Summary Gerontological nursing 3rd edition

Chapter Principles of Gerontology Key terms epidemiology 9 geriatrics 4 gerontologists 4 gerontology 4 homeostasis 17 homeostenosis 17 life expectancy 4 life span 11 risk factors 8 senescence 16 Learning OutCOmes On completion of this chapter, the reader will be able to: 1. Interpret demographic data according to race, gender, and age. 2. Relate leading causes of morbidity and mortality among older adults. 3. Identify common myths of aging and their contribution to ageism. 4. Describe the effects of chronic disease. 5. Contrast several major theories of aging. 6. Evaluate the natural history of disease using principles of epidemiology. 3 Robert W. Ginn/PhotoEdit 4 Unit 1 Foundations of Nursing Practice he aging of America will trigger a huge demand for increased healthcare services. Nurses with skills in caring for older people, or gerontological nurses, will be especially in demand because of their understand- ing of the normal changes of aging and the ways that symp- toms of illness and disease present differently in the older adult. Gerontological nurses recognize that the presenta- tion of disease is often more subtle and less typical when compared to the younger adult and response to treatment differs in the older adult when compared to other groups of patients. The care of the frail older person, defined as the older person with multiple chronic conditions or comorbid- ities, presents a unique challenge. This book addresses the key issues involved in caring for the older person, with an emphasis on health problems encountered by nurses caring for older persons in clinical settings. The diverse health needs of an older person mandate that care be holistic and delivered by professionals with varying but complementary viewpoints; the study of aging combines or integrates information from several separate areas of study including biology, psychology, and sociol- ogy but also considering public policy, economics, and the arts. Gerontology is the holistic study of the aging processes and individuals as they mature throughout the adult life span and includes the following: • Study of the physical, mental, and social changes of aging • Analysis of the changes in society as a result of an aging population • Application of this knowledge to policies and program development As a result of the multidisciplinary focus of gerontology, professionals from diverse fields, including nurses, call themselves gerontologists. Geriatrics is the field more closely aligned with medi- cine and involves: • Study of health and disease in later life • Comprehensive health care of older persons and the well-being of their caregivers The fields of gerontology and geriatrics are of interest to nurses, and some nurses providing care to older people call themselves geriatric nurses while others prefer the term gerontological nurses (Association for Gerontology in Higher Education, 2012). Older people receive nursing care in skilled nursing fa- cilities, retirement communities, adult day care, residen- tial care facilities, transitional care units, rehabilitation hospitals, community-based home care, and a variety of other settings. The underlying core values and principles of gerontological nursing include health promotion, health protection, disease prevention, and treatment of disease, with emphasis on evidence-based best practices and cur- rent clinical practice guidelines. A well-educated and confident gerontological nurse is a vital member of the healthcare team and brings improved health outcomes to older patients and their families by providing appropriate skilled nursing care, preventing adverse outcomes, and im- proving quality of life. Aging is an inevitable and steadily progressive process that begins at the moment of conception and continues throughout the remainder of life. The life or aging process is artificially divided into stages and usually includes an- tepartum, neonate, toddler, child, adolescent, young adult, middle age, and older adult. The final stage of life, called old age (this term usually applies to those over the age of 65), can be the best or worst time of life and requires work and planning throughout all of the previous stages to be a successful and enjoyable period. Old age can be further subdivided to reflect the longer life expectancy, defined as number of years from birth that an individual can expect to live, in the United States and other developed countries and includes the young-old (ages 65–74), middle-old (ages 75–84), and old-old (ages 85+). This designation reflects the philosophy that a 65-year-old will be as developmen- tally different from an 85-year-old as a 20-year-old is dif- ferent from a 40-year-old. Most people do not consider the issues related to aging during their childhood and youth unless they have reason to contemplate certain milestones. For instance, some ado- lescents may anticipate reaching the age of 16 so that they may learn to drive an automobile. Perhaps others will an- ticipate turning 18 so they may enlist in the military. How- ever, as we get older, we might begin to dread our own aging because of the perception that disease, disability, and decline are inevitable consequences of the aging process. Many attitudes and myths about older people can be con- sidered to be ageist or reflect negative stereotypes of aging. Box 1-1 lists myths of aging and the facts that prove them false. Some people may say “you can’t teach an old dog new tricks” when it comes to trying to change negative health behaviors in older people. Others may think that every- one over age 65 has lost the desire for sex and label older persons with a healthy sexual interest in another person a “dirty old man or woman.” Although comments such as these can be hurtful and reflect poorly on the speaker, they do further damage by perpetuating stereotypes. Negative stereotypes of aging make it more difficult to recruit the best and the brightest nurses to work with older patients, limit the opportunities for rehabilitation and health promo- tion services offered to older people, and segregate older T Chapter 1 Principles of Gerontology 5 Nurses should test their knowledge about aging to find out if they have the needed knowledge to provide the best gerontological nursing care to their patients. Nurses can take the aging IQ quiz developed by the NIA (2011). The NIA conducts and supports research on aging and educates the public about the findings. The study of aging and health is imperative for older people to enjoy quality of life in their final years. The new reality of aging reflects our understanding that there has been a dramatic reduction in the prevalence of the precursors to chronic disease including hypertension, high cholesterol, and smoking. The enlightened nurse now knows that having a healthy and productive old age is possible for growing numbers of aging Americans. Those persons who suffer from inherited illnesses such as cancers and blood dyscrasias that present in youth and middle age, weak immune systems, and the inevi- table damage from devastating poverty and substance abuse do not usually live to be old. Often, they carry the burden of chronic disease and poor health developed in younger years into old age, resulting in disability at the end of life. For those older persons who are fortunate enough to enter old age in relatively good health, grow- ing older is a reward and a time to be treasured and enjoyed. Some of the benefits of healthy aging are listed in Box 1-2. people from mainstream society. Gerontological nurses can help by educating others when they hear these negative attitudes about aging from their colleagues and peers. The study of gerontology is a relatively new science. Congress created the National Institute on Aging (NIA) in 1974 as part of the National Institutes of Health. In the 1950s and 1960s, little was known about aging. Much of the knowledge resulted from the study of diseases associ- ated with aging. This practice resulted in the widespread idea that decline and illness were inevitable in old age (Hamerman & Butler, 2007). The focus of gerontology and gerontological nursing at this time was to study, diagnose, and treat disease. However, in recent years, the study of gerontology has moved beyond the disease focus to the improvement of health holistically, including physical, mental, emotional, and spiritual well-being. Health promo- tion and “Tips for Healthy Aging” are a key component of the practice of gerontological nursing and many of the chapters in this book include this feature. The addition of a health promotion focus in the nursing care plan is appro- priate for essentially well older persons in order to main- tain and improve their state of good health; for those with chronic illness, so they can prevent or delay the progres- sion of their disease; and even for those in hospice, so they can retain function in order to enjoy every minute of their limited life span. • Myth: Being old means being sick. • Fact: Fewer than 5% of people over the age of 65 are frail enough to require care in a skilled nursing facility. • Fact: Many older adults have chronic diseases but still function quite well. • Myth: Most older people are set in their ways and cannot learn new things or take up new activities. • Fact: Older people can learn new things and should be chal- lenged to stay mentally active. • Fact: Healthy older adults find hobbies that they can enjoy to give life meaning and pleasure. • Myth: Health promotion is wasted on older people. • Fact: It is never too late to begin good lifestyle habits such as eat- ing a healthy diet and engaging in exercise. • Fact: Although it may not be possible to reverse all of the dam- age caused by bad habits, it is never too late to stop smoking cigarettes or drinking too much alcohol. Even people who quit smoking at older ages enjoy better health outcomes than those who continue to smoke. • Myth: Older adults do not pull their own weight and are a drain on societal resources. • Fact: Older people contribute greatly to society by supporting the arts, doing volunteer work, and helping with grandchildren. • Fact: Paid employment is not the only measure of value and productivity and older people continue to make contributions to society into advanced old age and many continue working, vol- unteering, and mentoring others long after formal retirement. • Myth: Older people are isolated and lonely. • Fact: Many older people join clubs and do volunteer work to stay active and connected. • Fact: There are many ways to maintain contact with people and healthy older adults have a variety of great options for staying connected with others. • Myth: Older people have no interest in sex. • Fact: Although sexual activity does decrease in some older people, there are tremendous differences. Most often, the human need for affection and physical contact continues throughout life. Myths of Aging Source: Adapted from Saison, Smith, Segal, & White, 2010. box 1-1 6 Unit 1 Foundations of Nursing Practice Demographics and Aging Countries all over the world are facing demographic ag- ing. In the United States, we often speak of “the graying of America,” but all nations are—or soon will be—faced with important issues regarding the provision of health care to older persons. As illustrated in Figure 1-1 ▶▶▶, the pro- portion of persons over the age of 60 is projected to double worldwide during the next 50 years (United Nations, 2012). The greatest increases will be seen in developing countries, many of which do not have healthcare systems geared to the health needs of older people. During the first half of the current century, the global population age 60 or over is pro- jected to expand by more than three times to reach nearly 2 billion in 2050. Declining fertility and improved health care have increased the number of older persons worldwide at a dramatic rate. By 2050, the United Nations estimated that the proportion of the world’s population ages 65 and older will more than double from 7.6% today to 16.2%. Countries in the world with the largest numbers of older people today include China (129 million older persons), India (77 million), the United States (40 million), and the Russian Federation (27 million) (United Nations, 2012). Industrialized countries made great progress in extend- ing life expectancy at birth. Japan has the highest life ex- pectancy of the world’s major nations, with the average Japanese born today expecting to live 82.9 years, while the The goal for nurses who provide health care to older people is not only to improve the length of life, but also to improve the quality of life. The healthcare needs of older patients are unique because of their stage of life, just as the health needs of children are different from those of adults. Most health- care professionals do not receive the education and training necessary to respond to the unique and complex health needs of older adults; however, it is now recognized that content and learning opportunities related to the care of older adults should be incorporated throughout the education of all nurses to ensure that the nurse of the future will be able to provide high-quality nursing care to the nation’s aging population (Hartford Institute for Geriatric Nursing, 2011). As a result, many older people who in the past received inappropriate health care that was unnecessary, harmful, or even dangerous will now have access to more appropriate health care with the desired outcome of improving their quality of life. • Creativity and confidence are enhanced. • Coping ability increases. • Gratitude and appreciation deepen. • Confidence increases with less reliance on the approval of others. • Self-understanding and acceptance increase. benefits of Healthy Aging box 1-2 40 35 30 20 25 15 10 5 0 Percentage 2050 World More developed regions Less developed regions Figure 1-1 ▶▶▶ Population over the age of 60, worldwide and developing regions. Source: United Nations, Population Division. (2012). World population aging 1950–2050. Retrieved from pdf/. Chapter 1 Principles of Gerontology 7 Longevity and the Gender Differential Prior to 1950, the male population outnumbered the fe- male population. In 1950, this trend reversed. Women now comprise the majority of the older population (55%) in all nations, and the majority of these women (58%) live in de- veloping countries. In the United States, women outnumber men and the ratio of men to women over the age of 65 is 49 men to every 100 women (U.S. Census Bureau, 2010). In the United States in 2010, the average life expectancy was 78.3 years, with the life expectancy of men at 75.7 years and of women at 80.8 years (U.S. Census Bureau, 2010). Disparities in life expectancy remain according to the race/ gender of the population, although all populations have en- joyed increases in life expectancy during the past decade. For instance, at the age of 65 a Caucasian male has a life expectancy of 17.3 remaining years, whereas an African American male is projected to have 15.5 remaining years. A Caucasian female has 19.9 remaining years, whereas an African American female has 18.9 projected years (U.S. Census Bureau, 2010). In recognition of this fact, Healthy People 2020 was recently released with one of its four ma- jor goals being to “achieve health equity, eliminate dispari- ties, and improve the health of all groups” including the growing number of racially and ethnically diverse older persons (U.S. Department of Health and Human Services [USDHHS], 2010). Central African Republic has the lowest average life expec- tancy at 47 years (World Bank, 2011). The United States is projected to experience rapid growth in its older population as well. In 1930, America’s older population numbered less than 7 million—about 5.4% of the population. According to the 2010 census, the population of the United States was 308.7 million. Those age 65 and over numbered 40.3 million persons, about 13% of the population (U.S. Census Bureau, 2010). By 2050, the number of Americans ages 65 and older is projected to be 88.5 million—more than twice today’s population of older adults. The “baby boomers” (those born between 1946 and 1964) are mostly responsible for the growth of older persons because they began crossing into the age 65+ category on January 1, 2011. By 2030, about one in five U.S. residents will be age 65 or older. The United States will also become more racially and ethnically diverse and in 2042, the aggregate minority population is projected to become the majority (Vincent & Velkoff, 2010). Aging trends occurring now and into the future will affect each of the three subgroups of older people in different ways: • The young-old (ages 65–74): During the next 20 years, 74 million baby boomers will retire. Medicare and So- cial Security will add 10,000 new retirees per day. • The middle-old (ages 75–84): During the next decade, increased life expectancy will add to the numbers of ag- ing baby boomers and increase the total numbers in this category. • The old-old (ages 85+): The old-old are the fastest growing segment of the population, growing at twice the rate of those ages 65 and over and four times faster than the total U.S. population. This group will triple from the current 5.7 million to over 19 million by 2050 (U.S. Census Bureau, 2010). Past fertility trends exerted the strongest influence on the U.S. age structure in the 20th century. Relatively high fer- tility at the start of the century, lower fertility in the late 1920s and 1930s, and higher fertility after World War II during the baby boom all affected the U.S. age composi- tion. In 1950 there were 3.01 children born to each woman in the United States; in 2000 the average was one child lower at 2.01 (U.S. Census Bureau, 2010). At the begin- ning of the 20th century, half of the U.S. population was younger than 22.9 years. At the century’s end, half of the population was younger than 35.3 years, the country’s highest median age ever (U.S. Census Bureau, 2010). The baby boomers (“boomers”) have had—and will continue to have—a profound impact on American culture and demo- graphics. Figure 1-2 ▶▶▶ illustrates the “bulge” in the U.S. population pyramid and the changes by age and sex as the baby boomers have aged between 2000 and 2010. Practice Pearl ▶▶▶ Older women greatly outnumber older men in most nations. Therefore, the study of gerontology is closely linked to the study of women’s health. Older women face different socioeconomic circum- stances than men as they age. They are more likely to be widowed, to live alone, to be less educated, and to have fewer years of labor experience, making older women (es- pecially those over the age of 75) more likely to live in poverty (Health Resources and Services Administration, 2010). By 2025, nearly three quarters of the world’s older women are expected to reside in what is known today as the developing world. The term feminization of later life describes how women predominate at older ages and how the proportions increase with advancing age (Transgenera- tional Design Matters, 2011). In most countries, including the United States, the relative female advantage due to in- creased life expectancy increases with advancing age and the number of males relative to females decreases as age increases (U.S. Census Bureau, 2010) (Figure 1-3 ▶▶▶).