Older Adult and Geriatric Care for Texas Nurses

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will have increased your knowledge of the unique issues related to caring for older adult patients. Specific learning objectives to address potential knowledge gaps include:

• Discuss the major age-related physiologic changes impacting older adults and related prevention and health maintenance.
• Discuss cognitive changes impacting the health of older individuals and related management recommendations.
• Describe mental health issues of older individuals.
• Review the assessment and management of elder abuse victims.
• Clarify the principles that guide end-of-life care.

INTRODUCTION

By 2034, older adults, defined as 65 years and older, are projected to outnumber young people for the first time in U.S. history, with people ages 65 and older numbering 77.0 million and children under 18 numbering 76.5 million. The main reason for this is the nation’s “baby boom” generation of the 1950s and 1960s. Almost 12% of Texans—3.2 million people—are 65 and older, and the number is growing. By 2050 that figure is expected to increase to almost 20% of the state population (TX HHS, 2021a).

Today, this topic still remains one of prime concern and must be addressed by all healthcare providers if we are to meet the unique medical and quality-of-life needs of this growing population. Continuing education of the healthcare community is an essential step in the process.

PHYSIOLOGIC CHANGES AND DISEASE PROCESSES OF AGING

Aging involves changes in physiology. Some changes result in declines in function of the senses and activities of daily life and increases in susceptibility to and frequency of disease or disability. Aging is a major risk factor for a number of chronic diseases, and many diseases appear to accelerate the aging process, manifesting in declines in function and quality of life (NIA, 2020; Kane et al., 2018).

Musculoskeletal System

Musculoskeletal disorders that are common among older patients include the triad of loss of muscle mass and function, tendinopathies, and arthritis. Their common trait is progressive loss of neuromuscular performance with a risk of adverse outcomes, including pain, mobility disorders, increased risk of falls and fractures, and disability or impaired ability to perform activities of daily living.

Bone mass decreases in healthy older people, and age-related changes in women are compounded by menopausal changes in bone mass and function. Osteoporosis due to vitamin D deficiency, common in older people, increases risk for bone fracture and slows rate of bone repair.

The vertebrae lose mineral content, making bones thinner, and vertebral discs lose fluid and thin. The spinal column curves and compresses, and overall height decreases. Posture becomes stooped, and postural hyperkyphosis (excessive curve of the spine) may occur. Shoulders may narrow, pelvis widen, knees and hips become more flexed, and neck tilt backward (LibreTexts, 2020).

With aging, muscle mass decreases in relation to body weight in both men and women, greater in the legs than arms. Lost muscle tissue may be replaced with tough, fibrous tissue. Loss of muscle is associated with decreased strength and slowed and limited movements, and contributes to age-related insulin resistance as well as changes in body composition and distribution for water-soluble drugs.

Tendons begin to shrink, lose mass, and contain less water, causing stiffness and decreased stress tolerance. Ligaments shorten and lose flexibility. Joint changes include inflammation, stiffness, deformity, and pain, leading to functional disability.

Gait becomes slower and shorter. Walking becomes unsteady, with less arm swinging and increased risk for injury from falls (NIH, 2020a).

Foot problems such as bunions are common and may interfere with functioning and daily activities (Besdine, 2019).

Common management strategies for musculoskeletal disorders include physical exercise, either alone or in combination with nutritional intervention. High-intensity resistance training can improve strength and mass of skeletal muscles and may counteract age-related decline in muscle size and function. A balanced program of both endurance and strength exercises performed on a regular schedule is usually recommended. Nutritional supplements may be advised, including vitamin D.

Interventions for managing arthritis may include physical modalities such as heat and cold, techniques to manage or control edema and inflammation, therapeutic activities and exercises, and provision of custom or prefabricated orthotic devices.

Most older adults can benefit from targeted programs to prevent falls and optimize bone health (Minetto et al., 2020).

Integumentary System

Skin changes are the most visible signs of aging. Growths such as skin tags, warts, rough patches (keratoses), and other blemishes are more common in older adults. More than 90% of all older people also have some type of skin disorder, such as xerosis, pruritus, eczematous dermatitis, and purpura (NIH, 2020b).

Decreased concentration of 7-dehydrocholesterol in the epidermis results in decreased synthesis of vitamin D necessary for bone health.

Ability to sense touch, pressure, vibration, heat, and cold may decrease.

Wound healing slows, and moisture retention decreases. Body hair decreases, and there is less sebum and cerumen, resulting in dryness and itchiness.

Blood vessels become fragile, leading to bruising and bleeding under the skin. Reduced sweating can lead to heat intolerance.

The subcutaneous layer thins and provides less insulation and padding, increasing risk of skin injury and reduced body temperature maintenance. Pressure injuries become more common.

Nails grow more slowly and thicken, and ingrown toenails become more common (NIH, 2020b).

Health maintenance for skin integrity in the older adult is essential and requires a holistic and interdisciplinary approach. Skin basics include:

• Educating patients and caregivers
• Performing regular skin assessments
• Maintaining mobility
• Relieving pressure
• Using safe manual handling techniques
• Providing skin care, paying attention to high-risk areas
• Encouraging good nutrition and hydration

Older patients and caregivers should be encouraged to inspect feet daily for skin color, dryness, swelling or tenderness, blisters, cracks, sores, ulcers, corns, ingrown toenails, paresthesia, or pain. Other common foot problems in older individuals include calluses, foot deformity, fungal infection, and warts. A podiatry consult may be recommended (Fraser, 2020; EHS, 2018).

Because many older adults had chicken pox as children, they are at risk for reactivation of the varicella zoster virus, which causes shingles, and should obtain a vaccine if there are no contraindications (Fraser, 2020; MSKL, 2020).

Cardiovascular System

Cardiac aging is associated with left ventricular hypertrophy, fibrosis, and diastolic dysfunction, resulting in reduced cardiac output. These changes result in reduced left ventricular filling, which can lead to heart failure, especially in older people with other diseases such as hypertension, obesity, and diabetes.

The walls of the arteries and arterioles also become harder and thicker (arteriosclerosis), and less elastic, affecting the ability of blood pressure to make adjustments when standing quickly, putting people at risk for dizziness or fainting. And because blood vessels become less elastic with age, they do not relax quickly, causing blood pressure to increase during systole (Gupta & Shea, 2019; Fajemiroye et al., 2018).

Approximately 80% of deaths attributed to acute coronary syndromes occur in patients 65 years of age and older. The prevalence and complexity of cardiac arrhythmias increase with age, the most common sustained dysrhythmia being atrial fibrillation. Older adults are also at increased risk of major complications from therapeutic interventions. The prevalence of peripheral arterial disease increases progressively with age and is often predictive of the presence of coronary artery and cerebrovascular disease (Kyriazis & Saridi, 2020; Harper et al., 2019).

Management and prevention of cardiovascular issues in the older adult include patient education regarding modifying controllable risk factors such as diabetes, hypertension, overweight, diet, exercise, smoking, and alcohol intake. This includes instruction on signs and symptoms of acute myocardial infarction; routine exercise; and nutrition, such as low-fat, low-cholesterol, and low-sodium diets.

Hypertension management also requires lifestyle changes and pharmaceutical therapy, often started at a low level and increased, if indicated. Education on stress management and encouragement of some form of relaxation technique are also recommended.

The goal of therapy for atrial fibrillation is the prevention of thromboembolism, which is often managed with anticoagulation therapy, such as warfarin (Coumadin) or apixaban (Eliquis).

Management of peripheral vascular disease includes general prevention measures such as avoiding prolonged standing or sitting, exercising on a regular basis, and other lifestyle recommendations. Pharmaceutical therapy includes antiplatelet or anticlotting agents, statins, and medications that increase blood supply. Nonpharmaceutical therapy includes extremity elevation, compression stockings, exercise, and wound care for ulcerations caused by chronic venous insufficiency (Cash & Glass, 2019).

Urinary System Changes

KIDNEYS

With aging, the volume of kidney tissue decreases. Over an average lifespan, nephrons are reduced by half, and by age 75 atherosclerosis of renal arteries reduces renal blood flow by half. Glomerular filtration rate and maximum excretory capacity are reduced by the same proportion.

The kidneys can still maintain normal homeostatic mechanisms and waste disposal within limits, but they are less efficient and need more time, and their reserves may be minimal. Therefore, relatively minor degrees of dehydration, infection, or impaired cardiac output may lead to kidney failure. Loss of renal reserve increases the risk for toxic accumulation of renally cleared medications.

The kidneys have a central role in maintaining normal levels of most electrolytes. Reduced diluting capacity of the kidney increases the risk of hyponatremia in older patients, particularly those on a low-protein diet (Physiopedia, 2021).

The kidneys play a role in glucose homeostasis. Under normal circumstances, the kidneys filter and reabsorb 100% of glucose. In addition, they produce glucose by gluconeogenesis, contributing 20% to 25% of circulating glucose (Bhimma, 2018).

Diabetes mellitus is the most common cause of chronic kidney disease. Hyperglycemia damages the glomeruli within each kidney, resulting in an increased glomerular filtration rate.

Kidney disease leads to a decline in production of erythropoietin, which is one of the causes of unexplained anemia in older adults. Most people with kidney disease will develop anemia (NKF, 2020; Artz, 2019).

There is no cure for chronic kidney disease, and once the kidneys are damaged, they cannot be repaired. If and when the kidneys fail, renal dialysis is required.

Prevention of chronic kidney disease involves lowering the risk by making healthy lifestyle changes, maintaining a normal blood pressure, and controlling diabetes (CDC, 2020a).

BLADDER AND URETHRA

Aging increases bladder dysfunction, including reduction in bladder capacity, uninhibited contractions, and decreased urinary flow rate. Urinary tract infections common in older people have more systemic effects. They are commonly seen in older adults admitted to the hospital because of a fall or acute confusion.

The urethra can become blocked. In women this can be due to weakened muscles caused by bladder or vaginal prolapse, and in men by an enlarged prostate gland (Physiopedia, 2021).

Urinary incontinence is a significant health problem for older adults, both physically and psychologically. Women are disproportionately affected. Common age-related physiologic changes predisposing to incontinence include decreased bladder capacity, benign prostatic hyperplasia (BPH) in men, and menopausal loss of estrogen in women. Other risk factors for incontinence include immobility, certain types of medications, obesity, smoking, malnutrition, delirium, depression, sensory impairment, and environmental barriers (NIH, 2020c; Dowling-Castronov & Spiro, 2020).

Patients presenting with symptoms of urinary tract infection should be placed on an appropriate antibiotic.

Urinary retention is most commonly caused by BPH, whose main treatments include:

• Active surveillance by a urologist
• Medications
• Less invasive procedures, such as a prostatic urethral lift (PUL), water vapor thermal therapy, and transurethral microwave therapy (TUMT) that destroys prostate cells; and catheterization, intermittent or indwelling
• Invasive surgical procedures, including transurethral resection of the prostate (TURP)
  (AUA, 2020)

Management of urinary incontinence depends on the type of incontinence, severity, and underlying cause, and a combination of treatments may be used (see table).

INTERVENTIONS FOR URINARY INCONTINENCE

Type	Interventions
(Mayo Clinic, 2019; Cunningham & Valasak, 2019)
Lifestyle changes	Weight loss Smoking cessation Alcohol avoidance Decreased caffeine intake Prevention of constipation Avoiding heavy lifting
Behavioral techniques	Scheduled or delayed timed urination Double voiding
Physical therapy	Pelvic floor exercises (e.g., Kegel’s) Muscle-strengthening exercises Electrical stimulation Biofeedback
Occupational therapy	Bladder retraining Modifications to food and fluids Relaxation techniques Support for integration of training
Medications	Anticholinergics Alpha blockers for men Topical estrogen for women
Medical devices	Vaginal rings and urethral inserts
Surgery	Single sling procedures Bladder neck suspension Prolapse surgery Artificial urinary sphincter implants
Supportive interventions and devices	Absorbent pads Protective undergarments, modified clothing Intermittent catheterization Condom catheter for men Urethral plugs and penile clamps

Respiratory System

Aging of the respiratory system reduces the capacity of all pulmonary functions, which may lead to decompensation when the system is stressed.

The effects of aging in other areas of the body also affect the lungs. These include changes in the bones and muscles of the chest and spine. Bones become thinner and change shape and can alter the shape of the ribcage, resulting in decreased expansion and contraction. The diaphragm becomes weakened, impairing both inhalation and exhalation. These changes may lower the oxygen level in the body and raise carbon dioxide levels, resulting in tiredness and shortness of breath.

Aging also causes the walls of the alveoli to deteriorate, lose shape, and become baggy. Dead space increases with age as larger airways increase in diameter.

The nervous system, which monitors respiratory volume and blood gas levels and regulates respiratory rate, may lose some of its function. Breathing may become more difficult and gas exchange impaired. Dysphagia or impaired esophageal motility, also common in old age, may exacerbate the tendency to aspirate.

Decline in effectiveness of the immune system means the body is less able to fight lung infections and less able to recover following exposure to smoke or other harmful substances (NIH, 2020d).

Normal aging results in a number of changes to the structure and function of the respiratory system.

Because older people are at highest risk of developing pneumonia, influenza and pneumococcal pneumonia vaccines are highly recommended.

Common respiratory diseases experienced by older persons include chronic obstructive pulmonary disease (COPD) and emphysema. There is a greater prevalence of COPD in older adults as a result of smoking. Management can be difficult because of those coexisting medical problems, requiring geriatric care and attention from a team of providers.

Risk for COPD and emphysema can be reduced through lifestyle management that includes encouraging older adults to stop smoking, avoid air pollution, and reduce weight to improve diaphragm function. Pulmonary function does not respond to exercise training, however; aging, therefore, may become an increasingly important limiting factor for physical activity (NIH, 2020d).

COPD affects the well-being of the older adult both physically and socially, increasing disability and dependency. The main treatment for COPD is inhaled medications, including steroids. Impact of using long-term inhaled steroids must be considered in this population. Therapies that have a proven impact on mortality include smoking cessation and oxygen therapy (Gill, 2017).

Emphysema, a form of COPD, can be treated with the Zephyr valve, a one-way valve placed in three to five airways that reduces hyperinflation of a portion of the lung (Dransfield et al., 2020).

Endocrine System

The endocrine system consists of organs and tissues that produce hormones that control the function of target organs. Aging results in changes in the way body systems are controlled, with some target tissues becoming less sensitive to their controlling hormones. Also, the amounts of hormone production may change. Many of the organs that produce hormones are controlled by other hormones, and aging also changes this process (van den Beld et al., 2018).

The thyroid gland produces hormones that help control metabolism, and with aging, metabolism slows. There is an increased risk of hypothyroidism with aging, which may increase the subsequent risk of death due to cardiovascular disease.

Parathyroid gland hormone affects calcium and phosphate levels. This hormone’s level rises with age, contributing to osteoporosis, leading to kidney stones and renal failure, and significantly decreasing the quality of life.

Insulin is produced by the beta cells in the pancreas, and after age 50, cells become less and less sensitive to its effects. An increase in fibrosis and fatty deposits increases glucose intolerance and decreases sensitivity to insulin. Type 2 diabetes is the most common type of diabetes among this age group and is on the rise due to increasing obesity and failure to remain physically active, both of which contribute to insulin resistance.

Normal aging results in changes in adrenal secretion of both ACTH and cortisol, most significantly an increase in cortisol levels, which can have serious consequences in the integrity of both the structure and function of various areas in the brain, leading to impairment in normal memory, cognitive function, and sleep cycles.

Melatonin is a hormone secreted by the pineal gland in response to darkness. A decline in melatonin level is believed to play a role in the loss of normal sleep-wake cycles with aging (NIH, 2020e).

Gonads begin to secrete less estrogen in females and less testosterone in males, increasing the risk for atherosclerosis and osteoporosis in both genders. Less estrogen leads to menopause, the decline of ovarian function, and changes in the uterus and vaginal tissues that may interfere with sexual satisfaction. For males, reduction in levels of testosterone occurs gradually during andropause. This decline in hormone may increase the risk of sexual dysfunction; however, age does not predict male fertility (Morley, 2019; NIH, 2020f).

Among other medical issues, older adults with the diagnosis of HIV/AIDS may develop endocrine problems specific to HIV infection and its treatment. These may include gonadal dysfunction, osteoporosis with increased fracture risk, and dyslipidemia with increased cardiovascular risk (Zaid & Greenman, 2019).

MANAGEMENT AND PREVENTION

Treatment of endocrine disorders can be complicated, as changing one hormone level can affect another. Management takes into account coexisting medical illness, medications, alterations in clearance rate of hormones, and changes in target organ sensitivity with older age.

Hyperthyroidism and Hypothyroidism

Patients with hyperthyroidism may be started on antithyroid medications such as methimazole or beta blockers to help control symptoms. For those with hypothyroidism, thyroid replacement medication such as levothyroxine may be started (Cleveland Clinic, 2020).

Diabetes Mellitus

For patients with diabetes, guidelines stress the importance of considering overall health, comorbidities, cognitive and physical status, hypoglycemia risk, and life expectancy to guide glycemic goal setting. Lifestyle modification is important, including diet and exercise, and when such modifications alone are unable to maintain target treatment goals, antihyperglycemic pharmaceutical agents are considered (Leung et al., 2018).

Hyperparathyroidism

Hyperparathyroidism, the most common cause of hypercalcemia, increases with age. Surgical treatment substantially improves quality of life and is more cost-effective than medical management (Dombrowsky et al., 2018).

Excess Adrenal Cortisol Secretion

Management of excess adrenal secretion of cortisol involves recommending participation in physical activity that improves physical performance in order to attenuate the negative impact of chronic stress and normalize adrenal secretion of cortisol (Tortosa-Martinez et al., 2018).

Menopause and Andropause

With the decline in sex hormones, both men and women face organic changes that can affect sexual functioning. For women it may include vaginal dryness, irritation/itching, inadequate lubrication, and dyspareunia (painful intercourse). For men, erectile dysfunction prevalence increases with age, and some men develop testosterone deficiency that can severely reduce libido.

Recommended treatments for the symptoms of menopause include vaginal moisturizers and lubricants, vaginal estrogens, and oral or transdermal hormone therapy.

The best way to manage and prevent erectile dysfunction (ED) is to make healthy lifestyle choices, manage any existing chronic health conditions, and be screened for depression or other possible psychological causes of ED. Exercise, especially moderate to vigorous aerobic activity, has been found to improve ED. Other treatments may include oral, rectal, or injected drugs; testosterone replacement; penis pumps; and penile implants.

Testosterone replacement for men can be recommended as long as maintenance of fertility is not desired. Testosterone replacement can restore lean body mass, physical strength, erectile function, and libido as well as improve mood, bone mineral density, and quality of life (Jannini & Nappi, 2018; Mayo Clinic, 2020a).

Gastrointestinal System

Age-related changes in the digestive system begin in the mouth and can affect virtually all aspects of the digestive system.

Contractions of the esophagus and tensions in the upper esophageal sphincter decreases, and some older adults can be affected by diseases or disorders that interfere with esophageal contractions.

The stomach lining’s capacity to resist damage decreases, which in turn may increase risk of peptic ulcer disease, especially in those who use aspirin or NSAIDs.

Minor changes occur in the structure of the small intestine. Lactase levels decrease, leading to intolerance of dairy products by many older adults. Excessive growth of certain bacteria becomes more common with age and can lead to pain, bloating, and weight loss. This may also lead to decreased absorption of certain nutrients, such as vitamin B₁₂, iron, and calcium.

The rectum enlarges somewhat, and constipation becomes more common related to a slight slowing in movements of contents through the large intestine, a modest decrease in contractions of the rectum when filled with stool, frequent use of drugs that can cause constipation, and less exercise or physical activity.

The number of secretory cells in the pancreas decreases with age, resulting in a decrease in the level of fat digestion. The liver reduces in size, and metabolism of many substances decreases. This is important when considering medications whose dosages often need to be decreased in older people. Production and flow of bile decreases, and as a result, gallstones are more common (Ruiz, 2020).

Management and prevention require ensuring that only those medications the patient needs are being taken. Lifestyle modifications such as staying active and managing weight can reduce the number of medications needed, thus avoiding digestive side effects. Staying well hydrated and increasing fiber can help reduce complaints related to constipation (Cleveland Clinic, 2021).

Sensory Changes

Sensory changes in later life affect how people perceive and experience the world and can have an enormous impact on independence, safety, and quality of life. All five senses (vision, hearing, taste, smell, and touch) diminish in acuity with age. Aging raises the threshold of the amount of stimulation necessary to become aware of a sensation, with stimulation required. Sensory changes can affect lifestyle by causing difficulties with communication, enjoyment of activities, and staying involved with others, which can then lead to isolation (NIH, 2020g).

Eyes become less able to tolerate glare, and problems with glare, brightness, and darkness may lead to impaired night vision and reduced color discrimination. Visual acuity gradually declines, causing difficulty focusing on close-up objects (presbyopia). Common eye disorders affecting older adults include cataracts, glaucoma, retinopathies and age-related macular degeneration (AMD), the leading cause of severe and permanent vision loss in older adults (NIH, 2020g).

Aging results in changes in the structures inside the ear, causing a decline in function and causing a major impact on independence, safety, and quality of life. With aging, the ability of the ear to pick up sounds decreases, and problems with maintaining balance may also occur.

It is important to remind older patients to follow the recommendation of the American Academy of Ophthalmology for a comprehensive vision exam every year or every other year, which can assure that the patient has the proper eyeglass or contact lens prescription and to check for common eye disorders (Boyd, 2020).

Preventing hearing loss involves management of hypertension and diabetes; smoking cessation; limiting alcohol use; avoiding ototoxic drugs whenever possible; eating foods high in vitamins A, C, E, and especially B₁₂; and wearing hearing protection in noisy environments. When hearing loss does occur in older adults, it is usually permanent, and it can be managed using adaptive techniques and assistive devices (NIH, 2020g).

Nutrition

Obesity is the most common nutritional disorder in the older adult living in the community, and malnutrition is most common in those in acute and long-term care facilities.

Malnutrition in older adults can lead to various health problems, including:

• A weak immune system, which increases the risk of infections
• Poor wound healing
• Muscle weakness and decreased bone mass, which can lead to falls and fractures
• A higher risk of hospitalization and risk of death
  (Mayo Clinic, 2020b)

Interventions for patients who are malnourished are directed at the underlying cause as well as dietary modification. Nutritional restrictions are lifted for patients with diabetes who may do well with a regular diet and adequate monitoring. High-calorie foods are recommended. Oral nutritional supplementation for patients who do not regain weight are also recommended, with adjustments in meal preparation and diet.

Advice regarding weight loss in the overweight older person is tailored to the individual, assessing the impact of excess weight on quality of life and the need for regular exercise. It is not recommended that people over the age of 80 who are slightly obese be placed on calorie-restricted diets. The best option is to eat at least three meals a day that provide 30 grams of protein each, and to engage in two or three weekly sessions of resistance training that taxes all the large muscle groups in order to preserve muscle mass (Ritchie & Yukawa, 2020).

AGE-RELATED COGNITIVE CHANGES

Normal age-associated cognitive changes include difficulties with memory, but:

• They do not noticeably disrupt daily life.
• They do not affect ability to complete tasks as usual.
• There is no difficulty learning and remembering new things.
• There is no underlying medical condition causing the difficulties.
  (UCSF, 2020)

In older adults, some forms of confusion may be temporary or reversible (e.g., due to infections, depression), while others may be irreversible or indicative of chronic confusion and dementia, including Alzheimer’s disease. Health professionals should begin with the assumption that confusion may be reversible, particularly confusion of sudden onset, and seek the possible causes (Mayo Clinic, 2020c).

Delirium

Delirium is a reversible acute state of confusion that develops quickly and is a medical emergency. Delirium is more common in older adults and can be traced to one or more contributing factors, including severe or chronic illness, changes in metabolic balance, medications, infection, surgery, or alcohol or drug intoxication or withdrawal. If the underlying disorder is not corrected, irreversible neuronal damage can occur (Mayo Clinic, 2020d).

Medical management of a patient with delirium involves treating the underlying organic cause, and the goal of management is to keep the patient safe and free from falls and injury while attempting to identify the cause. Supportive care should aim at preventing complications.

Preventive strategies include providing orienting communication; reducing restraints; encouraging early mobilization; focusing on dehydration; and allowing for uninterrupted sleep by turning down the lights and prohibiting care providers from waking patients at night to take vital signs (Halter, 2018).

Mild Cognitive Impairment (MCI)

Mild cognitive impairment is the stage between expected cognitive decline due to aging and dementia. It is characterized by problems with memory, language, thinking, or judgment. These changes, however, are not severe enough to significantly interfere with daily living and one’s usual activities.

There is no single cause of MCI and no single outcome for the disorder. MCI may increase the chances of later development of dementia, but some people never get worse and a few eventually improve (Mayo Clinic, 2020c).

Experts classify mild cognitive impairment based on the thinking skills affected:

• Amnestic MCI primarily affects memory. A person may start to forget important information that they would previously have recalled easily.
• Nonamnestic MCI affects thinking skills other than memory, including ability to make sound decisions, judge the time or sequence of steps needed to complete a complex task, or visual perception.
  (AA, 2021)

Currently there are no drugs or other treatments approved specifically for mild cognitive impairment. Cholinesterase inhibitors approved for Alzheimer’s disease may be prescribed, but they are not routinely recommended for MCI (Mayo Clinic, 2020c).

Research has found certain factors that may reduce the risk of cognitive impairment, including:

• Avoiding excessive alcohol use
• Limiting exposure to air pollution
• Reducing risk of head injury
• Not smoking
• Managing diabetes, cholesterol, hypertension, obesity, and depression
• Practicing good sleep hygiene and managing sleep disturbances
• Eating a nutrient-rich diet low in saturated fats
• Engaging socially with others
• Exercising regularly at moderate to vigorous intensity
• Wearing a hearing aid if hearing loss is present
• Engaging in mentally stimulating activities
  (Mayo Clinic, 2020c)

Dementia

Dementia is an umbrella term for a collection of symptoms of cognitive decline including disruptions in short-term memory, learning new information, planning, problem-solving, decision-making, language, orientation, visual perceptual skills, mood, and behavior, all of which interfere with daily activities. Dementia, however, is not a result of normal aging of the brain (CDC, 2020b).

Dementia often has more than one cause involving damage to the brain from a number of different sources, and those with Alzheimer’s disease may also have vascular dementia. Alzheimer’s disease and vascular dementia are the most common forms of dementia in older adults (AGS, 2020).

MANAGEMENT AND PREVENTION

There is no cure for dementia, but there are medications, treatments, and strategies that can slow decline and help patients with dementia utilize their abilities to function as well as possible in order to have the highest possible quality of life. These involve:

• Identifying, treating, and monitoring underlying problems that increase the risk of dementia and can worsen symptoms (e.g., heart disease and diabetes)
• Checking for and treating problems that can contribute to mental health changes (e.g., depression, pain, hearing or vision loss)
• Monitoring for development of new medical problems
• Monitoring for medication side effects
• Teaching caregivers how best to manage symptoms and behavioral problems and to find caregiving, financial, and legal support
  (AGS, 2020)

Medications that are often prescribed for those with dementia include cholinesterase inhibitors and MNDA receptor agonists. Antipsychotic drugs, antidepressants, and mood stabilizers may help control specific behaviors that may present in the patient diagnosed with dementia, but effectiveness is limited, and they are associated with an increased risk of death (AGS, 2020).

Nonpharmaceutical interventions are tailored to the person’s symptoms and needs in collaboration with the patient and caregiver. These may include physical therapy exercise programs, occupational therapy, pet therapy, message therapy, aromatherapy, or art therapy.

There is no way to prevent all types of dementia, but there is evidence that the risk can be reduced with a healthy lifestyle, including participating in regular activity and maintaining good heart health (Alzheimer’s Society, 2021a).

COMMUNICATING WITH THE PATIENT WITH DEMENTIA

It can be difficult and challenging to care for patients with dementia. It is helpful to remember that every behavior being expressed is the patient’s way of trying to communicate experiences, fears, prejudices, feelings, values, and beliefs that may require further assessment (Koch, 2020).

People with dementia retain the ability to interpret tone and body language, which is very important for them in making sense of the world. If a caregiver talks to them as if they were children, they will likely know they are being talked down to. It is best to avoid using baby talk, calling adults “Dear” or “Sweetie,” or speaking in a high-pitched, sing-song voice. This is likely to result in irritation and contribute to aggressive and uncooperative behavior and to the patient being labeled as “difficult.” It is always best to call the person by name.

Individuals with dementia are often living in an alternate reality, and it may do more harm than good to attempt to orient them to the current reality. The caregiver must enter the patient’s reality and work on that level.

Recommendations for effective communication include:

• Communicate in a dignified adult manner, using short sentences and speaking slightly more slowly and clearly.
• Do not assume the patient has lost a more sophisticated vocabulary and resort to simple or easier words.
• Allow a period of silence after speaking for the person to think before answering.
• Try to communicate in a conversational manner.
• Avoid asking ask question after question. As the disease progresses, ask questions that require a yes or no answer, and break down requests into single steps.
• Offer choices when making a request for which the patient might resist. For example, “Do you want to take a shower before breakfast or after breakfast?” instead of, “It’s time to take a shower.”
• Whenever possible, avoid distractions such as background noise that can make it difficult to hear, listen attentively, or concentrate.
• Avoid criticizing, correcting, and arguing. When listening to someone with dementia, it is pointless and counterproductive to argue about what the person is saying.
• Avoid asking questions that require concentration and memory to answer, such as “What did you eat this morning?”
  (Alzheimer’s Society, 2021b; Koch, 2020)

MENTAL HEALTH ISSUES

Most older adults enjoy good mental health, while some experience mental health issues that can adversely affect both physical health and ability to function. Besides cognitive impairment, common mental health issues among older adults include mood disorders such as depression and substance use. Mental health issues are often implicated as a factor in cases of suicide among this population.

Depression and Suicide

Depression is the most common mental health condition in adults age 65 and older (MHA, 2021). Negative effects of depression are far-reaching, further complicating existing conditions common among older adults.

Often depression in the older adult is confused with the effects of multiple illnesses and the medications used to treat them. Also, due to the belief that the older adult is expected to slow down, family and healthcare practitioners may miss signs of depression, and effective treatment is often delayed.

Suicide is the 17th leading cause of death among people age 65 and older. White males age 85 and older have the highest rate in the nation. Although older adults attempt suicide less often, they are more successful. Older adults should be screened for suicide risk using a tool such as the Patient Health Questionnaire (PHQ-2), a two-question depression screen (Wenker & Liebzeit, 2019).

Recognizing the symptoms and screening for depression and suicide in older people and referring them for appropriate diagnosis and treatment may greatly improve their quality of life and prevent suicide (NIA, 2017).

Management of depression includes antidepressants, psychotherapy, complementary therapies, electroconvulsive therapy, and stimulation techniques. Regular exercise may help prevent depression. Being fit and eating a balanced diet may help avoid illnesses that can increase the risk for disability or depression (NIMH, 2020).

Suicide protective factors include good physical and mental health, social relationships, and belief systems (CDC, 2019).

Substance Use in Older Adults

While illicit drug use typically is much lower in older adults than younger adults, it is currently increasing. Nearly 1 million older adults are living with a substance use disorder. Little is known about the effects of drugs and alcohol on the older brain, but older adults typically metabolize substances more slowly, and their brains can be more sensitive to drugs.

Alcohol is the most frequently used substance among older adults. Many older adults may use alcohol simply because it is a long-term habit that is part of their lifestyle. Some may use alcohol and other substances to cope with big life changes such as retirement, grief and loss, declining health, or a change in living situation.

Older adults may be more likely to experience mood disorders, lung and heart problems, or memory issues, and drug and alcohol use can worsen these conditions. Additionally, some drugs can impair judgment, coordination, or reaction, which can result in accidents, including falls and auto crashes (NIDA, 2020).

Despite the increasing prevalence of substance use among older adults, they are less likely to be screened compared to younger adults. Signs and symptoms of substance use may be mistaken for manifestations of chronic disease (Han & Moore, 2018). Several screening instruments for substance use are available for a range of substances (alcohol, tobacco, illicit drugs, and prescription drugs), but only a few are designed specifically for and validated in older adults.

One example of a validated screening tool that is commonly used with older adults in the primary care setting is the Substance Use Brief Screen (SUBS), a self-administered brief screen for tobacco, alcohol, and drug use (illegal and prescription). Screening positive with this tool would lead to further screening with longer, more reliable tools (Han & Moore, 2018).

The misuse and abuse of substances by the older adult presents unique challenges for recognizing the problem and determining the most appropriate treatment interventions. Misuse is the intentional use, for therapeutic purposes, of a drug by an individual in a way other than prescribed by the healthcare provider or for whom it was not prescribed. Abuse is the intentional nontherapeutic use of a drug, even once, for its desirable psychological or physiologic effects (U.S. FDA, 2019).

Treatment options specifically tailored for older adults are limited. The majority of older adults at risk for problem substance use do not need formal, specialized substance abuse treatment. However, many can benefit from prevention messages, screening, and brief interventions (Fulmer & Chernof, 2019).

ELDER ABUSE

Elder abuse is defined as an intentional or neglectful act by a caregiver or trusted individual that leads to or may lead to harm of a vulnerable older adult. Elder abuse is a problem estimated to affect up to 1.2 million older adults annually in the United States. Only 1 in 10 cases of elder abuse, however, are ever reported. Elder abuse can lead to early death, harm one’s physical and psychological health, destroy social and family ties, and cause devastating financial loss (CDC, 2020c; Kane et al., 2018).

Various types of elder abuse include:

• Physical abuse: Use of force to threaten or physically injure an older person, including acts such as hitting, kicking, pushing, slapping, and burning
• Emotional/psychological abuse: Verbal or nonverbal attacks, threats, rejection, isolation, or belittling acts that cause mental anguish, fear, or distress
• Sexual abuse: Sexual contact that is forced, tricked, threatened, or otherwise coerced, including sexual harassment
• Exploitation: Theft, fraud, misuse or neglect of authority, and use of undue influence as a lever to gain control over an older person’s money or property
• Neglect: Failure or refusal to provide for an older person’s basic needs of food, water, shelter, clothing, hygiene, essential medical care, safety, or emotional needs
• Abandonment: Leaving an older adult who needs help alone without planning for their care
  (NCEA, 2020)

Recognizing Elder Abuse

Many older adults are reluctant and/or ashamed to report mistreatment, or they are afraid if they do, it will get back to the abuser and make the situation worse. However, in cases of suspected or known abuse, further screening can be done with validated tools such as the Elder Assessment Instrument (EAI) (Fulmer, 2020).

Clinicians must be aware of the signs and symptoms that signal an older adult may be experiencing abuse.

• Physical abuse may cause injuries such as broken bones, bruises, scratches, burns, or multiple injuries in various stages of healing.
• Signs of sexual abuse may include bruising of breasts or the genital area, genital infections, or vaginal or anal bleeding.
• Possible indicators of economic abuse may include lack of appropriate clothing or grooming, patient complaints of missing clothing or jewelry, or sudden appearance of previously uninvolved relatives.
• Signs of neglect may include pressure injuries, poor hygiene, torn or dirty clothes, malnutrition, contractures, and lack of needed healthcare appliances or supplies.

Reporting Elder Abuse

Texas law requires anyone who suspects abuse, neglect, or exploitation of a person 65 years or older or an adult with disabilities to report it to the Texas Department of Family and Protective Services (DFPS). If an older adult is suspected to be in immediate, life-threatening danger, an individual should call 911. Reporting suspected abuse makes it possible for an individual and their family to get help.

A person who reports abuse in good faith is immune from civil or criminal liability. Anyone who does not report suspected abuse can be held liable for a misdemeanor or felony. DFPS keeps the name of the person making the report confidential. Reports can also be made anonymously according to the provisions of Texas state law.

To report suspected elder abuse, neglect, or exploitation:

• Call 911 or the local law enforcement agency for any emergency or life-threatening situation that must be dealt with immediately.
• Call the Texas Abuse Hotline (800-252-5400) 24 hours a day, 7 days a week, if the situation is urgent and needs to be investigated within 24 hours.
• Call the Texas Health and Human Services Commission (800-458-9858) to report suspected abuse occurring in nursing facilities, assisted living facilities, day activity and health services, home health and hospice agencies, and intermediate care facilities.
• Report online through the secure website at txabusehotline.org (however reports cannot be submitted via email)
  (TX DFPS, 2020; TX HHS, 2021b)

Timeframes for investigating reports are based on the severity of the allegations. Anyone convicted of elder abuse in Texas will be convicted of a felony in the first degree which earns a prison sentence of up to 10 years and a fine of up to $10,000 (TX DFPS, 2020).

(See also “Resources” at the end of this course.)

END-OF-LIFE CARE

End-of-life care describes the support and medical care given during the time surrounding death. Older people often live with one or more chronic illnesses and may need care for days, weeks, and even months before death. The goals are to prevent or relieve suffering as much as possible and to improve quality of life while respecting the dying person’s wishes.

Physicians are obligated to comply with the refusal of life-sustaining treatment by a competent patient who has been adequately informed of the consequences of referral and has applied their own values in making a decision to refuse or who have prepared an advance directive or living will. Likewise, clinicians may refuse to provide care if:

• There is no medical rationale for the treatment
• The treatment has proven ineffective for the person
• Expectation of survival is low
• The person is unconscious and will likely die in a matter of hours or days even if treatment is given

Treatments that have been started can also be stopped. This is appropriate if the treatments are not beneficial or are not consistent with an individual’s wishes and priorities. Even if life-sustaining treatments have been refused or stopped, the individual can still receive medical care to treat symptoms such as pain or shortness of breath (Health in Aging Foundation, 2020; Olejarczyk & Young, 2020).

Preparing older adults and their families to plan and anticipate making decisions regarding end-of-life care and treatment is important, especially in the event that the older adult is not able to make decisions for themself. Older adults should plan and discuss their preferences with significant others, family, and healthcare providers to communicate their wishes through advance directives, a living will, and appointing a healthcare proxy.

Palliative Care

Palliative care is an interprofessional team-based approach to patient care for the management of the discomfort, symptoms, and stress of serious illness and is appropriate for any person with a serious illness, regardless of the stage of the illness or how long the person is expected to live. Palliative care does not replace primary treatment but works together with the primary treatment being given.

The goals of palliative care are to:

• Provide relief from pain and other physical symptoms
• Maximize the quality of life
• Provide psychosocial and spiritual care
• Provide support to help family during the patient’s illness and in their subsequent bereavement

The ideal core palliative clinical team consists of:

• Physician(s)
• Nurses (inpatient and community care)
• Home health aides
• Social worker
• Physical therapist
• Occupational therapist
• Speech-language therapist
• Chaplain or pastoral care counselors
• Dietitians/nutritionists

Other professionals may include:

• Clinical psychologists
• Clinical pharmacists
• Massage therapists
• Music and/or art therapists
  (IAHPC, 2020)

Hospice Care

Hospice care begins after treatment is discontinued and is normally provided to patients with a life expectancy of six months or less. The goal of hospice care is to ensure that the remaining time the person has left is as comfortable and as meaningful as possible. Hospice provides expert medical care, pain management, and emotional and spiritual support tailored to the patient’s needs and wishes.

In 2018, 1.1 million Medicare beneficiaries died while enrolled in hospital care. Over 50% of the deaths occurred in the home and more than one third between nursing facilities, hospice in-patient facilities, and assisted-living facilities. The average spending per Medicare hospice patient was $12,200 (NHPCO, 2021).

Typically, a family member serves as the primary caregiver and, when appropriate, helps make decisions for the terminally ill individual. Hospice services assist these family caregivers by making regular visits to assess the patient and provide additional care or other services. Hospice staff is on-call 24 hours a day, 7 days a week.

The interdisciplinary hospice team usually consists of the patient’s personal physician, hospice physician or medical director, nurses, hospice aides, social workers, bereavement counselors, clergy or other spiritual counselors, trained volunteers, and speech, physical, and occupational therapists, if needed. The interdisciplinary team:

• Manages the patient’s pain and other symptoms
• Assists the patient and family members with the emotional, psychosocial, and spiritual aspects of dying
• Provides medications and medical equipment
• Instructs the family on how to care for the patient
• Provides grief support and counseling
• Makes short-term inpatient care available when pain or symptoms become too difficult to manage at home or the caregiver needs respite time
• Delivers special services like speech, occupational, and physical therapy when needed
• Provides grief support and counseling to surviving family and friends

Bereavement services for the patient and significant others is an essential part of hospice care and is offered to families for at least one year, either through hospice or a referral to a community resource.

The U.S. hospice movement was founded by volunteers, and hospice is the only provider with Medicare Conditions of Participation requiring volunteers to provide at least 5% of total patient care hours. Hospice volunteers spend time with families offering direct support and provide clerical and other services that support patient care and clinical services (Center for Hospice Care, 2018; NHPCO, 2021).

CONCLUSION

As America ages, healthcare organizations and healthcare professionals must rethink approaches to healthcare in general, since caring for the older population will soon take up a bigger portion of healthcare resources than caring for the health needs of the young. At the same time, there is a major deficit in adequately prepared healthcare professionals involved in providing geriatric care.

Healthcare professionals today must recognize that older people are a diverse group with different values, functional levels, and illnesses. They must begin to appreciate the need for improving and optimizing the older adult’s functioning rather than just focusing on diseases. This is, of course, challenging.

Effective management that engages older adults, family caregivers, and clinicians in collaboratively identifying the older adult patient’s needs and goals is necessary in order to implement an individualized care plan, while recognizing that health changes due to aging together with multiple chronic illnesses can make creating a personalized health strategy more complex.