Biologic changes: “Health in the later years is an accumulated product of your life before,” says geriatrician Dr Denise Eldemire Shearer. “Most of the illnesses in the later years are lifestyle-related and prevention is very important.” Concurrent with physical ageing – which all woman looked at last week – is biological ageing which, combined with the physical, our heredity and lifestyle habits, governs the functions of the body’s organs and systems as we grow older. The biological changes of ageing, Dr Eldemire Shearer continues, include: .
Decrease in total body water: which combined with shrinking of the sweat glands, causes an increase in the dryness and wrinkling of the skin and makes it more susceptible to disease and injury. Drinking several glasses of water daily and caring for the skin with oils and lotions (whole body, not just arms and legs, men as well as women) are good habits to cultivate. Coconut oil works just as well as the expensive ones. . Thickening and hardening of heart valves and arteries: which means that the heart rate is decreased and the heart pumps less blood with each beat.
There is also decreased blood flow to the organs such as the kidneys, so the toxins which they filter stay in the body longer. Good nutrition, regular moderate exercise and a reduction or elimination of the toxins we take in such as cigarettes, alcohol and other drugs, should ensure good organ health. . Decreased brain weight and reduction in the number of brain cells: resulting in a slower response time for some nervous system functions. A slight lessening of mental sharpness and quickness and short term memory are normal ageing-related changes and do not interfere with normal brain function.
Using a diary, writing things down and allowing yourself or the older person time to process information helps in this area. Any noticeable reduction in mental functioning, however, must be checked with your doctor as it is not a normal feature of ageing. . Reduction in the response of the immune system: which, combined with the reduction in efficiency of the respiratory and urinary systems and a reduced cough reflex, makes one more prone to infections in these areas.
This is where good nutrition combined with prescribed appropriate nutritional supplements gives you the edge. . Loss of bone substance and a tendency to osteoarthritis: which can decrease mobility and increase one’s susceptibility to bone injuries. These changes are primarily due to hormonal changes at midlife (female menopause/male andropause) combined with a btendency to reduce the level and/or frequency of exercise as we age. An increase in foods (and, if necessary, supplements rich in calcium and vitamin D & B12, prescribed and properly monitored hormone replacement therapy if needed, and a suitable exercise routine should take care of these.
It is of paramount importance that younger women build and maintain strong bones in order to maintain bone density and prevent osteoporosis in later life. Worthy of note is the fact that poverty is linked to inadequate access to food and nutrition and the health of older women often reflects the cumulative impact of poor diet, eg years of childbearing and sacrificing her own nutrition to that of the family can leave the older woman with chronic anaemia. This problem can be helped by improved nutrition and relatively inexpensive iron supplements.
Ageing individuals and their family members/caregivers must understand therefore, Dr Shearer emphasises, that regular medical check-ups are extremely important in preventing or reducing the incidence of the natural physical and biological ageing changes becoming medical problems. In addition, many cancers are more prevalent in the older years so it is essential that individuals be tested on a regular basis for these conditions. Cancer of the breast, ovaries and cervix in women, prostate cancer in men and cancer of the colon in both genders, have specific tests which should be performed in a timely and consistent manner to ensure early detection and treatment.
Whether the ageing individual has a disease or not, the importance of positive lifestyle habits cannot be overemphasised. Such practices as good nutrition and regular exercise play a vital role in the maintenance of the body’s functions at any age but particularly at midlife and beyond. Ask your health professional to guide you as you begin or continue with your exercise and nutrition regime. This is especially important if you have a disease or suspect that you have one. Pay attention to the signals that your body sends you.
A twinge here and a slight pain there may just be indicative of a larger problem which can be arrested or eliminated with early detection and treatment. The aims of geriatric medicine, Dr Shearer continues, are to enable people to lead full and active lives, to achieve the maximum function allowed by their physical, mental and social capabilities and to reduce to a minimum, the period of dependence. This is done by: .Maintenance of health by high levels of reactivity to the environment and avoidance of diseases. .Early detection and appropriate treatment of disease.
. Maintenance of maximum independence consistent with irreversible diseases and disability. It is important for all to remember that if the ageing individual already has a disease such as hypertension or diabetes, they will be even more at risk for acute and even severe medical problems. It is never too early or too late to improve your lifestyle and develop more positive life-enhancing habits, advises Dr Shearer.
Read more: http://www.jamaicaobserver.com/magazines/allwoman/115217_The-biological-changes-that-come-with-ageing#ixzz2frxw0GA2
Psycho: Understanding about the psychological changes of the elderly will help those who are caring for elderly patients to be better prepared as caregivers. As people get older bodily function decreases so some of the main functions that changes are in vision, hearing, touch, skin, endoctrine, renal, and musculoskeletal.
Health management for older adults consists of determining the reasons for loss of independence in the elderly, some symptoms include the high incidence of dementia caused by psychological changes such as in the decline of mental and physical abilities, the diminishing mental health and cognitive functions leads many adults to seek assistance from family members or institutions.
Physiological effects of Social Change
Studies have been conducted that show how the social changes in aging causes physiological effects for the elderly simply from the standpoint of how men and woman think of aging differently. Some social characteristics facing woman as they age is that they usually live longer and face the loss of family members and friends. This results in the need for emotional healing and elimination of stress.
Elderly men’s changing roles of social status allows them to create coping skills requiring more social involvement as well as the continuous process of learning ways to strengthen their mental abilities.
Physical health conditions caring for elderly
Some of the most common health conditions among the aging elderly are
• heart disease
• vision and eye disease
• mental health
• hearing and sleep disorders.
Aging is a process where over time individuals experience a decline in performance, productivity and health. Age related regenerative diseases are different from person to person due to genetics, lifestyle and the change between biological and physiological age. The breakthroughs in clinical medicine will help in the connection between age and disease.
National Institutes of Health and the U.S. National Library of Medicine
needs: Financial Needs
If elderly individuals happen to be living on their own, i.e., without anyone’s support, it is but natural that they will have a certain amount of financial needs. They will need to fend for themselves for everything such as food, groceries, medicines, etc. Pensioners would have the benefit of a steady source of monthly income (whatever be the amount trickling in). However, those senior citizens who do not have any pension facilities or any other sources of income, would have to live entirely on the basis of their savings or through special senior citizen government finance schemes.
Elderly people need familiar surroundings and people around them and hence prefer staying at home in old age. Being a familiar living place, the home can be modified according to their changing needs. Another advantage would be of having a safe and helpful neighborhood in case of any emergency. Transportation is easy and quick when older people are residing in a familiar area. However, if due to some reasons, they do not have a house of their own, there are government housing schemes designed specifically for older people. Also, there are certain private nursing homes that work for old people and take care of their health and other basic necessities.
Health is the most important requirement when it comes to elderly needs. With advancing age, the body tends to slow down and becomes less efficient. Elderly people are prone to a few age-related health issues. This is a normal aspect of life and one cannot help it. However, through proper care and nursing facilities, one can definitely help in keeping most of these health issues in check and preventing them from causing any serious harm.
Regular medical checkup in this case is a useful way to monitor the health of the elderly. It can help in anticipating potential future health-related issues. At the same time, it may help in identifying serious health problems at the initial stage during which treatment is possible.
As people age, their digestive system gradually starts weakening. Aged and elderly people especially, face this problem wherein they start finding certain foods indigestible or difficult to digest. What one must realize is that their diet can no longer be the same as it was say, twenty years ago. Their diet should be modified accordingly such that it remains a nutritious, balanced diet and yet, contains foodstuffs that their digestive system is able to accept, without causing them any discomfort or problems. Often, the diets of elderly people need to be altered depending on their medicinal prescriptions.
If you have an elderly family member whose mobility has become limited due to aging, he or she would require a certain amount of assistance in his or her daily routine. If it is not possible for someone in the family to be around the aged person the whole day long, you could consider having a full-time nurse to assist the elderly person. This could be beneficial, especially if the person requires assistance in basic activities like walking, eating, bathing, dressing, etc.
Social and Other Needs
One thing that you should keep in mind is, to shower all the love and care on your elderly relative or family member. Just because they have become old and slow, does not mean that you should ignore them or let them be confined to themselves. Remember, a few years down the line, you yourself will be in their position. Spend time with them, chat with them and make them feel wanted, cared for and loved. Pay special attention to their room.
You could consider installing a few senior citizen friendly appliances which they would be comfortable using. Also, you should consider installing certain medical alarms that are specially made keeping in mind elderly citizens. These were some basic elderly needs that you should bear in mind. Try your best to fulfill all of them so that they can spend the golden days of life happily and comfortably. Read more at Buzzle: http://www.buzzle.com/articles/needs-of-the-elderly.html
To cope with high out-of-pocket costs for drugs, many seniors use such cost-cutting measures as choosing generic drugs rather than brand-name drugs, asking their providers for free samples, or ordering drugs over the Internet or from Canada. Others take less than the recommended dosage (e.g., cutting pills in half) to make the medications last longer. Some are forced to choose between groceries and medications, a lose-lose solution.
Prescribing physicians should be aware of medication costs and design drug regimens that carry the lowest possible out-of-pocket costs without compromising treatment effectiveness. Social workers, nurses, and clinical pharmacists can often assist in designing these regimens to reduce the financial hardship on older patients who need medications.
FUNCTIONAL ASSESSMENT OF THE OLDER ADULT
The goal of functional assessment is to determine how well older patients can care for themselves, manage their living environment, and move about in the world. Approximately one quarter of people over 65 have difficulties with activities of daily living (ADLs) or with instrumental activities of daily living (IADLs). ADLs include bathing, dressing, eating, transferring from bed to chair, continence, and toileting. IADLs include driving or managing other transportation, shopping, cooking, using the telephone, managing finances, taking medications, doing housecleaning, and laundry.
Half of people over 85 have difficulties with ADLs, indicating the need for long-term care either at home or in a residential care facility. Those who have problems with IADLs are more likely to have cognitive impairment than those who can still perform IADLs independently.
Once an assessment is completed, a plan of care can be developed that specifies the type of support services and equipment that might be appropriate, including home care and/or modification of the home, or possible placement in assisted living or other long-term care facility.
Those who need assistance only with IADLs may continue to live independently with the help of family caregivers; perhaps a financial/legal consultant (accountant, attorney, or family member with durable power of attorney); a cleaning service; and someone to drive, shop, and run errands.
The Initial Assessment
The first step in assessment is to establish a trusting relationship. Make sure the patient is comfortable and take time to get acquainted before launching into assessment questions. Be sure the room is well-lighted, quiet, and warm. If the patient has brought a family member or friend, acknowledge that person but focus on the patient rather than the companion. Although the companion may assist in communication during the assessment, it is important that the patient feel that the discussion is between the two of you and that you are not addressing the (usually younger) companion.
The following recommendations are essential for communicating effectively with older patients:
Face patients directly so they can see your lips move when you speak; this is particularly important if the patient has a hearing problem. Speak in a clear, slow, lower pitch, and a slightly louder voice. Encourage questions from the patient and, if present, the companion. Ask only one question at a time and allow time for the responses. Even healthy older adults may take a little longer to process the question and frame a response. Tailor your communications to the individual’s learning style and incorporate language the patient uses into your questions, avoiding complex medical terminology and abbreviations. (Curry et al., 2005)
During your initial conversation and history taking, assess patients’ current knowledge and attitudes about healthcare and health behaviors. For example: How do they rate their own health? What do they do to maintain or improve their health? Do they think that feeling sick is just part of getting old? Or do they believe that their health problems can be treated successfully?
People often continue health habits and practices adopted years earlier that may no longer be effective or adequate to deal with age-related changes or chronic disease. Those without symptoms may tend to ignore recommendations for screenings such as mammography and colonoscopy.
Also assess the patient’s ability to adapt to change. Some people are inflexible in their attitudes and beliefs. Are patients open to changing their way of life to adapt to age-related problems they haven’t recognized? For example, do they know that the dishes they just washed still have bits of food clinging to them? Do they see the dribbled food stains on their clothes? Do they realize that it’s time to surrender their driver’s license?
Failure to admit problems such as these indicates an unwillingness and/or inability to make needed changes. This is where a trusted health professional may be able to assist them in making changes, whereas a relative or friend might be considered a “meddler.” Once trust is established, patients are more amenable to changes that will help ensure their safety and health.
Assess whether patients have the necessary resources to self-manage health. Can they afford the medications the doctor has prescribed or do they need financial assistance? Are they socially engaged with other seniors who can share health information? Are they sufficiently mobile to participate in an exercise class? How are they coping in today’s world? For example, do they use a computer (or are they willing to learn) to access health information?
Assessing Physical Function
Assessment of physical function in the older adult includes some of the same elements of any assessment: weight, height, vital signs, and body mass index (BMI). In addition, functional assessment may include vision and hearing screening tests; balance and gait assessment; assessment of oral health; assessment of skin for bruises, wounds, and other signs of skin breakdown; and questions about nutrition and incontinence.
Adequate vision is essential to safety and quality of life and vision changes with age. Visual impairment is an independent risk factor for falls. Age-related visual impairment is most often corrected by prescription eyeglasses or by contact lenses. Patients should be aware that eyeglasses need to be cleaned daily, rinsing with water or special eyeglass solution and wiping each lens with a soft cloth.
Improved lighting (brighter but using frosted bulbs and lampshades to reduce glare) can also compensate for visual impairment. For example, a 70 year old needs twice as much light to read or sew as a 35 year old.
Anyone with a family history of eye disease or who has diabetes and/or hypertension is at high risk of serious eye diseases. All people over 65 should have an annual examination by an ophthalmologist or optometrist to screen for these conditions and treat as necessary. Serious vision impairment and even blindness can result from untreated eye conditions such as cataracts, glaucoma, or age-related macular degeneration (AMD).
The incidence of serious eye diseases varies among racial groups. The leading cause of blindness among white Americans is AMD. Among African Americans, the leading causes of blindness are cataract and glaucoma. Among Hispanics, glaucoma is the most common cause of blindness.
A study of more than 4,600 Latinos showed that they developed visual impairment and blindness at the highest rate of any ethnic group in the country. Of Latinos age 80 and older, nearly 20% became visually impaired during the four years of the study and nearly 4% became blind in both eyes. Latinos are more likely to develop diabetic retinopathy than non-Hispanic whites. More than half of all eye disease in Latinos is undiagnosed and undetected (National Eye Institute, 2010).
AGE-RELATED MACULAR DEGENERATION (AMD)
Age is the primary risk factor for AMD. Because women live longer than men,
AMD is more prevalent among women. Aside from age, gender, and race, other risk factors for AMD include smoking, obesity, and family history.
Warning signs of AMD include:
Lines or edges that appear wavy or distorted
Blurry faces or difficulty seeing colors
Dark or empty spaces that block the center of your vision
Difficulty reading fine print or reading road signs from a moving vehicle Difficulty seeing at a distance or during twilight hours
Hearing impairment can limit social interaction, increase the risk of depression, and compromise safety. If the patient reports difficulty in hearing or understanding conversations, watching TV, or watching movies, use of the whisper test can quickly confirm the need for referral to an audiologist for more precise testing and prescription of an amplification device (hearing aid). To perform the whisper test, stand 6 to 12 inches behind the patient and whisper several short sentences. If the patient cannot hear and understand you, an audiology referral is in order.
Some types of hearing loss can be corrected by hearing aids worn in or behind the ear. These devices amplify sounds but may prove annoying in crowded rooms or public places because it can be difficult to separate what you want to hear from other sounds. Research shows that hearing aids for both ears are advisable (but may not be covered under some health plans). If hearing loss cannot be corrected with conventional hearing aids, cochlear implants may help some people.
According to the National Institute on Deafness and Other Communication Disorders (2008), before investing in a hearing aid, people with hearing problems should see an otolaryngologist, who may refer them to an audiologist for hearing assessment. Adults who do not see a physician before getting a hearing aid must sign a waiver.
Older adults with profound, uncorrectable hearing loss can benefit from a TTD/ TTY phone line and other signaling devices that use flashing lights rather than sound (alarm clocks, smoke alarms, doorbells). These adaptations not only help people with hearing loss stay connected with family and friends but they also are critical safety measures for those living alone. Other assistive devices include amplifiers for telephones and earphones for watching TV.
MOBILITY, STRENGTH, AND GAIT
Assessing mobility, strength, and gait is essential in determining the older patient’s risk for falling. One simple means for assessing mobility, strength, and gait is the Timed Up and Go (TUG) test. Ask the patient to rise from a sitting position without the use of hands, walk 10 feet, turn around, walk back, and sit down. Those who complete the TUG test in less than 10 seconds are probably normal. Anyone who is unable to do this in less than 14 seconds is at increased risk for falls.
The speed of walking, length of stride, and type of gait are also indicators of increased fall risk. Slower gait, smaller steps, and irregular gait can signal neurologic disorders that predispose the patient to falls. For example, slow gait may be caused by muscle weakness, inactivity, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), or angina. Short steps may be a sign of Parkinson’s disease. Unsteady frontal gait may be a sign of cerebrovascular disease or normal pressure hydrocephalus.
Falls and Traumatic Brain Injury (TBI)
Falls are one of the greatest threats to senior health, and they can be life threatening. Each year, one third of people over 65 suffer a fall, and one third of these falls cause injuries requiring medical treatment. Even low-level falls (e.g., slipping while stepping off a curb or on a tile floor) can be life threatening in people over 70. These people are 3 times more likely to die from such injuries as younger people (Spaniolas et al., 2010). Fall-related injuries, particularly those requiring hospitalization,
are the most frequent cause of developing new or worsening disability (Gill et al., 2010).
Patients and families need to know how to prevent falls. The CDC recommends the following four essentials:
Encourage exercises that improve balance and coordination, such as Tai Chi. Make the home or other environment safer.
Ask the healthcare provider to review all medications.
Take the patient in for a vision check.
To make the home safer, remove tripping hazards such as throw rugs from stairs and floors; place often-used items within easy reach so that a step stool is not needed; install grab bars next to the toilet and in the tub or shower; place non-stick mats in the bathtub and on the shower floor; add brighter lighting and reduce glare by using lampshades and frosted bulbs; and add handrails and lights on all staircases.
Seniors should wear shoes that offer good support and have thin, non-slip soles. They should avoid wearing slippers and socks (without shoes) and going barefoot.
Source: CDC, 2008b.
Fractures—of the hip, arm, leg, and ankle bones—are the most common injuries sustained in falls, but some falls result in traumatic brain injury (TBI). In 2005 half of all deaths due to unintentional falls were caused by TBIs. A sudden bump or jolt to the head of an older person can easily tear cerebral blood vessels and lead to long-term cognitive, emotional, and/or functional impairments. Any older person taking blood-thinning medication (warfarin/Coumadin) should be seen immediately by a healthcare provider if they have a bump or blow to the head, even if they do not have any of the symptoms of TBI (CDC, 2008b).
SYMPTOMS OF TRAUMATIC BRAIN INJURY (TBI)
Symptoms of Mild TBI
Low-grade headache that won’t go away
Having more trouble than usual remembering things, paying attention or concentrating, organizing daily tasks, or making decisions and solving problems Slowness in thinking, speaking, acting, or reading
Getting lost or easily confused
Feeling tired all of the time, lack of energy or motivation
Change in sleep pattern—sleeping much longer than before, having trouble sleeping Loss of balance, feeling light-headed or dizzy
Increased sensitivity to sounds, lights, distractions
Blurred vision or eyes that tire easily
Loss of sense of taste or smell
Ringing in the ears
Change in sexual drive
Mood changes like feeling sad, anxious, or listless, or becoming easily irritated or angry for little or no reason Symptoms of Moderate or Severe TBI
A headache that gets worse or doesn’t go away
Repeated vomiting or nauseas
Convulsions or seizures
Inability to wake up from sleep
Dilation of one or both pupils
Weakness or numbness in the arms or legs
Loss of coordination
Increased confusion, restlessness, or agitation
Source: CDC, 2008b.
Although most gait disorders in older adults cannot be treated medically or surgically, they sometimes can be compensated for by the use of ambulatory assistive devices such as canes, crutches, and walkers. These devices improve the patient’s balance and ability to bear weight. However, not all seniors are candidates for ambulatory assistive devices. For example, those with serious impairments in cognition, judgment, vision, or upper body strength may not be able to use one of these devices safely.
Patients who are candidates for canes, crutches, or walkers should be assessed to determine whether they need assistance for balance or weight bearing while walking. Canes are used primarily by those who need support only on one side; a cane widens the base of support and thereby increases balance.
People needing bilateral upper-extremity support for walking need to have crutches or a walker. Crutches also offer full weight-bearing support. Two types of crutches are available: axillary crutches and forearm crutches. Axillary crutches are generally used by people who have experienced a fracture or other temporary condition restricting normal ambulation. Forearm crutches, also called Canadian or Lofstrand crutches, are used by those who need ongoing bilateral upper-extremity support with some weight bearing. Forearm crutches allow freedom of hand movement without removing the crutches from the forearms.
Walkers improve balance by increasing the patient’s base of support and lateral stability, and supporting the patient’s weight. However, they can be difficult to maneuver through doorways and should not be used on stairs. Walkers also contribute to poor posture as the patient must bend forward while walking. Standard walkers are the most stable type of walker, having four legs with non-skid rubber tips.
Walkers are also available with front wheels only or with four wheels. Front-wheeled walkers are generally used by someone with a faster gait or who finds it difficult to lift a standard walker. Four-wheeled walkers provide a larger base of support but should not be used by someone who needs weight-bearing support, because full body weight could cause the walker to roll away and cause a fall.
All ambulatory assistive devices should be fitted to the individual patient, who will likely need training in using the device. Referral to a physical
therapist can be helpful in the process of assessing each patient’s needs and determining which assistive device would be most appropriate (Van Hook et al., 2003).
Older adults generally require fewer calories because they are not as physically active as they once were and their metabolic rates slow down. Nevertheless, their bodies still require the same or higher levels of nutrients for optimal health outcomes. Malnutrition is not synonymous with thinness. Some obese persons are also malnourished: they consume more than enough calories but insufficient nutrients essential to good health.
Functional assessment of nutrition in the older adult involves both physical and psychological factors as well as the type and quantity of food eaten. Is the patient able to bite, chew, and swallow properly? Edentulous patients may be greatly restricted in the types of food they can chew, either because they don’t or won’t wear their dentures or because the dentures do not fit properly, perhaps because of recent weight loss. Infected teeth or missing teeth also interfere with eating well, particularly fresh fruits and vegetables.
Do patients have sufficient financial, educational, visual, and neurologic resources to shop and prepare nutritious, well-balanced meals? Have they lost interest in food because the food at the long-term care facility is not appealing? Have they recently lost or gained a significant amount of weight (5% or more in 30 days, 10% or more in 180 days)?
Older adults at greatest risk for nutritional deficiencies are those with less education, low income, or who live alone or in long-term care facilities.
Chronic disease (including depression or dementia), use of three or more prescribed or OTC medications, and age over 80 years old further increase the risk of nutritional deficiencies. Residents in long-term care are at particular risk for malnutrition, especially protein-calorie malnutrition. An estimated 12% to 50% of long-term care residents are malnourished, increasing the risk of digestive, lung, and heart problems; pneumonia; and other serious infections. Malnutrition can also cause blood clots, pressure ulcers, and poor wound healing, and can worsen mental confusion and dementia.
THE DETERMINE SCREEN
Warning signs for poor nutrition include:
Tooth loss/mouth pain
Reduced social contact
Involuntary weight loss/gain
Needs assistance in self-care
Elder years, above age 80
Source: AAFP, 2005.
Older people need more of certain nutrients such as protein, calcium, and vitamin D than younger adults in order to maintain muscle strength and bone health. For example, research indicates that older adults should aim for a protein target (in grams) of half their body weight (in pounds) to protect muscle strength. In other words, someone weighing 140 pounds should have 70 grams of protein daily. Protein is particularly important for women, because it is more difficult for women than for men to replace age-related lost muscle mass as they age (Smith et al., 2008).
One study showed that seniors who consumed adequate or high levels of dietary protein and participated in resistance training not only strengthened skeletal muscles but also improved their oral glucose tolerance (Iglay et al., 2007). However, older adults tend to eat less protein because it’s easier and cheaper to fix a meal with more carbohydrates (toast and jelly rather than a scrambled egg). Meat and fish, dairy and eggs, beans, tofu, and veggie burgers are all good sources of protein.
Vitamin D and Calcium
Calcium and vitamin D are essential for bone health and reducing the risk of falls. Many older adults don’t get enough of either in their diets. Vitamin D insufficiency is highly prevalent among older adults (Barnard & Colón-Emeric, 2010) and is associated with increased risk of cardiovascular disease, depression, cognitive deficits, and mortality (Anderson et al., 2009; Stewart & Hirani, 2010; Milaneschi et al., 2010).
All of us get vitamin D from the sun, but in northern climates, especially in the winter, sun exposure is limited. Food sources of vitamin D include vitamin D–fortified dairy milk or soy milk; fish such as salmon, mackerel, and sardines; and some fortified cereals. However, it may be difficult to get enough vitamin D from food, so supplements are recommended.
Several studies have shown that daily vitamin D supplements (700–800 IU) in the diets of people in their seventies and eighties reduced the risk of falls and fractures (Bischoff-Ferrari et al., 2005; Broe et al., 2007). The International Osteoporosis Foundation recommends 800–1,000 IU per day for older adults and suggests that 2,000 IU may be needed by those who are obese, have osteoporosis, or have limited sun exposure (Dawson-Hughes et al., 2010).
Calcium deficiency in older adults is not uncommon because many have lactose intolerance and thus avoid milk and other dairy products. Experts recommend 1200 mg of calcium for both men and women age 50 and older. Sources of calcium other than dairy products include greens such as bok choy, broccoli, Chinese/napa cabbage, kale, okra, turnip and collard greens, and fortified foods (tomato, orange, and other fruit juices, and certain cereals). However, calcium supplements probably are necessary to reach the recommended amount in the diet. Caffeine interferes with the absorption of calcium, so calcium supplements should be taken at least two hours before or after
consuming caffeinated food or beverages (chocolate, coffee, tea, soft drinks).
Folate, Niacin, and Zinc
Malnourished older adults may also be deficient in folate, niacin (vitamin B3), and zinc (Anderson et al., 2009). Folate is essential to the synthesis of new cells. Gastrointestinal problems such as irritable bowel syndrome may interfere with folate absorption. Alcoholics have a high risk of folate deficiency because alcohol damages the gastrointestinal tract. The RDA of folate for older adults is 400 micrograms daily. Food sources include green leafy vegetables, dried beans and peas, liver, and orange juice, as well as bread, cereals, and other grains that are fortified with folic acid.
Niacin promotes nervous system function and acts as a coenzyme in energy metabolism. Deficiency in niacin can cause pellagra, characterized by dermatitis, diarrhea, and dementia; untreated, it can result in death. The RDA for niacin is 14 mg. Excess niacin can cause liver damage, gastric ulcers, low blood pressure, nausea, and vomiting. Food sources for niacin include all protein foods and whole grains, enriched breads, and cereals.
Zinc is a trace metal that promotes tissue growth and wound healing, protects immune function, provides vitamin A transport, and supports the sense of taste. Zinc deficiency can cause hair loss, diarrhea, delayed wound healing, taste abnormalities, and mental lethargy. Too much zinc can cause anemia, elevated LDL cholesterol, lowered HDL cholesterol, diarrhea, vomiting, impaired calcium absorption, fever, renal failure, muscle pain, and dizziness. The RDA for zinc is 11 mg for older men and 8 mg for older women. Food sources for zinc include oysters, red meat, poultry, dried peas and beans, nuts, whole grains, fortified breakfast cereals, and dairy products.
Vitamins B6, B12, and E
Vitamins B6 and B12 protect the nervous system, including memory and reasoning ability. They also decrease levels of homocysteine, which may reduce the risk of heart disease and Alzheimer’s disease. A large study by Swedish researchers found that higher levels of vitamin B12 decreased the risk of developing Alzheimer’s disease (Hooshmand et al., 2010). Deficiency of these vitamins can result in unsteady gate, muscle weakness, slurred speech, and psychosis.
Unfortunately, absorption of B6 and B12 is impaired in older people due to age-related changes in the digestive system; therefore, supplementation is necessary. The recommended daily allowance (RDA) of vitamin B6 is 1.7 mg for older men and 1.5 mg for older women. The RDA of B12 is 2.4 micrograms for women and men.
Vitamin E includes a family of eight antioxidants, but alpha-tocopherol is the only form of vitamin E considered active in the body. The RDA for vitamin E is 15 mg for both men and women. The upper tolerable limit of vitamin E is 1,000 mg per day. Research on vitamin E’s benefits has produced conflicting results, however some studies have shown that vitamin E reduces the risk of heart attack and death from cardiovascular disease.
A Dutch study of more than 5,000 people showed that those with the highest vitamin E intake were the least likely to develop dementia or Alzheimer’s disease (Devore et al., 2010). Vitamin E may also have visual benefits, decreasing the risk of cataract formation and macular degeneration.
Other studies indicate that vitamin E may improve immune function. For example, a large trial in nursing home residents found that daily supplementation with 200 IU of synthetic alpha-tocopherol for one year significantly lowered the risk of contracting upper respiratory tract infections, especially the common cold, but did not affect lower respiratory tract (lung) infections (Meydani et al., 2004).
Vitamin E deficiency is linked with physical decline in older adults (Bartali et al., 2008), including impaired balance and coordination (ataxia), peripheral neuropathy, and muscle weakness. Older adults with these symptoms should be screened for vitamin E deficiency. Food sources of vitamin E include vegetable oils (walnut, sunflower, cottonseed, safflower, canola)
nuts, whole grains, and green leafy vegetables.
Skin assessment in older persons is focused on monitoring for dryness, pruritis, signs of skin breakdown such as pressure ulcers, lesions such as bruising that could indicate abuse or unreported falls, and possible skin cancers (basal or squamous cell carcinomas or melanoma).
Clinicians need to be vigilant in inspecting both hands and feet of older adults, particularly people who have diabetes or vision or mobility problems (including obesity), which may make them unable to trim their nails and properly care for their feet. These individuals need regular care by a podiatrist, who can prevent or treat irritations and infections.
Very thin patients, those who are poorly nourished, and those who are confined to bed or a wheelchair are at greatest risk for developing pressure ulcers on bony prominences; shoulders, lower back, heels, hips, and buttocks should be carefully inspected at least once a day. In male patients, the underside of the scrotum should be examined for pressure and irritation. Avoid massaging skin on bony prominences because it can increase the risk of pressure ulcers.
Inspect the skin for brown actinic keratosis precancerous lesions, commonly found on the face, neck, and upper extremities. Untreated, these lesions may progress to squamous cell carcinomas, which are reddish dome-shaped lesions.
They may be found around the ear or on the head or neck. Basal cell carcinomas are the most common type of skin cancer, particularly in light-skinned individuals, appearing as a pearly papule with an ulcerated center; as an open sore that bleeds, oozes, or crusts for more than 3 weeks; or as a reddish patch on the chest, shoulders, arms, or legs. These cancers can be successfully treated if diagnosed early. Dark brown or black lesions may be melanoma, which can metastasize quickly and may prove fatal. Any suspicious lesions should be referred to dermatology for diagnosis.
During the physical examination, look for signs of possible abuse. Injuries may be found on many areas of the body, especially the face, throat, neck, chest, abdomen, and genitals. Note any bruises, burns, or wound patterns that resemble teeth marks, hand prints, belts, or cigarette tips. Note any pain or tenderness from touching. Be alert for puncture wounds, fractures, and dislocations, scars on the vulva or rectum, or any unexplained vaginal or anal bleeding, particularly in older people. Be aware that women may wear a glove or sock to conceal a scalded hand or foot. Women who show signs of physical abuse should also be screened for STIs, including chlamydia, human papilloma virus, gonorrhea, and syphilis.
DOCUMENTING SUSPECTED ABUSE
To be admissible in a court of law, medical documentation should include the following:
Photographs of the injuries, taken during the initial examination Body maps, which document the extent and location of the injuries Description of the patient’s demeanor (crying, angry, agitated, upset), including a record of the patient’s comments about how the injuries occurred (the patient’s own words should be set off in quotation marks or identified by such phrases as “the patient states” or “the patient reports”)
Any description in which the patient identifies the abuser, such as “my boyfriend kicked me” The time of day when the patient is examined and, if possible, how much elapsed time since the injuries occurred (e.g., “patient says that last night her husband punched her”) Legible handwriting (too often, doctors’ or nurses’ poor handwriting on medical records makes the documentation inadmissible as evidence) Source: Isaac & Enos, 2001.
When assisting patients in bathing themselves, avoid hot water and offer a mild cleansing agent that minimizes irritation and dryness of the skin. Minimize the force and friction applied to the skin. The frequency of bathing should be individualized according to need and/or patient preference. Minimize environmental factors leading to skin drying, such as low humidity (less than 40%) and exposure to cold. Dry skin should be treated with moisturizers.
Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, provide underpads or briefs made of materials that absorb moisture and present a quick-drying surface to the skin. Topical agents that act as barriers to moisture can also be used.
Urinary incontinence becomes more prevalent among both men and women as they age. The precise incidence of incontinence is unknown because shame and embarrassment make patients hesitant to talk with their physicians about it. Many physicians don’t screen for it, either sensing the patient’s embarrassment or because of limited time. However, when a health professional asks, “Do you have any problems with leakage of urine?,” those who experience incontinence will generally acknowledge it.
Screening for incontinence is essential because non-pharmacologic therapeutic measures can reduce or eliminate the condition, preventing complications such as skin breakdown, urinary tract infections, and withdrawal from social activities, which can lead to isolation.
Incontinence can be transient (potentially reversible) or chronic. Age-related changes in the urinary tract are only one of several factors contributing to incontinence. Potentially reversible factors include those summarized in the mnemonic DIAPPERS:
Delirium, which is the primary cause of incontinence in hospitalized patients (Those affected may not recognize the need to urinate or be unable to find a toilet or urinal. Once the delirium is resolved, so is the incontinence.) Infection in the urinary tract (UTI) that leads to urgency and incontinence Atrophic urethritis and vaginitis
Pharmaceuticals (as well as alcohol and caffeine)
Psychological factors (such as depression)
Excess urinary output (caused by diabetes, use of diuretics, or excess fluid intake, especially of alcohol and caffeinated beverages) Restricted mobility, because the patient is unable to reach the toilet in time to avoid leakage (Restoring or improving mobility can resolve the incontinence. Otherwise a bedside commode or urinal should be provided.) Stool impaction (Can cause temporary confusion, leading to incontinence of both urine and stool.
Removing the impaction generally restores continence.) People with diabetes are at high risk for incontinence due to neuropathy that affects pelvic nerves. Other high-risk groups include those with Parkinson’s or stroke-related neurologic problems, women with relaxed pelvic muscles, and men who have had prostate surgery. By observing how long it takes from intake to urinary output, caregivers can intervene at the appropriate time for toileting. Controlling UTIs also helps prevent incontinence.
Preventing incontinence is based on keeping the bladder empty by frequent toileting, bladder retraining, and in some cases, catheterization. However, limiting fluid intake (except in the evening) can cause dehydration, requiring other measures. Review of medications may identify one or more drugs that contribute to incontinence (see below); if it is not feasible to discontinue the drug(s), substituting another drug may help reduce incontinence.
MEDICATIONS ASSOCIATED WITH INCONTINENCE
Reserpine (Diupres, Hydropres)
Thioridazine, chloropromazine (Thorazine)
Anti-anxiety and muscle relaxant drugs
Benzodiazepines (Valium, Xanex, Klonopin)
Diuretics (water pills)
Furosemide (Lasix) or hydrochlorothiazide (Diuril)
Drugs that cause incomplete bladder emptying
Hyoscyamine (Cystospaz, Urised, Donnatal, Levbid, Levsin)
Drugs that increase stress incontinence
Any drug that includes a side effect of producing a chronic cough (e.g., anti-hypertensive drugs such as Vaseretic, Vasotec, Lotensin, Monopril, Zestril). Research indicates that behavioral modification should be the first-line therapy for incontinence in older patients. Pelvic floor exercises are helpful for stress incontinence, while bladder training is helpful for urge incontinence. Both modalities are helpful when the patient has both types of incontinence (Dumoulin & Hay-Smith, 2008).
Drug treatment for stress incontinence is limited, although some experts recommend a trial of topical estrogen for women with symptomatic atrophic urethritis. Surgery is considered a last resort, particularly in very elderly women, although the success rate is 75% to 85% even in older women (Johnston et al., 2010).
Stress incontinence is a particular problem for any older woman with a cough, either chronic or temporary. The patient will likely need protection for her clothing to prevent the odor of stale urine. Wearing a panty liner or sanitary pad should be tried before selecting bulkier incontinence garments. Frequent careful cleaning of the genital area can prevent odor and skin breakdown. If the patient is unable to clean herself, the care provider must do so.
When confusion and incontinence occur together, controlling the confusion may also help prevent incontinence. However, research suggests that patients who are taking medications for dementia (e.g., cholinesterase inhibitors) should not also take medications for incontinence (e.g., anticholinergic drugs) because the interaction of these two types of drugs can hasten functional decline (Sink et al., 2008). This finding has major public health implications because an estimated one third of people with dementia also take a drug for incontinence.
Assessing Psychosocial Function
Socially isolated older persons are difficult to find. Like other vulnerable older persons, they tend to be invisible. —GUSMANO & RODWIN (2006)
As the late Bette Davis said, “Getting old is not for sissies.” Whether life changes are slow or sudden, the result often affects both physical and mental health. For example, death, injury, or serious illness of a partner can alter living circumstances, social support, and economic security. These changes can lead to isolation, depression, and suicide among vulnerable elders.
Social isolation can be hazardous to health, particularly in older adults. One in 3 Americans lives alone, and 1 in 4 of those are typically older women who live in poverty and report poor health. These women are at higher risk for institutionalization and loss of independence—as well as heart disease, memory problems, depression, and suicide—than someone living with a spouse or other companion.
Living alone does not always mean being lonely or isolated, but health professionals need to be aware of the possibility. Risk factors for social isolation include low self-esteem, a history of abuse or homelessness, depression, chronic pain, incontinence, and mobility problems.
Research shows that having social networks and participating in social activities protects cognitive function and reduces dementia incidence, particularly among older women (Ertel et al., 2008; Crooks et al., 2008). Measures to increase social engagement include referral to a support group, telephoning or emailing friends, or adopting a pet. Another strategy would be to contact a volunteer visitation organization (such as Little Brothers-Friends of the Elderly in Boston and other cities or New York’s DOROT) that matches older adults who live alone with volunteer visitors.
Institutionalized elders may also be socially isolated because of their health problems or because they have no family to visit them. As mentioned earlier, loneliness is one of the three plagues of living in a nursing home. Volunteer visitation and pet therapy can also help reduce isolation among these elders.
Depression is a widely under-recognized and undertreated medical illness in older adults. Estimates of major depression in older people living in the community range from 1% to 5%, but the rate may rise as high as 42% among those in long-term care facilities (Blazer, 2003; Djernes, 2006). “Depressive disorder is not a normal part of aging. Emotional experiences of sadness, grief, response to loss, and temporary blue moods are normal. Persistent depression that interferes significantly with ability to function is not” (National Institute of Mental Health, 2010a).
Depression can be immobilizing and can interfere with normal sleep, nutritional intake, thinking and concentration, and quality of life. Therefore, depression contributes indirectly to a decline in physical and mental health. In fact, a number of studies have shown that depression is an independent risk factor for falls.
Recognizing the symptoms of depression in older people and referring them for appropriate treatment may greatly improve their quality of life. Symptoms include:
Sleep disturbance and fatigue
Changes in physical activity, ranging from slowing down to agitation or hyperactivity Loss of interest in living
Hopelessness about the future
Changes in appetite and/or weight
Inability to concentrate or make decisions
Complaints about poor memory and concentration
(Fiske et al., 2009)
Treatment for depression may include behavioral therapy, cognitive behavioral therapy, problem-solving therapy, brief psychodynamic therapy (also called insight-oriented therapy), life review (also called reminiscence therapy); however, these therapies are used too infrequently with older adults (Fiske et al., 2009).
Antidepressant medications may also be used but, unless accompanied by some form of psychotherapy, may not be effective (O’Connor et al., 2009.). In addition, antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs), increase the risk of falls (Kerse et al., 2008). If antidepressant medications are prescribed, care providers need to redouble efforts to prevent falls. Strategies include exercises to strengthen lower leg muscles and balance retraining, as well as home assessment and modification as needed.
Depression is one of the conditions most commonly associated with suicide. According to the National Institute of Mental Health (2010b), older Americans are disproportionately likely to die by suicide. The rate of suicide among people age 65 and older is higher than the national average. The incidence of suicide is highest among non-Hispanic white men, and guns are the most frequently used method. Among females, the incidence of suicide is highest among Asian Pacific Islanders. Suicide is most common among older adults who are divorced or widowed.
Risk factors for suicide in people age 65 or older include:
Chronic or terminal illness
Alcohol or drug abuse
History of other suicide attempts
Family history of suicide
Preoccupation with suicidal talk and plans
Preventing suicide depends on early recognition of suicidal intent and treating physical and psychiatric conditions, reducing social isolation, enhancing self-esteem, and helping people find meaning or satisfaction in life. Health professionals and family caregivers need to pay attention to statements such as “I’d be better off dead” or “I don’t want to live.” These suggest a need for counseling by a mental health professional.
Feeling helpless, hopeless, and worthless can lead to thoughts of suicide and, in some cases, committing suicide. “People who feel helpless need empowerment. People who feel worthless need to experience their own value to the folks who matter in their lives. People who feel hopeless need to see beyond today” (Hamilton, 2008).
CONFUSION AND COGNITION
Who among us has not been confused at one time or another? Losing our sense of direction when traveling in an unfamiliar city, waking up in the hospital after a serious car accident, becoming disoriented after hearing the news of a death in the family—all can cause confusion.
When we are young, or even middle-aged, confusion is considered temporary and reversible. In older adults, however, confusion is too often regarded as the first step on the road to dementia and “senility.” As Wolanin (1981) wrote, “Diagnosis often becomes prognosis, as health professionals use stereotypes for shaping their planning.” Labeling confusion as cognitive impairment can have life-altering effects on patients and affect their treatment socially, legally, medically, and psychologically.
Some forms of confusion may be temporary or reversible, while others may be irreversible or indicative of chronic confusion and dementia, including Alzheimer’s disease.
Gradual onset of confusion may be reversible if it is related to a treatable or correctible condition such as nutritional deficiency, hypothyroidism, vision or hearing impairment, or depression. Careful assessment is needed to avoid misdiagnosis and thereby perpetuate the confusional state. Health professionals need to assume that confusion may be reversible, particularly confusion of sudden onset, and seek the possible causes.
CAUSES OF REVERSIBLE CONFUSION
Dehydration and fluid/electrolyte imbalance
Drug related intoxications
Pellagra (niacin deficiency)
Obstruction to cerebral blood flow
Increased intracranial pressure
Brain cell death or loss
Sensory deprivation related to vision or hearing impairment
Sensory overload in noisy, crowded settings
Lack of variety, lack of personal contacts, and lack of meaning, especially in institutional settings Relocation/transfer from familiar surroundings to unfamiliar surroundings CASE Agnes Miller, age 86, is a widow who has lived alone successfully for years in her small apartment. She slipped and fell in her kitchen, fracturing her hip
. The fall also broke her glasses and dislodged her hearing aid, which slid out of reach under the kitchen table. Unable to reach the telephone, Agnes lay on the floor and shouted for help, hoping that a neighbor would hear her. It was a cold day and all windows were closed, so nearly 24 hours passed before someone heard her and dialed 911.
Paramedics whisked Agnes off to the hospital, leaving her broken glasses on the kitchen table and failing to notice her hearing aid underneath. Arriving in the ED, Agnes was weak, disoriented, and had difficulty hearing and responding to questions. She had been without food or water and was shivering and in pain. After her condition was stabilized with IV fluids and warm blankets, she was prepped for surgery to repair her hip.
A few days later she was moved to a long-term care facility, still without her glasses or her hearing aid. Her medical record indicated “confusion” and “disorientation.” Fortunately, a nurse at the long-term care facility was able to communicate with Agnes and learned about the missing glasses and hearing aid. By contacting Agnes’s neighbor, she was able to get the hearing aid and order new glasses. Over the next week or two, Agnes once again became alert, responsive, and communicative.
Researchers have found that the brain’s ability to selectively focus (called visual attention) while screening out irrelevant or distracting information diminishes with age. Instead of remembering only the important information, the brain also remembers the unimportant information. For example, searching for car keys on a cluttered table is more difficult than seeing them without the clutter. This phenomenon may account for some aspects of confusion in the elderly (Schmitz et al., 2010).
Delirium is an acute confusional state of rapid onset characterized by clouding of consciousness, disorientation, memory impairment, incoherent speech, and perceptual disturbance. Delirium can be caused by serious illness such as an infection, coronary ischemia, hypoxemia, fever, hypothermia, toxic-metabolic conditions, medication interactions, use of restraints, use of intravenous lines or urinary catheters, intracranial lesions, trauma, sensory deprivation, alcoholism, or stress.
Delirium is not unusual in older adult hospitalized patients, and it may progress to chronic confusion. According to Johnston and colleagues (2010), about one fourth of patients with delirium have dementia and about 40% of hospitalized people with dementia experience delirium.
Mild Cognitive Impairment (MCI)
Impairments in financial skills and judgment are often the first functional changes demonstrated by patients with incipient dementia. —TRIEBEL ET AL. (2010)
Mild cognitive impairment is a transitional state between the normal cognitive changes of aging and the development of Alzheimer’s disease (AD) or other dementia. Two subtypes of MCI have been established. Amnestic MCI is characterized by memory problems. Nonamnestic MCI affects cognitive functions other than memory, such as language, attention, critical thinking, reading, and writing. Experts estimate that MCI may affect more than 20% of the population over age 65. People diagnosed with MCI are at increased risk of developing AD or other dementias.
Researchers at the Mayo Clinic found that MCI was more prevalent in men than in women, and more than twice as many of the study participants had the amnestic form of MCI. Prevalence of MCI was higher among those with the APOE e4 gene, a known risk factor for late onset Alzheimer’s. More years of education was associated with decreased prevalence of MCI. Being single wasassociated with higher prevalence of MCI compared with being currently or formerly married (Petersen et al., 2010).
In 2001, the American Academy of Neurology (AAN) established the following criteria for an MCI diagnosis:
An individual’s self-report of memory problems, preferably confirmed by another person Measurable, greater-than-normal memory impairment detected with standard memory assessment tests Normal general thinking and reasoning skills
Ability to perform normal daily activities
Ongoing research on MCI suggests that earlier treatment with drugs approved for AD may slow its progression to AD. A 3-year, placebo-controlled clinical trial of more than 750 patients with amnestic MCI showed that donepezil (Aricept) reduced the risk of developing AD during the first year (Petersen et al., 2005). However, by the end of the three-year study, the risk was the same as those in the placebo group. Nevertheless, delaying the progression to AD by a year represents a significant reprieve for both patients and caregivers in terms of maintaining function and quality of life as well as reducing healthcare costs.
SCREENING FOR COGNITIVE IMPAIRMENT
The Mini–Mental State Examination (MMSE) is one of a number of screening tools for cognitive impairment and dementias. It measures an individual’s reality orientation, registration abilities, attention and calculation skills, recall, language, and visuoconstruction (seeing and copying designs) abilities.
The highest possible score is 30 points. Those who score less than 25 need further evaluation for possible AD or other dementias, depression, delirium, or schizophrenia. Those who score 20 or less generally have one of these disorders.
MINI–MENTAL STATE EXAMINATION
1. Orientation to time and place10The patient is asked to provide information on the time (e.g., year, season, month, date, and day of week). (1 point each) The patient is asked to provide information on the present location (e.g., state, county, city, hospital, floor). (1 point each) 2. Registration3The patient is asked to repeat three named prompts. (1 point each) 3. Attention and calculation5The patient is asked to spell WORLD backwards. (points given up to first misplaced letter, e.g., 2 points for “DLORW”) 4. Recall3
The patient is asked to recall the three objects memorized in “registration” above. 5. Language2The patient is asked to name two objects when they are displayed (pencil and watch). (1 point each) 6. Repetition1The patient is asked to speak back a phrase (“No ifs, ands, or buts”). (1 point) 7. Complex commands6The patient is asked to follow complex commands, which may involve drawing a shown figure. (6 points) Alzheimer’s Disease (AD) and Other Irreversible Dementias
No matter who you are, how old you are, what you’ve accomplished, what your financial situation is—when you’re dealing with a parent who has Alzheimer’s, you feel powerless. And as the disease unfolds, you feel ever more powerless because you don’t know what to do or what to expect. —MARIA SHRIVER (2010)
Alzheimer’s disease is an age-related, irreversible brain disorder that gradually erases memory, thinking, understanding, and sense of self. Over time, as neurons die in widespread areas of the brain’s cerebral cortex, mild sporadic memory loss evolves into severe cognitive dysfunction as well as behavior and personality changes and, eventually, loss of physical function. The course of AD and the rate of decline vary from person to person. On average, clients with AD live for 8 to 10 years after diagnosis but may live as long as 20 years.
Although the risk of developing AD increases with age, AD and other dementia symptoms are not a part of normal aging but the result of diseases that affect the brain. In the absence of disease, the human brain can function
well into the tenth decade of life.
Alzheimer’s disease is one of a group of disorders called dementias, which are characterized by progressive cognitive and behavioral changes. Symptoms commonly appear after age 60, beginning with loss of recent memory, followed by faulty judgment and personality changes. People in the early stages of AD often think less clearly and may be easily confused.
In progressive stages of the disease, people with AD may forget how to manage ADLs. In the late stages, people with AD are unable to function on their own and become completely dependent on others for their everyday care. Finally, they become bedfast and succumb to other illnesses and infections. Pneumonia is the most common cause of death in AD.
CAUSES AND PREVENTION
Alzheimer’s disease has no single, clear-cut cause and therefore no sure means of prevention. Scientists believe that AD results from the interaction of genetic, environmental, and lifestyle factors over many years, causing changes in brain structure and function.
A number of factors can contribute to declines in cognitive function:
Stroke or transient ischemic attacks (TIAs)
Presence of infarcts or white-matter lesions
Low mood (depression)
Higher body mass index (BMI)
Traumatic brain injury
Head injury in early adulthood
Smoking more than two packs of cigarettes per day
Exposure to lead and other metals (aluminum, methylmercury, iron, zinc,
Extremely low-frequency electromagnetic fields
(Bolin et al., 2006; Zawia & Basha, 2005; Basha et al., 2005; Hendrie et al., 2006; Rusanen, et al., 2011) Factors that protect cognitive function include:
Higher levels of education
Higher socioeconomic status (SES)
Better baseline cognitive function
Better lung capacity
More physical exercise
Moderate alcohol use
Use of vitamin supplements, especially B12
Preventing AD would save untold suffering of patients and families and billions of dollars for the healthcare system. Research studies to identify factors that increase or decrease the risk of developing AD are a first step toward making primary prevention a reality. For example, lifestyle choices related to diet and exercise that reduce the risk of diabetes, hypertension, stroke, and obesity could also reduce the risk of AD. Avoiding tobacco products is also important.
A large study in Sweden showed that smoking more than two packs of cigarettes per day doubled the risk of developing AD (Rusanen et al., 2010). Reducing human exposure (particularly among children and workers) to lead and other metals, pesticides, and electromagnetic fields could also reduce future incidence of AD.
DIAGNOSIS, CARE, AND TREATMENT
Alzheimer’s disease remains a diagnosis of exclusion, ruling out other conditions that may cause similar symptoms, such as stroke, hypothyroidism, depression, nutritional deficiency, brain tumor, Parkinson’s disease, or inappropriate medications.
Conclusive diagnosis of AD is still only possible at autopsy. However, researchers have reported some success in identifying proteins called biomarkers in the blood and spinal fluid that can provide earlier probable diagnosis of the disease. Combined with more accurate
neuropsychological testing and neuroimaging techniques such as positive emission tomography (PET) scans and magnetic resonance imaging (MRI), these advances enable clinicians to more accurately predict who will develop AD.
Care and treatment of the person with AD will change over time as the disease progresses. Care planning should begin at the time of diagnosis and should involve the patient and the family. The plan includes:
Cholinesterase inhibitor therapy to temporarily improve cognition or slow the rate of cognitive decline Management of co-morbid conditions, especially sensory deficits Treatment of behavioral symptoms and mood disorders
Support and resources for patient and caregiver
Discussion of advance directives
Compliance with state-mandated reporting requirements for driving impairment and elder abuse (Cummings et al., 2002)
The box below presents suggestions for creating and maintaining a supportive environment when caring for a person who has dementia.
CREATING A SUPPORTIVE ENVIRONMENT
Make change very slowly. Carefully prepare the person for any change in medications, nutrition, therapy, personnel, or location. Keep the patient active as long as possible. Daily exercise, outdoors if possible, helps maintain physical and emotional function. Maintain a routine. A dependable world and a structured life are reassuring. Provide social stimulation without overload. Encourage and maintain communication through every possible channel. Avoid crowds and large spaces without boundaries. Try to prevent sensory overload and provide easily visible boundaries and interior landmarks.
Monitor nutrition, attention to mouth and teeth, and footwear. Help with eating and oral hygiene to reduce the risk of infection. Comfortable, well-fitting shoes with nonslip soles help prevent falls. Keep activities and conversations simple. Avoid complexity; it creates confusion and anxiety. Provide positive input. Praise and compliments for any achievement help maintain self-esteem and encourage self-participation in activities of daily living. Provide reality checkpoints: calendars with large days and dates, clocks with large numbers marking the hours, and reminders of special events such as birthdays, anniversaries, and holidays.
Support bowel and bladder control. A consistent toileting routine helps preserve function and control. Use clothing with simple fasteners like Velcro or pants with elastic waistbands. Support family caregivers. Commend their efforts, refer them to support groups and respite care, and assist them in creating a helping network. Provide information and referrals for legal assistance such as drawing up advance directives for end-of-life care. Source: Wolanin & Phillips, 1981.
Until it becomes necessary to institutionalize the patient, the primary caregiver will most likely be the spouse (usually the wife) or a child (usually a daughter). That caregiver and other family members involved need education and support to help manage the care as the patient’s symptoms and needs change.
Patients receiving collaborative care from an interdisciplinary team or primary care providers working with the patient’s family caregiver have been shown to exhibit fewer behavioral and psychological symptoms of dementia than receiving usual care. Family caregivers also benefited, showing significant reduction in distress and improvement in depression. Researchers reported that these improvements “were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics” (Callahan et al., 2006).
When talking with older patients, especially those with dementia, health professionals and family caregivers should use a respectful, adult communication style rather than the baby talk that many well-intentioned caregivers use. Avoid a high-pitched, sing-song voice; terms like “sweetie,” “honey,” and “dearie”; and saying things like “Are we ready for our bath?” This style of communication can cause dementia patients to be uncooperative and resistant to care (Williams, 2008). Resistance to care includes pushing away, grabbing things, crying and screaming, and hitting and kicking.
Caring for someone with AD should include periodic assessment of the person’s ability to function as the disease progresses. Researchers at Duke University developed the Functional Dementia Scale (see below) to help caregivers monitor functional abilities and plan appropriate interventions.
FUNCTIONAL DEMENTIA SCALE
Source: Moore, 1983.
Position or relation to patient:
(Circle one rating for each item)
1 = None or little of the time, 2 = Some of the time, 3 = Good part of the time, 4 = Most or all of the time QuestionRatingTask
1.1 2 3 4Has difficulty completing simple tasks on own, e.g., dressing, bathing, doing arithmetic. 2.1 2 3 4Spends time either sitting or in apparently purposeless activity 3.1 2 3 4Wanders at night or needs to be restrained to prevent wandering 4.1 2 3 4Hears things that are not there
5.1 2 3 4Requires supervision or assistance in eating
6.1 2 3 4Loses things
7.1 2 3 4Appearance is disorderly if left to own devices
8.1 2 3 4Moans
9.1 2 3 4Cannot control bowel function
10.1 2 3 4Threatens to harm others
11.1 2 3 4Cannot control bladder function
12.1 2 3 4Needs to be watched so doesn’t injure self, e.g., careless smoking, leaving the stove on, falling 13.1 2 3 4Destructive of materials around self, e.g., breaks furniture, throws food trays, tears up magazines 14.1 2 3 4Shouts or yells
15.1 2 3 4Accuses others of doing self bodily harm or stealing possessions (when you are sure the accusations are not true) 16.1 2 3 4Is unaware of
limitations imposed by illness
17.1 2 3 4Becomes confused and is not oriented to place
18.1 2 3 4Has trouble remembering
19.1 2 3 4Has sudden changes of mood, e.g., gets upset, angry, or cries easily 20.1 2 3 4If left alone, wanders aimlessly during the day or needs to be restrained to prevent wandering SUPPORTING FAMILY CAREGIVERS
Two thirds of older people who need long-term and end-of-life care rely on family and friends for assistance. Almost one third supplement family care with help from paid providers. Family caregivers also bear an enormous burden in caring for a loved one at the end of life. They play a major role in actual care and in decision making about care provided by others.
Care provided by family and friends can make the difference between living at home and going to a nursing home or other long-term care facility. Likewise, reducing the burdens of caregiving can delay the need for nursing home care. Respite care, caregiver support groups, and skills training interventions can further reduce caregiver burden.
The caregiver experience holds a host of emotions, ranging from sadness, resentment, anger, and a sense of inadequacy, to deep gratitude for being able to care for the loved one. Physical exhaustion, inadequate sleep, disrupted routines, and endless responsibility can lead to mental health problems such as anxiety and depression. Nurses and other healthcare providers need to be aware of signs of depression or other mental health problems in caregivers and recommend that they take time to seek treatment.
Demands on caregivers’ time are significant. Most caregivers are women—wives, daughters, or other women, many of whom are juggling childcare, jobs, and other responsibilities. Many women are forced to work fewer hours outside the home, pass up a job promotion, switch from full-time to part-time employment, or even quit their jobs or retire early to provide care for an older loved one. These changes can affect women’s lifetime income, retirement security, and their own needs for long-term care.
Physical health is also impaired by caregiving. Problems such as coronary heart disease, hypertension, poor immune function, cancer, and increased risk of mortality can result (Christakis & Allison, 2006). Middle-aged or older women may not have the training or physical stamina necessary to lift, move, or turn terminally ill loved ones. Without professional help, this puts them at serious risk of physical injury. Clinicians need to anticipate this risk and offer assistance with physically strenuous aspects of care.
Caring for an older person at home inflicts financial stress on families of even moderate means. Paying for medications, purchasing consumable supplies, or modifying the home environment to prevent falls or to accommodate a wheelchair can create a financial hardship for families. Some may spend as much as 10% of their annual income on caregiving as well as sacrificing their savings.
Minority and low-income caregivers bear the greatest burden because they are less likely to be able to afford paid home care assistance or to enjoy a respite from their caregiving responsibilities. Even though the Medicare hospice benefit relieves some of the financial burden of end-of-life care, families can still face severe economic consequences and personal sacrifices.
LEGAL AND ETHICAL CONSIDERATIONS
Getting legal affairs in order—drawing up advance directives, powers of attorney, wills, or trusts—is important for all adults, regardless of health status. For those diagnosed with AD or other dementia, legal affairs should be taken care of as soon as possible after diagnosis, while the patient is able to participate in decisions. This helps ensure that one’s wishes are respected in end-of-life care and disposition of property after death. Otherwise, families will need to make difficult decisions without knowing the patient’s wishes.
Referral to the local chapter of the Alzheimer’s Association can help families find attorneys who specialize in elder law or estate planning. This referral should not be made abruptly but as a suggestion, emphasizing the universal need for such a plan.
An advance directive specifies a person’s preferences for care in the event that he or she is unable to communicate those wishes—for example, in the advanced stages of AD. A living will is one type of advance directive. In an advance directive, the person can also name a representative to see that his or her wishes concerning care are carried out. This is sometimes called a durable power of attorney for healthcare.
Physicians should have copies of advance directives available or be able to refer families to a source for the appropriate forms. Federal law requires hospitals to inform patients that they have a right to complete an advance directive (the Patient Self-Determination Act), but advance directives are regulated by state law and may differ from state to state.
Health professionals who see evidence of cognitive impairment in a patient should ask the spouse, partner, or other family member whether anyone has been designated to act on the patient’s behalf in managing his or her financial affairs, such as paying bills. This requires a general power of attorney, which does not include healthcare decisions. Designating a trusted family member or friend as a general power of attorney helps ensure that the patient’s financial affairs will be handled appropriately rather than exploited, a common type of elder abuse. If the patient has no family or friends, an attorney or an officer of a bank may serve this role.
A patient who has no spouse, partner, or other family member to fulfill this role may need both a guardian and a conservator, both of whom are appointed by the court. The guardian is responsible for the health and safety of the patient, and the conservator is responsible for controlling the financial affairs of the patient.
Family Caregiver Alliance can provide state-specific information and appropriate forms for advance directives (see “Resources” below).
CPR vs. DNAR Orders
Do-not-attempt-resuscitation orders (DNAR) (formerly known as “do-not-resuscitate orders”) have been renamed to emphasize the minimal likelihood of successful cardiopulmonary resuscitation (CPR). Patients and families need to understand not only the unlikely success of resuscitation but also the risks involved, which include fractured ribs, damaged internal organs, and neurologic impairment. Although the patient (or family) must ultimately decide about whether to attempt CPR, healthcare providers need to explain that withholding CPR does not equate with letting someone die.
Rather, as one physician suggested, a DNAR order should be considered an Allow Natural Death order, “which is the right thing to do in many cases” (Borenstein, 2008).
The DNAR order should be readily available in the event of an emergency to ensure that the patient’s wishes will be honored. It should be posted prominently, either on the head or foot of the bed, or if the patient is at home, on the refrigerator. The specifics of the order should also be carefully documented in the patient’s chart. Some patients prefer the additional safeguard of wearing a bracelet or necklace to alert care providers that a DNAR order is in force.
Physician Orders for Life-Sustaining Treatment (POLST)
Several states have adopted an advance directive form developed in Oregon and known as POLST, which stands for Physician Orders for Life-Sustaining Treatment (2005). This simple form, to be completed and signed by both patient and a physician or nurse practitioner, specifies the patient’s preferences concerning measures such as antibiotics, artificial nutrition (including tube feeding) and hydration, CPR, comfort measures, and mechanical ventilation/respiration.
The form is printed on bright-colored paper and stays with the patient during transfers from one care setting to another. Patients at home keep the POLST form on the refrigerator or where emergency responders can easily find it.
Long-term care facilities retain POLST forms in residents’ charts. Information about POLST programs in each state is available online at http://www.polst.org.
Artificial Nutrition and Hydration (ANH)
People with advanced Alzheimer’s disease or other dementias eventually forget how to feed themselves or even how to eat. These patients should be considered terminal, and care providers need to help families understand that forgoing artificial nutrition and hydration is not “killing” or “starving” the patient. People with advanced dementia are unlikely to benefit from tube feeding, either in terms of survival or quality of life. On the contrary, tube-fed patients with dementing illnesses have higher incidence of lung infections and agitation, which requires physical restraints and sedation, resulting in painful skin breakdown.
Despite evidence that feeding tubes cause more harm than help to the patient with advanced dementia, the practice continues. Research has shown that some nursing homes promote the idea of ANH for financial reasons. “System-wide [reimbursement] incentives favor use of tube feeding and may influence substitute decision-makers, bedside clinicians, gastroenterologists and administrators regardless of patient preferences or putative medical indications” (Finucane et al., 2007).
Reporting Unsafe Driving
Families are usually the first to notice unsafe driving behaviors in their older loved one but often find it difficult to convince the person to stop driving. Whether the problem is vision impairment, dementia, or some other health condition, there often comes a time when an older adult is no longer a safe driver.
Some patients willingly stop driving; others are reluctant to give up the independence that driving represents, thereby creating a significant threat to personal and public safety. Those who refuse to quit driving even though
they pose a hazard must be prevented from driving by other means, either by hiding the car keys or disabling the car. If family members can’t convince the impaired driver to stop driving, their physician needs to intervene.
Although many states encourage physicians and other health professionals to report people with conditions that may affect their ability to drive safely, only six states have mandatory reporting requirements for physicians to report specific conditions such as seizure disorders and AD, among other disorders: California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania. Health professionals need to know the reporting requirements in the state where they practice (AMA, 2010).
In Florida, any physician, person, or agency knowing of a licensed driver’s (or applicant’s) mental or physical disability to drive is authorized to report this to the Department of Highway Safety and Motor Vehicles. “Such reports are confidential and used only to determine the qualifications of the individual to operate a motor vehicle on Florida’s highways. No civil or criminal action may be brought against any physician, person, or agency for providing this information” (Florida DHSMV, 2003).
Abuse of older adults is a well-kept secret in the United States. Abuse may be physical, emotional, financial, sexual, or by neglect or abandonment. The actual prevalence of elder abuse is unknown; experts suggest that only 1 in 5 cases of abuse are reported. However, prevalence was recently reported at more than 11% in people over 60 (Acierno et al., 2010).
TYPES OF ELDER ABUSE
Source: Administration on Aging, 2010.
PhysicalInflicting physical pain or injury on a senior, e.g., slapping, bruising, or restraining by physical or chemical means EmotionalInflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts, e.g., humiliating, intimidating, or threatening SexualNon-consensual sexual contact of any kind
NeglectFailure by those responsible to provide food, shelter, healthcare, or protection for a vulnerable elder ExploitationIllegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else’s benefit AbandonmentDesertion of a vulnerable elder by anyone who has assumed responsibility for care or custody of that person Self-neglectFailure of a person to perform essential self-care tasks, which failure threatens his/her own health or safety Most known perpetrators of abuse and neglect are family members, usually an adult child or a spouse (Hildreth et al., 2009).
Most abuse happens in the elder’s own home. However, abuse also occurs in long-term care facilities. One recent study showed that nursing homes have the highest rates of all types of abuse, while paid home care had high rates of verbal abuse and assisted-living facilities had high rates of neglect (Page et al., 2009).
Financial exploitation is a serious risk for elders with any degree of cognitive impairment. Unscrupulous individuals, including family members, friends, attorneys, and financial advisors, have taken advantage of older people with impaired judgment and financial acumen. Many older people have lost their homes and their life savings because of financial exploitation. The Internet has increased the opportunity for scam artists to prey on elders who may be cognitively impaired.
People with Alzheimer’s disease or other cognitive impairment as well as people with disabilities are at higher risk than other older adults. Caring for a person with AD can cause stress, depression, feelings of isolation, financial worries, and substance abuse, any or all of which can lead to elder abuse. Violent behavior by the patient may also lead to physical abuse by the caregiver. Respite care for the patient and support group and counseling for the caregiver can help prevent elder abuse. In severe cases, it is usually necessary to separate the patient from the caregiver, initiate legal action, and find a safe facility for the patient.
A study of 600 women ages 50 to 64 found that more than 5% experienced some form of abuse by their partners within the two years prior to the study. Women on public assistance reported even higher proportions of intimate partner violence (IPV), as did those who had a recent history of homelessness (Somanti & Shibusawa, 2008). Women over 80 are the most frequent victims of abuse.
Risk factors for elder abuse include:
Lack of social support and isolation
Cognitive impairment, including Alzheimer’s or other dementias Mental health problems of abusers or victims
Abuse of alcohol or other drugs by abusers or victims
Polypharmacy or inappropriate use of medications
Screening and Reporting
Health professionals should be alert to any indication of elder abuse. Signs of physical abuse include bruises, skin wounds, burns or fractures, and lack of explanation for falls and injuries. Physical signs of neglect include severe weight loss, dehydration, poor personal hygiene, and pressure ulcers (bedsores).
Home care workers and prehospital care providers (paramedics) also need education on the signs and symptoms of elder abuse and neglect. In Maryland, one fourth of prehospital care providers surveyed defined elder abuse as a social problem, not a medical problem. One third of respondents indicated that they would suspect dementia, depression, or other reasons rather than abuse for a report of sexual assault in an elderly patient (Rinker, 2009).
The University of Maine Center on Aging (2007) developed a brief protocol for screening older patients for domestic abuse and violence. The center recommends that all patients 60 years old and older be routinely screened at least once a year for elder mistreatment. The protocol consists of a brief introduction followed by six questions:
Has anyone close to you called you names or put you down recently? Are you afraid of anyone in your life?
Are you able to use the telephone any time you want to?
Has anyone forced you to do things you didn’t want to do?
Has anyone taken things or money that belong to you without your OK? Has anyone close to you tried to hurt you or harm you recently? Patients should have the opportunity to respond to the questions in a confidential setting outside the presence of the patient’s family, caregiver, or the person who brings the patient to the appointment.
Nurses and physicians in all settings where older people receive care need to be aware of the possibility of elder abuse as well as their legal requirements for reporting the abuse to the appropriate government agencies. Anyone can and should report suspected elder abuse to the local adult protective services agency. State reporting numbers are available at the National Center on Elder Abuse website (see “Resources” below).
END-OF-LIFE CARE AND HOSPICE
Americans are reluctant to talk about death or to express their wishes about end-of-life care. But avoiding these subjects imposes a costly ignorance, which can mean less than optimal care and diminished quality of life for those who are dying and for their families. According to the National Hospice and Palliative Care Organization (NHPCO), three fourths of Americans do not know that hospice care can be provided in the home. The vast majority do not realize that the Medicare hospice benefit guarantees comprehensive high-quality care at little or no cost to terminally ill Medicare beneficiaries and their families.
Many people think hospice care means “giving up,” that it will shorten survival. However, research suggests the opposite—the mean survival was 29 days longer for hospice patients than for non-hospice patients. For hospice patients with congestive heart failure, lung cancer, and pancreatic cancer, the survival was significantly longer than for non-hospice patients with the
same conditions (Connor et al., 2007).
When the patient asks, “How long do I have?” the physician often cannot answer with certainty. One study showed that only 20% of physicians’ estimates of survival time were even approximately accurate (Christakis & Lamont, 2000); more than half were overly optimistic. An estimated 1 in 10 patients who enter hospice care are discharged alive by their own choice. Columnist Art Buchwald entered hospice after refusing dialysis for kidney failure—and left five months later to go home and write another book. He died nearly a year later.
Health professionals can help patients and families understand what palliative care and hospice care can offer before serious or life-threatening conditions occur. That understanding will enable them to plan for eventual care needs, including advance directives.
The Center to Advance Palliative Care (2009) states:
The goal of palliative care is to relieve the pain, symptoms, and stress of serious illness—whatever the prognosis. Palliative care is available to those undergoing curative treatments even at the early stages of a serious and complex illness.
Palliative care’s focus on communication in addition to pain and symptom management occurs long before the end of life. These are quality of life conversations that allow physicians to explore their patients’ values and goals. Patients facing serious illness may live for years. This is why palliative care is necessary for patients with chronic illnesses who want to remain in control of their lives and destiny.
Palliative care for those with life-limiting illness ideally begins at the time of diagnosis. Many people who do not fear death do fear the process of dying, the prospect of pain and suffering, and being a burden to their
families. Research by the National Hospice and Palliative Care Organization (2010) shows that the top priorities for a loved one with terminal illness are:
Someone to be sure that the patient’s wishes are honored
Choice among the types of services the patient can receive
Pain control tailored to the patient’s wishes
Emotional support for the patient and family
All the abovementioned priorities are available in hospice care, which is a delivery system for palliative care services. Hospice is considered the gold standard for end-of-life care. The central belief of hospice is that each person is entitled to a pain-free death with dignity and that families are entitled to the support necessary to allow that to happen.
Hospice care is based on an interdisciplinary team approach. Many hospices employ physicians and nurses with special expertise in pain management and symptom relief. Bereavement and spiritual counselors are also available to help the dying and their families explore their needs and preferences as they come to terms with death. The team develops an individualized care plan to meet each patient’s needs for pain management and symptom control. When the patient is cared for at home, hospice staff is on-call 24 hours a day, 7 days a week.
The hospice team includes:
A nurse, who usually serves as a case manager and coordinates care with other disciplines Counselors, including psychologists and clergy
A social worker
Home health aides
Many people mistakenly think that hospice refers to a place. Although there
are some residential hospice facilities, most hospice care takes place in the patient’s home or the home of a loved one, and less frequently in hospitals and nursing homes.
Hospice care is far less expensive than other types of end-of-life care (e.g., aggressive chemotherapy). Hospice patients are more often able to die at home. According to the National Hospice and Palliative Care Association, three fourths of the people who choose hospice care die at home, in a nursing home, or other residential facility.
ACCESSING HOSPICE CARE
Hospice is not just for people with cancer. Any patient who is diagnosed with terminal illness is eligible for hospice care. In fact, more than half of those admitted to hospice in 2008 had a non-cancer diagnosis, such as heart disease, kidney disease, emphysema, Alzheimer’s or other dementia, HIV/AIDS, or an unspecified condition.
To access the Medicare hospice benefit, the patient’s doctor must certify that the patient likely has six months or less of life remaining. If the patient lives more than six months, the benefit can be extended for an unlimited number of 60-day periods based on the physician’s recertification that the patient is likely to die within the next six months.
The patient must agree to forgo disease treatments such as chemotherapy and radiation. This requirement is one reason some people avoid hospice until the last days or weeks of life and continue with aggressive, expensive treatment, which may make little or no difference in survival time and may diminish the quality of life in the process.
Hospice services covered by Medicare are listed below. In addition, many private healthcare plans and Medicaid in 46 states and the District of Columbia cover hospice services.
HOSPICE SERVICES COVERED BY MEDICARE
Medicare covers these hospice services and pays nearly all of their costs:
Medical equipment (such as wheelchairs or walkers)
Medical supplies (such as bandages and catheters)
Drugs for symptom control and pain relief (patients may need to pay a small copayment) Short-term care in the hospital
Short-term respite care (patients may need to pay a small copayment) Home health aide and homemaker services
Physical and occupational therapy
Social worker services
Bereavement services for patients and families (up to 13 months after a patient’s death) Any other covered Medicare services needed to manage pain and other symptoms, as recommended by the hospice team VETERANS HOSPICE AND PALLIATIVE CARE BENEFITS
Veterans benefits include palliative care and hospice care, but some veterans may not know or understand about these benefits (Running, 2009). Although local VA medical centers have the flexibility to address end-of-life care according to veterans’ needs, national policy and standards stipulates that each VA facility have the following resources and services:
A designated hospice contact person who is part of an integrated network for local and national communications and information dissemination Provision of needed hospice services in all settings
Inpatient hospice beds or access to them in the community
An interdisciplinary palliative-care consultation team
Assistance with referrals to community hospices in its service area Tracking of hospice and palliative care services provided to veterans in all settings Health professionals need to be aware that veterans dying in the VA system may have a higher degree of social isolation, lack of family support, or lower income than those outside the system. In addition, military training
may have created in them an attitude of stoicism and a barrier to admitting pain or requesting pain medication. On the other hand, being in a hospice with other veterans offers a camaraderie that can be comforting.
Showing respect for a veteran and acknowledging service to the country is a first step in establishing a relationship. Simply asking, “What branch of the service were you in?” can be a key assessment question. Other factors that influence experiences at the end of a veteran’s life include age, whether enlisted or drafted, rank, and combat or POW experience (NHPCO, 2005). Not all veterans have served in combat; those who have may have witnessed horrific events.
Caring for America’s aging population presents enormous challenges to healthcare providers and the entire healthcare system. Their health care needs are every bit as specialized as those of America’s children. Given the uncertainty of what the healthcare system will look like over the next decades, it is impossible to predict just how those needs will be met.
Three fourths of Americans over age 65 have two or more chronic illnesses. Graying baby boomers will only intensify this burden. Chronic illness and the ongoing epidemics of cancer and HIV/AIDS point to exponential escalation in the demand for geriatric care.
As the healthcare system continues to change, self-care and prevention remain paramount elements in the health of older people. Nurses and other healthcare providers have a critical role in educating patients about what they can do to improve or maintain their health and independence, to prevent the complications of aging, and to achieve the highest possible quality of life. This course lays the groundwork for providing competent, compassionate care to older people—the kind of care we all want for ourselves.