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THEORIES OF AGING

There are many theories of aging. It is important to understand some theories of aging as they relate to taking care of the elderly. 1Psychological TheoriesMaslow Human NeedsFive basic needsEricksons PersonalityLife stages relate to life tasks

Grossman and Lange, 2006

We are all familiar with Maslows hierarchy of needs which include 1.physiologic needs 2. safety and security 3. love/belonging 4. self-esteem 5. self-actualization. For the aging population it is suggested that the order may be changed to honor the persons wishes at different times relating to health. It is important for all persons involved in the care of the elderly person to understand that different needs are more important at different times. Ericksons Personality theory focuses on development of the individual person. The elderly person can go through a stage that is described as ego integrity vs despair. In this stage, the person evaluates the accomplishments of their life people who were satisfied with their achievements tended have a greater sense of contentment than those who were not.2Social TheoriesBased on social order, balance and harmonyActivity TheoryNecessary for satisfaction with lifeDisengagement theoryNatural processGradual withdrawal

Phelan, 2010

The social theory is believed to have been founded after the second world war when society felt people had certain positions in society. Balance and harmony was maintained by preserving the social order. Two theories were developed from this basis. Self- identity, which is similar to Ericksons life stages theory, states that people must move through the stages of their life. The focus is that the person must remain active to counteract the aging process and maintain a healthy life style. While social participation is essential to a healthy aging process, decreased functional or cognitive status can impact involvement. Being aware of limitations and learning alternative activities would be important to facilitate social participation at the level of involvement a person can achieve.The disengagement theory beliefs are based on evidence that the older person gradually with draws from events in their life first from society and then from family before death. Some believe that this theory allows for other family members to take over the duties that the older person used to perform. As workers in the health care field, it is important to recognize how one begins to withdraw and support the person as well as their loved one through this time.3Biological TheoriesNon-stochasticPredicted damageStochasticRandom damage

Grossman and Lange, 2006

Two biological theories are stated above. The non-stochastic (stowkastic) theory is that all people age it happens over time and is predictable. Stochastic theory believes events that occur during a persons lifetime cause random damage and leads to aging. Some people believe that both of these theories are correct to a certain point, for instance one can have co-morbidities such as heart disease or diabetes which cause their body to deteriorate over time and maybe at a faster rate but a healthy person can suddenly age when in their 70s.4Ageismstereotypical, dehumanizing, negative constructions (Phelan, 2010)Three domainsCognitive Beliefs and stereotypesAffectiveprejudiceBehavioralDirect discriminatory practicesIndirect discriminatory practices

Phelan, 2010

We must touch on ageism which is typically viewed as prejudice or stereotyping of older adults. Phelans definition as stated above is stereotypical, dehumanizing, negative constructions. The three domains are listed above. Cognitive beliefs are that youth or youthfulness are more valued. Affective domain is the prejudicial attitudes towards the aging for example an elderly person is viewed as a burden to society. Behavioral can be direct or indirect such as avoiding to care for the elderly. This can also be seen as a fatalistic attitude in which one believes because the person is old, he or she doesnt deserve the best care. As health care professionals, it is important that we recognize our own feelings about the aging population to process our own thoughts and feelings and to provide the best care for our patients.5Assessment of Geriatric Needshealth historyphysical assessment laboratory studies radiological testingfunctional assessment of activities of daily livingcognitive assessment skin assessment social assessmentfinancial assessment

The first step in caring for any person, especially an elder, would be a thorough assessment that includes health history as well as a physical assessment including laboratory studies and radiological testing as needed. Included would also be a functional assessment of activities of daily living, a cognitive assessment and a skin assessment Many tools have been developed to help assess risks of the elderly. A few are listed above. Social and financial assessments are also important. A holistic nursing assessment includes nursing knowledge, skills and experience coupled with listening, observing, measuring, interpreting and recording the data collected about the elders biological, psychological, social and spiritual needs.6RISK ASSESSMENT TOOLSneeds assessmentfall risk assessmentpressure ulcer assessmentpain assessmentnutritional screening

Toofany, S. 2007

An assessment specific to risks that the elderly population face is also important. Included in the needs assessment is the assessment of the home situation as well as any financial needs. The rest of the assessment tools are self explanatory.7SPICESS is for Sleep DisordersP is for Problems with Eating or FeedingI is for IncontinenceC is for ConfusionE is for Evidence of FallsS is for Skin Breakdown

Fulmer, M. 2007

A quick assessment tool with an acronym for easy recall would be the SPICES assessment found at the Hartford web site. This tool is focused on assessing the elderly population for issues that are common to them.8Research StudyGeriatric Workforce Enhancement ProgramTrain the trainerBasic courseAdvanced courseOutcomesParticipants impacted change

Barba and Fay (2009)

The Geriatric Workforce enhancement project was a train the trainer program designed to train nurses in geriatrics so they could take the information back to their workplace and teach others. The basic course focused on age related changes, common health problems and other issues of the aging population. The advanced course was designed to help nurses who wished to seek a certification in geriatrics. The outcomes of this program showed that nurses felt more confident taking care of the geriatric population and helped staff to make changes that impacted quality of care for the patients and their families.9Research StudyGerontological Enrichment ProgramRisk factors for hospitalizationAdverse functional outcomesNormal consequence of agingError in professional intervention Environmental factorsGoals:Improve careimprove knowledgeSupportConference attendanceJournal readingsPresentationsParke, Ross, and Moss (2003)

This literature study showed how older adults are at risk when hospitalized. This hospital identified risk factors for the older population which included functional decline (presumed from decreased activity), med errors, erroneous use of meds, adverse reactions to meds or treatments, risk of infections. The goals were to improve outcomes of the older patient, decrease risks associated with hospitalization and improve knowledge of the staff taking care of the elderly patient. At the end of the study, support was given to continue the education of the staff by providing opportunities for conference attendance, time to study journals and providing on-going training for new staff at orientations.10Gerontological Clinical NursingResearch StudyStudent insight:enhanced knowledge confidence in identifying differences between normal aging and illness conditions, cognitive changes, functional independence, common health challengesimprovements in ability to engage w/older adults, stronger communication skillsencouraged focus on attitudes about the aging populationmore holistic approach less task orientedincreased understanding of transition, loss, grief, vulnerabilityimproved outlook on comfort care and spiritualityStaff Nurses insights:impressed with knowledge of student nurseability to provide holistic assessmentstudents were able to effect change on unit

Dahlke and Fehr (2010)

In this study, student nurses learned about caring for older adults in multiple units that were designed to meet the needs of the elderly population. Some of the reasons this program was developed included: student nurses were learning from seasoned nurses who lacked formal gerontological nursing education and identification of ageism. Both the students and the staff on the units provided some insight to the benefits of this program as shown above.11NICHENICHE stands for Nurses Improving Care for HealthSystem EldersGIAPTools Provided to the hospitals included:Staff development toolsNursing care modelsResearch-based clinicals

Boltz, Capezuti, Bowar-Ferres, Norman, Secic, Kim, Fairchild, Mezey, and Fulmer 2008

This study involved 8 hospitals where NICHE provided the hospital with tools to make the environment more responsive to the needs of the geriatric population. The study first measured nurses knowledge through use of a survey entitled Geriatric Institutional Assessment Profile. After the institution of tools, as listed above, nursing care of the geriatric population improved but knowledge itself did not.12Interpretation of informationQuality geriatric care is: evidenced basedensures best practicesincludes a holistic assessment individualized to patient needs promotes patient decision making

It is important to have nurses trained in geriatrics that are aware of the special needs this patient population has. Knowledge of how this patient population responds to medications, how their body has changed and risks specific to this population will help to improve patient outcomes and prevent untoward complications.13Assessment of the Health Care Environment National Patient Safety GoalsImprove accuracy of patient identificationImprove effectiveness of communication among caregiversImprove the safety of using medicationsReduce the risk of healthcare acquired infectionsAccurately and completely reconcile medications across the continuum of careReduce the risk of harm resulting from patient fallsEncourage patients active involvement in own careImprove recognition and response to changes in a patients condition

Munson Healthcare, 2009

National Patient Safety Goals taken from the Munson health care website apply to all patients but those that are of significant importance in the elderly population which can be at greater risk are listed above. Munson requires two patient identifiers when giving meds and even the dietary aide must ask the patient name and birth date. Many of these goals have been put in place to improve safety for the elderly population. For instance medication reconciliation at discharge ensures the patient will know what meds he needs to stop taking and what needs to continue as well as what is new.

14Assessment of the Health Care Environment National Patient Safety GoalsImprove accuracy of patient identificationImprove effectiveness of communication among caregiversImprove the safety of using medicationsReduce the risk of healthcare acquired infectionsAccurately and completely reconcile medications across the continuum of careReduce the risk of harm resulting from patient fallsEncourage patients active involvement in own careImprove recognition and response to changes in a patients condition

Munson Healthcare, 2009

National Patient Safety Goals taken from the Munson health care website apply to all patients but those that are of significant importance in the elderly population which can be at greater risk are listed above. Munson requires two patient identifiers when giving meds and even the dietary aide must ask the patient name and birth date. Many of these goals have been put in place to improve safety for the elderly population. For instance medication reconciliation at discharge ensures the patient will know what meds he needs to stop taking and what needs to continue as well as what is new.

15Environment Assessment continuedPatient safety guidePolicy for medication issues:AnalgesicsAntibioticsAnticonvulsantsAntidepressantsAnti-diabetic medsAnti-manic medsAnti-parkinson medsAnti-psychotic medsAnxiolyticsCardiovascular medsCholesterol lowering agents

Munson Healthcare 2009

GI medsGlucocorticoidsHematinicsLaxativesMuscle relaxantsAppetite stimulantsOsteoporosis medsPlatelet inhibitorsRespiratory medsSleep medsThyroid medsUrinary incontinence meds

Patients at Munson receive a pamphlet on admission that encourages patient to ask health care providers to wash their hands, ask questions of information they do not understand and provides them with a contact number of who to call if they have questions or concerns. This pamphlet also gives information on what to expect such as frequent identification checks. However the elderly population, based on their generation may need help understanding this. The policy for medication issues that are of particular significance to the elderly address issues and concerns that may occur how to monitor certain meds and adverse reaction symptoms. As you can see by the list, many types of meds can have adverse effects on the elderly population. Triggers must be in place when a med is ordered to protect the elderly to make sure meds dont work against each other, to make sure safe doses are administered, or to make sure that a lab indicates this med should not be used.16Iatrogenesis Common iatrogenic events can occur as a result of: Adverse reactions to medications Adverse reactions to diagnostic, therapeutic and prophylactic procedures Nosocomial conditions such as hospital-acquired infections, delirium, deconditioning, malnutrition, fecal impaction, incontinence and pressure ulcers Falls or other accidental and environmentally-induced accidents, and Harmful effects to patients related to the values, beliefs, prejudices, fears and attitudes of well intentioned, but ignorant providers Information quoted from Hartford Institute for Geriatric Nursing, Francis, 2oo8

Iatrogenesis means a complication or consequence of the actions of a healthcare intervention that was meant to be positive. These events occur most commonly amongst the very sick elderly or those that have a functional impairment. Listed above are common events taken directly from the Hartford Institute for Geriatric Nursing website. 17Root Cause AnalysisFall risk assessmentReasons why falls occurIdentification of high risk patientsInterventionsARTT

One root cause analysis performed at Munson Medical Center focused on patient falls. First a study was performed to determine when falls occurred and the reason for the fall. Common reasons for falls were the person was attempting to go to the bathroom, related to side effects of medications or impulsivity from impaired cognition. A fall risk assessment was introduced and nurses began scoring patients to determine their fall risk. Those that are identified as a fall risk have a sign outside they also wear red socks or have red socks tied to the foot of their bed. Another program was also introduced called ARTT which means Ambulating, rounding toileting and turning. This has helped to avoid falls by the commitment to checking on the patient every hour and providing the services of ambulating, turning and toileting. There is even a travelling trophy at Munson for the unit that does the best job for that month.18Prevention of poor outcomesImprove knowledge baseContinuing education in geriatricsNurses trained in geriatricsInstitution of National Patient Safety Goals especially those that focus on the elderly population

CLABSICAUTISSIVAPThose associated with increase use of antibiotics

Munson Healthcare, 2009

Research indicates that improved outcomes occur with increased knowledge and training in the care of the geriatric population. Older adults have more health problems than younger adults, use more prescription drugs, have more chronic health conditions such as heart disease, arthritis and high blood pressure. Some incidences also increase with age such as hip fractures from falls, cancer, and alzheimers. Institution of the national Patient safety goals with special attention to those events that affect the elderly population include prevention of catheter line associated blood stream infections, catheter associated urinary tract infections, surgical site infections, ventilator assisted pneumonia and those associated with increased use of antibiotics such as VRE, MRSA and Cdiff.19Who will Care for the Elderly Shortage of nurses285,000 by 2020500,000 by 2025Shortage of other healthcare providers including:NutritionistsSocial workersPharmacistsphysicians

Houde and Melillo, 2009

In an article by Houde and Melillo entitled Caring for an Aging Population, they identify the current nursing shortage is not as critical as it soon will become because of other economical factors: many nurses have returned to work fulltime because their spouse may be without a job. More nurses want overtime or are working more than one job to help alleviate the financial burden caused by other family members being out of work. They are predicting significant shortages as listed above. There will also be a shortage of other health care workers including nutritionists, social workers, pharmacists and dieticians.20Providing Quality Care for the Elderly: StatisticsCurrent training in geriatrics30 of 670 BSN programs meet criteria for best educational courses in geriatrics23% required geriatrics course24% had an elective available to take49% integrate geriatrics with other coursesThis reflects less than 1% of the nations nurses having a certification in geriatrics

Kovner, Mezey, and Harrington, 2002

Many nurses do not receive formal education in the treatment of the elderly population while in nursing school, and this can impact quality of care. As you can see, very few nurses have a certification in geriatrics. We have learned that the elderly population have needs that are different from their younger counterparts, they use more services and are more at risk. 21Competence in Care for the Elderly PopulationNurses are trained for pediatrics, shouldnt they also be for geriatrics?Recommendations for staff trained in geriatrics at colleges, universitiesContinuing education for nurses currently working with the elderly populationSome states already have mandates or policies in place regarding care of the elderly populationArizona example

A consensus has not yet been reached in what qualifications a nurse should have in caring for the elderly. However, our research shows us that increased knowledge and education with this population will lead to improved outcomes. Arizona is one of 6 states that has developed specific goals for the aging population. On their website aging 2020, Arizonas plan for an aging population, 8 goals are identified. These include making it easier to access services, increasing awareness of issues specific to the aging population, ensuring the aging can remain active and live in their own homes as long as possible, addressing safety issues of the elderly and programs available to help those with needs.22Characteristics of Optimal CareNursing staff: competence in caring for patient population you servesupport of patient autonomyfacilitate positive discharge planningknowledge of how patients respond to meds , signs of infection

Characteristic of optimal care include the above recommendations. In addition Nurses need to know how to take care of the patient in an acute care setting but also how the elder patient is affected. One example is meds elderly patients respond differently to meds, Infections can be presented as confusion, the elderly quickly become deconditionied from a long LOS. CMS should require facilities to show information on staff trained in geriatrics during surveys and offer incentives to those facilities that support training. 23RecommendationsCMS (Centers for Medicare and Medicaid Services)Survey studiesincentivesInstitute of MedicineHome health aidesFamily membersEconomist Intelligence UnitChange the mindset about the elderlyContinue preventative careMedication studies on the elderlyContinued training for health care professionals

According to Houde and Melillo (2009), Institute of Medicine recommends improved education for all health care workers involved in care of the geriatric population. Their recommendation for home health aides or nursing assistants is to increase education from 75 to 120 hours. They also recommend training for family or other non-health care related persons. The Institute of Medicine also recommends incentives for health care professionals to be trained in geriatrics. The Economist Intelligence Unit, an article by Phillips Health care also recommends further training for health care staff in the field of gerontology. This article also provides information that age discrimination exists and sometimes elders dont get the care they need because efforts are deemed futile. For example, a 50 year old may get a cholesterol lowering drug but not a 70 year old. Support is also given for performing research about medications and the elderly.

24Preventative Health care for the ElderlySmoking cessationImportance of exerciseHealthy NutritionVision and hearing screeningDental health

Takahashi, Okhravi, Lim, and Kasten ,2004

Screening for health issuesHigh blood pressureHigh cholesterolOsteoporosisCardiovascular careCancer screeningImmunizations

Preventative care in the elderly is also important because the elderly are living longer and helping them to be healthier longer is important to their functional status and quality of life. As nurses, we still need to ensure that we are discussing health risks and making sure these patients have the knowledge they need. They should still also be screened for health conditions that can affect their quality of life. 25Family CaregivingCurrently accounts for 80% of care provided:44% by children41% by spouse10% by other relative5% by non relativeRecognizing need for helpCaregiver strain

Economist Intelligence Unit, 2009

An important aspect in the care of the geriatric population is family care giving. Family care givers account for more than 80% of the care provided to the elderly in the United States. Statistics show the population is shifting to more elderly and less young people. As this occurs there will be less family to care for the elderly. Caring for the elderly is typically a long term job that can add stress to someone who may already have a job. Health care professionals need to recognize the signs of care giver strain and intervene. This can be accomplished by providing resources for help in caring for their loved one or a way to minimize stress and encourage self care.26Community or Home-Based CareIllinois study$117/day for ECF$650/month for home careUse of telemedicineCommunity day cares

Economist Intelligence Unit, 2009

An Illinois study showed that it costs $117 per day for care in an Extended Care Facility while similar home care costs $650 per month. Recommendations are to increase the use of telemedicine so medical personnel can monitor the elderly in their home, helping to recognize signs and symptoms that need intervention at an earlier stage. One diagnosis this is already used for is CHF. Community day cares for the elderly are not widely available yet but studies show more cities have facilities available.27Resources to Care for the ElderlyCommission on AgingChore servicesMeals on WheelsArea agency on agingMI choice waiver programNursing home transition programCare managementCare respiteInformation on help with medications and co-paysDementia coalitionMedicare.gov website

A few resources for the elderly are listed above. My experience, as a case manager, is that many people do not know that help is out there. As nurses, we can provide information to patients, family members and other care-givers that can make a significant impact on the health and well-being of the elderly population.28Hartford Institute e-learning websitewww.hartfordign.org/Spotlight/eLearning

consultGeriRNNICHENursing home modules Case studies

The Hartford e-learning website has a wealth of information at ones fingertips to help care for the geriatric population. By clicking on the consultgerirn icon, a number of programs are available to promote learning about the elderly population including elder abuse, dementia, age related changes, nutrition, etc. Many of the programs are evidenced based. There are also many other opportunities for learning available. I encourage you, if you take care of the elderly, to take some time to check out this website. Under the consultgerirn tab, one can find information on over 30 topics including falls, dementia, family caregiving, frailty, assessment and many more. The other sites have a wealth if information also.29ReferencesAhlich, B. and Spinniken, K. (2010). Medication Issues of particular Relevance in Older Adults. Retrieved September 30, 2011 from http://mmcv-sms01.ad.mhc.net

Barba, B. & Fay, V. (2009). Does continuing education in gerontology lead to changes in nursing practice? Journal of Gerontological Nursing 35(4). Retrieved September 12, 2011 from CINAHL database.

Boltz, M., Capesuti, E., Bowar-Ferres, S., Norman, R., Secic, M., Kim, H., Fairchild, S., MezeyM., and Fulmer, T. (2008). Changes in geriatric care environment associated with NICHE (nurses improving care for HealthSystem elders). Geriatric Nursing 29(3). Retrieved September 13, 2011 from CINAHL database

Boyce, P. (2003). Lighting for the elderly. Technology & Disability, 15 (3). Retrieved September 26, 2011 from CINAHL database

Center on an Aging Society. (2005). Adult Children: The likelihood of providing care for an older parent. Retrieved October 2, 2011 from ihcrp.georgetown.edu/agingsociety/pdfs/ CAREGIVERS2.pdf Dahlke, S. & Fehr, C. (2010). Implementing a gerontological clinical nursing practice with an interdisciplinary focus: lessons learned. Gerontology and Geriatrics Education 31(2). Retrieved September 13, 2011 from CINAHL database

Ebersole, P., Hess, P., Touhy, T., Jett, K., and Luggen, A., (2008). Toward Healthy Aging (7th ed.). Mosby Elsevier: St. Louis, MO./

References continuedEconomist Intelligence Unit (2009). Healthcare strategies for an aging society. The Economist. Retrieved October 2, 2011 from graphics.eiu.com/upload/.../Philips_Healthcare_ageing_ 3011WEB.pdf

Francis, D. (2008). Iatrogenesis. Retrieved from www.hartfordign.org/Spotlight/eLearning

Fulmer, T. (2007). How to try this: Fulmer SPICES. American Journal of Nursing. 107(10). Retrieved September 6, 2011 from consultgerirn.org/uploads/File/trythis/try_this_1.pdf Garm, A. (2006). Promoting excellence in gerontological nursing. Nursing 2. Retrieved September 13, 2011 from CINAHL databaseGrossman, S., and Lange, J. (2006). Theories of aging as basis for assessment. Medsurg Nursing 15(2). Retrieved September 24, 2011 from CINAHL database.Hansen, Linda (2010). Analysis of Geriatric Needs. FSU Gerontological Nursing.Hartford Institute for Geriatric Nursing (2008). E-learning center, retrieved September 6, 2011 from www.hartfordign.org/Spotlight/eLearning/Houde, S. & Melillo, K. (2009). Caring for an aging population. Journal of Gerontological Nursing 35(12). Retrieved 13, 2011 from CINAHL database Kovner, C., Mezey, M., and Harrington, C. (2002). Who cares for older adults? Workforce implications of an aging society. Health Affairs 21(5). Retrieved September 6, 2011 from CINAHL database.

References continuedMessecar, D. (2008). Family Caregiving. Retrieved September 28, 2011 from www.hartfordign.org/Spotlight/eLearning/National Patient Safety Goals at Munson Medical Center. (2009). Retrieved September 30, 2011 from http://mmc-websrv.mhc.netNursing Scope and Standards of Practice (2004). American Nurses Association: Washington, DC

Parke, B., Ross, D. and Moss, L. (2003). Creating a cultural shift: a gerontological enrichment program for acute care. Journal for Nurses in Staff Development 19(6). Retrieved September 13, 2011 from CINAHL database

Phelan, A. (2010). Socially constructing older people: examining discourses which can shape nurses understanding and practice. Journal of Advanced Nursing. Retrieved September 13, 2011 from CINAHL databaseSmith, C. and Cotter, V. (2008). Age-related changes in health. National guideline clearing house. Retrieved September 24, 2011 from Hartford Institute for Geriatric Learning www.hartfordign.org/Spotlight/eLearning/Starns, M. (2011). Aging 2020 - Arizona Plan for an Aging Population. Retrieved September 25, 2011 from azgovernor.gov/aging/Documents/Aging2020Report.pdfStolte, K. (1996). Wellness Nursing Diagnosis for Health Promotion. J. B. Lippincott Co.: Philadelphia, PATakahashi, P., Okhravi, H., Lim, L., and Kasten, M. (2004). Preventative health care in the elderly population: a guide for practicing physicians. Mayo Clinic Proc. 79:416-427. Retrieved September 28, 2001 from CINAHL database Toofany, S. (2007). Tools to care. Nursing Older People 19(10). Retrieved September 13, 2011 from CINAHL database.