Health Needs of Older
Adults
Upon mastery of this chapter, you should be able to:
● Provide an example of
primary, secondary, and tertiary prevention practices among the older
population.
● Identify and depict nutrition needs of older
adults.
● Identify exercise needs of older adults.
● Identify and describe economic security needs of
older adults.
● Identify and describe psychosocial needs of
older adults.
·
Coping With
Multiple Losses
·
Maintaining
·
Social Interaction, Companionship, and Purpose
·
Safety Needs
● Spirituality, Advance Directives, and Preparing for Death
Effective
nursing in any population requires familiarity with that group’s health
problems and needs. Aging in and of itself is not a health problem. Rather,
aging is a normal, irreversible physiologic process. Its pace, however, can
sometimes be delayed, as researchers are discovering, and many of the problems
associated with aging can be prevented (Menzey,
2001). The aging process is subtle, gradual, and lifelong. One can see
remarkable differences among individuals in the rate of aging. Even in a single
individual, various systems of the body age differently (Eliopoulos, 2001).
multiple, chronic, and often disabling
conditions.
The
elderly, like any age group, have certain basic needs: physiologic and safety
needs as well as the needs for love and belonging, self-esteem, and
self-actualization. Their physical, emotional, and social needs are complex and
interrelated. The following sections discuss these needs according to primary,
secondary, and tertiary prevention activities.
Primary Prevention
As
discussed previously in this text, primary prevention activities involve those
actions that keep one healthy. Such primary prevention activities as health
education, follow-through of sound personal health practices, and maintenance
of an appropriate immunization schedule ensure that older adults are doing all
that they can to maintain their health. The list in Display 30–2 includes
strategies for successful aging. Taken from a variety of sources, it provides
primary prevention activites the community health
nurse can use when working with elders, either individually or in groups.
Nutrition Needs
People
who have maintained sound dietary habits throughout life have little need to
change in old age. Many have not established such habits but may wish to. It is
generally believed
Most
people can keep their teeth for a lifetime with optimal personal, professional,
and population-based preventive practices. Yet, in 1997, 26% of adults age 65 to 74 years had had all their teeth extracted.
The Healthy People 2010 target is to reduce this number to 20% (USDHHS, 2000).
Since the 1960s, water supplies and toothpastes have been fluoridated, and
regular dental care has become more accessible and acceptable to most people.
These measures have helped prevent periodontal disease, a major component of
tooth loss in adults. Oral health and hygiene needs do not decrease with age.
Eating, chewing, and swallowing should be an uncomplicated and natural process.
Frequently, older adults are taking medications that cause dry mouth, taste
alterations, and loss of appetite that limit the desire for food. Eating should
remain a pleasurable social experience, preferably taking place in the company
of others. Community health nurses can assist older adults with meal management
by following the suggestions outlined in Display 30–3.
In
addition to maintaining a healthy diet, older adults should avoid the habitual
use of laxatives, instead adding more fiber and bulk to their diet. Inadequate
fluid intake often contributes to bowel and bladder problems. Consuming a diet
that includes six to eight 8-oz glasses of fluid (water, juices, tea) each day
assists the gastrointestinal and genitourinary system in their functions. Also,
more exercise helps keep an older adult’s bowel patterns regular.
AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKIT
Basics of nutrition counselling
1. Regularly weight and measure every patient. Advise them on their healthy weight range based on age,
gender and distribution of body fat.
2. Talk with all patients about their dietary habits,
including use of dietary supplements.
Use a brief nutritional
screening questionnaire accepted in your country if available to identify
nutritional vulnerability, or consider an evidence-based tool. (Green, S.M. and Watson, R. (2006) Nutritional screening and assessment tools for older
adults: Literature review. Journal of Advanced Nursing, 54, (4), 47-490
While nutritional
vulnerability is often associated with under nutrition, the prevalence of obesity
is increasing among older persons, with potential health risks.
3. Provide basic information about managing a healthy
diet. Use dietary guidelines of your country if available.
USA dietary guidelines
4. Use the following Food Guide Pyramid as an
educational tool for planning healthful diet.
Food Guide Pyramid
Eating right from bottom to top in people aged 70 and older
Source: A food guide for older
adults,
5. For women, recommend special dietarian particularly
for calcium. Counsel older women to consume adequate calcium, which helps in:
• building optimal bone
after menopause,
• controlling bone loss and
delay development of osteoporosis.
Dairy products are major sources of calcium. Other
sources of calcium are canned fish with soft bones, vegetables such as broccoli
and spinach, and fortified cereals and grains.
Optimal calcium requirements recommended
6. For overweight patients,
recommend:
• a
diet with fewer total calories from fat,
• a
modest increase in physical activity. See information on physical activity
counselling.
In general, the goal should
be a weight loss of 1 / 2 to 1 pound per week. Behaviour therapy and physical activity have been shown to help maintain
weight loss.
7. Ongoing support and
reinforcement to patients undertaking significant dietary changes.
This support can take
several forms, including
• follow-up
visits,
• telephone
calls and postcards.
Recommend making changes
gradually, in small, achievable steps over time. Encourage patients through the
plateaus and regressions that occur as a normal part of efforts at longterm change.
8. Refer if necessary:
patients with multiple or severe nutritional problems should benefit from a
nutrition professional counselling as possible.
Exercise Needs
Older
adults need to exercise; in fact, they thrive when exercise is incorporated
into their daily routine. Research shows that exercise can slow the loss of
bone density and increase the size and strength of muscles, including the heart
(Kressig & Echt, 2002;
USDHHS, 2000). Aging does not and should not involve passivity; instead,
physical activity and movement contribute to the quality of intellectual and
physical performance in old age. Exercise, such as a daily walk, can keep
muscles in good tone, enhance circulation, and promote mental health. Exercise
may occur in connection with such activities as homemaking chores, gardening,
hobbies, or recreation and sports. Often, such physical outlets are enjoyed in
the company of other people, meeting social and emotional needs as well as
physical ones. Preparing for exercise by warming up helps to keep muscles free
from injury and to prevent falls (American Institute for Cancer Research,
2002). Even among the very old, an exercise routine that includes activities
that improve strength, flexibility, and coordination may indirectly, but
effectively, decrease the incidence of osteoporotic
fractures by lessening the likelihood of falling (Burbank & Riebe,
AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKIT
Basics of physical activity counselling
1. Evaluation of patients'
usual physical activity
o Ask all patients about their physical activity
habits. Include organized activities, general activities and occupational
activities.
o Determine if the patient's level of activity is
sufficient using the following physical activity pyramid. Experts agree that
physical activity that is at least of moderate intensity, for 30 minutes or
longer, and performed on most days of the week is sufficient to confer health
benefits.
Tell patients, as doing the
moderate-intensity physical activity, they will feel faster heart rate, faster
breathing and slightly warmer.
Physical activity pyramid
* Avoid
sedentary lifestyle such as watching TV or sitting in front of a computer for
many hours a day.
Source: Rauramaa, R. & Leon, A.S. Physical Activity and risk of
cardiovascular disease in middle aged individuals. Sports
Medicine. 1996, 22(2):65-69.
2. Assist patients who lack
sufficient physical activity for health benefits and/or wish to improve physical activity habits in planning a
programme that should be:
• Medically Safe: Existing heart disease presents the
biggest risk.
o Medical Evaluation: recommended prior to embarking on
a vigorous exercise programme for the following individuals:
_ persons
with cardiovascular disease (CVD);
_ men
over 40 years and women over 50 years of age with multiple CVD risk factors –
hypertension, diabetes, elevated cholesterol, current smoker, or obesity.
o Additional advice to promote medically safe physical
activity includes:
_ increase the level of
exercise gradually rather than abruptly,
_ decrease the risk of
musculoskeletal injuries by performing alternate-day exercises and using
stretching exercises in the warm-up and cool-down phases of exercise sessions.
This is particularly important for older adults and those who have not been
physically active recently.
• Enjoyable: Patients will not continue activities
that they do not enjoy.
o They should:
_ choose activities they
find inherently pleasurable,
_ vary activities,
_ share
activities with friends or family.
o Encourage patients to identify barriers to enjoyment
and to find ways to overcome these barriers. Examples of methods for overcoming
barriers are listed in the next table:
Table 1. Overcoming barriers to exercise
• Convenient: Encourage participation in activities
that can be enjoyed with a minimum of special preparation, ideally those that
fit into daily activities.
• Realistic: A too difficult programme in terms of
goals and integration with other daily activities will lead to disappointment. Gradual change leads to
permanent change; therefore, stress the importance of gradually increasing the
intensity, frequency and duration of exercise.
• Structured: Having defined activities, goals for
performance and a set schedule and location may help improve some patients'
compliance. Signing a physical activity "contract"/"action
plan" may be helpful.
3. Encourage patients who are unwilling or unable to
participate in a regular exercise programme to increase the amount of physical
activity in their daily lives:
o taking the stairs rather than the elevator when
possible,
o leaving the subway or bus one or two stops early and
walking the rest of the way,
o doing household chores and yard work on a regular
basis.
4. Involve nursing and office staff in monitoring
patient progress and providing information and support to patients. Some form
of routine follow-up with patients about their progress is very helpful.
5. Convey positive messages about exercise and
physical activity using posters, displays, videotapes, and other resources in
offices or clinics.
6. Providers should try to engage in adequate physical
activity themselves. Studies show that providers who exercise regularly are
significantly better at providing exercise counselling to their patients than
those who do not.
Economic Security Needs
Economic
security is another major need for older adults. Worrying about finances is
often one of the most debilitating factors in old age. Fearing the potential
costs of major illness and not wanting to be a burden on family or friends,
many older people conserve their limited finances by establishing frugal eating
patterns, using health resources sparingly, taking medications in partial
doses, and spending little on themselves. Too often,
the fear—let alone the reality—of financial difficulties prevents
older adults from leading full and active lives.
For
older adults today who have lived many years past retirement and perhaps had
not planned for sufficient financial security to maintain them throughout these
additional, unexpected years, the fears are not unfounded. Putting older people
in touch with appropriate community resources can do much to relieve the source
of that stress and anxiety. The community health nurse can also help younger,
working adults plan for a physically and emotionally, as well as financially,
vigorous old age.
Psychosocial Needs
All
human beings have psychosocial needs that must be met for their lives to be
rich and fulfilling. Without healthy relationships with other people, life can
be very lonely and lacking in quality. With advancing age, the psychosocial
issues are many. A major issue is coping with multiple losses. In addition,
maintaining independence, social interaction, companionship, and purpose is
necessary for a healthy old age. Older adults who have maintained good health
and have developed a supportive system of family and friends have more
fulfilled lives.
Coping
With Multiple Losses
Elders
experience multiple losses, including loss of income and prestige from a career
once practiced or the economic stability of an enjoyable job; loss of space due
to replacement of a larger residence by a much smaller home or apartment; and
reductions in health and vitality that may result in limited movement or pain
as a daily concern or necessitate another move to a more dependent setting.
Repetitive losses occur as significant others,
relatives, friends, and acquaintances die (Worden, 2002).
Inadequate
coping with the compounding losses can make an older person believe that life
holds no meaning. Depression may be a difficult problem for older adults.
Social and emotional withdrawal can often occur, as can suicide. Although older
populations have a much lower rate of suicide attempts than younger age groups
do, the rate of completed suicide is high. It is highest among elderly men, who
account for about 80% of suicides among those age 65 years and older. Moreover,
elderly white men have a suicide rate six times the national average (USDHHS,
2000). Concern for the increased suicide rates among older white men led to a key
health objective in Healthy People 2000: to reduce the suicide rate to
38.9 per 100,000 people, from the 1987 baseline of 46.1 per
100,000 (USDHHS, 1991). By 1997, for white men aged 65 years or older, the
suicide rate was 35.5 per 100,000, exceeding the 2000 goal. Suicide continues
to be of concern and is included in the Healthy People 2010 objectives. Because
most elderly persons who commit suicide have visited their primary care
provider in the last month of their lives, recognition and treatment of depression
in health care settings is a promising way to prevent suicide in this age
group.
Mortality
after bereavement is high and can be prevented through nursing intervention.
Loss and the mourning process among elders have been examined in many studies.
It has been found that the ability to mourn prior states of one’s self and the
past is crucial to successful aging. This can be liberating and can provide
energy for current living, including planning for the future (Worden, 2002).
Although men and women experience similar levels of depression dur ing early bereavement, it is
more difficult for widowers to seek and receive social support. Higher levels
of perceived social support are associated with lower levels of depression in
widows and widowers (Moore & Stratton, 2002). In addition, more men than
women die soon after the death of their spouses. Women have stronger social
support systems throughout their lives, and these help sustain them during
losses in old age (Moore & Stratton, 2002).
In
addition to preventing early deaths after the loss of a spouse, the greater
goal for the nurse in promoting successful aging can be accomplished when the
nurse recognizes the significance of accepting all the losses of aging. The
loss of a spouse is much more frequent for women than for men (Eliopoulos,
2001). With this knowledge, a woman can age successfully by planning for the
future through anticipatory guidance, with the help of a community health
nurse. Many women can expect to live alone for up to 20 years at the end of
their life, because of a longer life expectancy and the fact that women in most
cultures marry men older than themselves. The nurse can help to make these
years meaningful and as healthy as possible.
Maintaining
Older
people need independence, and those who stay independent are happier. As much
as possible, the elderly need to make their own decisions and manage their own
lives. Even those with activity limitations because of disability can still
exercise decision-making options about many, if not most, aspects of their
daily living. The need for autonomy—to be able to assert oneself as a separate
individual—is great for all people. With life’s restrictions ever increasing
for the elderly person, this need is all the greater (Eliopoulos, 2001).
Social Interaction, Companionship, and
Purpose
Older
people need companionship and social interaction, particularly if they live
alone. The company of other people and the companionship of a household pet
offer avenues for expression and response and add meaning to life. Many studies
of mortality patterns demonstrate that older adults living together have a
greater survival rate and retain their independence longer than do those who
live alone (Miller, 1999).
The
problem is of greatest significance for women, who outnumber men considerably
in the later years and who live alone more frequently.
It is
also important for older adults without companions to discover and develop a
friendship with someone who can be considered a confidant, someone in whom the
older adult can confide, reflect on the past, and trust. It could be a close
friend, a sibling, a son or daughter, or an acquaintance. This person is
usually seen daily or talked with on the telephone each week. In particular,
mothers and daughters form confidant bonds. Many women consider a sibling a
confidant, especially if that person lives close by; this is especially true
for childless and single women.
Meaningful
activity is another need of the elderly that adds purpose to life. Some kind of
active role in community life is essential for mental health, satisfaction, and
self-esteem. These activities can range from involvement in hobbies, such as
gardening or crafts, to volunteer work or even full-time employment. Examples
include the federally supported Foster Grandparents and Senior Companions
programs, which engage the help of more than 20,000 seniors. These older adults
work part-time offering companionship and guidance to handicapped children, the
terminally ill, and other people in need. Senior Partners is another program
that keeps older adults involved. Volunteers earn service credits by providing
support services so that persons age 60 years or older can remain independent
and active in their own homes. Each hour of volunteer service earns one service
credit. Credits may be “spent” in several ways. They can be used to obtain
services, should the volunteer need them, or they can be donated to another
person in need or donated back to Senior Partners to help others.
Additional
volunteering opportunities abound. Internationally, many older professionals
join the Peace Corps, which was initiated in the early
1960s. In this program, people of all ages work for 2-year periods in global
communities that are in need of services to improve personal health, education,
environment, and the larger community. On the national level, the newer AmeriCorps*VISTA (Volunteers in Service to
Many
older adults choose not to engage in long-term volunteering, and other programs
are more appropriate for them. Elderhostel, Inc., is a nonprofit organization
with more than 25 years of experience providing high-quality, afford able,
educational adventures for adults who are 55 years of age and older. It is the
nation’s first and the world’s largest education and travel organization for
adults age 55 and over, offering more than 10,000 learning adventures each year
in more than 100 countries. Their theme-based, short-term (3 days to 3 weeks)
educational programs are infused with a spirit of camaraderie and adventure
(Elderhostel, 2002). In 2002, even when many others were limiting their travel,
more than 175,000 adults took advantage of the unique experiences that
Elderhostel has to offer. The success of this program is based on the fact that
learning is a lifelong process that is rewarding at any age, and it is learning
without testing or papers due! Elderhostel is inspired by the youth hostels and
folk schools of
Safety Needs
People
of all ages have safety needs, and this concept has been threaded throughout
the five chapters in this unit on developmental needs of clients. Likewise,
safety issues are a major concern for older adults and the community health
nurses who work with them. Several areas of safety focus are discussed here:
personal health and safety, home safety, and community safety.
Personal
health and safety include three major areas: immunizations, prevention of
falls, and drug safety. Immunizations are not just for children. Older adults
are at risk for not only contracting influenza or pneumonia but dying from
them. Pneumococcal disease, influenza, and hepatitis
B account for more than 45,000 deaths annually, mostly among older adults.
Ninety percent of influenza-related deaths occur in people age 65 years and older
(USDHHS, 2000). Although the overall influenza immunization rate among elders
has increased, from 33% in 1989 to 63% in 1997, and pneumonococcal
vaccine coverage rates have increased from 15% to 43%, improvement is still
needed. Despite the increases, coverage rates for certain racial and ethnic
groups remain substantially below that of the general population. For example,
the influenza vaccination rate for whites was 66% in 1997, whereas for
African-Americans it was 45% and for Hispanics it was 53%. In September of
1997, the USDHHS approved an agency-wide plan to improve adult immunization
rates and reduce disparities among racial and ethnic minorities through their
“Put Prevention Into Practice” program, a national
campaign to improve delivery of clinical preventive services (USDHHS, 2000).
Attempts to improve immunization coverage involve changing provider knowledge,
attitudes, and behavior through reminders and standing orders so that “missed
opportunities” when seeing clients are prevented. Additional opportunities for
vaccinating people exist beyond the primary care setting, as community health
nurses are well aware. People can be reached during emergency department
visits, at neighborhood and senior centers, at religious facilities, and in
other innovative settings where elders may gather. Regardless of the site, a
method for tracking and communicating vaccinations is needed so that
vaccination information may be documented and shared with the elder’s primary
care provider. Immunizations protect more than the at-risk population—they
protect society as a whole. People of any age with a chronic illness, such as
heart disease, diabetes, or chronic respiratory disease, and people older than
65 years of age should be encouraged to receive the flu vaccine each year and
the pneumonia vaccine every 5 years.
Each
year, approximately one third of people older than 65 years of age who are
independent and living on their own experience a fall; for those individuals
residing in long-term care settings, the percentage is 50% (Hill-Westmoreland, Soeken, & Spellbring, 2002).
Every year in the
For more information go to Elderly
Safety, Home Safety for
the Elderly.
A
significant safety issue for the older adult arises from adverse drug effects.
Older people may need to take several medications to control the effects of
chronic conditions, and their bodies may react differently than those of
younger people (on whom most new drugs are tested). It is not unusual for older
people to be taking four to six medications daily and filling 13 prescriptions
each year. It is estimated that 25% of all older people who live independently
receive prescriptions for inappropriate medications (Jech,
2000). Elders receive multiple prescriptions from multiple providers and are in
danger of receiving double doses of the same or similar medications. Multiple
medications or complicated drug regimens for many older people can lead to
unexpected and dangerous drug interactions. The use of more than four
prescribed medications is related to an increased risk of falling (Jech, 2000). Elderly clients need education about the drugs
they take and their possible effects. They also need proper supervision of
their overall medication intake. This is an area in which the community health
nurse can intervene very effectively and with much success.
Safety
in the community is an additional concern. Safety involves pedestrian and
driving issues, crime and fear of crime against elders, and environmental
factors such as sun exposure, pollution, heat, and cold.
Because
of age-related changes in vision, hearing, mobility, and the effects of polypharmacy, elders are at risk in the community as
pedestrians and as drivers. Automobile crashes and pedestrian injuries can be
life-threatening events when elders are involved. As pedestrians, elders must
be increasingly vigilant to traffic patterns, sidewalk irregularities, and the possibility
of being a victim of street crime. Often out of necessity and pride, elders
drive longer than their abilities permit. In 1998, 23.7 of every 100,000 older
adults died of motor vehicle-related injuries. Only the 15- to 24-year-old
population had a higher rate (
Actual
crime against elders in the community is as much as 50% lower than among other
segments of the population. However, the fear of crime among elders is
perceived as a major issue by the general public, and about 25% of elders
consider the fear of crime a major concern. Display 30–5 lists client-centered
nursing interventions designed to reduce fear among older adults and empower
them to feel safer in their communities.
Environmental
factors can have an effect on the health and safety of elders when they are
outside. Sun exposure, pollution, and exposure to heat and cold can have
negative effects on older adults. They are just as vulnerable as infants and
children to climatic changes and should take a variety of preventive measures,
including using sun block when gardening, reading, or walking outside for
longer than 10 minutes, even on days with an overcast sky; staying indoors on
days when the air quality is poor or there is an air safety alert; drinking
additional fluids, wearing protective covering, and limiting outdoor activities
and exposure on days with elevated temperatures; and, conversely, limiting
outdoor exposure and wearing appropriate winter clothing, especially layers of
clothes, on cold, snowy, or icy days. Teaching geographically and seasonally
appropriate safety precautions is the responsibility of the community health
nurse providing services to groups of elders in the community.
Spirituality, Advance Directives, and
Preparing for Death
A
final need of the elderly, and one that is receiving increasing attention, is
that of preparing for a dignified death. Elisabeth Kubler-Ross
(1975) described death as the final stage of growth and one that deserves the
same measure of quality as other stages of life. Many older people fear death
as an experience of pain, humiliation, discomfort, or financial concern for
their loved ones. Planning for a dignified death is an important issue for many
older people. For most, this includes choosing, if possible, where and under
what circumstances death will occur; being free of financial worries; knowing
that their affairs and their family members are taken care of; having the
opportunity to receive spiritual counseling; and dying in peaceful
surroundings, preferably at home with the support of loved ones (Cicirelli, 2002; O’Brien, 2003).
Some elders
make arrangements with a funeral home of their choice, selecting interment or
cremation, a memorial service or a celebration of life gathering, music to be
played, and other personal details rather than leaving these choices to their
families. Others place less emphasis on the rituals, as was demonstrated by one
elder who left these choices to her children by telling them, “Surprise me!”
Living
wills and medical directives are legal documents whose purpose is to give
people legal power over the medical treatment they would want if they became
incapacitated or terminally ill. Living wills are legal in all states and the
Additional readings:
Age-friendly Primary Health Care Centres TOOLKIT // World Health Organization, 2008.
Cicirelli, V.G. (2002). Older adults’ views on death.
Ebersole,
P., & Hess, P. (2004). Toward healthy aging (6th
ed.).
WEB SITES on Aging
American Diabetes Association, Facts and
Figures: http://www.diabetes.org
Assisted Living Federation of
National Institute on Aging. http://www.nia.nih.gov