Chapter 5
Chronic Illness and Older Adults
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Chronic Illness (1 of 5)

Acute illness—rapid onset, short duration; return to
previous level of function after treatment


Examples: Colds, flu, GI virus
Chronic illness—prolonged illness, no cure; results
in irreversible changes, possible disability; requires
rehab and/or long-term medical management and
nursing care

Examples: Arthritis, COPD, diabetes, stroke, heart
failure (See Table 5-2 in the textbook)
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2
Chronic Illness (2 of 5)
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3
Chronic Illness (3 of 5)
Seven tasks of chronic Illness (Corbin & Strauss)
1. Preventing and managing a crisis

Understanding potential for crisis and how to prevent or
modify the threat
2. Carrying out prescribed treatment regimen

May be challenging (degree of difficulty) or impact lifestyle
(time consuming)
3. Controlling symptoms

Modify lifestyle or living situation to maintain safety
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4
Chronic Illness (4 of 5)
Seven tasks of chronic illness
4. Reordering time

Change schedules and/or eliminate activities
5. Adjusting to changes in the course of disease

Include chronic illness as part of identity and make
necessary lifestyle changes
6. Preventing social isolation

Patient chooses to withdraw or others don’t associate with
patient
7. Attempting to normalize interactions with others

Manage symptoms to hide disability/disfigurement
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5
Chronic Illness (5 of 5)

Prevention of chronic illness

Preventive health behaviors
• Primary—diet, exercise, immunizations
• Secondary—early detection/screening
• Tertiary—rehabilitation; limit progression of disease
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6
Nursing Management

Nurses play an important role

Conducting a comprehensive history and physical
assessment; ADLs, IADLs
 Participate in plan of care; encourage selfmanagement
 Teaching patient and caregiver about treatment plan
and how to manage symptoms
 Evaluating patient outcomes
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7
Demographics of Aging (1 of 2)

U.S. Demographics (2015) : 47.8 million (14.9% of
population) age 65+
• Fastest growing age group is 85+
• More access to education, employment, technology,
and resources
• More ethnically diverse
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8
Demographics of Aging (2 of 2)

Those reaching age 65 can expect 19.4
additional years of life
 18
for men; 20.6 for women
• Young-old adults are 65 to 74 years
• Old-old adults are 85 and older
• Frail old have conditions that may interfere with
independent ADLs
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9
Attitudes Toward Aging

Aging is normal
• Influenced by many factors

Older adults have diverse characteristics
• Value their life experiences and history

Assess their perceptions of age and health
• Care should not be based on age alone

Myths and stereotypes can lead to poor care
 “Ageism”—negative attitude; leads to discrimination and
disparities in care
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10
Biologic Aging
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11
Special Older Adult Populations (1
of 5)

Chronically ill older adults



Incidence of chronic illness triples after age 45
Most over age 65—at least one chronic condition
Most common: HTN, heart failure, CAD, COPD,
cancer, diabetes, and osteoarthritis
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12
Special Older Adult Populations (2
of 5)

Cognitively impaired older adults
Effect of Aging
Cognitive Function
Improves with aging
Vocabulary and verbal reasoning
Crystallized intelligence
Declines during middle age
Mental performance speed
Synthesis of new information
Fluid intelligence
Declines during old age
Short-term recall memory
Constant (no changes with
aging)
Long-term recall memory
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13
Special Older Adult Populations (3
of 5)

Rural older adults

Five barriers to health care access include:
•
•
•
•
•
*Transportation
Limited access to health care facilities/ workers
Lack of quality health care
Social isolation
Financial limits
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14
Special Older Adult Populations (4
of 5)

Homeless older adults




Numbers are increasing due to health, economic, or
social status crisis
Higher risk of health problems and mortality.
Less likely to use shelters and meal sites
Requires an interprofessional approach to provide
access to health care resources
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15
Special Older Adult Populations (5
of 5)


Frail older adults
Manifestations of frailty—3 or more of:






Unintentional weight loss
Self-reported exhaustion
Weakness
Slow walking speed
Low level physical activity
Stress and strain— ineffective coping

See: mobility limitations, sensory impairment, cognitive
decline, and falls
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16
SCALES (Table 5-7)

Nutritional assessment of older adults






Sadness or mood change
Cholesterol, high
Albumin, low
Loss or gain or weight
Eating problems (swallowing, poor dentition)
Shopping or food preparation problems
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17
Culturally Competent Care



Ethnogeriatric specialty—culturally competent care
for older adult
Societal changes influence: cultural practices,
language, food preferences, support neighborhoods,
safety, financial resources
Important to:


Show respect and communicate clearly
Identify support systems/services
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18
Social Support for Older Adults (1
of 7)


Primary: Family caregivers (preferred providers)
Semiformal levels of support


Senior centers, adult day care, clubs, religious
organizations
Formal systems of support

Health facilities, social welfare, government support
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19
Social Support for Older Adults (2
of 7)

Family caregivers




Care for themselves, parents, children, and
grandchildren in addition to chronically ill
Demands are physical, emotional, and economic
Stress—anger, depression, resentment, and social
isolation contribute to burnout, neglect, and abuse
Care giver self-care—healthy habits, support groups,
outside contact, humor
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20
Social Support for Older Adults (3
of 7)

Elder mistreatment (EM)




Intentional acts of omission or commission by a
caregiver or “trusted other”
Result in harm or serious risk of harm to a vulnerable
older adult.”
May occur at home, assisted-living, or institution
Underreported by victims and HCP
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21
Social Support for Older Adults (4
of 7)

90% of domestic EM by family members

Adult children—dependent on housing & finances; history
of violence, substance use, or mental illness; unemployed
 Spouse/partner—begin or continue violence

Risk factors:






Physical or cognitive limitations
Psychiatric disorders
Alcohol misuse
Lack of social support
Living with many others
Inadequate income
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22
Social Support for Older Adults (5
of 7)

Types of EM ( See Table 5-8)


Physical, psychologic, sexual, or financial abuse;
neglect, abandonment, violation of personal rights
Institutions: above plus failure to follow plan of care,
use of physical or chemical restraints; over or under
medicating, punishment by isolation
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23
Social Support for Older Adults (6
of 7)

Nursing assessment and intervention


H&P
Screening
• Safety plan

Evidence
• Photos, with consent

Document
• Report

Mandatory reporting exists in most states



Adult protective services (APS)
Law enforcement
Know legal responsibilities and state laws
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24
Social Support for Older Adults (7
of 7)
Self-neglect





Unable to meet basic needs; refuse help
Have multiple, untreated medical or psychiatric
conditions
Live alone, often in squalor
Experience higher rates of mortality
Nursing: refer for interprofessional case
management or to APS
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25
Social Services for Older Adults

Administration on aging (AoA)
 Part
of the Department of Health and Human
Services
 Federal agency responsible for many older adult
programs

Area agency on aging
 State
and local agencies funded from the AoA
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26
Social Services for Older Adults:
Medicare (1 of 2)

Medicare is federally funded insurance for
people greater than 65
 Covers
those less than 65 with disabilities or endstage renal disease


Coverage is limited
Out-of-pocket expenditures continue to rise
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27
Social Services for Older Adults:
Medicaid (2 of 2)


Medicaid is a state-administered, needs-based
program to assist eligible low-income people
with medical expenses
Covers most long-term care in United States if
not privately paid
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28
Care Alternatives for Older Adults
(1 of 2)
Adult day care

Provides social and recreational services,
and ADL assistance in supervised setting
Adult day health care

Higher level of care; monitoring and training
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29
Care Alternatives for Older Adults
(2 of 2)

Home health care (HHC)
 Homebound
 Intermittent
or acute health needs
 Supportive caregiver involvement
 Need physician order and require skilled nursing
care for Medicare reimbursement
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30
Long-Term Care Facilities

Placement factors:

Rapid patient deterioration or function
 Caregiver stress and burnout
 Alteration in or loss of family support system

Caregiver concerns:

Resistance
 Insufficient care
 Loneliness
 Cost

Relocation stress syndrome

Disruption, confusion
 Anxiety, depression, and disorientation
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31
PACE

Programs for All-Inclusive Care for the Elderly
 Care
for adults age 55 and older
 Provides many services
 Long-term Care
• Medicaid—no monthly premium
• Medicare—monthly premium
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32
Legal and Ethical Issues

Legal issues:


Ethical issues:


Examples: Advance directives, estate planning, taxes,
denied services, finances, exploitation
Examples: Resuscitation, treatment of infections,
nutrition, hydration, transfer to higher level of care
Nursing:



Current on ethical issues
Identify when ethical issue occurs
Advocate/Ethics committee guidance
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33
Nursing Management (1 of 17)

Specialty of gerontologic nursing




Complex, skilled, creative care
Older adult disease symptoms are often atypical and
underreported
Cascade disease pattern
Stress of illness may lead to fear and anxiety about
both health problems and institutions of care
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34
Nursing Management (2 of 17)

Nursing assessment





First attend to primary needs
Ensure assistive devices are used
Allow plenty of time
Interview family or caregivers separately
Comprehensive assessment involves an
interprofessional approach
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35
Nursing Management (3 of 17)

SPICES
(Adapted from Fulmer T: The geriatric nurse specialist role: a new model, Nursing Management
22:91, 1991. © Copyright Lippincott Williams & Wilkins, http://lww.com)
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36
Nursing Management (4 of 17)

Falls

Risk factors: medications, infections, orthostatic
hypotension, dehydration, electrolyte or other lab
abnormalities, musculoskeletal problems, neurologic
disorders, visual changes
 Other: environmental hazards (clutter, rugs, slippery
floors, bed too high, poor lighting, uneven pavement),
improper footwear or use of assistive devices
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37
Nursing Management (5 of 17)

Planning



Identify strengths and abilities
Include patient and caregivers
Priority goals
• Gain a sense of control
• Feel safe
• Reduce stress
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38
Nursing Management (6 of 17)

Nursing implementation





Modify approach based on the older adult’s physical,
functional, and mental status
Safety first
Allow extra time; assist as needed
Adaptive equipment
Calm approach
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39
Nursing Management (7 of 17)

Nursing implementation
 Health promotion
• Population health






Vaccines
Reduce hazards in environment
Drink liquids; reduce sugar and salt
Regular exercise; 3 to 5 times/wk
Nutrition for healthy weight
Meds, herbs, and supplements as ordered
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40
Nursing Management (8 of 17)

Nursing implementation

Acute and ambulatory care
• Common conditions: falls, dysrhythmias, heart failure,
stroke, fluid and electrolyte imbalances, urosepsis, and
hip fractures

Hospitalized older adult (Table 5-10)
• Identify risks/complications
• Consider discharge needs early
• Special needs teams/community services
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41
Nursing Management (9 of 17)

Nursing implementation



Care transitions can be challenging; need to prepare
Rehospitalization is a risk
Transitional care model: evidence-based and
innovate care coordination and management model
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42
Nursing Management (10 of 17)
Rehabilitation goals


Adapt to/recover from disability or functional
decline; strive for maximal function and physical
capabilities
Influenced by: preexisting conditions, immobility,
falls, nutrition, and finances
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43
Nursing Management (11 of 17)

Nursing implementation

Assistive devices
• Have the potential to increase function
• Technology can assist with rehabilitation and living with
functional impairments
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44
Nursing Management (12 of 17)

Nursing implementation


Safety
Older adults are at higher risk for accidents
• Sensory changes, slowed reaction time, gait/balance
changes, medications, impaired thermoregulation
• Most occur in or around the home; need to “safetyproof”
• Falls, MVAs, and fires—accidental death

Hospitalized/long-term care
• Carefully orient older adults on admission
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45
Nursing Management (13 of 17)
Nursing implementation

Medication use




Management difficult due to: cognitive impairment,
altered sensory perception, limited hand mobility, and
cost; nonadherence common
Causes of errors—see Table 5-11
Age-related changes on pharmacokinetics
Polypharmacy, overdose, and addiction
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46
Nursing Management (14 of 17)

Effects of aging on drug metabolism
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47
Nursing Management (15 of 17)

Nursing implementation

Depression
• Not a normal part of aging
• Second highest rate of suicide; age greater than 75
• Occurs together with medical conditions and affects
adherence with treatment
• Older adults and caregivers with depression should
seek medical attention and support
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48
Nursing Management (16 of 17)

Nursing implementation

Use of restraints
• Physical restraints or chemical restraints





Used ONLY to ensure safety; last resort
Assess need for restraint; requires HCP order
Determine unmet physiologic or psychosocial needs
Standards: least restrictive approach, time limits,
observations and care, alternatives tried; ability to
discontinue
Careful documentation
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49
Nursing Management (17 of 17)

Nursing implementation
 Inadequate


sleep is a common concern
Trouble going to and maintaining sleep
Nursing evaluation (see Table 5-13)
 Determine
improvement in function and quality of
life
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50
Audience Response Question (1 of
2)
The nurse teaches a student nurse about health care
disparities and older adult women. Which statement, if
made by the student nurse, would indicate an
understanding of the teaching?
a. “Women have a shorter life expectancy than men.”
b. “Women have fewer financial resources than men.”
c. “Women are not likely to be a caregiver to their
spouses.”
d. “Women more often have age-related cognitive
impairments.”
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51
Audience Response Question (2 of
2)
Answer: B
“Women have fewer financial resources than
men.”
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52
Audience Response Question (1 of
2)
An older adult male is having his blood pressure checked by the
nurse at the senior center, where the nurse notes large bruises
on both of his upper arms. When questioned by the nurse about
the cause of the bruises, the patient responds, “I must have
bumped myself.” Which is the most appropriate initial action for
the nurse to take?
a. Ask the patient if anyone has been mistreating him.
b. Report the finding to the state agency for elder abuse.
c. Question the patient about his living situation and activities.
d. Reassure the patient that all information will be confidential.
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53
Audience Response Question (2 of
2)
Answer: C
Question the patient about his living situation and
activities.
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54