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Introduction to Gerontological Nursing

NURS 4100 Care of the Older Adult Spring 2014Joy Shepard, PhD(c), MSN, RN, CNE, BC

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Objectives

Explain different ways older adults are viewed in contemporary society

Describe major characteristics of today’s older population

Discuss projected demographic changes in future generations of older people and the implications for health care

Describe the nursing process in care of older adults Discuss standards, major roles, principles, and future

challenges for gerontological nurses

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"Old age is like everything else. To make a success of it you've got to start young."

Theodore Roosevelt

"Anyone who stops learning is old,

whether at twenty or eighty." Henry Ford

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Aging: A Natural Process… NOT a disease!

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Defining Old AgeChronological age – Exact age

from birthBiological age - Age determined by

physiology rather than chronologyFunctional age – Age in terms of

functional performance

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Activities of Daily Living (ADLs) Basic: Bathing (hygiene,

grooming) Dressing Eating Toileting Transferring

(mobility)

Instrumental: Light housework Preparing meals Taking medications Shopping for

groceries or clothes Using the telephone Managing money

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Characteristics of Aging Population “Typical” older person? Age 65 start of “old

age?” Energetic, vibrant,

influential, diverse Gerontology - identifies

common characteristics, problems, disease processes, & concerns

Nurse must consider individual differences & characteristics when planning & implementing care

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Gerontological Nursing

“The purpose of gerontological nursing is not to save lives, but to prevent untimely death and needless suffering. Both these goals include respect for human dignity – the preservation of personhood as long as life continues.”

-Doris Schwartz, 1989

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Definition of Terms Ageism - Prejudice, negative stereotyping based

solely on age Geriatrics - Branch of medicine that deals with

problems & diseases of old age, aging people Gerontology – Comprehensive, multidisciplinary study

of aging process & problems of older people with holistic focus, including biologic, sociologic, psychological, spiritual, & economic issues

Graying of America – Increased number older adults in US

Senescence - Process of aging within cells and organs accompanied by loss of organ function

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Definition of Terms Primary prevention – Activities directed

toward the protection from or avoidance of potential health risks

Secondary prevention – Activities designed for early diagnosis & treatment of disease or illness

Tertiary prevention – Activities designed to restore disabled individuals to their optimal level of functioning

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Gerontological Nursing: Specialty Area Nursing – caring for the vulnerable Gerontological nursing – newest &

youngest, most rapidly growing nursing specialty

‘Nursing’s forgotten… little understood specialty’

Challenging practice areas: complex In just 50 yrs…. foremost concern of health care

GerontologyGerontology: ComplexComplex FieldEncompassing ThreeThree Levels of Complexity

1. Normal aging changes

2. Chronic conditions associated with aging

3. Acute exacerbations of chronic conditions

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Development of Gerontological Nursing 1904: First article on care of the aged published in

the American Journal of Nursing 1914: Dr. I. L. Nascher—“Father of Geriatrics”—

first geriatric textbook 1935: Federal Old Age Insurance Law, or Social

Security 1950 – First geriatric nursing textbook 1962: First meeting of the ANA’s Conference

Group on Geriatric Nursing Practice

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Development of Gerontological Nursing 1965: formation of the Administration on Aging,

Older Americans Act, Medicare, & Medicaid 1966: Division of Geriatric Nursing—

gerontological nursing as a nursing specialty 1976 – Professional Standards for

Gerontological Nursing Practice (ANA) – Certification – geriatric nurses – 1st certification program by ANA

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Development of Gerontological Nursing Growth in the last few decades

– Increase in gerontological nursing texts– Increase in journal articles– Gerontological nursing education– Certification in gerontological nursing– Subspecialization– Hartford Institute for Geriatric Nursing

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Advanced Practice Nursing Roles Gerontological Clinical Nurse Specialist Gerontological Nurse Practitioner Preparation: unique principles, best practices

for older adult– Broad knowledge base– Capacity for independent practice – Leadership– Complex clinical problem-solving abilities

Programs Adult-Gerontology Nurse Practitioner

– ECU College of Nursing (Online) Adult-Gerontology Nurse Practitioner

– UNC-Chapel Hill School of Nursing Adult Gerontological Nurse Practitioner Concentration

– UNC-Greensboro School of Nursing Gerontological Nurse Practitioner

– Duke University School of Nursing Adult-Gerontology CNS & Adult-Gerontology Critical Care CNS

– Rush University (Online)

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In Great Demand… Challenges for the

future– Gerontological

nursing as a dynamic specialty

– Multitude of opportunities

– Development of new practice models

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Geriatric Patients… The Core Business of Health Care

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An Aging Population

Increased #’s older people, particularly “old-old” 41.4 million older adults in 2011 – 13.3% of the

population By 2030, adults 65 years, 20% of population 5.7 million 85+ population

– 2040: 14.1 million– 2050: 19 million

Source: A Profile of Older Americans http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf

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An Aging Population

As the aging population expands, it will affect all aspects of society (esp healthcare)

Currently 13.3% of U.S. population; consume disproportionate amount of healthcare resources

Aging-associated diseases – complications arising from senescense

2025: need an extra 260,000 full-time nurses to take care of aging population

Source: A Profile of Older Americans http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf

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Myths & Stereotypes of Aging

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Ageism Prejudice towards any

age group Defined as “the

prejudices and stereotypes that are applied to older people sheerly on the basis of their age….”

True or False???To be old is to be sick

?

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Myths & Stereotypes of Aging Many cultures: older people accorded respect American society is youth-driven

– Aging synonymous with death– Younger individuals – negative view of aging

process– Fear & lack of exposure to older individuals

contribute to ageism Older adults stereotyped: ill, bald, hard of

hearing, forgetful, rigid, grumpy, or boring

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Myths of Aging “You can’t teach an old dog new

tricks” “Dirty old man” Disease & disability are inevitable

part of aging Health promotion is wasted on

older people Elderly do not pull their own

weight Most people spend their last years

in nursing homes

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Myths of Aging Senility is a result of aging Incontinence is a result of

aging Older adults are no longer

interested in sexuality All elderly persons are

financially impoverished

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*Realities of Aging*

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Myths of Aging Lead to: Ageism Reduced healthcare services Segregation of elders from mainstream society Nurse recruitment difficulties Health professionals must be diligent in

avoiding age prejudice, as believing stereotypes can influence interactions between older adults & caregivers

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The Older Adult Population

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Subsets of the Older Adult Population Young-old: 65-74 yrs Middle-old: 75-84 yrs Old-old: 85-100 yrs Centenarians: 100+ yrs Diversity rather than

homogeneity

The Graying of the Population

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Number of Old and Old-Old

Distribution of the Projected Older Population by Age for the US: 2010 to 2050

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An Aging Population - Increased Life Expectancy Older adults currently 13% of U.S. population By 2030 – 20% of population Increasing life expectancy:

– 1900: 47.3 years– 1930: 59.7 years– 1965: 70.2 years– Present: 78.7 years (2010)– 2050: projected to be 82.6 yrshttp://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf

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First Wave of 76 Million Baby Boomers Started Turning 65 in 2011!

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Age Distribution of U.S. Population

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Factors Influencing Increased Life Expectancy Advancements in disease control & health

technology (esp. vaccines & antibiotics) Lower infant & child mortality rates Improved sanitation (clean water & sewage

disposal) Better living conditions

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Life Expectancy: Race and Gender Gap between women

& men (narrowing) Gap between Whites

& Blacks (narrowing)– Societal issues– Concern for nurses

Gender /Race

Whites Blacks Total

Females 81.3 78.0 81.1

Males 76.5 71.8 76.2

Total 79 75.1 78.7

http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf

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Marital Status & Living ArrangementsWomen more likely to be widowed,

living alone in old age More than half of women 65 are

widowedOlder men more likely to be married Potential for living alone increases with age

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Aging Women Women outlive men, outnumber

men 4 to 3– Feminization of later life

Women predominate at older ages, proportions increase with advancing age

– Health & socioeconomic problems of elderly = problems of elderly women

Study of gerontology – closely linked to study of women’s health

Potential problems:– Widowhood– Living alone– Poor

– Coping with loss of mate– Difficulty finding another

life companion– Lack of a caregiver– Financial problems

Gender Distribution of Elderly Americans, by Age Group, 2010

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Aging Men Shorter life expectancy,

die at younger age More likely to remarry if

widowed– Widows outnumber

widowers 5 to 1 Fewer financial problems

than women– More likely to have worked 30

years or longer, qualify for full Social Security benefits

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Marital Status of Older Adults

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Income of Older Adults 8.7% live below poverty level “Fixed” income “Asset rich and cash poor” – What does this

mean? Median net worth twice national average related

to home ownership Dependent on Social Security for more than half

of their income Women & minority groups poorer than white men

Geographic Distribution: Older Adults Greatest number

(percentage wise): Florida, Maine, West Virginia, Pennsylvania, Montana

Dramatic increases in past decade: Alaska, Nevada, Arizona, Idaho, Georgia

Lowest percentage: Alaska, Utah, Texas, Georgia, Colorado

North Carolina?50

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Illness in the Older Population

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Health Status of Older Adults:

Acute Conditions (p. 8)Relatively fewer acute illnesses (i.e.,

infections & parasites, colds, or influenza)Lower death rates from acute illnessesAfter an acute illness…

– Longer period of recovery – More complications

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Illness in the Older Population Chronic illness – major concern for older adult Chronic illnesses – cause disabilities, complicate

care, need skilled nursing care 80% – at least one chronic illness (i.e., heart

disease, diabetes, arthritis, or hypertension) Many elderly people with two or more chronic

illnesses (comorbid) Comorbidity: the presence of multiple chronic

conditions simultaneously Challenge: reach highest functional capacity

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Health Status of Older Adults:

Chronic ConditionsChronic Conditions Major problem: increases

with age Most have at least one

chronic disease; many have several (comorbidity)

Comorbidity: the presence of multiples chronic conditions simultaneously

Result: limitations in ADLs & IADLs

Leading cause: disability & death

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Leading Chronic Conditions (Box 1-3, p. 8)

1. Arthritis 2. Hypertension 3. Hearing impairments

4. Heart conditions 5. Visual impairments 6. Orthopedic

impairments

Question

The leading chronic condition associated with older adults is:

(A) Arthritis (B) Diabetes (C) Hearing impairments (D) Hypertension (E) Orthopedic impairments

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Question

Is the following statement true or false?

Chronic disorders most prevalent in the older adult population are ones that can have a significant impact on independence and the quality of life

CDC: Chronic Diseases are Leading Causes of Death & Disability in U.S.

*7 of 10 deaths each year are from chronic diseases

*1 of 2 adults (of all ages) at least 1 chronic illness

*Obesity: major health concern: 1 in 3 adults

*One-fourth of people with chronic conditions: At least one ADL limitation

*Arthritis: most common cause of disability: 19 million Americans report ADL limitationhttp://www.cdc.gov/chronicdisease/overview/index.htm#1

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Heart diseaseHeart disease Malignant neoplasms (cancer)Malignant neoplasms (cancer) Chronic lower respiratory dz (COPD)Chronic lower respiratory dz (COPD) Cerebrovascular dz (stroke)Cerebrovascular dz (stroke) Alzheimer’s diseaseAlzheimer’s disease Diabetes mellitusDiabetes mellitus Influenza/ pneumoniaInfluenza/ pneumonia Nephritis, nephrotic syndrome, nephrosis Accidents Septicemia

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Leading Causes of Death for Persons 65 Yrs of Age & Older (Table 1-3, p. 9)

http://www.cdc.gov/nchs/data/databriefs/db64.pdf

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Question

When planning a course about mortality rates for a group of elderly clients, emphasis should be given to which of these topics because it is the leading cause of death for ages over 65?– A. Heart disease– B. Cancer– C. Infectious diseases– D. Accidents

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Health Promotion & Disease Prevention

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Health Promotion Health promotion: “the science and art of helping people change

their lifestyle to move toward a state of optimal health" (American Journal of Health Promotion, 1986)

Multidimensional, enhances wellness, self-actualization & individual fulfillment (Pender, 2002)

Purpose:– Help older adults achieve a sense of well-being– Reduce premature mortality, enhance quality of life

The Health Continuum

Balance of physical, emotional, social, spiritual, and intellectual health

Healthy People 2020

Vision: A society in which all people live long, healthy livesA society in which all people live long, healthy lives Overarching Goals: Attain high quality, longer lives free of preventable disease,

disability, injury, and premature death Achieve health equity, eliminate disparities, and improve the

health of all groups Create social and physical environments that promote good

health for all Promote quality of life, healthy development and healthy

behaviors across all life stages

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Proposed Healthy People 2020 Goals for Older Adults Reduce the proportion of older adults who have moderate to

severe functional limitations. (Developmental) Reduce the proportion of unpaid caregivers of

older adults who report an unmet need for caregiver support services.

(Developmental) Increase the proportion of older adults with one or more chronic health conditions who report confidence in managing their conditions.

(Developmental) Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for long-term services and supports.

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Proposed Healthy People 2020 Goals for Older Adults Cont’d… Reduce the rate of pressure ulcer-related hospitalizations among

older adults. Increase the proportion of the health care workforce with geriatric

certification. Increase the number of States and Tribes that publicly report

elder maltreatment and neglect. Increase the proportion of older adults with reduced physical or

cognitive function who engage in light, moderate, or vigorous leisure-time physical activities.

Reduce the rate of emergency department visits due to falls among older adults.

Healthy People 2020: The Road Ahead

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70% Physical Decline due to Modifiable Risk FactorsInactivityPoor nutritionTobaccoAlcohol Lack of preventive care

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70% Physical Decline Modifiable Through

Physical activity Improved nutrition Smoking cessation Alcohol in moderation Prevention of injuries from

falls Improved use Medicare-

covered preventive services

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Question

Name modifiable risk factors for physical decline and illness in older adults…

Name non-modifiable risk factors for older adults…

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Health Promotion & Disease Prevention Chronic conditions develop

over time Older adults must be

alerted to means of preventing disease and reducing risks

Important components of health maintenance:– Knowledge of self-care– Participating in screening

tests

Nurses intervene using three levels of prevention– Primary– Secondary– Tertiary

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Health Promotion and Disease Prevention Nurses should be aggressive in health promotion efforts Older adults must be alerted to means of preventing

disease & reducing risks– Take advantage preventive health services– Make healthy lifestyle changes

Preventive care: most effective strategy to reduce risk of disability & chronic illness– HP 2020 goal: “Attain high quality, longer lives free of

preventable disease, disability, injury, and premature death”

Primary Prevention

In primary prevention, a disorder is actually prevented from developing…

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Primary Prevention – Health Promotion Behaviors Education: Patient, family, caregiver; health care provider

– Falls prevention– Pressure ulcer prevention

Immunizations– Influenza, pneumococcal, tetanus/diphtheria, hepatitis B

Maintain body weight ( 10% age-adjusted normal weight) Regular physical activity (as appropriate) Nutritional assessment & guidance

– Well-balanced diet Fiber, calcium, vitamin D

Avoidance of tobacco Alcohol in moderation

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Primary Prevention – Health Promotion Behaviors Eight hours of sleep a night Positive mental attitude

– Encourage family members to participate in positive life review with elderly client

At least one friend to trust & confide in Self-discipline to enjoy pleasant things in moderation Relaxing & pleasant activities to look forward to Limiting exposure or avoiding known carcinogens

Secondary Prevention

In secondary prevention, disease that has not yet become symptomatic is detected and treated early, thereby minimizing serious consequences…

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Secondary Prevention – Early Diagnosis, Prompt Treatment Important components of

health maintenance practices – Self-care, screening– Regular visits PCP– Reduce cholesterol– Monitor blood pressure

Appropriate diagnostic, screening tests:– Fecal occult blood test– Glaucoma screen (tonometry &

visual field testing)– Fasting glucose– Colonoscopy– Prostate exam: PSA & DRE– Mammogram– Pap test, pelvic– Bone mass screening

Tertiary Prevention

In tertiary prevention, an existing, usually chronic disease is managed to prevent complications or further damage. For example, tertiary prevention for people with diabetes focuses on tight control of blood sugar, excellent skin care, frequent examination of the feet, and frequent exercise to prevent heart and blood vessel disease…

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Tertiary Prevention – Restoration, Rehabilitation Manage clinical diseases (esp chronic diseases) to prevent

them from progressing– Aim: optimal functioning; avoid disability & complications

Rehabilitation (physical, occupational, speech, recreational therapy) – Short-term placement or– Aggressive in-home rehabilitation

Appropriate services/ aids to increase independence – Walkers, canes, homemaker/ home health aid, visiting nurse

Disaster relief – Safe housing, counseling, physical care

Question

Which of the following is an example of primary prevention?

A. Administering digoxin to treat heart failure B. Obtaining a smear for a screening test C. Using occupational therapy to help a patient

cope with arthritis D. Vaccinating an older adult during the flu

season

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Question

The gerontological nurse is teaching 86-year-old Patricia Smith and her family about exercise programs for the elderly. Which of the following statements about arthritis is an example of tertiary preventive care?– A. Exercise cures arthritis– B. Exercise can help control and manage the symptoms of

arthritis and prevent complications– C. Exercise is important for healthy joints and it also

strengthens the surrounding muscles– D. Exercise helps prevent arthritis from developing

Question

Which of the following describes secondary prevention?

A. aims to prevent disease from developing in the first place B. aims to detect and treat disease that has not yet become

symptomatic C. directed at those who already have symptomatic disease,

in an attempt to prevent further deterioration, recurrent symptoms and subsequent events

D. set of health activities that mitigate or avoid the consequences of unnecessary or excessive interventions in the health system

Question

As they get older, men are more likely to be screened for prostate cancer: 48% of men 50 to 59 years as compared to 56% of men 80 years and older. The nurse concludes that this is:

A. An example of ageism and negative stereotyping B. An illustration of the belief that primary prevention

strategies should be promoted in the older adult population C. A proper allocation of scarce health care resources D. A societal trend based on higher numbers of aging men

Question While Medicare pays for some medical screenings for older

Americans, nine of every ten adults over the age of 65 go without screenings, such as bone mass screenings, colorectal cancer screening, glaucoma screenings, mammograms, and pap tests and pelvic examinations. Findings show that primary care providers are less aggressive when recommending preventive measures to the elderly.

The nurse concludes that this is: A. An example of ageism B. An illustration of the belief that tertiary prevention strategies are

wasted on elders C. A proper allocation of scarce health care resources D. Correct, since there is no need for aggressive screening measures

within this age group

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Prolongation of Frailty vs Compression of Morbidity?

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Functional Assessment of the Older Adult

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Nursing Process and the Older Adult Assessment

– Health History– Physical Examination

Goal: Individualize & tailor assessments and interventions to each patient

Functional abilities should be a central focus of comprehensive assessment

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Assessment of Function

Three domainsThree domains: ADLs, IADLs, & mobility Systematic, focus on individual needs Two approaches: asking & observing Basis for care planning, goal setting, &

discharge planning Eligibility to obtain many services

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Assessment

Health History– Nurse draws facts and interpretations from

older client that will shed light on current health status and health concerns

– Eliciting data requires time & patience on the part of both the nurse and client

– Nurse may interview client & client’s support members

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AssessmentPhysical Examination

• Nurse must be knowledgeable about normal physical changes of aging in order to conduct physical examination

• Client may need assistance with disrobing or position changes

• Be alert to potential for injury

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Challenges in Health and Functioning Adjustment to a new body image Effect on body image and self-concept Self-concept and roles Acceptance of bodily changes Declining function resulting in illness and

disability Loss of independence

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Diagnoses Frequently Seen in the Older Adult Impaired Physical Mobility Activity Intolerance Risk for Injury, Falls Risk for Infection Self-Care Deficits Social Isolation Risk for Loneliness Acute, Chronic Confusion

Imbalanced Nutrition Impaired Home

Maintenance Ineffective Role

Performance Ineffective Health

Maintenance Ineffective Therapeutic

Regimen Management

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Important Qualities of the Gerontological Nurse

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“The care of old people requires just as much skill, tact, ingenuity, and patience as the care of children, and perhaps more, because one must keep in mind that old people cannot be treated like children and that feebleness of physical and mental powers is not accompanied by forgetfulness of early experiences. A genuine affection, gentleness, sympathy, and imagination sufficient to grasp the patient’s point of view are necessary.”

Jessie Breeze, private duty nurse, 1909

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Important Qualities of the Gerontological Nurse Ability to form a

therapeutic relationship with elderly adults

Appreciation of the uniqueness of elders

Clinical competence in basic nursing skills

Good communication skills

Knowledge of physical & psychosocial changes that occur with age

Ability to work with & supervise others

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Therapeutic Communication

Ongoing, continuous, dynamic process

Includes verbal and nonverbal signals

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Nonverbal Communication Nonverbal communication

composes up to 80% of information exchange– Body language– Position– Eye contact– Touch– Tone of voice– Facial expression

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Verbal Communication Guidelines Do not yell or speak too

loudly to patients – Yelling into a hearing aid can

be disturbing and painful

Try to be at eye level Minimize background

noise

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Verbal Communication Guidelines Touch if appropriate

and acceptable Supplement with

written instructions as needed

Avoid complicated explanations

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Verbal Communication Guidelines Ask how the patient

would like to be addressed

Avoid demeaning terms such as sweetie, honey, or dearie

Use caring responses and careful listening

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Verbal Communication Guidelines Use open-ended statements

– “Tell me more…” or “How does this affect you?”

Avoid misunderstandings by clarifying– “I’m not sure what you mean…”

Encourage reminiscing