Chapter 9 and 11
Chronic Illness and Disability
Healthcare of the Older Adult
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Definitions of Chronic Diseases or Conditions
• Medical conditions or health problems with associated symptoms or
disabilities that require long-term management
• Persist for months or years rather than days or weeks
• U.S. National Center of Health Statistics “chronic disease is a condition
lasting 3 or more months”
• World Health Organization “long lasting condition that can usually be
controlled but not cured”
• Both share the characteristics of being irreversible, having a prolonged
course, and unlikely to resolve spontaneously (Larsen, 2016)
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Chronic Disease Versus Chronic Illness
• Chronic disease refers to noncommunicable diseases, chronic conditions, or
disorders
• Chronic illness refers to the human experience of living with a chronic
disease or condition
• Disability is a restriction or lack of ability to perform an activity in a normal
manner
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Multiple Chronic Conditions
• One of four adults has two or more chronic health conditions
• Increases complexity of care
• Risk for conflicting medical advice, adverse effects of medications,
unnecessary and duplicative tests, preventable hospitalizations
• Costs of care increase with the number of chronic conditions
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Prevalence of Chronic Conditions
• Occurs in every age group, socioeconomic level, race, and culture
• 7 of the 10 leading causes of death in the United States
• Most frequently occurring account for Responsible for 2/3 of the deaths
that occur globally
• Cardiovascular disease, cancer, diabetes, and chronic lung disease
• Increasing in lower income populations
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Managing Chronic Conditions
• Prevention
• Lifestyle changes
• Managing symptoms to avoid complications
• Quality of life
• Health promotion behaviors
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Challenges of Living With Chronic Illness
• Alleviate, manage symptoms
• Psychologically adjust to, physically accommodate disabilities
• Prevent, manage crises, complications
• Carry out regimens as prescribed
• Validate individual self-worth, family functioning
• Manage threats to identity
• Establish networks of support, resources that can enhance quality of life
• Return to satisfactory way of life after acute debilitating episode or
reactivation of chronic condition
• Die with dignity and comfort
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Prevalence of Disabilities
• Approximately 60 million in United States
• 20% of persons in United States have a disability
• 10% of persons in United States have a severe disability
• Numbers expected to increase
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Types of Disabilities
• Developmental
• Acquired
• Age related
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Questions to Ask to Ensure Quality Care
• Does the patient require or prefer special accommodations?
• Are special accommodations made to communicate with the patient?
• Are efforts made to direct all conversations to the patient rather than to
others who have accompanied the patient?
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Accessibility of Health Care
• Are health care facilities accessible as legally required?
• Has accessibility been verified by a person with a disability?
• Is a sign interpreter, other than family, available?
• Does the facility have appropriate equipment to provide health care for a
person with disabilities?
• Use “people-first” language
• The person, not the illness or disability, is most important
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Health Promotion
• Do not neglect health promotion issues
• Need for healthy diet
• Exercise
• Social interaction
• Preventive health screening
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Gerontologic Considerations
• Rates of disability increase with age
• Effects of aging upon disabled
• Aging caretakers of individuals with disabilities
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Demographics of Aging
• The proportion of Americans 65 years of age and older has tripled in the
past 100 years
• Life expectancy varies by gender and race
• Life expectancy has risen dramatically in the past 100 years
• 1900—47 years of age
• 2009—78.8 years of age
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Leading Causes of Death in Older Adults
• Heart diseases
• Malignant neoplasms
• Chronic obstructive pulmonary diseases
• Stroke
• Alzheimer disease
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Preventive Health Care
• Encouragement
• Community-based support services
• Promote lifelong health behaviors
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Lung mass decreased
by 20%
Number of alveoli
decreased
Impaired gas
exchange
Decreased sensitivity
to beta stimulation
Anatomical Changes
Increased risk
for respiratory
failure, air
trapping,
barotrauma,
and
pneumonia
Decreased cilliary
function
Decreased mucous
production, thicker
Decreased immunity
Less protective
mechanisms
Past Environmental
Exposures
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Pacing cells become
worn out and reduce in
number by 10%
Pacemaker gives up the
lead
Arrythmias
Impulses are blocked
Walls of blood vessels
thicken and the
muscular tissue is
replaced with
connective tissue
which is irregular in
size and shape causing
turbulent blood flow
Blood clots
and
peripheral
vascular
disease
Ventricular wall loses
elasticity
Calcium deposits in
valves and they
become stiff
Heart
Failure
Highly responsive to
alpha stimulation
Decreased sensation
of thirst/ don’t drink
enough water
Vasopressin release
can dehydrate the
body
Postural
hypotension/
Syncope
Medications
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Stiff irregular lumens of
the small vessels
prevent oxygen and
glucose from getting to
some parts of the brain
Number of
neurotransmitters and
receptors in the brain
decreases with age
Cognitive functioning
slows so it takes longer
to process and respond
to information
Brain mass decreases
by 1% every year after
age 50= normal
atrophy
TIA, Stroke
and altered
mental status
Thought
processes
take longer,
short term
memory loss
Simple falls
may cause
severe
injuries
Bad=
bridging
veins
stretch
with blunt
injury can
cause
subdural
bleeding
Good=
more room
for blood
to pool,
late S/S
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Muscle cells are
replaced with fat
which is weaker
Alteration
in mobility
Arthritis can be
painful
Cartilage between
vertebrae discs dry
up
Walking style
changes to
accommodate
changes in
strength, balance,
abilities and
physical changes
Fear of falling
Pain
Group
Activit
y
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Metabolism and peristalsis slows=
constipation
Changes in taste, decreased saliva
production
Depression, loneliness
Inability to obtain healthy foods
(travel or money)
Reluctance to
eat, alteration
in nutrition
Physical limitations, Ill fitting
dentures, SOB
Pain/ Reflux associated with eating
During meals/ eating blood shunts
to the gut which can decrease
perfusion to heart
Medical
events
associated
with eating=
Chest pain,
syncope
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Dehydration
(multiple causes)
Chronic 50 ml
residual
Bladder shrinks
from 500-600ml
down to 300ml
Delayed sense of
urgency
Hypertension/
hypotension,
urinary outflow
obstruction
Urinary
tract
infections
Incontinenc
e= teach
bladder
scheduling
q 2-3 H
Renal
Failure
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Electrolyte
disturbances,
Drug toxicity
Decreased sweat
gland activity in older
adults
Hyperthermia
Inability to sweat
effectively
Decreased elasticity
Increased
bleeding
under the
skin,
Thinner epidermis
Loss of SQ fat
increased
skin tears
Infection
Bacteria can
enter more
easily
Increased skin
permeability
Transdermal
meds vary
in
absorption
rates
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Lid laxity= vision
obstruction
Decreased tear
production= Dry
eyes= Floaters
Decreased pupillary
response= more
difficult to see in low
light
Risk for fall, need
for adaptations/
aids
Decreased visual
acuity
Conductive hearing
loss= bones have
degenerated
Sensorineural hearing
loss= nerve damage
Mixed= combo of
both types of hearing
loss
Pt adaptation/ aids
Caregiver speaks in
lower tone of voice
and from a
position that is
visible
Difficult localizing
sounds
Decreased
amount/specificity of
pain receptors
Atypical
presentations,
Risk for
injury/burns
Neuropathies
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Polypharmacy
activity
Polypharmacy
• At any given time an elderly patient takes an average of 5
prescriptions and two OTC meds.
• There are more OTC meds available and they are popular
• More healthcare providers more opinions
• Incidence of drug to drug interactions reaches 50% if you take 5
medications
• Pharmacokinetics- what the body does to the drug
• Pharmacodynamics- what the med does to the body
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Pharmacokinetics
•Absorption is
slower through
GI
•Faster topically
• Medications
may affect the
absorption of
others
Distribution may
vary depending on
chemical make up
(water or fat
soluble)
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Medication
clearance
decreases
•Blood flow
through the liver
decreases
•Size and renal
blood flow
decreases with
age
Nursing Implications
• Need adjustment of dosage due to age; “start low, go slow”
• Assess knowledge of medications and use
• Review need for medication, coordination of prescriber
• Factors that affect compliance
• Keep medication regimen as simple as possible
• Strategies to improve compliance
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Holistic care of the Elderly
• Nutrition
• Depression
• Function
• Abuse
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Stress and Coping
Common stressors:
•
•
•
•
•
Normal aging changes that impair physical function, activities, and appearance
Disabilities from injury or chronic illness
Social and environmental losses related to loss of income
Decreased ability to perform previous roles and activities
Deaths of significant others
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Coping
• Abilities to adapt to change, make decisions, and respond predictably are
also determined by past experiences
• Often has fewer choices and diminished resources to deal with stressful
events
• Many rely strongly on their families and spiritual beliefs for comfort during
stressful times
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Living Arrangements
• 90% live in the community
• 3.4% reside in nursing homes
• Live at home or with family
• Continuing care retirement communities
• Assisted living
• Long-term care facilities
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Nursing Management
• Supporting cognitive function
• Promoting physical safety
• Promoting independence in self-care activities
• Reducing anxiety, agitation
• Improving communication
• Providing for socialization, intimacy needs
• Promoting adequate nutrition
• Promoting balanced activity, rest
• Supporting home- and community-based care
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