Chronic illness and Older Adults

Chronic illness and Older Adults 150 150 Tony Guo

Chronic illness and Older Adults

 

Older Adults

  • Aging population
    • Surviving acute illness
    • Living with chronic illness
    • Becoming more educated and resourceful
    • More ethnically diverse

 

Demographics of Aging

  • Those reaching age 65 can expect additional years of life
    • 17.8 for men 
    • 20.4 for women
      • Young-old adults are 65-74 years
      • Old-old adults are 85 and older
      • Frail old have conditions that may interfere with independent ADLs

 

Attitude toward aging

  • Aging is normal
    • Older adults have diverse characteristics
    • Care should not be based on age alone
    • Myths and stereotypes can lead to poor care
    • Ageism leads to discrimination and disparate care

Special Older Adult population

  • Homeless Older Adults 
    • Numbers are increasing
    • Mortality rates are higher than for those with housing
    • Have a higher risk for more health problems 
    • Require an inter-professional approach
  • Frail Older Adults
    • Clinical manifestations of frailty
      • Unintentional weight loss
      • Self-reported exhaustion
      • Weakness
      • Slow walking speed
      • Low level physical activity

 

Social support and older adults

  • Family caregivers
  • Semiformal levels of support
  • Formal systems of support
  • Elder mistreatment/abuse
    • From 2%-10% of community-dwelling older adults in the United States are abused, neglected, or exploited by trusted others
    • Mortality risk is 3 times higher
  • Mandatory reporting exists in most states
  • Self-Neglect
    • Unable to meet basic needs
    • Refuse help
    • Have multiple, untreated medical or psychiatric conditions
    • Live alone, often in squalor
    • Experience higher rates of mortality

 

Social services for older adults

  • Administration on Aging (AoA)
    • Part of the Department of Health and Human Services
    • Federal agency responsible for many older adult programs
  • Area Agency on Aging
    • State and local agencies funded from the AoA

Medicare and Medicaid

  • Medicare
    • Medicare is federally funded insurance for people >65
  • Also covers those < 65 with disabilities or end-stage kidney disease
  • Coverage is limited
  • Out-of-pocket expenditures continue to rise
  • Medicaid
    • Medicaid is a state-administered, needs-based program to assist eligible low-income people with medical expenses

 

Care alternatives for older adults

  • Adult day care and adult day health care
    • Centers provide social, recreational, and health-related services to individuals in a safe, community-based environment
  • Home health care
    • Can be a cost-effective care alternative for older adults who are homebound, have health needs that are intermittent or acute, and have supportive caregiver involvement.
  • Long-term care facilities
    • Rapid patient deterioration or function
    • Caregiver stress and burnout
    • Alteration in or loss of family support system
      • Transition may be difficult for patients and families
      • Relocation stress syndrome
  • Program for All-Inclusive Care for the Elderly (PACE)

 

Legal and Ethical issues

  • Many complex situations may arise for older adults
  • Decisions may be difficult 
  • You can help
    • Stay informed about concerns
    • Be knowledgeable about resources
    • Advocate for patients and resolution

 

Nursing management

  • Nurses play a critical role
    • Conducting a comprehensive history and physical assessment
    • Participating in plan of care
    • Teaching patient and caregiver
    • Symptom management
    • Evaluating patient and family outcomes
  • Nursing assessment
    • First attend to primary needs 
    • Ensure assistive devices are used
    • Allow plenty of time
    • Interview family or caregivers separately
    • Involves an inter-professional approach
  • Planning
    • Identify strengths and abilities
    • Priority goals 
    • Gain a sense of control
    • Feel safe
    • Reduce stress
  • Nursing implementation
    • Modify approach based on the older adult’s physical, functional, and mental status
    • Safety first
    • Health Promotion
    • Acute and Ambulatory Care
    • Care transitions can be challenging
    • Re-hospitalization is a risk
    • Traditional Care Model: evidence-based and innovate care coordination and management model
    • Medication use
      • Medication use in older adults requires thorough and regular assessment, care planning, and evaluation. 
      • Older adults may have difficulty due to cognitive impairment, altered sensory perceptions, limited hand mobility, and the high cost of many prescriptions. 
      • Nonadherence to medication regimens is common. 
      • Many older adults are unable to read prescription drug labels or understand the health information that is provided to them.
      • Older adults may have difficulty managing medication regimens due to cognitive impairment, altered sensory perceptions, limited hand mobility or dexterity, and the high cost of many drugs. 
      • Polypharmacy, overdose, and addiction to prescription drugs are major causes of illness in older adults.
      • Errors from (1) administration of both brand and generic medications, (2) refilling medications too soon or too late resulting in taking the medication incorrectly, and (3) drug-drug interactions can be prevented by having a pharmacist review the medication regimen regularly. 
      • The American Geriatrics Society Beers Criteria are designed to reduce problems with medications in older adults.
Effects of aging
Drug-receptor interaction
  • Brain receptors become more sensitive, making psychoactive drugs very potent.
Metabolism
  • Liver mass shrinks.
  • Hepatic blood flow and enzyme activity decline.
  • Metabolism drops to 1/2 to 2/3 the rate of young adults.
  • Enzymes lose ability to process some drugs, thus prolonging drug half-life.
Absorption
  • Gastric emptying rate and gastrointestinal motility slow.
  • Absorption capacity of cells and active transport mechanism decline
Circulation
  • Vascular nerve control is less stable.
  • Anti-hypertensives, for example, may overshoot, dropping BP too low.
  • Digoxin, for example, may slow the heart rate too much.
Excretion
  • In kidneys, renal blood flow, glomerular filtration rate, renal tubular secretion and reabsorption, and number of functional nephrons decline.
  • Age-related changes increase half-life for renally excreted drugs.
  • Oral antidiabetic drugs, among others, stay in the body longer.
Distribution
  • Lean body mass falls.
  • Adipose stores increase.
  • Total body water declines, raising the concentration of water-soluble drugs, such as digoxin, which can cause heart dysfunction.
  • Plasma protein levels decrease, reducing sites available for protein-bound drugs and raising blood levels of free drug.
  • Safety
    • Older adults are at higher risk for accidents
  • Most occur in or around the home
  • Declining thermoregulation accounts for the higher rate of deaths during severe cold spells and heat waves
  • Carefully orient older adults on admission
  • Depression
    • Not a normal part of aging
    • Second highest rate of suicide occurs in those over 75
    • Occurs together with medical conditions
  • Adequacy of sleep is a common concern
  • Evaluation
    • Is there an identifiable change in ADLs, IADLs, mental status, or signs and symptoms of the disease?
    • Does the individual consider his or her health state to be improved?
    • Does the individual think the plan is helpful?
    • Do the individual and caregiver think the care is worth the time and cost?
    • Can you document positive changes that support the interventions?

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