theories of aging there are many theories of aging. it is important to understand some theories of...
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THEORIES OF AGING There are many theories of aging. It is
important to understand some theories of aging as they relate to
taking care of the elderly. Psychological Theories
Maslow Human Needs Five basic needs Ericksons Personality Life
stages relate to life tasks Grossman and Lange, 2006 We are all
familiar with Maslows hierarchy of needs which include1.physiologic
needs 2. safety and security 3. love/belonging 4. self-esteem 5.
self-actualization.For the aging population it is suggested that
the order may be changed to honor the persons wishes at different
times relating to health.It is important for all persons involved
in the care of the elderly person to understand that different
needs are more important at different times.Ericksons Personality
theory focuses on development of the individual person.The elderly
person can go through a stage that is described as ego integrity vs
despair. In this stage, the person evaluates the accomplishments of
their life people who were satisfied with their achievements tended
have a greater sense of contentment than those who were not. Social
Theories Based on social order, balance and harmony
Activity Theory Necessary for satisfaction with life Disengagement
theory Natural process Gradual withdrawal The social theory is
believed to have been founded after the second world war when
society felt people had certain positions in society.Balance and
harmony was maintained by preserving the social order.Two theories
were developed from this basis.Self- identity, which is similar to
Ericksons life stages theory, states that people must move through
the stages of their life.The focus is that the person must remain
active to counteract the aging process and maintain a healthy life
style. While social participation is essential to a healthy aging
process, decreased functional or cognitive status can impact
involvement. Being aware of limitations and learning alternative
activities would be important to facilitate social participation at
the level of involvement a person can achieve.The disengagement
theory beliefs are based on evidence that the older person
gradually with draws from events in their life first from society
and then from family before death.Some believe that this theory
allows for other family members to take over the duties that the
older person used to perform.As workers in the health care field,
it is important to recognize how one begins to withdraw and support
the person as well as their loved one through this time. Phelan,
2010 Biological Theories Non-stochastic Stochastic Predicted
damage
Random damage Grossman and Lange, 2006 Two biological theories are
stated above. The non-stochastic (stowkastic) theory is that all
people age it happens over time and is predictable. Stochastic
theory believes events that occur during a persons lifetime cause
random damage and leads to aging.Some people believe that both of
these theories are correct to a certain point, for instance one can
have co-morbidities such as heart disease or diabetes which cause
their body to deteriorate over time and maybe at a faster rate but
a healthy person can suddenly age when in their 70s. Ageism
stereotypical, dehumanizing, negative constructions (Phelan, 2010)
Three domains Cognitive Beliefs and stereotypes Affective prejudice
Behavioral Direct discriminatory practices Indirect discriminatory
practices Phelan, 2010 We must touch on ageism which is typically
viewed as prejudice or stereotyping of older adults.Phelans
definition as stated above is stereotypical, dehumanizing, negative
constructions.The three domains are listed above.Cognitive beliefs
are that youth or youthfulness are more valued. Affective domain is
the prejudicial attitudes towards the aging for example an elderly
person is viewed as a burden to society.Behavioral can be direct or
indirect such as avoiding to care for the elderly. This can also be
seen as a fatalistic attitude in which one believes because the
person is old, he or she doesnt deserve the best care. As health
care professionals, it is important that we recognize our own
feelings about the aging population to process our own thoughts and
feelings and to provide the best care for our patients. Assessment
of Geriatric Needs
health history physical assessment laboratory studies radiological
testing functional assessment of activities of daily living
cognitive assessment skin assessment social assessment financial
assessment The first step in caring for any person, especially an
elder, would be a thorough assessment that includes health history
as well as a physical assessment including laboratory studies and
radiological testing as needed. Included would also be a functional
assessment of activities of daily living, a cognitive assessment
and a skin assessment Many tools have been developed to help assess
risks of the elderly. A few are listed above. Social and financial
assessments are also important. A holistic nursing assessment
includes nursing knowledge, skills and experience coupled with
listening, observing, measuring, interpreting and recording the
data collected about the elders biological, psychological, social
and spiritual needs. RISK ASSESSMENT TOOLS needs assessment fall
risk assessment
pressure ulcer assessment pain assessment nutritional screening
Toofany, S. 2007 An assessment specific to risks that the elderly
population face is also important.Included in the needs assessment
is the assessment of the home situation as well as any financial
needs.The rest of the assessment tools are self explanatory. SPICES
S is for Sleep Disorders
P is for Problems with Eating or Feeding I is for Incontinence C is
for Confusion E is for Evidence of Falls S is for Skin Breakdown
Fulmer, M A quick assessment tool with an acronym for easy recall
would be the SPICES assessment found at the Hartford web site. This
tool is focused on assessing the elderly population for issues that
are common to them. Research Study Geriatric Workforce Enhancement
Program
Train the trainer Basic course Advanced course Outcomes
Participants impacted change Barba and Fay (2009) The Geriatric
Workforceenhancement project was a train the trainer program
designed to train nurses in geriatrics so they could take the
information back to their workplace and teach others.The basic
course focused on age related changes, common health problems and
other issues of the aging population.The advanced course was
designed to help nurses who wished to seek a certification in
geriatrics.The outcomes of this program showed that nurses felt
more confident taking care of the geriatric population and helped
staff to make changes that impacted quality of care for the
patients and their families. Research Study Gerontological
Enrichment Program
Risk factors for hospitalization Adverse functional outcomes Normal
consequence of aging Error in professional intervention
Environmental factors Goals: Improve care improve knowledge Support
Conference attendance Journal readings Presentations Parke, Ross,
and Moss (2003) This literature study showed how older adults are
at risk when hospitalized. This hospital identified risk factors
for the older population which included functional decline
(presumed from decreased activity), med errors, erroneous use of
meds, adverse reactions to meds or treatments, risk of infections.
The goals were to improve outcomes of the older patient, decrease
risks associated with hospitalization and improve knowledge of the
staff taking care of the elderly patient.At the end of the study,
support was given to continue the education of the staff by
providing opportunities for conference attendance, time to study
journals and providing on-going training for new staff at
orientations. Gerontological Clinical Nursing Research Study
Student insight: enhanced knowledge confidence in identifying
differences betweennormal aging and illness conditions, cognitive
changes, functional independence, common health challenges
improvements in ability to engage w/older adults, stronger
communication skills encouraged focus on attitudes about the aging
population more holistic approach less task oriented increased
understanding of transition, loss, grief, vulnerability improved
outlook on comfort care and spirituality Staff Nurses insights:
impressed with knowledge of student nurse ability to provide
holistic assessment students were able to effect change on unit
Dahlke and Fehr (2010) In this study, student nurses learned about
caring for older adults in multiple units that were designed to
meet the needs of the elderly population.Some of the reasons this
program was developed included:student nurses were learning from
seasoned nurses who lacked formal gerontological nursing education
and identification of ageism. Both the students and the staff on
the units provided some insight to the benefits of this program as
shown above. NICHE NICHE stands for Nurses Improving Care for
HealthSystem Elders
GIAP Tools Provided to the hospitals included: Staff development
tools Nursing care models Research-based clinicals Boltz, Capezuti,
Bowar-Ferres, Norman, Secic, Kim, Fairchild, Mezey, and Fulmer 2008
This study involved 8 hospitals where NICHE provided the hospital
with tools to make the environment more responsive to the needs of
the geriatric population. The study first measured nurses knowledge
through use of a survey entitled Geriatric Institutional Assessment
Profile.After the institution of tools, as listed above, nursing
care of the geriatric population improved but knowledge itself did
not. Interpretation of information
Quality geriatric care is: evidenced based ensures best practices
includes a holistic assessment individualized to patient needs
promotes patient decision making It is important to have nurses
trained in geriatrics that are aware of the special needs this
patient population has.Knowledge of how this patient population
responds to medications, how their body has changed and risks
specific to this population will help to improve patient outcomes
and prevent untoward complications. Assessment of the Health Care
Environment National Patient Safety Goals
Improve accuracy of patient identification Improve effectiveness of
communication among caregivers Improve the safety of using
medications Reduce the risk of healthcare acquired infections
Accurately and completely reconcile medications across the
continuum of care Reduce the risk of harm resulting from patient
falls Encourage patients active involvement in own care Improve
recognition and response to changes in a patients condition Munson
Healthcare, 2009 National Patient Safety Goals taken from the
Munson health care website apply to all patients but those that are
of significant importance in the elderly population which can be at
greater risk are listed above. Munson requires two patient
identifiers when giving meds and even the dietary aide must ask the
patient name and birth date. Many of these goals have been put in
place to improve safety for the elderly population. For instance
medication reconciliation at discharge ensures the patient will
know what meds he needs to stop taking and what needs to continue
as well as what is new. Assessment of the Health Care Environment
National Patient Safety Goals
Improve accuracy of patient identification Improve effectiveness of
communication among caregivers Improve the safety of using
medications Reduce the risk of healthcare acquired infections
Accurately and completely reconcile medications across the
continuum of care Reduce the risk of harm resulting from patient
falls Encourage patients active involvement in own care Improve
recognition and response to changes in a patients condition Munson
Healthcare, 2009 National Patient Safety Goals taken from the
Munson health care website apply to all patients but those that are
of significant importance in the elderly population which can be at
greater risk are listed above. Munson requires two patient
identifiers when giving meds and even the dietary aide must ask the
patient name and birth date. Many of these goals have been put in
place to improve safety for the elderly population. For instance
medication reconciliation at discharge ensures the patient will
know what meds he needs to stop taking and what needs to continue
as well as what is new. Environment Assessment continued
Patient safety guide Policy for medication issues: Analgesics
Antibiotics Anticonvulsants Antidepressants Anti-diabetic meds
Anti-manic meds Anti-parkinson meds Anti-psychotic meds Anxiolytics
Cardiovascular meds Cholesterol lowering agents Munson Healthcare
2009 GI meds Glucocorticoids Hematinics Laxatives Muscle relaxants
Appetite stimulants Osteoporosis meds Platelet inhibitors
Respiratory meds Sleep meds Thyroid meds Urinary incontinence meds
Patients at Munson receive a pamphlet on admission that encourages
patient to ask health care providers to wash their hands, ask
questions of information they do not understand and provides them
with acontact number of who to call if they have questions or
concerns. This pamphlet also gives information on what to expect
such as frequent identification checks.However the elderly
population, based on their generation may need help understanding
this.The policy for medication issues that are of particular
significance to the elderly address issues and concerns that may
occur how to monitor certain meds and adverse reaction symptoms.As
you can see by the list, many types of meds can have adverse
effects on the elderly population.Triggers must be in place when a
med is ordered to protect the elderly to make sure meds dont work
against each other, to make sure safe doses are administered, or to
make sure that a lab indicates this med should not be used.
Iatrogenesis Common iatrogenic events can occur as a result
of:
Adverse reactions to medications Adverse reactions to diagnostic,
therapeutic and prophylactic procedures Nosocomial conditions such
as hospital-acquired infections, delirium, deconditioning,
malnutrition, fecal impaction, incontinence and pressure ulcers
Falls or other accidental and environmentally-induced accidents,
and Harmful effects to patients related to the values, beliefs,
prejudices, fears and attitudes of well intentioned, but ignorant
providers Information quoted from Hartford Institute for Geriatric
Nursing, Francis, 2oo8 Iatrogenesis means a complication or
consequence of the actions of a healthcare intervention that was
meant to be positive. These events occur most commonly amongst the
very sick elderly or those that have a functional impairment.
Listed above are common events taken directly from the Hartford
Institute for Geriatric Nursing website. Root Cause Analysis Fall
risk assessment Reasons why falls occur
Identification of high risk patients Interventions ARTT One root
cause analysis performed at Munson Medical Center focused on
patient falls. First a study was performed to determine when falls
occurred and the reason for the fall.Common reasons for falls were
the person was attempting to go to the bathroom, related to side
effects of medications or impulsivity from impaired cognition.A
fall risk assessment was introduced and nurses began scoring
patients to determine their fall risk.Those that are identified as
a fall risk have a sign outside they also wear red socks or have
red socks tied to the foot of their bed.Another program was also
introduced called ARTT which means Ambulating, rounding toileting
and turning. This has helped to avoid falls by the commitment to
checking on the patient every hour and providing the services of
ambulating, turning and toileting.There is even a travelling trophy
at Munson for the unit that does the best job for that month.
Prevention of poor outcomes
Improve knowledge base Continuing education in geriatrics Nurses
trained in geriatrics Institution of National Patient Safety Goals
especially those that focus on the elderly population CLABSI CAUTI
SSI VAP Those associated with increase use of antibiotics Munson
Healthcare, 2009 Research indicates that improved outcomes occur
with increased knowledge and training in the care of the geriatric
population.Older adults have more health problems than younger
adults, use more prescription drugs, have more chronic health
conditions such as heart disease, arthritis and high blood
pressure. Some incidences also increase with age such as hip
fractures from falls, cancer, and alzheimers. Institution of the
national Patient safety goals with special attention to those
events that affect the elderly population include prevention of
catheter line associated blood stream infections, catheter
associated urinary tract infections, surgical site infections,
ventilator assisted pneumonia and those associated with increased
use of antibiotics such as VRE, MRSA and Cdiff. Who will Care for
the Elderly
Shortage of nurses 285,000 by 2020 500,000 by 2025 Shortage of
other healthcare providers including: Nutritionists Social workers
Pharmacists physicians Houde and Melillo,2009 In an article by
Houde and Melillo entitled Caring for an Aging Population, they
identify the current nursing shortage is not as critical as it soon
will become because of other economical factors: many nurses have
returned to work fulltime because their spouse may be without a
job. More nurses want overtime or are working more than one job to
help alleviate the financial burden caused by other family members
being out of work.They are predicting significant shortages as
listed above. There will also be a shortage of other health care
workers including nutritionists, social workers, pharmacists and
dieticians. Providing Quality Care for the Elderly:
Statistics
Current training in geriatrics 30 of 670 BSN programs meet criteria
for best educational courses in geriatrics 23% required geriatrics
course 24% had an elective available to take 49% integrate
geriatrics with other courses This reflects less than 1% of the
nations nurses having a certification in geriatrics Kovner, Mezey,
and Harrington, 2002 Many nurses do not receive formal education in
the treatment of the elderly population while in nursing school,
and this can impact quality of care.As you can see, very few nurses
have a certification in geriatrics. We have learned that the
elderly population have needs that are different from their younger
counterparts, they use more services and are more at risk.
Competence in Care for the Elderly Population
Nurses are trained for pediatrics, shouldnt they also be for
geriatrics? Recommendations for staff trained in geriatrics at
colleges, universities Continuing education for nurses currently
working with the elderly population Some states already have
mandates or policies in place regarding care of the elderly
population Arizona example A consensus has not yet been reached in
what qualifications a nurse should have in caring for the elderly.
However, our research shows us that increased knowledge and
education with this population will lead to improved
outcomes.Arizona is one of 6 states that has developed specific
goals for the aging population. On their website aging 2020,
Arizonas plan for an aging population, 8 goals are identified.
These include making it easier to access services, increasing
awareness of issues specific to the aging population, ensuring the
aging can remain active and live in their own homes as long as
possible, addressing safety issues of the elderly and programs
available to help those with needs. Characteristics of Optimal
Care
Nursing staff: competence in caring for patient population you
serve support of patient autonomy facilitate positive discharge
planning knowledge of how patients respond to meds , signs of
infection Characteristic of optimal care include the above
recommendations. In addition Nurses need to know how to take care
of the patient in an acute care setting but also how the elder
patient is affected. One example is meds elderly patients respond
differently to meds, Infections can be presented as confusion, the
elderly quickly become deconditionied from a long LOS. CMS should
require facilities to show information on staff trained in
geriatrics during surveys and offer incentives to those facilities
that support training. Recommendations CMS (Centers for Medicare
and Medicaid Services)
Survey studies incentives Institute of Medicine Home health aides
Family members Economist Intelligence Unit Change the mindset about
the elderly Continue preventative care Medication studies on the
elderly Continued training for health care professionals According
to Houde and Melillo (2009), Institute of Medicine recommends
improved education for all health care workers involved in care of
the geriatric population.Their recommendation for home health aides
or nursing assistants is to increase education from 75 to 120
hours.They also recommend training for family or other non-health
care related persons.The Institute of Medicine also recommends
incentives for health care professionals to be trained in
geriatrics.The Economist Intelligence Unit, an article by Phillips
Health care also recommends further training for health care staff
in the field of gerontology. This article also provides information
that age discriminationexists and sometimes elders dont get the
care they need because efforts are deemed futile. For example, a 50
year old may get a cholesterol lowering drug but not a 70 year old.
Support is also given for performing research about medications and
the elderly. Preventative Health care for the Elderly
Smoking cessation Importance of exercise Healthy Nutrition Vision
and hearing screening Dental health Takahashi, Okhravi, Lim, and
Kasten ,2004 Screening for health issues High blood pressure High
cholesterol Osteoporosis Cardiovascular care Cancer screening
Immunizations Preventative care in the elderly is also important
because the elderly are living longer and helping them to be
healthier longer is important to their functional status and
quality of life.As nurses, we still need to ensure that we are
discussing health risks and making sure these patients have the
knowledge they need.They should still also be screened for health
conditions that can affect their quality of life. Family Caregiving
Currently accounts for 80% of care provided:
44% by children 41% by spouse 10% by other relative 5% by non
relative Recognizing need for help Caregiver strain Economist
Intelligence Unit, 2009 An important aspect in the care of the
geriatric population is family care giving. Family care givers
account for more than 80% of the care provided to the elderly in
the United States. Statistics show the population is shifting to
more elderly and less young people.As this occurs there will be
less family to care for the elderly. Caring for the elderly is
typically a long term job that can add stress to someone who may
already have a job.Health care professionals need to recognize the
signs of care giver strain and intervene.This can be accomplished
by providing resources for help in caring for their loved one or a
way to minimize stress and encourage self care. Community or
Home-Based Care
Illinois study $117/day for ECF $650/month for home care Use of
telemedicine Community day cares Economist Intelligence Unit, 2009
An Illinois study showed that it costs $117 per day for care in an
Extended Care Facility while similar home care costs $650 per
month. Recommendations are to increase the use of telemedicine so
medical personnel can monitor the elderly in their home, helping to
recognize signs and symptoms that need intervention at an earlier
stage.One diagnosis this is already used for is CHF.Community day
cares for the elderly are not widely available yet but studies show
more cities have facilities available. Resources to Care for the
Elderly
Commission on Aging Chore services Meals on Wheels Area agency on
aging MI choice waiver program Nursing home transition program Care
management Care respite Information on help with medications and
co-pays Dementia coalition Medicare.gov website A few resources for
the elderly are listed above. My experience, as a case manager, is
that many people do not know that help is out there.As nurses, we
can provide information to patients, family members and other
care-givers that can make a significant impact on the health and
well-being of the elderly population. Hartford Institute e-learning
website
consultGeriRN NICHE Nursing home modules Case studies The Hartford
e-learning website has a wealth of information at ones fingertips
to help care for the geriatric population. By clicking on the
consultgerirn icon, a number of programs are available to promote
learning about the elderly population including elder abuse,
dementia, age related changes, nutrition, etc.Many of the programs
are evidenced based. There are also many other opportunities for
learning available.I encourage you, if you take care of the
elderly, to take some time to check out this website. Under the
consultgerirn tab, one can find information on over 30 topics
including falls, dementia, family caregiving, frailty, assessment
and many more. The other sites have a wealth if information also.
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