Consequences of an ageing population

The increase in longevity is an indicator of success in health and social circumstances but the complex issues of an older population have to be faced by governments and planners. Economic consequences are relevant as this sector of the population is not, generally, economically active (Vincent 2003) and the issues of retirement and pension payments are significant for individuals and the wider society. Importantly for health care providers, there has been an increase in the prevalence of diseases that are, largely, associated with old age (Armour & Cairns 2002). These include cancer, heart disease and dementia. The likely impact on health and nursing services, and how this should be addressed, was recognised in the UK when the Royal Commission on Long Term Care (1999) reported to the UK government at the end of the last century. The increasing, but not inevitable, likelihood of developing particular diseases with age demands health service resources at the primary and secondary levels. It is the job of governments to introduce policies to address these facts and ensure older people have fair access to financial and health resources. It is the job, increasingly, of nurses and other members of the multidisciplinary team, to work with individual older people who have health needs. It is important that health care workers such as nurses, doctors, social workers and therapists work together to coordinate appropriate care of a high standard.

In one sense, older people are no different from other people nurses come into contact with in the course of their work, despite the negative images that are often used to portray older people in our society (Carrigan & Szmigin 2000). Like any patient, the older person requires sensitivity, tact and professionalism. In relation to the media and advertising, one could be mistaken for assuming that the best things in life are only available for younger people (Loretto et al 2000). Advertising of clothes, cars and cosmetics, albeit that many of these are designed to hide the signs of ageing, is conveyed as purely of interest to younger people. If the subject of an advertisement is not pensions and retirement issues, the target audience is almost exclusively younger people (Carrigan & Szmigin 2000). Nurses are part of society and it is understandable that they too may have negative images of older people. Such images will not be dispelled by propaganda on behalf of older people but by evidence and an understanding of the ageing process and the facts about ageing. Nurses should avoid, in particular, holding and conveying stereotypes. One popular stereotype, for instance, is that older people are either no longer interested in sex or are incapable of sexual relations. There is plenty of evidence to the contrary (Gott & Hinchliff 2003, Araujo et al 2004), but the stereotype persists (Box 34.1).

Changes in blood pressure control

In later life, the blood vessels are less adaptable because of structural alteration; this can lead to increased blood pressure. The heart and blood vessels become less responsive to adrenaline and noradrenaline, which means that the homeostatic mechanisms for maintaining blood pressure become less efficient (Herbert 2006). One tangible outcome of this is a tendency towards postural hypotension, whereby a sudden change in position from sitting to standing is less well tolerated and blood pressure remains low, leading to dizziness or even fainting due to cerebral insufficiency (Watson & Fawcett 2003). Another consequence of changes in the cardiovascular system, through a combination of arterial disease and raised blood pressure, is a greater tendency in older people to suffer from cerebrovascular accidents, more commonly known as stroke (Department of Health [DH] 2001a). Deterioration in the blood supply to the brain can also lead to more chronic cerebrovascular disease which may lead to ischaemic dementia (McKeith & Fairbairn 2001), transient ischaemic attacks, or a fully evolved stroke (see Ch. 9).

Changes in exercise tolerance

Along with changes in the cardiovascular system there are changes in the respiratory system such that it becomes less efficient at extracting oxygen from the blood (Herbert 2006). This is not usually a problem but it does lead to exercise intolerance. The older person may well be able to go about their normal level of activity as these systems have considerable reserve capacity but will, for instance, be less able to run to catch a bus than they were when they were younger.

Changes in muscles, bones and teeth

With age our muscles atrophy, tendons and ligaments become less flexible and the skeleton becomes weaker due to the fact that less bone material is laid down in the skeleton (Herbert 2006). This is particularly marked in postmenopausal women but some men may also suffer from osteoporosis (NIH Consensus Development Panel 2001). The combined effects of osteoporosis and thinning of the cartilaginous discs between the vertebrae lead to a more stooped posture and this, in conjunction with the atrophy of skeletal muscle and a loss of elasticity in the lungs, can contribute to the reduced efficiency of the respiratory system (Herbert 2006). Teeth also change in later life. They lose their enamel covering and become worn and more brittle (Clay 2000). Combined with receding gums and poor hygiene this can lead to decay and eventual tooth loss.

Changes in reaction to temperature

Older people take longer to acclimatise when they move between climates of extreme temperature (Schofield 2000). This is due to the fact that acclimatisation is achieved by changes in the levels of circulating thyroxine: levels of thyroxine increase in cold climates and decrease in warmer climates. With age, the pituitary–thyroid axis is less sensitive to these changes, leading to slower acclimatisation in older people (Schofield 2000).

Changes in resistance to infection

The changes in the immune system that occur with age are complex. The overall levels of immunoglobulins remain relatively stable with ageing but the composition of these immunoglobulins changes and more immature T cells are produced (Ferrini & Ferrini 2008). This may lead to decreased defences against infections and also to the phenomenon in some older people whereby they do not necessarily exhibit pyrexia when they have a bacterial or viral infection (Adams & Herbert 2006). Instead, the presence of an infection may only be noticed when it is quite advanced, when confusion and drowsiness may occur. In old age, the immune system may become less able to distinguish ‘self’ from ‘non-self’, leading to autoimmunity whereby the immune system begins to attack its own tissues. Type 2 diabetes is, for example, a disease with autoimmune components and is definitely associated with ageing. The immune system also plays a key role in keeping cancer cells under check via immune surveillance, which becomes less effective with age (Ferrini & Ferrini 2008).

Changes in sensory perception

Despite misconceptions, the nervous system remains relatively unchanged with ageing (Ferrini & Ferrini 2008) but there are changes that affect the way older people perceive and make sense of their surroundings. There is an inevitable decline in vision as we age and this is due to changes in the eye, rather than in the neural conduction system from the eye to the brain. With age it is common for the lens to become more opaque (Wolf 2004) and some older people suffer from cataracts which, if untreated, severely limit their vision (see Ch. 13). In the ear, the bones that transmit sound waves from the outer to the inner ear tend to become fused together, thereby reducing their ability to transmit sound, leading to reduced hearing – presbycusis (Herbert 2006). This does not mean that all older people are blind and deaf but this reduction in hearing and vision has to be taken into account when considering their care and support. Similarly, it is clear that older people can suffer from pain. Seers (2006) argues that older people may experience pain differently to younger people and it is important that they are encouraged to describe their pain so that it can be managed effectively.

Changes in thought processes

Older people are no less intelligent, no less able to remember and recall and no more stubborn than their younger counterparts. The facts are plain; other than in neurodegenerative conditions such as dementia, memory and intelligence remain relatively intact with age and the personality we are born with is usually the one we take into old age. There is some change in short-term memory with ageing (Ponto 2006) but this does not usually interfere with leading a normal life. Some older people do suffer from age-associated memory impairment (Ferrini & Ferrini 2008); however, it is unclear whether or not this is a precursor to dementia. Intelligence, measured using standard IQ tests, does not decline with age. There is some change in intelligence, with a decline in fluid intelligence (e.g. problem solving) and an increase in crystallised intelligence (the application of learning to new problems), but these changes do not have a significant impact on daily living (Ponto 2006).

Changes in emotional life

There are theories that relate to psychological and sociological changes in later life. Erikson et al’s classic study (1986) identified stages of ageing during which the ageing person either manages or fails to come to terms with their life in order to develop as a person. The ultimate stage during later life leads to the older person being at peace with life and reconciled to what they have, or have not, done and experienced. The activity theory of ageing and the disengagement theory of ageing (Ponto 2006) acknowledge psychosocial changes with ageing: the former that as people age they give up certain activities and take up others, and the latter, that as people age they give up activities and gradually withdraw from life and from society. Broadly speaking, these types of theories try to explain how people sustain themselves and grow whilst negotiating losses that may be incurred through ageing. Sometimes this relates to social or culturally determined losses such as retirement or the family position of grandparents, whilst other losses are brought on by individual circumstances such as illness and physical dependence. It can be argued that much of ageing depends on the ability to negotiate and transcend loss and grief and ultimately to face the end of one’s life (Box 34.2).

See website Critical thinking question 34.1

Key policies and frameworks

In 1998, with specific reference to the care for older people in acute wards in general hospitals, the Health Advisory Service [HAS] 2000 produced a pivotal report entitled Not Because They Are Old (HAS 2000). The HAS report can be described as ‘pivotal’ because it gave rise to two further influential reports: Caring for Older People: A Nursing Priority – Integrating Knowledge, Practice and Values (SNMAC 2001) and the National Service Framework for Older People (DH 2001a), which outlines UK government policy with regard to the care of older people. Not Because They Are Old catalogued the lamentable level of care that many older people experience in hospital. Amongst other things, the HAS 2000 report recommended the following:

As a response to the need for better education of nurses highlighted by the HAS (2000), in 2001 the Standing Nursing and Midwifery Advisory Committee (SNMAC) commissioned research into the care of older people, as it related to nurse education, and produced a report (SNMAC 2001). It was noted that older people comprise the majority of all patients in acute settings and that they and their carers were the least satisfied of all groups with the care they received. In particular the care for older people was deficient in the fundamental aspects of care, often failing to meet basic needs for food, fluid, rest, activity and elimination (SNMAC 2001). The National Service Framework for Older People produced by the UK Department of Health in 2001 (DH 2001a) provides a guide for care for older people and used the research findings to set standards in key areas:

Long-term conditions

The effects of long-term conditions have been identified as having significant impact on an older person’s life (DH 2001a). The common long-term conditions of old age include cancer, heart disease, diabetes, stroke and Alzheimer’s disease. As a disease progresses or the individual develops other concurrent illness, nurses and carers can support and care for the person and help them develop coping skills in order to adapt. The reasons why older people need nursing care are complex: they are often unrelated to a single medical diagnosis and more related to the poorly defined concept of frailty (Markle-Reid & Browne 2003). Frailty occurs not only as the result of one or more medical condition but also as a result of the difficult losses sometimes experienced in later life.

Nursing management and health promotion: working with older people

In this section important aspects of nursing care are discussed. The issues have been identified by the National Service Framework for Older People (DH 2001a) or subsequent reports and explore the complexity of care provision. It is not possible to cover all relevant topics so there is a list of resources at the end of the chapter where further information can be found.

Equity, dignity and care for older people

It is important that care offered to older people is equitable to the care given to younger people. This means that decisions about access to treatment and care should not be based on age and that it is not appropriate to restrict specific services to certain populations based on age criteria (DH 2001a). Diverse needs in relation to culture, ethnicity, religion, gender, sexuality and disability should be considered and respected in an older client group as in any other (Nursing and Midwifery Council [NMC] 2009). It is important to address issues that affect particular groups, for example health promotion material needs to recognise that black and Asian elders are at higher risk of diabetes. Services also need to be sensitive to people whose needs may be overlooked such as lesbian and gay residents in care homes.

Equitable care also means that the care services predominantly offered to older people should be of a similar quality to other services. A particular area of concern for older people themselves is that care offered to older people should sustain or promote dignity (DH 2006). The notion of dignity is complex and involves many overlapping concepts (Cass et al 2009). Dignified care should promote a person’s self-respect and usually involves giving respect. At the simplest level this can mean older people’s care environments have proper toilet facilities and that curtains are clean and of sufficient quality to provide privacy. At the more complex level it means developing a culture of care that respects the personal needs of individuals. This is sometimes called ‘person-centred care’ (DH 2001a). Developing person-centred care can be challenging when there are competing demands on the nurses’ and carers’ practical and emotional resources. It is important that nurses and carers receive meaningful and regular supervision so they can understand the emotional component of their work and provide practical care that prioritises the person in their care (Davenhill 2009).

Person- and relationship-centred care

In person-centred care, nurses and carers get to know the patient, client or resident in a more intimate way. It is still important to plan care to meet the clinical needs of the older person, but this is in the context of the whole person, including their life history (Ashburner et al 2004). By taking this approach, communication and care interactions are more likely to prioritise the older person’s needs rather than those of the care organisation. A criticism of person-centred care is that it ignores the fact that caring is a two-way process and that the needs of the carers play a significant role in how they can carry out their work. Nolan et al (2001) identified a relationship-centred care framework that acknowledges the needs of those delivering care (Table 34.1). This shifts the focus to the organisation of care rather than just the individuals providing it. Nolan et al (2001) suggest that where care delivery is of an optimal standard, the culture of an organisation provides a certain atmosphere or feeling. They suggest that the organisation should promote a sense of security, continuity, belonging, purpose, fulfilment and significance. Importantly, these senses should not only be felt by the older people being cared for, but also the staff working with them. Table 34.1 illustrates how the senses framework applies to older people and their carers.

Table 34.1 The senses framework

First published in Nolan et al (2001). Reproduced with permission of the authors.