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Ebersole and Hess

Gerontological Nursing & Healthy Aging

Ebersole and Hess

Gerontological Nursing & Healthy Aging

FOURTH EDITION

THERIS A. TOUHY, DNP, CNS, DPNAP

Emeritus Professor

Christine E. Lynn College of Nursing

Florida Atlantic University

Boca Raton, Florida

KATHLEEN F. JETT, PhD, GNP-BC

Gerontological Nurse Practitioner

Oak Hammock at the University of Florida

Gainesville, Florida

Research Consultant

College of Nursing

University of Florida

Gainesville, Florida

3251 Riverport Lane

St. Louis, Missouri 63043

EBERSOLE AND HESS GERONTOLOGICAL NURSING

AND HEALTHY AGING ISBN: 978-0-323-09606-5

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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 informa tion 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.

Library of Congress Cataloging-in-Publication Data

Touhy, Theris A.

Ebersole and Hess gerontological nursing & healthy aging / Theris A. Touhy, Kathleen F. Jett.4th ed. p. ; cm.

Gerontological nursing & healthy aging

Includes bibliographical references and index.

ISBN 978-0-323-09606-5 (pbk. : alk. paper)

I. Jett, Kathleen Freudenberger. II. Ebersole, Priscilla. III. Title. IV. Title: Gerontological nursing & healthy aging.

[DNLM: 1. Geriatric Nursing. 2. Aged. 3. Aging. 4. Health Promotion. 5. Holistic Nursing. WY 152]

618.97'0231dc23

2012047074

Content Manager: Michele D. Hayden

Associate Content Development Specialists: Sarah Jane Watson and Melissa Rawe

Publishing Services Manager: Jeff Patterson 291426253389

Project Manager: Megan Isenberg

Design Direction: Paula Catalano

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my beautiful grandchildren, Colin, Molly, and Auden Touhy.

Being your Gramma TT makes growing older the best time of my life and I love you. To my sons and daughters-in-law, thanks for surrounding me with love and family. To my husband, just thanks for loving me for 45 years even though its not always easy! To the older people I have been privileged to nurse, and their caregivers, thanks for making the words in this book a reality for the elders you care for and for teaching me how to be a gerontological nurse.

Theris Touhy

To my husband Steve, who is a source of never-ending support.

Without his willingness to keep me supplied with food,

the long hours sitting in front of the computer and writing

would not have been possible.

To the older adults who have opened their lives to me so that I may learn. To our four children and four wonderful grandchildren, Haley, Amelia, Emory, and Logan, who always remind me that the best part of life is the time we spend together and that the older we get, the more we have loved

and the more adventures we have shared.

Kathleen Jett

Reviewers

Patricia Burbank, DNSc, RN

Professor, College of Nursing

University of Rhode Island

Kingston, Rhode Island

Sarah Gilbert, RN, MSN, G-CNS, BC

Instructor, School of Nursing

Radford University

Radford, Virginia

Vickie Ann Grosso, PhD, RN

Professor, Department of Nursing

Essex County College

Newark, New Jersey

Colleen J. Hewes, RN, MSN, DC

Instructor of Nursing

Lake Washington Technical College

Kirkland, Washington

Laurie Kennedy-Malone, PhD, APRN-BC, FAAN Professor, School of Nursing

University of North Carolina at Greensboro Greensboro, North Carolina

Judy Kopka, RN, MSN

Clinical Associate Professor, Columbia College of Nursing Columbia-St. Marys, Inc.

Milwaukee, Wisconsin

Marie Messier, BSN, MSN, MEd

Associate Professor of Nursing

Germanna Community College

Locust Grove, Virginia

Carmella M. Mikol, PhD, MN, BSN

Professor, Nursing Program

College of Lake County

Grayslake, Illinois

Claudia Mitchell, RN, MSN

Assistant Professor of Clinical Nursing College of Nursing

University of Cincinnati

Cincinnati, Ohio

Margaret Moriarty-Litz, BSN, MNA Instructor/Coordinator

St. Joseph School of Nursing

Nashua, New Hampshire

Lillian A. Rafeldt, RN, MA, CNE

Assistant Professor of Nursing

Three Rivers Community College

Norwich, Connecticut

Janine Ray, RN, MSN

Instructor, Nursing Program

Cisco Junior College

Abilene, Texas

Katherine Seibert, EdDc, RN

Associate Professor of Nursing, School of Nursing Mercy College of Health Sciences

Des Moines, Iowa

Tracy A. Szirony, PhD, RNC, CHPN Associate Professor of Nursing

College of Nursing

University of Toledo

Toledo, Ohio

Jane Tanking, RN, MSN

School of Nursing Lecturer

Washburn University

Topeka, Kansas

Judith Townsend Rocchiccioli, PhD, RN Professor of Nursing

James Madison University

Harrisonburg, Virginia

Anne Viviano, RN, MSN

Nursing Faculty

Baker College

Clinton Township, Michigan

REVIEWERS vii

Loretta Wack, RN, MSN

Associate Professor of Nursing

Blue Ridge Community College

Weyers Cave, Virginia

Tricia Wickers, RN, MSN

Associate Professor of Nursing

Los Angeles Harbor College

Wilmington, California

Preface

This text is about health, wellness, and aging. It is designed to provide nurses, faculty, and students with the most cur rent information on evidence-based gerontological nurs ing, an area often neglected in basic nursing education and nursing texts. The fourth edition provides content consis tent with the Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults developed by AACN in collaboration with the John A. Hartford Foundation Institute for Geriatric Nursing at New York University. The book sections have been revised with totally updated content and new chapters on meta bolic and neurological disorders. The goals set forth by Healthy People 2020 provide the framework for the study of healthy aging. Although Maslows Hierarchy of Needs is the organizing framework, it includes additional frame works for a range of situations.

Section 1, Foundations of Healthy Aging, explores gerontological nursing history, education, and roles; care across the continuum; the impact of culture and health disparities; theories of aging and physical changes; and the social, psychological, spiritual, and cognitive aspects of aging. In Section 2, Fundamentals of Caring, content ranges from assessment tools, skillful documentation, and safe medication use to evidence-based nursing responses to promote healthy nutrition, sleep, elimination, skin, and the maintenance of mobility and safety. Section 3, Coping with Chronic Disorders in Late Life, focuses on common health problems seen in older adults and what nurses can do to help elders living with chronic illness to achieve optimum wellness. This section does not provide the in depth coverage of the topics that one would find in a medical-surgical nursing textbook, but highlights the key aspects of the problems as they relate specifically to older

adults. In Section 4, Caring for Elders and Their Care givers, we present discussions of the global topics that affect all of us as we age: economic and legal issues; rela tionships; caregiving; roles and transitions; coping with grief and loss; and dying and death.

The text is organized for optimal student learning ex periences. Each chapter begins with the phenomenological consideration of the lived experience of an elder. Key con cepts, glossaries, learning activities, and discussion ques tions summarize the important points presented and relate directly to the objectives of the chapter. For readers who wish to seek additional information, resources are provided at http://evolve.elsevier.com/Ebersole/gerontological.

Gerontological nurses have always assumed a leader ship role in improving care for elders, ensuring fulfillment of all levels of Maslows Hierarchy of Needs, and promot ing healthy aging. Since the first edition of this text, there has been an explosion of knowledge, research, interest, and resources in gerontological nursing. The specialty contin ues to grow in importance, and gerontological nursing competencies are now recognized as basic education re quirements for nurses in all specialties. Today, the expecta tion is that all nurses will be prepared to care for the growing number of diverse older adults and have the knowledge and skills to promote healthy aging for people of all ages around the globe. We can look forward to the coming years when aging in health will be the norm, and we hope this text will provide the knowledge nurses need to play a key role in making this happen.

Theris A. Touhy

Kathleen F. Jett

viii

Ancillaries

Ancillaries are available at http://evolve.elsevier.com/ Ebersole/gerontological.

For Instructors

TEACH for Nurses: A NEW resource for this edition, TEACH for Nurses Lesson Plans for each book chap ter include learning objectives; key terms; student and instructor resources; suggested classroom activities; an swers to Critical Thinking Activities in the book; and clinical activities that can be used for classroom discus sion, projects, and further study. Also included is an outline of nursing curriculum standards for each chapter that includes QSEN, Concepts, and BSN Essentials, and a unique Case Study for each book chapter.

PREFACE ix

PowerPoint Presentations: PowerPoint slide presen tations to accompany each chapter (approximately 480 slides total)

Test Bank: Approximately 500 questions in the latest NCLEX examination format (ExamView format) Image Collection: Over 50 illustrations and photos that can be used in a presentation or as visual aids

For Students

Animations: Full-color animations that visually enhance the material in the text

NCLEX-Style Review Questions: Questions orga nized by chapter for additional help in preparing for the NCLEX examination

Resources: Additional resources organized by chapter for further study of concepts presented in the chapter

Acknowledgments

We would like to thank Priscilla Ebersole and Patricia Hess for the opportunity to author this book and to share their beautiful words and passion for gerontological nurs ing. We hope that our work honors them and the specialty

we all love. It has been a real privilege for us to be a part of the work of two gerontological nurses from whom we have learned how to care for older people.

Theris A. Touhy

Kathleen F. Jett

Contents

Section 1 Foundations of Healthy Aging

1 Introduction to Healthy Aging 1 Aging in the United States 1

Improving Transitions Across

the Continuum of Care 37

Moving Toward Healthy Aging 3 Maslows Hierarchy of Human

Needs 7 2 Gerontological Nursing History, Education, and Roles 11 Care of Older Adults: A Nursing

Imperative 11 History of Gerontological Nursing 13 Gerontological Nursing Education 16 Roles in Gerontological Nursing 18 Gerontological Nursing and

Gerontology Organizations 22 3 Care Across the Continuum 26 Elder-Friendly Communities 27 Residential Options In Later Life 28 Community and Home Care 30 Acute Care 32 Nursing Homes (Long-Term

Care Facilities) 32

Section 2 Fundamentals of Caring

7 Assessment and Documentation for Optimal Care 88 Assessment Tools in

Gerontological Nursing 89 Activites of Daily Living 96 Instrumental Activities of

Daily Living 98 Documentation for Quality Care 101

4 Culture and Aging 43 The Gerontological Explosion 45 Health Disparities 45 Increasing Cultural Competence 46

5 Theories of Aging and Physical Changes 55 Biological Theories of Aging 56 Physical Changes that

Accompany Aging 57 6 Social, Psychological, Spiritual, and Cognitive Aspects of Aging 72 Life Span Development Approach 73 Types of Aging 73 Sociological Theories of Aging 74 Psychological Theories of Aging 75 Spirituality and Aging 77 Cognition and Aging 80 Learning in Late Life 83

Documentation Across Health

Care Settings 101 Appendix 7-1: Chapters in Which

Assessment Topics Are Addressed 105 8 Safe Medication Use 106 Pharmacokinetics 107 Pharmacodynamics 110 Chronopharmacology 112

xii Contents

Medication-Related Problems

and Older Adults 112 Potentially Inappropriate

Medication (PIM) 114 Psychoactive Medications 120 9 Nutrition and Hydration 127 Nutrition 127 Age-Related Requirements 128 Obesity (Overnutrition) 130 Malnutrition 130 Factors Affecting Fulfillment

of Nutritional Needs 132 Special Considerations in Nutrition

for Older People: Hydration,

Dysphagia, Oral Care 140 10 Elimination 151 Bladder Function 152 Bowel Elimination 162

11 Rest, Sleep, and Activity 169 Rest and Sleep 169 Activity 175 Interventions 177 12 Promoting Healthy Skin

and Feet 182 Skin 182 Healthy Feet 191

13 Promoting Safety 196 Falls and Fall Risk Reduction 196 Restraints and Side Rails 209 Environmental Safety 210 Transportation Safety 217

Section 3 Coping with Chronic Disorders in Late Life

14 Living with Chronic Illness 223 Chronic Illness 223 Theoretical Frameworks for

Chronic Illness 226 15 Pain and Comfort 233 Acute and Persistent Pain 235 16 Diseases Affecting Vision

and Hearing 246 Vision 247 Hearing Impairment 253

17 Metabolic Disorders 260 Thyroid Disease 261 Diabetes 262

18 Bone and Joint Problems 271 Musculoskeletal System 272 Osteoporosis 272 The Arthritides 275

19 Cardiovascular and Respiratory Disorders 281 Cardiovascular Disease 282 Respiratory Disorders 287

20 Neurological Disorders 296 Cerebrovascular Disease 297

Parkinsons Disease 301 Communication and Elders

with Neurological Disorders 304 21 Cognitive Impairment 309 Cognitive Assessment 311 Delirium 311 Dementia 316 Caregiving for Persons

with Dementia 330 22 Mental Health 336 Factors Influencing Mental

Health Care 337 Mental Health Disorders 339 Psychiatric Symptoms in

Older Adults 342 Schizophrenia 344 Bipolar Disorder 345 Depression 346 Suicide 352 Substance Misuse and Alcohol

Use Disorders 353

Contents xiii

Section 4 Caring for Elders and Their Caregivers

23 Economic and Legal Issues 361 Social Security 362 Medicare and Medicaid 363 Care For Veterans 366 Long-Term Care Insurance 367 Legal Issues in Gerontological

Nursing 368 Elder Mistreatment and Neglect 370 Appendix 23-1: Definitions

of Elder Abuse and Neglect 375 24 Relationships, Roles, and

Transitions 377 Families 378 Later Life Transitions 381

Caregiving 385 Intimacy and Sexuality 391 HIV/AIDS and Older Adults 399

25 Loss, Death, and Palliative Care 404 The Grieving Process 405 Dying, Death, and Palliative Care 410 Dying and the Nurse 414 Decision Making at the End

of Life 415

This page intentionally left blank

CHAPTER

Introduction to Healthy Aging

L E A R N I N G O B J E C T I V E S

Upon completion of this chapter, the reader will be able to:

Kathleen F. Jett

evolve.elsevier.com/Ebersole/gerontological

Identify at least three factors that influence the aging experience.

Define health and wellness within the context of aging and chronic illness.

Describe the trends seen in global aging today.

Apply Maslows Hierarchy of Needs to gerontological nursing.

G L O S S A R Y

Cohort A Group in which members share some common experience.

Wellness A state of health that is optimal for the individual person at any point in time. Centenarian A person who is at least 100 years of age.

Holistic health care That which considers the whole person and the interaction with and between the parts.

T H E L I V E D E X P E R I E N C E

I believe a human life is like a river, meandering through its course, rushing through rapids, flowing placidly over the plains, twisting and turning through countless bends until it spends itself. It is the same river; yet it looks very differ ent from one place to another. So it is with our lives; circumstances vary from one time to another in the course of a life, but I think each stage has its own value.

Georgia, 35 years old

Caring for older adults gives us a unique opportunity to influence their quality of life in so many ways. Nursing student, age 19

Providing nursing care to older persons is a reward ing, life-affirming vocation. Through this textbook

we hope to provide students with the basics to be gin a career as a gerontological nurse and care for older adults with more skill and sensitivity. We present an over view of aging, the most common health care needs of older adults, and the vital and exciting role of the nurse in facilitating healthy aging and wellness.

Aging in the United States

Although all of us begin aging at birth, both the meaning of aging and those who are identified as elders are determined by society and culture and influenced by history and gender. In the early American Puritan community of the 1600s, the process of aging was considered a sacred pilgrimage to God, and as such, persons in late life were revered. However, by

2 SECTION 1 Foundations of Healthy Aging

the late 1800s, aging was devalued as youth became the symbol of growth and expansion. In 1935, with the estab lishment of Social Security, the time when one became old was set at 65. In the 2000s this age is creeping toward

70 along with the eligibility for retirement benefits. Psychologists have traditionally divided the old into three groups: the young-old, roughly 65 to 74 years of age; the middle-old, 75 to 84 years of age; and the old-old, or those over 85. Those 100 years of age and older (centenar ians) are the most rapidly growing group today; those over 110 are referred to as supercentenarians (Willcox et al., 2008) (Box 1-1). In 2009 about 12.9% of the population in the United States or 39.6 million persons were 65 and over, compared with 0.1% in 1901. The total number is expected to double between 2000 and 2030, increasing to about 72.1 million or 19% of the population (Administration on Aging [AOA], 2011).

Those born within the same decade and country may share a common historical context and are referred to as a cohort. For example, men born between 1920 and 1930 were very likely to have been active participants in World War II or the Korean War. In comparison, men born between 1940 and 1950 were likely to have been involved in the Vietnam conflict, an entirely different experience. It is not surprising that these two groups of men have different perspectives and different health problems. Likewise, privileged women born between 1920 and 1930 were raised with what are known as traditional values and roles and may have either never

BOX 1-1 Super-Centenarian Extraordinaire: Jeanne Louise Calment

Jeanne Louise Calment died in France at age 122. At that time she was believed to be the longest-lived person in the world. She outlived her husband, her daughter, her only grandson, and her lawyer. Her husband died in 1942, just four years before their 50th anniversary. Her daughter died in 1936 and her grandson in 1963. She was four when the Eiffel tower was built and reportedly once sold art supplies to Vincent Van Gogh. Not only did she live a long life, but did so with vigor. Madame Calment took up fencing at 85 and was still riding a bike at 107. She smoked until she was 117 and ate a lifelong diet rich in olive oil. Her longevity remains a mystery to experts and researchers.-136595-108090

From Dollemore D: Aging under the microscope: a biological quest, Bethesda, MD, 2006, National Institute of Aging, National Institutes of Health, Publication #02-2756.

worked outside the home or been limited to what was con sidered womens work, such as housekeeping, teaching, and nursing. In contrast, similar women born between 1940 and 1950 had pressure to work outside the home and had considerably more opportunities, partially as a result of the feminist revolution of the 1960s and 1970s.

Gender can have a significant effect on various aspects of aging. Women usually live longer than men and live alone after widowhood. Men who survive their wives often re marry and live alone significantly less often than women. Women usually have larger social networks outside the work environment than men, which could potentially reduce so cial isolation after the death of a spouse or companion (see Chapter 24).

Finally, the United States is experiencing a geronto logical explosion of all persons over 65, including ethni cally diverse older adults. Persons comprising groups that have been considered statistical minorities in the late 1900s can now be considered an emerging majority as the relative percentage of their numbers rises rapidly. See Figure 1-1 for the projected changes in the demographics of older adults by ethnicity and race by the year 2050. Although the health status of racial and ethnic groups has improved over the past century, disparities in major health indicators between white and nonwhite groups are growing (Box 1-2). Increasing the numbers of health care providers from dif ferent cultures as well as ensuring cultural competence of all providers is essential to meet the needs of a rapidly grow ing, ethnically diverse elderly population (see Chapter 4).

Global Aging

Before the year 2050, the number of persons 60 years of age and older worldwide is likely to exceed those younger than 15 years for the first time in recorded history, most notably in developing or low-income countries (National Institute on Aging, National Institutes of Health, 2007) (Figure 1-2). This occurred in Europe in 1995 but will not occur in North America until 2015. Those older than 60 years of age will not surpass children until 2040 in Asia, Latin American, and the Caribbean (United Nations [UN], 2007a). However in 2007, Japan already had the highest percentage of persons 60 years of age and older at 27.9% (UN, 2007b). These changes pose major challenges in meeting the needs of the aging global community as the number of younger adults providing care and financial support diminishes. Although the number of the very old remains small, the relative number of centenar ians in the worlds population is growing dramatically in the United States alone (Figure 1-3). The U.N. estimates that a worldwide population of 270,000 centenarians will grow to 2.3 million by the year 2050 (Kinsella & He, 2009, p. 28).

100

80 80 70

CHAPTER 1 Introduction to Healthy Aging 3

2008

2050 (projected)

1 37

Non-Hispanic White alone

Black alone Asian alone All other races alone or in combination

Hispanic

(of any race)

FIGURE 1-1 Population 65 years of age and over, by race and Hispanic origin: 2008 and projected 2050. (Redrawn from Federal Interagency Forum on Aging-Related Statistics: Older Americans 2010: key indicators of well-being, Washington DC, 2010, U.S. Government Printing Office.)

BOX 1-2 Use of Select Clinical Preventive Services by Race and Ethnicity

American Indian/Alaskan Native Adults 40% need influenza vaccination -139452-104649

35% need pneumococcal vaccination

Asian/Pacific Islander Adults

49% need colorectal cancer screening

47% need diabetes screening

Black American Adults

47% need pneumococcal vaccination

44% need influenza vaccination

Hispanic Adults

51% need pneumococcal vaccination

47% need colorectal screening

White Adults

34% need colorectal cancer screening

31% need diabetes screening

From Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services: Enhancing use of clinical preventive services among older adults, Washington, D.C., AARP, 2011. Available at www.cdc/gov/aging.

Among centenarians, women are between four and five times more numerous than men (UN, 2007b, p. xxviii) (Figure 1-4).

Africa stands out as the only major region where the population is still relatively young and the number of el derly, although increasing, will still be far below the number of those 0 to 59 years of age in 2050. Those between 15 and 59 years of age in Africa is projected to rise from half a billion in 2005 to more than 1.2 billion in 2050 (UN, 2007a), while those older than 60 will only increase from 0.05 billion to 0.2 billion in the same period.

Moving Toward Healthy Aging

The definitions of health vary greatly and are influenced by both culture and where one is on the life span. The strong emergence of the holistic health movement has resulted in even broader definitions of wellness and changes in Medi

care (see Chapter 23) to support preventive care have pro moted healthier aging (Table 1-1). Wellness involves ones whole beingphysical, emotional, mental, and spiritualall of which are vital components (Figure 1-5). In a classic work, Dunn (1961) defined the holistic approach to health as an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable within the environment where he [or she] is functioning. Wellness involves achieving a balance between ones internal and external environment and ones emotional, spiritual, social, cultural, and physical processes.

4 SECTION 1 Foundations of Healthy Aging 20

Under 5

10 5

65 and over

1950 1960

1970 1980 1990 2000 2010 2020 2030 2040 2050

FIGURE 1-2 Average annual percent growth of older population in developed and developing countries: 1950 to 2050. (From Kinsella K, Wan H: U.S. Census Bureau, International Population Reports, P95/09-1, An aging world: 2008, Washington DC, 2009, U.S. Government Printing Office.)

All ages 65

100

164

301

746

FIGURE 1-3 Percent change in world population by age, 2005 to 2040. (From U.N. Department of Economic and Social Affairs, 2007. Available at www. un.org/esa/population/publications/WPA2007/wpp2007.htm.)

Wellness is a state of being and feeling that one strives to achieve through effective health practices. An individual must work hard to achieve wellness. In working toward wellness, an individual may reach plateaus in his or her as

cension to higher-level wellness. The person may also re gress because of an illness or acute event or crisis, but these events can be a potential stimulus for growth and a return

to moving along the wellness continuum (Figure 1-6). Consistent with Dunn (1961), health in later life is often thought of in terms of functional ability (i.e., the ability to do what is important to a given person) rather

than the absence of disease. This may mean the persons ability to live independently or the ability to enjoy great grandchildren when they visit at the nursing home, but it is always individually determined. Well-being for those older than 60 years of age is strongly related to functional status but is affected also by socioeconomic factors, degree of social interaction, marital status, and aspects of ones living situation and environment.

In a push toward wellness, the health goals of the United States were recently updated in the document Healthy People 2020 (U.S. Department of Health and

90 80 70 60 50 40 30 20 10 0

CHAPTER 1 Introduction to Healthy Aging 5

4059 60

Age

80 100

FIGURE 1-4 Proportion of women in specific age groups, worldwide, 2009. (From United Nations, Department of Economic and Social Affairs: World population ageing 2009, New York, 2009, United Nations. Available at www.un.org/esa/population/publications/WPA2009/WPA2009_WorkingPaper.pdf.)

TABLE 1-1 Intervention to Promote Wellness Preventive Service Wellness and Person-Oriented Intervention

Promoting influenza and pneumococcal vaccination* Breast Cancer Screening Mammogram and Clinical Breast Exam*

Consider new approaches to community outreach, such as home visits, neighbor-to-neighbor campaigns. Develop effective reminder systems.

Develop effective reminder systems.

One-to-one education and counseling.

Reduce structural barriers, such as transportation difficulties.

Colorectal Screening Coverage depends on type of test used. Develop effective reminder systems. Reduce structural barriers, such as transportation difficulties.

Abdominal Aortic

Aneurysm Screening*

For those persons at risk on physician referral. Inform the public.

Bone Mass Measurement* Once every 24 months. May be covered 100%. Nurse can participate in community screening efforts.

Cervical and Vaginal Screening*

Covered at least every 24 months, depending on circumstances. Help person determine eligibility and appropriateness.

Diabetes Screenings* Covered at least two times a year based on risk factors. Help identify persons at risk

Diabetes Self-Management Training*

For those with diabetes. Encourage participation.

Glaucoma Tests Once a year for those at high risk. Help identify persons at risk.

Hearing and Balance Exams For those with identified potential problems. Identify those with impairments and work with them to obtain care.

Hepatitis B Immunizations* Identify those at risk. Nurse usually administers the vaccine.

HIV Screening Once every 12 months for persons at risk. Participate in campaigns to inform persons about who is at risk and how to reduce their risk.

Prostate Screenings (PSA and digital rectal exam (DRE))

Covered for the PSA, 20% co-pay for the DRE. Stay informed about current status and recommen dations about this screening.

Tobacco Use Cessation Coverage depends on circumstances. Co-pay and deductible may apply.

Welcome to Medicare and Annual Wellness Visits*

Thorough exam including a Health Risk Appraisal and wellness counseling. Inform persons of this health care benefit and help them make the best of the visit.

*This is of no cost if the provider accepts assignment or that amount that Medicare has approved. No co-pays are required. No cost

In most cases a 20% co-pay and deductible apply

From Centers for Medicare and Medicaid Services: Medicare & you. Publication #10050-27, August 2011. Baltimore, MD. See also http://www. healthcare.gov/news/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforWomenIncludingPregnantWomen.

6 SECTION 1 Foundations of Healthy Aging

Social

Environmental

Successful

healthy

aging

Cultural

Spiritual

FIGURE 1-5 Healthy aging. (Developed by Patricia Hess.)

Biological

Psychological

Human Services [USDHHS], 2012; see the Healthy People boxes). For the first time, older adults are identified as a priority group, with the specific goal to improve their health, function, and quality of life (USDHHS, 2012). The importance of this is triggered by the recognition

Wellness Illness

High-level

wellness

Higher level of functioning

of the growth of the population and the number of chronic conditions they are or will be facing as well as an emphasis on the use of clinical preventive services (USDHHS, 2012).

Approaching aging from a viewpoint of health even if

Previous level of functioning

Hazardous event

Growth

New

coping

the person has an illness emphasizes strengths, resilience, resources, and capabilities rather than focusing on existing pathological conditions. A wellness perspective is based on the belief that every person has an optimal level of health independent of his or her situation or functional ability or ability to manage day-to-day activities. Movement toward higher wellness is possible if the emphasis of care is placed

mechanisms Inadequate

coping

mechanisms

Intervention

Crisis

FIGURE 1-6 Growth potential: crisis as a challenge.

HEALTHY PEOPLE 2020

Overarching Goals

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

Achieve health equity, eliminate disparities, and improve the health of all groups.

Create social and physical environments that promote good health for all.

Promote quality of life, healthy development,

and healthy behaviors across all life stages.

From U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Introducing healthy people 2020 (2012). Available at http://www.healthypeople.gov/2020.

HEALTHY PEOPLE 2020

Emerging Issues in the Health of Older Adults Coordinate care.

Help older adults manage their own care.

Establish quality measures.

Identify minimum levels of training for people who care for older adults.

Research and analyze appropriate training to equip providers with the tools they need to meet the needs of older adults.

From U.S. Department of Health and Human Services: Healthy people 2020. Topics and objectives: older adults (2012). Available at http://www. healthypeople.gov/2020.

on the promotion of well-being in the least restrictive environment, with support and encouragement for the per son to find meaning in the situation, whatever it is.

Maslows Hierarchy of Human Needs

Maslows theory of the hierarchy of human needs provide an organizing framework for this text and for understanding individuals and their concerns at any particular time or situ ation (Figure 1-7). It also can serve as a guide for prioritizing nursing interventions to promote healthy aging and as a framework for this text. The hierarchy ranks needs from the most basic, related to the maintenance of biological integrity, to the most complex, associated with self-actualization.

CHAPTER 1 Introduction to Healthy Aging 7

According to this theory, the needs of higher levels cannot be met without first meeting those of lower levels at least to some extent. In other words, moving toward healthy aging is an evolving and developing process. As basic-level needs are met, the satisfaction of higher-level needs is possible, with ever deepening richness to life, regardless of ones age. The nurse prioritizes care from the most essential to those things thought of as quality of life.

As far back as Hippocrates and Galen, the necessities of all living people were recognized as the need for air, fluids, nutrition, hygiene, elimination, activity, and skin integrity. In 1990, nurse theorist Dorothea Orem described basic human needs of Maslows model as self-care require

ments (Box 1-3). Along with those listed in the box is the need for comfort or relief from suffering. The gerontologi cal nurse works to ensure that these needs are met for older adults and realizes that as this is accomplished, higher levels of wellness are possible. The person with dementia may begin to wander or become agitated because of the need to find a toilet and not knowing where to look. Until toileting needs are met, the nurses attempt to com fort may be ineffective. As peoples basic needs are met they will feel safe and secure (Maslows second level). They will likely sleep better and feel more comfortable interact ing with others. While interacting with others, people often begin to meet their needs of belonging (Maslows third level). Participation in church, synagogue, or mosque activities; civic or social organizations; and the mainte nance of ties to family and friends all are ways people fulfill belonging needs. After retirement a member of a work organization may instead become involved in special interest groups. Involvement is an opportunity to form new alliances and associations and to create environments in which relationships and activities can remain a part of life and contribute to bring life meaning (fourth level) regardless of the setting.

According to Maslows model, a person whose basic needs are met, who feels safe and secure, and who has a sense of belonging will also develop self-esteem and a belief in self-efficacy (fourth level). In other words, people will accept and honor who they are and feel that they have some personal power and self-confidence; they will know that they are important as people and that they inherently have value. Self-esteem is not something that can be given. It is, however, something that others can negatively influence through ageist attitudes and behavior. For example, a nurse who assumes that a patient cannot do something based solely on the persons age is being ageist and is actually belit tling the individual. Unfortunately this is common, but it can be challenged by the knowledgeable and sensitive gerontological nurse.

8 SECTION 1 Foundations of Healthy Aging

Human Needs and Wellness Diagnoses

Self-Actualization and Transcendence

(Seeking, Expanding, Spirituality, Fulfillment)

Maintains a healthy lifestyle

Takes preventive health measures

Seeks out stimulating interests

Manages stress effectively

Celebrates ones uniqueness

Self-Esteem and Self-Efficacy

(Image, Identity, Control, Capability)

Exerts choices needed

Seeks out services when needed

Plans and follows a healthful regimen

Belonging and Attachment

(Love, Empathy, Affiliation)

Has an effective support network

Able to cope successfully

Develops reciprocal relationships

Safety and Security

(Caution, Planning, Protections, Sensory Acuity)

Able to perform functional ADLs

Exercises to maintain balance and prevent falling

Makes effective changes in his/her environment

Follows recommended health screening for his/her age

Seeks health information

Biological and Physiological Integrity

(Air, Fluids, Comfort, Activity, Nutrition, Elimination, Skin Integrity)

Engages in aerobic exercise

Engages in stretching and toning body

Maintains adequate and appropriate nutritional intake

Practices health maintenance

These are not all the possible wellness diagnoses that may be identified. The above

are examples of nursing diagnoses that should be considered when planning care

for the older adult.

FIGURE 1-7 Human needs and wellness diagnoses using Maslows Hierarchy framework. ADLs, Activities of daily living.

Finally, some people reach Maslows highest level of wellness, that of self-actualization. Self-actualization is seen as people reaching out beyond themselves and finding meaning and a sense of fulfillment. This may not seem possible for all, but the nurse can foster this in unique and important ways. The author was asked to speak to a group in a nursing home about death and dying. To her surprise the room was not filled with staff, as she had expected, but

with the frailest of elders in wheelchairs. Instead of the usual lecture, she spoke of legacies and asked the silent audience, What do you want people to remember about you? What made your life worthwhile? Without excep

tion each member of the audience had something to say, from I had a beautiful garden to I was a good mother to I helped design a bridge. Meaning can be found for life everywhereyou just have to ask.

BOX 1-3 Orems Universal Self-Care Requirements

1. Maintaining sufficient intake of air, water, food a. Taking in the quantity required for normal functioning b. Preserving the integrity of associated anatomic structures and physiologic processes -273869-108089

2. Maintaining satisfactory elimination function

a. Preserving the integrity of associated anatomic structures and physiologic processes

b. Providing hygienic care of body surfaces and parts to the extent necessary to prevent injury or exposure to infection

c. Maintaining adequate and sanitary disposal systems 3. Maintaining a balance between activity and rest a. Selecting activities that stimulate, engage, and keep in balance physical movement and rest adequate for health

CHAPTER 1 Introduction to Healthy Aging 9

b. Responding to manifestations of needs for rest and activity

c. Using personal capabilities, interests, and values as well as culturally prescribed norms as bases for development of a rest-activity pattern

4. Maintaining a balance between solitude and social interaction

a. Maintaining the ability and interest necessary for the development of personal autonomy and enduring social relations

b. Fostering bonds of affection, love, and friendship c. Participating in situations of social warmth and closeness

d. Pursuing opportunities for satisfying group interactions

Based on the work of Dorothea Orem. See Hartweg, D: Dorothea Orem: self-care deficit theory, Newbury Park, CA, 1991, SAGE.

Implications for Gerontological

Nursing and Healthy Aging

It is the responsibility of the nurse to assist elders to achieve the highest level of wellness in relation to whatever situation exists. The nurse can, through knowledge and af firmation, empower, enhance, and support the persons movement toward the highest level of wellness and quality of life possible. The nurse assesses and helps explore the underlying situation that may be interfering with the achievement of wellness, and work with the person and significant others to develop affirming and appropriate plans of care. The nurse can utilize the resources available, such as Healthy People 2020 and the Clinical Preventive Services Guidelines to maximize the potential for health (see Table 1-1). The nurse and the elder collaboratively implement interventions to achieve individual goals and evaluate their effectiveness. The goals of the nurse are to care and comfort always, to cure sometimes, and to prevent that which can be prevented.

KEY CONCEPTS

Gerontological nursing is an opportunity to make a significant difference in the lives of older adults. The meaning of aging is influenced by many factors. Nurses have a responsibility to contribute to the nations goals of increasing the quality of life lived and to reduce health disparities.

Health, history, and gender are among the major factors influencing the aging experience.

Each age cohort is distinctly different from others in some ways.

Individual persons become more unique the longer they live. Thus one must be cautious in attributing any specific characteristics of older adults to old age.

All persons, regardless of age or life and/or health situ ation, can be helped to achieve a higher level of wellness, which is uniquely and personally defined.

Maslows Hierarchy of Needs can be used as an orga nizing framework for health promotion, regardless of age or situation.

Gerontological nurses have key roles in the provision of the highest quality of care to older adults in a wide range of settings and situations.

Ageist attitudes and behaviors undermine not only the self-esteem of the individual but societys acknowledg ment of the value of the contributions of older adults.

ACTIVITIES AND DISCUSSION QUESTIONS 1. Discuss the ways in which elders contribute to society today.

2. Activity: Interview an older person, and ask what has changed since he or she was 25 years of age. Compare your findings with others in your class.

3. Discuss health and wellness with your peers. Develop a definition of aging.

10 SECTION 1 Foundations of Healthy Aging

4. Consider Maslows Hierarchy of Needs and discuss the level you feel is the most important. Explain your choice.

5. Explain wellness in the context of chronic illness. 6. Discuss how you seek wellness in your own life. 7. Discuss what you can do to enhance the wellness and

quality of life for the persons to whom you provide care. 8. Activity: Draw a picture of yourself at 80 years of age. Compare your drawing to those of others who have done the same and discuss the implications of the representation.

9. Discuss how older adults are portrayed in popular TV shows, commercials, and movies.

REFERENCES

Administration on Aging [AOA]: Aging statistics (2011). Available at http://www.aoa.gov/AoARoot/Aging_Statistics/index.aspx. Centers for Medicare and Medicaid Services: Enhancing use of clinical services among older adults, Washington, DC, 2011, AARP.

Dunn HL: High-level wellness, Arlington, VA, 1961, Beatty. Kinsella K, He W: An aging world (2009). Available at http:// www.census.gov/prod/2009pubs/p95-09-1.pdf.

National Institute on Aging, National Institutes of Health: Why population aging matters: a global perspective (2007). Available at http://www.nia.nih.gov/sites/default/files/WPAM.pdf.

United Nations [UN], Department of Economic and Social Affairs, Population Division: Fact sheet, Series A (2007a). Available at http://www.un.org/esa/population/publications/ wpp2006/FS_aging.pdf.

United Nations [UN]: World population aging (2007b). Available at http://www.un.org/esa/population/publications/WPA2007/ wpp2007.htm.

U.S. Department of Health and Human Services [USDHHS], Office of Disease Prevention and Health Promotion: Healthy people 2020 (2012). Available at http://www.healthypeople. gov/2020.

Willcox BJ, Willcox DC, Ferrucci L: Secrets of healthy aging and longevity from exceptional survivors around the globe: Lessons from octogenarians to supercentenarians, J Gerontol A Biol Sci Med Sci 63(11):12011208, 2008.

CHAPTER

Gerontological Nursing History, Education, and Roles

L E A R N I N G O B J E C T I V E S

Upon completion of this chapter, the reader will be able to:

Theris A. Touhy

evolve.elsevier.com/Ebersole/gerontological

Discuss the implications of a growing older adult population on nursing education, practice, and research.

Identify several factors that have influenced the development of gerontological nursing as a specialty practice.

Examine the American Nurses Association Scope and Standards of Gerontological Nursing Practice and the recommended competencies for gerontological nursing practice.

Recognize and discuss the importance of certification.

Compare various gerontological nursing roles and requirements.

Discuss formal gerontological organizations and their significance to the gerontological nurse.

T H E L I V E D E X P E R I E N C E

I dont think I will work in gerontological nursing; it seems depressing. I dont know many older people, but they are all sick without much hope to get better. Ill probably go into labor and delivery or the emergency room where I can really make a difference.

Student nurse, age 24

To know that I have made them feel they are human, that theyre lovedthat someone still cares about them. I believe that lots of times they feel ignored and as if they have no value. Its very important to me that they feel valued and they know that they still contribute not only to society but to the personal growth of everyone who comes into interac tion with them.

Gerontological nurse, age 35, working in a nursing home

Care of Older Adults: A Nursing Imperative

The world population is aging. By 2050, one in five Americans will be over 65 years of age, with those over 85 showing the greatest increase in numbers. The number of people living to 100 years of age is projected to grow at

more than 20 times the rate of the total population by 2050. Older people today are healthier, better educated, and expect a much higher quality of life as they age than did their elders. Healthy aging is now an achievable goal for many and it is essential that we have the knowledge and skills to help people of all ages, races, and cultures achieve this goal.

12 SECTION 1 Foundations of Healthy Aging

The developmental period of elderhood is an essential part of a healthy society and as important as childhood or adulthood (Thomas, 2004). We can expect to spend 40 or more years as older adults and our preparation for this time in our lives certainly demands attention as well as expert care from nurses. How does one maximize the experience of aging and enrich the years of elderhood despite the physical and psychological changes that may occur?

Most nurses care for older people during the course of their careers. In addition, the public looks to nurses to have knowledge and skills to assist people to age in health. Every older person should expect to receive care provided by nurses with competence in gerontological nursing. Gerontological nursing is not only for a specialty group of nurses. Knowledge of aging and gerontological nursing is core knowledge for the profession of nursing (Young, 2003).

Eldercare is projected to be the fastest growing em ployment sector in the health care industry. Older adults are the core consumers of health care, with higher rates of outpatient provider visits, hospitalizations, home care, and long-term care service use than other age groups. Despite demand, the number of health care workers who are inter ested in and prepared to care for older people remains low. Americas eldercare workforce is dangerously understaffed and unprepared to care for the growing numbers of older adults (Institute of Medicine, 2008). Less than 1% of reg istered nurses (RNs) and only 3% of advanced practice

registered nurses (APRNs) are certified in gerontology (Institute of Medicine, 2008; Stierle et al., 2006). Geriatric medicine faces similar challenges with just 7,128 geriatricians, one for every 2,546 older Americans. By 2030, it is estimated that this number will increase to only 7,750, one for every 4,254 older Americans, far short of the predicted need for 36,000 geriatricians (Institute of Medicine, 2008). Other professions such as social work have similar shortages. These issues are critical not only in the United States but across the globe. If these issues remain unresolved, the cumulative impact for our aging population and our overall health care system will be significant. Pro jected consequences include, but are not limited to extremely high nurse-patient ratios; proliferation of high-tech, low touch care systems; and a decline in public trust for nursing (American Nurses Association, 2010, p. 23). Healthy People 2020 includes goals related to geriatric education (see the Healthy People box).

Enhancing interest, recruitment, and preparation of students and practicing nurses in care of older adults across the continuum is essential. Positive role models, a deep commitment to caring, and an appreciation of the signifi

cant contribution of a nursing model of care to the well being of older people, are often the motivating factors that draw nurses to the specialty. Box 2-1 presents the views of some of the geriatric nursing pioneers, as well as current leaders, on the practice of gerontological nursing and what draws them to care of older adults.

BOX 2-1 Reflections on Gerontological Nursing from Gerontological Nursing Pioneers and Current Leaders in the Field

Doris Schwartz, Gerontological Nursing Pioneer We need to remind ourselves constantly that the purpose of gerontic nursing is to prevent untimely death and need less suffering, always with the focus of doing with as well as doing for, and in every instance to attempt to preserve personhood as long as life continues. (From interview data collected by Priscilla Ebersole between 1990 and 2001.)

Mary Opal Wolanin, Gerontological Nursing Pioneer

I believe that one of the most valuable lessons I have learned from those who are older is that I must start with looking inside at my own thinking. I was very guilty of age ism. I believed every myth in the book, was sure that I would never live past my seventieth birthday, and made no plan for my seventies. Probably the most productive years

of my career have been since that dreaded birthday and I now realize that it is very difficult, if not impossible, to think of our own aging. (From interview data collected by Priscilla Ebersole between 1990 and 2001.) -2881281-108090

Terry Fulmer, Dean, College of Nursing, New York University and Co-Director, John A. Hartford Institute for Geriatric Nursing

I soon realized that in the arena of caring for the aged, I could have an autonomous nursing practice that would make a real difference in medical outcomes. I could practice the full scope of nursing. It gave me a sense of freedom and accomplishment. With older patients, the most important component of care, by far, is nursing care. Its very motivat ing. (From Ebersole P, Touhy T: Geriatric nursing: growth of a specialty, New York, 2006, Springer, p. 129.)

CHAPTER 2 Gerontological Nursing History, Education, and Roles 13

BOX 2-1 Reflections on Gerontological Nursing from Gerontological Nursing Pioneers and Current Leaders in the Fieldcontd

Neville Strumpf, Edith Clement Chair in Gerontological Nursing, University of -143364-104647

Pennsylvania, Director of the Hartford

Center of Geriatric Nursing Excellence and Center for Gerontological Nursing Science My philosophy remains deeply rooted in individual choice, comfort, and dignity, especially for frail, older adults. I fer vently hope that the future will be characterized by a health care system capable of supporting these values throughout a persons life, and that we shall someday see the routine application of evidence based practice to the care of all older adults, whether they are in the community, a hospital, or the nursing home. We have not yet achieved that dream. (From Ebersole P, Touhy T: Geriatric nursing: growth of a specialty, New York, 2006, Springer, p. 145.)

Mathy Mezey, Professor Emeritus and Associate Director, The Hartford Institute for Geriatric Nursing, New York University College of Nursing Because geriatric nursing especially offers nurses the unique opportunity to dramatically impact peoples lives for the better and for the worst, it demands the best that you have to offer. I am very optimistic about the future of geriatric nursing. Increas ing numbers of older adults are interested in marching into old age as healthy and involved. Geriatric nursing offers a unique opportunity to help older adults meet these aspirations while at the same time maintaining a commitment to the oldest and

HEALTHY PEOPLE 2020

Older Adults

Increase the proportion of the health care workforce with geriatric certification (physicians, geriatric psychiatrists, registered nurses, dentists, physical therapists, dietitians)

From U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Healthy people 2020 (2012). Available at http://www.healthypeople.gov/2020.

History of Gerontological Nursing

Historically, nurses have always been in the frontlines of caring for older people. They have provided hands-on care, supervision, administration, program development, teach ing, and research and are, to a great extent, responsible for

frailest in our society. (From Ebersole P, Touhy T: Geriatric nurs ing: growth of a specialty, New York, 2006, Springer, p. 142.)

Jennifer Lingler, PhD, FNP

When I was in high school, a nurse I knew helped me find a nursing assistant position at the residential care facility where she worked. That experience sparked my interest in older adults that continues today. I realized that caring for frail elders could be incredibly gratifying, and I felt privileged to play a role, however small, in peoples lives. At the same time, I became increasingly curious about what it means to age successfully. I questioned why some people seemed to age so gracefully, while others succumbed to physical illness, mental decline, or both. As a Building Academic Geriatric Nursing Capacity (BAGNC) alumnus, I now divide my time serving as a nurse practitioner at a memory disorders clinic, teaching an ethics course in a gerontology program, and conducting research on family caregiving. I am encouraged by the realization that as current students contemplate the array of opportunities before them, seek counsel from trusted men tors, and gain exposure to various clinical populations, the next generation of geriatric nurses will emerge. And, I am confident that in doing so, they will set their own course for affecting change in the lives of societys most vulnerable members. (Jennifer Lingler as cited in Fagin C, Franklin P: Why choose geriatric nursing? Six nursing scholars tell their stories, Imprint, September/October, 2005, p. 74.)

the rapid advance of gerontology as a profession. Nurses have been, and continue to be, the mainstay of care of older adults (Mezey & Fulmer, 2002). Gerontological nurses have made substantial contributions to the body of knowledge guiding best practice in care of older people. In examining the history of gerontological nursing, one must marvel at the advocacy and perseverance of nurses who have remained deeply committed to the care of older adults despite strug

gling against insurmountable odds over the years. We are proud to be the standard-bearers of excellence in care of older people. Table 2-1 presents a timeline of significant accomplishments in the history of gerontological nursing.

Early History

The origins of gerontological nursing are rooted in England and began with Florence Nightingale as she accepted a posi tion in the Institution for the Care of Sick Gentlewomen in

14 SECTION 1 Foundations of Healthy Aging

TABLE 2-1 Professionalization of Gerontological Nursing 1906 First article is published in American Journal of Nursing (AJN) on care of the elderly.

1925 AJN considers geriatric nursing as a possible specialty in nursing.

1950 Newton and Anderson publish first geriatric nursing textbook.

Geriatrics becomes a specialization in nursing.

1962 American Nurses Association (ANA) forms a national geriatric nursing group.

1966 ANA creates the Division of Geriatric Nursing.

First masters program for clinical nurse specialists in geriatric nursing developed by Virginia Stone at Duke University. 1970 ANA establishes Standards of Practice for Geriatric Nursing.

1974 Certification in geriatric nursing practice offered through ANA; process implemented by Laurie Gunter and Virginia Stone. 1975 Journal of Gerontological Nursing published by Slack; first editor, Edna Stilwell.

1976 ANA renames Geriatric Division Gerontological to reflect a health promotion emphasis.

ANA publishes Standards for Gerontological Nursing Practice; committee chaired by Barbara Allen Davis. ANA begins certifying geriatric nurse practitioners.

Nursing and the Aged edited by Burnside and published by McGraw-Hill.

1977 First gerontological nursing track funded by Division of Nursing and established by Sr. Rose Therese Bahr at University of Kansas School of Nursing.

1979 Education for Gerontic Nursing written by Gunter and Estes; suggested curricula for all levels of nursing education. 1980 Geriatric Nursing first published by AJN; Cynthia Kelly, editor.

1983 Florence Cellar Endowed Gerontological Nursing Chair established at Case Western Reserve University, first in the nation; Doreen Norton, first scholar to occupy chair.

National Conference of Gerontological Nurse Practitioners is established.

1984 National Gerontological Nurses Association is established.

Division of Gerontological Nursing Practice becomes Council on Gerontological Nursing (councils established for all practice specialties).

1989 ANA certifies gerontological clinical nurse specialists.

1992 John A. Hartford Foundation funds a major initiative to improve care of hospitalized older patients: Nurses Improving Care for Healthsystem Elders (NICHE).

1996 John A. Hartford Foundation establishes the Institute for Geriatric Nursing at New York University under the direction of Mathy Mezey.

2000 Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care published by the American Association of Colleges of Nursing and the John A. Hartford Foundation Institute for Geriatric Nursing. The American Academy of Nursing established Building Academic Geriatric Nursing Capacity (BAGNC) in 2000 with support from the John A. Hartford Foundation.

2001 Hartford Coalition of Geriatric Nursing Associations formed.

2002 Nurse Competence in Aging (funded by the Atlantic Philanthropies Inc.) initiative to improve the quality of health care to older adults by enhancing the geriatric competence of nurses who are members of specialty nursing. 2004 Nurse Practitioner and Clinical Nurse Specialist Competencies for Older Adult Care published by the American Association of Colleges of Nursing and the Hartford Institute for Geriatric Nursing.

Atlantic Philanthropies committed its resources to postdoctoral fellowships in gerontology nursing.

2007 Atlantic Philanthropies provides a grant to the American Academy of Nursing of $500,000 to improve care of older adults in nursing homes by improving the clinical skills of professional nurses.

American Association for Long-Term Care Nurses formed.

CHAPTER 2 Gerontological Nursing History, Education, and Roles 15

TABLE 2-1 Professionalization of Gerontological Nursingcontd 2008 Four new Centers of Geriatric Nursing Excellence (CGNE) are funded by the John A. Hartford Foundation bringing the total number of Centers to nine. Existing Centers are at the University of Iowa, University of California San Francisco, Oregon Health Sciences University, University of Arkansas, University of Pennsylvania, Arizona State University, Pennsylvania State University, University of Minnesota, and University of Utah.

Research in Gerontological Nursing launched by Slack Inc; Dr. Kitty Buckwalter, Editor.

Geriatric Nursing Leadership Academy established by Sigma Theta Tau International with funding from the John A. Hartford Foundation. John A. Hartford Foundation funds the Geropsychiatric Nursing Collaborative (Universities of Iowa, Arkansas, Pennsylvania, American Academy of Nursing)

Institute of Medicine publishes Retooling for an aging America: building the health care workforce report. 2009 National Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education designates adult gerontology as one of 6 population foci for APRNs.

John A. Hartford Foundation funds Phase 2 of the Fostering Geriatrics in Pre-Licensure Nursing Education, a partnership between the Community College of Philadelphia and the National League for Nursing.

2010 Adult-gerontology primary care nurse practitioner competencies published by the John A. Hartford Foundation Institute for Geriatric Nursing, the AACN, and NONPF.

Sigma Theta Taus Center for Nursing Excellence established.

ANCC Pathways to Excellence Long-Term Care Program.

2012 The Gerontological Society of America is now home to the Coordinating Center for the National Hartford Centers of Gerontological Nursing Excellence (HCGNE), also known as the Building Academic Geriatric Nursing Capacity Initiative. U.S. Department of Health and Human Services provides funding to five designated medical center hospitals for clinical training to newly enrolled APRNs to deliver primary care, preventive care, transitional care, chronic case management, and other services appropriate for Medicare recipients.

2013 Adult-Gerontology Acute Care Nurse Practitioner and Adult-Gerontology Primary Care Nurse Practitioner certifications through ANCC begin.

For a complete listing of John A. Hartford Foundation funding for geriatric nursing, see http://www.hgni.org/091008%20HGNI%20Project% 20Descriptions.pdf.

Distressed Circumstances. Nightingales concern for the frail and sick elderly was continued by Agnes Jones, a wealthy Nightingale-trained nurse, who in 1864 was sent to Liver pool Infirmary, a large Poor Law institution. The care in the institution was poor, the diet meager, and the nurses often drunk. But Miss Jones, under the tutelage of Nightingale, improved the care dramatically, as well as reduced the costs.

In the United States, almshouses were the destination of destitute older people and were insufferable places with de plorable conditions, neglect, preventable suffering, contagion, and death from lack of proper medical and nursing care (Crane, 1907, p. 873). As early as 1906, Lavinia Dock and other early leaders in nursing addressed, in the American Journal of Nursing (AJN), the needs of the elderly chronically ill in almshouses. Dock and her colleagues cited the immedi ate need for trained nurses and pupil education in almshouses, so that these evils, all of which lie strictly in the sphere of housekeeping and nursing,two spheres which have always been lauded as womens ownmight not occur (Dock, 1908, p. 523). In 1912 the American Nurses Association (ANA) Board of Directors appointed an Almshouse Committee to continue to oversee nursing in these institutions. World War I

distracted them from attention to these needs. But in 1925, the ANA advanced the idea of a specialty in the nursing care of the aged.

With the passage of the Social Security Act of 1935, federal monies were provided for old-age insurance and public assistance for needy older people not covered by insurance. To combat the fear of almshouse placement, Congress stipulated that the Social Security funds could not be used to pay for care in almshouses or other public institutions. This move is thought to have been the genesis of commercial nursing homes. During the next 10 years, many almshouses closed and the number of private board ing homes providing care to elders increased. Because re

tired and widowed nurses often converted their homes into such living quarters and gave care when their boarders became ill, they can be considered the first geriatric nurses and their homes the first nursing homes.

Two nursing journals in the 1940s described centers of excellence for geriatric care: the Cuyahoga County Nursing Home in Ohio and the Hebrew Home for the Aged in New York. An article in the AJN by Sarah Gelbach (1943) recommended that nurses should have not only an aptitude

16 SECTION 1 Foundations of Healthy Aging

for working with the elderly but also specific geriatric edu cation. The first textbook on nursing care of the elderly was published by Newton and Anderson in 1950, and the first published nursing research on chronic disease and the el derly (Mack, 1952) appeared in the premier issue of Nurs ing Research in 1952.

In 1962 a focus group was formed to discuss geriatric nursing, and in 1966 a geriatric practice group was convened. However, it was not until 1966 that the ANA formed a Division of Geriatric Nursing. The first geriatric standards were published by the ANA in 1968, and soon after, geriatric nursing certification was offered. Geriatric nursing was the first specialty to establish standards of practice within the ANA. In 1976 the Division of Geriatric Nursing changed its name to the Gerontological Nursing Division to reflect the broad role nurses play in the care of older people. In the mid 1970s, certificate and masters programs to prepare geronto logical nurse practitioners were begun with funding from the Department of Health, Education, and Welfare. Whereas most specialties in nursing practice developed from those identified in medicine, this was not the case with the spe

cialty of gerontological nursing since health care of older adults was traditionally considered to fall within the domain of nursing (Davis, 1984).

In 1984 the Council on Gerontological Nursing was formed and certification for geriatric nurse practitioners (GNPs) and gerontological clinical nurse specialists (GCNSs) became available. Nursing was the first of the professions to develop standards of gerontological care and the first to pro

vide a certification mechanism to ensure specific professional expertise through credentialing (Ebersole & Touhy, 2006). The most recent edition of Scope and Standards of Gerontologi cal Nursing Practice (ANA, 2010) provides a comprehensive overview of the scope of gerontological nursing and identifies levels of gerontological nursing practice (basic and advanced) and standards of clinical gerontological nursing care and gerontological nursing performance.

Current Initiatives

The most significant influence in enhancing gerontological nursing has been the work of the Hartford Institute for Geriatric Nursing, funded by the John A. Hartford Foundation. Mathy Mezey, EdD, RN, FAAN, directed the institute, located in the College of Nursing at New York University, from its inception in 1996 until 2010 and now serves as an Associate Director. It is the only nurse-led organization in the country seeking to shape the quality of the nations health care for older Americans by promoting geriatric nursing excellence to both the nursing profession and the larger health care community. Initiatives in nursing

education, nursing practice, nursing research, and nursing policy include enhancing geriatrics in nursing education programs through curricular reform and faculty develop ment; the development of nine Centers of Geriatric Nurs ing Excellence; predoctoral and postdoctoral scholarships for study and research in geriatric nursing; and clinical practice improvement projects to enhance care for older adults (Mackin et al., 2006; Miller et al., 2006; Souder et al., 2006) (see www. hartfordign.org).

Another significant influence on improving care for older adults was the Nurse Competence in Aging (NCA) project, a five-year initiative created in 2002 through an alliance of the ANA, the American Nurses Credentialing Center (ANCC), and the Hartford Institute for Geriatric Nursing. Funded by Atlantic Philanthropies, through the American Nurses Foundation, the initiative addressed the need to ensure competence in geriatrics among nursing specialty organizations. The initiative provided grant and technical assistance to more than 50 specialty nursing organizations; developed a free web-based comprehensive gerontological nursing resource center (http://consultgerirn. org) where nurses can access evidence-based information on topics related to the care of older adults; and conducted a national gerontological nursing certification outreach (Stierle et al., 2006). An extension of this work, the Re

sourcefully Enhancing Aging in Specialty Nursing (REASN) project, will focuses on building intensive collaborations with 13 hospital-based specialty associations to create geriatric educational products and resources to ensure the geriatric competencies of their members (see http://hartfordign.org/

practice/reasn/).

In 2008 a $1.6 million grant from the John A. Hartford Foundation was awarded to Sigma Theta Tau International (STTI) to establish the Geriatric Nursing Leadership Academy (GNLA). Working with the Hartford Centers of Geriatric Nursing Excellence, the purpose of the GNLA is to develop the leadership skills of geriatric nurses in positions of influence in a variety of health care settings and to improve the quality of health care for older adults and their families (www.nursingsociety.org/LeadershipInstitute/ GeriatricAcademy/Pages/introduction.aspx).

Gerontological Nursing Education

According to the ANA Scope and Standards of Geronto logical Nursing Practice (2010), Nurses require the knowledge and skills to assist older adults in a broad range of nursing care issues, from maintaining health and pre venting illnesses, to managing complex, overlapping chronic conditions and progressive/protracted frailty in physical and mental functions, to palliative care (p. 12-13). Basic

CHAPTER 2 Gerontological Nursing History, Education, and Roles 17

competence is critical to ensure the best possible care for diverse populations of older adults. All nursing education programs, from entry-level to advanced practice, should be gerontologized to ensure that graduates are competent to meet the needs of an aging population.

Essential educational competencies and academic stan dards for care of older adults have been developed by national organizations such as the American Association of Colleges of Nursing (AACN) for both basic and advanced nursing education (ANA, 2010). The Essentials of Baccalau reate Education for Professional Nursing Practice (AACN, 2008) specifically address the importance of geriatric content and structured clinical experiences with older adults across the continuum in the education of students. In 2010, AACN and the Hartford Institute for Geriatric Nursing, New York University, published the Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults, a supplement to The Essen tials document. In addition, gerontological nursing com petencies for advanced practice graduate programs have also been developed. All of these documents can be ac cessed from http://www.aacn.nche.edu/education-resources/ competencies-older-adults.

Despite these lists of competencies, however, there remains a lack of consistency among nursing schools in helping students gain needed gerontological nursing infor mation and skills (ANA, 2010, p.12). Those in the field of nursing education must seriously consider specific minimal requirements in the care of older adults at each level of education to fulfill the responsibility of nurses to the pub lic and the profession and to meet accreditation criteria. However, schools of nursing have only begun to include gerontological nursing content in their curricula and most still do not have freestanding courses in the specialty similar to courses in maternal/child or psychiatric nursing. When content is integrated throughout the curriculum, less than 25% of the content is devoted to geriatric care (Berman et al., 2005). Gerontological nursing content needs to be integrated throughout the curriculum, in addi tion to a stand-alone course, so that gerontology is valued and viewed as an integral part of nursing care (Miller et al., 2009, p. 198).

It is important to provide students with nursing prac tice experiences caring for elders across the continuum of care. For clinical practice sites, one is not limited to the acute care setting or the nursing home. Experiences with well elders in the community and opportunities to focus on health promotion should be the first experience for students. This will assist them to develop more posi tive attitudes toward older people, understand the full scope of nursing practice with older adults, and learn

nursing responses to enhance health and wellness. Reha bilitation centers, subacute and skilled nursing facilities, and hospice settings provide opportunities for leadership experience, nursing management of complex problems, interprofessional teamwork, and research application for more advanced students.

Faculty with expertise in gerontological nursing are scarce; less than 30% of baccalaureate programs have at least one full-time faculty member certified in gerontological nursing (Berman et al., 2005; Mackin et al., 2006). Impor

tant resources for faculty education in gerontological nursing include the Geriatric Nursing Education Consortium (GNEC), the Advancing Care Excellence for Seniors (ACES), the Hartford Geriatric Nursing Initiative (HGNI), and the Building Academic Geriatric Nursing Capacity (BAGNC).

The purpose of the GNEC, a national initiative of the American Association of Colleges of Nursing (AACN) with funding from the John A. Hartford Foundation, is to enhance geriatric content in senior-level under

graduate courses. The GNEC educational curriculum and evidence-based modules reflecting the state-of-the science approach to care for older adults are available electronically and via webinars (see http://www.aacn. nche.edu/gnec.htm).

Advancing Care Excellence for Seniors (ACES), a three-year grant funded by the John A. Hartford Foun dation to foster gerontological nursing education in pre licensure programs, is a collaborative effort between the National League for Nursing (NLN) and the Commu nity College of Philadelphia. ACES provides faculty with development materials, teaching tools and strate gies, curricular guidelines, and essential nursing actions (see www.nln.org/ACES).

The BAGNC initiative includes the Building Geriatric Nursing Capacity Scholars and Fellows Awards Program and the nine Hartford Centers of Geriatric Nursing Excellence. This program, coordinated by the American Academy of Nursing, has stimulated increas

ing interest in academic geriatric nursing through schol arships and fellowships for research, faculty, and leader ship development (see http://www.geriatricnursing.org/ about/about.asp).

The Patient Protection and Affordable Care Act, signed into law in March 2010, provides many initiatives that will have a direct impact on gerontological nursing with regard to workforce, education, and practice. It is anticipated that there will be additional federal funding to support advanced education in gerontological nursing, education of faculty, and advanced training for direct care workers employed in long-term care settings.

18 SECTION 1 Foundations of Healthy Aging

Gerontological Nursing Research

Nursing research has significantly affected the quality of life of older people and gains more prominence each de cade. Nurses have generated significant research over the past 20 years in the management of common conditions of older adults and settings of care. A solid foundation has been established for the practice of gerontological nursing. Some of the most important nursing studies have investi gated interventions for improving the care for individuals with dementia, reducing falls, the use of restraints, pain management, delirium, care transitions, and end-of-life care. More research is needed on community and home care resources for older adults, family caregiving issues (particularly minority elders), research on diverse older populations, and health in aging. Translational research and continued attention to interdisciplinary studies are increasingly important. Gerontological nurse scholars and researchers May Wykle and Ruth Tappen have identified areas in most need of research (Box 2-2).

Research with older adults receives considerable funding from the National Institute of Nursing Research (NINR). Their website (www.nih.gov/ninr) provides information about results of studies as well as funding opportunities. Gerontological nurse researchers publish in many of the journals devoted to gerontology. Although nursing research has contributed significantly to knowledge about care of older adults, aging has become a public health issue requir

ing new approaches to care. More nurse scientists are needed to provide the evidence for interventions and health care policy to improve the quality and quantity of life for older adults (ANA, 2010, p. 23).

Roles in Gerontological Nursing

Gerontological nursing roles encompass every imagin able venue and circumstance. The opportunities are expanding rapidly because we are a rapidly aging soci ety. Nurses have the potential to improve elder care across settings through effective screening and compre hensive assessment, facilitating access to programs and services, educating and empowering older adults and their families to improve their health and manage chronic conditions, leading and coordinating the ef forts of members of the health care team, conducting and applying research, and influencing policy (Young, 2003, p. 9).

A gerontological nurse may be a generalist or a spe cialist. The generalist functions in a variety of settings (primary care, acute care, home care, subacute and long term care facilities, the community) providing nursing

BOX 2-2 Future Directions for Gerontological Nursing Research as Suggested by

Wykle and Tappen

Staffing patterns and the most appropriate mix to improve care outcomes in long-term care settings The influence of culture, diversity, and ethnicity on aging Health disparities and health literacy -144074-107903

Factors contributing to successful aging, health pro motion, and wellness in the Baby Boomer generation Retirement decisions of the Baby Boomers: how they are made and how they are changing

Dementia as a chronic illness and staying well in the presence of the disease

Caregiving, particularly intergenerational

Values and attitudes of the current generation toward aging and expectations of its members

Interventions to assist with the increasing prevalence of drug and alcohol abuse and other mental health problems of the current and future generations of

older adults

Integration of current best practice protocols into settings across the continuum in cost-effective and care-efficient models

Models of acute care designed to prevent negative outcomes in elders

Strategies to increase preparation in gerontological nursing and increased recruitment of the brightest and best into gerontological nursing

Models of interdisciplinary practice

Health promotion and illness management interven tions in the assisted living setting; role of professional nurses and advanced-practice nurses in this setting; aging in place

Development of models for end-of-life care in home and nursing home

From Ebersole P, Touhy T: Geriatric nursing: growth of a specialty, New York, 2006, Springer.

care to individuals and their families. The gerontological nursing specialist has advanced preparation at the masters level and performs all of the functions of a generalist but has developed advanced clinical expertise, as well as an understanding of health and social policy and proficiency in planning, implementing, and evaluating health programs. With shortages in nursing faculty pre

pared in gerontological nursing, there is a critical need for nurses who have masters and doctoral preparation

CHAPTER 2 Gerontological Nursing History, Education, and Roles 19

and expertise in care of older adults to assume faculty roles.

Certifications in gerontological nursing are available at the generalist and specialist level and should be encour aged as a way of enhancing and recognizing the needed knowledge and skills to care for this rapidly growing population (see www.nursecredentialing.org). The majority of nurses practicing today and in the future will be caring for older adult patients and the public will expect nurses to have this specialized knowledge.

Specialist Roles

Under the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (2008), APRNs must be educated, certified, and licensed to practice in a role and a population. APRNs may special

ize but they may not be licensed solely within a specialty area. APRNs are educated in one of four roles; one of which is the adult-gerontology nurse practitioner. This population focus encompasses the young adult to the older adult, including the frail elder. Titles of APRNs educated and certified across both areas of practice will include the following: Adult-Gerontology Acute Care Nurse Practi

tioner (2013), Adult-Gerontology Primary Care Nurse Practitioner (2013), and Adult-Gerontology Clinical Nurse Specialist (2014) (http://www.nursecredentialing. org/Certification/APRNCorner/APRN-FAQ.aspx#10). Because the number of APRNs with gerontological certi fication and interest in the specialty practice is low, this new focus in role and population, combining ANP and GNP specialty education, will assist in meeting the critical need for APRNs well prepared to care for the growing numbers of older people.

Advanced practice nurses have demonstrated their skill in improving health outcomes and cost-effectiveness. Advanced practice nurses with certification in adult gerontology will find a full range of opportunities for collaborative and independent practice both now and in the future. Practice sites include geriatric and family practice clinics, long-term care, acute and subacute care, home health care agencies, continuing care retirement communities, assisted living facilities, hospice, managed care organizations, specialty care clinics (e.g., Alzheimers, heart failure, diabetes), Area Agencies on Aging, public health departments, care management, elder care con

sulting, schools of nursing, and private practice (see www. gapna.org). One of the most important advanced prac tice nursing roles that emerged over the last 30 years is that of the gerontological nurse practitioner (GNP) and the gerontological clinical nurse specialist (GCNS) in

skilled nursing facilities. The education and training programs arose from evident need, particularly in the long-term care setting.

Many of these advanced practice nurses have nursing facility practices managing complex care of frail older adults in collaboration with interprofessional teams. This role is well established and positive outcomes include in

creased patient and family satisfaction, decreased costs, less frequent hospitalizations and emergency room visits, and improved quality of care (Bakerjian, 2008; Kane et al., 2004; Kappas-Larson, 2008). The Evercare Care Model, a federally funded Medicare demonstration project, origi

nally designed by two nurse practitioners, is a very suc cessful innovative model with a long history of positive outcomes. This model utilizes APRNs either certified in gerontology or specially trained by Evercare, for care of long-term nursing home residents and individuals with severe or disabling conditions (Kappas-Larson, 2008) (see www.innovativecaremodels.com).

Generalist Roles

Acute Care

Even though most nurses working in acute care are caring for older patients, many have not had gerontological nurs ing content in their basic nursing education programs and few are certified in the specialty. Only a small number of the countrys 6000 hospitals have institutional practice guidelines, educational resources, and administrative prac tices that support best practice care of older adults (Boltz et al., 2008, p. 176). Kagan (2008) reminds us that older adults are the work of hospitals but most nurses practicing in hospitals do not say they specialize in geriatrics . . . We, as a profession and a force in an aging society, must make the transformation to understanding care of older adults is acute care nursing . . . Care of older adults would be the rule instead of the exception (2008, p. 103). Kagan goes on to suggest that such a transformation would mean that acute care nurses would proudly describe themselves as geriatric nurses with subspecialities (geriatric vascular nurses, geriatric radiology nurses) and, along with geriatric nurse generalists, would populate hospital nursing services across the country.

Nurses caring for older adults in hospitals may func tion in the direct care provider role, as care managers, discharge planners, transitional care coordinators, as well as in leadership and management positions. The Nurses Improving Care for Health System Elders (NICHE), a program developed by the Hartford Geriatric Nursing Institute in 1992 to prevent iatrogenesis and improve outcomes for hospitalized older adults, offers many

20 SECTION 1 Foundations of Healthy Aging

opportunities for new roles for acute care nurses. NICHE is built on the premise that the bedside nurse plays a pivotal role in influencing the older adults hos pital experience and outcomes, through direct nursing care, as well as coordination of interdisciplinary activi ties (Resnick, 2009, p. 81). More than 300 hospitals in more than 40 states, as well as parts of Canada, are involved in NICHE projects. NICHE units of vari ous types have been developed, including the geriatric resource nurse (GRN) model and the acute care of the elderly (ACE) unit (www. nicheprogram.org).

Community- and Home-Based Care

Nurses will care for older adults in hospitals and long-term care facilities, but the majority of older adults live in the community. Community-based care settings include home care, independent senior housing, retirement communities, residential care facilities, adult day health programs, pri

mary care clinics, and public health departments. The growth in home- and community-based health care is ex pected to continue because older people prefer to age in place. Other factors influencing the growth of home and community-based care include rapidly escalating health care costs.

The Independence at Home Act, part of the Affordable Care Act, supports home-based primary care teams, including physicians and nurse practitioners, to deliver primary care services to high-risk patients. This three-year demonstration project will receive mandatory appropria

tions of $5 million per year. After the project ends, the Department of Health and Human Services will evaluate the program and report to Congress. See the Centers for Medicare and Medicaid Services Innovations at http://www.cms.gov/ and http://www.aoa.gov/AoARoot/

Aging_Statistics/docs/AoA_Affordable_Care.pdf for more information.

Advances in technology for remote monitoring of health status and safety, and point-of-care testing devices show promise in improving outcomes for elders who want to age in place (see Chapter 13). These technologies present exciting opportunities for nurses in the manage

ment and evaluation of care and call for increased educa tion and practice experiences for nursing students in home-based care.

Nurses in the home setting provide comprehensive assessments and care management. They may provide and supervise care for elders with a variety of care needs including chronic wounds, intravenous therapy, tube feed

ings, unstable medical conditions, and complex medica tion regimens, and for those receiving rehabilitation and palliative and hospice services. Gerontological nurses will

find opportunities to create practices in community-based settings with a focus not only on care for those who are ill, but also on health promotion.

Skilled Nursing Facilities/Nursing Homes Nursing homes are the settings for the delivery of around the-clock skilled care for those needing specialized care that cannot be provided elsewhere. Nursing homes have evolved into a significant location where health care is provided across the continuum. Nursing homes today are complex health care settings that are a mix of hospital, rehabilitation facility, hospice, and dementia-specific units, and are for many elders a final home. The settings called nursing homes or nursing facilities most often include up to two levels of care: a skilled nursing care (also called sub acute care) facility is required to have licensed professionals with a focus on the management of complex medical needs; and a chronic care (also called long-term or custodial) facility is required to have 24-hour personal assistance that is supervised and augmented by professional and licensed nurses. Often, both kinds of services are provided in one facility. Most nursing homes offer subacute units that function much like the general medical-surgical hospital units of the past.

Subacute care is more intensive than traditional nurs ing home care and several times more costly, but far less costly than care in an acute-care hospital. The expectation is that the patient will be discharged home or to a less in tensive setting. In addition to skilled nursing care, reha bilitation services are an essential component of subacute units. Length of stay is usually less than 1 month and is largely reimbursed by Medicare. Patients in subacute units are usually younger and less likely to be cognitively impaired than those in traditional nursing home care. Generally, higher levels of professional staffing are found in the subacute setting than those in the traditional nurs ing home setting because of the acuity of the patients condition.

Nursing homes also care for patients who may not need the intense care provided in subacute units but still need ongoing 24-hour care. This may include individuals with severe strokes, dementia, or Parkinsons disease, and those receiving hospice care. More than 50% of residents in nursing homes are cognitively impaired, and nursing homes are increasingly caring for people at the end of life. In the United States, one in four persons die in a nursing home, and by 2020 nearly one in two will die in this setting (Federal Interagency Forum on Aging Related Statistics, 2012; Teno, 2004). Nursing home residents represent the most frail of all older adults. Their need for 24-hour care could not be met in the

CHAPTER 2 Gerontological Nursing History, Education, and Roles 21

home or residential care setting, or may have exceeded what the family was able to provide.

Roles for professional nursing may include nursing administrator, manager, supervisor, charge nurse, educa tor, infection control nurse, Minimum Data Set (MDS) coordinator, case manager, quality improvement coordi nator, and direct care provider. The American Health Care Association (2010) predicts a 41% increase in the need for RNs in long-term care between 2000 and 2020.

Professional nurses in nursing facilities must be highly skilled in the complex care concerns of older people, rang ing from subacute care to end-of-life care. Excellent as sessment skills; ability to work with interprofessional teams in partnership with residents and families; skills in acute, rehabilitative, and palliative care; and leadership, management, supervision, and delegation skills are essen tial. Practice in this setting calls for independent decision making and is guided by a nursing model of care because there are fewer physicians and other professionals on site at all times. In addition, stringent federal regulations gov erning care practices and greater use of licensed practical nurses and nursing assistants influence the role of profes sional nursing in this setting. Many new graduates will be entering this setting upon graduation so it is essential to provide education and practice experiences to prepare them to function competently in this setting, particularly leadership and management skills.

Nurses accustomed to practicing in an acute care hospital will find many differences in subacute and skilled nursing facilities. Differences in focus of care and goals between acute and long-term care are pre

sented in Boxes 2-3 and 2-4. For many nurses at both the generalist and specialist levels, nursing in long-term care settings (home, skilled nursing facilities) offers the opportunity to practice the full scope of nursing, estab

lish long-term relationships with patients and families, and make a significant difference in patient outcomes. Although medical management is important, the need for expert nursing care is the most essential service pro

vided. The American Association for Long Term Care Nursing offers a certification program for long-term care nurses (www.LTCNursing.org).

Professional nurse staffing ratios continue to be a critical concern in this setting, especially with the in creasing acuity of patients. Current federal standards require only one RN in the nursing home for 8 hours a daya figure quite shocking considering the ratio of RNs to patients in acute care. More RN direct-care per resident time in nursing homes is associated with fewer pressure ulcers, hospitalizations, urinary tract in fections, catheterizations, and with less weight loss,

BOX 2-3 Focus of Acute and Long-Term Care

Acute Care Orientation -131032-104460

Illness

High technology

Short term

Episodic

One-dimensional

Professional

Medical model

Cure

Long-Term Care Orientation

Function

High touch

Extended

Interdisciplinary model

Ongoing

Multidimensional

Paraprofessional and family

Care

Adapted from Ouslander J, Osterweil D, Morley J: Medical care in the nursing home, New York, 1997, McGraw-Hill.

BOX 2-4 Goals of Long-Term Care

1. Provide a safe and supportive environment for chronically ill and functionally dependent people. 2. Restore and maintain highest practicable level of functional independence. -134473-107904

3. Preserve individual autonomy.

4. Maximize quality of life, well-being, and satisfaction with care.

5. Provide comfort and dignity at the end of life for residents and their families.

6. Provide coordinated interdisciplinary care to subacutely ill residents who plan to return to home or a less

restrictive level of care.

7. Stabilize and delay progression, when possible, of chronic medical conditions.

8. Prevent acute medical and iatrogenic illnesses and identify and treat them rapidly when they do occur. 9. Create a homelike environment that respects dignity of each resident.

Adapted from Ouslander J, Osterweil D, Morley J: Medical care in the nursing home, New York, 1997, McGraw-Hill.

22 SECTION 1 Foundations of Healthy Aging

less deterioration in the ability to perform activities of daily living, and fewer quality of care deficiencies (Harrington et al., 2010; Horn et al., 2005; Kim et al., 2009). Many groups dealing with issues of the aging, as well as the American Nurses Association, have supported the critical need for adequate staffing in nursing homes, but to date, the federal government has not acted to mandate increases in minimum staffing requirements nor provided funding to support increases.

There are several new initiatives nurses can be involved with that are aimed at improving professional nursing practice and quality outcomes in long-term care, includ ing Sigma Theta Taus new Center for Nursing Excellence in Long Term Care, and the Advancing Excellence in Americas Nursing Homes (www.nhqualitycampaign.org). The culture change movement (see Chapter 3) is an excit ing opportunity that is transforming our vision of tradi tional nursing homes from an institutional model to a person-centered culture. Continued research on new models of care delivery and the appropriate mix of all levels of nursing staff in subacute and long-term care units is needed to improve outcomes.

Certified Nursing Assistants and Nurse Aides Although it is important to promote professional nursing care for all elders, certified nursing assistants (CNAs) provide the majority of direct care in nursing homes and significantly contribute to the quality of life for nursing home residents. Critical shortages of CNAs exist now in both skilled care and home care, and these shortages will worsen in the future. Difficulty recruiting and retaining these long-term care workers continues to plague nursing homes, as turnover rates approach 100% (Carpenter & Thompson, 2008). Several recent studies have investigated the relationship of factors such as turnover, work satisfac tion, staffing, and power relations to quality of care and positive outcomes in nursing homes. Results support the importance of developing a culture of respect in which the work of CNAs is understood and valued at all levels of the organization. Research findings also indicate that the most influential factor in turnover among CNAs was the perception that they were not appreciated or valued by the organization (Bowers et al., 2003).

Results of several studies confirm the deep committment and passion that nursing assistants bring to their jobs as they struggle to find and maintain a balance between the task oriented needs of residents (e.g. bathing, toileting, feeding) and developing relationships and building community (Carpenter & Thompson, 2008, p. 31). The significance and importance of close personal relationships between nursing assistants and residents, often described as like family, is emerging as a central dimension of quality of care and

postive outcomes (Bowers et al., 2000, 2003; Carpenter & Thompson, 2008; Ersek et al., 2000; Fisher & Wallhagen, 2008; Sikma, 2006; Touhy et al., 2005). The commitment and dedication of nursing home staff must be honored and supported. They have much to teach us about aging, nursing, and caring.

One of the most important components of the culture change movement is the creation of models of care that value and honor the important work of nursing assistants. Culture change (see Chapter 3) must be equally con

cerned about the needs of residents and the well-being of staff (Thomas & Johnson, 2003). An organization that learns to give love, respect, dignity, tenderness, and toler ance to all members of the staff will soon find these same virtues being practiced by the staff (Thomas & Johnson, 2003, p. 3). Until health care professionals and society make a real commitment to providing adequate wages, individual supports (e.g., health insurance, education, career ladders), and an appreciation of their significant contribution to quality of nursing home care, these ne

glected workers cannot be expected to have the energy or incentive to extend themselves to the elders in their care (Kash et al., 2007).

Gerontological Nursing and

Gerontology Organizations

The Gerontological Society of America (GSA) demon strates the need for interdisciplinary collaboration in re search and practice. The divisions of Biological Sciences, Health Sciences, Behavioral and Social Sciences, Social Research, and Policy and Practice include individuals from myriad backgrounds and disciplines who affiliate with a section based on their particular function rather than their educational or professional credentials. Nurses can be found in all sections and occupy important positions as officers and committee chairs in the GSA.

This mingling of the disciplines based on practice in terests is also characteristic of the American Society on Aging (ASA). Other interdisciplinary organizations have joined forces to strengthen the field. The Association for Gerontology in Higher Education (AGHE) has part nered with the GSA, and the National Council on Aging (NCOA) is affiliated with the ASA. These organizations and others have encouraged the blending of ideas and functions, furthering our understanding of aging and of the integration necessary for optimal care. International gerontology associations, such as the International Fed eration on Aging and the International Association of Gerontology and Geriatrics, also have interdisciplinary membership and offer the opportunity to study aging internationally.

CHAPTER 2 Gerontological Nursing History, Education, and Roles 23

Organizations specific to gerontological nursing include the National Gerontological Nursing Association (NGNA), the Gerontological Advanced Practice Nurses Association (GAPNA), the National Association Directors of Nursing Administration in Long Term Care (NADONA/LTC) (also LPNs/LVNs as associate members), the American Association for Long-term Care Nursing (AALTCN), the American Assisted Living Nurses Association (AALNA), and the Canadian Gerontological Nursing Association (CGNA). The CGNA, founded in 1985, addresses the health needs of older Canadians and the nurses who care for them. In 2003, the CGNA formed an alliance with the NGNA to exchange information and share mutual goals and opportunities for the advancement of both groups (Mantle, 2005). In 2001, the Coalition of Geriatric Nursing Organizations (CGNO) was established to improve the health care of older adults across care settings. The CGNO represents more than 28,700 geriatric nurses from eight national organizations and is supported by the Hartford Institute for Geriatric Nursing and located at New York University College of Nursing (New York, NY).

An important organization for nursing assistants in nursing homes is the National Association of Geriatric Nursing Assistants (NAGNA). NAGNA was established in 1995 as a professional association of CNAs. The purpose of NAGNA is to ensure that the highest quality of care is provided to elders living in nursing homes, achieved by elevating the professional standing and performance of the caregivers. With a membership of more than 30,000 CNAs representing more than 500 nursing homes, the organization provides recognition for outstanding achieve ments, development training for CNAs, mentoring pro

grams to reduce CNA turnover, and advocacy for issues important to long-term care and CNAs.

Another organization, the National Clearinghouse on the Direct Care Workforce, supports efforts to improve the quality of jobs for frontline workers who assist people who are elderly and/or living with disabilities. This organization provides information and resources needed to effect change in industry practice, public policy, and public opinion. The clearinghouse is also working with the Paraprofessional Healthcare Institute to improve understanding for the direct care workforce crisis through research and analysis funded by the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services.

Implications for Gerontological Nursing and Healthy Aging

Nursing is a vital aspect of the health care of older people, and the practice of gerontological nursing provides a unique vantage point from which to make an impact on it.

Nurses attracted to this specialized field recognize that expertise in caring for older adults can make a significant difference in the quality of life of the persons served. In times of illness and rehabilitation and end-of-life care, outcomes for the older person most often depend on the nursing care received. Through research, gerontological nurses have made substantial contributions to the body of knowledge of best practices in the care of elders, and they are recognized as leaders in aging care.

Gerontological nurses have opportunities to provide care across the continuum of aging services, caring for ev eryone from the most ill and frail elders to those who are active and independent. As phrased by Mezey and Fulmer (2002), the commitment of gerontological nurses to tackle difficult but exceptionally meaningful issues that impact profoundly on the health and quality of life for older adults, the opportunities for decision making, independent action, innovation, and the significant contribution of ge riatric nursing research to improved patient outcomes and health policy position the specialty for continued growth, recognition, contribution and value to society (Mezey & Fulmer, 2002, p. 440). Gerontological nursing may be the most needed specialty in nursing, both now and in the future (Ebersole & Touhy, 2006).

KEY CONCEPTS

Certification assures the public of nurses commitment to specialized education and qualification for the care of older adults.

All students graduating from nursing programs and all practicing nurses working with older adults should have competency in gerontological nursing.

The major changes in health care delivery and the increasing numbers of older adults have resulted in numerous revised, refined, and emergent roles for nurses in the field of gerontological nursing. There is a critical shortage of competent and compassionate gerontological nurses.

Advanced practice registered nurses may have either nurse practitioner qualifications or clinical nurse specialist education or a combination of both.

Advanced practice role opportunities for nurses are numerous, offer more independence, are cost-effective, and facilitate more holistic health care and improved outcomes for patients.

ACTIVITIES AND DISCUSSION QUESTIONS 1. Identify factors that have influenced the progress of gerontological nursing as a specialty practice. 2. Consider and discuss with classmates the various ge rontological nursing roles that you find most interesting and stimulating.

24 SECTION 1 Foundations of Healthy Aging

3. Discuss the gerontological organizations of today and their significance to the practicing nurse.

4. Why do you think more students do not choose geron tological nursing as a specialty? What would increase interest in this area of nursing?

5. What do you think are the most important issues in gerontological nursing education at this time? 6. Discuss your clinical education experiences and reflect on how they have influenced your views about care of older people and gerontological nursing?

REFERENCES

American Association of Colleges of Nursing (AACN): The es sentials of baccalaureate education for professional nursing practice (2008). Available at http://www.aacn.nche.edu/education resources/baccessentials08.pdf.

American Health Care Association: U.S. long term care workforce at a glance (2010). Available at http://www.ahcancal.org/research_ data/staffing/Documents/WorkforceAtAGlance.pdf.

American Nurses Association: Scope and standards of geronto logical nursing practice, Silver Springs, MD, 2010, Nurses books.org.

Consensus model for APRN regulation: licensure, accreditation, certification and education. Completed through the work of the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee, July 7, 2008. Available at http://www.aacn.nche.edu/education

resources/APRNReport.pdf.

Bakerjian D: Care of nursing home residents by advanced practice nurses: a review of the literature, Res Gerontol Nurs 1:177, 2008.

Berman A, Mezey M, Kobayashi M, et al: Gerontological nursing content in baccalaureate programs: comparison of findings from 1997 and 2003, J Prof Nurs 21:268, 2005.

Boltz M, Capezuti E, Bower-Ferres S, et al: Changes in the geriatric care environment associated with NICHE (Nurses Improving Care for Health System Elders), Geriatr Nurs 29(3):176185, 2008.

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Bowers B, Esmond S, Jacobson N: Turnover reinterpreted: CNAs talk about why they leave, J Gerontol Nurs 29(3):3643, 2003.

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Kash B, Castle N, Phillips C: Nursing home spending, staffing and turnover, Health Care Manage Rev 32(3):253262, 2007. Kim H, Kovner C, Harrington C, et al: A panel data analysis of the relationships of nursing home staffing levels and standards of regulatory deficiencies, J Gerontol B Psychol Sci Soc Sci 64B:269, 2009 .

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CHAPTER 2 Gerontological Nursing History, Education, and Roles 25

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CHAPTER

Care Across the Continuum

L E A R N I N G O B J E C T I V E S

Upon completion of this chapter, the reader will be able to:

Theris A. Touhy

evolve.elsevier.com/Ebersole/gerontological

Compare the major features, advantages, and disadvantages of several residential options available to the older adult.

Identify interventions to improve care for older adults in acute and long-term care settings. Describe factors influencing the provision of long-term care including the culture change movement. Discuss interventions to improve transitions of care and outcomes for older adults moving between health care settings.

Discuss strategies to assist an older adult and their family in making an informed choice when relocation to a more protected setting becomes necessary.

G L O S S A R Y

Hospital-acquired events (HACs) Target conditions that are high cost or high volume, resulting in a higher payment when present as a secondary diagnosis in hospitalized patients, are not present on admission, and could have reasonably been prevented through use of evidence-based guidelines (e.g. catheter-associated urinary tract infections, pressure ulcers, falls).

Orthotist A person specially trained to measure, design, fabricate, fit, or service orthoses, and/or assists in the formulation of orthoses. An orthosis is a device that is intended to be fitted to a person to correct a disability, or to support the person who has a disability

Physiatrist Medical doctors who have completed training in the medical specialty of physical medicine and rehabilitation

Prosthetist A health care professional who is skilled in making and fitting artificial parts (prosthetics) for the human body

Transitional care The broad range of services and environments designed to promote the safe and timely passage of patients between levels of care and across care settings (Naylor & Keating, 2008, p. 65).

T H E L I V E D E X P E R I E N C E

This is my home. We are all like a family, and I will die here. The girls that help me during the day, we treat one another like family members. We have some days when we are grumpy, some days we are happy, and we dont hold our feelings back, like you would do with your own family at home.

An 85-year-old resident of a skilled nursing facility

We are their family now, and that is how we have to treat them. I think we do a pretty good job here because a lot of patients say when they leave and come back, Oh, I am so glad to be home. Our philosophy here is that we dont work at this facility, we are guests in these peoples home.

A 50-year-old director of nursing in a skilled nursing facility

mobile, youth-oriented society may find it diffi cult to fully comprehend the insecurity that el ders feel when moving from one site to another

in their later years. In addition to the stress of relocation and the initial anxiety of adapting to a new setting, elders typically move to ever more restrictive environments, often in times of crisis. This chapter discusses residential care options across the continuum and transitions between health care settings with related implications for nursing practice. Professional nursing roles in settings across the continuum where care is provided to older adults are dis

cussed in Chapter 2.

Elder-Friendly Communities

Home provides basic shelter, is a place to establish secu rity, and is the place where one belongs. It should provide the highest possible level of independence, function, safety, and comfort. Most older people prefer to remain in their own homes and age-in-place, rather than relocate to more protected settings, especially institutional living. Future generations of older people will be much more likely to want to remain living independently and seek opportunities to adapt homes and communities to meet their needs. The ability to age-in-place depends on appropriate support for changing needs so the older person can stay where he or she wants. Developing elder-friendly communities and

Addresses Basic Needs

Provides appropriate and

affordable housing

Promotes safety at home and

in the neighborhood

Ensures no one goes hungry

Provides useful information about

available services

CHAPTER 3 Care Across the Continuum 27

increasing opportunities to age-in-place can enhance the health and well-being of older people. Enabling the com munity to become the good neighbor to older citizens

provides mutual benefits to all who are involved. Components of an elder-friendly community include the following: (1) addresses basic needs; (2) optimizes physical health and well-being; (3) maximizes indepen dence for the frail and disabled; and (4) provides social and civic engagement. Figure 3-1 presents elements of an elder-friendly community. Many state and local govern ments are assessing the community and designing inter ventions to enhance the ability of older people to remain in their homes and familiar environments. These inter ventions range from adequate transportation systems to home modifications and universal design standards for barrier-free housing. Home design features such as 36-inch-wide doorways and hallways, a bathroom on the first floor, an entry with no steps, outlets at wheelchair level, and reinforced walls in bathrooms to support grab bars will become standard nationwide in the next 50 years (Robinson & Reinhard, 2009).

Advancements in all types of technology hold promise for improving quality of life, decreasing the need for per sonal care, and enhancing the ability to live safely at home and age-in-place (Daniel et al., 2009). Some emerging technologies to enhance safety and independent living for older adults are discussed in Chapter 13.

Promotes Social and Civic

Engagement

Fosters meaningful connections

with family, neighbors, and friends

Promotes active engagement

in community life

Provides opportunities for meaningful

paid and voluntary work

Makes aging issues a community-wide

priority

Optimizes Physical and Mental Health and Well-Being

Promotes healthy behaviors Supports community activities that enhance well-being Provides ready access to preventive health services Provides access to medical, social, and palliative services

An Elder-Friendly Community

Maximizes Independence for Frail and Disabled

Mobilizes resources to

facilitate living at home

Provides accessible transportation Supports family and other caregivers

FIGURE 3-1 Essential elements of an elder-friendly community. (From Advantage Initiative, Center for Home Care Policy and Research, Visiting Nurse Service of New York. Available at www.vnsny.org/advantage/.)

28 SECTION 1 Foundations of Healthy Aging

Among Asians, South Americans, and African Americans,

Residential Options In Later Life

Some older people, by choice or by need, move from one type of residence to another. A number of options exist, especially for those with the financial resources that allow them to have a choice. Residential options range along a continuum from remaining in ones own home; to senior retirement communities; to shared housing with family members, friends, or others; to residential care communi

ties such as assisted living settings; to nursing facilities for those with the most needs (Figure 3-2). There are many different models of senior housing, and older peo ple may seek assistance from nurses in choosing what kind of living situation will be best for them. It is impor tant to be aware of the various options available in your local community as well as the advantages, disadvantages, cost, and services provided in each option. When dis charging older people from the hospital or long-term care facility, knowledge of where they live or the type of setting to which they are being discharged will assist in providing appropriate resources and teaching so that outcomes can be enhanced for both the individual and his or her family.

Shared Housing

Shared housing among adult children and their older rela tives has become a choice for many because of cultural preferences or need. The sharing may relieve the economic burdens of maintaining a home after widowhood or retire ment on a fixed income. Historically, strong cultural influ ences predict the frequency of multigenerational residences.

Independence

it is often an expectation. Growth of multigenerational households has accelerated during the economic downturn among all cultures and races and this trend is expected to continue (Hooyman & Kiyak, 2011). Relocating from ones own home to the home of an adult child can have many benefits for both, but without adequate preparation it can also be stressful. Box 3-1 presents some factors to consider when planning to add an older person to the household.

A variation of multigenerational housing has long ex isted in what has become known as granny flats. These may be apartments added to existing homes or the con struction of small housing units on family property with privacy as well as sharing of time and resources. Such arrangements allow families to be close enough to be of assistance if needed but to remain separate. They are prac tical and economical, and their production has continually expanded, particularly in Australia. In the United States, use of this model is minimal, but existing mother-in-law cottages and apartments have served a similar purpose for many families for years.

Another model of shared housing is that of opening ones personal home to others. Older people often live in houses that were purchased in their young adult years and find that, as they age, much of the space may be underused. Sharing a house can be easily implemented by locating, screening, and matching older people looking for houses to share with those who have them. The National Shared Housing Resource Center (NSHRC) (http://www.nationalsharedhousing.org/) has established subgroups to assist individuals interested in home sharing. Those who have done so report feeling safer and less lonely.

Home ownership

Single-room occupation (SRO) Condominium ownership Apartment dwelling

Shared housing

Congregate lifestyles

Independence to

partial dependence

Retirement communities Public housing complexes Residence with family Foster homes

Board and care

Residential homes

Continuing care retirement communities (CCRCs)

Partial dependence

to complete dependence

Nursing facilities

Skilled nursing facilities

Acute care facilities

Inpatient hospice care facilities

Independence Dependence FIGURE 3-2 Continuum of residential options based on level of assistance needed.

CHAPTER 3 Care Across the Continuum 29

BOX 3-1 Planning to Add an Older Person to the Household

Questions You Should Ask: -143364-104648

What are the needs of the new member and of the family? Where will space be allotted for the new member? How will this new member be included in existing family patterns?

How will responsibilities be shared?

What resources in the community will assist in the adjustment phase?

Is the environment safe for this new member? How will family life change with the added member, and how does the family feel about it?

What are the differences in socialization and sleeping patterns?

What are the older personsstrong needs and expectations? What are the older persons skills and talents?

Modifications You Have to Make:

Arrange semiprivate living quarters if possible. Regularly schedule visits to other relatives to give each family respite and privacy.

Arrange adult day health programs and senior activities for the older person to help keep contact with members of his or her own generation. Consider how the older person will feel about giving up familiar surroundings and friends.

Discuss Potential Areas of Conflict:

Space: especially if someone has given up his or her space to the older relative.

Possessions: older people may want to move possessions into the house; others may not find them

Population-Specific Communities

As the number of senior communities expands, older adults will have more options of moving somewhere that they find especially welcoming. These options include communities that emphasize a particular sport, like tennis or golf. Groups of people can also come together to form intentional communities, buying a cluster of home tracts and building in such a way to support their particular lifestyles or needs or personalities. Still others provide unique additional services, such as those in communities that specialize in providing residences for persons with, for example, a mental illness, alcoholism, or developmen tal disabilities.

Lesbian, gay, bisexual, and transgender (LGBT) seniors face several problems in housing in their older years. They

attractive or may insist on replacing them with new things.

Entertaining: times when old and young feel the need or desire to exclude the other from social events.

Responsibilities and chores: the older person may feel useless if he or she does nothing and may feel in the way if he or she does something; the young may feel that their position is usurped or may be angry if they are expected to wait on the parent.

Expenses: increased cost of home maintenance, food, clothing, and recreation may not be shared appropriately. Vacations: whether to go together or alone; the young may feel uneasy not taking the older person out and resentful if they must.

Child rearing: disagreement over child-rearing policies. Child care: grandparental babysitting may be welcomed by family and resented by the older person; or if not allowed, the older person may feel a lack of trust in capability.

Decrease Areas of Conflict by the Following: Respecting privacy.

Discussing space allocations.

Discussing the elder persons furnishings before move. Making it clear in advance when social events include everyone or exclude someone.

Clearing decisions about household tasksall should have responsibility geared to ability.

Paying a share of expenses and maintaining a separate phone reduces strain and increases feelings of

independence.

may have little family support and may face discrimination in housing options. Many LGBT seniors say they do not feel welcome at traditional residential options. Those who want to live together are discouraged from doing so by some organizations. Residential facilities and communities designed specifically for LGBT seniors are increasing in number across the country. Nurses should be aware of this heretofore invisible group of older adults who need access to welcoming resources. Chapter 24 discusses issues spe cific to LGBT seniors in more depth.

Senior Retirement Communities

Communities designed for elders are proliferating. Numerous combinations of single-family homes, apartments, activities,

30 SECTION 1 Foundations of Healthy Aging

optional services, meals in the home, cafeterias, restaurants, housekeeping, and security are available. In some cases, emer gency services and health clinics are adjacent. These are all designed to make independent living feasible with the least effort on the part of the elder. Some senior communities are luxurious and have a wide range of physical and cultural ame nities; others are simpler, providing only the basic necessities. Prices are consistent with the level of luxury provided and the range of services available.

Although the costs of the majority of senior communi ties are borne by the consumers, for elders with limited incomes, federally subsidized rental options are available in some areas of the country. Older adults benefiting from this option are assisted through rental housing subsidized by the U.S. Department of Housing and Urban Develop ment (HUD). Although not all HUD housing is desig nated for senior living, Section 202 of the Housing Act, U.S. Department of Housing and Urban Development, approved the construction of low-rent units especially for older people. These units may also have provisions for health care, recreation, and transportation.

Community and Home Care

Nurses will care for older adults in hospitals and long term care, but the majority of older adults live in the com munity. Community-based care settings include home care services, independent senior housing, retirement communities, residential care facilities, adult day health programs, primary care clinics, and public health depart ments. The growth in home and community health care is expected to continue because older people prefer to age in place. Other factors influencing the growth of home based care include rapidly escalating health care costs. Chapter 2 discusses roles for nurses in home and com munity care.

An innovative long standing community-based pro gram is Program for All-Inclusive Care for the Elderly (PACE). PACE is an alternative to nursing home care for frail older people who want to live independently in the community with a high quality of life. It provides a com prehensive continuum of primary care, acute care, home care, nursing home care, and specialty care by an interdis ciplinary team. PACE is a capitated system in which the team is provided with a monthly sum to provide all care to the enrollees, including medications, eyeglasses, and trans portation to care as well as urgent and preventive care. Participants must meet the criteria for nursing home ad mission, prefer to remain in the community, and be eligible for Medicare and Medicaid. Adult day services are also provided.

PACE is now recognized as a permanent provider un der Medicare and a state option under Medicaid. PACE has been approved by the U.S. Department of Health and Human Services (USDHHS) as an evidence-based model of care. Models such as PACE are innovative care delivery models, and continued development of such models are important as the population ages. More information about PACE models and outcomes of care can be found at http://www.npaonline.org/website/article.asp?id512.

Adult Day Services

Adult day services (ADS) are community-based group programs designed to provide social and some health ser vices to adults who need supervised care in a safe setting during the day. They also offer caregivers respite from the responsibilities of caregiving, and most provide educa tional programs for caregivers and support groups. The most recent nationwide survey of adult day centers con firmed that there are over 4600 adult day services centers in the United States providing care for 150,000 care re cipients each daya 35% increase since 2002. Adult day centers are serving populations with higher levels of physical disability and chronic disease, and the number of older people receiving adult day services has increased 63% over the last 8 years (National Adult Day Services Association, Ohio State University College of Social

Work, MetLife Mature Market Institute, 2010). Adult day services are an important part of the long term care continuum and a cost-effective alternative or supplement to home care or institutional care. ADS are increasingly being utilized to provide community-based care for conditions like Alzheimers disease and for transitional care and short-term rehabilitation following hospitalization. Local Area Agencies on Aging are good sources of informa tion about adult day services and other community-based options.

Residential Care Facilities

Residential care facility (RCF) is the broad term for a range of nonmedical, community-based residential settings that house two or more unrelated adults and provide services such as meals, medication supervision or reminders, activi

ties, transportation, or assistance with activities of daily living (ADLs). RCFs are known by more than 30 different names across the country, including adult congregate

facilities, foster care homes, personal care homes, homes for the elderly, domiciliary care homes, board and care homes, rest homes, family care homes, retirement homes, and assisted living facilities.

RCFs are the fastest growing housing option available for older adults in the United States. This kind of facility is viewed as more cost effective than nursing homes while providing more privacy and a homelike environment. Medicare does not cover the cost of care in these types of facilities. In some states, costs may be covered by private and long-term care insurance and some other types of as

sistance programs. Residential care payment is primarily private pay, although 41 states currently have a Medicaid Waiver/Medicaid State Plan for a limited amount of eligible individuals. The use of Medicaid financing for services in RCFs has gradually increased in recent years. The rates charged and what services those rates include vary considerably, as do regulations and licensing.

Assisted Living

A popular type of residential care can be found in assisted living facilities (ALFs), also called board and care homes or adult congregate living facilities (ACLFs). Assisted living is a residential long-term care choice for older adults who need more than an independent living environment but do not need the 24 hours/day skilled nursing care and the constant monitoring of a skilled nursing facility. The typi

cal ALF resident is an 86-year-old woman who is mobile but needs assistance with two ADLs (Box 3-2). Assisted living settings may be a shared room or a single-occupancy unit with a private bath, kitchenette, and communal meals. They all provide some support services.

Assisted living is more expensive than independent living and less costly than skilled nursing home care, but it is not inexpensive. There are 31,110 ALFs in the United States and most are private, for-profit facilities. Costs vary by geographical region, size of the unit, and relative luxury. The national average base rate for an

CHAPTER 3 Care Across the Continuum 31

ALF (single room and board and limited other services) is $3300 monthly (AssistedLivingFacilities.org, 2012). Most ALFs offer two or three meals per day, light weekly housekeeping, and laundry services, as well as optional social activities. Each added service increases the cost of the setting but allows for individuals with resources to remain in the setting longer, as functional abilities decline.

Many seniors and their families prefer ALFs to nurs ing homes because they cost less, are more homelike, and offer more opportunities for control, independence, and privacy. However, many residents of ALFs have chronic care needs and over time may require more care than the facility is able to provide. Services (e.g., home health, hospice, homemakers) can be brought into the facility, but some question whether this adequately substitutes for 24-hour supervision by registered nurses (RNs). Not every ALF has an RN or licensed practicalvocational nurse (LPN/LVN), and, in most states, any skilled nursing pro

vided by the staff other than nurse-delegated assistance with self-administered medication is prohibited. In the ALF, there is no organized team of providers such as that found in nursing homes (i.e., nurses, social workers, reha

bilitation therapists, pharmacists).

With the growing number of older adults with demen tia residing in ALFs, many are establishing dementia specific units. It is important to investigate services avail able as well as staff training when making decisions as

to the most appropriate placement for older adults with dementia. Continued research is needed on best care practices as well as outcomes of care for people with de mentia in both ALFs and nursing homes. The Alzheimers Association has issued a set of dementia care practices for ALFs and nursing homes (Alzheimers Association, 2009)

BOX 3-2 Profile of a Resident in an Assisted Living Facility

86.9 years old -150311-108090

Female (74%)

70% moved to the ALF from a private home or apartment Needs help with at least two activities of daily living (ADLs)

Bathing: 64%

Dressing: 39%

Toileting: 26%

Transferring: 19%

Eating: 12%

Needs help with instrumental activities of daily living (IADLs)

Meal preparation: 87%

Medications: 81%

42% have Alzheimers disease or other dementia types of diagnosis

Length of stay: 28.3 months

59% move to a nursing facility

33% die while a resident

Data from National Center for Assisted Living: Resident profile (2010). Available at http://www.ahcancal.org/ncal/resources/Pages/ResidentProfile.aspx.

32 SECTION 1 Foundations of Healthy Aging

and an evidence-based guideline, Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes is also available (Tilly & Reed, 2006) (see also www. guideline.gov).

The Joint Commission and the Commission for Accreditation of Rehabilitation Facilities have published standards for accreditation of ALFs, but many are advocat ing for more comprehensive federal and state standards and regulations. Appropriate standards of care must be developed and care outcomes monitored to ensure that residents are receiving quality care in this setting, which is almost devoid of professional nursing. Further research is needed on care outcomes of residents in ALFs and the role of unlicensed assistive personnel, as well as RNs, in these facilities.

The American Assisted Living Nurses Association has established a certification mechanism for nurses working in these facilities and has also developed a Scope and Standards of Assisted Living Nursing Practice for Registered Nurses (www.alnursing.org). Advanced practice geronto

logical nurses are well suited to the role of primary care provider in ALFs, and many have assumed this role. Con sumers are advised to inquire as to exactly what services will be provided and by whom if an ALF resident becomes more frail and needs more intensive care. The Assisted Living Federation of America provides a consumer guide for choosing an assisted living residence (http://www.alfa. o r g / i m a g e s / a l f a / P D F s / g e t f i l e . c f m _ p r o d u c t _ id594&file5ALFAchecklist.pdf).

Continuing Care Retirement Communities

Continuing care retirement communities (CCRCs), also known as life care communities, provide the full range of residential options, from single-family homes to skilled nursing facilities all in one location. Most of these com

munities provide access to these levels of care for a com munity members entire remaining lifetime, and for the right price, the range of services may be guaranteed. Having all levels of care in one location allows community members to make the transition between levels without life-disrupting moves. For married couples in which one spouse needs more care than the other, life care communi ties allow them to live nearby in a different part of the same community. This industry is maturing, and there are 1900 CCRCs in the United States, housing more than 745,000 older adults (Leading Age, 2011).

Most CCRCs are managed by not-for-profit organiza tions. They usually charge an entry fee ranging from $60,000 to $120,000 that covers and reflects the cost of the residence in which the member will live, the possible future care needed, and the quality and quantity of the

community services. The average monthly cost of living in a not-for-profit CCRC is $2,672. Important to remember about these types of communities is that the residence purchased usually belongs to the community after the death of the owner.

Acute Care

Older adults often enter the health care system with admis sions to acute care settings. Older adults comprise 60% of medical-surgical patients and 46% of critical care patients (Mezey et al., 2007). Acutely ill older adults frequently have multiple chronic conditions and comorbidities and present many care challenges. Hospitals are dangerous places for elders: 34% experience functional decline, and iatrogenic complications occur in as many as 29% to 38%, a rate three to five times higher than in younger patients (Inouye et al., 2000; Kleinpell, 2007). Common iatrogenic complications include functional decline, pneumonia, delirium, new-onset incontinence, urinary tract infections (UTIs), malnutrition, pressure ulcers, medication reactions, and fallsmany of the geriatric syndromes. Geriatric syndromes are groups of specific signs and symptoms that occur more often in older adults and can impact morbidity and mortality. Nor

mal aging changes, multiple comorbidities, and adverse effects of therapeutic interventions contribute to the devel opment of geriatric syndromes. These syndromes are dis cussed in Chapters 7, 9 to 13, and 21. Nursing roles in acute care and model programs to improve care are discussed in Chapter 2.

Recognizing the impact of iatrogenesis, both on patient outcomes and cost of care, the Centers for Medicare and Medicaid Services (CMS) has instituted changes to the inpatient prospective payment system that will reduce pay

ment to hospitals relative to poor care. The changes target conditions (hospital-acquired events (HACs) that are high cost or high volume, result in a higher payment when present as a secondary diagnosis, are not present on admission, and could have reasonably been prevented through the use of evidence-based guidelines. Targeted conditions include catheter-associated UTIs, pressure ulcers, and falls. Use of evidence-based nursing protocols, particularly for these geriatric syndromes, thorough assessment, prevention, and monitoring of treatment responses, and accurate docu mentation is essential.

Nursing Homes (Long-Term Care Facilities)

There are approximately 16,100 certified nursing homes in the United States, and more than 1.4 million older adults

reside in nursing homes. The majority of nursing homes are for-profit organizations (67%), and nursing home chains own 54% of all nursing homes (Leading Age, 2011). The number of nursing home beds is decreasing in the United States and the number of Medicaid-only beds has decreased by half since 1995 (Gleckman, 2009). This is most likely a result of the increased use of RCFs and more reimbursement by Medicaid programs for community-based care alternatives.

However, skilled nursing facilities are the most fre quent site of postacute care in the United States, treating 50% of all Medicare beneficiaries requiring postacute care following hospitalization (Alliance for Quality Nursing Home Care and the American Health Care Association, 2011). With the increasing number of older people, pro jections are that there will be a threefold increase in the number who will need care in this setting by 2030. Al though the percentage of older people living long-term in nursing homes at any given time is low (4% to 5%), people who reach age 65 will likely have a 40% chance of entering a nursing home and those who live to age 85 will have a 1 in 2 chance of spending some time in this setting (Medi care.gov, 2012). This could be for subacute care, ongoing long-term care, or end-of-life care. Chapter 2 discusses the changing nature of skilled nursing facilities and roles for professional nurses in more depth.

People who are cared for in subacute units, as well as long-term units of nursing facilities, require access to re habilitation and restorative care services that maintain or improve their function and prevent excess disability. These services are required under federal and state regulations and are integral to quality indicators in nursing facilities. Restorative nursing programs for ADLs (e.g., toileting, range of motion, ambulation, and feeding) contribute to restoration and maintenance of function for nursing facil ity residents who may have been discharged from skilled therapy services or who are not eligible for Medicare

BOX 3-3 Members of the Rehabilitation Care Team

Rehabilitation nurse specialist -150311-108090

Physical therapist

Occupational therapist

Speech therapist

Social worker

Discharge planner

Psychologist

Prosthetist and orthotist

CHAPTER 3 Care Across the Continuum 33

reimbursement for rehabilitation services by physical, oc cupational, or speech therapists. Both rehabilitation and restorative programs require comprehensive multidisci plinary assessment and involvement of the patient and family in development of a plan of care with short and long-term goals (Box 3-3). Rehabilitation and restorative care is increasingly important in light of shortened hospi tal stays that may occur before conditions are stabilized and the older adult is not ready to function independently.

Costs of Care

Costs for nursing homes vary by geographical location, ownership, and amenities, but the average annual cost for a semiprivate room is $215 per day or $78,475 annually. Nursing home rates have increased more than 10% since 2008 and nearly 50% since 2004. The majority of the cost of care in nursing homes is borne by Medicaid (42%), fol

lowed by Medicare (25%), out of pocket (22%), and private insurance and other sources (11%) (Prudential Insurance Company of America, 2010). Medicare covers 100% of the costs for the first 20 days if the individual requires skilled care services. Beginning on day 21 of the nursing home stay, there is a significant co-payment. This co-payment may be covered by a Medigap policy. After 100 days, the individual is responsible for all costs. For a nursing home stay to be covered by Medicare, you must enter a Medi care-approved skilled nursing facility or nursing home within 30 days of a hospital stay that lasted at least 3 days (Medicare.gov, 2012). Complex medical treatments (e.g., feeding tube, tracheostomy, intravenous [IV] therapy) and rehabilitation services such as occupational therapy (OT), physical therapy (PT), or speech therapy (ST), are consid

ered skilled care.

Medicare does not cover the costs of care in chronic, custodial, and long-term units. If the older person was ad mitted to the nursing home because of a dementia diagnosis

Physiatrist

Chaplain

Dietitian

Audiologist

Physician, nurse practitioner

Vocational rehabilitation specialist

Person in rehabilitation

Persons significant others

34 SECTION 1 Foundations of Healthy Aging

and the need for assistance with ADLs and maintenance of safety, Medicare would not cover the cost of care unless there was some skilled need. Medicare does provide cover age for hospice care services in nursing homes with some exceptions (room charges) provided eligibility requirements are met.

Concern is growing nationwide about the financing of long-term care and the ability of the states and the federal government to continue to support costs through the Medicaid programs. The reimbursement levels of both Medicare and Medicaid do not cover actual costs, and there is fear that if further cuts are made, quality of care will be more drastically compromised. The increasing bur

den on Medicaid is unsustainable. The purchase of long term care insurance is an option, but it is expensive and pays for less than 5% of long-term care costs. Health care coverage for people with long-term care needs is a major national issue that demands attention.

Quality of Care

Nursing homes are one of the most highly regulated in dustries in the United States. The Omnibus Reconciliation Act (OBRA) of 1987, and the frequent revisions and up dates, are designed to improve the quality of resident care and have had a positive impact. Some of the requirements of OBRA and subsequent legislation include the follow ing: comprehensive resident assessments (Minimum Data Set [MDS]), increased training requirements for nursing assistants, elimination of the use of medications and re straints for the purpose of discipline or convenience, higher staffing requirements for nursing and social work staff, standards for nursing home administrators, and qual ity assurance activities.

Both the federal and state governments describe the standards that nursing facilities must meet to comply with the law and qualify for reimbursement. Quality trends are monitored and available to the public (https://www.cms.gov/

MDSPubQIandResRep/01_Overview.asp#TopOfPage). Nursing homes were the first to publish online quality infor mation, which is now available for hospitals and other health care organizations. Findings from the recent report on care quality in nursing and rehabilitation facilities reported that since 2009, nursing facilities have made measurable improvements in 9 out of 10 quality measures (Leading Age, 2011).

Although nursing homes recognize the need to ensure quality and have responded to improvement initiatives, the lack of additional funding for legislated initiatives has left many nursing homes struggling to maintain quality and meet standards with few resources. Care of the frail elderly

and seriously ill persons is labor-intensive, costly, and re quires specialized knowledge. Reasonable workloads, en hanced education and training, and adequate reimburse ment are essential. Oversight has too often been conducted

in a punitive fashion rather than a collaborative effort to enhance outcomes similar to that which is seen in other health care institutions.

The Five-Star Quality Rating system for nursing homes, established by the CMS, was created to help con sumers, their families, and caregivers to compare nursing homes (www.medicare.gov/NHCompare). This rating sys tem is based on the nursing homes most recent health inspection, staffing, and quality measures. The CMS ad vises consumers to use additional sources of information because the Five Star rating system should not substitute for visiting nursing homes since it is a snap shot of the care in individual nursing homes.

The most appropriate method of choosing a nursing home is to personally visit the facility, meet with the director of nursing, observe care routines, discuss the potential residents needs, and use a format such as the one presented in Box 3-4

to ask questions. The CMS provides a nursing home checklist on their website, and the National Citizens Coalition for Nursing Home Reform also provides resources for choosing a nursing home (http://www.theconsumervoice.org/resident/

nursinghomes/fact-sheets). Nurse researchers Marilyn Rantz and Mary Zywgart-Stauffacher published a book, How to Find the Best Eldercare, based on their research.

Regulations have also been created to protect the rights of the residents of nursing homes. Residents in long-term care facilities have rights under both federal and state law. The staff of the facility must inform residents of these rights and protect and promote their rights. The rights to which the residents are entitled should be conspicuously posted in the facility (Box 3-5). Also, the Long-Term Care Ombudsman Program is a nationwide effort to support the rights of both the residents and the facilities. In most states, the program provides trained volunteers to investi gate rights and quality complaints or conflicts. All report

ing is anonymous. Each facility is required to post the name and contact information of the ombudsman assigned to the facility.

The Culture Change Movement

Across the United States, the movement to transform nurs ing homes from the typical medical model into homes that nurture quality of life for older people and support and em power frontline caregivers is changing the face of long-term care. Begun by the Pioneer Network, a national not-for profit organization that serves the culture change movement,

BOX 3-4 Selecting a Nursing Home

Central Focus

Residents and families are the central focus of the facility

Interaction

Staff members are attentive and caring

Staff members listen to what residents say

Staff members and residents smile at one another Prompt response to resident and family needs Meaningful activities provided on all shifts to meet individual preferences

Residents engage in activities with enjoyment Staff members talk to cognitively impaired residents; cognitively impaired residents involved in activities designed to meet their needs

Staff members do not talk down to residents, talk as if they are not present, ignore yelling or calling out Families are involved in care decisions and daily life in facility

Milieu

Calm, active, friendly

Presence ofcommunity,volunteers,children, plants, animals

Environment

No odor, clean and well maintained

Rooms personalized

Private areas

ADLs, Activities of daily living; RNs, registered nurses.

CHAPTER 3 Care Across the Continuum 35

Protected outside areas -2893511-108090

Equipment in good repair

Individualized Care

Restorative programs for ambulation, ADLs

Residents well dressed and groomed

Resident and family councils

Pleasant mealtimes, good food, residents have choices Adequate staff to serve meals and assist residents Flexible meal schedules, food available 24 hours per day Ethnic food preferences

Staff

Well trained, have high level of professional skill Professional in appearance and demeanor

RNs involved in care decisions and care delivery Active staff development programs

Physicians and advanced practice nurses involved in care planning and staff training

Adequate staff (more than the minimum required) on each shift

Low staff turnover

Safety

Safe walking areas indoors and outdoors

Monitoring of residents at risk for injury

Restraint-appropriate care, adequate safety equipment and training on its use

Adapted from Rantz MJ, Mehr DR, Popejoy L, et al: Nursing home care quality: a multidimensional theoretical model, J Nurs Care Qual 12(3):30-46, 1998.BOX 3-5 Bill of Rights for Long-Term Care Residents

The right to voice grievances and have them remedied The right to information about health conditions and treatments and to participate in ones own care to the extent possible

The right to choose ones own health care providers and to speak privately with ones health care providers The right to consent to or refuse all aspects of care and treatments

The right to manage ones own finances if capable, or to choose ones own financial advisor

The right to be transferred or discharged only for appro priate reasons

The right to be free from all forms of abuse The right to be free from all forms of restraint to the extent compatible with safety -2893510-108091

The right to privacy and confidentiality concerning ones person, personal information, and medical information The right to be treated with dignity, consideration, and respect in keeping with ones individuality

The right to immediate visitation and access at any time for family, health care providers, and legal advisors; the right to reasonable visitation and access for others

Note: This list of rights is a sampling of federal and several states lists of rights of residents or participants in long-term care. Nurses should check the rules of their own state for specific rights in law for that state.

36 SECTION 1 Foundations of Healthy Aging

many facilities are changing from a rigid institutional approach to one that is person-centered (http://www. pioneernetwork.net/). Culture change is the process of mov ing from a traditional nursing home modelcharacterized as a system unintentionally designed to foster dependence by keeping residents, as one observer put it, well cared for, safe, and powerlessto a regenerative model that increases residents autonomy and sense of control (Brawley, 2007, p. 9).

Older people in need of long-term care want to live in a homelike setting that does not look and function like a hospital. They want a setting that allows them to make decisions they are used to making for themselves, such as when to get up, take a bath, eat, or go to bed. They want caregivers who know them and understand and respect their individuality and their preferences. No matter how old, how sick, how disabled, how forgetful we are, each of us deserves to have a homenot an institution (Baker, 2007; Baker as cited by Haglund, 2008, p. 8). Box 3-6 presents some of the differences between an institution

centered culture and a person-centered culture. Although further research is needed, some results sug gest that person-centered care is associated with improved organizational performance, including higher resident and staff satisfaction, better workforce performance, and higher occupancy rates. Examples of philosophies and programs of culture change are the Eden Alternative (www.edenalt.com) founded by Dr. Bill Thomas, the

BOX 3-6 Changing the Culture in Nursing Homes

Institution-Centered Culture -144253-104648

Schedules and routines are designed by the institution and staff, and residents must comply.

Focus is on tasks to be accomplished.

Rotation of staff from unit to unit occurs.

Decision making is centralized with little involvement of staff or residents and famlies.

There is a hospital environment.

Structured activities are provided to all residents. There is little opportunity for socialization.

Organization exists for employees rather than residents. There is little respect for privacy or individual routines.

Person-Centered Culture

Emphasis is on relationships between staff and residents.

From The Pioneer Network. Available at www.pioneernetwork.net.

Green House Project (www.thegreenhouseproject.org), and the Wellspring Model developed by Wellspring Innovative Solutions in Seymour, Wisconsin (http://

www.innovations.ahrq.gov/content.aspx?id5259). The Eden Alternative is best known for the addition of animals, plants, and children to nursing homes. However, cats and dogs are not the heart of culture change. Truly transforming a nursing home starts at the top and requires involvement of all levels of staff and changes in values, at titudes, structures, and management practices. Some of the principles of culture change activities are as follows: Staff empowerment

Resident involvement in decision making Individualized rather than routine task-oriented care Relationship building

A sense of community and belonging

Meaningful activities

A homelike environment

Increased attention to respect of staff and the value of caring

Culture change has moved from a grassroots movement to one supported by policy makers, providers, national and state associations, and CMS. The CMS has endorsed cul ture change and has also released a self-study tool for nurs ing homes to assess their own progress toward culture change. The Affordable Care Act includes a national dem onstration project on culture change to develop best prac tices and the development of resources and funding to

Individualized plans of care are based on residents needs, usual patterns, and desires.

Staff members have consistent assignments and know the residents preferences and uniqueness.

Decision making is as close to the resident as possible. Staff members are involved in decisions and plans of care.

Environment is homelike.

Meaningful activities and opportunities for socialization are available around the clock.

There is a sense of community and belonging like family.

There is involvement of the communitychildren, pets, plants, outings.

undertake culture change. The culture change movement is growing rapidly, and ongoing research is needed to demon strate costs, benefits, and outcomes (Rahman & Schnelle, 2008; White-Chu et al., 2009).

Improving Transitions Across the Continuum of Care

Care transition refers to the movement of patients from one health care practitioner or setting to another as their condi tion and care needs change. Older people have complex health care needs and often require care in multiple settings across the continuum. An older person may be treated by a family practitioner in the community, hospitalized and treated by a hospitalist, discharged to a nursing home and followed by another practitioner, and then discharged home or to a less care-intensive setting (e.g., ALF) where the pri mary care provider may or may not continue to follow him or her. Most health care providers practice in only one setting and are not familiar with the specific requirements of other settings. Many factors contribute to gaps in care during critical transitions including poor communication, incom plete transfer of information, inadequate education of older adults and their family members, medication errors, limited access to essential services, and the absence of a single point person to ensure continuity of care (Naylor & Keating, 2008, p. 65). Language and health literacy issues and cultural dif

ferences exacerbate the problem (Corbett et al., 2010). Transitions happen often, and there is increasing evi dence that serious deficiencies exist for older patients under going transitions across sites of care. Approximately one fifth of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days, and 34% were rehospi talized within 90 days of hospital discharge. Of these rehos pitalizations, about 10% were planned. Estimated costs to Medicare for unplanned hospitalizations is $17.4 billion (Jencks et al., 2009). Additionally, 1 in 4 Medicare patients

SAFETY ALERT

Medication discrepancies are the most prevalent adverse event following hospital discharge and the most challenging component of a successful hospital-to-home transition. Nurses attention to an accurate prehospital medication list, medication reconciliation during hospitalization and at dis charge, identification of high-risk medications, and patient and family education about medications is required to enhance safety.

CHAPTER 3 Care Across the Continuum 37

admitted to skilled nursing facilities from hospitals is re admitted to the hospital within 30 days. Up to two thirds of hospital transfers are rated as potentially avoidable by expert long-term care health professionals (see http://interact2.net/). These rehospitalizations are costly, potentially harmful, and often preventable.

Transitions during the course of hospitalization can also be problematic for older patients. Minimizing the number of transfers from unit to unit during a single hos pitalization is associated with more consistent nursing care, fewer adverse incidents (e.g., nosocomial infections, falls, delirium, medication errors), shorter hospital stays, and lower overall costs (Kanak et al., 2008).

Individuals at high risk for transitional care problems include older people with multiple medical conditions or depression or other mental health disorders, isolated elders without family or friends, non-English speakers, recent immigrants, and low-income individuals (Graham et al., 2009). Compared to other groups of older adults, ethnically and racially diverse elders have slower rates of recovery after hospitalization and increased incidence of potentially pre

ventable rehospitalizations (Graham et al., 2009). Heart failure is the most frequent reason for rehospitalization, and patients with heart failure experience a 27% rate of readmission within 30 days of a hospital discharge (Hines

et al., 2010).

Improving Transitional Care

Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of care and across care settings (Naylor & Keating, 2008, p. 65). National attention to improving patient safety during transfers is increasing, and a growing body of evidence-based research provides data for design of care to improve transition out

comes. Nurses play a very important role in ensuring the adequacy of transitional care, and many of the successful models involve the use of advanced practice nurses and registered nurses in roles such as transition coaches and care managers (Coleman et al., 2006; Chalmers & Coleman, 2008; Naylor et al., 2009).

Nurse researcher Mary Naylor has significantly con tributed to knowledge in the area of transitional care. The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults (Bixby & Naylor, 2009) can be found at http://consultgerirn.org/ uploads/File/trythis/try_this_26.pdf. In a study by Hain et al. (2012), skilled nursing facilities had the highest rehospitalization rates followed by home with home health care, areas in which nursing had a strong presence. Nurses

38 SECTION 1 Foundations of Healthy Aging

play an important role in the development of interventions aimed at reducing rehospitalization (p. 32). In addition to roles as care managers and transition coaches, nurses play a key role in many of the elements of successful transi

tional care models, such as medication management, family caregiver education, comprehensive discharge plan ning, and adequate and timely communication between providers and sites of service (Box 3-7).

Further research is needed to evaluate what transitional care models are most effective in various settings and for which group of patients. Particularly important is research on transitions from nursing home to hospital, racial and cultural disparities in transitional care, and ways to im

prove family caregiver preparation and involvement during transitions. The Family Caregiver Alliance provides a hos pital discharge planning guide for families and caregivers (www.caregiver.org). Other transitional care resources can be found at http://interact2.net/care.html, http://www.

caretransitions.org/, and www.ahrq.gov/qual/pips. The CMS and The Joint Commission (TJC) have also increased efforts to promote better outcomes, patient safety, and effective care by requiring hospitals to collect data on the core measures and other quality indicators. The CMS posts 30-day, all cause, risk-adjusted readmission rates on its website for heart failure, acute myocardial infarction, and pneumonia. Participating hospitals are classified as better than U.S. national rate; no different than U.S. national rate; or worse than U.S. national rate (see www.hospitalcompare. gov). Medicare is also implementing initiatives to reduce

the amount of improper payments to providers as a result of medically unnecessary care (Hines et al., 2010). A major goal of the Patient Protection and Affordable Care Act (PPACA) is improving care coordination and out comes for individuals with multiple comorbid conditions who require high-cost care. The health care reform law cre ates several programs based on promising models that in clude the following: the Medicare Community-Based Care Transitions Program; the Medicare Independence at Home demonstration; bonus payments for Medicare Advantage plans with care management programs; Medical (Health) Home models in Medicare and Medicaid; and Community Health Teams to support the Medical (Health) Homes. Many of these new initiatives include nurse practitioners and offer opportunities for new roles for registered nurses with preparation in care of older adults as well. The American Nurses Association provides information on key provisions related to nursing in health care reform (http://www. nursingworld.org/MainMenuCategories/Policy-Advocacy/ HealthSystemReform).

Relocation

For many older adults, relocation is a major stressor and often a crisis for the older person and his or her family. Relocation to a long-term care facility is identified as one of the most stressful and one that many older people fear. With each move, if the adaptation is to be satisfying, one must begin to claim personal space by somehow placing

BOX 3-7 Suggested Elements of Transitional Care Models

Utilize interdisciplinary teams guided by evidence-based protocols -295852-108089

Comprehensive geriatric assessments

Performance measures and evaluation

Use information systems such as electronic medical records that span traditional settings

Target high-risk patients

Improve communication between patients, family caregivers, and providers

Improve communication between sending and receiving clinicians

Well-designed and structured patient transfer records Simplify posthospital medication regimen; identifying high-risk medications

Reconcile patients prehospitalization and posthospitalization medication lists

Improve patient/family knowledge of medications prior to discharge

Educational materials adapted for language and health literacy

Schedule follow-up care appointments prior to discharge

Discuss warning signs that require reporting and medi cal evaluation

Follow up discharge with home visits/telephone calls Care coordination by advanced nurse practitioners Assessment of informal support

Involvement, education, and support of family caregivers Knowledge of community resources and appropriate referrals to resources and financial assistance Enhance discussions of palliative and end-of-life care and communication of advance directives

ones stamp of individuality on the new surroundings. Because the older adult is particularly likely to move or be moved, the subject of relocation is significant. Nurses in hospitals, the community, and long-term care institutions frequently care for elders experiencing relocation.

The first issue to address in any move is whether it is necessary and whether it will provide the least restrictive lifestyle appropriate for the individual. Questions that must be asked to assess the impact on the individual after a move are presented in Box 3-8. Nurses concerns are with assessing the impact of relocation and determining meth

ods to mitigate any negative reactions.

Relocation stress syndrome is a nursing diagnosis de scribing the confusion resulting from a move to a new environment. Characteristics of relocation stress syndrome include anxiety, insecurity, altered mental status, depres sion, insecurity, loss of control, and physical problems. An abrupt and poorly prepared transfer actually increases ill ness and disorientation. Research suggests that individuals are better able to meet the challenges of relocation if they have a sense of control over the circumstances and the confidence to carry out the needed activities associated with a move.

To avoid some of the effects of relocation stress syn drome, the individual must have some control over the environment, preparation regarding the new situation, and maintenance of familiar situations to the greatest degree possible. Nurses must carefully assess and monitor older people for relocation stress syndrome effects. Working with families to help them plan relocations, understanding the effects of relocation, and implementing effective ap proaches are also necessary. It is important that some

BOX 3-8 Assessment of Relocation

Are significant persons as accessible in the new location as they were before the move? -292996-108089

Is the individual developing new and reciprocal relation ships in the new setting?

Is the individual functioning as well, better, or not as well in the new location? This determination cannot be made immediately, but this assessment must be done within at most 6 weeks of the move.

Was the individual given options before the move? Was the individual given the opportunity to assess the new environment before making a decision to move? Has the individual been able to move important items of furniture and memorabilia to the new setting?

CHAPTER 3 Care Across the Continuum 39

familiar and some treasured items accompany the transfer. Too often, elders arrive at long-term care institutions via ambulance stretcher from the hospital with nothing but a hospital gown. Everything familiar and necessary in their lives remains at the home they have left when they became ill.

Even more distressing is when families or responsible parties sell the home to finance long-term care stays with out the input of the elder. It is no wonder so many resi dents with dementia in nursing homes wander the hall ways looking for home and for something familiar and comforting. Family members will need considerable sup port when an elder is moved into an institution. No matter what the circumstances, the family invariably feels that they have in some way failed the elder (see Chapter 24). A summary of relocation stress syndrome and nursing actions to prevent relocation stress during transition to long-term care are presented in Box 3-9.

Implications for Gerontological Nursing and Healthy Aging

Nurses in all practice settings play a key role in improving care for older people across the continuum. New roles for nursing are emerging in the era of health care reform and heightened attention to improved patient outcomes. Most nurses work in only one setting and are not familiar with the requirements of other settings or the needs of patients in those settings. As a result, there are often significant misunderstandings and criticisms of care in the different settings across the continuum. As Barbara Resnick pointed out: We can stop the finger pointing and start working

Has a particular individual who is familiar with the environment been available to assist with orientation? Was the decision to move made hastily or with inadequate information?

Does the new situation provide adequately for basic needs (food, shelter, physical maintenance)?

Are individual idiosyncratic needs recognized, and is there an opportunity to actualize them?

Does the new situation decrease the possibility of privacy and autonomy?

Is the new living situation an improvement over the previous situation, similar in quality, or worse?

40 SECTION 1 Foundations of Healthy Aging BOX 3-9 Relocation Stress Syndrome-29191607694

Relocation stress syndrome is a physiological and/or psycho social disturbance as a result of transfer from one environ ment to another.

Defining Characteristics

Major

Change in environment or location

Anxiety

Apprehension

Increased confusion

Depression

Loneliness

Minor

Verbalization of unwillingness to relocate

Sleep disturbance

Change in eating habits

Dependency

Gastrointestinal disturbances

Increased verbalization of needs

Insecurity

Lack of trust

Restlessness

Sad affect

Unfavorable comparison of posttransfer and pretransfer staff Verbalization of being concerned or upset about transfer Vigilance

Weight change

Withdrawal

Related Factors

Past, concurrent, and recent losses

Losses involved with the decision to move

Feeling of powerlessness

Lack of adequate support system

Little or no preparation for the impending move

Moderate to high degree of environmental change History and types of previous transfers

Impaired psychosocial health status

Decreased physical health status

Sample Diagnostic Statement

Relocation stress syndrome related to admission to long-term care setting as evidenced by anxiety,

insecurity, and disorientation

Expected Outcomes

1. The resident will socialize with family members, staff, and/or other residents.

2. Preadmission weight, appetite, and sleep patterns will remain stable. If previous patterns were dysfunctional, more appropriate health patterns will develop.

3. The resident will verbalize feelings, expectations, and disappointments openly with members of the staff and/ or family.

4. Inappropriate behaviors (e.g., acting out, refusing to take medicines) will not occur.

Expected Short-Term Goals

1. The resident will become independent in moving to and from areas within the facility during the next 3 months.

2. The resident will react in a positive manner to staff effort to assist in adjusting to nursing home placement in the next 3 months.

3. The resident will express his or her thoughts or concerns about placement when encouraged to do so during individual contacts in the next 3 months.

4. During the next 3 months, the resident will not develop physical or psychosocial disturbances indicative of trans location syndrome as a result of the change in living environment.

Expected Long-Term Goals

1. The resident will verbalize acceptance of nursing home placement within the next 6 months.

2. The resident will indicate acceptance of nursing home placement through positive body language within the next 6 months.

Specific Nursing Interventions

1. Identify previous coping patterns during admission assessment. Clearly document these, and share the information with other staff members.

2. Include the resident in assessing problems and developing the care plan on admission.

3. Adjust for limitations in sensory-perceptual disturbances when planning care for residents. Visual disturbances necessitate special intervention to assist residents in finding their way around.

4. Staff members will introduce themselves when entering the residents room, indicating the nature of their relationship with the resident. Example: Hello, Mr. S. My name is Nancy. Ill be your nurse attendant today, helping you with your meals and your bath.

5. Each staff member providing care for the resident should make it a point to spend at least 5 minutes each day with new admissions to just visit.

BOX 3-9 Relocation Stress Syndromecontd

6. Allow the resident as many opportunities to make independent choices as possible. -328733-108092

7. Identify previous routines for activities of daily living (ADLs). Try to maintain as much continuity with the residents previous schedule as possible. Example: If Mr. S. has taken a bath before bed all of his life, adjust his schedule to continue that practice.

8. Familiarize the resident with unit schedules.

9. Encourage family participation through frequent visits, phone calls, and activity sessions. Be sure to let the family know schedules.

10. Establish familiar landmarks for the resident when leaving his or her room so that he or she can recognize areas more quickly.

together through the common transitions patients endure in our health care system. This will be a win-win situation for patients and providers alike (2008, p. 154).

It is essential that educational programs prepare students for competent care of older adults in a variety of health care settings, including acute, long-term, home, and community based care. Nurses in all settings need to increase awareness of the roles and responsibilities of nursing practice across the continuum and work collaboratively to improve care out comes, particularly during times of transition. We can no longer work in our individual silos and not be concerned with what happens after the patient is out of our particular unit or institution. Nurses are well positioned to create services and environments that embrace values that are at the core of this professionpatient/caregiver centered care, communication and collaboration, and continuity (Naylor, 2002, p. 140).

KEY CONCEPTS

A familiar and comfortable environment allows an elder to function at his or her highest capacity. Nurses must be knowledgeable about the range of resi dential options for older people so they can assist the elder and the family to make appropriate decisions. Nursing homes are an integral part of the long-term care system, providing both skilled (subacute) care and chronic, long-term, and palliative care. Projections are that this setting will provide increasing amounts of care to the growing numbers of older adults.

Culture change in nursing homes is a growing move ment to develop models of person-centered care and improve care outcomes and quality of life.

CHAPTER 3 Care Across the Continuum 41

11. Encourage family members to bring familiar belongings from home for the residents room decorations.

12. Provide reorientation cues frequently. Example: You are in the dining room. Your room is down the hall three doors just past the window.

13. Encourage the resident to talk about expectations, anger, and/or disappointments and the recent life changes that he or she has experienced.

14. Review the patients medication list with the physician to verify the need for medications that might promote disorientation.

15. Provide for constructive activities. Initiate activity therapy consultation.

Nurses play a key role in insuring optimal outcomes during transitions of care.

Relocation has variable effects, depending on the indi viduals personality, health, cognitive capacities, sense of control, opportunities for choice, self-esteem, and preferred lifestyle.

ACTIVITIES AND DISCUSSION QUESTIONS 1. Identify three objects in your living space that are important to you, and explain why these are significant. Will you take these with you whenever you relocate? 2. Ask an older relative about the items or conditions in his or her home that make him or her feel secure and comfortable.

3. Discuss with this elder various moves he or she has made and how he or she felt about them.

4. How might the care needs of an older adult in assisted living, subacute care, and a nursing home differ? What is the role of the professional nurse in each of these settings?

5. Select three places listed in your phone book as retire ment communities, and make inquiries regarding pos sible placement of an older adult parent. What ques tions did you ask? What is the cost? What are the

provisions for health care? What types of activities and assistance are available? Which would you select for your grandmother and why?

6. In your experience in the acute care setting, what im provements would you suggest to improve transitions to other care settings? Discuss any experience you or your friends or family may have had with transitions after hospital discharge.

42 SECTION 1 Foundations of Healthy Aging

7. If you were the director of nursing, what would your nursing home be like (design, staffing, quality of care, training)?

REFERENCES

Alliance for Quality Nursing Home Care and the American Health Care Association: Annual quality report: a comprehen sive report on the quality of care in Americas nursing homes and rehabilitation facilities (2011). Available at http://www.aqnhc. org/www/file/AHCA_Alliance_2011_Quality_Report_v2. pdf.

Alzheimers Association: Dementia care practice: recommendations for as sisted living residences and nursing homes (2009). Available at http:// www.alz.org/national/documents/brochure_DCPRphases1n2.pdf.

AssistedLivingFacilities.org: Assisted living costs (2012). Available at http://www.assistedlivingfacilities.org/articles/assisted-living costs.php.

Baker B: Old age in a new age: the promise of transformative nursing homes, Nashville, TN, 2007, Vanderbilt University Press. Baker B, as cited in Haglund K: Closing keynote speaker found hope in changes benefiting residents and staff, Caring Ages 9(6):8, 2008.

Bixby M, Naylor M: The Transitional Care Model (TCM): hospital discharge screening criteria for high risk older adults (2009). Available at http://consultgerirn.org/uploads/File/try this/try_ this_26.pdf.

Brawley E: What culture change is and why an aging nation cares, Aging Today 28:910, 2007.

Chalmers S, Coleman E: Transitional care. In Capezuti E, Swicker D, Mezey M, et al, editors: The encyclopedia of elder care, ed 2, New York, 2008, Springer.

Coleman EA, Parry C, Chalmers S, et al: The Care Transitions Intervention: results of a randomized controlled trial, Arch Intern Med 166(17):18221928, 2006.

Corbett C, Setter S, Daratha K, et al: Nurse identified hospital to home medication discrepancies: implications for improving transitional care, Geriatr Nurs 31:188, 2010.

Daniel K, Carson C, Ferrell S: Emerging technologies to enhance safety of older people in their homes, Geriatr Nurs 30(6): 384389, 2009.

Gleckman H: The death of nursing homes (2009). Available at http://www.kaiserhealthnews.org/Columns/2009/ September/092809Gleckman.aspx.

Graham C, Ivey S, Neuhauser L: From hospital to home: assessing the transitional care needs of vulnerable seniors, Gerontologist 49:23, 2009.

Hain D, Tappen R, Diaz S, Ouslander J: Characteristics of older adults rehospitalized within 7 and 30 days of discharge: implica tions for nursing practice, J Gerontol Nurs 38(8):3244, 2012.

Hines P, Yu K, Randall M: Preventing heart failure readmissions: is your organization prepared? Nurs Econ 28:74, 2010. Hooyman N, Kiyak A: Social gerontology. Boston, 2011, Pearson.

Inouye S, Baker DI, Leo-Summers L: The hospital elder life prog ress: a model of care to prevent cognitive and functional de cline in older hospitalized patients, J Am Geriatr Soc 48(12):16571706, 2000.

Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare fee-for-service program, N Engl J Med 360(14):14181428, 2009.

Kanak MF, Titler M, Shever L, et al: The effect of hospitalization on multiple units, Appl Nurs Res 21(1):1522, 2008. Kleinpell R: Supporting independence in hospitalized elders in acute care, Crit Care Nurs Clin N Am 19:242252, 2007. Leading Age: Choosing a provider (2011). Available at http://www. leadingage.org/Choosing_A_Provider.aspx.

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Mezey M, Stierle L, Huba G, et al: Ensuring competence of specialty nurses in care of older adults, Geriatr Nurs 28(6S): 913, 2007.

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able at http://www.metlife.com/assets/cao/mmi/publications/ studies/2010/mmi-adult-day-services.pdf.

Naylor M: Transitional care of older adults. In Archbold P, Fitzpatrick J, Stewart B, editors: Annual review of nursing research. New York, 2002, Springer, pp. 127147.

Naylor M, Keating S: Transitional care: moving patients from one care setting to another, Am J Nurs 108(9 Suppl):58, 2008. Naylor M, Kurtzman E, Pauly M: Transitions of elders between long term care and hospitals, Policy Polit Nurse Pract 10:187, 2009. Omnibus Budget Reconciliation Act (OBRA) of 1987 (Public

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CHAPTER

Culture and Aging

L E A R N I N G O B J E C T I V E S

Upon completion of this chapter, the reader will be able to:

Kathleen F. Jett

evolve.elsevier.com/Ebersole/gerontological

Identify factors contributing to the nurses cultural sensitivity.

Discuss approaches that facilitate an appreciation of diverse cultural and ethnic experiences. Explain the prominent health care belief systems.

Identify nursing care interventions appropriate for ethnically diverse elders.

Formulate a plan of care incorporating ethnically sensitive interventions.

G L O S S A R Y

Culture Beliefs, customs, and values that are shared by a group and passed on from one generation to the next. Ethnicity Identifying with or deriving from the cultural, racial, religious, or linguistic traditions of a people or country.

Ethnocentrism The belief in the inherent superiority of ones ethnic group, accompanied by devaluation of other groups.

Folk medicine Healing methods originating among the people of a given culture and primarily transmitted from person to person.

Interpreter A person who transmits the meaning of what is spoken in one language to another spoken language.

Stereotype Belief applied to a group of persons based on assumed knowledge of an individual member of the group.

Translator A person who converts written materials from one language to another.

T H E L I V E D E X P E R I E N C E

I feel so out of place here. If my children werent so busy, I suppose I could live with them, but they seemed so relieved when this retirement home would accept me. I wonder if they knew I was the only Chinese person in this place. A sweet young Chinese student tried to talk with me, but she only spoke Mandarin and I speak Cantonese. She had never lived in China. I want so much to talk to someone my age who lived in China and speaks my language.

Shin, a 75-year-old woman

Interest in and attention to culture and health care are

increasing. In the field of gerontology, this interest is stimulated to a great extent by two major issues: the realization of a gerontological explosion and the recogni tion of the significant health disparities and inequities in

the Unites States.The gerontological explosion refers both to the rapid increases in the total numbers of older adults, especially those over 85 years of age, and to the relative proportion of older adults in most countries across the globe (see Chapter 1). Health disparities refers to the

44 SECTION 1 Foundations of Healthy Aging

differences in the state of health and health outcomes between people.

Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on racial or ethnic group; religion; socioeco nomic status; gender; age; mental health; cognitive,sensory or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion (U.S. Department of Health and Human Services [USDHHS], 2012).

Health inequities refers to the excess burden of illness or the difference between an expected incidence and prevalence and that which actually occurs in excess in a

comparison population group.The inequities are often the result of both historical and contemporary injustices. Those found to be especially vulnerable to health dispari ties and inequities are older adults from ethnically distinct groups (Table 4-1).

Todays nurse is expected to provide competent care to persons with different life experiences, cultural per spectives, values, styles of communication and ages than their own. The nurse may need to effectively communi cate with people regardless of the languages and manner being spoken. In doing so, the nurse may have to depend on limited verbal exchanges and attention to more facial expressions, postures, and gestures. However, these forms

TABLE 4-1 Blacks Compared with Whites on Measures of Quality and Access: Specific Measures, 2009* Topic Better than Whites Worse than Whites

Cancer Colorectal cancer diagnosed at advanced stage Adults 50 years of age and over who report they ever received

a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult

blood test

Colorectal cancer deaths per 100,000 population

Breast cancer diagnosed at advanced stage

Cancer deaths per 100,000 female population due to breast cancer

Heart disease Deaths per 1000 admissions with

acute myocardial infarction as

principal diagnosis, 18 years of

age and over

Hospital patients who received

recommended care for heart

failure

HIV and AIDS New AIDS cases per 100,000 population 13 years of age and over Respiratory diseases Adults 65 years of age and over who ever received pneumococcal vaccination

Hospital patients with pneumonia who received recommended

care

Functional status preservation and rehabilitation

Supportive and palliative care

Long-stay nursing home residents who were physically restrained

Female Medicare beneficiaries 65 years of age and over who reported ever being screened for osteoporosis

High-risk long-stay nursing home residents with pressure sores

Short-stay nursing home residents with pressure sores Home health care patients who were admitted to the hospital

Timeliness Emergency department visits in which patients left without being seen

Access People without a usual source of care due to a financial or

insurance reason

People who have a usual primary care provider

From The National Healthcare Quality Report, 2009; Chapter 4. Priority Populations. Available at http://www.ahrq.gov/qual/nhdr09/Chap4.htm.*Modified for those most relevant to older adults.

of communication are heavily influenced by age, culture and ethnicity and easily may be misunderstood. To skill fully assess and intervene, nurses must first develop sen sitivity through awareness of their own ethnocentrism and ageist attitudes. Effective nurses develop competence and the ability to work sensitively with older adults through new knowledge about aging, ethnicity, culture, language, and health belief systems, and develop the skills needed to optimize communication.

Knowing how to provide competent care is especially important in gerontological nursing because many older adults are just now immigrating to the United States.Many others have spent their lives in self-contained, homoge neous communities and may not have become acculturated to a Western model of care.This situation is likely to result in cultural conflict in the health care setting.

This chapter provides an overview of culture and aging, as well as strategies that gerontological nurses can use to best respond to the changing face of aging and in doing so, help reduce health inequities. These strategies include in creasing sensitivity, knowledge and skills, decreasing age ism and working with diverse groups of older adults.

The Gerontological Explosion

The population of the United States is rapidly becoming more diverse. Persons of color, who have long been classi fied as those from minority groups, will represent about 50% of the population in the next 50 years. The greatest increase in the number of ethnically diverse elders in the United States will be those who identify themselves as African American, followed by Hispanic, followed by Asian and Pacific Islanders (Table 4-2).Those who report white alone will decrease from 87% to 77%; African American alone will increase from 9% to 12% between 2010 and 2050 (Vincent & Velkoff, 2010).The effect of the overall growth in the numbers of elders currently in all groups is being

TABLE 4-2 6476156861

Percentage of Persons 65 Years of

Age and Older in the United States

from Minority Groups in 2009

African American 8.3

Asian/Pacific Islander 3.4

CHAPTER 4 Culture and Aging 45

seen in all aspects of nursing (Administration on Aging [AOA], 2010). For example, it would not be unusual for nurses working in states with the greatest number of im migrant elders (especially California, Nevada, Florida, Texas, New Jersey, and Illinois) to care for persons from a variety of backgrounds in the same day (Gelfand, 2003). It must be noted, however, that these and many of the figures available today are drawn from the U.S. Census, in which persons of color are often underrepresented and those who reside illegally are not included at all.In reality,the numbers of elders from diverse backgrounds residing in the United States may be and may become substantially higher.

Health Disparities

In 2003 the Institute of Medicine (IOM) prepared the landmark analysis of health disparities. It began with the acknowledgement that persons of color had difficulty accessing the same care as their white counterparts. The study showed that even among those who had the same access, health care treatment in the United States in and of itself was unequal (Smedley et al., 2003) (Box 4-1). The barriers to quality care were found to be wide and were consistently found across the spectrum of disease areas and clinical services. Although there has been some improve ment, significant problems remain (Centers for Disease Control and Prevention, 2009; National Institute on Aging, 2010). The goals published in Healthy People 2020 are to work to achieve health equity, eliminate disparities and improve the health of all groups (USDHHS, 2012).

BOX 4-1 Examples of Health Disparities Relevant to Older Adults

African Americans -137267-104647

Although African American adults are 40% more likely to have hypertension , they are 10% less likely than their non-Hispanic white counterparts to have their blood pressures controlled.

In 2009 African American men were 30% more likely than non-Hispanic white men to die of heart disease. African American women are 1.6 times more likely

American Indian/ Native Alaskan

to have hypertension than their non-Hispanic white

counterparts.

More than one race 0.6

Hispanic (any race) 7.0

Data from A profile of older Americans (2010). Available at www.aoa. gov/AoARoot/Aging_Statistics/Profile/2010/7.aspx.

From CDC Office of Minority Health Disparities: Heart disease and African Americans. From: Summary statistics for U.S. adults: 2010. Available at http://minorityhealth.hhs.gov/templates/content.aspx?lvl52&lvlID5 51&ID53018.

46 SECTION 1 Foundations of Healthy Aging

Reducing Health Disparities

The IOM study also provided a number of recommenda tions for reducing health disparities. However, before change can occur, health care providers must become more culturally competent. The objective is not just to become competent but to become culturally proficient, that is, able to move smoothly between the world of the nurse and the world of the patient (in this case, the world of the elder). Moving toward proficient gerontological nursing care is one of the major strategies to improve the health of all persons regardless of age or ethnicity.

Increasing Cultural Competence

As nurses move toward gerontological cultural proficiency, they increase their awareness, knowledge, and skills.Nurses can learn of their personal biases, prejudices, attitudes, and behaviors toward persons different from themselves in race, ethnicity, age, gender, sexual orientation, social class, economic situations, and many other factors. Through in creased knowledge, nurses can better assess the strengths and weaknesses of the older adult within the context of their lives and know when and how to effectively intervene to support rather than hinder long-held patterns that enhance wellness and coping. Competence means having the skills to put cultural knowledge to use in assessment, communication, negotiation, and intervention.

Awareness

Increased awareness calls for openness and self-reflection. It is a conscious effort to recognize the bias we express in our interactions with others, especially those who are dif ferent than we are (Stone & Moskowitz, 2011). If the nurse is white, especially those who are younger, it is real izing that this means special privilege and freedoms in a predominantly white and youth-oriented society. Those who are especially affected are older adults of color who may not have had the same advantages or experiences as the nurse (McIntosh, 1989). For example, in many regions of the United States, especially in the rural South, the current cohort of African Americans was limited to a fourth-grade education, with far-reaching implications. African Americans who are elders today lived during the time of Jim Crow laws which legalized discrimination and segregation and significantly restricted their lives. Events of the time included numerous murders by lynching (see www.jimcrowhistory.org and Box 4-2). These elders are also aware of the Tuskegee Experiment, in which black men with syphilis were purposely deceived and not treated

BOX 4-2 Racism in the Boston Naming Test*

During a study to evaluate the cultural applicability of several standard psychological tools sometimes adminis tered by nurses, an 82-year-old African American woman reluctantly agreed to take what is called the Boston Nam ing Test. This measure of verbal fluency used in the diagno sis of dementia comprises a packet of pictures. The patient is asked to name the pictures. After doing so the volunteer shared, Did you know that one of the pictures is a hang mans noose? Do you have any idea what that means to a black person to look at that picture! Indeed, none of the white researchers had noticed this. -137394-108089

*Personal experience of Kathleen Jett.

so scientists could study its effect over time (see www. cdc.gov/tuskegee/timeline.html). For some, this has left a continuing distrust of the health care system and a reluc tance to become involved in research.

Cultural awareness means recognizing the presence of the ismssuch as the racism just described.It is imperative to understand how these affect not only the pursuit and receipt of health care, but also the quality of life for older adults (Smedley et al., 2003).Moreover, as older adults they also may have faced sexism, classism, ageism, and so on.

Ageism is a term coined in 1968 by Robert Butler, the first director of the National Institute on Aging, to de scribe the discrimination and negative stereotypes that are based solely on age. Cole (1997) examined the historic roots of ageism in America. At one time, power in the United States was held almost exclusively by older white males.With the shift to urban industrialism and a growing emphasis on productivity and the ability to withstand the rigors of factory work, power and influence shifted from older to younger white men. With a near cultural obsession with youth today,it is easy to see that ageism is alive and well. Gift shops and department stores are replete with products such as antiaging products and graphic portrayals mocking the abilities of those formerly known as elders (Associated Press, 2011). In 2004, Americans spent $45.5 billion on antiaging products, and spending is expected to reach $72 billion by 2009 (International Longevity Center, 2006, p. 28). We often think in personal terms when negative stereotypes are applied to the person due to his or her age, but ageism may also be institutional, such as in mandatory retirement policies or the absence of older adults in research clinical trials. Ageism may be intentional, such as when older workers are targeted in financial scams, but

BOX 4-3 Unintentional Ageism in Language and Its Effects

Use of general labeling terms: sweet old lady, little old lady, geezer. -294138-108089

Use of terms applied in the health care setting: fossil, bed blocker (debilitated person in the hospital

awaiting a bed in a nursing home), GOMER (get out of my emergency room).

When speaking: exaggerated pitch, demeaning emotional tone, lower quality of speech.

Consequences of ageism in language: reduced sense of self, lowered self-esteem, lowered sense of

self-competence, decreased memory performance.

From International Longevity Center: Ageism in America (2006). Available at http://www.graypanthersmetrodetroit.org/Ageism_In_Amerca_-_ILC_ Book_2006.pdf.

more often in nursing it is unintentional, but nonetheless present and hurtful (Box 4-3). Some health care profes sionals demonstrate ageism, undoubtedly in part because providers tend to see many frail older persons and fewer of those who are healthy and active.The impact of these per ceptions has largely been ignored but almost certainly negatively affects health outcomes.

We now know that ageism is not universal but is most often reflective of the Euro-American culture.In many other cultures, elders are treated with special respect and honor.For example, for the most part, African American elders are respected.They may provide wisdom and insight to younger members of the family. Owing to a number of factors, African American grandparents are increasingly assuming the role of parent, for grandchildren and other teenage and younger relatives (Caminha-Bacote, 2008) (see Chapter 24).

Before the nurse provides quality care to elders, it is useful to self-reflect and consider whether one holds any personal beliefs about such persons and whether these beliefs are negative or positive, how they affect care deliv ery, and if they are based on facts rather than anecdotal experiences resulting in stereotypes.

Knowledge

Cultural knowledge is both what the nurse brings to the caring situation and what the nurse learns about older adults, their families, their communities, their behaviors, and their expectations. Essential knowledge includes the elders way of life (ways of thinking, believing, and acting).

CHAPTER 4 Culture and Aging 47

This knowledge is obtained formally and informally through the individuals professional experience of nursing. Some nurses prefer to use what can be called an ency clopedic approach to details of a particular culture or ethnic group, such as proper name usage, touch, greeting, eye contact, gender roles, foods, and beliefs about relevant topics such as health promoting practices, pain expression, death rituals, or caregiving. This information is available in many compendiums of cross-cultural information (see the Evolve website for this book). The work of the Stanford Geriatric Education Center is especially helpful in this area (http://sgec.stanford.edu/training). When working with elders from a specific culture, knowledge about attitudes toward caregiving, decision making, and death rituals are especially important and may be particu larly sensitive.

Although cultural knowledge is helpful and essential, caution must be used with regard to the potential for stereotyping. Stereotyping is the application of limited knowledge about one person with specific characteristics to other persons with the same characteristics; negative characteristics are especially prone to this treatment. Stereotyping limits the recognition of the heterogeneity of the group. At the same time, relying on knowledge of a positive stereotype can be useful as a starting point in understanding, but it too can be used to limit understand ing of the uniqueness of the individual and impose unre alistic expectations. For example, a common stereotype of the African American culture is to assume that the church is a source of support. The nurses assumption can easily have a negative outcome,such as fewer referrals for formal services support (e.g., home-delivered meals).This stereo type can also be used to shortcut conversation about discharge planning. In discussing discharge plans with an African American elder,the nonAfrican American nurse may say,I understand that the church is often a source of support in the African American community. Is this one of the resources you will be able to depend on when you return home?

Persons from a specific ethnic group may share a com mon geographical origin, migratory status, race, language or dialect, or religion. Traditions, symbols, literature, folklore, food preferences, and dress are expressions of ethnicity. These may be particularly seen in older adults who have had no need to leave their culture-specific neighborhoods such as Chinatowns in the major cities, or the barrios of the Southwest. Persons who identify with the same ethnic group may or may not share a common race. For example, persons who consider themselves Hispanic are members of the most diverse ethnic group in the United States and may be from any race and from any one of a number of countries.

48 SECTION 1 Foundations of Healthy Aging

However, they usually have the Catholic religion and the Spanish language in common.

Health beliefs and practices are usually a mixed expres sion of life experience and cultural knowledge. In most cultures, older adults are likely to treat themselves for familiar or chronic conditions in ways they have found successful in the past, practices that are referred to as domestic medicine, folk medicine, or folk healing. The basis for much folk medicine was, and remains, to make the most of whatever is available. When self-treatment fails, a person will consult others known to be knowledge able or experienced with the problem, such as a commu nity or indigenous healer, often an elder known to the community. Only when this too fails do people seek help within the formal health care system.

The culture of nursing and health care in the United States is one that advocates what is called the Western or biomedical system with its own set of beliefs about the cause of illness,the choice of treatments, and so on.In most settings this belief system is considered superior to all others, an ethnocentric viewpoint. However, many of the worlds people have different beliefs, such as those of the personalistic (magicoreligious) system or the naturalistic (holistic) system. Each system is complete with beliefs about disease causation and recommendations for preven tion and treatment.It is not uncommon for ethnic elders to adhere to belief systems other than the biomedical system or a combination of systems. Nurses who are familiar with the range of health beliefs and realize their importance will be able to provide more sensitive and appropriate care. In the absence of understanding there is great potential for conflict.This is especially important to remember when working with those who have lived in culturally homoge neous communities.

Western or Biomedical System

In the Western or biomedical belief system, disease is thought to be the result of abnormalities in the structure and function of body organs and systems, often caused by an invasion of germs or genetic mutation. The terms dis ease and illness are subjective; they are used by care pro viders and not always understood by others. In the bio medical system, assessment and diagnosis are directed at identifying the pathogen or the process causing the ab normality by using laboratory and other procedures. Treatment is based on removing or destroying the invad ing organism or repairing, modifying, or removing the affected body part. Prevention involves the avoidance of pathogens, chemicals, activities, and dietary agents known to cause abnormalities. Health is often considered the absence of disease (see Chapter 1).

Personalistic or Magicoreligious System

Those who follow the personalistic or magicoreligious system believe that illness is caused by the actions of the supernatural, such as gods, deities, or nonhuman beings, such as ghosts, ancestors, or spirits. Health is viewed as a blessing or reward of God and illness as a punishment for a breach of rules, breaking a taboo, or displeasing or failing to please the source of power. Beliefs about illness and disease being caused by the wrath of God are prevalent among members of the Holiness, Pentecostal, and Funda mentalist Baptist churches. Examples of magical causes that illness can be attributed to are voodoo, especially among persons from the Caribbean; root work among southern African Americans; hexing or spells among Mexican Americans and African Americans; and Gaba among Filipino Americans. Knowledge about hexing became popularized in the Harry Potter series. Treatments may include religious practices, such as praying, meditating, fasting, wearing amulets, burning candles, and establishing family altars. Making sure that social networks with their fellow humans are in good working order is viewed as the essence of pre vention. It is therefore important to avoid angering family, friends, neighbors, ancestors, and gods. This belief system can be traced back to the ancient Egyptians, thousands of years before the common era, and persists in its entirety or in parts in many groups. Current practices that would be included in this group include rituals such as laying of the hands and prayer circles. It is not uncommon to hear an older adult pray for a cure or lament, What did I do to cause this?

Naturalistic or Holistic Health System

The naturalistic or holistic health belief system is based on the concept of balance and stems from the ancient civiliza tions of China, India, and Greece (Wang & Paulanka, 2008). Many people throughout the world view health as a sign of balanceof the right amount of exercise, food, sleep, evacuation, interpersonal relationships, or the geo physical and metaphysical forces in the universe,such as chi. Disturbances in this balance result in disharmony and sub sequent illness. Diagnosis calls for the determination of the type and extent of imbalance.The appropriate intervention, therefore, is to restore balance and harmony.

Traditional Chinese medicine is based on this belief, on the balance between yin and yang, darkness and light. Older adults who were raised in one of the countries on the Pacific Rim (especially in Asia and the Pacific Islands) or in a traditional American Indian community frequently rely on this system. The naturalistic system practiced in India and some of its neighboring countries is known as ayurvedic medicine.

Another variation is seen in those who follow the hot cold beliefs, apart from traditional Chinese medicine. Held by many of Hispanic backgrounds, illness is believed to be the result of an excess of heat or cold that has entered the body and caused an imbalance. Hot and cold are generally metaphoric, although at times actual temperature is consid ered. Various foods, medicines, environmental conditions, emotions, and body conditions, such as menopause, may possess the characteristics of either hot or cold (Spector, 2008). Selecting an appropriate treatment requires the iden tification of disease type, either hot or cold; treatments are likewise divided.They are focused on using the opposite ele ment; if the disease is the result of excess heat,treatment will be with something that has cold properties, and vice versa. The treatments include teas, herbs, food, dietary restrictions, techniques, or medications from Western medicine that have hot and cold properties.

Naturalistic healers can also be advanced practice nurses, physicians, or herbalists who specialize in symptomatic treatment and know which medicines will restore the bodys equilibrium. In the American Indian culture, the healer is referred to as a medicine man or woman who combines naturalistic and magicoreligious systems. Prevention is directed at protecting oneself from imbalance.

Skills

Skillful nursing requires mutual respect between the nurse and the elder.It is working withthe person rather than on the person. Providing the highest quality of care for diverse elders and enhancing healthy aging calls for a new or refined set of skills. These skills include listening carefully to the person, especially for his or her perception of the situation, and attending not just to the words but to the nonverbal communication and the meaning behind the words. It is a skill to be able to listen to the elders perception of the situ ation, desired goals, and ideas for treatment. Cultural skills include the ability to explain your (the nurses) perceptions clearly and without judgment, acknowledging that there are both similarities and differences between your perceptions and goals and those of the elder. Finally, cross-cultural skills include the ability to develop a plan of action that takes both perspectives into account and negotiate an outcome that is mutually acceptable (Berlin & Fowkes, 1983).

Working with Interpreters

Caring for persons cross-culturally often includes working with an interpreter. Interpreting is the process of rendering oral expressions made in one language into another in a manner that preserves the meaning and tone of the original

CHAPTER 4 Culture and Aging 49

without adding or deleting anything. The job of the inter preter is to work with two different linguistic codes in a way that will produce equivalent messages. The interpreter tells the elder what the nurse has said and the nurse what the el der has said without adding meaning or opinion but in a way in which communication is as accurate as possible. This is often confused with translation (when interpreters are called translators), which instead deals with the written word.

Respectful communication is called for at all times; it is essential, however, with older adults from cultures in which this is the expectation and for those with limited or no English proficiency. Respectful communication includes addressing the person in the appropriate manner (surname unless otherwise instructed by the elder) and using accept able body language. For example in most cultures other than those of northern Europe (including Euro-Americans) direct eye contact is considered disrespectful. To press eye contact with an elder may be particularly rude.

An interpreter is needed any time the nurse and the elder speak different languages, when the elder has limited English proficiency, or when cultural tradition prevents the elder from speaking directly to the nurse, for example as a result of the nurses being a man or woman.The more com plex the decision that must be made, the more important the skills of the interpreter are, such as when determining the elders wishes regarding life-prolonging measures or the familys plan for caregiving.

It is ideal to engage persons who are trained medical interpreters who are of the same age,sex, and social status as the elder whenever possible. Unfortunately it is usually nec essary to call upon younger interpreters; the effectiveness of the exchange may be hampered by the presence of intergen erational boundaries. Children and grandchildren are often called on to act as interpreters.In such a situation the nurse should realize that the child or the elder is editing com ments because of cultural restrictions about the sharing of certain information (i.e., what is or is not considered appropriate to speak of to an elder or a child).

When working with an interpreter, the nurse first introduces herself or himself to the client and the inter preter and sets guidelines for the interview. Sentences should be short, employ the active voice, and avoid meta phors because they may be impossible to convert from one language to another.The nurse asks the interpreter to articulate exactly what is being said, and all conversation is addressed directly to the client (Enslein et al., 2002). Most guides will have the interpreter sit to the side and slightly behind the person. However, due to age-related hearing loss the interpreter may need to sit aside the nurse so the speaker can be seen for optimal communication (Box 4-4).

50 SECTION 1 Foundations of Healthy Aging BOX 4-4 Working with Interpreters-29191612304

Before an interview or session with a client, meet with the interpreter to explain the purpose of the session. Encourage the interpreter to meet with the client before

the session to identify the clients educational level and attitudes toward health and health care and to determine the depth and type of information and explanation needed.

Look and speak directly to the client, not the interpreter. Be patient. Interpreted interviews take more time because long, explanatory phrases are often needed.

Use short units of speech. Long, involved sentences or complex discussions create confusion.

Use simple language. Avoid technical terms, professional jargon, slang, abbreviations, abstractions, metaphors, or idiomatic expressions.

Encourage interpretation of the clients own words rather than paraphrased professional jargon to get a better sense of the clients ideas and emotional state.

Request that the interpreter avoid inserting his or her own ideas and to avoid omitting information.

Listen to the client and watch nonverbal communica tion (facial expression, voice intonation, body move ment) to learn about emotions regarding a specific topic even when words are not understood.

Clarify the clients understanding and the accuracy of the interpretation by asking the client to tell you in his or her own words what he or she understands, facilitated by the interpreter.

From Enslein J, Tripp-Reimer T, Kelley LS, et al: Evidence-based protocol: interpreter facilitation for individuals with limited English proficiency, J Gerontol Nurs 28(7):5-13, 2002.

Implications for Gerontological Nursing and Healthy Aging

The contact between elders and gerontological nurses often begins with assessment. During that process, each has an opportunity to know the other. Listening is the key; the nurse tries to understand the meaning of the persons perceptions. A thorough assessment includes a cultural assessment. A comprehensive assessment takes time. It is clear that this cannot be done in all situations, but even if it must be done bit by bit over time, it will give the care giver a better understanding of how to work with and within the culture of the client.

Several tools or instruments can assist the nurse in the conduct of sensitive assessments. Although Leiningers Sunrise Model (Shen, 2004; Schim et al., 2007) is often recommended, alternative models may be more useful in the fast-paced health care situations of today. The ex planatory model developed by Kleinman and associates (1978) has become a classic and has helped nurses and other health care professionals obtain the basic informa tion needed in a culturally sensitive manner (Box 4-5). An adaptation of this assessment, LEARN, appears in Box 4-6. The LEARN Model (Berlin & Fowkes, 1983) serves as a guide in the clinical setting and can be used easily to increase the effectiveness of nursing interven tions. Through it, the nurse will increase his or her cul tural sensitivity and in doing so will be instrumental in

providing more proficient care, thus helping reduce health disparities.

With an understanding of the basics, the nurse can negotiate a clear understanding of problems and solutions with the person or with the identified support figure in his or her life. When an understanding is reached, the nurse may need to include consultation or collaboration with traditional or alternative healers if the patient believes this is important. Priests, monks, rabbis, ministers, or indige nous healers may provide expert consultation, support, and interventions of their own. A sense of caring is con veyed in giving support to the elders traditional beliefs and practices. Unbiased caring can surmount cultural and age differences.

Also critical to the cultural assessment is to determine the persons system of health beliefs. Most people (nurses and patients alike) subscribe to more than one system, combining Western biomedical approaches with those that may be considered more traditional. People choose among the health belief systems or include aspects of several of them in their attempt to make sense of health, illness, and treatments. To optimize the healthy aging of the person who depends on the nurse for intervention and caring, the nurse must be sensitive to the possibility that the person may hold one or more of these beliefs.

When a patient refuses biomedical treatments because the health problem is viewed as Gods will or destiny, this is often particularly difficult for the nurse and other health

CHAPTER 4 Culture and Aging 51

BOX 4-5 The Explanatory Model for Culturally Sensitive Assessment

1. How would you describe the problem that has brought you here? (What do you call your problem; does it have a name?) a. Who is involved in your decision making about health concerns?

2. How long have you had this problem?

a. When do you think it started?

b. What do you think started it?

c. Do you know anyone else with it?

d. Tell me what happened to that person when dealing with this problem.

3. What do you think is wrong with you?

a. How severe is it?

b. How long do you think it will last?

4. Why do you think this happened to you? -2885701-108090

a. Why has it happened to the involved part? b. What do you fear most about your sickness? 5. What are the chief problems your sickness has caused you? 6. What do you think will help clear up this problem? (What treatment should you receive; what are the most important results you hope to receive?)

a. If specific tests and/or medications are listed, ask what they are and do.

7. Apart from me, who else do you think can make you feel better?

a. Are there therapies that make you feel better that I do not know? (Maybe in another discipline?)

Modified from Kleinman A: Patient and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry, Berkeley, 1980, University of California Press; Pfeifferling JH: A cultural prescription for mediocentrism. In Eisenberg L, Kleinman A, editors: The relevance of social science for medicine, Boston, 1981, Reidel.

care providers. Finding out more about the persons beliefs about disease causation and the type of treatments he or she believes are appropriate in the given circumstances can enable the nurse to navigate the cultures of the medical establishment and that of the patient and work to promote better health.

Nurses should not attempt to change the persons belief system.It is difficult, if not impossible, and usually counter productive.This is particularly so when working with older

BOX 4-6 The LEARN Model

L Listen carefully to what the elder is saying. Attend to not just the words but to the nonverbal communica tion and the meaning behind the stories. Listen to the elders perception of the situation, the desired goals, and the ideas for treatment. -252381-108089

E Explain your perception of the situation and the problems.

A Acknowledge and discuss both the similarities and the differences between your perceptions and goals and those of the elder.

R Recommend a plan of action that takes both perspec tives into account.

N Negotiate a plan that is mutually acceptable.

From Berlin EA, Fowkes WC: A teaching framework for cross-cultural health care: application in family practice, West J Med 139(6):934-938, 1983.

adults who carry a lifetime of beliefs and illness experiences. However, negotiating health, treatment, or prevention op tions may be possible.The nurse attempts to preserve helpful beliefs and practices, accommodate beliefs that are neither helpful nor harmful, and help clients to modify beliefs or practices that have been shown to be harmful.While it was not about aging, the book The Spirit Catches You and You Fall Down (Anne Fadiman), describes the hardships caused by a lack of sensitivity and the benefits when attempts to under stand are made. For the nurse who has little or no knowl edge of a belief or practice, it will be necessary to study and evaluate it to determine its helpfulness or its potential harm. In this way beliefs and practices can be preserved whenever possible. Respectfully explaining concern about potentially harmful practices with the offer of possible alternatives may show the person that the nurse is considering the persons preferences.

When care is provided in the home, nurses must adapt home care strategies to the beliefs and culture of the indi vidual and the family if they hope to promote healthy aging and wellness. Special attention should be given to caregivers who are torn between their acculturated beliefs such as those related to nursing home stays, work versus caregiver demands, and expectations of the role of the child. The fictionalized accounts portrayed in Amy Tans The Bonesetters Daughter and Julia Alvarez Yo! present some of the dilemmas and conflicts between the traditional elder and the acculturated children. Nurses work with the family to attempt to find a solution to potential cross-cultural and intergenerational conflicts in the caregiving and health

52 SECTION 1 Foundations of Healthy Aging

care settings. The nurse also focuses on the elders overall health and assists the elder and the family in gaining access to needed services.This is done by ascertaining the following: affordability, efficacy, accessibility, and availability of infor mation;satisfaction; illness perspective; and informal support systems. Maintaining respect for clients health beliefs is always paramount.

Cross-Cultural Caring and Long-Term Care

The term long-term care refers to ongoing assistance provided to persons who are physically or mentally fragile and unable to independently meet their basic needs (see Chapter 3). In many cultures outside the United States and in subcultures in the United States, families are expected to take care of their older members; institutional long-term care is less often used than in families of European descent (Jett, 2006) (see Table 4-2). Long-term care takes place in family homes, group homes, assisted living, skilled nursing facilities, and hospices.The preference for where care is received is cultur ally determined but often economically influenced. Senior centers also provide a type of ongoing long-term care, most of it social in nature. Only rarely do they provide service or a setting that is welcoming to other groups, such as new immigrants (McCaffrey, 2008) (Box 4-7).

The On Lok Project in San Francisco is the ultimate model for the provision of long-term care services to di verse elders. Originally designed to meet the home care

BOX 4-7 Providing Culturally Welcoming Services

Dr. Ruth McCaffrey and colleagues received a grant in 2006 and integrated Haitian elders into a senior center in the very diverse community of Belle Glade, Florida. The centers staff and usual participants were introduced to culturally oriented ideas, music, art, and language. They were given an opportunity to ask questions of the local Haitian priest. The Haitian elders were similarly oriented. On a prearranged date, transportation was provided to the Haitian elders and a welcoming party was held; the event was facilitated by a bilingual native speaker-advocate-helper. The project was a success; both the long-term participants of the center and the newer participants expressed a new appreciation of each other and of the center. -137395-108089

Summarized from McCaffrey RG: Integrating Haitian older adults into a senior center in Florida: understanding cultural barriers for immigrant older adults, J Gerontol Nurs 33(12):13-18, 2007.

needs of Chinese and Italian immigrants, it now has the capacity to provide every level of short- and long-term care as well as senior housing to the diverse populations of San Francisco. Services are provided in the language of the elder and in the manner that optimizes each persons wellness and cultural heritage (Kornblatt et al., 2003). Nurses can learn from the work of On Lok and other programs to enhance the care and encourage the health of ethnically diverse elders (AOA, n.d.).

Modifications to existing long-term care services that On Lok and others have found to enhance the well-being of ethnically diverse elders includes:

1. Ensuring that the resident has access to professional interpreter services if needed

2. Developing programs that reflect the diversity of the residents and the staff

3. Considering monocultural facilities or units, where population demographics warrant

4. Attempting to employ staff that reflects the diversity of the residents or participants

The study of the uniqueness and individuality of each elder is one of the most complex and intriguing opportuni ties of our day. Realistically it is almost impossible to be come familiar with the whole range of clinically relevant cultural differences of older adults one may encounter. Caring for elders holistically and sensitively is the most challenging and potentially satisfying opportunity.

Culture, Nursing, and Maslows Hierarchy of Needs

Promoting healthy aging in the care of diverse elders fre quently provides the gerontological nurse with new chal lenges and necessitates a slightly different conceptualiza tion of Maslows Hierarchy. Unfortunately, poverty is very common in many older adult households especially those elders of color, and meeting basic needs (level one) may be difficult.The nurse can be sensitive to this possibility with out making assumptions.The nurse can assess the compo nents of biological integrity and, if necessary, facilitate the elder or the family in obtaining whatever supports (e.g., food stamps, home-delivered meals) are possible and appropriate.

Although some elders born outside of the United States did not experience trauma during their move to the United States, there are many others who suffered horrifi cally in their home country prior to the move or during their immigration process and for whom safety and secu rity (level two) may have special meaning. The staff of a nursing home for Jewish residents complained that it was particularly difficult getting some of the residents with

dementia to shower. Some were Holocaust survivors. It was some time before the staff realized that as the resi dents dementia progressed, they were no longer able to distinguish the difference between a shower for hygiene and the fear of going to the showers (i.e., to the gas chamber) in the concentration camps of their youth (Weissman, 2004).

Cultural identity may be one of the major elements of self-concept and a key to self-esteemincreasingly so as a person becomes more mentally or physically frail. Often elders of a distinct ethnic background are closely tied to family and community. Estrangement from their country of origin may be ameliorated if they live in homogeneous communities and exacerbated if they live in social isolation or away from persons with similar backgrounds (Averill, 2005). The ethnic community (e.g., barrios, Nihonmachi, Chinatown) serves as a buffer and a means of strengthen ing social cohesiveness for elders and others of various cultural groups (Chiang-Hanisko, 2005).Within the com munity, members are protected from discrimination and the language and customs of the society outside.

Family, religion, community, and history are important reference points for self-worth and identity for persons from any ethnic group. Familial supports vary among groups, so cial classes, and subcultures, yet the nuclear or extended family is the chief avenue of transmitting cultural values, beliefs, customs, and practices. In some groups, elders are considered repositories of cultural knowledge.The elder and extended family provides orientation, stability, and often, sanctuary. In gross generalizations, we must consider the possibility that persons of Asian descent value familial piety; Hispanics, the extended family; African Americans, ex tended or fictive kin (family members due to emotional bond) supports; Native Americans, a system of kinship and line of descent; and persons of northern European descent, the desire for independence and autonomy above all other things (Purnell & Paulanka, 2008).

Changes are threatening the historical role of the older adult in the traditional family (see Chapter 24). Economic independence and mobility of the younger members of the family are chipping away at the insulation afforded by the community (Jett, 2006). Intergenerational discontinuities created by assimilation produce a communication gap be tween the young and the old.This may cause isolation and estrangement between the oldest and youngest generations. Members of ethnic minorities are extremely vulnerable in old age. They may be devalued by the majority culture be cause of both age and ethnicity or any of the isms.Nurses can take an active role in facilitating self-actualization by facilitating expression of the uniqueness of the individual, by attending to the elders spiritual and cultural needs, and

CHAPTER 4 Culture and Aging 53

by taking the lead in optimizing the health and abilities of those who seek our care.

KEY CONCEPTS

Population diversity will continue to increase rapidly for many years.This suggests that nurses will be caring for a greater number of persons from a broad range of ethnicities and ages than in the past.

Recent research has revealed significant and persistent inequities in the outcomes of health for persons from minority groups,with the members of these groups bear ing the burden of morbidity and mortality in most areas.

Nurses can contribute to the reduction of health dis parities and inequities through increasing their own awareness, knowledge, and skills.

Negative stereotyping is never appropriate. Cultural awareness, knowledge, and skills are necessary to increase cultural competence.

Nurses caring for diverse elders must let go of their own ethnocentrism before they can give effective care. Many elders hold health beliefs that are different from those of the biomedical or Western medicine used by most health care professionals in the United States. Lack of awareness of the elders health belief system has the potential to produce conflict in the nursing situation.

The more complex the communication or decision making needs in a given situation, the greater the need for skilled interpreter services for persons with limited English proficiency.

Programs staffed by persons who reflect the ethnic background of the participants and speak their lan guage may be preferred by the elderly.

Kleinmans explanatory model and the LEARN Model provide a useful framework for working with elders of any ethnicity or background.

ACTIVITIES AND DISCUSSION QUESTIONS 1. Discuss your personal beliefs regarding health and illness and how they fit into the three major classifications of health systems. How can this affect culturally competent care for ethnically diverse elders?

2. Explain the types of questions that would be helpful in assessing an elders health problem or problems in a way that is respectful of the person and his or her cultural background and ethnic identity.

3. Propose strategies that would be helpful in planning care for elders from different ethnic backgrounds. 4. Activity: Discuss your familial and culturally deter mined views of aging after speaking to older family members.

54 SECTION 1 Foundations of Healthy Aging

REFERENCES

Administration on Aging [AOA]: A profile of older Americans: 2010. Available at http://www.aoa.gov/AoARoot/Aging_ Statistics/Profile/2010/7.aspx.

Administration on Aging [AOA]: A toolkit for serving diverse com munities (n.d). Available at http://www.aoa.gov/AoARoot/ AoA_Programs/Tools_Resources/DOCS/AoA_Diversity Toolkit_full.pdf.

Associated Press: Ageism in America: as boomers age, bias against the elderly becomes a hot topic (2011). Available at http://www.msnbc. msn.com/id/5868712/ns/health-aging/t/ageism-america.

Averill JB: Studies of rural elderly individuals: merging critical ethnography with community-based action research, J Gerontol Nurs 31(2):1118, 2005.

Berlin EA, Fowkes WC: A teaching framework for cross-cultural health care: application in family practice, West J Med 139(6):934938, 1983.

Caminha-Bacote J: People of African American heritage.In Purnell L, Paulanka BJ, editors: Transcultural health care: a culturally competent approach, Philadelphia, 2008, Davis.

Centers for Disease Control and Prevention [CDC]. The state of aging and health in America (2009). Available at http://www. cdc.gov/aging/data/stateofaging.htm.

Chiang-Hanisko L: Transnational perspective: ethnic identity and older adult immigrants health care decision making, Geriatr Nurs 26(6):349, 2005.

Cole T: The journey of life: cultural history of aging in America, Cambridge, England, 1997, Cambridge University Press. Enslein J, Tripp-Reimer T, Kelley LS, et al: Evidence-based

protocol: interpreter facilitation for individuals with limited English proficiency, J Gerontol Nurs 28(7):513, 2002. Gelfand D: Aging and ethnicity: knowledge and service, ed 2, New York, 2003, Springer.

International Longevity Center. Ageism in America (2006). Available at http://www.graypanthersmetrodetroit.org/Ageism_In_America_-_ ILC_Book_2006.pdf. See also http://www.mssm.edu/research/ programs/international-longevity-center.

Jett K: Mind-loss in the African American community: a normal part of aging, J Aging Stud 20(1):110, 2006.

Kleinman A, Eisenberg L, Good B: Culture, illness, and care: clinical lessons from anthropologic and cross-cultural re search, Ann Intern Med 88(2):251258, 1978.

Kornblatt S, Eng C, Hansen JC: Cultural awareness in health and social services: the experience of On Lok, Generations 26(3):4653, 2003.

McCaffrey R: The lived experience of integrating Haitian elders into a senior center, J Transcult Nurs 19(1):3339, 2008. McIntosh P: White privilege: unpacking the invisible knapsack (1989). Available at http://www.library.wisc.edu/EDVRC/ docs/public/pdfs/LIReadings/InvisibleKnapsack.pdf. National Institute on Aging [NIA]: Review of minority aging research at the NIA (2010). Available at http://www.nia.nih.gov/ AboutNIA/MinorityAgingResearch.htm.

Purnell L, Paulanka BJ: Transcultural health care: a culturally compe tent approach, Philadelphia, 2008, Davis.

Schim SN, Doorenbos A, Benkert R, et al: Culturally congruent care: putting the pieces together, J Transcult Nurs 18(2):5762, 2007.

Shen Z: Cultural competence models in nursing: a selected annotated bibliography, J Transcult Nurs 15(4):317322, 2004. Smedley B, Stith A, Nelson A, editors: Unequal treatment: confronting racial and ethnic disparities in health care,Washington,

DC, 2003, National Academy Press. Available at http://www. nap.edu/catalog.php?record_id512875.

Spector RE: Cultural diversity in health and illness, ed 7, Uppar Saddle River, NJ, 2008, Prentice-Hall Health.

Stone J, Moskowitz GB: Non-conscious bias in medical decision making: what can be done to reduce it? Medical Education 45(8):768-776, 2011.

U.S. Department of Health and Human Services [USDHHS], Office of Disease Prevention and Health Promotion: Dispari ties (2012). Available at http://www.healthypeople.gov/2020/ about/DisparitiesAbout.aspx.

Vincent GK, Velkoff VA: Current Population Reports: The next four decades: the older population in the United States, 2010 to 2050, U.S. Department of Commerce (2010). Available at http:// www.census.gov/prod/2010pubs/p25-1138.pdf.

Wang Y, Paulanka BJ: People of Chinese culture. In Purnell L, Paulanka BJ, editors: Transcultural health care: a culturally competent approach, Philadelphia, 2008, Davis, pp. 129144. Weissman G: Personal communication, April 10, 2004.

Theories of Aging

CHAPTER

and Physical Changes

Kathleen F. Jett

evolve.elsevier.com/Ebersole/gerontological

L E A R N I N G O B J E C T I V E S

Upon completion of this chapter, the reader will be able to:

Identify the physical changes that are associated with normal aging.

Begin to differentiate normal age-related changes from those that are potentially pathological. Describe at least one age-related change for each body system.

Develop a plan of care for the older adult that targets prevention and health promotion.

G L O S S A R Y

Glomerular filtration rate (GFR) The rate at which the kidneys filter blood.

Kyphosis C-shaped curvature of the cervical vertebrae.

Presbycusis Progressive, bilaterally and symmetrical age-related hearing loss.

Presbyopia Reduced near vision occurring normally with age, usually resulting in improved distance vision.

Xerostomia Excessive mouth dryness.

T H E L I V E D E X P E R I E N C E

Strange how these things creep up on you. I really was surprised and upset when I first realized it was not the headlights on my car that were dim but only my aging night vision. Then I remembered other bits of awareness that forced me to recognize that I, that 16-year-old inside me, was experiencing changes that go along with getting older. Sally, age 60

ging comprises a series of complex changes and occurs in all living organisms. Most of these changes are intrinsic, coming from within; others

for decades as they have unceasingly searched for the mythical fountain of youth, yet it is now well accepted that the maximum possible age in the human is about

are a result of extrinsic, environmental factors, such as exposure to smoke or other pollutants. Some changes are beneficial (e.g., learned experiences, resistance to some infections), others are to ones disadvantage (e.g., slowed reaction time) and others are neutral (e.g., graying of hair). Just why the changes occur has been of interest to scientists

120 years (Walston, 2010). It is known that the triggers of aging are greatly influenced by genetics and by injury to or abuse of the body earlier in life.

Later life is a time of challenge and opportunity. Among the challenges are physical changes which occur to many or most persons as they accumulate years. Other

56 SECTION 1 Foundations of Healthy Aging

challenges are the result of pathological conditions, many of which are the manifestations of lifestyle choices made at younger ages, such as smoking and obesity. Some indica tions of pathological conditions are mistakenly considered an expected part of the aging process.

In this chapter the prominent biological theories of aging and some of the major physical changes associated with normal aging are discussed. For a more thorough discussion see Toward Healthy Aging (Jett, 2011). With this knowledge the nurse can begin to differentiate nor

mal aging from health problems that necessitate treat ment and help facilitate prompt intervention, which in turn promotes healthy aging. When health is optimized the person can more easily move toward self-actualization (see Chapter 1).

Biological Theories of Aging

A theory is an explanation of some phenomenon that makes sense to us. Theories remain reasonable explanations until someone finds them to be incorrect. Most theories can neither be proved nor disproved, but they are useful as points of reference. Each theory in its own right provides a clue to the aging process. However, many unanswered questions remain.

BOX 5-1 Emerging Biological Theories of Aging

Neuroendocrine Control or Pacemaker Theory The neuroendocrine system regulates many essential activi ties related to an organisms growth and development. The neuroendocrine (or pacemaker) theory focuses on the changes in these systems over time. It may be that common neurons in the higher brain centers act as pacemakers that regulate the biological clock during development and aging, and slow down and eventually shut off at the predetermined time. Much of the current research in this area is on the examina tion of the influence of hormones on neuroendocrine func tioning over time, especially dehydroepiandrosterone (DHEA) and melatonin. -137852-104648

Genetic Research

As the human genome is being mapped, scientists continue to examine the roles that genetics, and RNA in particular, has in both random and programmed aging and may eventually be able to explain senescence. Among the findings are that telomeres, which serve to cap the ends of the chromosomes, shorten with each cellular reproduction until a time when the

The biological theories of aging today have evolved from the early study of changes over the life span of the organism. Two related theoretical views form the founda tion of biological theories: error (stochastic) theories and predetermined aging (nonstochastic) theories. Although they differ, both viewpoints agree that, in the end, the cells in the body become disorganized or chaotic and are no longer able to replicate, and cells die. When enough cells die, so does the organism. In recent years, research on the biological theories of aging has emphasized the cells, the genes, and other components within the cell. The physical traits that identify one as older (e.g., gray hair, wrinkled skin) are referred to as the aging phenotype, that is, an outward expression of ones individual genetic makeup (Carnes, Staats, Sonntag, 2008). A short description of emerging theories can be found in Box 5-1.

Error (Stochastic) Theories

Error theories explain aging as the result of an accumula tion of errors in the synthesis of cellular DNA and RNA, the basic building blocks of the cell (Short et al., 2005). With each replication, more errors occur, until the cell is no longer able to function. The visible signs of aging, such as gray hair, are thought to be the result of the accumulation

telomere disappears and the cell can no longer reproduce and dies. Abnormal cells such as cancer cells produce an enzyme called telomerase, which actually lengthens the telomeres, enabling the cells to continue to reproduce. Learning to manipulate telomerase may have significant implications for controlling both cellular reproduction and aging.

Progerin and Telomers

Some of the latest research in this field has found an associa tion between telomeres which cap either end of chromosomes and a toxic protein call progerin. As long as a telomere is securely bound to the chromosome, the cell is able to replicate and in essence live forever. However, the telomeres actually wear away with aging at the same time the cell produces more and more progerin. The progerin, a mutated version of normal cell protein, interferes with the stability of the telomeres and ultimately the length of the cells life. (From Cao K, Faddah DA, Kieckhaefer JE, et al: Progerin and telomere dysfunction collaborate to trigger cellular senescence in normal fibroblasts, J Clin Invest 121(7): 28332844, 2011.)

CHAPTER 5 Theories of Aging and Physical Changes 57

of these cellular errors. Three of the most common theories of error are wear-and-tear, cross-linkage, and free radical.

Wear-and-Tear Theory

One of the earliest theories of aging is known as wear and-tear. According to this theory, cell errors are the result of wearing out over time because of continued use and trauma. Internal and external stressors increase the num bers of errors and the speed with which they occur (e.g., in shoulder joints of pitchers or knees of runners). These errors may cause a progressive decline in cellular function.

Cross-Link Theory

Cross-link theory explains aging in terms of the accumula tion of errors by cross-linking, or the stiffening of proteins in the cell. Proteins link with glucose and other sugars in the presence of oxygen and become stiff and thick (Marin Garcia, 2008). Because collagens are the most plentiful proteins in the body, this is where the cross-linking is most easily seen. Skin that was once smooth, silky, firm, and soft becomes drier and less elastic with age. Collagen is also a key component of the lungs, the arteries, and the tendons, and similar changes can be seen there, such as in stiffened joints.

Oxidative Stress Theory (Free Radical Theory) The oxidative stress theory, otherwise known as the free radical theory of aging, is among those most understood and accepted (Jang & Van Remmen, 2009). Free radicals are natural by-products of cellular activity and are always present to some extent. It is believed that cellular errors are the result of random damage from molecules in the cells called free radicals.

It is known that exposure to environmental pollutants increases the production of free radicals and increases the rate of damage. The best-known pollutants include smog and ozone, pesticides, and radiation (Abdollahi et al., 2004; Lodovici & Bigagli, 2011). Other environmental sources thought to cause increases in free radicals are gaso

line, by-products from the plastic industry, and drying linseed oil paints. There is also new evidence that chronic exposure to racial discrimination increases evidence of oxidative stress. This may provide some explanation for a number of the disparities in incidence and prevalence of several diseases that are associated with free radicals, such as heart disease (Pashkow, 2011). In youth, naturally oc

curring vitamins, hormones, enzymes, and antioxidents neutralize the free radicals as needed (Valko et al., 2005). However, with aging, the damage caused by free radicals occurs faster than the cells can repair themselves, and cell death occurs (Hornsby, 2009; Marin-Garcia, 2008).

Programmed Aging (Nonstochastic Theories)

The nonstochastic theories attribute the changes of aging to a process that is thought to be predetermined or pro grammed at the cellular level. This means that each cell has a natural life expectancy. As more and more cells cease to replicate, the signs of aging appear, and ultimately the person dies at a predetermined age. These theories evolved from the groundbreaking work of Hayflick and Moorehead (1981). They referred to this process as the inner biological clock. In other words, each cell is born with a limited number of replications and then it dies.

Neuroendocrine-Immunological Theory

Closely tied to both programmed and free radical theory is the immunity theory of aging. It is based on changes in the integrated neuorendocrine and immune systems. In this case, the emphasis is on the programmed deaths of the immune cells from damage caused by the increase of free radicals as aging progresses (Effros et al., 2005; Marin-Garcia, 2008). The immune system in the human body is a complex network of cells, tissues, and organs that function separately and together to protect the body from substances from the outside, such as bacteria. It is highly dependent on the release of hormones. In the simplest terms, the specialized B lymphocytes (humoral) and the T lymphocytes (cellular) protect the body against invasion by infection or other mat ter that is considered foreign, such as tissue or organ trans

plants. The results of animal studies have demonstrated that the cells of the immune system become progressively more diversified with age and in a somewhat predictable fashion lose some of their ability to self-regulate. The T lymphocytes show more signs of aging than do the B lymphocytes. The reduced T cells are thought to be responsible for hastening the age-related changes caused by autoimmune reactions as the body battles itself; healthy cells are mistaken for foreign substances and are attacked.

It is important for the nurse to understand that the exact cause of aging is unknown; there is considerable variation in the aging process. Not only is there variation between per sons but also between the systems of any one person. Aging is a wholly unique and individual experience.

Physical Changes that Accompany Aging

Integumentary

The skin is composed of the epidermis, the dermis, and the hypodermis. As the largest, most visible organ of the body,

58 SECTION 1 Foundations of Healthy Aging

the various layers of the skin mold and model the indi vidual to give much of his or her personal and sexual identity. The skin and hair provide clues to heredity, race, and physical and emotional health.

Many age-related changes in the skin are functionally inconsequential, but others have implications for organs throughout the body and have more far-reaching impact. Skin changes occur due to both genetic (intrinsic) factors and environmental (extrinsic) factors such as wind, sun, and pollution, to which skin is especially sensitive. Cigarette smoking causes coarse wrinkles, and the photo-damage of the sun is evidenced by rough, leathery texture, itching, and mottled pigmentation, among other signs. Changes that may be genetic, environmental, or both include dryness, thinning, decreased elasticity, and the development of prominent small blood vessels. Skin tears, purpura (large purple spots), and xerosis (excessive dryness) are common but not normal aspects of physical aging. Visible changes of the skinquality of color, firmness, elasticity, and texture affirm that one is aging.

Epidermis

The epidermis is the outer layer of skin and is composed primarily of tough keratinocytes and squamous cells. Mela nocytes produce melanin, which gives the skin color. With age, the epidermis thins, making blood vessels and bruises much more visible. T-cell function declines, and there may be a reactivation of latent conditions such as herpes zoster (shingles) or herpes simplex, making a shingles immuniza tion particularly important for persons who had chicken pox or varicella when younger.

Cell renewal time increases by up to one third after 50 years of age; 30 or more days may be necessary for new epithelial replacement (Gosain & DiPietro, 2004). This change significantly affects wound healing. In a younger adult, if the skin is injured (e.g., a cut or scrape), the surrounding tissue becomes red (erythematous) almost immediately. This inflammatory response is the first step in the natural healing process. In an older adult, this inflam

mation may not begin to occur for 48 to 72 hours. A lac eration that becomes pink several days after the event may be misinterpreted by the nurse as having become infected, when in reality, the healing process has only just started. Evidence of true skin infection in older adults is no different than in younger adults, namely, increasing redness and purulent drainage.

The number of melanocytes in the epidermis decreases. Fewer melanocytes means a lightening of the overall skin tone, regardless of original skin color, and a decrease in the amount of protection from ultraviolet rays; the importance of sunscreen is thus significantly increased (see Chapter 12).

However, in some body areas, melanin synthesis is in creased. Pigment spots (freckles and nevi) enlarge and can become more numerous with increased exposure to natural and artificial light. Lentigines appear, commonly referred to as age spots or liver spots. They are frequently found on the backs of the hands and the wrists, and on the faces of light-skinned persons older than 50 years of age. Thick, brown, raised lesions with a stuck on appearance (sebor rheic keratoses) are more common in men and are of no clinical significance but can become cosmetically disfigur ing if severe.

Dermis

The dermis, lying beneath the epidermis, is a supportive layer of connective tissue composed of a combination of yellow elastic fibers that provide stretch and recoil and white fibrous collagen fibers that provide strength. It also supports hair follicles, sweat glands, sebaceous glands, nerve fibers, muscle cells, and blood vessels, which provide nourishment to the epidermis. Sun exposure accelerates skin tissue changes by hastening changes in collagen fiber.

Many of the visible signs of aging skin are reflections of changes in the dermis. The dermis loses about 20% of its thickness (Friedman, 2011). This thinness causes older skin to look more transparent and fragile. Dermal blood vessels are reduced, which accounts for resultant skin pallor and cooler skin temperature. Collagen synthesis decreases, causing the skin to give less under stress and tear more easily. Elastin fibers thicken and fragment, leading to loss of stretch and resilience and a sagging appearance. Loss of elasticity accentuates jowls and elongated ears and con tributes to the formation of a double chin. Breasts that were full and firm begin to sag. As will be seen, the impact of the change in elastin has implications for a number of other systems as well.

Hypodermis: Subcutaneous Layer

The hypodermis is the innermost layer of the skin, and it contains connective tissues, blood vessels, and nerves, but the major component is subcutaneous fat (adipose tissue). The primary purposes of the adipose tissue are to store calo

ries and provide temperature regulation. It also provides shape and form to the body and acts as a shock absorber against trauma. With age, some areas of the hypodermis thin. As the natural insulation of fat decreases, a person becomes more sensitive to the cold.

Changes in the hypodermis also increase the chance for the person to become overheated (hyperthermia) as a result of the reduced efficiency of the eccrine (sweat) glands. Sweat glands are located all over the body and respond to thermostimulation and neurostimulation in response to

CHAPTER 5 Theories of Aging and Physical Changes 59

internal changes (e.g., fever, menopausal hot flashes) or increases in environmental temperatures. The usual body response to heat is to produce moisture or sweat from these glands and thus cool the skin by evaporation. With aging, the glands become fibrotic, and surrounding connective tissue becomes avascular, leading to a decline in the effi

ciency of the body to cool down. It is not uncommon for persons to complain of being either too hot or too cold in environments that are comfortable to others.

Sebaceous (oil) glands also atrophy. Sebum, produced by the gland, protects the skin by preventing the evapora tion of water from the epidermis; it possesses bactericidal properties and contains a precursor of vitamin D. When the skin is exposed to sunlight, vitamin D is produced and absorbed into the skin. Continuing to produce Vitamin D is especially important because of the high incidence of osteoporosis (see Structure, Posture, and Body Composition later in this chapter and Chapter 18). All people need some sunshine and probably vitamin D supplementation every day, especially those living in residential care facilities who have fewer opportunities to be outside.

Older adults are at significant risk for both hyper thermia and hypothermia. When caring for frail older adults, gerontological nurses can promote healthy aging by helping their patients avoid extremes of temperature, prevent drying, and prevent exposure to toxic products (see Chapter 13).

Hair and Nails

Hair, as part of the integument, has biological, psychologi cal, and cosmetic value. Hair is composed of tightly fused horny cells that arise from the dermal layer of the skin and are colored by melanocytes. Genetics, race, sex, and hormones influence hair color and distribution in both men and women.

Men and women in all racial groups have less hair as they grow older. Hair on the head thins. Scalp hair loss is prominent in men, beginning as early as the twenties. The hair in the ears, the nose, and the eyebrows of older men increases and stiffens. Women have less pronounced scalp hair loss (Luggen, 2005). For some, the accustomed hair color remains, but for most, there is a gradual loss of pig

mentation (melanin) and it becomes dryer and coarser. Older women develop chin and facial hair because of the decreased estrogen to testosterone ratio. Leg, axillary, and pubic hair lessens and in some instances disappears in postmenopausal women. The absence of leg hair can be misinterpreted as a sign of peripheral vascular disease in the older adult, whereas it is a normal change of aging.

The various races have distinctive hair characteristics, which should be kept in mind when caring for or assessing

the person. Almost all Asians have sparse facial and body hair that is dark, silky, and most often straight. African Americans have slightly more head and body hair than Asians; however, the hair texture varies widely. It is always fragile, and it ranges from straight to spiraled, and thin to thick. Whites have the most head and body hair, with an intermediate texture and form ranging from straight to curly, fine to coarse, and thick to thin.

The nail becomes harder and thicker, and more brittle, dull, and opaque. It changes shape, becoming at times flat or concave instead of convex. Vertical ridges appear be cause of decreasing water, calcium, and lipid content. The blood supply, as well as the rate of nail growth, decreases. The half moon (lunule) of the fingernail may entirely dis appear; the color of the nails may vary from yellow to gray, although with the widespread use of acrylics on the nails, long-term effects are not yet known. The development of a fungal infection of the nails (onychomycosis) is not the result of aging but is quite common. Fungus invades the space between the layers of the nails, leaving a thick and unsightly appearance. The slowness of growth and the reduced circulation in the older nail make it very difficult to treat.

For suggestions of nursing interventions that promote healthy skin during aging see Box 5-2.

Musculoskeletal

A functioning musculoskeletal system is necessary for the bodys movement in space, for gross responses to environ mental forces, and for the maintenance of posture. This complex system comprises bones, joints, tendons, ligaments, and muscles.

Although none of the age-related changes to the mus culoskeletal system are life-threatening, any of them could affect ones ability to function and therefore ones quality of life. Some of the changes are visible to others and have the potential to affect the individuals self-esteem. As seen with the skin, changes in the musculoskeletal system are influ enced by many factors, such as age, sex, race, and environ ment; signs begin to become obvious in the forties.

BOX 5-2 Promoting Healthy Skin While Aging

Avoid excessive exposure to ultraviolet light. -150311-108089

Keep skin moisturized.

Avoid use of drying soaps.

Always use sunscreens.

Keep well hydrated.

60 SECTION 1 Foundations of Healthy Aging

The musculoskeletal changes that have the most effect on function are related to the ligaments, tendons, and joints; over time these become dry, hardened, and less flex ible. In joints that had been subjected to trauma earlier in life (injuries or repetitive movement), these changes can be seen earlier and are more severe. If joint space is reduced, arthritis is diagnosed.

Muscle mass can continue to build until the person is in his or her fifties. However, between 30% and 40% of the skeletal muscle mass of a 30-year-old may be lost by the time the person is in his or her nineties (Crowther

Radulewicz, 2010). Disuse of the muscles accelerates the loss of strength. Age-related changes to muscles are known as sarcopenia and are seen almost exclusively in the skeletal muscle. Muscle tissue mass decreases (atrophies) whereas adipose tissue increases in key areas. The replacement of lean muscle by adipose tissue is most noticeable in men in the area of the waist and in women between the umbilicus and the symphysis pubis. The nurse can encourage older adults to exercise, especially through weight-bearing exer cises, to help maintain healthy bones and muscles and flexibility (Box 5-3). See Chapter 11 for discussion on exercise.

Structure, Posture, and Body Composition Changes in stature and posture are two of the more obvi ous signs of aging and are associated with multiple fac tors involving skeletal, muscular, subcutaneous, and fat tissue. Vertebral disks become thin as a result of dehydra tion, causing a shortening of the trunk. These changes may begin to be seen as early as the fifties (Crowther Radulewicz, 2010). The trunk shortens as a result of grav ity and dehydration of the vertebral disks. The person may have a stooped appearance from kyphosis, a curva ture of the cervical vertebrae arising from reduced bone mineral density (BMD). Some loss of BMD in women is associated with the reduction of estrogen levels after menopause. With the shortened appearance, the bones of

BOX 5-3 Promoting Healthy Bones and Muscles

Ensure regular and adequate intake of vitamin D and calcium. -292995-108090

Engage in regular weight-bearing exercise, for example, Tai Chi.

Engage in regular flexibility and balance exercises, for example, yoga.

For women: consider preventive pharmacotherapeutics.

the arms and the legs may appear disproportionate in size. If a persons bone mineral density is very low, it is diagnosed as osteoporosis and a loss of 2 to 3 inches in height is not uncommon (see Chapter 18).

Alteration in body shape and weight occurs as lean body mass declines and body water is lost: 54% to 60% in men; 46% to 52% in women (Kee et al., 2009). Fat tissue increases until 60 years of age; therefore body density is higher in youth because of the density of muscle compared to the lightness of fat. From 25 to 75 years of age, fat content of the body increases by 16%. Cellular solids and bone mass decline; extracellular water, however, remains relatively constant. The water loss has significant implica tions for the dramatically increased risk for dehydration (Figure 5-1).

Cardiovascular

The cardiovascular system is responsible for the transport of oxygen and nutrient-rich blood to the organs and the transport of metabolic waste products to the kidneys and the bowels. The most relevant age-related changes in this system are myocardial and blood vessel stiffening and de

creased responsiveness to sudden changes in demand (Brashers & McCance, 2010). Changes in the cardiovas cular (CV) system are progressive and cumulative.

Cardiac

The age-related changes of the heart (presbycardia) are structural, electrical, and functional. The size of the heart remains relatively unchanged in healthy adults. However, the left ventricle wall thickens by as much as 50% by 80 years of age, and the left atrium increases in size slightlyan adaptation that enhances ventricular filling (Taffet & Lakatta, 2003). Maximum coronary artery blood flow, stroke volume, and cardiac output are decreased. In health, the changes have little or no effect on the hearts ability to function in day-to-day life. The changes only become significant when there are environmental, physical, or psychological stresses. With sudden demands for more oxygen the heart may not be able to respond adequately (Marin-Garcia, 2008). It takes longer for the heart to accelerate and then return to a resting state.

For the gerontological nurse, this means that the in creased heart rate one might expect to see when the person is in pain, anxious, febrile, or hemorrhaging may not be present or will be delayed. Similarly, the older heart may not be able to respond to other calls for increased cardiac demand such as infection, anemia, pneumonia, cardiac dysrhythmias, surgery, diarrhea, hypoglycemia, malnutri tion, and drug-induced and noncardiac illnesses such as

t h

CHAPTER 5 Theories of Aging and Physical Changes 61

Proportion of Body Weight Represented by Water

100 3787662762

Newborn infant

(80%)

Adult male over age 65 (60%)

Adult female over age 65 (45%50%)

FIGURE 5-1 Changes in body water distribution. (From Thibodeau GA, Patton KT: Structure and function of the body, ed 12, St. Louis, 2004, Mosby.)

renal disease and prostatic obstruction. Instead, the nurse must depend on other signs of distress in the older patient and be diligently alert to signs of rapid decompensation of both the previously well elder and one who is already medically fragile, such as those in nursing homes.

Heart disease is the number one cause of nonaccidental death in developed nations. Often the changes associated with disease are thought to be normal, but they are not. The nurse promotes healthy aging with recommendations for heart-healthy life choices and urging the elder to seek and receive excellent health care.

Blood Vessels

Several of the same age-related changes seen in the skin and muscles affect the lining (intima) of the blood vessels, espe cially the arteries. As in the skin, the most significant change is decreased elasticity which allows some blood to circulate. The blood supply to various organs decreases, and resistance in the blood vessels increases. Change in flow to the coronary arteries and the brain is minimal, but decreased blood flow to other organs, especially the liver and kidneys, has potentially serious implications for medication use (see Chapter 8). When a person already has or develops arteriosclerosis or hypertension, the age-related changes can have serious consequences.

Less dramatic changes are found in the veins; although they do stretch somewhat, the valves which keep the blood from flowing backward become less efficient. This means that lower extremity edema develops more quickly and that the older adult is more at risk for deep vein thrombo

sis (blood clots) because of the increased sluggishness of the venous circulation. The normal changes, when com bined with long-standing but unknown weakness of the vessels, may become visible in varicose veins and explain the increased rate of stroke and aneurysms in older adults. However, the promotion of a healthier cardiovascular sys tem is always possible (Box 5-4).

BOX 5-4 Promoting a Healthy Heart

Engage in regular exercise. -150311-108090

Eat a low-fat, low-cholesterol, balanced diet.

Maintain tight control of diabetes.

Do not smoke, and avoid exposure to smoke.

Avoid environmental pollutants.

Practice stress management.

Minimize sodium intake.

Maintain ideal body weight.

62 SECTION 1 Foundations of Healthy Aging

Respiratory

The respiratory system is the vehicle for ventilation and gas exchange, particularly the transfer of oxygen into and the release of carbon dioxide from the blood. The respira tory structures depend on the musculoskeletal and ner vous systems to function fully. The respiratory system matures by the age of 20 and then begins to decline even in healthy individuals. Although subtle changes occur in the lungs, the thoracic cage, the respiratory muscles, and the respiratory centers in the central nervous system, the changes are small and, for the most part, insignificant. The specific changes include loss of elasticity resulting in stiffening of the chest wall, inefficiency in gas exchange, and increased resistance to air flow (Figure 5-2). Respira tory problems are common but almost always the result of exposure to environmental toxins (e.g., pollution, ciga rette smoke) rather than the aging process (Sheahan & Musialowski, 2001).

Like the cardiovascular system, the biggest change is in the efficiency, in this case, of gas exchange. Under usual conditions, this has little or no effect on the performance of customary life activities. However, when an individual is confronted with a sudden demand for increased oxygen, a respiratory deficit may occur. The body is not as sensitive to low oxygen levels or elevated carbon dioxide levels, each

indicating the need to increase the rate of breathing. The changes that occur in the anatomical structures of the chest and altered muscle strength can significantly affect ones ability to cough forcefully enough to quickly expel materials that accumulate in or obstruct airways. In addi

tion, the respiratory cilia, small fibers in the respiratory system, are less effective. Together these place the person at high risk of potentially life-threatening infections and as piration. In the presence of impairment, such as difficulty swallowing or decreased movement in the esophagus, the risk is significantly increased; this is often the case after a person has had a stroke. All of these make the promotion of health through the prevention of respiratory illnesses of the highest importance (Box 5-5).

Renal

The renal system is responsible for regulating water and salts in the body and maintaining the acid/base balance in the blood. The glomerulus is the key structure in the kid ney that controls the rate of filtering (glomerular filtration rate [GFR]). With each beat of the heart the blood passes through the smallest tubes (nephrons) in the kidneys for filtering. This filtering is the mechanism wherein waste products are removed by the production of urine and needed products like water and salts are held back. Among the many changes to the kidneys are those of blood flow, GFR, and the ability to regulate body fluids. Blood flow through the kidneys decreases by about 10% per decade, from about 1200 mL/min in young adults to about 600 mL/min by 80 years of age, as a result of vascular and fixed anatomical and structural changes

YOUNGER -33054-602901

LUNG

Inspiratory

reserve volume Tidal volume

Expiratory

reserve volume Residual volume

AGING

LUNG

Total lung

capacity

Vital capacity

(Macias-Nunez & Cameron, 2008; Wiggins & Patel, 2009). Yet the kidneys lose as many as 50% of the neph rons with little change in the bodys ability to regulate body fluids and maintain adequate day-to-day fluid homeostasis. The age-related decrease in size and function

BOX 5-5 Promoting Healthy Lungs

Obtain pneumonia immunization. -150310-108090

Obtain annual influenza immunization.

Avoid exposure to smoke and pollutants.

Do not smoke.

Avoid persons with respiratory illnesses.

Seek prompt treatment of respiratory infections. Wash hands frequently.

FIGURE 5-2 Changes in lung volumes with aging. (From McCance KL, Huether SE, editors: Pathophysiology: the biologic basis for disease in adults and children, ed 5, St. Louis, 2006, Mosby.)

Eat meals in relaxed atmosphere. Practice regular oral hygiene.

CHAPTER 5 Theories of Aging and Physical Changes 63

occurs primarily in the kidney cortex, the top of the kidney, begins in the thirties, and becomes significant by the seventies. There is no significant variation by sex or race (Macias-Nunez & Cameron, 2008). Like the other organs, renal reserve is lost and/or the ability to quickly respond to the stress of either a salt or water excess or loss is decreased even in a healthy elder (Choudhury & Levi, 2011). Kidney function is measured through the calcula

tion of the creatinine clearance rate (CrCl) (see Chapter 8). Creatinine is the end product of the breakdown in musl ces as they are used. Whereas creatinine in the plasma is constant throughout life, urine creatinine shows a decline because of normal age-related loss of lean muscle mass. The urine creatinine clearance is an important indicator for ap propriate drug therapy, reflecting the ability to handle medi cations passing through and metabolized by the kidneys (see Chapter 8). Persons with a reduced creatinine clearance usually need a reduction in the dosages of their medications to prevent potential toxicity, and caution must be used in the administration of intravenous fluids.

Age-related changes in the renal system are significant due to resultant heightened susceptibility to fluid and electrolyte imbalance and structural damage from medica tions and contrast media of diagnostic tests. Under normal circumstances, renal function is sufficient to meet the regu lation and excretion demands of the body (Macias-Nunez & Cameron, 2008). However, with the stress of disease, surgery, or fever, the kidneys have reduced capacity to re spond and are therefore at greater risk for damage or even acute failure.

Endocrine

The endocrine system, working along with the neurologi cal system, helps regulate and control the activities within the body so that they work together. This is done through the secretion and distribution of hormones from glands found throughout the body. As the body ages, most glands atrophy and decrease their rate of secretion. However, other than a dramatic decrease in estrogen, which causes menopause, the impact of the changes is not clear.

Pancreas

The endocrine pancreas secretes insulin, glucagon, somatosta tin, and pancreatic polypeptides. The secretion of these sub stances does not appear to decrease to any level of clinical significance. However, for reasons unknown, the tissues of the body often develop decreased sensitivity to insulin. When combined with increased needs for insulin in the presence of obesity, the result is often the development of type 2 diabetes (see Chapter 17). Older adults have the highest rate of

type 2 diabetes of any age group, with significant variation by ethnicity and region. When the pancreas is stressed with sudden concentrations of glucose, such as a high carbohydrate meal, blood levels are higher for longer. These temporary levels of increased blood glucose sometimes make the diagnosis of true diabetes difficult.

Thyroid

Slight changes occur in the structure and function of the thyroid gland, which may explain the slight, but nonethe less important, increased incidence of hypothyroidism, or lowered function, in older adults (Brashers & Jones, 2010). Some atrophy, fibrosis, and inflammation occurs. Although other evidence of change is inconclusive at this time, diminished secretion of thyroid-stimulating hormone (TSH) and thyroxine (T4) and decreased plasma triiodothyronine (T3) appear to be age related. Serum T3

decreases with age, perhaps as a result of decreased secre tion of TSH by the pituitary gland. When thyroid re placement is needed, lower doses are usually effective and higher doses contraindicated. In addition, the therapeutic dose of medication may change over time and monitoring is required (see Chapter 17).

Collective signs, such as a slowed basal metabolic rate, thinning of the hair, and dry skin, are characteristic of hypothyroidism in the young but are normal manifes tations in the aged who have no history of thyroid defi ciencies, making the recognition of thyroid disturbances difficult.

Reproductive

The reproductive systems in men and women serve the same physiological purposehuman procreation and also control the phyenotypes (external appearance) that we recognize as male and female. Although both aging men and women undergo age-related changes, the changes affect women significantly more than men. Women lose the ability to procreate after the cessation of ovulation (menopause), whereas men remain fertile their entire lives. Regardless of the physical changes, the need for sexual expression remains (see Chapter 24).

Female Reproductive System

As menopause signals the end of the reproductive phase in a womans life, several other age-related changes occur, particularly in breast tissue and urogenital structures. Older breasts are smaller, pendulous, and less firm. Outwardly, the labia majora and minora become less prominent and pubic hair thins. The ovaries, cervix, and uterus slowly atrophy. The vagina shortens, narrows, and loses some of its

64 SECTION 1 Foundations of Healthy Aging

elasticity, typical of aging muscle and skin. Vaginal walls also lose their ability to lubricate quickly, especially if the woman is not sexually active. More stimulation is needed to achieve orgasm. The vaginal epithelium changes consider

ably; the pH rises from 4.0 to 6.0 before menopause to 6.5 to 8.0 afterward (Deneris & Huether, 2010). The vagi nal changes result in the potential for dyspareunia (painful intercourse), trauma during intercourse, and increased sus ceptibility to infection.

Male Reproductive System

Although men have the ability to produce sperm through out their lives, they also experience changes in the func tioning of the reproductive and the urogenital organs in late life. The changes are usually more subtle and noticed only as they accumulate, beginning when men are in their 50s. The testes atrophy and soften. The seminiferous tu bules where semen is produced thicken, and obstruction caused by sclerosis and fibrosis can occur. Although sperm count does not decrease, fertility may be reduced because of the higher number of sperm lacking motility or because of the structural abnormalities just noted. Erectile changes are also seen: more stimulation is needed to achieve a full erection, ejaculation is slower and less forceful, and the period between the ability to have an erection increases (Deneris & Huether, 2010). As with women, alterations in hormone balances may play a part in the age-related changes in men. Testosterone level is reduced in all men but only rarely to the level at which it would be considered a true deficiency.

By 80 years of age, up to 80% of men have some de gree of prostatic enlargement (Kamel & Dornbrand, 2004). The condition known as benign prostatic hyperpla sia (BPH) is so common that some are beginning to call it a normal part of aging. The only time it is considered a problem is when the enlargement is such that it causes compression of the urethra and urinary retention. BPH is most often the cause of repeated urinary tract infec tions. Intervention is pursued only when the symptoms of BPH interfere with the mans quality of life (Kamel & Dornbrand, 2004).

Digestive

The digestive system includes the gastrointestinal (GI) tract and the accessory organs that aid in digestion. Like the en docrine system, few true age-related changes affect function. However, a number of common health problems can have a great effect on the digestive system. Changes in other sys tems can also affect GI structure and function; with these changes seen as early as the fifties (Huether, 2010).

Mouth

Age-related changes affect both the teeth and the mouth. With the wear and tear of years of use, the teeth eventually lose enamel and dentin and then become more vulnerable to decay (caries). The roots become more brittle and break more easily. For unknown reasons, the gums are also more susceptible to periodontal disease. Without care, teeth may be lost. Taste buds decline in number, and salivary secre

tion lessens. A very dry mouth (xerostomia) is common. It is still common to care for persons over 80 or 90 years of age who have had all of their teeth removed (edentulous) and who may or may not wear dentures. It is important that the nurse ensure the fit and cleanliness of the dentures or the appropriate choice of diet. Even in health, these changes combine to create the potential for decreased pleasure and comfort in eating, which in turn can lead to loss of appetite (anorexia) and weight loss. A number of medications taken for common health problems can quickly exacerbate potential problems, especially xerosto mia. When the gerontological nurse administers medica

tions to an older adult or conducts medication education, he or she needs to know if these effects apply and should warn persons about this potential and work with the person to manage this problem (see Chapter 8).

Esophagus

In youth, food passes quickly through the esophagus to the stomach because of the strong and coordinated contrac tions of the surrounding muscles. In aging, the contrac tions increase in frequency but are more disordered, and therefore movement forward is less effective. This is re ferred to as presbyesophagus. The sluggish emptying of the esophagus may cause the lower end to dilate, creating greater stress in this area and possibly causing digestive discomfort. Pathological processes that are increasingly seen as adults become older include gastroesophageal re flux disease (GERD) and hiatal hernias.

Stomach

There are several age-related changes in the stomach. These include decreased gastric motility and volume and reduc tions in the secretion of bicarbonate and gastric mucus. The reductions are caused by gastric atrophy and result in hypo chlorhydria (insufficient hydrochloric acid). Decreased pro duction of something called intrinsic factor can lead to pernicious anemia if the stomach is not able to utilize an adequate amount of ingested vitamin B12, needed for the production of red blood cells. The protective alkaline viscous mucus of the stomach is lost because of the increase in stomach pH. This makes the stomach more susceptible to peptic ulcer disease, particularly with the use of nonsteroidal

CHAPTER 5 Theories of Aging and Physical Changes 65

antiinflammatory drugs such as aspirin and ibuprofen. Loss of smooth muscle in the stomach delays emptying time, which may lead to anorexia or weight loss as a result of distention, or the sensation of being overfull after a meal (Price & Wilson, 2002).

Intestines

The age-related changes of the small intestine include those noted earlier that involve smooth muscles and those related to the gastric villi, the anatomical structures in the intestinal walls where nutrients are absorbed from in

gested food. The villi become broader and shorter and less functional. Nutrient absorption is affected; proteins, fats, minerals (including calcium), vitamins (especially B12), and carbohydrates (especially lactose) are absorbed more slowly and in lesser amounts (Huether, 2010b). Changes in motility, epithelial membranes, vascular perfusion, and gastrointestinal membrane transport may affect absorp

tion of lipids, amino acids, glucose, calcium, and iron. Peristalsis (surrounding muscular contraction) is slowed with aging and there is blunted response to rectal filling; the extent of the change should not be such to cause problems with defecation. In other words, constipation, which is often thought of as a normal part of aging, is not. Instead, consti pation is more often a side effect of medications, life habits, immobility, inadequate fluid intake, and lack of attention to the gastrocolic reflex, the urge to defecate following a meal. The role of the gerontological nurse and elimination needs are presented in Chapter 9 and suggestions on promoting healthy digestion are found in Box 5-6.

Accessory Organs

The accessory organs of the digestive system are the liver and the gallbladder. The liver continues to function

BOX 5-6 Promoting Healthy Digestion

Practice good oral hygiene. -150311-108090

Wear properly fitting dentures.

Seek prompt treatment of dental caries and

periodontal disease.

Eat meals in relaxed atmosphere.

Maintain adequate intake of fluids.

Provide time for response to gastrocolic reflex. Respond promptly to urge to defecate.

Eat a balanced diet.

Avoid prolonged periods of immobility.

Avoid tobacco products.

throughout life despite a decrease in volume and weight (mass) and a concomitant decrease in liver blood flow of 30% to 40% by the late nineties (Hall, 2009); this carries implications for impaired drug metabolism and is associ

ated with an increased half-life of fat-soluble medica tions (see Chapter 8). While slow, liver regeneration is not greatly impaired, and liver function tests remain un altered with age.

There does not seem to be a specific change in the gallbladder; however, the incidence of gallstones increases (Hall, 2009). This is possibly caused by the increased lipogenic composition of bile from biliary cholesterol. The decrease in bile salt synthesis increases the incidence of gallstones (Hall, 2009). In addition, the decrease in bile acid synthesis causes a reduction in the ability of the body to rid itself of unnecessary cholesterol. This, in con

junction with a decrease in hepatic extraction of low density lipoprotein (LDL) cholesterol from the blood, increases the level of serum cholesterol in the older adult. For women, the increase in cholesterol begins to be seen following menopause.

Neurological

Contrary to popular belief, the older nervous system, in cluding the brain, is remarkably resilient and other than very slight disturbances in recent memory, changes in cog nitive functioning are not a normal part of aging. Neither the elder nor the nurse should accept an assessment of confusion without making sure the cause is identified and treated if at all possible. Although many neurophysiological changes occur in some older adults, they do not occur in all and do not affect everyone the same way, therefore cannot be attributed to normal aging. For example, the presence of neurofibrillary tangles is a classic sign of dementia and is found in the brains of all persons with Alzheimers disease, but they are found also in the brains of persons without dementia. Although it is very difficult to show a true cause and effect of age-related changes in the nervous system, several changes appear to be consistent.

Central Nervous System (CNS)

The major changes in the aging nervous system are found in the CNS. With aging, the number of neurons (cells in the nervous system) decreases and the dendrites which extend from the neurons appear to be wearing out, and correlate with a decrease in brain weight and size (Figure 5-3). This change in size is seen primarily in the frontal lobe and appears as atrophy on computed tomography (CT) scans or mag

netic resonance imaging (MRI) While its meaning is contro versial (Snowdon, 2002), it is usually considered clinically

HH/NURS3750 Healthy Aging Summer 2023 (35%) Paper Rubric

Criteria* A+ to A

Exceptional - Excellent B+ to B

Very Good - Good C+ to C

Competent Fairly Competent D+ or less

Does not meet criteria

Briefly describe your experience with an older person or group of older persons with reference to the cultural community in which they live Excellent discussion on the experience- Details and descriptions provided Good discussion on the experience- Some details and descriptions provided Satisfactory discussion on the experience- little detail and descriptions provided Poor discussion on the experience- No detail or descriptions provided

How does the person experience life within their culture? Provide some examples Excellent discussion with various examples provided Good discussion with one or two examples provided Satisfactory discussion with one example provided Poor discussion no examples provided

What characteristics does this person(s) possess that might contribute to healthy aging? Excellent illustrations with an in-depth discussion on the persons attributes to healthy aging

Good illustrations with discussions on the persons attributes to healthy aging

Satisfactory illustration with brief discussion on the persons attributes to healthy aging

Poor illustration with no discussion on the persons attributes to healthy aging

What resources are in this cultural community that contribute to healthy aging? Identify if the client uses these resources in the community and how. Excellent dialogue on the community resources that the person is using contribute to healthy aging Good dialogue on the community resources that the person is using contribute to healthy aging Satisfactory dialogue on the community resources that the person is using contribute to healthy aging Poor dialogue on the community resources that the person is using contribute to healthy aging

Select one theory or concept from class that fits your observations/experiences and demonstrate how it fits with this paper. Include what may be missing in this theory/concept or does not fit your observation/experiences. Excellent discussion on a Theory/concept discussed and analyzed in depth as to how it relates or does not relate to the person and their culture identified Good discussion on a Theory/concept discussed and analyzed as to how it relates or does not relate to the person and their culture identified Satisfactory discussion on a Theory/concept discussed and analyzed somewhat as to how it relates or does not relate to the person and their culture identified Poor discussion on a Theory/concept discussed no analysis provided as to how it relates or does not relate to the person and their culture identified

From a nursing perspective, what did you learn from writing this paper that enhanced your understanding of health and aging with respect to culture? (2 paragraphs) Excellent discussion on how health care providers can gain from this understanding in the management of an aging population with clear examples Good discussion on how health care providers can gain from this understanding in the management of an aging population with clear examples Satisfactory discussion on how health care providers can gain from this understanding in the management of an aging population with examples Poor discussion on how health care providers can gain from this understanding in the management of an aging population. No examples provided.

APA and formatting

spelling and grammar Great read. Thank you!

APA 7th near perfect. Meanings and conclusions are personal and valid.

References were near with no errorsReads mainly well with some issues of grammar, spelling, APA, meaningReferences were with minor errorsNeed to Proof Reading?

there are many APA errors -see comments on the paperMany reference errors Very difficult to read

you have great difficulty and need more assistance with APA

Week 6, 7, 8, & 9, June 21,

July 5, 12, & 19 Group Presentation ( Relates to Course Learning Outcomes 2-4, 6,7) 15%

Week 11 August 2nd Aesthetic Work on How you view aging and older people 20%

Week 12 August 9 Final in class test

(Relates to Course Learning Outcomes # 1 7)

20%

Description of Course Evaluation

Analysis and discussion about readings related to the topic of the week (Learning groups). Assignments worth 2.5% each for total 10% (weeks 2, 4, 5, 10)

Learning Groups of 6-7 people will be established in the first class of the course on May 11, 2022. You will be pre-assigned and will receive a number for the group you are in. You cannot change your assigned group unless it is via a trade with another student. Any trades must be made prior to week 2 and I must be made aware of any cha

Cultural Perspectives of Aging paper worth 35% of Course Grade

The purpose of this scholarly assignment is for you to gain new or different perspectives of aging by observing aging through a cultural lens. You are encouraged to step away from how you currently think about aging, and instead explore and reflect upon the perspectives of an aging person within their culture. In the context of this paper the aging population is anyone 65 years of age or older.

You may choose to consider observations of one or more older persons in your own culture or the experiences you have/have had with older persons in another community culture. (An example might be if you work in a long-term care setting that is mostly Jewish or Chinese when you are from a South Asian culture.) The person(s) you are observing need(s) to be currently living in Canada.

Based on these observations and experiences answer the questions and/or provide information:

Briefly describe your experience with an older person or group of older persons with reference to the cultural community in which they live. (1-2 paragraph)

How does the person experience life within their culture? Provide some examples (2-3 paragraphs)

What characteristics does this person(s) possess that might contribute to healthy aging? (1-2 paragraphs)

What resources are in this cultural community that contribute to healthy aging? (2-3 paragraphs)

From a nursing perspective, what did you learn from writing this paper that enhanced your understanding of health and aging with respect to culture? (2 paragraphs)

NOTE: refer to chapter 4 in the text for a background of culture and aging

NOTE: Remember that sometimes an immigrant community will express culture differently than how it is expressed in their home country. Make a note if this is the case.

Additional criteria for this paper:

Typed following APA 7th ed. guidelines for writing and format (double spaced, 1 or 2.5cm margins on all sides of the page, font Times Roman 12, appropriate citations and referencing).

This is a scholarly paper, so provide a formal introduction and conclusion.

Remember that you must provide credit for ideas you read using appropriate quotations and/or citations; to do otherwise is plagiarism. You are expected to cite at least three references in this paper; the course text can be considered as one reference only.

Submit between 5-6 pages typed excluding title page, references, and appendix if relevant (can be shorter). Length of sections noted provides a guideline.

One copy of the complete paper must be submitted on Turnitin by 2359 on June 15th. Marks will be deducted if the assignment is late and not negotiated previously with the CD.

A letter grade, not a percentage grade, will be given for this assignment. Grades will be reflective of the grading criteria provided later in this course outline.

Criteria for Grading:

Demonstrate critical self-reflection and analysisLogical flow of idea.

Touhy, T, A., Jett, K, F., Boscart, V., & McCleary, L. (2019). Ebersole and Hess Gerontological Nursing and Healthy Aging. (2nd Canadian Ed) Elsevier, Canada.

Chapter 4; pp 368-372; pp 395-401

Required Texts

Touhy, T. A., Jett, K. F., Boscart, V., & McLearly, L. (2019). Ebersole and Hess gerontological nursing and healthy aging (2nd Canadian ed.). Elsevier Canada.

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.).

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