GERIATRIC NURSING

 "Doing the best for elders to meet their health needs"

INTRODUCTION

Ageing is a natural process, characterized by continued development and maturation. It is estimated that by 2013 the number of people aged 65 and over will exceed 15 million people and comprise 23% of the whole population. This population shift will have dramatic effects on healthcare provision and it is essential not only that the services are in place to meet this demand but also that the nurses have the skills to care for this age group. They are unique people because they have lived the longest and have participated in and adapted to complex social changes. Rapidly growing older adult population and continuing shortage of advanced practice nurses educated to care for older adults.

Dr. Ignatz Leo Nascher, the father of modern geriatrics coined the term "geriatrics" in 1909. The term "geriatrics" comes from the Greek word "geron" meaning "old man", and "iatros" meaning "healer". The ancient Indian system of medicine Ayurveda has mentioned about the Jara Rasayana (geriatrics). The term "geria" is very close to the Sanskrit word "jara". "Rasayana" is defined as a branch of medicine that deals with the prevention of premature ageing, management of diseases and especially the management of diseases related to Old age.

Geriatric nursing is important to meet the health needs of an aging population. Due to longer life expectancy and declining fertility rates, the proportion of the population that is considered old is increasing. Between 2000 and 2050, the number of people in the world who are over age 60 is predicted increase from 605 million to 2 billion. The proportion of older adults is already high and continuing to increase in more developed countries. In 2010, seniors (aged 65 and older) made up 13% and 23% of the populations of the US and Japan, respectively. By 2050, these proportions will increase to 21% and 36%.

According to a report by UNFPA and Help Age International says "India will be the youngest country in the world by 2020 with a median age of 29 years. India has around 100 million elderly at present that divides into three categories: the young old (60-70) the middle-aged old (70-80) and the oldest old (80 plus). India's population is likely to increase by 60% between 2000 and 2050 but the number of elders, who have attained 60 years of age, will shoot up by 360%. Out of this, the oldest old segment, which is the most vulnerable on account of suffering from disabilities, diseases, terminal illness and dementia, is also the largest growing segment of the elderly population, at a rate of 500%." (UNFPA and Help Age International, 2013)

The increasing population of the elderly is "a development concern that warrants priority attention for economic, health and social policies to become senior citizen-friendly," the report said. Therefore, the demands of the geriatric nursing and nurses will increase in India.

DEFINITIONS

• "Old age is an incurable disease." (Seneca)
• "You do not heal old age; you protect it; you extend it." (Sir James Sterling Ross)
• "Ageing is the progressive and generalized impairment of functions resulting in the loss of adaptive response to stress and in increasing the risk of age related diseases." (Dr. A.B. Dey)
• Geriatrics – Geriatrics is the branch of medicine dealing with the physiological and psychological aspects of ageing and with diagnosis and treatment of diseases affecting older adults.
• Gerontology – Gerontology is the study of all aspects of the ageing process and its consequences.
• Gerontological Nursing – It is concerned with assessment of the health and functional status of older adults; diagnosis, planning and implementing health care and services to meet the identified needs and evaluating the effectiveness of such care.
• Gerontic Nursing – Gerontic Nursing is a seldom-used term considers the nursing care of older adults to be the art and practice of nurturing, caring and comforting rather than merely the treatment of disease.
• Geriatric Nursing- "The adaptation of professional nursing knowledge, skills and attitude in recognizing and meeting the nursing, health & emotional needs of an aging population."

DEVELOPMENT OF GERIATRIC NURSING

• Gerontological nursing involves advocating for the health of older persons at all levels of prevention.
• In the 1960's gerontological nursing became a subspecialty of nursing.
• In the 1980's gerontological leaders stated that most practicing nurses did not have sufficient knowledge about gerontological nursing.
• As a result since 1990's schools of nursing provide classes or courses about nursing care of the elderly. Practicing gerontological nursing can obtain gerontological nursing certification through the American Nurses Association.
• Advanced practice in gerontological nursing requires a master's degree in nursing, of which here are two options: the gerontological clinical nurse specialist and the gerontological nurse practitioner.

CATEGORIES OF AGED POPULATION

• A modern classification is categorized the old age into the following categories -
  • Young old     : 60-70 yrs.
  • Middle-aged old     : 70-80 yrs.
  • Oldest old        : 80-100 yrs.
  • Elite old        : Over 100 yrs.
• Women have a longer life expectancy than men. Women are more likely than men to be widowed. Education level of older adults is increasing gradually. Older people who live alone are more likely to live in poverty than people in the same age group are with family.

MYTHS ABOUT OLD AGE

S. No.	MYTHS	REALITY
	Old age is a disease	It is a normal physiological process.
	Begins at 65 yrs.	Defining 65 years of age as old age happened arbitrarily when 65 years of age was set for social security payments in the 1930's based on the labor market and the economy of that time.
	Most older adults live in nursing homes	Only about 5% of older adults live in nursing homes. Most own their own homes, 315 live alone, 54% live with spouses and the rest live with family or friends.
	Most older adults are sick	Fully 71%of all older adults rate their health as good or excellent
	Means mental deterioration	Although response time may be prolonged from a longer processing time neither intelligence nor personality normally decreases because of ageing.
	Are not interested in sex	Although sexual activity may be less frequent the ability to perform and enjoy sexual activity last well into the 90's in healthy older adults.
	Don't care how they look	Older adults want to be attractive to others.
	Cannot learn complex new skills	Are capable of learning new things, but the speed with which they process information slows with age.
	Lonely &socially isolated	Due to loss of partner or friends of same age group.

IMPORTANT CONCEPTS IN THE PRACTICE OF GERIATRICS

The manifestation of disease and its course in old people is different from that in younger individuals. It is important to remember the following concepts of geriatric medicine.

• Older patients get symptomatic early but seek health care much later due to socioeconomic reasons.
• Some s/s, such as anemia confusion, and recent onset of incontinence warrant immediate attention, as they may be associated with several life threatening conditions.
• Not all clinical abnormalities complained or detected can be given equal importance and need to be prioritized.
• A single diagnosis for many coexisting symptoms is not possible in old age .Many diseases coexist and needs a multiple management strategy.
• Multiple small deficits often produce major disability and multiple small interventions produce dramatic results.
• Older people often require rapid access to health care and may need specialized care.
• Apart from medicines and surgeries, physiotherapy and counseling play a major role in the care of older patients.
• Contrary to popular belief, all kinds of prevention are effective in old age .Nurses and health care workers; therefore provide preventive interventions in all situations.

THEORIES OF AGEING

There are many theories of aging, but few are widely accepted. Aging proceeds at different rates in different species. Even within a species, aging proceeds at different rates among individuals. A reasonable conclusion is that aging must be genetically controlled, at least to some extent. Both within and between species, lifestyle and exposures may alter the aging process.

Some theories of aging focus on what controls the degenerative and entropic processes that occur with aging and why the controls exist as they do. Other theories focus on the evolutionary origins of senescence. All of these theories generally agree that senescence does not offer a genetic advantage and developed mainly because it is not selected against.

BIOLOGICAL THEORIES

Biological theories attempt to explain the physical process of aging, including alterations in structure and function, development, longetivity and death. It also attempts to explain why people age differently over time and what factors affect longetivity, resistance to organisms, and cellular alterations or death. An understanding of the biological perspective can provide the nurse with knowledge about specific risk factors associated with aging and about how people can be helped minimize or avoid risk and maximize health. They categorized into stochastic theories and non-stochastic theories.

• Stochastic theories view aging as the result of random cellular damage that occurs over time.
• Non-stochastic theories view aging as genetically programmed physiological mechanisms within the body control of the process of aging.

Genetic Theory

Some scientists regard this as a Planned Obsolescence Theory because it focuses upon the encoded programming within our DNA. Our DNA is the blue-print of individual life obtained from our parents. It means we are born with a unique code and a predetermined tendency to certain types of physical and mental functioning that regulate the rate at which we age.

But this type of genetic clock can be greatly influenced with regard to its rate of timing. For example, DNA is easily oxidized and this damage can be accumulated from diet, lifestyle, toxins, pollution, radiation and other outside influences. Thus, we each have the ability to accelerate DNA damage or slow it down.

One of the most recent theories regarding gene damage has been the Telomerase Theory of Aging. First discovered by scientists at the Geron Corporation, it is now understood that telomeres (the sequences of nucleic acids extending from the ends of chromosomes), shorten every time a cell divides. This shortening of telomeres is believed to lead to cellular damage due to the inability of the cell to duplicate itself correctly. Each time a cell divides it duplicates itself a little worse than the time before, thus this eventually leads to cellular dysfunction, aging and indeed death.

Wear and Tear Theory

The Wear and Tear Theory proposes that the cumulative damage to vital irreplaceable body parts leads to the death of cells, tissues, organs, and finally the whole body. Thus, cumulative damage to DNA leads to a decline in cell function. The problem with this theory is that there are no research models that give credible support at this time.

Environmental Theory

According to this theory, factors in the environment (e.g., industrial carcinogens, sunlight, trauma, and infection) bring about changes in the aging process. Although these factors are known to accelerate aging, the impact of the environment is a secondary rather than a primary factor in aging. Nurses can have a profound impact on this aspect of aging by educating all age groups about the relationship between environmental factors and accelerated aging. Science is only beginning to uncover the many environmental factors that affect aging.

Immunity Theory

As the body ages, the immune system is less able to deal with foreign organisms & increasingly make mistakes by identifying ones own tissues as foreign (thus attacking them). These altered abilities result in increased susceptibility to disease & to abnormalities that result form autoimmune responses.

Neuroendocrine Theory

First proposed by Professor Vladimir Dilman and Ward Dean MD, this theory elaborates on wear and tear by focusing on the neuroendocrine system. This system is a complicated network of biochemicals that govern the release of hormones which are altered by the walnut sized gland called the hypothalamus located in the brain.

The hypothalamus controls various chain-reactions to instruct other organs and glands to release their hormones etc. The hypothalamus also responds to the body hormone levels as a guide to the overall hormonal activity. But as we grow older the hypothalamus loses it precision regulatory ability and the receptors which uptake individual hormones become less sensitive to them. Accordingly, as we age the secretion of many hormones declines and their effectiveness (compared unit to unit) is also reduced due to the receptors down-grading.

Free radical theory

Unstable free radicals result from the oxidation of organic materials. These radicals cause biochemical changes in the cells and cells cannot regenerate themselves.

Cross-linking theory

Irreversible ageing of proteins such as collagen is responsible for the ultimate failure of tissues and organs. As cells, age chemical reactions create strong bonds between proteins. These bonds cause loss of elasticity, stiffness, and eventual loss of functions.

PSYCHOSOCIOLOGICAL THEORIES

These theories focus on behavior and attitude changes that accompany advancing age, as opposed to the biological implications of anatomic deterioration.

Disengagement Theory

Refers to an inevitable process in which many of the relationships between a person and other members of society are severed & those remaining are altered in quality. Withdrawal may be initiated by the aging person or by society, and may be partial or total. It was observed that older people are less involved with life than they were as younger adults. As people age they experience greater distance from society & they develop new types of relationships with society. In America, there is evidence that society forces withdrawal on older people whether or not they want it. Some suggest that this theory does not consider the large number of older people who do not withdraw from society. This theory is recognized as the first formal theory that attempted to explain the process of growing older.

Activity Theory

This is another theory that describes the psychosocial aging process. Activity theory emphasizes the importance of ongoing social activity. This theory suggests that a person's self-concept is related to the roles held by that person i.e. retiring may not be so harmful if the person actively maintains other roles, such as familial roles, recreational roles, volunteer & community roles. To maintain a positive sense of self the person must substitute new roles for those that are lost because of age. And studies show that the type of activity does matter, just as it does with younger people.

Continuity Theory -

This theory states that older adults try to preserve & maintain internal & external structures by using strategies that maintain continuity. It means that older people may seek to use familiar strategies in familiar areas of life. In later life, adults tend to use continuity as an adaptive strategy to deal with changes that occur during normal aging. Continuity theory has excellent potential for explaining how people adapt to their own aging. Changes come about as a result of the aging person's reflecting upon past experience & setting goals for the future.

AGING CHANGES OF OLD AGE

• general tissue desiccation and slowed cell vision
• slowed, weakened speed of response to stimuli
• slowed rate of tissue repair
• decreased metabolism
• mechanisms of homeostasis less rapid and less efficient
• rate of change is individual
• high incidence of health problems

PHYSIOLOGICAL CHANGES

As the person ages a number of physical changes occur some are visible, some are not. The normal physiologic changes associated with aging are:

Skin

• Loss of subcutaneous supporting tissues
• Sensititive to pressure and ulcer
• Wrinkle and sag
• Dry, wrinkled , loss elasticity
• Decreased perspiration and sebum
• Fragile, easily injured
• Decrased skin tugor
• Decreased sebaceous secretions
• Dry, flabby, prone to itching
• Atrophy of tiny arterioles near epidermis
• Impired vasomotor homeostatic mechanism
• Poor temperature regulation (feels cold even in warm climate)
• HAIR- decreased number of hair follicles, scant, fine, graying, hirsutism, possible hereditary baldness
• NAILS- dry, thick, brittle
• Health promotion teaching about skin care for elders, include:
  • Maintaining healthy skin
  • Ensure optimal function
  • Maintain adequate hydration
  • Prevent skin dryness by using emollient lotions after bathing or showering when the skin is still moist.
  • Avoid skin products that contain perfume or alcohol.
  • Assess the frequency of bathing/ showering
  • Avoiding sun damage
    • Use sunscreen lotions with sun protection factor of 15 or higher.
    • Wear wide brimmed hats, sun visors and sunglasses when exposed to sun.
    • Observe for any skin changes and seek medical evaluation.
  • Preventing skin injury
    • Do not use strong detergents to launder clothes.
    • Avoid rough texture in clothing
    • Avoid highly starched linens
    • Use soft wash clothes, towels and bed linens

Musculoskeletal

• Increase fat substitution for muscle
• Muscle atrophy
• Decreased muscular strength and function
• Loss of Calcium from bones
• Deterioration of cartilage
• Wear, friction, stiffness of joints
• Easily tired, less stamina
• Impaired range of motion resulting from stiff joints
• Generalized loss of 6-10 cm in stature because of: flexion of knee and hip joint, narrowing of intervertebral disks
• Body takes on bony angular apperance
• Osteoporosis is common
• For health promotion the nurse assess the musculoskeletal functioning of the elder and identifies any risk factors that may contribute to falls or the ability of the elder to perform ADLs. Health promotion interventions often include providing information about the risk factors for osteoporosis and the importance of adequate intake of calcium and vitamin D.

Cardiovascular

• Thickened cardiac valves
• Decreased myocardial contractability
• Decreased elasticity of blood vessels
• Decreased elasticity and increased stiffness of the arterial wall
• Loss of atrial pacemaker
• Reduction of hemapoietic activity
• Increased blood coagulability
• Decreased efficiency of baroreceptors
• Health promotion activities involve
  • Detecting and reducing risks for cardiovascular diseases.
  • To detect risks the elder should have his or her blood pressure checked annually. The elder should be aware of his or her cholesterol level and have it rechecked at appropriate intervals depending on the result of the blood test.
  • Smoking cessation if applicable, maintaining ideal body weight, exercising daily, avoiding foods high in sodium and fat and eating fruits and vegetables and discussing the use of low dose aspirin therapy with the elder's primary provider.

Respiratory

• Reduced chest compliance
• Increased AP diameter of thorax
• Reduced breathing capacity
• Reduced vital capacity
• Increased residual volume
• Decreased cough reflex
• Decreased ciliary activity
• Decreased elasticity of tissue
• Health promotion teaching includes:
  • Cessation of smoking, if appropriate
  • Preventing respiratory infections by washing hands
  • Ensuring the influenza and pneumonia vaccinations are up to date.

Nervous

• General
  • slow speed of impulse transmission
  • progressive decrease in number of functioning neurons in CNS and sense organs
  • normal neurological functioning possible because of tremendous reserve number of neurons
• Mental and cognitive function
  • altered capacity to retain new information and learn new tasks
  • some impairment of memory and metal endurance
• Sensory
  • some impairment of sensory perception
  • gradual decrease of visual and auditory acuity
• Motor
  • slowed reaction to stimuli; lenthening of reaction time
  • decreased coordination and balance
• Degeneration and atrophy of neurons
• Decreased nerve acuity and sensation
• Loss of memory
• Reduced concentration ability
• Decrased attention span
• Decision-making and judgement ablility remain intact
• Decreased muscle coordination

Gastrointestinal

• Minimal loss of digestive enzymes
• Decreased absorption
• Decreased peristalsis
• Slowed digestion;increased food intolerance
• Decreased metabolism: caloric requirement approximately 1000 calories per day
• Redistribution of body fat; increased fat in trunk, especially in abdomen
• Teeth and gum problems common
• Atonia constipation in common
• Health promotion teaching for elders includes
  • Effective oral hygiene and preventive dental care.
  • Nutrition is important including appropriate diet, as needed by the elder and sufficient fluid intake.
  • Maintenance of a regular bowel routine is helpful and screening for colorectal cancer is important.

Renal/Genitourinary

• Decrased blood flow
• Reduced GFR
• Reduced nephrons
• Decrased creatinine clearance
• Increased propensity to toxic effects of drugs
• decrased renal capacity to concentrate urine at night
• genital
  • ability to function sexually may continue well in older years
  • female: menopause secondary to decreased estrogen
  • male: decreased testosterone, spermatogenesis, and size of testes, increase in size of prostate
• Health promotion activities for good urinary function in the elder are:
  • Drink sufficient fluids daily
  • Drink fluids even if you do not feel thirsty
  • Avoid foods that can irritate the bladder
  • Practice pelvic muscle exercise to stop or control stress incontinence

Endocrine

• Decrased utilization of insulin
• Cessatiomn of progesterone
• Decreased then plateau of estrogen
• Gradual decline in testosterone
• Reduced BMR

Sexual

• Minimal change in amount of sexual response
• Increased in time for full sexual response
• Reduced vaginal lubrication
• Increased refractory peroids in male
• Decreased cell mass and weight

Immunity

• Reduced humoral and cellular immunocompetence
• Slowed, less efficient, response to antigens increases susceptibility to infections

Sensory

• Vision
  • Loss of accomodation
  • Loss of color sensitivity
  • Decreased dark adaptation
  • Decreased peripheral vision
  • Reduced sensitivity to glare
  • Slowed accomodation to light
  • Decreased visual acuity-farsightedness d/t slow lens accomodation, narrowed field of vision (tunnel vision)
• Hearing
  • Decreased threshold for high frequencies
  • Decreased auditory acuity
  • Sesorineural hearing deficit (presbycusis) gradual loss of ability to discriminate to high frequensy tools
• Taste and smell
  • Lack of appetite
  • Prefer salty diet
• Touch
  • Safety hazard

Dental

• Gums becomes less elastic;less vascular
• Recede from remaining teeth, exposing areas of teethe not covered with enamel

PSYCHOSOCIAL CHANGES

• A number of theories have attempted to explain psychosocial aging. They are disengagement theory, activity theory and continuity theory. According to Erikson, the developmental task is ego integrity versus despair.
• People who attain ego integrity versus life with a sense of wholeness and derive satisfaction from accomplishments. By contrast, people who despair often believe they have made poor choices during life and wish they could live life ever.
• Peck proposed the three following developmental tasks of the elder in contrast to Erikson's task of ego integrity versus despair.
  • Ego differentiation versus work role preoccupation
  • Ego transcendence versus body preoccupation
  • Ego transcendence versus ego preoccupation

Developmental tasks of older adult

• 65 to 75 years
  • Adjusting to decreasing physical strength and health
  • Adjusting to retirement and lower and fixed income
  • Adjusting to the death of parents, spouses and friends
  • Adjusting to new relationship with adult children
  • Adjusting to leisure time
  • Adjusting to slower physical and cognitive responses
  • Keeping active and involved
  • Making satisfying living arrangements as aging progresses
• 75 years and older
  • Adapting to living alone
  • Safeguarding physical and mental health
  • Adjusting to the possibility of moving into a nursing home
  • Remaining in touch with other family members
  • Finding meaning in life
  • Adjusting to one's own death
• Retirement
  • It is a stage of life characterized by transition and role changes. There may be problems related to social isolation and finances.
  • People who plan in advance for retirement generally have a smoother transition. Retirement has an impact on more individuals than the retired persons. Loss of the work role has a major impact on same retired person.
  • The most powerful factor that influence the retired person's satisfaction with life are health status, the option to continue working and sufficient income. Adequate financial resources enable the older person to remain independent.
• Economic Change
  • Problems with income are often related to low retirement benefits, lack of pension plans for many workers and the increased length of the retirement years.
  • Food and medical costs alone are often a financial burden. Adequate financial sources enable the elders to remain independent.
  • Nurses should be aware of the costs of health care. The supplies used in a client's care should be as economical as possible. While assisting a client to plan a diet, the nurse must consider which foods the client can afford to buy. The nurse or the client can request the physician to order lower priced medication or assist the older client to apply for medication assistance programs operated by pharmaceutical companies.
• Grand parenting
  • The rate of grandparents being the primary caregiver for their grandchildren is increasing.
  • While loving their grand children the grandparents often experience stress, anxiety, financial hardships and potential deteriorating health.
  • It is important for the nurse to assess and help maintain the health of grandparents.
• Social Isolation
  • Many older persons experience social isolation and the degree of isolation may increase with the age.
  • The vulnerability to isolation is increased in the absence of supportive others. Some older person withdraws from society due to feeling of rejection.
  • The nurse can help the lonely adults in rebuilding social networks and reversing the pattern of isolation. Many communities have outreach programs designed to make contact with isolated older adults.
• Sexuality
  • All older adults, whether healthy or trail need to express sexual feelings. It involves love, warmth m sharing and touching. Provide privacy to discuss sexuality provide information on age related changes.
• Relocation
  • Many people experience relocation due to variety of factors. Making decision to move is stressful. Some elders need to move nearer to children for general support and supervision. They have to leave friends and neighbors from decades. More living choices and options are available for the old adult today. They are:
  • Assisted living
• Adult day care
  • Adult foster care and group homes
  • Nurses in hospital should find out whether a client is being discharged to a nursing home or to a private home. Nursing homes require appropriate information to provide for continuity of care. Clients returning home however may require the assistance of a home care nurse.
• Maintaining independence and self esteem
  • It is important to them to be able to look after themselves even if they have to struggle to do so.
  • To maintain the elders, sense of self respect nurse and family members need to encourage them to do as much as possible for themselves provided that safety is maintained.
  • Nurse need to acknowledge the elders ability to think, reason and make decisions. The nurse can support a decision by an elder even if eventually the decision is reversed because of failing health. The values and standards held by older people need to be accepted whether they are related to ethical, religious or household matters.
• Facing death and grieving
  • Older person usually thrive on companionship.
  • Great bonds of affection & closeness can develop during this period of ageing together & nurturing each other.
  • With the death of mate, they experience feelings of loss, emptiness & loneliness. More women than men face bereavement & solitude because women usually live longer.
  • Some meaningful friendships economic security, ongoing interests in the community, private hobbies, & a peaceful philosophy of like copes more easily with bereavement

COGNITIVE CHANGES

Perception

• It is the ability to interpret the environment. If the aging person's senses are impaired, the ability to perceive the environment and react appropriately is diminished.
• The brain loses mass with aging. Blood flow to the brain decreases the meninges thicken and brain metabolism slows. Changes in the nervous system may also affect perceptual capacity.

Cognitive ability

• Overall, older adults maintain intelligence, problem solving, judgment, creativity & other well-practiced cognitive skills.
• Memory impairment is more prevalent in persons over age 85. Cognitive impairment that interferes with normal life is not considered part of normal ageing.
• Family members should be advised to seek prompt medical evaluation.

Memory

• Sensory memory – It is the momentary perception of stimuli from the environment
• Short-term memory - Information held in the brain for immediate use, also referred recent memory.
• Long-term memory - Information stored for periods longer than 72 hrs. & usually weeks & years.
• The retrieval of information from long-term memory can be slower. Older adults, tend to forget the recent past. Nurse can help by providing memory aids, making notes, and placing object in consistent locations.

Learning

• Needs additional time for learning, largely because of the problem of retrieving information. Have more difficulty than younger ones in learning information they do not consider useful.

Moral Reasoning Changes

• The value and belief patterns that are important to elders may be different from those held by younger people because they developed during a time that was very different from today.
• Cultural background, life experiences, gender, religion and socioeconomic status all influence one's values.
• The nurse must identify and consider the specific values of the older client when nursing care is planned.

Spirituality Changes

• Many elders take their faith and religious practice very seriously and display a high level of spirituality. Involvement in religion often helps the older adult to resolve issues related to the meaning of life to adversity or to good fortune.
• It is an important coping resource leading to enhanced well being.
• Assisting the older person to participate in religious and spiritual practices is an important nursing responsibility.

HEALTH PROBLEMS OF ELDERLY

Injuries

• Healthy people 2010 reports that falls account for 87% of all fractures among adults 65 years and older. Because vision is limited, reflexes are slowed and bones are brittle caution is required in climbing stairs, driving a car and even walking.
• Fires are a hazard for the elder with a failing memory.
• Because of reduced sensitivity to pain and heat, care must be taken to prevent burns when the person bathes or uses heating devices.
• Many elders die and suffer from hypothermia. A lowered metabolism and loss of normal insulation from thinning subcutaneous tissue decreases the older client's ability to retain heat.
• Nurses can help elders make the home environment safe by identifying and correcting specific hazards. The nurse teaches the importance of taking only prescribed medications and contacting a health professional at the first indication of intolerance to them.

Chronic Disabling Illness

• Many older adults function well but some are afflicted with one or more chronic illnesses that may seriously impair their functioning.
• Chronic illness brings many changes to the client and the family members. They may need increasing help with the activities of daily living such as ambulation, feeding, hygiene and so on; health care expenses often escalate and may become an economic concern.
• Family roles may need to be altered and family members may need to change their lifestyle to meet caregiving needs.

Drug Use and Misuse

• Self-administration of medication may lead to a variety of misuse situations including taking too much or too little medications, combining alcohol and medication, combining prescribed medications with OTC drugs, taking medications at the wrong time or taking someone else's medications.
• The pharmacodynamics of drugs are altered in older adults.
• The following strategies taught by the nurse can promote safe medication use by the elder:
  • Make a note of medications taking and any medication allergies. Keep the list current and carry it in purse.
  • Know the reason of taking medication. Ask doctor for the reason of new medication.
  • Consider using a pill organizer system to remember how to take medications.
  • Minimize the number of drugs
  • Avoid the use of OTC drugs

Alcoholism

• Chronic drinking has major effects on all body systems.
• It interacts with various drugs.
• Nursing considerations should be:
  • Clients who are alcoholics should not be stereotyped or prejudged by the nurse. Rather, they should be accepted listened to and offered help.
  • The nurse should assess the number and type of alcoholic beverages consumed as well as the pattern and frequency of consumption.
  • It is important that the nurse discuss any medications the client is taking and review the side effects and interaction effects of alcohol and medication.
  • The role of the nurse is to act as a client advocate and facilitate the treatment of the drinking problem in addition to the prevention of possible complications.

Dementia

• It is a progressive loss of cognitive function. The most common type of dementia is Alzheimer's disease.
• The most prominent symptoms are cognitive dysfunctions, including decline in memory, learning, attention, judgment, orientation and language skills. The symptoms are progressive and exhibit a steady decline in cognitive and physical abilities lasting between 7 and 15 years and ending in death. In the last stage client requires total assistance is unable to communicate is incontinent and may be unable to walk.
• The caregivers may experience physical and emotional exhaustion while they render continuous care. Care giving is complicated when the client no longer recognizes family members or close friends. The nurse's responsibility is to provide supportive nursing care, accurate information and referral assistance. It is important for the nurse to do an ongoing assessment of both the client and the caregiver, because changes will occur as the client's condition deteriorates.

Elder Mistreatment/ abuse

Elder abuse refers to the ill treatment of an older person. Home is usual place of abuse. It can be physical abuse, psychological, financial and sexual abuse.

• Physical abuse: Intentional use of force leading to pain and injury.eg. slapping, hitting., pushing, burning and sprains, cuts etc.
• Psychological abuse: Repeated and consultant use of threats, humiliation, scolding.
• Financial abuse: Includes unauthorized and improper use of resources of the older person.
• Sexual abuse: Includes direct/indirect involvement in sexual activity without consent e.g. Indecent exposure, harassment bruises, bleeding and mental trauma.
• Neglect: Includes repeated deprivation of the assistance that the older person needs for activities of daily living eg. Failure to provide food, shelter, clothing, medical fee, hygiene, bedsores, over sedation, depression, confusion etc.
• Identification of older abuse
  • Usually difficult to recognize.
  • Skin injuries, bruises, bedsores with inadequate explanation.
  • Evidence of severe malnutrition.
  • Poor personal hygiene
  • Bleeding from genitor urinary tract.
  • Afraid /hesitant to talk about.
  • Left alone without much to do for enjoyment.
  Note: Most commonly victim are widows, economically dependent, cognitive impaired or those living in isolation.
• Prevention:
  • Assessment of older physical, mental capacity.
  • Assessment of general quality of care.
  • Assessment of relation with the abuser at home or in the institution and his problems.
  • Counseling of abuser.
  • Information to appropriate agencies.

ROE OF NURSE IN THE CARE OF ELDERLY

The nurse should teach the patient and family the following general health promotion activities.

• Eat a diet that includes all food groups; is low in fat, saturated fat and cholesterol balances calories with physical activity, has recommended amount of fruits, vegetables and grains and uses sugar and salt in malnutrition.
• Make exercise a part of daily activities.
• Have annual health screening examinations; also include examination of the urine, thyroid, testes, mouth, skin and lymph nodes.
• Maintain immunizations for diphtheria, tetanus, influenza and pneumonia.

AREA OF CONCERN	NURSING ACTIONS
Physiologic function	Maintain physiologic reserves. Maintain ongoing assessments for early detection of problems. Review perceptions of current health status, health problems and prescribed or over the counter medications Include nursing care that maintains physical status such as skin care and planned rest and activity
Cognitive function	Slow pace of activity and wait for responses Repeat teaching as often as necessary Be sure eyeglasses and hearing aids are used; ensure lenses are clean and batteries are strong
Psychosocial needs	Be aware that illness, hospitalization or changes in living arrangements are major stressors Assess and support sources of strength, including cultural and spiritual values and rituals Encourage use of support systems: family, friends, community resources, pet Set mutual goals and encourage the patients role in making decisions about care Encourage life review and reminiscence Encourage self care Consider the patients background, interests, capabilities, values, culture and lifestyles when planning care
Nutrition	Assess for lost or damaged teeth, ensure dentures fit properly. Provide foods appropriate to the patient's ability to chew Assess height, weight, eating patterns and food choices. If weight is being lost, assess income, storage and transportation
Sleep and rest	Discourage excessive napping Assess normal bed time, time for rising, bed time rituals, effects of pain, medications, anxiety and depression
Elimination	Assess frequency of bladder elimination as well as problems with incontinence Assess normal times for bowel movements, changes in activity, privacy and medications Ensure that the floors is not cluttered, the toilet is easily accessible, lighting is adequate and privacy is provided Suggest having safety bars installed in the bath room Review diet for necessary fluid and fiber content
Activity and exercise	Assess ability to walk, ensure that assistive devices are available Consider effects of illness, surgery, medications and changes in diet and fluid intake on strength and motor function Ensure an uncluttered environment with good lighting, suggest using a night light and removing throw rugs Slow the pace of care, allowing extra time to carry out activities
sexuality	Assist as necessary with hygiene, hair care, oral care, clean clothing and bedding, make up and shaving Maintain a clean, odor-free environment Demonstrate genuine caring, ask preferred name, listen carefully, respect belongings, provide touch
Meeting developmental tasks	Promote continued development and maintenance of functional health by identifying unmet tasks, feelings of isolation and physical or sensory limitations Assist in finding creative solutions to developmental tasks Collaborate with other health care providers to provide information and referral to community resources for the patient and family

ROLE OF FAMILY AS CAREGIVER

• Traditionally daughter–in-law are for to the care of the elderly, but with change in society setup, more a more women are working outside. As a result, traditional care model is disrupted.
• Due to improvement in health facilities elders are living for more years and sometimes two generation of elders are surviving, so the caregiver level of stress increases in providing care. The caregivers are usually the hidden patient and attention must be directed to take care of her.
• Long term care of elders leads to physical, emotional, social and financial burdens. Therefore, the caregiver needs to be supported to maintain physical and mental health to promote good quality of life for the entire family. The caregiver is as much in need of care and attention as the older person.
• Although informal care providers provide most long-term home care, no external regulatory mechanisms exist to monitor the quality of this care. Substantial evidence suggests that the quality of informal home care is adequate to meet the needs of some care recipients; the quality of informal home care, however, varies widely. Research indicates that:
  • The quality of care is less than optimal for many care recipients, resulting in unmet physical, emotional, and social needs; and
  • Some care recipients are at high risk for abuse, neglect, and other forms of maltreatment by their informal care providers (Giordano & Giordano, 1983).

COUNSELING THE OLDER PATIENT

• Counseling is defined as a helping relationship in which the counselor adopts a supportive and non-judgmental role.
  • The counselor choose a course of action that fits his/her values, resources and life style.
  • It is not only treatment of mental illness but also helping normal functional people to solve problems.
  • The counselor should be non-judgmental, able to maintain confidentiality and respect the views of the person.
  • Prone to multidimensional problems. Therefore, the aim is to improve the well-being and consequently the quality of life.
• While counseling the elders, the following the problems should be kept in mind.
  • Fear of retirement.
  • Relation with children and spouse.
  • Awareness of aging.
  • Physical illness or dependence on others.
  • Loneliness, fear of death, bereavement.
  • Perceived loss of control.
  • Fear of disability and dependency.

The counselor should keep in mind that the problem of old age usually develops gradually over time and old people are reluctant to accept the problem. They may not want to open up and confide in a younger person about their personal problems. Successful counseling can help the old person and his family to lead a quality life.

HEALTH EDUCATION FOR ELDERS

• Human Biology: Inform about biological changes and difference between age related changes and the pathological states.
• Family Health: Whole family should be included in care of elders.
• Nutrition: Inform about the balance diet, nutritive values of food and adequate water intake.
• Hygiene: Personal hygiene and Environmental hygiene.
• Control of Disease: Specific to old age.
• Mental Health: Educate about need to adjust to the changing role and retirement etc.
• Prevention of Accidents: make aware that older person is vulnerable to accidents and fractures.
• Use of Health services: Provide information about social health services available for elders.

CARE SETTINGS FOR ELDERS

Acute care facilities

• Acute care facilities focus on protecting the health of the older adults, with the goal of the older adult returning to his prior level of independence.eg.
  • Preventing nosocomial infections.
  • Preventing therapy related problems (eg. confusion, sleeplessness, dehydration and decreased nutrition).
  • Assessing for potential undiagnosed health problems(eg. depression ,drug or alcohol abuse)
  • Preventing complications (e.g. decubitis ulcer).

Long term care facilities

• Individual is referred to as a resident. These may include as;
  • Assisted living - provides meals, weekly activities, and a pleasant environment to socialize:
  • Intermediate living - provides additional assistance, no longer able to live independently, 24hrs direct nursing contact.
  • Skilled care units - care for clients on tube feeds, IVs chronic wounds, and ventilators.
  • Alzheimer's units - involves patients with progressive dementia, memory loss, inability to care for themselves.

Hospice

• Requires a great deal of patience, expertise, understanding, interdisciplinary communication, and compassion skills on the part of gerontology nurses.
• Rehabilitation: Goal is to maintain physical independence (eg. After orthopedic surgery, stroke, or amputation). The role of the nurse is often as a health care coordinator, manager, and counselor for elders and their families. Nurses monitor the client's health care, assist with ADLs and facilitate the client's adjustment and coping with the disability.

Community

• Home health care - prevents hospital readmissions.
• Nurse run clinics- helps to manage chronic illness.
• Adult day care- focus is on social activities where the level of nursing varies from giving bath, administering medication to wound dressing .Family members who care for their elders and are working during the day often use these settings.

ETHICAL & LEGAL ASPECTS OF GERIATRIC NURSING

The most common legal and ethical issues in geriatric care involve assessment of decisional capacity and competence, identification of decision makers, resolution of conflicts about care, disclosure of information, termination of treatment at the end of life, and decisions about long-term care. Although the approach to resolution of these issues is similar for all age groups, the physiologic, psychologic, and social reserves of the elderly place them at greater risk of adverse outcomes. The fact that the elderly often lack the support of family and friends makes them especially vulnerable to the automatic and sometimes unthoughtful process of the health care system.

Capacity

• A clinical determination of a patient's ability to make decisions about treatment interventions or other health-related matters.
• Capacity is determined by the health care practitioner or, ideally, by the health care team with the aid of cognitive testing, discussion over time, and observation. Capacity is related to memory but is not extinguished by memory loss.

Competence

• A legal designation that recognizes that persons beyond a certain age generally have the cognitive ability to negotiate certain legal tasks, such as entering into a contract or making a will.
• In most states, persons are declared competent at age 18, at which time they can vote, sign binding contracts, and otherwise make legally binding decisions about their lives. Incompetence can only be decided by a court of law.
• All adult patients who are not mentally retarded or who have not been declared incompetent by a court have the same legal rights. Elderly patients, however, are at greater risk of having their legal rights abrogated because they are more likely to be isolated, poor, demented or confused, or institutionalized.
• When the court declares a person incompetent or functionally unable to act in certain areas, it appoints a guardian, who is responsible for making some legally binding decisions for the incompetent person, or ward.

Informed Consent

• A divisionally capable patient's legally binding treatment decision reached voluntarily and based on information about risks, benefits, and alternative treatments gained from discussion with a health care practitioner. The right of informed consent carries the implicit right of informed refusal.

Confidentiality and Disclosure

• Ethical oaths and specific statutes protect the confidentiality of physician-patient communication, an ethical and legal bedrock of the therapeutic relationship.
• All patients are entitled to confidentiality unless they give permission for disclosure or they clearly can no longer express a preference (eg, a severely confused, comatose, or decisionally incapacitated patient). Even in these cases, secrets should be guarded, although decisions about care may require discussion with appropriate surrogates. When a patient can no longer make health care decisions, prior expressed preferences should be respected whenever possible.

Advance Directives

• Legal statements that allow persons to articulate values and establish treatment preferences to be honored in the future when capacity has lapsed.

Living Wills

• A living will lists the interventions the patient would request, accept, or reject in the future, usually at the end of life. Physicians often have difficulty accepting a patient's choice to abandon aggressive care and permit death.
• Most patients use living wills to refuse life-sustaining care when the prognosis for improvement or recovery is hopeless and the ability to relate to others is severely diminished or destroyed. However, as managed care becomes more pervasive and as patients become concerned about being denied care, living wills that request care are becoming more common.

Surrogate Decision Making

• A surrogate is a statutorily designated health care decider or an informally identified person, such as a close family member or friend. The more informal the appointment, the less likely the surrogate will be able to refuse life-sustaining treatment, especially in states with very restrictive laws. If the patient is incapacitated and no advance directive exists, some other person or persons must provide the direction (either a loved one or the medical staff).

Do-Not-Resuscitate Orders

• A statement in the medical record that cardiopulmonary resuscitation will not be performed. It is essential to clarify that DNR does not mean do not treat. Only CPR will not be performed. Other treatments (eg, antibiotics, transfusions, dialysis, ventilatory support) may and should still be provided if indicated.

Euthanasia & Assisted Suicide

• Euthanasia, an action taken by a health care practitioner intended to result in a patient's death, is illegal in the INDIA.
• Assisted suicide, an action taken by a patient intended to cause his own death with drugs supplied by a physician, is illegal in all states except Oregon.

FACILITIES PROVIDED BY GOVT. OF INDIA

In most of the society family members provide the bulk of support and care to older adults. Traditionally home is the best place for elders. With changing socio-economic scenario in most of the societies the family as a unit is on decline. Providing care to elders has become challenging. Older persons who need assistance tend to rely on family or personal resources.

SOCIAL PROGRAMS

In India, the social programs are minimal as follow:-

• National old pension scheme.
• Widow pension scheme.
• Pension and family pension scheme for government employees.
• Supply of grains under "Annapurna Scheme".
• Income tax benefits.
• Medical insurance for accident and hospital treatment.
• Govt. run old age homes.
• Priority telephone connections.
• Special counters for railways reservation, filling of income tax returns.
• Training of informal career by National Open School and National Institute of Social defense.

POLICY FOR RAILWAY CONCSSION

Ministry of Railways has provided concession to senior citizens. It was stated that with effect from 15.08.1998 the persons aged 60 years above shall be granted 30% concession and the concessions will be admissible in all classes and trains including Rajdhani and Shatbadi. Separate reservation counters shall be earmarked for the senior citizens.

NATIONAL POLICY FOR OLDER PERSONS

The National Policy for Older Persons (NPOP) was announced in January, 1999, with the primary objectives -

• to encourage individuals to make provision for their own as well as their spouse's old age;
• to encourage families to take care of their older family members; enable and support voluntary and non-governmental organizations to supplement the care provided by the family;
• to provide care and protection to the vulnerable elderly people; provide health care facility to the elderly;
• to promote research and training facilities, train geriatric care givers and organizers of services for the elderly;
• to create awareness regarding elderly persons to develop themselves into fully independent citizens.

ORGANISATIONS WORKING FOR ELDERS

• HELP AGE INDIA
  • Help Age India is a secular, not for profit organization registered the Societies' Registration Act of 1860.It was set up in 1978, and since then have been raising resources to protect the rights of India's elderly and provide relief to them through various interventions.
  • Help Age India voice the needs of 81 million "grey" populations, and directly impact the lives of 15 lakh elders through our services every year.
  • Advocates with national &local govt. to bring about policy, beneficial to the elderly.
  • Aware the society about concerns of the aged and promote better understanding of ageing issues.
  • Help the elderly to become aware of their own rights so that they get their due and are able to play an active role in society.
• SERVANTS OF PEOPLE SOCIETY
• GERIATRIC SOCIETY OF INDIA

CONCLUSION

Caring for older people involves special expertise as their needs are varied. It is essential that all nurses are able to recognize and help address the specialist needs of the older person and this should be viewed as an integral part of nursing and not specific to those interested in caring for older people.

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