a loss
L Welcome changes can result if retired adult remains socially engaged.
ECONOMIC CHANGES
A Most older adults live on fixed incomes.
B Of older adult persons, 1 out of 10 lives below the U.S. poverty level.
C Independence declines as costs increase and buying power decreases.
D For many older adults Social Security is the sole source of income.
E Many older adults are not receiving the assistance to which they are entitled.
F SSI: may qualify for this in addition to or instead of Social Security benefits
G Economic penalties: limit on the amount a Social Security beneficiary can earn annually without losing some monthly payments
H Income tax reforms (e.g., once-in-a-lifetime capital gains tax exemption on sale of personal residence for person over 55 years of age)
HOUSING
A Most older adults prefer to remain independent as long as family and friends live nearby.
B Most older adults live with spouse, alone, or with family.
C A large percentage of older adults continue to own their home and prefer this lifestyle because it provides:
4. Life care facilities: living, recreational, medical facilities on the premises
5. Nursing homes: Of individuals aged 65 to 85 years, 5% live in nursing homes. After the age of 85 years, 25% live in nursing homes. The typical nursing home resident is a woman over 80 years of age; the terms extended-care facility (ECF), skilled nursing facility (SNF), and long-term care facility (LTCF) may be used interchangeably with the term nursing home.
6. Assisted-living facilities are increasing to meet the needs of older adults with minor-to-moderate health care problems.
E Special assistance needs of older adults enable them to remain in their own homes longer.
