geriatric nurse

Contents in Brief UNIT I  Overview of Aging, 1 14 Values and Beliefs, 235   1 Trends and Issues, 1 15 End-of-Life Care, 245   2 Theories of Aging, 27 16 Sexuality and Aging, 261   3 Physiologic Changes, 31 UNIT IV  Physical Care of Older Adults, 269 UNIT II  Basic Skills for Gerontologic 17 Care of Aging Skin and Mucous Membranes, 269 Nursing, 73 18 Elimination, 289 19 Activity and Exercise, 305   4 Health Promotion, Health Maintenance, 20 Sleep and Rest, 331 and Home Health Considerations, 73 APPENDIX A Laboratory Values for Older   5 Communicating with Older Adults, 88 Adults, 341   6 Maintaining Fluid Balance and Meeting APPENDIX B The Geriatric Depression Scale Nutritional Needs, 102 (GDS), 345   7 Medications and Older Adults, 130   8 Health Assessment for Older Adults, 148 APPENDIX C Dietary Information for Older   9 Meeting Safety Needs of Older Adults, 165 Adults, 346 UNIT III  Psychosocial Care of Older Adults, 180 APPENDIX D Resources for Older Adults, 348 10 Cognition and Perception, 180 11 Self-Perception and Self-Concept, 200 References, 350 12 Roles and Relationships, 214 Bibliography, 353 13 Coping and Stress, 224 Glossary, 364

Basic Geriatric Nursing

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6 EDITION Basic Geriatric Nursing Patricia Williams, RN, MSN, CCRN Formerly, Nursing Educator University of California Medical Center San Francisco, California; Alumnus, iSAGE Mini Fellowship Program Successful Aging Project Stanford University Medical School Stanford, California

3251 Riverport Lane St. Louis, Missouri 63043 BASIC GERIATRIC NURSING, SIXTH EDITION ISBN: 978-0-323-18774-9 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2012, 2008, 2004, 1999, and 1993. NANDA International, Inc. Nursing Diagnoses: Definitions & Classifications 2015-2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses. NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks and service marks of the National Council of State Boards of Nursing, Inc. Library of Congress Cataloging-in-Publication Data Williams, Patricia, 1961–, author.   Basic geriatric nursing / Patricia Williams.—6th edition.    p. ; cm.   Preceded by Basic geriatric nursing / Gloria Hoffmann Wold. 5th ed. c2012.   Includes bibliographical references and index.   ISBN 978-0-323-18774-9 (pbk. : alk. paper)   I.  Wold, Gloria. Basic geriatric nursing. Preceded by (work):  II.  Title.   [DNLM:  1.  Geriatric Nursing—methods.  2.  Aged.  3.  Aging.  4.  Nursing Care. WY 152]   RC954   618.97’0231—dc23   2015003574 Senior Content Strategist: Nancy O’Brien Content Development Specialist: Heather Rippetoe Content Development Manager: Ellen Wurm-Cutter Publishing Services Manager: Jeff Patterson Senior Project Manager: Tracey Schriefer Design Direction: Renee Duenow Printed in China Last digit is the print number:  9  8  7  6  5  4  3  2  1

I dedicate this book to Cynthia and Lorna— Two nanogenarians and life long friends who personify longevity at its finest Patricia

Contributor and Reviewers CONTRIBUTOR Elaine A. Patron, RN, BA Staff Nurse Predrag Miskin, DHSc, MScN, RN, PHN Santa Clara Valley Medical Center Nursing Faculty San Jose, California Division of Biological and Health Sciences Laura Travis, MSN, BSN, RN De Anza College Health Careers Coordinator Cupertino, California; Tennessee Center at Dickinson Assistant Professor Burns, Tennessee School of Nursing Samuel Merritt University ANCILLARY DEVELOPMENT Oakland, California Kristen M. Bagby, RN, MSN, CNL REVIEWERS Staff Nurse, Neonatal ICU St. Louis Children’s Hospital Jeanne Hately, PhD, MSN, RN St. Louis, Missouri President Interactive NCLEX Review Questions Professional Nurse Consultants Candice Kumagai, MSN, RN Aurora, Colorado Formerly Instructor in Clinical Nursing Alice Hildenbrand, MSN, RN, CNE University of Texas Interim RN-BSN Program Chair Austin, Texas Nursing Department Online Study Guide Vincennes University Laura Travis, MSN, RN Jasper and Vincennes, Indiana Director Practical Nursing Candice Kumagai, MSN, RN Tennessee College of Applied Technology—Dickson Formerly Instructor in Clinical Nursing Burns, Tennessee University of Texas Testbank and TEACH Lesson Plans Austin, Texas Cindy Lee, BA Adjunct Instructor, Adapted PE College of San Mateo San Mateo, California Catherine Meyers, RN, BSN, MSN (Nursing Education track) Director LPN Program Louisiana State University Shreveport, Louisiana vi

LPN/LVN Advisory Board Nancy Bohnarczyk, MA Dawn Johnson, MSN, RN, Ed Adjunct Instructor Practical Nurse Program Director College of Mount St. Vincent Great Lakes Institute of Technology New York, New York Erie, Pennsylvania Sharyn P. Boyle, MSN, RN-BC Kristin Madigan, MS, RN Instructor, Associate Degree Nursing Nursing Faculty Passaic County Technical Institute Pine Technical and Community College Wayne, New Jersey Pine City, Minnesota Nicola Contreras, BN, RN Hana Malik, RN, MSN, FNP-BC Faculty Academic Director Galen College Illinois College of Nursing San Antonio, Texas Lombard, Illinois Dolores Cotton, MSN, RN Barb Ratliff, RN, MSN Practical Nursing Coordinator Associate Director of Health Programs Meridian Technology Center Butler Technology and Career Development Schools Stillwater, Oklahoma Hamilton, Ohio Sharon Gordon, MSN, RN, CNOR-E Faye Silverman, RN, MSN/Ed, PHN, WOCN Practical Nursing Faculty Director of Professional Nursing Lehigh Carbon Community College Kaplan College—North Hollywood Campus Schnecksville, Pennsylvania North Hollywood, California Nancy Haughton, MSN, RN Russlyn A. St. John, RN, MSN Practical Nursing Program Faculty Professor and Coordinator, Practical Nursing Chester County Intermediate Unit Practical Nursing Department Downingtown, Pennsylvania St. Charles Community College Shelly Hovis, MS, RN Cottleville, Missouri Director, Practical Nursing Fleur de Liza S. Tobias-Cuyco, BSc, CPhT Kiamichi Technology Centers Dean, Director of Student Affairs, and Instructor Antlers, Oklahoma Preferred College of Nursing Los Angeles, California vii

To the Instructor The changing demographic of today’s world presents limited proficiency in English to develop a greater an immense challenge to health care providers and command of the pronunciation of scientific and society as a whole. Nurses must be well prepared to nonscientific English terminology. recognize and respond appropriately to the needs of • Key Points at the end of each chapter correlate our aging population. The goal of this text is to give to the objectives and serve as a useful chapter the beginning nurse a balanced perspective on the review. realities of aging and to broaden the beginning nurse’s • In addition to consistent content, design, and viewpoint regarding aging people so that their needs support resources, these textbooks benefit from the can be met in a compassionate, caring, and profes- advice and input of the Elsevier LPN/LVN Advisory sional manner. Board (see p. vii). ABOUT THE TEXT ORGANIZATION Unit One presents an overview of aging, examining The sixth edition of Basic Geriatric Nursing presents the trends and issues affecting the older adult. These the theories and concepts of aging, the physiologic include demographic factors and economic, social, cul- and psychosocial changes and problems associated tural, and family influences. The unit explores various with the process, and the appropriate nursing inter- theories and myths associated with aging and reviews ventions. The LPN Threads design has been revised and the physiologic changes that occur with aging. provides even more consistency among Elsevier’s LPN/LVN textbooks. Many key features have been Unit Two includes a wide range of information on retained, including extensive coverage of cultural modifying basic nursing skills for the aging popula- issues, clinical situations, delegation, home health tion. There is a strong focus on (1) health promotion care, health promotion, patient teaching, and comple- and health maintenance for older adults; (2) age- mentary and alternative therapies. Numerous Critical appropriate verbal and nonverbal communication; Thinking exercises provide practice in synthesizing (3) relevant nutritional and fluid needs, alterations in information and applying it to nursing care of the pharmacodynamics, and concerns related to medica- older adult. tion administration for older adults; (4) health assess- LPN THREADS ment of older adults; and (5) meeting safety needs of The sixth edition of Basic Geriatric Nursing shares some the older adults. features and design elements with other Elsevier LPN/ LVN textbooks. The purpose of these LPN Threads is to Unit Three addresses the psychosocial needs of the make it easier for students and instructors to use the older adult through the nursing process. Psychosocial variety of books required by the relatively brief and care precedes physiologic care, reflecting the order in demanding LPN/LVN curriculum. The following fea- which the content is most often taught. Areas of content tures are included in the LPN Threads: include (1) cognition problems, (2) self-perception • The full-color design, cover, photos, and illus­ and self-concept, (3) changing roles and relationships, (4) coping and stress management, (5) values and trations are visually appealing and pedagogically beliefs, and (6) sexuality. useful. • Objectives (numbered) begin each chapter and Unit Four addresses the physical needs of the older provide a framework for content and are especially adult through the nursing process. Areas of content important in providing the structure for the TEACH include (1) safety, (2) hygiene and skin care, (3) elimi- Lesson Plans for the textbook. nation, (4) activity and exercise, and (5) sleep and rest. • Key Terms with phonetic pronunciations and page Units Three and Four both offer assessment, nursing number references are listed at the beginning of diagnoses, and nursing interventions across care each chapter. They appear in color in the chapter settings. and are defined briefly, with full definitions in the Glossary. The goal is to help the student with SPECIAL FEATURES viii • Nursing process sections that provide a strong framework for discussing care of older adults in the context of specific disorders

TO THE INSTRUCTOR ix • Nursing interventions grouped by health care FOR STUDENTS setting (e.g., acute care, extended care, home care) The Evolve Student Resources include the following assets: • Special boxes for critical thinking, clinical situa- • Answer Guidelines for Nursing Care Plan Critical tions, health promotion, safety, patient teaching, complementary and alternative therapies, delega- Thinking Questions tion, and more (see p. x) • Answers and Rationales for Review Questions for • Increased cultural content on the impact of aging in the NCLEX® Examination various cultures • Audio Glossary with pronunciations in English and • Focus on changing demographics including Spanish Baby Boomers and the impact of their aging on • Calculators for determining body mass index (BMI), health care body surface area, fluid deficit, Glasgow coma score, • Additional information on home health for both IV dosages, and conversion of units patients and caregivers • Fluids and Electrolytes Tutorial • Interactive Review Questions for the NCLEX® • New Review Questions for the NCLEX® Exam­ Exam ination at the end of every chapter • Study Guide Worksheets for additional practice. Answer keys provided • Updated Laboratory Values for Older Adults (Appendix A) ACKNOWLEDGMENTS • The Geriatric Depression Scale (GDS) (Appen­ First, I owe a huge debt of gratitude to Gloria Wold. dix B) The previous editions of this textbook under her helm were an amazing starting point, which I was • A revised Dietary Information for Older Adults fortunate to inherit. I truly hope that this edition meets (Appendix C) her obviously high standards. I would also like to thank Teri Hines Burnham, Nancy O’Brien, Heather • Revised list of Resources for Older Adults, includ- Rippetoe, Kelly Skelton, Ellen Wurm-Cutter, as well ing relevant websites (Appendix D) as the other staff at Elsevier, for their professional expertise, tenacity, insights, infinite patience, and • Bibliography and reader references grouped by steady encouragement throughout the development chapter and listed at the end of the book for easy of this edition. I would also like to extend thanks to access reviewers of this book as well as writers of the ancil- lary materials—your questions and critique were TEACHING AND LEARNING PACKAGE helpful in making this book even stronger. Thanks also to Dr. V.J. Periyakoil of Stanford University for her FOR INSTRUCTORS mentorship during my mini-fellowship on Successful The comprehensive and free Evolve Resources with Aging and for providing valuable resources for this TEACH Instructor Resource include the following: text. Thanks to my colleague Diana Whittiker, RN, • Test Bank with approximately 525 multiple-choice M.Div. We had so much fun implementing our Stanford fieldwork with the Hispanic older adults and alternate-format questions with topic, step of and really brought our projects to life. Last but not the nursing process, objective, cognitive level, least—I thank Dr. Peter Miskin and Elaine Patron, RN, NCLEX® category of client needs, correct answer, for their wonderful contributions to and suggestions rationale, and textbook page reference for this textbook. • TEACH Instructor Resource with Lesson Plans, Lecture Outlines, and PowerPoint slides—with Audience Response System questions embedded— that correlate each text and ancillary component • Image Collection that contains all the illustrations and photographs in the textbook • Tips for Teaching English as a Second Language (ESL) Students

To the Student Nurses are privileged to share in some of the most • A Glossary of key terms provides definitions of all intimate aspects of people’s lives. We not only help the terms that appear at the beginning of chapters. people when they are weak and vulnerable, but also help people gain and appreciate new strengths. SPECIAL FEATURES Although much of our youth and young adulthood focus on achieving independence, our older adult The following special features are designed to foster years demonstrate the value in interdependence— effective learning and comprehension and reflect the being able to rely on others, as well as give back to LPN Threads design: others in new and different ways. As nurses, we help others compensate for their deficits and build upon   Clinical Situation boxes relate the text to patient their strengths. We rejoice in and point out small suc- situations and care scenarios. cesses and help build these to greater successes. It is   ComplementaryandAlternativeTherapiesboxes important to remember that the older person for whom address nontraditional and adjunct therapies. you are caring was once a lot like you. Try to view the   Coordinated Care boxes address leadership and older adult under your care not just as the person in management issues for the LPN/LVN and include need that you see in front of you, but rather in the topics such as restraints and end-of-life care. context of their whole life: Was he a three-star general   Critical Thinking boxes pose questions designed who now needs your help getting dressed? Was she to stimulate thought and to help students develop someone who devoted her life to raising children and and improve their critical-thinking skills. caring for grandchildren and now needs care of her   Cultural Considerations boxes provide advice own? Was he a neurosurgeon who now cannot control on culturally diverse patient care of older adults. his movement because of Parkinson disease? Was she   Health Promotion boxes recommend quality-of- a judge who is now unable to express her preferences life tips for older adults. due to Alzheimer disease? Care for every older adult   Home Health Consideration boxes give essential the way you would care for your grandmother or information for home care for the older adult. grandfather—the way you wish to be cared for one   Medication tables provide quick access to day. The older adults under your care are fortunate: information about medications commonly used growing old is an accomplishment not everyone is able in geriatric nursing care. to achieve.   Nursing Care Plans with Critical Thinking Questions provide students with real-world READING AND REVIEW TOOLS examples of nursing care plans and encourage them to think critically about the given scenarios. • Objectives introduce the chapter topics.   Patient Teaching boxes instruct and inform both • Key Terms are listed with page number references, older patients and their caregivers about health promotion, disease prevention, and age-specific and difficult medical, nursing, or scientific terms are interventions. accompanied by simple phonetic pronunciations. • Each chapter ends with a Get Ready for the NCLEX® Examination! section that includes (1) Key Points that reiterate the chapter objectives and serve as a useful review of concepts, (2) a list of Additional Resources including the Study Guide and Evolve Resources, and (3) an extensive set of Review Questions for the NCLEX® Examination with Answers and Rationales on Evolve. • A complete Bibliography and Reader Refer­ences in the back of the text cite evidence-based infor­ mation and provide resources for enhancing knowledge. x

Contents UNIT I  OVERVIEW OF AGING, 1 Muscles, 36 Expected Age-Related Changes, 37 1 Trends and Issues, 1 Common Disorders Seen with Aging, 38 The Respiratory System, 40 Introduction to Geriatric Nursing, 1 Upper Respiratory Tract, 40 Historical Perspective on the Study of Aging, 1 Lower Respiratory Tract, 40 What’s in a Name: Geriatrics, Gerontology, Air Exchange (Respiration), 40 and Gerontics, 2 Expected Age-Related Changes, 40 Common Disorders Seen with Aging, 41 Attitudes Toward Aging, 3 The Cardiovascular System, 43 Gerontophobia, 4 Heart, 43 Blood Vessels, 43 Demographics, 6 Conduction System, 44 Scope of the Aging Population, 6 Expected Age-Related Changes, 44 Gender and Ethnic Disparity, 6 Common Disorders Seen with Aging, 45 The Baby Boomers, 8 The Hematopoietic and Lymphatic Systems, 47 Geographic Distribution of the Older Adult Blood, 47 Population, 8 Lymph System, 48 Marital Status, 8 Expected Age-Related Changes, 48 Educational Status, 8 Common Disorders Seen with Aging, 49 The Gastrointestinal System, 49 Economics of Aging, 9 Oral Cavity, 50 Poverty, 9 Tongue, 50 Income, 9 Salivary Glands, 50 Wealth, 12 Esophagus, 50 Stomach, 50 Housing Arrangements, 12 Small Intestine, 50 Health Care Provisions, 15 Large Intestine, 50 Expected Age-Related Changes, 51 Medicare and Medicaid, 15 Common Disorders Seen with Aging, 51 Rising Costs and Legislative Activity, 16 The Urinary System, 53 Costs and End-of-Life Care, 17 Kidneys, 53 Advance Directives and POLST, 18 Ureters and Bladder, 53 Impact of Aging Members in the Family, 18 Characteristics of Urine, 54 Reflection by a Nursing Professor, 19 Expected Age-Related Changes, 54 The Nurse and Family Interactions, 20 Common Disorders Seen with Aging, 54 Self-Neglect, 21 The Nervous System, 55 Abuse or Neglect by the Family, 21 Central Nervous System, 55 Abuse by Unrelated Caregivers, 24 Peripheral Nervous System, 56 Support Groups, 25 Expected Age-Related Changes, 56 Respite Care, 25 Common Disorders Seen with Aging, 57 The Special Senses, 60 2 Theories of Aging, 27 The Eyes, 61 Refraction, 61 Biologic Theories, 27 Expected Age-Related Changes, 61 Psychosocial Theories, 29 Common Disorders Seen with Aging, 63 Implications for Nursing, 29 The Ears, 64 Expected Age-Related Changes, 64 3 Physiologic Changes, 31 Common Disorders Seen with Aging, 64 The Integumentary System, 32 xi Expected Age-Related Changes, 32 Common Disorders Seen with Aging, 33 The Musculoskeletal System, 35 Bones, 35 Vertebrae, 36 Joints, Tendons, and Ligaments, 36

xii CONTENTS 5 Communicating with Older Adults, 88 Taste and Smell, 65 Information Sharing (Framing the Message), 88 Expected Age-Related Changes, 65 Formal or Therapeutic Communication, 89 The Endocrine System, 66 Informal or Social Communication, 90 Pituitary Gland, 66 Nonverbal Communication, 90 Thyroid Gland, 66 Parathyroid Glands, 66 Symbols, 90 Pancreas, 66 Tone of Voice, 91 Adrenal Glands, 66 Body Language, 91 Ovaries and Testes, 67 Space, Distance, and Position, 91 Expected Age-Related Changes, 67 Gestures, 91 Common Disorders Seen with Aging, 68 Facial Expressions, 92 The Reproductive and Genitourinary Systems, 69 Eye Contact, 92 Female Reproductive Organs, 70 Pace or Speed of Communication, 92 Male Reproductive Organs, 70 Time and Timing, 92 Expected Age-Related Changes, 70 Touch, 93 Common Disorders Seen with Aging, 71 Silence, 93 Acceptance, Dignity, and Respect in UNIT II  BASIC SKILLS FOR GERONTOLOGIC Communication, 93 NURSING, 73 Barriers to Communication, 94 Hearing Impairment, 94 4 Health Promotion, Health Maintenance, Aphasia, 95 and Home Health Considerations, 73 Dementia, 95 Cultural Differences, 96 Recommended Health Practices for Older Skills and Techniques, 97 Adults, 74 Informing, 97 Diet, 74 Direct Questioning, 97 Exercise, 74 Using Open-Ended Techniques, 97 Tobacco and Alcohol, 74 Confronting, 97 Physical Examinations and Preventive Communicating with Visitors and Families, 97 Overall Care, 75 Delivering Bad News, 98 Dental Examinations and Preventive Having Difficult Conversations, 98 Oral Care, 76 Improving Communication Between Older Adult Maintaining Healthy Attitudes, 77 and Physician, 99 Factors That Affect Health Promotion Communicating with Physicians, 99 and Maintenance, 77 Patient Teaching, 100 Religious Beliefs, 78 Cultural Beliefs, 78 6 Maintaining Fluid Balance and Meeting Knowledge and Motivation, 78 Nutritional Needs, 102 Mobility, 79 Perceptions of Aging, 79 Nutrition and Aging, 102 Impact of Cognitive and Sensory Changes, 79 Caloric Intake, 102 Impact of Changes Related to Accessibility, 80 Nutrients, 103 Functional Foods, 109 Home Health, 80 Water, 109 Unpaid Caregiver, 80 Paid Caregivers, 81 Malnutrition and the Older Adult, 110 Types of Home Services, 81 Factors Affecting Nutrition in Older Adults, 110 Nursing Process for Ineffective Health Social and Cultural Aspects of Nutrition, 112 Maintenance and Ineffective Health Management, 82 Nursing Process for Risk for Imbalanced Assessment/Data Collection, 82 Nutrition, 114 Nursing Diagnoses, 82 Assessment/Data Collection, 115 Nursing Goals/Outcomes Identification, 83 Appetite Changes, 115 Nursing Interventions/Implementation, 83 Nutritional Intake, 115 Social and Cultural Factors, 116 Nursing Process for Noncompliance, 84 Home Care or Discharge Planning, 116 Assessment/Data Collection, 85 Nursing Diagnoses, 116 Nursing Diagnosis, 85 Nursing Goals/Outcomes Identification, 116 Patient Goals/Outcomes, 85 Nursing Interventions/Implementation, 116 Nursing Interventions, 85

CONTENTS xiii Nursing Process for Risk for Imbalanced Measuring Vital Signs in Older Adults, 153 Fluid Volume, 120 Temperature, 153 Assessment/Data Collection, 120 Pulse, 154 Deficient Fluid Volume, 121 Respiration, 155 Excess Fluid Volume, 121 Blood Pressure, 155 Nursing Diagnoses, 122 Nursing Goals/Outcomes Identification, 122 Sensory Assessment of Older Adults, 158 Nursing Interventions/Implementation, 122 Psychosocial Assessment of Older Adults, 158 Nursing Process for Impaired Swallowing, 124 Special Assessments, 159 Assessment/Data Collection, 124 Assessment of Condition Change in Older Nursing Diagnosis, 124 Nursing Goals/Outcomes Identification, 124 Adults, 161 Nursing Interventions/Implementation, 124 Fulmer SPICES, 161 Fancapes, 162 Nursing Process for Risk for Aspiration, 126 Assessment/Data Collection, 126 9 Meeting Safety Needs of Older Adults, 165 Nursing Diagnosis, 126 Nursing Goals/Outcomes Identification, 126 Internal Risk Factors, 165 Nursing Interventions/Implementation, 126 Falls, 166 Fall Prevention, 167 7 Medications and Older Adults, 130 Tools to Assess for Falls, 167 Specific Strategies to Prevent Falls, 167 Risks Related to Drug-Testing Methods, 130 Risks Related to the Physiologic Changes External Risk Factors, 169 Fire Hazards, 169 of Aging, 131 Home Security, 170 Pharmacokinetics, 131 Vehicular Accidents, 170 Pharmacodynamics, 132 Thermal Hazards, 172 Potentially Inappropriate Medication Use in Older Adults, 133 Summary, 174 Risks Related to Cognitive or Sensory Nursing Process for Risk for Injury, 174 Changes, 134 Risks Related to Inadequate Knowledge, 136 Assessment/Data Collection, 174 Risks Related to Financial Factors, 137 Nursing Diagnoses, 174 Medication Administration in an Institutional Nursing Goals/Outcomes Identification, 174 Setting, 137 Nursing Interventions/Implementation, 174 Nursing Assessment and Medication, 137 Nursing Process for Hypothermia/ Medication and the Nursing Care Plan, 139 Hyperthermia, 177 Nursing Interventions Related to Medication Assessment/Data Collection, 177 Nursing Diagnoses, 177 Administration, 139 Nursing Goals/Outcomes Identification, 177 Patient Rights and Medication, 143 Nursing Interventions/Implementation, 177 Self-Medication and Older Adults, 143 To Prevent Hyperthermia, 178 To Prevent Hypothermia, 178 In an Institutional Setting, 143 In the Home, 143 UNIT III  PSYCHOSOCIAL CARE OF Teaching Older Adults About Medications, 144 OLDER ADULTS, 180 Safety and Nonadherence (Noncompliance) Issues, 144 10 Cognition and Perception, 180 8 Health Assessment of Older Adults, 148 Normal Cognitive-Perceptual Functioning, 180 Cognitive and Intelligence, 181 Health Screening, 148 Cognition and Language, 181 Health Assessments, 149 Interviewing Older Adults, 150 Nursing Process for Disturbance in Sensory Perception, 182 Preparing the Physical Setting, 150 Assessment/Data Collection, 182 Establishing Rapport, 150 Nursing Diagnoses, 183 Structuring the Interview, 151 Nursing Goals/Outcomes Identification, 183 Obtaining the Health History, 151 Nursing Interventions/Implementation, 183 Physical Assessment of Older Adults, 151 Inspection, 152 Nursing Process for Chronic Confusion, 185 Palpation, 153 Assessment/Data Collection, 188 Auscultation, 153 Nursing Diagnosis, 189 Percussion, 153 Nursing Goals/Outcomes Identification, 189 Nursing Interventions/Implementation, 189

xiv CONTENTS Nursing Goals/Outcomes Identification, 219 Nursing Interventions/Implementation, 219 Nursing Process for Impaired Verbal Nursing Process for Social Isolation and Communication, 192 Impaired Social Interaction, 219 Assessment/Data Collection, 194 Assessment/Data Collection, 220 Nursing Diagnosis, 194 Nursing Diagnosis, 220 Nursing Goals/Outcomes Identification, 194 Nursing Goals/Outcomes Identification, 220 Nursing Interventions/Implementation, 194 Nursing Interventions/Implementation, 220 Nursing Process for Interrupted Family Nursing Process for Pain, 195 Processes, 220 Assessment/Data Collection, 197 Assessment/Data Collection, 220 Nursing Diagnoses, 197 Nursing Diagnosis, 221 Nursing Goals/Outcomes Identification, 197 Nursing Goals/Outcomes Identification, 221 Nursing Interventions/Implementation, 197 Nursing Interventions/Implementation, 221 11 Self-Perception and Self-Concept, 200 13 Coping and Stress, 224 Normal Self-Perception and Self-Concept, 200 Normal Stress and Coping, 224 Self-Perception/Self-Concept and Aging, 202 Physical Signs of Stress, 226 Cognitive Signs of Stress, 226 Depression and Aging, 203 Stress and Illness, 227 Suicide and Aging, 203 Stress and Life Events, 228 Nursing Process for Disturbed Self-Perception Stress-Reduction and Coping Strategies, 228 and Self-Concept, 203 Assessment, 203 Nursing Process for Ineffective Coping, 229 Nursing Process for Disturbed Body Image, 204 Assessment/Data Collection, 229 Assessment/Data Collection, 204 Nursing Diagnosis, 230 Nursing Diagnosis, 204 Nursing Goals/Outcomes Identification, 230 Nursing Goals/Outcomes Identification, 204 Nursing Interventions/Implementation, 230 Nursing Interventions/Implementation, 204 Nursing Process for Risk for Situational Low Nursing Process for Relocation Stress Self-Esteem, 205 Syndrome, 231 Assessment/Data Collection, 205 Assessment/Data Collection, 232 Nursing Diagnosis, 205 Nursing Diagnosis, 232 Nursing Goals/Outcomes Identification, 205 Nursing Goals/Outcomes Identification, 232 Nursing Interventions/Implementation, 205 Nursing Interventions/Implementation, 232 Nursing Process for Fear, 207 Assessment/Data Collection, 208 14 Values and Beliefs, 235 Nursing Diagnosis, 208 Nursing Goals/Outcomes Identification, 208 Common Values and Beliefs of Older Adults, 238 Nursing Interventions/Implementation, 208 Economic Values, 238 Nursing Process for Anxiety, 208 Interpersonal Values, 238 Assessment/Data Collection, 208 Cultural Values, 238 Nursing Diagnosis, 208 Spiritual or Religious Values, 239 Nursing Goals/Outcomes Identification, 208 Nursing Interventions/Implementation, 208 Nursing Process for Spiritual Distress, 241 Nursing Process for Hopelessness, 209 Assessment/Data Collection, 241 Assessment/Data Collection, 209 Nursing Diagnosis, 241 Nursing Diagnosis, 209 Nursing Goals/Outcomes Identification, 241 Nursing Goals/Outcomes Identification, 209 Nursing Interventions/Implementation, 241 Nursing Interventions/Implementation, 209 Nursing Process for Powerlessness, 210 15 End-of-Life Care, 245 Assessment/Data Collection, 210 Nursing Diagnosis, 210 Death in Western Cultures, 245 Nursing Goals/Outcomes Identification, 211 Attitudes Toward Death and End-of-Life Nursing Interventions/Implementation, 211 Planning, 246 12 Roles and Relationships, 214 Advance Directives, 247 Caregiver Attitudes Toward End-of-Life Normal Roles and Relationships, 214 Roles, Relationships, and Aging, 215 Care, 247 Nursing Process for Complicated Grieving, 217 Values Clarification Related to Death and Assessment/Data Collection, 218 End-of-Life Care, 247 Nursing Diagnosis, 219 What Is a “Good” Death?, 248 Where People Die, 249 Palliative Care, 249

CONTENTS xv Collaborative Assessment and Interventions for Amount, Distribution, Appearance, End-of-Life Care, 249 and Consistency of Hair, 272 Communication at the End of Life, 249 Nursing Process for Impaired Skin Integrity, 276 Psychosocial Perspectives, Assessments, Assessment/Data Collection, 276 Nursing Diagnoses, 276 and Interventions, 251 Nursing Goals/Outcomes Identification, 276 Cultural Perspectives, 251 Nursing Interventions/Implementation, 276 Communication About Death, 251 Decision-Making Process, 251 Age-Related Changes in Oral Mucous Spiritual Considerations, 252 Membranes, 282 Depression, Anxiety, and Fear, 253 Dental Caries, 282 Physiologic Changes, Assessments, Periodontal Disease, 283 and Interventions, 253 Pain, 283 Pain, 253 Dentures, 283 Fatigue and Sleepiness, 255 Dry Mouth, 283 Cardiovascular Changes, 255 Leukoplakia, 284 Respiratory Changes, 255 Cancer, 284 Gastrointestinal Changes, 255 Disorders Caused by Vitamin Deficiencies, 284 Urinary Changes, 257 Suprainfections, 284 Integumentary Changes, 257 Alcohol and Tobacco-Related Problems, 284 Sensory Changes, 257 Problems Caused by Neurologic Conditions, 284 Changes in Cognition, 257 Death, 257 Nursing Process for Impaired Oral Mucous Recognizing Imminent Death, 258 Membrane, 285 Funeral Arrangements, 258 Assessment/Data Collection, 285 Bereavement, 259 Nursing Diagnosis, 285 Nursing Goals/Outcomes Identification, 285 16 Sexuality and Aging, 261 Nursing Interventions/Implementation, 285 Factors That Affect Sexuality of Older Adults, 261 18 Elimination, 289 Age-Related Changes in Women, 262 Age-Related Changes in Men, 262 Normal Elimination Patterns, 289 Impact of Illness on Sexual Health, 263 Elimination and Aging, 289 Effects of Alcohol and Medications on Sexual Health, 263 Constipation, 290 Loss of a Sex Partner, 263 Fecal Impaction, 291 Nursing Process for Constipation, 291 Marriage and Older Adults, 263 Assessment/Data Collection, 291 Caregivers and the Sexuality of Older Adults, 264 Nursing Diagnosis, 292 Sexual Orientation of Older Adults, 264 Nursing Goals/Outcomes Identification, 292 Sexually Transmitted Disease, 264 Nursing Interventions/Implementation, 292 Diarrhea, 294 Privacy and Personal Rights of Older Nursing Process for Diarrhea, 294 Adults, 265 Assessment/Data Collection, 294 Nursing Diagnosis, 294 Nursing Process for Sexual Dysfunction, 265 Nursing Goals/Outcomes Identification, 294 Assessment/Data Collection, 265 Nursing Interventions/Implementation, 294 Nursing Diagnosis, 266 Bowel Incontinence, 296 Nursing Goals/Outcomes Identification, 266 Nursing Process for Bowel Incontinence, 296 Nursing Interventions/Implementation, 266 Assessment/Data Collection, 296 Nursing Diagnosis, 296 UNIT IV  PHYSICAL CARE OF OLDER Nursing Goals/Outcomes Identification, 296 ADULTS, 269 Nursing Interventions/Implementation, 296 Urinary Retention, 297 17 Care of Aging Skin and Mucous Membranes, 269 Urinary Tract Infection, 297 Urinary Incontinence, 297 Age-Related Changes in Skin, Hair, and Nails, 269 Nursing Process for Impaired Urinary Skin Color, 270 Elimination, 299 Dry Skin, 270 Assessment/Data Collection, 299 Rashes and Irritation, 271 Nursing Diagnoses, 299 Pigmentation, 271 Nursing Goals/Outcomes Identification, 299 Tissue Integrity, 272 Nursing Interventions/Implementation, 299 Pressure Ulcers, 272

xvi CONTENTS Nursing Goals/Outcomes Identification, 325 Nursing Interventions/Implementation, 325 19 Activity and Exercise, 305 Rehabilitation, 327 Negative Attitudes: The Controlling or Normal Activity Patterns, 305 Activity and Aging, 306 Custodial Focus, 327 Positive Attitudes: The Rehabilitative Exercise Recommendation for Older Adults, 306 Effects of Disease Processes on Activity, 308 Focus, 328 Nursing Process for Impaired Physical 20 Sleep and Rest, 331 Mobility, 309 Sleep-Rest Health Pattern, 331 Assessment/Data Collection, 309 Normal Sleep and Rest, 331 Nursing Diagnosis, 309 Sleep and Aging, 332 Nursing Goals/Outcomes Identification, 309 Sleep Disorders, 333 Nursing Interventions/Implementation, 309 Nursing Process for Disturbed Sleep Nursing Process for Activity Intolerance, 315 Pattern, 336 Assessment/Data Collection, 315 Assessment/Data Collection, 336 Nursing Diagnosis, 315 Nursing Diagnosis, 336 Nursing Goals/Outcomes Identification, 315 Nursing Goals/Outcomes Identification, 336 Nursing Interventions/Implementation, 315 Nursing Interventions/Implementation, 336 Nursing Process for Problems of Oxygenation, 317 Appendix A Laboratory Values for Older Adults, 341 Assessment/Data Collection, 317 Nursing Diagnoses, 317 Appendix B The Geriatric Depression Scale Nursing Goals/Outcomes Identification, 318 (GDS), 345 Nursing Interventions/Implementation, 318 Nursing Process for Self-Care Deficits, 321 Appendix C Dietary Information for Older Assessment/Data Collection, 321 Adults, 346 Nursing Diagnoses, 321 Nursing Goals/Outcomes Identification, 321 Appendix D Resources for Older Adults, 348 Nursing Interventions/Implementation, 321 Nursing Process for Deficient Diversional References, 350 Activity, 323 Bibliography, 353 Assessment/Data Collection, 323 Glossary, 364 Nursing Diagnosis, 325

Unit I  Overview of Aging chapter Trends and Issues 1  Objectives http://evolve.elsevier.com/Williams/geriatric 1. Describe the subjective and objective ways that aging 9. Describe the housing options that are available to older is defined. adults. 2. Identify personal and societal attitudes toward aging. 10. Discuss the health care implications of an increase in the 3. Define ageism. population of older adults. 4. Discuss the myths that exist with regard to aging. 5. Identify recent demographic trends and their impact 11. Describe the changes in family dynamics that occur as family members become older. on society. 6. Describe the effects of recent legislation on the 12. Examine the role of nurses in dealing with an aging family. economic status of older adults. 7. Identify the political interest groups that work as 13. Identify the different forms of elder abuse. 14. Recognize the most common signs of abuse. advocates for older adults. 15. Describe approaches that are effective in preventing 8. Identify the major economic concerns of older adults. elder abuse. Key Terms gerontics  (p. 2) abuse  (p. 21) gerontology  (p. 2) ageism  (p. 4) gerontophobia  (p. 4) chronologic age  (krŏ-nŏ-LŎJ-ĭk, p. 2) mandated reporter  (p. 25) cohort  (KŌ-hŏrt, p. 8) neglect  (nĭ-glĕkt, p. 21) demographics  (dĕm-ŏ-GRĂF-ĭks, p. 6) respite  (RĔS-pĭt, p. 25) geriatric  (jĕr-ē-ĂT-rĭk, p. 2) INTRODUCTION TO GERIATRIC NURSING substages are related to obvious physical changes or to significant life events, this classification method is now HISTORICAL PERSPECTIVE ON THE STUDY accepted as logical and necessary. OF AGING Until the middle of the nineteenth century, only Until recently, society also viewed adults of all ages two stages of human growth and development were interchangeably. Once you became an adult, you identified: childhood and adulthood. In many ways, remained an adult. Perhaps society perceived dimly children were treated like small adults. No special that older adults were different from younger adults, attention was given to them or to their needs. Families but it was not greatly concerned with these differences had to produce many children to ensure that a few because few people lived to old age. Additionally, the would survive and reach adulthood. In turn, children physical and developmental changes during adult- were expected to contribute to the family’s survival. hood are more subtle than those during childhood; Little or no concern was given to those characteristics therefore, these changes received little attention. and behaviors that set one child apart from another. Until the 1960s, sociologists, psychologists, and As time passed, society began to view children dif- health care providers focused their attention on ferently. People learned there are significant differ- meeting the needs of the typical or average adult: ences between children of different ages, and children’s people between 20 and 65 years of age. This group was needs change as they develop. Childhood is now the largest and most economically productive segment divided into substages (i.e., infant, toddler, preschool, of the population; they were raising families, working, school age, and adolescence). Each stage is associated and contributing to the economy. Only a small percent- with unique challenges related to the individual age of the population lived beyond age 65. Disability, child’s stage of growth and development. Because the illness, and early death were accepted as natural and unavoidable. 1

2 UNIT I  Overview of Aging • Explore the impact of medication and medication administration on older adults. In the late 1960s, research began to indicate that adults of all ages are not the same. At the same time, The dictionary defines old as “having lived or existed the focus of health care shifted from illness to wellness. for a long time.” The meaning of old is highly subjec- Disability and disease were no longer considered tive; to a great degree, it depends on how old we unavoidable parts of aging. Increased medical knowl- ourselves are. Few people like to consider themselves edge, improved preventive health practices, and tech- old. A recent study reveals that people younger than nologic advances helped more people live longer, 30 years view those older than 63 as “getting older.” healthier lives. People 65 years of age and older do not think people are “getting older” until they are 75. Older adults now constitute a significant group in society, and interest in the study of aging is increasing. Aging is a complex process that can be described The study of aging will be a major area of attention for chronologically, physiologically, and functionally. years to come. Chronologic age, the number of years a person has lived, is most often used when we speak of aging WHAT’S IN A NAME: GERIATRICS, because it is the easiest to identify and measure. Many GERONTOLOGY, AND GERONTICS people who have lived a long time remain functionally The term geriatric comes from the Greek words “geras,” and physiologically young. These individuals remain meaning old age, and “iatro,” meaning relating to physically fit, stay mentally active, and are productive medical treatment. Thus, geriatrics is the medical spe- members of society. Others are chronologically young cialty that deals with the physiology of aging and but physically or functionally old. Thus, chronologic with the diagnosis and treatment of diseases affecting age is not the most meaningful measurement of aging. older adults. Geriatrics, by definition, focuses on abnormal conditions and the medical treatment of When we use chronologic age as our measure, these conditions. authorities use various systems to categorize the aging population (Table 1-1). To many people, 65 is a magic The term gerontology comes from the Greek words number in terms of aging. The wide acceptance of age “gero,” meaning related to old age, and “ology,” 65 as a landmark of aging is interesting. Since the meaning the study of. Thus, gerontology is the study 1930s, the age of 65 has come to be accepted as the age of all aspects of the aging process, including the of retirement, when it is expected that a person will- clinical, psychologic, economic, and sociologic prob- ingly or unwillingly stops paid employment. However, lems of older adults and the consequences of these before the 1930s, most people worked until they problems for older adults and society. Gerontology decided to stop working, until they became too ill to affects nursing, health care, and all areas of our work, or until they died. When the New Deal politi- society—including housing, education, business, and cians established the Social Security program, they set politics. 65 as the age at which benefits could be collected, but the average life expectancy of the time was 63. The The term gerontics, or gerontic nursing, was coined Social Security program was designed as a fairly low- by Gunter and Estes in 1979 to define the nursing care cost way to win votes because most people would not and the service provided to older adults. Gerontic live long enough to collect the benefits. Although 65 nursing encompasses a holistic view of aging with the was considered old then, it certainly is not now. If the goal of increasing health, providing comfort, and same standards were applied today, the retirement age caring for older adult needs. This textbook focuses on would be 77. However, for various reasons, society gerontic nursing. It addresses ways to promote high- clings to 65 as the “retirement age” and resists political level functioning and methods of providing care and proposals designed to move the start of Social Security comfort for older adults. benefits to a later age. Despite the resistance, the age to qualify for full Social Security benefits is changing. The objectives of this book are as follows: • Examine trends and issues that affect the older Table 1-1  Categorizing the Aging Population person’s ability to remain healthy. AGE (YEARS) CATEGORY • Explore theories and myths of aging. 55 to 64 Older • Study the normal changes that occur with aging. • Review pathologic conditions that are commonly 65 to 74 Elderly observed in older adults. 75 to 84 Aged • Emphasize the importance of effective communica- 85 and older Extremely aged tion when working with older adults. • Explore the general methods used to assess the 60 to 74 Or Young-old health status of older adults. • Describe the specific methods of assessing func- 75 to 84 Middle-old tional needs. 85 and older Old-old • Identify the most common nursing diagnoses asso- ciated with older adults, and discuss nursing inter- ventions related to these diagnoses.

Trends and Issues  CHAPTER 1 3 Individuals born before 1937 still qualify for full ben- Older people never ____________________________________ efits at age 65, but there are incremental increases in _____________________________________________________. age for all persons born after that time. Individuals The best thing about aging is ___________________________ born in 1960 or later must wait until age 67 to qualify _____________________________________________________. for full benefits. Reduced benefits are calculated for The worst thing about aging is __________________________ individuals who claim Social Security benefits after _____________________________________________________. age 62 but before the full retirement age. To be consis- Looking back at my responses, I feel that aging is _________ tent with other sources, however, this text will refer to _____________________________________________________. individuals age 65 and above as “older adults.” Critical Thinking ATTITUDES TOWARD AGING   Before we look at the attitudes of others, it is important to examine our own attitudes, values, and knowledge Your Current Knowledge About Aging about aging. The three Critical Thinking boxes that follow are designed to help you assess how you feel Respond to the following questions to the best of your about aging. knowledge. You are “old” at age ___________________________________ Critical Thinking _____________________________________________________. There are ____________________________________________   ________________________ older adults in the United States. Most older people live in _______________________________ Your Views and Attitudes About Aging _____________________________________________________. Economically, older people are __________________________ • How many older adults do you know personally? _____________________________________________________. • Do you think they are “old?” Do they consider themselves With regard to health, older people are ___________________ _____________________________________________________. “old?” Mentally, older people are ______________________________ • How do you personally define “old?” _____________________________________________________. • Why is aging an issue today? • Should Social Security laws be changed to reflect today’s After you have filled out the Critical Thinking box below, look at the characteristics you described, and longer life expectancy? think about the feelings you experienced as you con- Please complete the following statements. Write as many sidered these individuals. Do your feelings correspond applicable comments as you can. There are no right or wrong to your attitudes about aging? Were these three answers. people’s characteristics similar or different? What do A person can be considered “old” when __________________ these characteristics say about your values? _____________________________________________________. When I think about getting older, I _______________________ Our attitudes are the product of our knowledge and _____________________________________________________. values. Our life experiences and our current age Growing older means __________________________________ strongly influence our views about aging and older _____________________________________________________. adults. Most of us have a rather narrow perspective, When I get older, I will lose my __________________________ and our attitudes may reflect this. We tend to project _____________________________________________________. our personal experiences onto the rest of the world. Seeing an older person makes me feel ___________________ Because many of us have a somewhat limited exposure _____________________________________________________. Older people always ___________________________________ _____________________________________________________. Critical Thinking   Your Values About Aging Quickly name three older adults who have had an impact on your life. List five characteristics that you associate with each person. There are no right or wrong answers. PERSON 1 PERSON 2 PERSON 3 Name _____________________________ Name _____________________________ Name ______________________________ Relationship ________________________ Relationship ________________________ Relationship ________________________ CHARACTERISTICS: 1. _________________________________ 1. _________________________________ 1. _________________________________ 2. _________________________________ 2. _________________________________ 2. _________________________________ 3. _________________________________ 3. _________________________________ 3. _________________________________ 4. _________________________________ 4. _________________________________ 4. _________________________________ 5. _________________________________ 5. _________________________________ 5. _________________________________

4 UNIT I  Overview of Aging For the most part, mainstream American society does not value its elders. The United States tends to be a to older adults, we may believe quite a bit of inaccurate youth-oriented society in which people are judged by information. When dealing with older adults, our age, appearance, and wealth. Young, attractive, and limited understanding and vision can lead to serious wealthy people are viewed positively; old, imperfect, errors and mistaken conclusions. If we view old age as and poor people are not. It is difficult for young people a time of physical decay, mental confusion, and social to imagine that they will ever be old. Despite some boredom, we are likely to have negative feelings cultural changes, becoming old retains negative con- toward aging. Conversely, if we see old age as a time notations. Many people continue to do everything they for sustained physical vigor, renewed mental chal- can to appear young. Wrinkles, gray hair, and other lenges, and social usefulness, our perspective on aging physical changes of aging are actively confronted with will be quite different. makeup, hair dye, and cosmetic surgery. Until recently, advertising seldom portrayed people older than 50 It is important to separate facts from myths when years except to sell eyeglasses, hearing aids, hair dye, examining our attitudes about aging. The single most laxatives, and other rather unappealing products. The important factor that influences how poorly or how message seemed to be, “Young is good, old is bad; well a person will age is attitude. This statement is true therefore, everyone should fight getting old.” It is sig- not only for others but also for ourselves. nificant that trends in advertising appear to be chang- ing. As the number of healthier, dynamic senior citizens Throughout time, youth and beauty have been with significant spending power has increased, adver- viewed as desirable, and old age and physical infir- tising campaigns have become increasingly likely to mity have been loathed and feared. Greek statues portray older adults as the consumers of their prod- portray youths of physical perfection. Artists’ works ucts, including exercise equipment, health beverages, throughout history have shown heroes and heroines and cruises. Despite these societal improvements, as young and beautiful, and evildoers as old and ugly. many people do not know enough about the realities Little has changed to this day. A few cultures cherish of aging, and, because of ignorance, they are afraid to their older members and view them as the keepers of get old. Some media studies have found that people wisdom. Even in Asia, where tradition demands who watch more television are likely to have more respect for older adults, societal changes are destroy- negative perceptions about aging. ing this venerable mindset. GERONTOPHOBIA Cultural Considerations The fear of aging and the refusal to accept older adults into the mainstream of society is known as geronto-   phobia. Senior citizens and younger persons can fall prey to such irrational fears (Box 1-1). Gerontophobia The Role of the Family sometimes results in very odd behavior. Teenagers buy antiwrinkle creams. Thirty-year-old women consider Cultural heritage may work as a barrier to getting help for an facelifts. Forty-year-old women have hair transplants. older parent. Many cultures emphasize the importance of inter- Long-term marriages dissolve so that one spouse can generational obligation and dictate that it is the role of the pursue someone younger. Often these behaviors arise family to provide for both the financial and personal assistance from the fear of growing older. needs of older adults. This can lead to high stress and exces- sive demands, particularly on lower-income families. Ageism The extreme forms of gerontophobia are ageism and Nurses need to recognize the impact that culture has on age discrimination. Ageism is the disliking of aging expectations and values and how these cultural values affect and older adults based on the belief that aging makes the willingness to accept outside assistance. Nurses need to people unattractive, unintelligent, and unproductive. be able to identify the workings of complex family dynamics It is an emotional prejudice or discrimination against and determine how decision making takes place within a people based solely on age. Ageism allows the young unique cultural context. to separate themselves physically and emotionally from the old and to view older adults as somehow Critical Thinking having less human value. Like sexism or racism, ageism is a negative belief pattern that can result in   irrational thoughts and destructive behaviors such as intergenerational conflict and name-calling. Like other Caregiver Choices forms of prejudice, ageism occurs because of myths and stereotypes about a group of people who are dif- • What expectations does your cultural heritage dictate ferent from us. regarding your obligation to frail older family members? • Who in your family culture makes decisions regarding the care of older family members? • Should Medicare or insurance plans pay low-income family members to stay at home and provide care for infirm older adults? • To what extent should family members sacrifice their personal lives to keep frail or infirm older adults out of institutional care? • Can family obligations be met in a society that provides little support or relief to caregivers?

Trends and Issues  CHAPTER 1 5 Box 1-1  Aging: Myth Versus Fact confront signs of ageism whenever and wherever they appear. Activities such as increased positive interac- MYTHS: OLDER ADULTS… tions with older adults and improved professional • Are pretty much all alike. training designed to address misconceptions regard- • Generally are alone and lonely. ing aging are two ways of fighting ageism. The Nursing • Tend to be sick, frail, and dependent on others. Competence in Aging (NCA) initiative, started in • Are often cognitively impaired. 2002, focuses on enhancing competence in geriatrics • Suffer from depression. by expanding nurses’ knowledge, skills, and atti- • Become more difficult and rigid with advancing years. tudes. Although originally a five-year initiative, the • Can barely cope with the inevitable declines NCA resulted in an ongoing resource for nurses, Geronurseonline.org. Research coming from this ini- associated with aging. tiative can help nurses in all areas of practice. Becca Levy, a Yale University professor, found that young FACTS: OLDER ADULTS… people who hold positive feelings toward older adults • Are a very diverse age group. live 7.5 years longer than those with negative percep- • Typically maintain close contact with family. tions of aging. Even if just on a purely self-serving • Usually live independently. basis, health care providers should work to end ageism. • May experience some decline in intellectual abilities, Age Discrimination but it is usually not severe enough to cause problems Age discrimination reaches beyond emotions and in daily living. leads to actions; older adults are treated differently • Generally have lower rates of diagnosable depression simply because of their age. Examples of age discrimi- when they live in community settings, when compared nation include refusing to hire older people, not with younger adults. approving them for home loans, and limiting the types • Tend to maintain a consistent personality throughout or amount of health care they receive. Age discrimina- the life span. tion is illegal. Some older adults respond to age dis- • Typically adjust well to the challenges of aging. crimination with a passive acceptance, whereas others are banding together to speak up for their rights. Modified from the American Psychological Association. Reprinted with permission. http://www.apa.org/pi/aging/olderadults.pdf. The reality of getting old is that no one knows what it will be like until it happens. But that is the The combination of societal stereotyping and a lack nature of life—growing older is just the continuation of positive personal experiences with older adults of a process that started at birth. Older adults are affect a cross section of society. Studies have shown fundamentally no different from the people they were that health care providers share the views of the when they were younger. Physical, financial, social, general public and are not immune to ageism. Very and political conditions may change, but the person few of the “best and brightest” nurses and physicians remains essentially the same. Old age has been seek careers in geriatrics despite the increasing need described as the “more-so” stage of life because some for these services. Some health care providers errone- personality characteristics may appear to amplify. ously believe that they are not fully using their skills Older adults are not a homogeneous group. They by working with the aging population. Working in differ as widely as any other age group. They are intensive care, the emergency department, or other unique individuals with unique values, beliefs, experi- high technology areas is viewed as exciting and chal- ences, and life stories. Because of their extended years, lenging. Working with older adults is viewed as their stories are longer and often far more interesting routine, boring, and depressing. As long as negative than those of younger persons. attitudes such as these are held by health care provid- ers, this challenging and potentially rewarding area of Aging can be a liberating experience. Aging seems service will continue to be underrated, and the older to decrease the need to maintain pretenses, and the adult population will suffer for it. older adult may finally be comfortable enough to reveal the real person that has existed beneath the Ageism can have a negative effect on the way health facade. If a person has been essentially kind and caring care providers relate to older patients, which, in turn, throughout life, he or she will generally reveal more can result in poor health care outcomes in these indi- of these positive personal characteristics over time. viduals. Research by the John A. Hartford Foundation Likewise, if a person was miserly or unkind, he or she (2012) found that only 7% of older adults surveyed will often reveal more of these negative personality received seven important health care services that characteristics with age. The more successful a person support healthy aging, including medication review, has been at meeting the developmental tasks of life, fall assessment and history, referral to community the more likely he or she will successfully face aging. health services, and discussion about their ability to Perhaps the best advice to all who are preparing for perform routine daily tasks independently. Because an old age is contained in the Serenity Prayer: increasing portion of the population consists of older adults, health care providers need to think carefully about their own attitudes. Furthermore, they must

6 UNIT I  Overview of Aging • During the twentieth century, the life expectancy of Americans has increased by approximately 29 years. O God, give us the serenity to accept what cannot be A child born in the United States in the year 2004 changed; courage to change what should be changed; and has an average life expectancy of nearly 77.4 years. wisdom to distinguish one from the other. • Projections indicate that a child born in 2010 will Reinhold Niebuhr have a life expectancy of 78.4 years. DEMOGRAPHICS Since the beginning of the twentieth century, advances in technology and health care have dramatically Demographics is the statistical study of human popu­ changed the world, especially in industrialized nations lations. Demographers are concerned with a popu­ where food production exceeds the needs of the popu- lation’s size, distribution, and vital statistics. Vital lation. Diseases, such as cholera and typhoid, have statistics include birth, death, age at death, marriage(s), been eliminated or significantly reduced by improved race, and many other variables. The collection of sanitation and hygiene practices. Dreaded communi- demographic information is an ongoing process. The cable diseases that at one time were often fatal (e.g., Bureau of the Census conducts the most inclusive smallpox, measles, whooping cough, and diphtheria) demographic research in the United States every 10 are now preventable through immunization. Even years. The most recent census was completed in the pneumonia and influenza are no longer the fatal dis- year 2010. eases they once were. Today, vaccines can be given to those who are at higher risk, and treatment can be Demographic research is important to many given to those who become infected. groups. Demographic information is used by the government as a basis for granting aid to cities and A longer life is a worldwide phenomenon. Almost states, by cities to project their budget needs for schools, 8% of the world’s population is age 65 or older. by hospitals to determine the number of beds needed, Developed countries, including Japan, Switzerland, by public health agencies to determine the immuniza- Australia, and Sweden, lead the world in longevity tion needs of a community, and by marketers to sell statistics. People in many parts of the world live longer products. The politicians of the 1930s used demo- than they do in the United States, including top ranked graphics to formulate plans for the Social Security Monaco; Singapore and Hong Kong are also in the top program. Demographic studies provide information ten. The standing of the United States has steadily about the present that allows projections into the declined and now ranks 42nd of 223 countries, accord- future. ing to the CIA’s estimates (Central Intelligence Agency, 2014). Some possible explanations for the disparity One important piece of demographic information is between the United States and other countries include life expectancy. Life expectancy is the number of years higher levels of accidental and violent deaths, obesity, an average person can expect to live. Projected from relatively high infant mortality, and the high cost of the time of birth, life expectancy is based on the ages health care. Much of the world’s net gain in older of all people who die in a given year. If a large number persons has occurred in the still-developing countries, of infants die at birth or during childhood, the life such as Africa, South America, and Asia (Figure 1-1). expectancy of that year’s group tends to be low. The life expectancy throughout history has been low SCOPE OF THE AGING POPULATION because of environmental hazards, wars, accidents, According to the U.S. Department of State, for the first food and water scarcity, inadequate sanitation, and time in recorded history, the number of people over contagious diseases. age 65 is projected to exceed the number of children • During biblical times, the average life expectancy under age 5. In 2010, there were 40 million people, or 13% of the population, age 65 and older, living in the was approximately 20 years. Some people did live United States. By 2060, this is expected to increase to significantly longer, but 40 years was considered a 92 million people age 65 or older, roughly 20% of the good, long life. total population. Individuals older than 85 years now • By 1776, when the Declaration of Independence was make up 4% of the entire U.S. population and repre- signed, the life expectancy had risen to 35 years. It sent the fastest-growing segment of the older popula- was not uncommon for people to live into their tion. We are becoming an increasingly older society sixties. (Figure 1-2). • By the 1860s, at the time of the American Civil War, the life expectancy had increased to 40 years. The GENDER AND ETHNIC DISPARITY 1860 census revealed that 2.7% of the American The Administration on Aging projects that minority population was older than 65 years. populations will represent 26.4% of the older popula- • By the beginning of the twentieth century, the tion by 2030, an increase from 16% in 2000. It is pro- overall life expectancy had increased to 47 years, jected that by 2030, the white non-Hispanic population and 4% of the American population was 65 years of will increase by 77%. During the same time period, the age or older. In a span of more than 2000 years, life expectancy had increased by only 27 years.

Trends and Issues  CHAPTER 1 7 Healthy life expectancy (HALE) at birth, both sexes, 2012 HALE (years) Not applicable 0 875 1,750 3,500 Kilometers Ͻ50 Data not available 50–59 60–64 65–69 70–76 The boundaries and names shown and the designations used on this map do not imply the expression Data Source: World Health Organization of any opinion whatsoever on the part of the World Health Organization concerning the legal status of Map Production: Health Statistics and any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or Information Systems (HSI) boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may World Health Organization not yet be full agreement. FIGURE 1-1  Life expectancy world map. (© 2014 World Health Organization. All Rights Reserved. http:// gamapserver.who.int/mapLibrary/Files/Maps/Global_HALE_BothSexes_2012.png) 65–74 years 75ϩ 65–74 years 75ϩ 65–84 years 85ϩ 55–64 years 55–64 years Under 18 Under 18 Under 18 18–54 years 18–54 years 18–64 years 1950 2010 2060 Projected FIGURE 1-2  Percentage of population in five age groups: United States, 1950, 2010, and 2060 (Data from the United States Census Bureau.) percentage of minority persons of the same age cohort women to 17.5 million older men. Women currently is expected to grow by 223% (Hispanics, 342%; African outlive men by 5 to 6 years, and whites tend to live Americans, 164%; American Indians, Eskimos, and longer than blacks, although disparities seem to be Aleuts, 207%; and Pacific Islanders, 302%). declining. The life expectancy is variable within the U.S. popu- White women have a life expectancy of about 81 lation. The populations of men and women are not years. Black women have a life expectancy of about equal, and in the older-than-65 age group, this dispro- 76.9 years; white men, 76 years; and black men, 70 portion is very noticeable. There are 23 million older years. Hispanic men can expect to live 79.7 years;

8 UNIT I  Overview of Aging and Pennsylvania (more than 2 million each); Ohio, Illinois, Michigan, North Carolina, New Jersey, and Hispanic women have the longest life expectancy of 84 Georgia (more than 1 million each). Population distri- years. This longer life expectancy despite generally bution data show that Florida leads the nation, with having lower income and education levels is known as 17.4% of its population being older than 65 years. the Hispanic Paradox. Eight states, including Alaska, Nevada, Idaho, Arizona, Colorado, Georgia, Utah, and South Carolina, have In 2010, 20% of those over age 65 were identified as shown an increase in the older-than-65 population minorities. Approximately 9% were black, 3% Asian, of more than 30%. Almost 79% of older adults and 7% Hispanic of any race. It is projected that by reside in metropolitan areas, with approximately 2050, the population will be almost 40% minority: 20% 36% residing in principle cities. Only approximately Hispanic, 12% black, and 9% Asian. 20% of older adults reside in nonmetropolitan areas (Figure 1-3). THE BABY BOOMERS A major contributing factor to this rapid explosion in Statistical evaluation of minority populations the older adult population is the aging of the cohort, reveals that groups tend to concentrate in a limited commonly called the Baby Boomers. Age cohort is a number of states. Half of older blacks live in New York, term used by demographers to describe a group of Florida, California, Texas, Georgia, North Carolina, people born within a specified time period. The most Illinois, and Virginia; 71% of the Hispanic elderly live significant cohort today is the group known as Baby in California, Texas, Florida, and New York; and 60% Boomers. This cohort consists of people who were of older persons of Asian, Hawaiian, or Pacific Island born after World War II between 1946 and 1964. Baby descent favor California, Hawaii, and New York. The Boomers account for approximately 26% of all majority of older adults of Native American or Native Americans today. Because of its size, this group has Alaskan descent live in California, Oklahoma, Arizona, had, and will continue to have, a significant influence New Mexico, Texas, and North Carolina. in all areas of society. In fact, presently 10,000 Baby Boomers reach age 65 every day! It remains to be seen MARITAL STATUS whether this group will experience aging in the same In 2012, 72% of men over age 65 were married com- way that previous generations have experienced pared to 45% of older women. The percentage of changes or whether they will reinvent the aging and married people drops significantly as age progresses, retirement experience. The oldest Baby Boomers but the percentage of men over age 90 who are married reached age 65 in 2011; by 2029, all Baby Boomers will remains high at 40%. At age 65, 37% of women were be 65 or older. Based on the sheer size of this group, widows compared with only 12% of men. By age 90, the older population in 2030 will be twice the number 80% of women were widows compared to only 49% of it was in 2000. The implications of this for all areas of men. The percentage of older adults who are separated society, particularly health care, are unprecedented. or divorced has increased to 12%. A further increase in the number of divorced elders is predicted as a result Critical Thinking of a higher incidence of divorce in the population approaching age 65.   The number of single, never-married seniors Demographics and You remains somewhat consistent at about 4% of the older- • What impact will the changing demographics have on you than-65 population. personally? EDUCATIONAL STATUS • How is your community’s age distribution changing? The educational level of the older adult population in • Are you a Baby Boomer? Is this an advantage or a the United States has changed dramatically over the past three decades. In 1970, only 28% of senior citizens disadvantage as you age? had graduated from high school. By 2012, 81% were • Were you born after the baby boom? Before the baby high school graduates or more, and 24% had a bachelor’s degree or higher. Completion of high boom? What difficulties do you expect to encounter as school varied by race and ethnicity, with whites (86%) you age? completing high school at higher rates, followed by Asians (74%), African-American and American- GEOGRAPHIC DISTRIBUTION OF THE OLDER Indian/Alaskan Natives (69%), and Hispanics (49%). ADULT POPULATION The older adult population is not equally distributed In addition to being better educated, today’s older throughout the United States. Climate, taxes, and other adult population is more technologically sophisticated. issues regarding the quality of life influence where A Pew research study conducted in 2012 revealed that older adults choose to live. All regions of the country more than half of Americans over age 65 use the are affected by the increase in life expectancy, but not Internet. Seventy percent of older adults use a cell to the same degree. According to census data from the year 2010, approximately half of the older-than-65 population resides in 11 states. In descending order of the older adult population, the states are California (4.3 million); Florida (3.3 million); New York, Texas,

Trends and Issues  CHAPTER 1 9 Persons 65+ as a Percentage of Total Population, 2010 Percent of persons 65+ in 2010 by state 17.4% to 14.0% (17) 13.8% to 13.0% (17) 12.9% to 12.1% (10) 11.4% to 10.4% (5) 9.0% to 7.7% (2) FIGURE 1-3  Persons 65 or older as a percentage of total population, 2010. (From the Administration on Aging, Department of Health and Human Services. http://www.aoa.gov/Aging_Statistics/Profile/2011/8.aspx) phone, and 33% of older adults use social networking INCOME sites, such as Facebook and LinkedIn. As of 2011, the median income of men over age 65 was $27,707, whereas that for women over age 65 was only ECONOMICS OF AGING $15,362. The median income of households headed by a person 65 years of age or older was approximately The stereotypical belief that many older adults are $48,538. Median income is the middle of the group poor is not necessarily true. The economic status of with half earning less and half earning more. It is not older persons is as varied as that of other age groups. an average amount. Median figures can be deceptive Some of the poorest people in the country are old, but because income is not distributed equally among so are some of the richest. whites and minority groups (Figure 1-4). POVERTY In 2011, over 3.6 million (8.7%) older adults lived at or The major sources of aggregate income for older below the poverty level, with another 2.4 million clas- adults include Social Security benefits earnings, asset sified as “near poor.” Older women were more likely income, pensions, and other earnings. Figure 1-5 shows to be impoverished than older men. The highest rates the sources of income for five different income levels of poverty were among older Hispanic women who (income quintiles). live alone and older black women who live alone. Above-average rates of poverty among older adults Of older adults who receive Social Security, almost were found among those who lived inside principal one quarter of those married and almost half of those cities and in the South. unmarried rely on this benefit for 90% of their income. Average monthly Social Security income in 2012 was $1,250 for a retired worker and $2,051 for retired worker and spouse. Low-earning individuals and

10 UNIT I  Overview of Aging Persons 65+ Reporting Income, 2011 couples are more likely to rely on Social Security as the major source of income. High earners are less reliant Under $5,000 3.0% on Social Security. $5,000–$9,999 14.0% Social Security funding may become inadequate as the number of retirees drawing benefits increases, $10,000–$14,999 18.0% while the pool of workers paying into the system decreases. There are presently 2.8 million workers for $15,000–$24,999 24.0% each social security beneficiary; by 2033, this number will decrease to 2.1 million. People, both within and $25,000–$34,999 13.0% outside the government, have proposed plans to ensure the long-term survival of the Social Security. If $35,000–$49,999 11.0% no changes are made, it is estimated that social security reserves will be depleted in 2034 (Paletta, 2014). $50,000 and over 16.0% Asset income, income derived from investments 0% 20% 40% 60% 80% 100% such as stocks, bonds, and other retirement accounts, has dropped drastically since 2008. The economic FIGURE 1-4  Median individual income by demographic traits, 2011. downturn has been compared in severity to the Great (From the Administration on Aging, Department of Health and Depression of the 1930s. Many retirees and those near Human Services. http://www.aoa.gov/Aging_Statistics/ retirement lost a large percentage of the monies they Profile/2012/9.aspx) had saved and invested for retirement. Many of those who invested personally and those who had their Percentage Distribution of Sources of Income for Married money in employer-directed programs were severely Couples and Nonmarried Persons age 65 and Over, affected. These financial losses have forced many indi- by Income Quintile, 2010 viduals nearing retirement to continue working. 100 2 3 2.5 3 3 Approximately one-third of people age 65 and older 4 0.5 receive pensions from public or private sources. People 7 7 10 who retire from a government agency are more likely 23 to receive a pension than those who retire from a 23 19 private industry. Not only are former government employees more likely to receive a pension, but also 80 16 government pensions tend to be more generous than those in the private sector, because government wages 45 have historically been below those of the private sector. The median federal government pension in 2011 was 5 $23,137, the median state or local government pension 26 was $18,289, and the median private pension or annuity was $8,853. 60 Early retirement was popular from the 1970s until Percent 40 84 83 8 about 1985. Since then, the trend has shown more 19 people working for pay after age 65. For those over 65 who work, the median weekly wages in the first 66 quarter of 2013 were $745 ($38,740 annually). This is significantly less than what the person earned earlier 16 in life and reflects a decrease in hours worked and 20 44 in wages. 17 Earnings make up a substantial portion of income for many people over age 65. Those who are in higher 0 Second Third Fourth Highest income brackets, generally professionals, may con- Lowest fifth fifth fifth fifth tinue to work well beyond age 65 as long as they are fifth healthy and interested in what they are doing. Socialization, time away from a retired spouse, intel- Other Earnings Asset income lectual challenge, and a sense of self-worth are verbal- Public assistance Pensions Social Security ized as reasons for working, particularly by those in the baby boom generation. Some Baby Boomers need NOTE: A married couple is age 65 and over if the husband is age 65 and over or the to continue to work to maintain the standard of living husband is younger than age 55 and the wife is age 65 and over. The definition of “other” they desire. Some need to work because they neglected includes, but is not limited to, unemployment compensation, workers compensation, to save enough for retirement or need to make up for alimony, child support, and personal contributors. Quintile limits are $12,600, $20,683, $32,880, and $57,565 for all units; $24,634, $36,288, $53,000, and $86,310 for married couples; and $10,145, $14,966, $21,157, and $35,405 for nonmarried persons. Reference population: These data refer to the civilian noninstitutionalized population. FIGURE 1-5  Sources of income. (From the Federal Interagency Forum on Aging Related Statistics. http://www.agingstats.gov/ Main_Site/Data/2012_Documents/Economics.aspx)

Trends and Issues  CHAPTER 1 11 Table 1-2  Legislation That Has Helped Older Adults Box 1-2  Politically Active Senior Citizen Groups YEAR LEGISLATION AARP (FORMERLY KNOWN AS AMERICAN ASSOCIATION OF 1965 Medicare and Medicaid established RETIRED PERSONS) Administration on Aging established • Membership is open to people who are at least 50 1967 Age Discrimination Act passed years of age and spouses (regardless of age) • Currently has 38 million members 1972 Supplemental Security Income Program • Uses volunteers and lobbyists to advance the political instituted and economic interests of older adults Social Security benefits indexed to reflect • Provides a wide variety of membership benefits, inflation, cost-of-living adjustment including insurance programs and discounts Nutrition Act, which allows for providing nutrition • Instrumental in helping Medicare be enacted in 1965 programs for older adults, passed ASA (AMERICAN SENIORS ASSOCIATION) 1973 Council on Aging established • Has 13 million members presently • Self-described “conservative alternative to AARP” 1978 Mandatory retirement age changed to 70 years ARA (ALLIANCE FOR RETIRED AMERICANS) 1986 Mandatory retirement age eliminated for most • Has more than 4 million members employees • Focuses on political and legislative issues • Formerly known as National Council of Senior Citizens 1988 Catastrophic health insurance became part of • Occasionally clashes with AARP on issues such as Medicare Medicare Drug Benefits 1990 Americans with Disabilities Act OWL (OLDER WOMEN’S LEAGUE) 1992 Vulnerable Elder Rights Protection Program • Has 20,000 members • Focuses on needs of midlife and older women 1997 Balanced Budget Act (Medicare Part C) GRAY PANTHERS 2000 Amendment to Older Americans Act (Nutrition • Has approximately 15,000 members programs) • Consists of local groups and a national organization • Attempts to increase public awareness of the needs 2006 Drug Benefit Program added to Medicare of older adults by means of demonstrations, door-to- 2010 The Patient Protection and Affordable Care Act door canvassing, and other attention-getting methods (theoretically: benefit remains to be seen) losses in their investments. Those in lower income possibilities if the person experienced a serious illness brackets may need to continue to work, or to seek and placement in a care facility. work, to pay for necessities of life or a few luxuries. Older people may choose not to seek help, despite Legislation and political activism among older the availability of assistance programs designed to aid people have helped improve the economic outlook for them. Many older adults are suspicious of “getting older adults (Table 1-2). Through activist organiza- something for nothing” or are reluctant to disclose the tions, older adults have united to consolidate their details of their financial status, which is necessary to political power and to use the power of the vote to qualify for most assistance programs. Many older initiate programs that benefit them (Box 1-2). Over the people feel that asking for help is humiliating. Some past 25 years, these groups have helped improve the may fear they will lose what little they have if they economic welfare of older adults. The Federal Housing seek assistance. As in all age groups, other older people Authority and other lending agencies have proposed have no difficulty seeking or, in some cases, demand- the use of reverse mortgages, which are plans that ing financial assistance or concessions. Factors that allow older adults to remain in their homes and receive can affect the financial well-being of older adults are monthly payments based on their equity in the prop- described in Box 1-3. erty. Monthly income realized from these plans could range from as little as $100 to as much as several thou- Be sensitive when dealing with the financial issues sands of dollars, depending on the value of the prop- of older adults. The Critical Thinking box should erty and the age of the residents. This money could be help you assess your attitudes, and therefore your sen- a much-needed income supplement for older adults. sitivity, toward these kinds of situations. Many older Plans such as these may become more common in the adults who find it easy to talk about their intimate future when more older adults recognize their eco- physical and medical problems are reluctant to discuss nomic benefits. Reverse mortgages are not right for finances. Nurses may suspect financial need if an older everyone, however. They have extremely high fees person lacks adequate shelter, clothing, heat, food, or associated with them, up to $40,000 and can become medical attention. When an economic problem causes due in full if the older person moves out of their home real or potential dangers, be prepared to respond for a year or more—which is not outside the realm of appropriately.

12 UNIT I  Overview of Aging homes can initiate referrals to social workers or other professionals who are knowledgeable about assistance Box 1-3  Factors That Influence the Economic programs. Most states and counties throughout the Conditions of Older Adults United States have services for older adults or depart- ments on aging. These are typically listed in the • Many older adults bought their homes when housing government section of a telephone directory. Many costs and inflation were low. If they paid off their publish directories of resources available in their mortgages, housing costs are limited to taxes, specific community. maintenance, and utility bills. WEALTH Although many older people receive less cash on a • The number of older adults who receive pensions is yearly basis from Social Security and pensions than greater now than it will be in the future. Businesses some younger individuals earn, a substantial number now offer smaller pensions to fewer employees. have accumulated assets and savings from their working years. Frugal lifestyles and self-reports by • Older adults qualify for several tax breaks that are older adults of being “poor” should be viewed cau- unavailable to younger people. tiously. Some individuals are truly impoverished, • Most older adults pay no Social Security taxes; whereas others have significant estates to leave to their younger working adults pay increasingly higher children or to charities. rates. • Social Security and government pensions are Approximately 81% of households headed by a largely exempt from taxation. person older than 65 years of age own their homes. Of • Taxpayers older than 65 years of age can take these homes, 65% are owned outright. In 2011, the additional tax deductions. median value of homes owned by older persons was • A one-time capital gains tax exclusion applies $150,000 (with a median purchase price of $55,000). A when the house is sold. home is usually an older person’s largest asset. Many older people choose not to sell their houses because • Most older adults qualify for government income they fear they will have nowhere to live. Many prefer programs. to remain “house rich and cash poor,” making do on a • The income from Social Security exceeds the limited income, rather than selling their homes. program contributions of most recipients. Recently, there has been a high foreclosure rate result- • Medicare covers about 50% of medical costs. ing in a surplus of houses for sale. This makes a profit- • Programs such as Social Security, SSI, Medicare, able sale of property by older adults more difficult to housing programs, and energy assistance provide achieve. Additional considerations regarding home- an annual average of approximately $10,000 per ownership and housing options are discussed in more every older adult. detail later in the chapter. Critical Thinking Economic well-being is usually measured in terms of income, which is the amount of money a household   receives on a weekly, monthly, or yearly basis. However, this measurement is not always a reliable indicator Your Sensitivity to the Financial Problems of Older Adults of financial security in older adults. People older than 65 years of age generally have more discretionary Respond to the following statements: income (i.e., money left after paying for necessities • Older adults control all of the money in the country. such as housing, food, and medical care) available • Most older adults are poor. than do younger people. Younger individuals, particu- • Older adults have it easy; the younger working people larly those with growing families, may have a higher income, but they also have higher nondiscretionary have it rough. demands. • Older adults have too much political power, and they get HOUSING ARRANGEMENTS too many benefits and entitlements. • Older adults worked for what they are getting, and they Many people assume that older adults live in senior citizen housing or nursing homes. They are wrong. deserve everything they receive from the government. Most older adults either live with a spouse or alone. • A society that does not care for its older people is cruel Less than 3% of older adults live in senior housing with supportive services available. Approximately and uncivilized. 3.6% of all older adults are institutionalized, and this • The properties of older adults should be used to pay for percentage increases with advancing age. Only 1% of 65- to 74-year-old individuals are institutionalized. their physical needs and medical care. Because regulations covering assistance programs change often, it is difficult for older patients and the nurses trying to help them to keep current and up to date. Nurses may be called on to help older adults deal with the paperwork required when applying for assis- tance, to provide emotional support as they work through the frustration of bureaucratic processes, or to arrange transportation to the appropriate agencies. Nurses usually are not expected to be experts in this area, but they should know how to locate appropriate resources. Nurses working in community health should be aware of community agencies providing assistance to older adults so that appropriate referrals can be made. Nurses working in hospitals and nursing

Trends and Issues  CHAPTER 1 13 This rate increases to 3% with individuals 75 to 84 • What kinds of alternative housing for older adults are years of age and reaches 11% with people older than available in your community? age 85. • Should older adults live in housing that is separated from Older individuals often try to keep their homes, people in other age groups? Why? Why not? despite the physical or economic difficulties in doing so. A house is more than just a physical shelter; it rep- Independent or assisted-living centers are becoming resents independence and security. The home holds common. These centers combine privacy with easily many memories. Being in a familiar neighborhood available services. Most consist of private apartments close to friends and church is important. A sense of that are either purchased or rented. For additional community is important to many older adults, who charges, the residents can be served meals in restaurant- dislike the thought of leaving security for the unknown. style dining rooms and receive laundry and house- The physical exertion and emotional trauma involved keeping services (Figure 1-7). Different levels of in moving can be intimidating, even overwhelming, medical, nursing, and personal care services are avail- to older adults. Moving to a different, often smaller, able. Health care services may include assistance with residence is a difficult decision, particularly when it hygiene, routine medication administration, and even involves giving up precious possessions because of preventive health clinics. Many centers have commu- lack of space. nal activity rooms, art-and-craft hobby centers, swim- ming pools, lounges, beauty salons, mini-grocery For some older people, keeping the family home is stores, greenhouses, and other amenities. Transportation not a sensible option for many reasons. Many of the to church, shopping, and other appointments is pro- houses owned by older adults are in central cities with vided by some of these facilities. Most independent high crime rates. Expenses, such as increasingly high and assisted-living facilities are privately operated, property taxes and ongoing maintenance costs, often and costs are significant—although far cheaper than present excessive strain on older persons with limited nursing home care. Some states offer subsidies to older financial resources. Home maintenance, including individuals with limited resources because these living even simple tasks such as housecleaning, becomes arrangements are often more cost-effective than other increasingly difficult with advancing age or illness. housing alternatives. Ownership may require more effort in terms of money and time than some older people possess; yet many Did You Know? struggle to remain independent and keep their houses.   Some older individuals remain in their own houses and refuse to give them up long after it is safe for them Cruise Care to be alone. They may be able to cope as long as family, friends, and neighbors are willing to help. However, if A study reported in the Journal of the American Geriatrics there is a change in their support system, dangerous, Society described an interesting alternative to assisted living— life-threatening situations may arise. Some older “Cruise Care.” The article asserted that, with slight modifica- people try to live in their houses, despite broken tions for help with the activities of daily living, a senior citizen plumbing, inadequate heat, and insufficient access to might be better off living on a cruise ship than in an assisted- food. Families, health care professionals, and social living facility. The ship provides a higher employee-to-resident service agencies may have to step in to protect the ratio, more activities, more and better choices of food, better welfare of these aging individuals. scenery, and more companionship for a comparable price. Although not appropriate for individuals suffering from demen- Some older people recognize the problems associ- tia, it might be an option (at least temporarily) for some adven- ated with living alone and decide to seek housing turous seniors. arrangements that are more in keeping with their needs and abilities. They may choose to move into an Life-lease or life-contract facilities are another apartment, condominium, senior citizen complex, or housing option. For a large initial investment and some other type of housing. As the older adult popula- substantial monthly rental and service fees, older per­ tion grows, a variety of new types of housing and sons or couples are guaranteed a residence for life. living arrangements is evolving (Figure 1-6). The fol- Independent residents occupy apartment units, but lowing Critical Thinking box should help you deter- extended-care units are either attached to this apart- mine your attitudes toward housing for older adults. ment complex or located nearby for residents who require skilled nursing services. If one spouse needs Critical Thinking skilled care, the other may continue to live in the apart- ment and can easily visit the hospitalized loved one.   When the occupants die, control of the apartment reverts to the owners of the facility. The costs for this Your Attitudes Toward Housing for Older Adults type of housing are high and may be out of the range • Is it safe for older adults to remain indefinitely in their own of the average older adult. However, despite the costs, many find this option appealing because it meets their houses? needs for independence, socialization, and services. • When should an older person sell his or her house? • Once a house is sold, what are the best types of living accommodations for older adults?

14 UNIT I  Overview of Aging Evacuation plan Main route Enclosed Room 9 Room 10 Room 11 Room 12 Room 13 patio Alternate route Dining Patio Multi Room 14 Exit Office Office Private Room 15 dining arSeoacial Room 20 Room 19 Room 16 Mech Exit Kitchen Laundry Porch Room 17 Room 1 Social Room 18 area Exit Exit West Room 2 Hair Room 8 South Residents, staff and East care visitors should assemble to the south of the Mech building for a head count Point of rescue Fire extinguishers Tornado shelter Room 3 Room 7 Room 4 Room 5 Room 6 FIGURE 1-6  A living plan for CBRF with evacuation plan. (Courtesy Elness Swenson Graham Architects, Inc., Minneapolis, Minnesota.) FIGURE 1-7  Dining room in an assisted living facility. (Photo courtesy financial standards and limits. Government-subsidized Era Living, Seattle, Washington.) housing units may be simple apartments without any special services, or they may have limited services, Many find security in knowing that skilled care is such as access to nursing clinics and special transpor- easily available if needed. tation arrangements. Most communities are finding that the demand for these facilities exceeds the avail- Less-well-to-do people are more limited in their ability. Waiting lists with up to 2-year delays are housing options. Some older adults qualify for common; some communities have started awarding government-subsidized housing if they meet certain the housing via lotteries. Interpretation of government regulations is causing some concern with regard to senior citizen housing. Residences originally intended for older adults may be required to accept a variety of medically disabled people, regardless of age. Some of these younger residents suffer from psychiatric or drug-related problems, and the presence of these indi- viduals may leave older adult residents feeling threat- ened and fearful for their own safety and well-being. Some older adults who are not related to each other are forming group-housing plans. In this type of arrangement, two or more unrelated people share a household in which they have private bedrooms but

Trends and Issues  CHAPTER 1 15 share the common recreational and leisure areas, as Subacute care falls between the traditional care pro- well as the tasks involved in home maintenance. Some vided in an acute care hospital and that provided in communities offer services to help match people who a skilled nursing home. For example, a ventilator- are interested in this option. Roommates are selected dependent patient or someone requiring frequent so that the strengths of one individual compensate for respiratory treatments would find appropriate care in the weaknesses of the other. In some cases, a large a subacute facility. house may shelter 10 or more residents. Not all of these arrangements are limited to older adults. In some situ- Specialty care facilities, such as residences designed ations, younger adults who need reasonable housing to meet the special needs of people with Alzheimer may be included. By providing services for older adult disease or other memory loss and their families are residents, the younger residents are able to reduce gaining in popularity around the country. Other spe- their rental costs. Both younger and older individuals cialty care facilities are numerous and include inpa- who have chosen this option report benefits from the tient hospice facilities, long-term care spinal cord extended-family atmosphere. injury facilities, and skilled nursing facilities that provide dialysis treatment. A more formal type of group home called a community-based residential facility (CBRF) is avail- HEALTH CARE PROVISIONS able in some communities. For a monthly fee, this type of facility provides services such as room and board, Health care is a major area of concern in the United help with activities of daily living, assistance with States. Everyone wants the best and most comprehen- medications, yearly medical examinations, informa- sive medical care for themselves and their family. The tion and referrals, leisure activities, and recreational or expense of this level of care is the problem. At one therapeutic programs. Fees for this type of housing time, individuals were personally responsible for the may be paid by the individual or may be provided by payment of physician and hospital bills. This gradu- county or state agencies. Most of these facilities provide ally changed, and health care insurance, either indi- private or semiprivate rooms with community areas vidually purchased or paid for by an employer, became for dining and socialization. the norm. Insurance companies paid the bills, and the individual became less aware and involved in the Older adults that require more extensive assistance rising cost of health care. may need placement in nursing homes or extended- care facilities. Nursing homes provide room and Government played a minimal role until the estab- board, personal care, and medical and nursing ser- lishment of Medicare in 1965. vices. They are licensed by individual states and regu- lated by both federal and state laws. Three levels of MEDICARE AND MEDICAID care are provided by nursing homes: skilled care, inter- Medicare is the government program that provides mediate care, and custodial care. Skilled care is daily health care funding for older adults and disabled nursing care, including medication administration persons. Medicare is a popular program, and most and skilled treatments or procedures that require the Americans believe it must be preserved. This will be expertise of licensed nurses. It also includes services increasingly difficult when the Baby Boom generation performed by specially trained professionals, such as becomes eligible for coverage. In 2005, Medicare pro- speech, physical, occupational, and respiratory thera- vided coverage for approximately 42.5 million citizens. pists. Intermediate care describes professional care By 2031, when all Baby Boomers are eligible for cover- that is not required on a daily basis. It is a step down age, this number is expected to swell to 77 million citi- from skilled care. Custodial care is the next step down zens. Most Americans older than 65 years of age and refers to care that is considered nonskilled, per­ qualify for Medicare. sonal care, such as assistance with activities of daily living (ADLs). Medicare has four distinct programs, none of which pays all of the health care costs. Medicare Part A is Critical Thinking hospital insurance. It covers inpatient hospital care; skilled nursing care following hospitalization; some   home health services, such as visiting nurses and occu- pational, speech, or physical therapists; and hospice Nursing Home Insurance services, but only after the patient pays an initial Medicare will pay for a maximum of 100 days in a skilled care deductible and any co-payments. During the 1980s, facility after a 3-day hospital stay. After that time, the cost of Medicare instituted the diagnosis-related group care is usually the responsibility of the older person or his or (DRG) system in an attempt to contain hospital costs. her family, unless he or she qualifies for Medicaid. In light of Under this system, a hospital is paid a set amount this, do you think that people approaching retirement should based on the patient’s admitting diagnosis. If the purchase nursing home insurance? Why or why not? patient is discharged in fewer days than predicted, the hospital keeps the excess money. If the patient needs Subacute care facilities provide comprehensive inpa- to stay longer than projected, the hospital absorbs the tient care designed for individuals who have an acute illness, injury, or exacerbation of a disease process.

16 UNIT I  Overview of Aging ($2.65) and brand name ($6.60), only after this large additional costs. Although DRGs have resulted in cost amount is reached in a single year. Because of the reduction, they have also resulted in the discharge of Affordable Care Act, the donut hole will disappear people “quicker and sicker” than in the past. Many by 2020. older people are released from the hospital before they have actually recovered from their illnesses, placing an Supplemental Medicaid (Title 19) assistance may increased health care burden on families and home be available for those older adults who meet certain health agencies. financial need requirements. Many of those who have assets do not qualify; they are left with a Medicare gap Medicare Part B is medical insurance. It is optional, (or “medigap”) that they must pay themselves. Many but most people choose this coverage. This plan covers older people buy private medical insurance—often at 80% of the “customary and usual” rates charged by unreasonable prices—to pay medical bills that are not physicians after deductibles are met. In addition to covered by Medicare. However, the Affordable Care physicians’ fees, Medicare Part B covers medically Act now requires states to expand Medicaid coverage, necessary ambulance transport; physical, speech, and without regard to assets. occupational therapy; home health services when medically necessary; medical supplies and equipment; Critical Thinking and outpatient surgery or blood transfusions. The patient is responsible for the remaining 20% of the   costs plus the difference between the actual fee and the government’s “customary and usual” rate. The Medicaid and Personal Assets actual costs of medical care often exceed the amount Do you think that people should qualify for Medicaid if they that the government pays. Many older adults pay for hold valuable assets, such as a house or expensive cars? Or private supplemental health care insurance to cover do you think they should liquidate their assets (i.e., sell their these expenses rather than pay out of pocket. house) before receiving Medicaid? Why or why not? Medicare Part C, Medicare Advantage Plans, are RISING COSTS AND LEGISLATIVE ACTIVITY optional plans offered by private companies approved The costs of health care have increased dramatically in by Medicare to individuals who are eligible for Part A recent years. The United States spends more money on and enrolled in Part B. These plans allow beneficiaries health care than any other country in the world, yet to receive their Medicare benefits through private health care is not provided for all U.S. citizens. Many insurance companies. The older adult enrolls in a other nations do a better job of meeting their citizens’ private plan offered by a health maintenance organiza- health care needs. tion (HMO), preferred provider organization (PPO), provider sponsored organization (PSO), private fee for The Centers for Medicare & Medicaid Services service (PFFS) organization, or medical savings account (CMS) reports that the United States spent approxi- (MSA). These plans are designed to cover total costs mately $2.7 trillion on health care in 2011. This exceeds so that supplemental insurance coverage is not neces- the amount spent on any other activity, including sary. They usually also include prescription drug ben- defense. This amount is expected to grow to $3.9 tril- efits. They do, however, limit the pool of available lion by 2018—a ballooning number, but decreased health care providers, and premiums and rules vary from earlier projections because of the Affordable Care depending on the plan selected. Act and the sequestration process of the Budget Control Act of 2011 that cut Medicare payments by 2% starting Medicare Part D, prescription drug coverage, went in 2013. A significant proportion of health care spend- into effect during 2006. It is a voluntary plan available ing is spent on the older adult population. These costs to anyone enrolled in Part A or B of Medicare. It cannot are staggering considering the expanding population be used if someone chooses a Medicare Advantage of older adults. To contain health care costs, there has Plan (Part C) that has prescription drug coverage. been an upsurge in initiatives, such as managed care Under Part D, prescription drugs are distributed and insurance reform. If we expect to continue to through local pharmacies and administered by a wide provide adequate health care in the future, we can variety of private insurance plans. In many plans, expect to see more changes in the way health care is there is a significant gap between the cost of the drugs financed and delivered. This is a major, and often divi- and the benefits provided. Individuals will need to be sive, political issue. cautious when selecting coverage to ensure that they select a plan that is most cost-effective for their specific The cost of Medicare alone has grown dramatically situation and needs. Older adults who have high med- from $3 billion in 1967, the first year of funding, to ication costs may experience the coverage gap, referred $55.5 billion in 1983; $297 billion in 2004; $499 billion to as the “donut hole.” As of 2015, when medication in 2009; and $551 billion in 2012. The Congressional costs (the cost paid by the plan and the older adult) Budget Office (CBO) (2013) projects it will reach $596 exceed $2960, the elder enters the “donut hole” and billion in 2017 and $862 billion in 2022 (Figure 1-8). must pay the full cost of medication until out-of-pocket expenses reached $4700. Costs drop to either 5% of the In December 2009, the United States Congress cost (while your plan pays 95%) or a set fee for generic passed the Patient Protection and Affordable Care Act (PPACA). It was signed into law by President

Trends and Issues  CHAPTER 1 17 Projected Medicare Spending in Billions of Dollars those patients’ personal assets are depleted about 40% $1,200 of the time (Wang, 2012). Serious questions are being raised about the appropriateness of using intensive, $1,000 expensive interventions to extend the lives of termi- nally ill older people. $800 Financial concerns are forcing health care providers $600 and society to face ethical dilemmas regarding the allo- cation of limited health care resources. This is a highly $400 emotional issue with no easy answers. Many people are alive today because of advances in medical tech- $200 nology. Some of those who benefit are young, whereas others are old. Some go on to lead lives of high quality; $0 others never lead normal lives again. By virtue of their 1967 1983 2004 2012 2017 2022 training, physicians are inclined to try to cure every- one. Most doctors do not feel comfortable allowing a FIGURE 1-8  Projected Medicare spending in billions of dollars. patient to die, regardless of the person’s age. Most (Data from the Congressional Budget Office Estimates, 2013. doctors will use all available technology to save a life. www.cbo.gov/publication/43947) Talking about death is not easy for anyone, including physicians. It is easier to avoid end-of-life issues than Obama in 2010. The law includes numerous health- to take time for this difficult discussion. Many physi- related provisions to take effect over several years. cians are unwilling to take time away from other activ- This legislative initiative includes major changes in ities to have this discussion, particularly because they health insurance, health care funding, student loans, can do only minimal billing for the time spent counsel- and a wide range of spending considerations. The ing the patient. In spite of these concerns, more physi- costs of these provisions are to be offset by a variety of cians need to take time to have honest discussions with taxes, fees, and cost-saving measures. patients while they are competent to understand and make informed decisions. There is a great deal of controversy because the long-term effects of the legislation are still unknown. Reputable authorities, ethicists, and politicians have Those in favor of the legislation cite expanded cover- widely differing points of view on this issue. Some age, greater competition among insurance companies, believe that health care restrictions on older adults are coverage of people with preexisting medical condi- the ultimate in age discrimination. Others argue that tions, and closure of the “donut hole” affecting senior the benefits gained, which can usually be measured in citizens. Those opposed to the legislation cite cuts in months, do not outweigh the costs. Private citizens Medicare funding, cuts to the Medicare Advantage examining this dilemma are equally confused. Even program, increases in the Medicare tax, and expansion those who believe that health care costs are excessive of Medicaid. They fear increased costs of health care, frequently want everything possible done to save their more taxes, and decreased incentives to primary care lives or those of their loved ones. This dilemma is physicians. moral, ethical, and legal, with no simple right answer. Part of the debate regarding health care reform involves Legal challenges regarding the constitutionality of differing viewpoints regarding end-of-life care. Per­ this bill were raised by several states; yet it was ruled haps this issue will encourage an honest national dis- constitutional by the Supreme Court in June of 2012. cussion among spouses, families, spiritual advisors, In writing the majority opinion, however, Justice John physicians, and other health care providers. Roberts stated that the program is a tax—which may pave the way for different legal challenges. Health care The Critical Thinking box is designed to increase providers should pay attention because this legislation your awareness and insight into these problems. is likely to have an impact on how health care is pro- vided and funded. Other aspects of the law continue Critical Thinking to be challenged in court. COSTS AND END-OF-LIFE CARE   Not all older people use the available health care resources equally. Most health care services are con- Your Understanding of the Health Care Dilemma sumed by the very ill or terminally ill minority, many of whom happen to be older adults. One quarter of all • Should an 80-year-old person have a coronary bypass Medicare dollars are spent on services for 5% of surgery at a cost of approximately $100,000? Medicare patients in their last year of life. Despite this, • Should dialysis be provided to individuals older than 65? Older than 75? Older than 85? • Should people older than 65 receive organ transplants? • Should a respirator be used on a terminally ill patient? • Are feeding tubes a part of basic physical care, or are they extraordinary means? • Should the individual, the family, or the physician decide the type and amount of medical intervention necessary? • What should be the role of the government in health care?

18 UNIT I  Overview of Aging go into effect only when two physicians agree in writing that the necessary criteria are met. ADVANCE DIRECTIVES AND POLST All adults who are 18 years of age or older and of Usually, either of these documents is adequate to sound mind have the right to make decisions regard- communicate one’s wishes; both are not needed. Those ing the amount and type of health care they desire. who choose to initiate both documents should ensure Because older adults are more likely to experience that there is no conflict between the directions pro- significant health problems, the question of what vided in each document. Either document can be and how much medical care to administer must be revoked at any time. An advance directive should be addressed. Such important decisions are best made stored in a safe place where it can be located easily during a stress-free time when the individual is alert when needed. A safe deposit box is not recommended and experiencing no acute health problems. A person’s for this purpose. Family members and the family wishes can best be communicated using advance direc- lawyer should know the content of the document tives, which are legally recognized documents that and its location. An advance directive should be pro- specify the types of care and treatment the individual vided to the physician so that it becomes part of the desires when that individual cannot speak for himself patient’s permanent medical record. These documents or herself. Areas typically addressed in advance direc- are often required and kept available for emergency tives include (1) do not attempt to resuscitate (DNAR) situations when an individual resides in an institu- or allow natural death (AND) orders; (2) directives tional setting, such as an independent or assisted- related to mechanical ventilation; and (3) directives living apartment, community-based residential facility, related to artificial nutrition and hydration. or a nursing home. Two formal types of advance directive are recog- Laws and specifics differ from state to state. Nurses nized in most states: (1) the durable power of attorney should be aware of the legal standing of such docu- for health care; and (2) the living will. Information ments in the particular state where they practice and about both of these is typically provided when a person should understand any legal ramifications engendered enters the hospital. Each patient is expected to make a by these documents. POLST, or physician orders for decision about the type and extent of care to be admin- life-sustaining treatment, is a legal document that has istered if his or her condition becomes terminal. been adopted by several states and takes the person’s wishes further by creating actual doctor’s orders to be These documents are designed to help guide the carried out by emergency personnel. The POLST con- family and medical professionals in planning care. The tains three or four sections, depending on the state, family is often relieved to have this information when including specifics about CPR (whether to attempt making difficult decisions during a stressful time. resuscitation or allow natural death), medical interven- Advance directives are generally recognized and tions (comfort care, limited interventions, or full treat- respected, but various agencies or health care provid- ment including when to transfer to hospital), antibiotics ers may have beliefs or policies that prohibit them (use freely, use for comfort, or don’t use at all), and from honoring certain advance directives. Individuals artificial nutrition (no tube feeding, trial of tube feeding, should discuss their wishes with their health care pro- or long-term tube feeding). The POLST is printed on viders when these documents are written. If irreconcil- bright paper, the color of which is determined by the able differences exist between an individual and the state, and signed by the physician and patient. Sample care provider, changes in either the document or the POLST forms are freely available on the internet. care provider must be considered. Critical Thinking Durable power of attorney for health care transfers the authority to make health care decisions to another   person, called the health care agent. The agent may act only in situations in which the person is unable to Advance Directives and POLST make decisions for himself or herself. Because the • How would you as a nurse approach a patient regarding health care agent must be trusted to follow through with the older person’s wishes, the agent specified in initiation of an advance directive? the document is usually a family member or friend. • Can a person who is diagnosed with Alzheimer disease These wishes are specified in writing and usually wit- nessed by unrelated individuals to reduce the possibil- initiate a living will or durable power of attorney? ity of undue influence. Standardized legal forms are • Does your state have POLST? available to initiate a power of attorney for health care. • How do hospitals and extended-care facilities identify a A living will informs the physician that the indi- patient’s advance directive? vidual wishes to die naturally if he or she develops an illness or receives an injury that cannot be cured. IMPACT OF AGING MEMBERS IN THE FAMILY Living wills prohibit the use of life-prolonging mea- sures and equipment when the individual is near The family is undergoing significant change in our death or in a persistent vegetative state. Living wills society. Many factors, including increasing divorce rates, single parenting, and a mobile population, are creating a less stable, less predictable family structure. Blended families, extended families, and separated

Trends and Issues  CHAPTER 1 19 FIGURE 1-9  Fun, quality time with granddaughter. It is estimated that 80% of older adults who need care will receive assistance from their families. The Box 1-4  Demographic Changes Affecting the Family problems encountered in such situations can differ widely, depending on the respective ages of the family • Extended life spans are leading to more older family members. In some families, the “children” who are members. attempting to provide care for the oldest members are likely to be older than 65 themselves. They may have • More people are living with chronic conditions and health problems of their own that make caregiving need some degree of care or assistance. difficult or impractical. • The number of people in the younger generations is Middle-aged family members often become the decreasing in proportion to the number of older caregivers. The generation in their 40s and early members. 50s is sometimes called the “sandwich” generation because its members are caught in the middle—trying • There is an increasing number of widows who may be to work, to raise their own children, and perhaps unprepared to provide for their own needs and will provide assistance to one or two generations of aging need assistance. family members. Sometimes, they are also trying to help raise grandchildren by giving financial or physi- • The role of women is changing. As women cal assistance. increasingly must work outside the home, many are attempting to meet the demands of their parents, Although the financial, psychological, and physical home, children, and workplace. demands of assisting aging relatives affect all family members, women are likely to be the most affected. It families all present challenges. In addition to these is estimated that 66% of the caregivers in the United societal changes, the demographic changes discussed States are female (Box 1-5). Typically, sons contribute previously are having, and will continue to have, financially, but the brunt of the emotional and physical repercussions that we can only begin to appreciate care burden falls to the daughters. It is estimated that (Box 1-4). as the population ages, women will spend more time caring for their parents than they did caring for their Families today face historically unprecedented situ- children. ations. Because of the life span extension, it is not uncommon for four or five generations of a family to Families try to help aging family members in many be alive at one time (Figure 1-9). Until recently, this ways. If the older adult is able to live alone, families was an unheard-of occurrence. Using 20 years as a may assist by visiting frequently and helping with typical generation, a family might resemble one such transportation to shopping and doctor appointments. as that described in Table 1-3. If the generation time is Some prepare meals, help with housecleaning, and less than 20 years, even more generations might be make major home repairs. Running between two alive at the same time. REFLECTION BY A NURSING PROFESSOR Table 1-3  The Family GENERATION Parents Some years ago, as death was approaching for a 91-year- AGE (YEARS) Children old gentleman, his family gathered at the hospital. His 80+ Grandchildren wife of 69 years asked that “the children” come into the 60+ Great-grandchildren room. This sounded rather strange because “the children” 40+ Great-great-grandchildren were all in their 60s, the grandchildren were all mature 20+ adults, and the great-grandchildren were fast approaching Less than 20 adulthood. It sounded even stranger to me, because this older man was my grandfather, and my father was “the Box 1-5  Caregivers in the United States baby” of the family. • Average caregiver age is 48. Gloria Wold • 72% of caregivers are caring for a parent, step-parent, mother-in-law, or father-in-law. • 66% of caregivers are female; 34% care for 2 or more people. • Nearly 17% of American workers function as caregivers. • 70% of working caregivers report work-related difficulties, such as having to rearrange work schedules, decrease hours, or take unpaid leave. Data from Family Caregiver Alliance: Selected Caregiver Statistics, https:// caregiver.org/selected-caregiver-statistics

20 UNIT I  Overview of Aging adult can be given enough privacy to maintain inde- households and trying to maintain both can be men- pendence, the blending of the older person into the tally and physically exhausting, but many are willing child’s home may be successful. Some families feel that to help their loved ones in any way they can. a resident grandparent is rewarding and enriching. However, if the presence of the older person intrudes A family crisis may occur when the aging person is excessively on the family unit, the situation may be no longer able to live alone. Important decisions must unpleasant for both the family and the older person. be made. Most families find that there is no perfect solution. The two most common options are bringing If the older family member requires a substantial the aging parent into the home of one of the children amount of physical care, the demands on family or placing the parent in a long-term care facility. There members can be intense. Regardless, many children are problems and concerns with both of these options. feel duty-bound to care for their aging parents. This It is essential that the family making this difficult deci- sense of obligation may be based on cultural, religious, sion consider many factors. The amount of care needed or personal beliefs. If the children determine that they by the parent; the availability of a willing and able are unable to care for their parent and instead opt for family member; the amount of available space in the nursing home placement, children often feel that they child’s home; the added financial and emotional have failed in their responsibilities. This can lead to burden of an additional household member; the wishes intense feelings of guilt, even if nursing home place- of the parent, the child, and the child’s family; and the ment is the most realistic and reasonable option. interpersonal dynamics within the family must be con- sidered before a decision is made. THE NURSE AND FAMILY INTERACTIONS When we as nurses care for older adults, particularly Children may take older parents into their homes in hospital or nursing home settings, we see the person when the older parents can no longer maintain their only as he or she is now. We often forget that these own homes. Although this arrangement works well in people have not always been old. They lived, loved, some families, in others it is problematic for everyone worked, argued, and wept as each of us does. Often, involved. The familiar roles and responsibilities often the older adults we care for are very ill or infirm, and, reverse when children step in and attempt to take care as nurses, we tend to focus on their physical needs, of their parents. This places the aging person into the cares, and treatments. In our preoccupation with our role of the child, which he or she usually resents duties, we can easily lose our perspective of the older strongly. “Don’t tell your mother what to do!” or “I’m patient as both a person and a member of a family. still your father!” is often heard in aging parent-child interactions. In hospitals and nursing homes, family members come and go. Some families show a great deal of inter- Loss of independence is probably the most signifi- est and concern for their aging members, visit regu- cant issue that aging parents and their children must larly and interact with the patient and the staff. This face. The aging family members have spent decades allows us to increase our understanding and apprecia- making their own decisions. As independent adults, tion of our patients as people. Other older individuals they made their own choices about where to live, what may never have family members visit them. They to do, and when to do it. They chose what to eat, seem to be alone in the world, even though the charts obtained their food, and prepared it without interfer- list children and their telephone numbers for emergen- ence. They went to bed when and where they chose. cies. Even in home settings, family attention and inter- They went where they wanted to go without asking action vary greatly. In some households, a great deal permission. They had control of their lives. Most inde- of interest is given to each family member, whereas in pendent adults do not want to ask anyone for help. others little or none is shown. Why do we see such a wide variation of family attention? As physical changes or diseases affect older adults, some or all of their independent function may be lost. The answer often lies in family dynamics and pro- Aging persons find it difficult to accept that they can cesses that began long ago when the older adult was no longer do the things they once did. It is also dis- a young spouse and parent. Some families are very tressing for the family to watch their loved ones stable and cohesive. They are together often and share change. While the aging person tries to cope with these close, loving bonds. They have developed healthy changes, the family tries to determine how to respond. methods for interacting, responding, and meeting each If “the right thing to do” is not obvious, family members other’s needs. Because of the strong bonds that have begin to have mixed feelings and confusion. Feelings developed over many years, these families remain of grief, anger, frustration, and loss are common in all interested in and supportive of aging members. affected individuals. Other families never develop the closeness that is When an aging family member moves in with a ideal in a family. The family unit may have been dis- child’s family, the dynamics within the home are rupted by divorce, mental illness, or other serious unavoidably changed. The ability of the family to problems. There may have been problems with abuse, adapt and cope with an additional member of the alcoholism, or drugs. Long-term problems that have household varies greatly from situation to situation. If all parties are agreeable to the move, and if the older

Trends and Issues  CHAPTER 1 21 developed over time do not go away when a person 5. The inability to manage personal finances as gets old. When the family unit is weak, supportive indicated by the failure to pay bills or by behavior from family members is unlikely. hoarding, squandering, or giving away money inappropriately Most families we interact with fall somewhere between these extremes. Few families are perfect, and 6. Failure to keep important business or medical few are terrible. Families are made up of human beings appointments who respond to stress in many different ways. Coping with the stresses related to aging is difficult for both 7. Life-threatening or suicidal acts, such as wandering, the aging individual and for the family. The behavior isolation, or substance abuse we see at any given time is the best that the person is capable of at that time. That does not mean that it is Self-neglect in the community is most likely to be rec- the best that he or she will be capable of at some other ognized by neighbors and reported to the police, public time. We as nurses need to examine the stresses affect- health nurses, or social workers. It may also be sus- ing the family so that we can best respond to the needs pected by emergency department nurses who see these of all family members. The Critical Thinking box individuals after they are found injured on the street, should help you determine your stress factors. after a fire, or in some other state of distress. Critical Thinking Self-neglect is often connected with some form of mental illness or dementia. Once the problem is recog-   nized, legal action through the courts may be needed to place the person in the custody of a family member You and Your Family or adult protective services. Complete the following: When my parents are unable to care for themselves, I will ABUSE OR NEGLECT BY THE FAMILY _____________________________________________________. Many older adults will need some form of long-term If both my parents and grandparents were alive and in need care in the home. Attempts to meet these demands of assistance, I would __________________________________ may be accompanied by high levels of stress for the _____________________________________________________. caregivers. The American Psychological Association If both my children and my parents needed help from me, I estimates that 4 million older Americans are the victims would ________________________________________________ of abuse or neglect every year, and states that most ______________________________________________________. elder abuse takes place at home. Increased demands If my parents were in a nursing home, I would want the on limited resources, physical exhaustion, or mental nurses to _____________________________________________ fatigue can result in deviant behaviors on the part of _____________________________________________________. the caregiver. Inappropriate behavioral responses When I grow old, I want my family to _____________________ include abuse and neglect of the older family members. _____________________________________________________. Intentional abuse occurs when any person deliberately plans to mistreat or harm another person. Abusive SELF-NEGLECT behavior cannot be justified at any time or in any way. Abuse and neglect are usually something done to Intentional abuse is most likely to occur in families someone, but, unfortunately, self-neglect is a common with preexisting behavioral or social problems. High- problem in the older adult population. Self-neglect is risk families include those that have a history of family more likely to be seen when an older person has few conflict and those with a history of violence or sub- or no close family or friends, but it can occur despite stance abuse, those with mental impairment of either their presence. Because our society has laws to protect the dependent person or caregiver, and those with the rights of adults, it may be difficult for concerned severe financial problems or unemployment. parties to intervene until a situation has reached criti- cal or even life-threatening proportions. Not all forms of abuse are intentional, but even unintentional abuse is devastating to older adults. Self-neglect is defined as the failure to provide for Unintentional abuse or neglect is most likely to occur the self because of a lack of ability or lack of awareness. when the caregiver lacks the necessary knowledge, Indicators of self-neglect include the following: stamina, or resources needed to care for an older loved 1. The inability to maintain activities of daily living one. Often, the caregiver is an older spouse or an aging child who physically cannot meet the high-level care such as personal care, shopping, meal preparation, demands. Situations that trigger abuse are more likely or other household tasks when the older person requiring care is confused or 2. The inability to obtain adequate food and fluid as needs continual care. indicated by malnutrition or dehydration 3. Poor hygiene practices as indicated by body odor, Continuous demands on caregivers can virtually sores, rashes, or inadequate or soiled clothing make them prisoners within their own homes. Stress 4. Changes in mental function, such as confusion, builds, leaving the caregiver feeling trapped, frus- inappropriate responses, disorientation, or trated, or angry. Unable to cope with the stress of these incoherence continual demands, caregivers may strike out at older adults, lock them in a room, restrain them in a chair,

22 UNIT I  Overview of Aging from family members out of fear of losing their independence. or leave them unattended. When stress is high and the coping ability is low, caregivers may not be able to Emotional Abuse identify any better options. They may not intend to Even when physical abuse is absent and adequate hurt the older person or may rationalize that they are physical care is provided, emotional abuse may be doing it to only “keep Dad from hurting himself,” but present. Emotional abuse is the most subtle and diffi- the end result is still abuse. cult to recognize type of abuse. It often includes behav- iors such as isolating, ignoring, or depersonalizing Abuse can be physical, financial, psychological, or older adults. Emotional abusers may forbid visitors emotional. Neglect and abandonment also constitute and isolate the older person from more responsible forms of abuse. and sympathetic friends or family members. They may prohibit the use of the telephone or interfere with com- Physical Abuse munication by mail. There are many types of physical abuse. Physical abuse is any action that causes physical pain or injury. Abuse Emotional abusers can use verbal or nonverbal may involve a physical attack upon a frail older adult means to inflict their damage. Verbal abuse includes who is unable to defend himself or herself from shouting or voicing threats of punishment or confine- younger, stronger family members. Older people may ment. Emotional abusers often threaten older adults be locked in bedrooms, closets, or basements. Older with all manners of horrors if they tell anyone about women may be sexually abused or raped by caregivers their plight. Displeasure, disgust, frustration, or anger or family members. Some older people are starved by can be communicated nonverbally through sighing, family members or given food that is unsuitable or head shaking, door slamming, or other negative unfit for human consumption. Failure to provide ade- body language. Repeatedly ignoring what the older quate food or fluids also constitutes physical abuse. person has to say and avoiding social interaction The inappropriate use of drugs, force-feeding, and the with the individual are subtle forms of emotional use of physical restraints or punishment of any kind abuse. Signs of emotional abuse may include the are examples of physical abuse. Warning signs of phys- lack of eye contact, trembling, agitation, evasiveness, ical abuse include bruising, lacerations, broken teeth, or hypervigilance. broken glasses, sprains, fractures, burn marks, wounds in various stages of healing, unexplained injuries, torn Negative communications are devastating because or bloody underwear, signs of vaginal trauma, delay they can attack the older person’s mind and emotions. in seeking medical treatment or history of “doctor These messages can be so subtle and routine that shopping,” and refusal by the caregiver to let visitors people may not even recognize them as abusive. see the older adult. Emotional abuse is insidious in that it can damage the older adult’s sense of self-esteem and can Neglect even destroy the will to live without leaving any Physical abuse involves one or more actions that cause obvious signs. harm. Neglect is a passive form of abuse in which caregivers fail to provide for the needs of the older Financial Abuse person under their care. Neglect, whether intentional Financial abuse exists when the resources of an older on unintentional, accounts for almost half of the veri- person are stolen or misused by a person whom the fied cases of elder abuse. Neglect includes situations older adult trusts. Children and grandchildren may in which caregivers fail to meet the hygiene or safety take money from the older adult, rationalizing that needs of the older adult. Examples include situations money is owed to them for providing care or that it in which a bedridden person is left wet and soiled with will eventually be theirs anyway. People who expect body wastes without care or in which an older person to benefit from the older person’s estate may be afraid suffers from exposure due to lack of adequate clothing. that the needs of the older adult will consume all of Failure to provide necessary medical care may consti- the money and leave them with nothing, so they decide tute neglect because, with no means of accessing care, to take it while they can. Regardless of the caregivers’ the older person may suffer or die. However, it is not rationalizations in these situations, it is financial abuse considered neglect if the mentally competent older if the older person’s money is taken and spent by person refuses treatment. Neglect may be deliberate others for their own purposes. On the other hand, it is on the part of the caregiver, or it may result from not abusive to use the older adult’s resources to provide lack of knowledge, inadequate financial resources, or for his or her personal needs. an insufficient support system. Neglect is not uncom- mon in situations where one elderly spouse cares Many older adults are overly trusting of family for the other. In spite of the best intentions, the caregiv- members, refusing to believe that their children would ing spouse may be unable to provide adequately for steal from them. This denial often continues despite the needs of the more dependent partner. It is not clear evidence to the contrary. Often, all of the savings uncommon for an older couple to hide these deficits have been spent, the house has been sold, and any

Trends and Issues  CHAPTER 1 23 objects of value have disappeared before they will to do my best, but since she had always done all of the accept the truth. Even then, some older adults make cooking, I didn’t know what to do.” He made sure she took excuses to try to cope with the harsh reality. Abusive her prescribed medicines, and he tried to see to it that she caregivers often abandon the older person once all of had enough to eat and drink, but he said that she was “picky.” his or her assets are gone. In such cases, older adults He also stated that he was unsure just how to take care of his are left homeless, penniless, and in despair. Signs of wife’s hygiene needs: “I tried to wash her up, but she said she financial abuse include unusual banking activity, such wanted to be left alone.” He explained that he shopped for as large or frequent withdrawals, missing bank state- groceries when she was asleep. He was afraid that if he called ments, missing valuable personal belongings, and sig- anyone for help, they would place his wife in an institution, and natures on checks or documents that do not match the he could not cope with this idea. She had not complained to older adult’s. anyone for the same reason. Their children all lived out of state and had not visited since she had the stroke. The patient and Some actions that senior citizens can take to protect her husband had assured their children by phone that every- their financial assets include: (1) arranging for direct thing was all right. It was only when she complained of chest deposit of Social Security, pension, and any other pain that they sought medical attention. benefit checks; (2) taking great care in the selection of anyone appointed as the power of attorney or giving Older people who manifest signs of abuse must be advice regarding a will; (3) keeping ATM pin numbers assessed carefully (Box 1-6). They may try to protect secure—do not write them in a location where others and defend the abuser, deny that abuse is occurring, may see them, and do not give the number to anyone; or seem resigned to the situation, believing that there (4) having written agreements regarding expectations is no better alternative. and fees for any services; (5) keeping valuables in a secure location such as a safe deposit box; and (6) All questioning about and assessment of abuse remembering that home helpers or attendants are must be done with great tact and sensitivity. It is best employees not friends—pay the fair and agreed wage, to question the older adult alone so they can speak and keep tips and gifts for special occasions. freely and without intimidation from the potential abuser. The rights of older people to determine their Abandonment own affairs to the full extent of their abilities must be Abandonment occurs when dependent older persons respected. Information obtained must be kept confi- are deserted by the person or persons responsible for dential and shared only with agencies as authorized their custody or care under circumstances in which a by the patient or necessitated by law. All observations, reasonable person would continue to provide care. both objective and subjective, must be carefully docu- Abandonment usually leaves the older person physi- mented in case legal action is required. Detailed records cally, emotionally, and financially defenseless. Older should be kept regardless of whether legal action is adults who have been abandoned by their families anticipated. Data may become significant only at a usually become wards of the state. later date when they are impossible to reconstruct if not appropriately recorded. Photographs may be nec- Responses to Abuse essary to provide proof of neglect or abuse. These may It is natural to think that an older person suffering include pictures of wounds, injuries, or living condi- from one or more forms of abuse would complain, but tions. It is wise to avoid using the term abuse when this is rarely the case. Fear of being treated even worse or fear of being institutionalized or abandoned may Box 1-6  Signs the Older Person May Be prevent the victim from seeking help. Experiencing Abuse Clinical Situation • Excessive agreement or compliance with the caregiver   • Signs of poor hygiene such as body odor, Trends and Issues uncleanliness, or soiled clothing or undergarments An 84-year-old woman was admitted to the hospital for dehy- dration and malnutrition. Six months earlier, she had suffered • Malnutrition or dehydration a mild stroke. Since then, her 86-year-old husband had been • Burns or pressure sores caring for her at home. On admission, the woman weighed 91 • Bruises, particularly clustered on trunk or upper arms pounds. Stage 2 pressure ulcers were present on both but- • Bruises in various stages of healing that may indicate tocks. Her clothing and undergarments were soiled, and she was in serious need of a bath. She reported episodes of incon- repeated injury tinence of bladder and bowel. Her only reported activity con- • Inadequate clothing or footwear sisted of sitting in a lounge chair watching TV. She was wearing • Inadequate medical attention a wig, which covered hair that was matted tightly on her scalp. • Lack of food, medication, or care After several days of carefully combing out the snarls, the nurse • Verbalization of being left alone or isolated realized the woman’s shoulder-length hair had not been • Verbalization of fear of the caregiver washed in months. The patient’s husband explained, “I tried • Verbalization of a lack of control in personal activities or finances

24 UNIT I  Overview of Aging Coordinated Care working with older adults, because they may become   defensive and will probably deny it. Using words such as problems or concerns is more likely to yield truthful Collaboration information. ELDER ABUSE IN INSTITUTIONS When there is any question of abuse, an experienced Abuse in institutional settings is most likely to occur when the professional who is skilled in dealing with elder abuse nursing assistants are forced to work under stressful condi- should oversee the case. Physical abuse and financial tions and have a poor ability to deal with that stress. The risk abuse are criminal offenses. Nurses have a moral, for abuse increases when caregivers perceive that they are not legal, and ethical responsibility to report any suspected valued, supported, or acknowledged. cases of abuse (see Critical Thinking box). Nurses who provide care to at-risk groups, particularly the The following are ways that may help decrease stress and young and the older adult population, must be aware the likelihood of abuse: of their legal obligations with regard to suspected • Create a positive team environment with full staffing abuse. Nurses must know the state laws pertaining to abuse, the proper authorities to contact, and how to levels; convey true respect and appreciation for the work contact them. Once the responsible authorities are every team member does. notified, they are obligated by law to investigate and • Encourage staff to take breaks on time, and to rest and pursue any legal action necessary to protect the safety re-energize with healthy snacks. Provide a staff member of the abused and to protect them from further harm. responsible for “break relief” so that care may continue during breaks. Critical Thinking • Rotate any “difficult” assignments, to avoid overwhelming any one team member.   • Improve staff training to identify and defuse potential abuse situations. Your Knowledge of Elder Abuse • Initiate a stress-reduction program, including staff support • Is elder abuse increasing today? If so, why? groups and exercise options. • What would you do if you thought a close friend or relative • Recognize the value of nursing assistants to the team’s effort by involving them in care planning and consulting was an elder abuser? with them regarding potential problems and possible • What do you think is the best way to reduce the incidence solutions. • Increase recognition of good, compassionate caregiving of elder abuse? Why? through verbal praise, employee-of-the-month recognition, • What would you do if you suspected that a nursing bonuses, and other rewards. • Institute a “get to know the resident” program, whereby assistant was abusing patients? on a monthly basis, one resident is featured, with • What can you as a student nurse do to prevent elder accomplishments from his or her past. Team members may be surprised to learn that the dependent older adult abuse? they now care for once served as an elite military Special • What resources are available in your community to help Forces member, raised twelve children, volunteered as a docent at the local aquarium, or played in a rock band. prevent elder abuse? • Provide an institutional mechanism for dealing with nursing assistants’ complaints and concerns in a ABUSE BY UNRELATED CAREGIVERS proactive rather than punitive manner. Understandably, we would like to think that all persons seeking employment as caregivers to older adults Specific federal and state laws designed to prevent are responsible, caring individuals, but, unfortunately, undesirable persons from contact with vulnerable this is not the case. People who are hired to provide people, such as the young and the older adult popula- for the safety and well-being of older adults can tion, are in force today; however, sometimes people sometimes become their greatest threat. Increased use with criminal records, inadequate training, or other of unrelated caregivers exposes older adults to addi- serious shortcomings manage to gain employment, tional risks. despite safeguards such as state registries, employ- ment histories, and reference checks. Undesirable indi- As the number of older adults increases and as more viduals may unwittingly be hired to provide care for frail older people remain in their homes, the demand older adults by families, home health agencies, and for nursing assistants, home health aides, and house- even health care institutions. keepers increases. Most people who work as nursing assistants or housekeepers are decent, caring individu- In home settings, unscrupulous caregivers have als who provide difficult services for little reward. The been known to take money and personal belongings salaries paid to nursing assistants and housekeepers from defenseless older people under their care. They are low, the hours are long, and the work is emotion- may physically abuse older persons and threaten them ally and physically demanding. It can be difficult to with physical harm if the abuse is reported. They may find caring, responsible people who are willing to threaten to quit, leaving the older person in fear of provide this service. When the demand for caregivers being placed in an institution. Using threats enables exceeds the supply of desirable workers, employers these individuals to remain undetected until they have may be forced to hire people who are willing to take these jobs only because they cannot find other employment.

Trends and Issues  CHAPTER 1 25 Box 1-7  Abusive Behaviors in Health Care Settings and their caregivers are available. The availability and type of services vary from area to area. Nurses who • Use of sedative or hypnotic drugs that are not work with older adults should become knowledgeable medically necessary about the services available in their communities. Resources may include education programs designed • Use of restraints when they are not medically to improve an awareness of elder abuse, support indicated groups for caregivers, respite care programs, and senior day care centers. Many hospitals and health care • Use of derogatory language, angry verbal interactions, agencies provide educational in nutrition, medication or ethnic slurs administration, bedside care, and other aspects of elder care. The need for these programs is growing as • Withholding of privileges such as snacks or cigarettes the older adult population increases. • Excessive roughness in handling during care or during SUPPORT GROUPS transfers Caregivers of older adults are often isolated from other • Delay in taking a resident to the bathroom or allowing people. The demands of providing care prevent care- givers from getting the rest, encouragement, and a resident to lie in body waste support they need. Caregivers who want or need to • Consumption of a resident’s food share their experiences and frustrations have started • Theft of money or personal belongings forming support groups to help one another cope with • Physical striking or any other assaultive behavior stress. These support groups may be specialized (e.g., for caregivers of people with Alzheimer disease) or toward a resident more general in nature. Support groups allow care­ • Violation of a resident’s right to make decisions givers to share their feelings and to learn new strate- • Failure to provide privacy gies to improve coping skills. Some groups schedule speakers to discuss topics of common interest or offer caused serious harm. When they are discovered, they social activities to promote stress reduction. often disappear, only to reappear somewhere else and repeat their pattern of abuse. RESPITE CARE Respite care allows the primary caregiver to have time Even health care institutions are not immune to away from the demands of caregiving, thereby decreas- problems of elder abuse. Most people assume that ing stress and the risk for abuse. Many caregivers are because hospitals and nursing homes are licensed and unable to lead normal lives because they cannot leave regulated, this type of behavior does not occur. their responsibilities for very long without fear of Unfortunately, this is wishful thinking. Many institu- some disaster occurring. Respite care gives the primary tions have difficulty hiring enough people to meet the caregiver the opportunity to attend church, go shop- required staffing levels. Although most health care ping, conduct personal business, obtain medical care, institutions and agencies screen applicants in an or simply participate in leisure activities. Respite care attempt to find the most qualified individuals and to may be provided by family members, volunteers, or avoid hiring anyone with a history of abusive or crimi- one of the many service agencies that have proliferated nal behavior, some unscrupulous people manage to within the past few years. The Veterans Administration avoid detection and are employed as caregivers to offers respite care for enrolled members of the VA older adults. These unsuitable caregivers may victim- health care system. Caregivers may be reluctant to use ize older adults before they can be detected. Nurses respite care out of guilt, fear, or other misguided emo- who supervise other caregivers must constantly be on tions. Nurses should encourage caregivers to protect the lookout for abusive behaviors (Box 1-7). Nurses are their own health and well-being by regularly taking mandated reporters of elder abuse, which means it is advantage of respite care. against the law if you suspect elder abuse and do not report it. You must know and follow the reporting laws in your state. Report any indication of abuse as soon as possible if you ever suspect it so that appropriate action can be taken and the abusive person removed. A wide variety of services to reduce abuse and to meet the emotional and physical needs of older adults Get Ready for the NCLEX® Examination! • A large segment of today’s aging population lives a more dynamic, positive lifestyle than ever before. Key Points • Stereotyping and negative perceptions of aging • Chronologic age is not always the most reliable way to and older persons appear to be on the decline, measure aging because the number of years a person yet subtle forms of ageism still exist and must be has lived provides little information about his or her addressed. physiologic or functional ability.

26 UNIT I  Overview of Aging • The United States will face significant challenges to 5. What does the Durable Power of Attorney for health meet the costs of providing adequate health care to an care enable the health care agent to do? aging population. 1. Decide whether the older adult should be resuscitated • As older adults become an increasingly larger segment 2. Act only when the older adult is unable to act for of the population, they are having a significant impact himself or herself on politics, economics, housing, and social family 3. Determine when the older adult should be dynamics. hospitalized 4. Change care decisions if he or she thinks these will • Providing quality care for an increasingly large aging benefit the older adult population places increased demands on both family and professional caregivers. 6. What is one of the most significant changes that impact the older adult and his or her family? • Although many positive changes have occurred, the 1. Loss of independence frailest older adults remain vulnerable to physical, 2. Change in physical appearance emotional, and financial abuse. 3. Decreased financial resources 4. Sensory and cognitive decline Additional Learning Resources 7. A nurse is assessing an alert for an elderly woman who Go to your Evolve website at http://evolve.elsevier was admitted to the emergency room accompanied by .com/Williams/geriatric for the additional online resources. her daughter with whom she resides. What observation might arouse suspicion of elder abuse? (Select all Online Resources: that apply.) 1. Bruises are observed on the arms and upper body. • Official geriatric nursing website of the American 2. The daughter answers all questions for her mother. Nurses Association (ANA): Geronurseonline.org 3. She has body odor and soiled clothing. 4. The woman states that she does not like to see the Review Questions for the NCLEX® Examination doctor. 5. The daughter states her mother does not get along 1. What are myths related to aging? (Select all that apply.) with the grandchildren. 1. Most older adults live in institutional settings. 6. Skin is intact with good turgor. 2. Most older adults suffer from a significant loss of intellectual function. 8. A student nurse observes caregivers in a long-term 3. Most older adults have frequent interaction with care facility where she is employed. Which observations family and friends. might indicate abusive behavior? (Select all that apply.) 4. Most older adults experience significant personality 1. Failing to close bedside curtains during care changes. activities 5. Most older adults are seriously depressed. 2. Use of physical restraints to decrease wandering 6. Most older adults are sick, frail, and dependent on behavior others. 3. Providing extra snacks as a reward for good behavior 2. Which is true of the Baby Boom generation? 4. Laughing and talking with co-workers while 1. Members were born between 1946 and 1964. providing care 2. Members will all be age 65 or older by 2025. 5. Speaking negatively about an older adult while in the 3. Members are reaching age 65 at the rate of about break room 200 cohort members each day. 6. Responding slowly to the call light of a demanding 4. It comprises about one third of the population today. older adult 3. When was Medicare legislation established? 9. Which type of document indicates someone’s wishes 1. 1940s by creating physician orders to be followed? 2. 1950s 1. Advance directive 3. 1960s 2. Living will 4. 1970s 3. Durable power of attorney for health care 4. POLST 4. What is the overall percentage of senior citizens who live in an institutional setting? 1. approximately 1% 2. approximately 3.6% 3. approximately 11% 4. approximately 17%

Theories of Aging chapter 2  Objectives http://evolve.elsevier.com/Williams/geriatric 1. Discuss how a theory is different from a fact. 4. Discuss the relevance of these theories to nursing 2. Describe the most common biologic theories of aging. practice. 3. Describe the most common psychosocial theories immunologic  (ĭm-ū-nō-LŎJ-ĭk, p. 29) of aging. psychosocial  (sī-kō-SŌ-shŭl, p. 27) theory  (p. 27) Key Terms antioxidants  (ăn-tē-ŎK-sĭ-dănts, p. 28) biologic  (bī-ō-LŎJ-ĭk, p. 27) free radical  (p. 28) There is no single universally accepted definition of aging are not completely understood. Because we do aging. Aging is best looked at as a series of changes that not have definitive and reproducible evidence indicat- occur over time, contribute to loss of function, and ing exactly why we age, all of the following remain ultimately result in the death of a living organism. Like theories. other living organisms, humans age and then die. The maximal life expectancy for humans today appears to BIOLOGIC THEORIES be 120 years, but why is this so? Theories of aging have been considered throughout history as mankind has Biologic theories of aging attempt to explain the sought to find ways to avoid aging. The quest for a physical changes of aging. Researchers try to identify “fountain of youth” has motivated explorers, such as which biologic factors have the greatest influence on Ponce de Leon. The search for the extension of youth longevity. It is known that all members of a species has led some people to seek the potions of conjurers, suffer a gradual, progressive loss of function over often more poisonous than beneficial. time because of their biologic structure. Many of the biologic theories of aging overlap because most assume No one has identified a single unified rationale that the changes that cause aging occur at a cellular for why we age and why different people live lives level. Each theory attempts to describe the processes of of different lengths. Theories abound to help explain aging by examining various changes in cell structures and give some logical order to our observations. or function. Observations, including physical and behavioral data, are collected and studied to scientifically prove or dis- Some biologic theories look at aging from a genetic prove their effects on aging. perspective. The programmed theory proposes that everyone has a “biologic clock” that starts ticking at Studies of families and identical twins show that conception. In this theory, each individual has a genetic there is a strong correlation in the life expectancies of “program” specifying an unknown but predetermined genetically related people. If your grandparents and number of cell divisions. As the program plays out, parents live to be 60, 70, 80, or 90 years of age, you are the person experiences predictable changes such as likely to have a similar life span. This is not always atrophy of the thymus, menopause, skin changes, and the case, however. Some individuals fail to meet graying of the hair. A closely related theory is the run- genetic expectations, whereas others significantly out-of-program theory, which proposes that every person exceed expectations. Biologic and environmental has a limited amount of genetic material that will run factors are being studied to explain these variations. out eventually, and the rate of living theory, which pro- poses that individuals have a finite number of breaths Although there is no question that aging is a bio- or heartbeats that are used up over time. The gene logic process, sociologic and psychological compo- theory proposes the existence of one or more harmful nents play a significant role. All of these areas—genetic, genes that activate over time, resulting in the typical biologic, environmental, and psychosocial—have pro- changes seen with aging and limiting the life span of duced theories that attempt to explain the changes the individual. seen with aging. Despite extensive interest in this topic, the specific causes and processes involved in 27

28 UNIT I  Overview of Aging the brain. Stimulation or inhibition of various endo- The molecular theories propose that aging is con- crine glands by the hypothalamus initiates the release of various hormones from the pituitary and other trolled by genetic materials that are encoded to prede- glands, which, in turn, regulate bodily functions, termine growth and decline. The error theory proposes including growth, reproduction, and metabolism. With that errors in ribonucleic acid protein synt­hesis cause age, the hypothalamus appears to be less precise in errors to occur in cells in the body, resulting in a pro- regulating endocrine function, leading to age-related gressive decline in biologic function. The somatic muta- changes such as decreased muscle mass, increased tion theory is similar but proposes that aging results body fat, and changes in reproductive function. It is from deoxyribonucleic acid (DNA) damage caused proposed that hormone supplements may be designed by exposure to chemicals or radiation and that this to delay or control age-related changes. damage causes chromosomal abnorm­ alities that lead to disease or loss of function later in life. Complementary and Alternative Therapies Cellular theories propose that aging is a process that   occurs because of cell damage. When enough cells are damaged, overall functioning of the body is decreased. Alternative and Complementary Therapies to Slow or The free radical theory provides one explanation for cell Reverse Aging damage. Free radicals are unstable molecules pro- duced by the body during the normal processes of ANTIOXIDANT THERAPY respiration and metabolism or following exposure to • Proposed as a method of neutralizing free radicals, which radiation and pollution. These free radicals are sus- pected to cause damage to the cells, DNA, and the may contribute to aging and disease processes immune system. Excessive free radical accumulation • Includes a number of vitamins and minerals, such as in the body is purported to contribute to the physio- logic changes of aging and a variety of diseases, such vitamins A, B6, B12, C, and E; beta carotene; folic acid; as arthritis, circulatory diseases, diabetes, and athero- and selenium sclerosis. One free radical, named lipofuscin, has been • Generally safe when consumed as fruits and vegetables identified to cause a buildup of fatty pigment granules as part of the overall diet that cause age spots in older adults. Individuals who • High doses of some antioxidants may cause more harm support this theory propose that the number of free than benefits radicals can be reduced by the use of antioxidants, such • No proof that antioxidants are effective as vitamins A, C, and E, carotenoids, zinc, selenium, • Discuss with physician before starting use and phytochemicals. HORMONE THERAPY One variation of this theory is the crosslink or con- • Proposed to replace a reduction in hormones, which nective tissue theory, which proposes that cell molecules from DNA and connective tissue interact with free naturally decrease with aging radicals to cause bonds that decrease the ability of • Includes hormones, such as dehydroepiandrosterone tissue to replace itself. This results in the skin changes typically attributed to aging such as dryness, wrinkles, (DHEA), estrogen, testosterone, melatonin, and human and loss of elasticity. Another variation, the Clinker growth hormone (HGH) theory, combines the somatic mutation, free radical, • Little evidence to support claims made by advocates and crosslink theories to suggest that chemicals pro- • May actually cause more harm than provide benefits duced by metabolism accumulate in normal cells and • Usually requires prescription or supervised medical cause damage to body organs, such as the muscles, administration heart, nerves, and brain. SUPPLEMENTS The wear-and-tear theory presumes that the body is • Proposed to replace or enhance nutritional status; often similar to a machine, which loses function when its parts wear out. As people age, their cells, tissues, and marketed as “natural” remedies organs are damaged by internal or external stressors. • Include substances such as ginseng, coral calcium, When enough damage occurs to the body’s parts, overall functioning decreases. This theory also pro- Echinacea, and other herbal preparations poses that good health maintenance practices will • No proof of effectiveness reduce the rate of wear and tear, resulting in longer • Not regulated by the Food and Drug Administration, so and better body function. In a similar vein, the reli- ability theory of aging and longevity is a complex math- there is no control regarding the amount of active ematical model of system failures first used to describe ingredients, purity, and quality failure of complex electronic equipment. It is used as • High risk for interaction with prescription medications; a model to describe degradation (disease) and failure physician must be notified if these products are used (death) of human body systems. CALORIE-RESTRICTED DIET The neuroendocrine theory focuses on the complicated • Proposes that significant calorie reduction can extend chemical interactions set off by the hypothalamus of life; based on studies in rats, mice, fish, and worms; not proven in humans • Severe calorie restriction can result in inadequate consumption of necessary nutrients • Studies show that severely underweight persons have a higher risk for some diseases and even death • Dietary changes should be discussed with a physician or nutritionist to ensure that adequate nutrition is maintained

Theories of Aging  CHAPTER 2 29 The immunologic theory proposes that aging is a function of changes in the immune system. identity confusion; (6) intimacy versus isolation; (7) According to this theory, the immune system— generativity versus stagnation; and (8) integrity versus an important defense mechanism of the body— despair. The last of these stages is the domain of late weakens over time, making an aging person more adulthood, but failure to achieve success in tasks susceptible to disease. The immunologic theory also earlier in life can cause problems later in life. Late proposes that the increase in autoimmune diseases and adulthood is the time when people normally review allergies seen with aging is caused by changes in the their lives and determine whether they have been neg- immune system. ative or positive overall. The most positive outcomes of this life review are wisdom, understanding, and A fairly new theory of aging correlates aging to acceptance; the most negative outcomes are doubt, calorie intake. Animal research has shown that a point gloom, and despair. of metabolic efficiency can be achieved by consuming a high-nutrient but low-calorie diet. It is hypothesized Havighurst’s theory details the process of aging and that this diet, when combined with regular exercise, defines specific tasks for late life, including: (1) adjust- may extend optimal health and life span. ing to decreased physical strength and health; (2) adjusting to retirement and decreased income; (3) PSYCHOSOCIAL THEORIES adjusting to the loss of a spouse; (4) establishing a relationship with one’s age group; (5) adapting to Psychosocial theories of aging do not explain the social roles in a flexible way; and (6) establishing sat- physical changes of aging; rather they attempt to isfactory living arrangements. explain why older adults have different responses to the aging process. Some of the most prominent psy- Newman’s theory identifies the tasks of aging as: (1) chosocial theories of aging are the disengagement coping with the physical changes of aging; (2) redirect- theory, the activity theory, life-course or develop­ ing energy to new activities and roles, including retire- mental theories, and a variety of other personality ment, grandparenting, and widowhood; (3) accepting theories. one’s own life; and (4) developing a point of view about death. The highly controversial disengagement theory was developed to explain why aging persons separate from Jung’s theory proposes that development continues the mainstream of society. This theory proposes that throughout life by a process of searching, questioning, older people are systematically separated, excluded, or and setting goals that are consistent with the individ- disengaged from society because they are not per- ual’s personality. Thus, life becomes an ongoing ceived to be of benefit to the society. This theory further search for the “true self.” As individuals age, they proposes that older adults desire to withdraw from go through a reevaluation stage at midlife, at which society as they age; the disengagement is mutually point they realize there are many things they have beneficial. Critics of this theory believe that it attempts not done. At this stage, they begin to question whether to justify ageism, oversimplifies the psychosocial the decisions and choices they have made were the adjustment to aging, and fails to address the diversity right choices for them. This is the so-called midlife and complexity of older adults. crisis, which can lead to radical career or lifestyle changes or to the acceptance of the self as is. As aging The activity theory proposes that activity is neces- continues, Jung proposes that the individual is likely sary for successful aging. Active participation in to shift from an outward focus (with concerns about physical and mental activities helps maintain func- success and social position) to a more inward focus. tioning well into old age. Purposeful activities Successful aging, according to Jung, includes accep- and interactions that promote self-esteem improve tance and valuing of the self without regard to the overall satisfaction with life, even at an older age. view of others. “Busy work” activities and casual interaction with others were not shown to improve the self-esteem of IMPLICATIONS FOR NURSING older adults. Physical theories of aging indicate that, although Life-course theories are perhaps the theories best biology places some limitations on life and life expec- known to nursing. These theories trace personality and tancy, other factors are subject to behavior and personal adjustment throughout a person’s life. Many life choices. Nursing can help individuals achieve of these theories are specific in identifying life-oriented the longest, healthiest lives possible by promoting tasks for the aging person. Four of the most com­ good health maintenance practices and a healthy mon theories—Erikson’s, Havighurst’s, Newman’s, environment. and Jung’s—are worth exploring. Psychosocial theories help explain the variety of Erikson’s theory identifies eight stages of develop- behaviors seen in the aging population. Understanding mental tasks that an individual must confront through- all of these theories can help nurses recognize prob- out the life span: (1) trust versus mistrust; (2) autonomy lems and provide nursing interventions that will help versus shame and doubt; (3) initiative versus guilt; aging individuals successfully meet the developmen- (4) industry versus inferiority; (5) identity versus tal tasks of aging.

30 UNIT I  Overview of Aging that the approach more likely to cause harm than good is which one? Get Ready for the NCLEX® Examination! 1. Intake of antioxidants, such as vitamins A, B6, B12, Key Points C, and E 2. Replacing of hormones, such as HGH, DHEA, and • Many biologic, environmental, and psychosocial theories have been proposed to explain why we age. estrogen 3. Calorie-restricted diet • These theories remain theories because the exact 4. Intake of herbal and nutritional supplements processes that cause the changes seen with aging are not completely understood. 2. The same friend asks how long humans can live. What is the nurse’s best reply? • Further research and study are needed to determine 1. 100 years which theory or combination of theories is most 2. 105 years accurate. 3. 110 years 4. 120 years • Once this is determined, we will be able to institute measures to slow aging and prolong the human life 3. According to Erikson, what is the primary span. developmental task of the older adult population? 1. Generativity versus stagnation • To date, hormone replacement therapy appears to have 2. Trust versus mistrust more risks than benefits. 3. Intimacy versus isolation 4. Integrity versus despair Additional Learning Resources 4. A friend tells you she thinks her father is experiencing a Go to your Evolve website at http://evolve.elsevier “midlife crisis,” because he purchased a new red sports .com/Williams/geriatric for the additional online resources. car, started wearing trendy clothing, and is considering a career change. Whose theory explains this behavior? Online Resources: 1. Newman’s 2. Jung’s • American Federation for Aging Research: www.afar.org/ 3. Havighurst’s 4. Erikson’s Review Questions for the NCLEX® Examination 1. A friend asks the nurse what could be done to improve the chance of a long life. Using current biologic theories of aging, the nurse recommended that her friend discuss this first with her physician, but advises

Physiologic Changes chapter 3  Objectives http://evolve.elsevier.com/Williams/geriatric 1. Describe the most common structural changes observed 5. Identify the most common diseases related to aging in in the normal aging process. each of the body systems. 2. Discuss the impact of normal structural changes on the 6. Differentiate between normal changes of aging and older adult’s self-image and lifestyle. disease processes. 3. Describe the most commonly observed functional 7. Discuss the impact of age-related changes on nursing changes that are part of the normal aging process. care. 4. Discuss the impact of normal functional changes on the ischemic  (ĭs-KĒ-mĭk, p. 45) older adult’s self-image and lifestyle. nystagmus  (nĭs-TĂG-mŭs, p. 65) orthostatic hypotension  (ŏr-thō-STĂT-ĭk hī-pō-TĔN-shŭn, Key Terms p. 45) carcinoma  (kăr-sĭ-NŌ-mă, p. 33) osteoporosis  (ŏs-tē-ō-pă-RŌ-sĭs, p. 38) cardiomegaly  (kăhr-dē-ō-MĔG-ă-lē, p. 46) presbycusis (p. 64) cataracts  (KĂT-ă-răkts, p. 63) seborrheic dermatitis  (sĕb-ō-RĒ-ĭk dĕr-mă-TĪ-tĭs, p. 35) dementia  (dĕ-MĔN-shē-ă, p. 57) seborrheic keratosis  (sĕb-ō-RĒ-ĭk kĕr-ă-TŌ-sĭs, p. 32) diverticulosis  (dī-vĕr-tĭk-ū-LŌ-sĭs, p. 52) senile lentigo  (SĒ-nīl lĕn-TĪ-gō, p. 32) gastroesophageal reflux disease (p. 52) senile purpura  (SĒ-nīl PŪR-pū-ră, p. 33) glaucoma  (glă-KŌ-mă, p. 63) xerosis  (zĕr-Ō-sĭs, p. 33) hiatal hernia (p. 51) hypothyroidism  (hī-pō-THĪ-royd-ĭzm, p. 59) intermittent claudication (ĭn-tĕr-MĬT-ĕntklaw-dĭ-KĀ-shŭn, p. 46) Changes in body function with age are part of a con- As a person moves into his or her fifth and sixth tinuum that starts the moment life begins. From the decades of life, these physiologic changes become moment of conception, tissues and organs develop more apparent. In the seventh and eighth decades in an orderly manner. When fully developed, these and beyond, they are significant and no longer organs and tissues perform specific functions and deniable. interact together in a predictable way. Throughout life, human growth and development occur methodically. It is important to recognize that although age- related changes are predictable, the exact time at which Early in life, the physical changes are dramatic. In they occur is not. Just as no two individuals grow and only 9 months of gestation, the human organism devel- develop at exactly the same rate, no two individuals ops from the union of two almost invisible cells into a show the signs of aging at the same time. There is unique, functioning individual measuring approxi- wide person-to-person variation in when—and to mately 20 inches in height and usually weighing what degree—these changes occur. Heredity, environ- between 6 and 9 pounds. For the next 13 to 15 years, ment, and health maintenance significantly affect the rapid physical growth continues. By approximately timing and magnitude of age-related changes. Some age 18, the human body reaches full anatomic and people are chronologically quite young but appear old. physiologic maturity. The most severe cases of this occur in a rare condition called progeria. When they are only 8 or 9 years of The peak years of physiologic function last from the age, children with progeria have the physiology and late teens through the thirties—the so-called prime of appearance of 70-year-olds. At the other extreme, there life. Physiologic changes are still occurring during this are persons in their sixties, seventies, and even older time, but they are subtle and not easily recognized. who are vigorous and appear much younger than their Because these changes do not happen as rapidly or chronologic age. Most people show the signs of aging as dramatically as those earlier in life, they may be at a rate somewhere between these two extremes. ignored. 31

32 UNIT I  Overview of Aging the amount of melanin produced by the follicle and, We can observe many normal changes in the body’s like skin pigmentation, is hereditary. Nails are rigid structures that protect the sensitive, nerve-rich tissue structure and function during the aging process. There at the tips of the fingers and toes. Nails also aid dexter- are also changes that indicate the onset of disease or ity in fine finger manipulation. illness. Nurses are expected to be able to distinguish between normal changes and abnormal changes that Subcutaneous tissue consists of areolar connective signify a need for medical or nursing intervention. To tissue, which connects the skin to the muscles, and identify these differences, nurses must have a good adipose tissue, which provides a cushion over tissue understanding of the normal body structures and and bone. Subcutaneous tissue provides insulation to functions. This knowledge should help nurses under- regulate body temperature. It is here that white blood stand how normal and abnormal changes affect the cells (WBCs) are available to protect the body from day-to-day functional abilities of older adults. As microbial invasion through the skin. Blood vessels in nurses, we must be aware of physical changes that the subcutaneous tissue supply the tissue with nour- are likely to occur, assess each person to determine ishment and assist in the process of heat exchange. the extent to which these changes have occurred, and These superficial blood vessels dilate or constrict as then make our care plans in response to that individ- needed to release heat or to conserve heat lost through ual’s needs. convection. EXPECTED AGE-RELATED CHANGES Some diseases are more common with advanced With aging, the epidermis becomes more fragile, age. Older adults typically experience one or more increasing the risk for skin damage such as tears, mac- chronic conditions. The leading cause of disability over eration, and infection. Rashes caused by contact with age 65 in the United States is arthritis. Other common chemicals, such as detergents or cosmetics, are increas- causes are heart disease, stroke, hypertension, diabe- ingly common in older individuals. Skin repairs more tes, and cancer. According to the Centers for Disease slowly in older individuals, increasing the risk for Control and Prevention (CDC), the five leading causes infection. of death among older adults are (1) heart disease, (2) cancer, (3) chronic lower respiratory disease, (4) cere- Melanocyte activity declines with age, and in light- brovascular disease, and (5) Alzheimer disease. skinned individuals, the skin may become very pale, making older individuals more susceptible to the Nurses must learn that each aging person is unique. effects of the sun. Melanocyte clusters can form areas The type and extent of changes seen with aging are of deepened pigmentation, a condition called senile specific and unique to each person. Nurses must avoid lentigo; these areas are often referred to as age spots or falling into the trap of stereotyping older adults. liver spots and are most often seen on body areas that Stereotyping is dangerous because it leads us to accept are most exposed to sunlight. In a condition called as inevitable some changes that are not inevitable. seborrheic keratosis, slightly raised, wartlike macules Stereotyping can also cause us to mistake early signs with distinct edges appear (Figure 3-1). These lesions, of disease as a part of aging. FIGURE 3-1  Seborrheic keratoses usually appear at approximately THE INTEGUMENTARY SYSTEM the fifth decade of life and gradually increase in number with age. These superficial, benign growths can enlarge to 20 mm in diameter The integumentary system, which includes the skin, and have a convoluted surface. (From White GM, Cox NH: Diseases hair, and nails, undergoes significant changes with of the skin: A color atlas and text, ed 2, Philadelphia, 2006, Mosby.) aging. Because many of these structures are visible, changes in this system are probably the most obvious and are evident to both the aging individual and others. The epidermis, the outermost layer of the skin, is an important structure that provides protection for internal structures, keeps out dangerous chemicals and microorganisms, functions as part of the body’s fluid regulation system, and helps regulate body tem- perature and eliminate waste products. It also contains melanocytes that produce the pigment melanin, which provides protection from ultraviolet radiation. The dermis contains collagen and elastin fibers, which give strength and elasticity to the tissues. The sebaceous (oil-producing) and eccrine (sweat- producing) glands are located in the subcutaneous tissue, as are the hair and nail follicles and the sensory nerve receptors. Hair and nails are composed of dead keratinized cells. Hair pigment, or color, is related to