Ageing and Community Nursing By Dr. N. Haliyash, MD, BSN

Ageing In almost every country, the proportion of people aged over 60 years is growing faster than any other age group, as a result of both longer life expectancy and declining fertility rates.

Classification of Older Adults Older adults are 65-years-old and older 65-74 young old 75-84 middle old 85-99 old-old (fastest growing subgroup) 100 + elite old

Health Care of the Older Adult (continued) 50% of hospitalized clients on med-surg units are older than 65 8% of elderly have 1 or more chronic illnesses 50% have 2 or more chronic illnesses 5% live in institutional settings

Assessment Guidelines for Older Adults Adjust to physiologic changes Be familiar with sensory changes, changes in each body system Adapt assessment techniques to diminishing energy and ability Allow for frequent breaks if a lengthy assessment is needed

Assessment Guidelines (continued) In addition to physical assessment, the older adult may need assessment of: Ability to perform ADL’s (Activities of Daily Living - functional assessment) Network of support (family and friends) Health beliefs in nutrition, exercise, etc. Sleep patterns Living arrangements Financial assessment Self-esteem View of life and acceptance of death

Reminiscence/Life Review An adaptive function that allows them to recall the past and assign meaning to these experiences Can be a nursing intervention to encourage self-esteem, increase communication skills, and increase social interaction

Pain and the Older Adult May not report pain as feels it is a part of aging 85% of patients in nursing homes have pain Pain response: have similar pain tolerance as young adults

Pain Assessment Use methods as with adults (pain scale) Don’t assume that if patient is busy or sleeping, they don’t have pain; need to ask them If cognitive impairment is present, watch for non-verbal cues Agitation Aggression Wandering Change in vital signs Grimacing

Pain Management Ask what they usually use for pain and is it working If acute pain, can use narcotics but may need a decreased dose

Medications and the Older Adult 25% of all prescriptions are written for people older than 65 Physiologic changes caused by aging affect the activity and response of drugs Absorption, distribution, metabolism, excretion

Polypharmacy Many older adults are using multiple medications, use multiple pharmacies, have multiple physicians Multiple drugs may lead to adverse reactions

Polypharmacy Most common adverse reaction in the elderly is confusion Confusion in the absence of disease is not normal!!

Nursing Interventions for Polypharmacy Assess medications they are taking Encourage client to use one pharmacy for all medications Encourage client to review with primary caregiver all medications they are taking

Medication Noncompliance in the Older Adult May be non-compliant due to: Not understanding how to take medication Forgetful Don’t like the side effects Don’t have the money to purchase medications

Nutrition and the Older Adult Risk of nutritional problems increases with age Energy needs decrease but nutrient needs remain the same

Causes of Malnutrition in the Older Adult Loss of teeth Digestive system changes Loss/decrease of appetite Lactose intolerance Fixed income Lack of socialization during meals

Nursing Interventions to Improve Nutrition Small, frequent meals Assist with food choices Identify causes of decreased appetite Refer to dentist for teeth issues Refer to social services for financial problems Discuss ways to improve socialization during meal time

Goals for Older Adults Follow therapeutic plan of care Ensure transportation to MD visits Ensure primary physician is aware of all medications currently taking Maximize independence in self-care activities Educate about resources to assist them with care if needed

Goals (continued) Maintenance of ability to communicate Educate about assistive devises such as hearing aids Assist with financial counseling to help pay for these aids if needed

Goals (continued) Maintenance of positive self-image Assist the patient to participate in appropriate social activities to enhance the feeling of worth Encourage open expression of concerns such as feelings of hopelessness

Goals (continued) Remain free of injury In the hospitalized patient Perform fall risk assessment Orient to surroundings and re-orient as needed Provide assistance with ADL’s

Goals (continued) Maintain bowel and bladder elimination patterns Discuss nutrition to promote elimination Discuss use of medications if prescribed Urinary incontinence (loss of bladder control) is a symptom, not a disease.

Goals (continued) Maintain adequate nutritional status When hospitalized Intake and output Daily weight Dietary referral for preferences Socialization Assist with feeding Liquid supplements as needed

Goals (continued) Maintain adequate fluid and electrolyte status Place water within easy reach of the client Offer fluids every 1-2 hours Monitor electrolytes Intake and output Administer and monitor IV fluids if needed

End-of-Life Issues Death and Dying Nurses must recognize influences on the dying process Legal Ethical Religious Spiritual Biological Provide sensitive, skilled and supportive care

End-of-Life Issues (continued) Both the patient who is dying and the family members grieve as they recognize the loss Nursing Diagnosis of Anticipatory Grieving includes: Denial worthlessness Anger concentrate Feelings of guilt Inability to concentrate

End-of-Life Legal Issues Medical Directive to Physician (Living Will) Addresses only the withholding or withdrawal of medical treatment that would artificially prolong life Becomes effective when the primary physician and one other doctor say in writing that an individual is in a terminal or irreversible condition and that death will occur if life-sustaining medical care is not given Some states allow for personal instructions to be added to this document

End-of-Life Legal Issues (continued) Advanced Health Care Directive Used to be called Durable Power of Attorney An Advance Directive that allows an individual to appoint representatives to make health care decisions if they become incapacitated This document affects only health care and should not be confused with granting power of attorney for other matters Becomes effective when the person becomes terminally ill or incapacitated.

Nursing Responsibility for Advance Directives Each state varies; nurses need to be aware of requirements for their state Be prepared to answer questions from the patient about these directives Ask if your patient has these and make sure copies are placed in their charts Advance Directives must be honored

End-of-Life Issues (continued) Artificial Nutrition and Hydration is another important ethical and legal issue Feelings about withholding food and fluids are emotionally charged and often have religious connotations. U.S. Supreme Court has upheld the right of patients to accept or reject the administration of artificial nutrition and hydration.

End-of-Life Issues (continued) Hospice Care Focuses on support and care of the dying person and family Goal: to facilitate a peaceful and dignified death Based on holistic concepts Improve quality of life rather than cure Support patient and family

Hospice Care (continued) Principles of hospice care can be carried out in a variety of settings Home and hospital are the most common settings Palliative care: differs from hospice in that the client is not necessarily believed to be dying

Nursing Care of the Dying Patient Provide personal hygiene measures Relieve pain Essential for patient to maintain some quality in their life Assist with movement, nutrition, hydration, elimination

Nursing Care (continued) Provide spiritual support Arrange access to individuals who can provide spiritual care Facilitate prayer, meditation and discussion with appropriate clergy or spiritual advisor

Nursing Care (continued) Support patient’s family Use therapeutic communication to facilitate their feelings Display empathy and caring Educate family on what is happening and what the family can expect Encourage family members to participate in the physical care of the patient

Do Not Resuscitate Also called DNR, No Code Must be written Must be reviewed regularly as per policy May have specific requests Example: may okay vasopressors and fluids but no chest compressions or intubation

Q & A ? This population ageing can be seen as a success story for public health policies and for socioeconomic development, but it also challenges society to adapt, in order to maximize the health and functional capacity of older people as well as their social participation and security. This population ageing can be seen as a success story for public health policies and for socioeconomic development, but it also challenges society to adapt, in order to maximize the health and functional capacity of older people as well as their social participation and security.