Moira Sugden PGDips Adult branch tutorialFeb 2012

*At the end of this session you should be able to:*Contextualise what ageing means to you, your

clients and for others as individuals or within our society*Look at a range of changes that occur to

individuals as they age*Identify mental health issues related to ageing *Assess the range of needs that older people

using health and social services may have*Analyse how to work with those with complex

need, how to prioritise and refer on.

*How do you feel about getting old?

*Those over 65 are 16% of population but account for almost 50% of health and social care expenditure*The ageing demographic is set to continue to grow in Britain*By 2050 it is estimated that there will three times the numbers of those over 85 that there are now*These “very old” 85) are particularly high users of acute hospitals and health and social services.*Audit Commission 2000

*How do individuals remain independent and active as they age?*How can health promotion and prevention

policies be strengthened especially related to older people.*As generally people in Britain are living longer

– how can quality of life be improved?*Might the numbers bankrupt the health and

social care systems?*How can we balance the role of the family and

state in caring for our elders?*How can we acknowledge and support the

major role that people play as they age in caring for others?*Philp 2007

*Physical

*Social

*Emotional

*Financial

*Cognitive

*As we age, we undergo a number of physiological changes, which affect not only how we look, but also how we function and respond to daily living. Overall, the changes in the later life span described below involve a general slowing down of all organ systems due to a gradual decline in cellular activity. It should be noted that individuals experience these changes differently - for some, the level of decline may be rapid and dramatic; for others, the changes are much less significant. The effects of these changes also differ widely. While approximately 85% of older adults experience chronic conditions, only about 20% experience significant impairment in their ability to function. For those with disabilities this process may occur more rapidly.

*“The rate of age-related decline in organ function varies greatly; thus, people become less alike as they age. Also, within any individual, the functions of different organs decline at different rates, so that kidney function may decline more quickly than heart or lung function.

*“ Usual aging refers to changes due to the combined effects of the aging process and of disease and adverse environmental and lifestyle factors.”

*Merck Manual of Geriatrics

*The sedentary lifestyle of many community dwelling older persons has led to erroneous conclusions regarding the impact of aging on cardiac functional reserve capacity (Merck)*Individuals who have decreased activity that is accompanied by weight gain are much more likely to experience cardiovascular problems than those who are able to remain active and mobile in their aging years. An example are persons with high level spinal cord injury who may not be able to feel the early warning signs of angina or other heart related pains.

*It is understood that Cardiac changes may impact more severely on those with learning disabilites

*People who are aging experience significant overall change by reduced blood flow to the body, which typically becomes serious in the eighth decade. This results from a number of factors including:*normal atrophy of the heart muscle,

especially in the left ventricle which pumps oxygenated blood out to the body *calcification of the heart valves *loss of elasticity in artery walls

(arteriosclerosis or "hardening of the arteries") *intra-artery deposits (atherosclerosis)

* The reduced blood flow results in less strength since:* less oxygen is being exchanged * reduced kidney and liver function * less cellular nourishment

*As a consequence, the individual is more vulnerable to:

* drug toxicity * has a slower rate of healing * a lower response to stress

*Other consequences of these cardiovascular changes are:

* hypertension with an increased risk of stroke * heart attack * congestive heart failure

*Aging affects not only the physiologic functions of the lungs (ventilation and gas exchange) but also the ability of the lungs to defend themselves*As with the cardiovascular system, there is

also a reduction in the efficiency of the respiratory system in later life. The airways and lung tissue become less elastic with reduced cilia activity, resulting in decreased oxygen uptake and exchange. *The muscles of the rib cage also atrophy,

further reducing the ability to:*breathe deeply *cough *expel carbon dioxide

*These changes worsen if the individual smokes or lives in a polluted environment. The result of these changes can include lower stamina with shortness of breath and fatigue, which in turn may impair one's ability to perform activities of daily living. Lack of oxygen can also increase anxiety.

“The endocrine and metabolic control systems offer many of the greatest opportunities for preventing disabilities associated with aging. Thyroid disease is common and often undiagnosed, but early detection and treatment can prevent unnecessary disability. Diabetes mellitus is extremely common, and normalizing blood glucose levels reduces its devastating vascular and neurologic complications...”

*A substantial reduction in renal function accompanies normal aging, although the senescent kidney ordinarily functions sufficiently to remove wastes and adequately regulate the volume and composition of extracellular fluid. Nevertheless, changes in renal function reduce the older person's capacity to respond to a variety of physiologic and pathologic stresses, with important clinical implications.”

*Maintaining a safe environment *Communication *Breathing *Eating and drinking *Elimination *Washing and dressing *Controlling temperature *Mobilisation *Working and playing *Expressing sexuality *Sleeping *Death and dying

*Underpinning concepts…..

*Removing Age discrimination

*Person Centred Care

*What do these mean?

1. Rooting out Age Discrimination2. Person Centred Care3. Intermediate Care4. General Hospital Care5. Stroke6. Falls 7. Mental Health in Older People8. The promotion of health and active

life9. Medicines management booklet

*Possible :

*Reduction of social network

*Limited ability to keep contact with range of friends and family

*Culture

*Perhaps living with family in cramped/noisy conditions

*Pets

*Vulnerability

*Poverty

*Pension reduced earning potential

*May be in large accommodation with little money to maintain it (hypothermia)

*Dealing with a range of losses, physical, social, financial, emotional

*bereavement

*Resolution issues

*Future?

*Cognitive impairment does not happen to everybody once they hit 65 but may be slowed/ crystallised

*Reduced ability to manage change.

*Confusion

*Anxiety

*Delirium

*Depression

*Dementia

*Substance misuse

*Suicide

*Psychosis

*There are several medical causes of confusion. One of the easiest ways to remember these causes is to use the mnemonic AEIOU TIPS: *A - alcohol *E - epilepsy or exposure (heat stroke,

hypothermia) *I - insulin (diabetic emergency) *O - overdose or oxygen deficiency *U - uremia (toxins due to kidney failure) *T - trauma (shock or head injury) *I - infection *P - psychosis or poisoning *S - stroke

*25% of older people in General Hospitals will have an episode during their stay.

*Most common post hip fracture

*Often fatal - 15 - 40%

*Acute Onset - over hours or days

*Fluctuation over time - within a day, day to day or day to night

*Reduced Attention - inability to focus, shift or maintain attention to external stimuli.

*Disorganised Thought - reduced comprehension, perplexity, rambling, irrelevant or incoherent speech.

*Altered Perception - misinterpretations, illusions and hallucinations.

*Altered Psychomotor Activity - hypo or hyper activity, shifting form one to the other, increased reaction time

*Altered Sleep/Wake Pattern - insomnia, sleep reversal, daytime drowsiness, disturbing dreams

*Disturbance of Emotion - anxiety, depression, euphoria, apathy, irritability, fear

*Altered Memory - reduced recall of recent events, reduced new learning

*Impaired Orientation - time and place

*8-15%

*Much more common in the presence of physical illness, especially stroke, parkinsons disease and dementia

*40% in long term care

*26% of carers

*25% of those receiving care at home* (study figures vary widely)

*Low mood or loss of interest must be present

*Four of these over a two week period: -

*appetite loss/gain

*significant unintentional weight loss/gain

* insomnia/hypersomnia

* loss of energy

*psychomotor retardation/agitation

* loss of sexual drive

* feelings of self reproach or guilt

* (suicidal ideation and/or intent)

* (delusions may be present)

*The prevalence and incidence of dementia increase with age - 5% of population over 65 rising to 20% at 80 and over

* Various causes of dementia 3 main types:

*Alzheimer’s disease 60%

*Vascular dementia 20%

*Lewy Body dementia 15%

*Down’s is a risk factor for AD

*The fact that Down’s is characterised by Trisomy 21, prompted genetic research into AD focussing on chromosone 21

*Not all Down’s patients get AD but they all have neurological changes similar to AD

*Special requirements: training and carer support for people with the dual diagnosis of AD and LD

* Alzheimer's disease is caused by the destruction of certain brain cells leading to the loss of the neurotransmitter acetylcholine. This alters the transmission of signals through the brain.

*Vascular dementia/ multi-infarct dementia, is caused by small blood vessels in the brain becoming blocked. These blockages prevent oxygen from reaching the nearby brain cells, leading to their death. It is like having many tiny strokes in the brain, causing a gradual decline in mental ability.

*Other dementias include Lewy body dementia, which is often found in people with Parkinson's disease, frontal lobe dementia (including Pick's disease), Creutzfeldt-Jakob disease, AIDS dementia and Huntington's disease.

*Dementia can also be caused by excess alcohol intake or syphilis. These types of dementia can be treated and in the early stages it may be possible for the dementia to be reversed. However, most types of dementia cannot be prevented or cured.

*Dementia is the global impairment of higher cortical functions, including memory, the capacity to solve problems of day to day living, the performance of learning perceptual-motor skills, the correct use of social skills and control emotional reactions n the absence of gross ‘clouding of consciousness’. The condition is often irreversible and progressive (WHO 1986)

*On your community caseload is Mrs Cohen, 82, type 2 diabetic, overweight with poorly healing leg ulcers.

*Today it has taken a while to persuade her to let you in and she appears suspicious of you.

*What might be going on here?

*Whilst dressing the wound she continues to look worried, answers monosylabically and refers to the “guards”

*Assess her needs as far as you are able and prioritise some objectives (using SMART) for handover to the DN and the class

*Mrs Ende has been admitted into A&E by ambulance from the nursing home that she has been resident at for some years. The report accompanying her states that she has become confused, aggressive and unmanageable over the last few days.*She smells of urine and something else you can’t yet identify

and says she wants a wee.*A) how can you assist her to the toilet whilst unsure of her

mobility and maintain her privacy and dignity?*Whilst assisting her you notice a deep sacral sore which is

offensive in smell and extremely painful when she knocks it.*B) What are your thoughts and actions in this situation both

immediate and long term?*With the limited information you have start to asses her

needs and prioritise and write objectives (using SMART) for handover to MAU and to discuss with the class

*Mr Xanthos, 78, is one of your patients on the rehabilitation unit recovering from a CVA. He owns several kebab shops and most of his family are involved in them, they do however, make great efforts to always have at least one member at each visiting time.*Physically Mr X appears to be recovering however he is resistant to taking part in his programme of rehabilitation. His communication is limited and often it is in Greek. He is not eating much even though his family bring in plenty of food.*Assess and prioritise his needs at this point in his rehabilitation. Plan objectives (using SMART).*How will you work with Mr Xanthos to encourage him to rehabilitate?

*Mr Murphy, 82, is one of your patients on the medical unit, he has long term COPD

*An ex- postman with a keen interest in gardening and a heavy smoker since he was in his teens, he has now managed to cut down to 5 a day. His mobility is limited due to his breathing difficulties.

*He is currently in with an acute exacerbation of his COPD and is receiving oxygen.

*On passing you notice Mr Murphy is clearly distressed, despite the oxygen he seems unable to catch his breath, he is struggling to remove the oxygen. You ask him what you can do for him but he is unable to answer.

*Later you find out that Mr Murphy has always had an anxious disposition but managed it with exercise and cigarettes.

*How might you work with Mr Murphy tp manage his COPD and his anxiety?

*Assess and prioritise his needs and write smart objectives for handover and to discuss with the class.

*You meet Mrs Janssen, 76, on her return from Orthopaedic surgery for fracture neck of femur. She has been recovering from the anaesthaetic and still has an IVI in situ. You have been told you can now offer sips of water and approach with Jug and cup, but on offering it to her, Mrs Janssen looks at you wildly, knocks it from your hand and appears to be trying to pull her drip out*A) what are you immediate actions?*The other patients are finding the disruption upsetting and

are asking what is happening, *B) what should you tell them?*C) What should happen about bed rails?*Assess Mrs Janssen’.s needs as you see them at this time

and prioritise some objectives using SMART for handover to the next shift and discussion with the class

*1. A sense of security – feeling safe*2. A sense of continuity – experiencing

links between the past the present and the future *3.A sense of belonging – having a ‘place’ *4.A sense of purpose –having a direction*5. A sense of fulfilment – feeling you’re

getting somewhere*6. A sense of significance –feeling you

matter*Davies et al 2001, Nolan et al. 2001

* DH 2001 National Service Framework for Older People’. The Stationary Office London

* DH 2001 Valuing People: A new strategy for learning disability for the 21st century planning with people towards person centred approaches- guidance for partnership boards. London: Department of Health

* DH 2001 Essence of Care: Patient-focused benchmarking for health care practitioners'

* DH 2005 ‘A New Ambition for Old Age: Next Steps in Implementing the National Service Framework’. The Stationary Office London

* DH 2005 The Long Term (Neurological) Conditions National Service Framework ’. The Stationary Office London

* Foundation for People with Learning Disablilties 2003 Good practice guidelines in supporting older family carers of people with learning disabilities www.learningdisabilities.org.uk

* King N 2004 New Provision for Older People with learning disabilities. Factsheet No 3. Housing Learning and Improvement Network. Health and Social Care Change Agent Team. DH London

* Philp I 2007. A recipe for Care- not a Single ingredient: Clinical case for change. Department of Health. London

* RCP 2006 Guidelines for the prevention, diagnosis and management of delirium in older people. Concise Guidance to Good practice Series no.6. London. Royal College of Physicians

* Reed J, Inglis P, Cook G, Clarke C, Cook M 2007 Specialist nurses for older people: implications from UK development sites. Journal of Advanced Nursing, 2007 May; 58( 4) : 368-76

* Snell J 2007 “Learning disabilities: elderly people face loss of independence “ Community Care www.communitycare.co.uk 4.10.08