Gerontological Nursing: Aging, Functional Consequences, and Health Promotion

Chronologic age

Length of time since birth

Subjective age

How old a person feels

Perceived age

How old other people think someone is

Functional age

Physiologic health, psychological well-being, socioeconomic factors, and ability to function and participate in activities

Ageism

Prejudice and stereotypes applied to older adults based on age (example: less aggressive medical treatment because of age)

Aging anxiety

A person's own fears and worries about the harmful effects of aging (social loss, financial insecurity, appearance, declining health)

Age attribution

Blaming a problem or symptom on "just aging" instead of a treatable condition; delays care and raises risk

High-level wellness

Integration toward maximizing one's potential, with balance and purposeful direction in the environment

Fragile elder

Older adult with multiple chronic conditions affecting both health and function

Sandwich generation

Middle-aged adults caring for both children and aging parents

Skipped-generation household

Grandparents raising grandchildren with no middle generation present

Percent of older adults in nursing homes

Only 4% to 5% (about 93% live in independent housing)

Percent of care for older adults given by family

About 80%

Does diversity increase or decrease with age?

Increases; people become more different from each other with age

Cause of most disability in older adults

Disease and adverse medication effects (risk factors), not normal aging

Cause of wrinkles

Mostly UV exposure and smoking

Is constipation part of normal aging?

No; caused by restricted activity and poor dietary habits

Functional Consequences Theory (FCT)

Miller's nursing theory: age-related changes + risk factors lead to functional consequences; nursing interventions turn negative ones into wellness outcomes

Age-related changes

Inevitable, progressive, irreversible changes independent of disease or environment; can be compensated for but not reversed

Risk factors

Conditions that increase vulnerability to negative functional consequences (disease, environment, lifestyle, support, medications, attitudes); can be modified or eliminated

Functional consequences

Observable effects of age-related changes, risk factors, and actions on daily activities and quality of life

Negative functional consequences

Interfere with function or quality of life and increase dependency

Positive functional consequences

Facilitate the highest level of function, least dependency, and best quality of life

Wellness outcomes

Positive functional consequences that result from nursing interventions

Environment in the FCT

A risk factor when it interferes with function (glare, poor lighting); an intervention when it enhances function (grab bars, nonglare lighting)

Medication in the FCT

Can be both an intervention (opioid treats pain) and a risk factor (opioid causes constipation)

Example of an age-related change

Increased sensitivity to glare

Examples of risk factors

Cataracts, polished floors, anticholinergic medications, glossy paint

How to respond to age-related changes vs. risk factors

Compensate for age-related changes; modify or eliminate risk factors

Gerontology

Multidisciplinary study of aging and older adults, with a focus on healthy and successful aging

Geriatrics

Medical subspecialty focused on the medical problems of older people

Gerontological nursing

Nursing specialty and a responsibility of all nurses in adult care; promotes autonomy, wellness, comfort, function, and quality of life

Healthy life expectancy

Average number of years a person can expect to live without significant illness or disability

Health promotion

Programs or interventions focused on behavior change to improve health and well-being

Four types of health promotion interventions

Screening programs, risk-reduction interventions, environmental modifications, health education

Stages of Change (in order)

Precontemplation, contemplation, preparation, action, maintenance

Precontemplation

Client does not see a problem ("My eating is fine"); best intervention is consciousness raising with objective data

Contemplation

Client knows there is a problem but is ambivalent and unsure ("I need to lose weight, but I'm not sure I can")

Preparation

Client is getting ready to change ("I'm planning to start next week"); help make a specific plan

Action

Client is actively changing the behavior; support and build self-efficacy

Maintenance

Client is sustaining the change; teach relapse prevention

Consciousness raising

Sharing objective data and risks to help a client see a problem (precontemplation)

Self-efficacy

A person's belief that they can succeed; built by praising progress and expressing confidence

Motivational interviewing

Collaborative, person-centered counseling that strengthens a person's own motivation to change

Appreciative inquiry

Positive model focused on possibilities instead of deficits: discover, dream, design, delivery

Appreciative inquiry: Discover

Ask about a past positive experience and what supported it

Appreciative inquiry: Dream

Imagine what the future could look like

Appreciative inquiry: Design

Decide what can be done now

Appreciative inquiry: Delivery

Decide how to start

Physical activity in older adults

Fewer than one-third are regularly active; benefits include fewer falls and improved mood; safe for people with multiple chronic conditions

Adult day center

Structured daytime supervision, activities, and meals; benefits the client and gives caregivers a break

Respite care

Temporary relief that mainly supports the caregiver

Geriatric care manager

Assesses, plans, arranges, monitors, and reassesses services

Skilled home care

Intermittent skilled nursing or rehab at home (example: IV antibiotics, wound care)

Four requirements for Medicare skilled home care

Homebound, ordered by a primary care provider, needs skilled nursing or rehab, needs intermittent (not full-time) care

Nonmedical home care

Help with everyday activities (cooking, cleaning, companionship); no skilled need required

Skilled nursing facility (SNF) care

Short-term daily skilled nursing or rehab; goal is recovery

Medicare SNF requirements

Physician referral, daily skilled need, and a qualifying hospital stay of at least 3 consecutive inpatient days within the previous 30 days

Long-term (custodial) care

Ongoing help with ADLs; goal is maintaining function and quality of life

Culture change movement

Began in 1997; shifts nursing homes from institution-centered to person-centered, homelike care

Person-centered care

Care that respects the resident's dignity, choices, and preferences while balancing safety

Eden Alternative

Culture change model with a homelike setting including pets, plants, and children

Green House Project

Culture change model with small houses of about 7 to 12 residents

ACE

Acute Care for Elders: specialized multidisciplinary hospital care to prevent functional decline

NICHE

Nurses Improving Care for Healthsystem Elders: improves geriatric nursing practice using Geriatric Resource Nurses

HELP

Hospital Elder Life Program: prevents delirium and functional and cognitive decline in hospitalized older adults

Medicare Part A

Admitted: hospital stays, limited SNF care, hospice, some home health

Medicare Part B

Basic outpatient and medical care: physician visits, outpatient services, preventive care, some equipment

Medicare Part C

Combined (Medicare Advantage): private plans that replace Original Medicare and often include drug coverage

Medicare Part D

Drugs: prescription drug coverage

Medigap

Private supplement for Original Medicare only (not Medicare Advantage); helps with copays and deductibles

Medicaid (Medi-Cal in California)

Joint federal-state program based on financial need; major payer of long-term nursing home care

Does Medicare pay for long-term custodial care?

Generally no; it covers skilled, short-term care

PACE

Coordinated community-based care for adults who qualify for a nursing-home level of care but live at home; includes medical care, adult day care, and transportation through one program

Medicaid vs. PACE

Medicaid is a payer based on financial need; PACE is a care program that delivers and coordinates services

Older Americans Act (OAA)

Funds individual community services such as meals, transportation, caregiver support, adult day, and respite

CAPABLE

RN plus occupational therapist plus handyman team that improves safe function at home

CMS

Federal agency overseeing Medicare and Medicaid regulations

Functional assessment

Measurement of a person's ability to fulfill responsibilities and perform self-care

Baseline function

What the person could do before the illness, injury, or hospitalization

Six ADLs

Bathing, dressing, toileting, transferring, continence, feeding

Eight IADLs

Shopping, housekeeping, meal preparation, telephone use, transportation, medication management, laundry, financial management

Katz Index

Tool for basic ADL independence

Lawton Scale

Tool for IADLs

Fulmer SPICES

Screen for Sleep disorders, Problems eating or feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown

Cleveland Scale (CSADL)

ADL scale for people with Alzheimer's disease

Comprehensive Geriatric Assessment (CGA)

Multidimensional, interprofessional assessment of medical, cognitive, psychosocial, functional status and caregiver needs

Minimum Data Set (MDS)

Standardized resident assessment in Medicare/Medicaid-certified nursing homes

Function-focused care

Encourages patients to use and maintain abilities to prevent unnecessary dependence

First-level assessment

The functional behavior: WHAT can't the person do?

Second-level assessment

The stimulus: WHY (pain, weakness, cognition, caregiver, environment)?

Most reliable way to assess function

Direct observation of the person performing the task

Best question when you cannot observe

Open-ended "describe how you do it from beginning to end"

Best-written functional goal

SMART: specific, measurable, attainable, realistic, timely, and stated as what the patient will do

what side does the cane go?

- on the side with the stronger leg

- opposite of the weaker side

Cane on stairs

Hold the cane on the stronger side; up with the good, down with the bad

Constipation definition

Decrease in normal frequency of defecation with difficult or incomplete passage of stool or excessively hard, dry stool; normal is 3 times a day to 3 times a week

Constipation: first-line interventions

Bowel retraining at a regular time, privacy, high-Fowler's with knees flexed if bedridden, more fiber, fluids 2,000 to 3,000 mL a day unless contraindicated, exercise

Medications that cause constipation

Opioids, NSAIDs, anticholinergics, calcium carbonate, calcium channel blockers, ferrous sulfate, lithium, tricyclic antidepressants, laxative overuse

Why opioids cause constipation

They slow GI motility, so more water is absorbed and stool becomes hard and dry