Caring for the Elderly-The New AGEnda
Issues for carers and nursing staff when looking after elderly patients
A timely introduction
IF YOU WERE TO BE HONEST WITH YOURSELVES, HOW MANY OF YOU HAVE EMBRACED THE CONCEPT OF AGEING?
"Don't worry, you are not being shouted at!" This is a simple illustration of the font-size required to assist a vast majority of our mature population with failing sight.
Ageing is much more than 'growing old gracefully'. It is something that most of us try to suppress and conceal, becoming consumed with the more superficial aspects (i.e. the cosmetic appearance).
I imagine that confessions would be common in keeping with, 'making sure we keep that slender figure' and 'using the most up-to-date anti-ageing products', in hope to conceal our 'true' age identity.
Despite all efforts, ageing is inevitable as we are well aware, and not even the most advanced technology to date, can trick 'father time'.
The reality of ageing can be a very difficult process as it highlights many issues that we have taken for granted in performing our daily living activities.
Caring for the elderly was much less of an issue 100 years ago, as medical intervention and health promotion were scarcely popular. Technology at these times was limited, and essentially, the ageing population was more 'vulnerable' and they were essentially 'dying out'. They were decreasing rapidly in number compared to the remaining 'younger' generations, and this gave a 'pyramidal' population distribution pattern with a wider base (youth) and narrow apex (elderly).
However, with the growth of technology, advancements in medication, and patient focus with elderly medical departments and palliative care, we are now able to keep the elderly population alive for longer! This is evident from the increasing life-expectancy of the population. For example, in the United Kingdom in 2009, a male had the average life expectancy of 77.4 years, and a female, 81.6 years; which is data gathered from extrapolating the mortality rates from previous years.
We should not be focussing only on increasing the age of our life-expectancy, but we should be doing more to concentrate on the 'quality of life-years'.
This can be achieved by understanding the issues related to ageing and addressing not only the medical aspects of 'pain management, breathing difficulties, blood pressure control and weight management etc', but to also consider the psychosocial aspects of ageing, i.e. the restlessness, agitation, loneliness, anxiety, and boredom.
It is essential that we are aware of the issues faced by our growing ageing population, and how functional capacity can deteriorate.
As a carer, a nurse, or even a person of selfless consideration; it is our moral responsibility to assist in areas of difficulty to maintain one of the most important attributes in the elderly....their independence.
In this article, I hope to cover a few of the important relevant issues faced by elderly patients, and how we can minimize related problems.
The issues of ageing
Be sensitive of senses!
It is essential to be aware of the 'sense status' of our elderly population. The quality of our sight naturally changes as we age, due to the lens becoming more rigid and less versatile at accommodating to near-and-far objects.
Therefore, a vast majority of elderly patients will wear glasses.
Likewise, with hearing, which can deteriorate over time due to long-standing 'noise pollution', this can make people reliant on a hearing aid.
It is worthwhile considering these sense-aids when an elderly patient is moved to new surroundings.
Many elderly patients have been admitted to hospital in the past, having not had these aids recorded in their admission histories, they have woken up in unfamiliar environments, i.e.on a hospital ward after surgery, thought by staff to be 'confused', when in fact they were disorientated due to the absence of aids, such as glasses, and because they were not well informed of what was happening.
Helping a patient 'fit' their hearing aid will assist you with communication, so it is worthwhile being patient and considering this.
Loose-fitting dentures could account for poor quality of speech (dysarthria), which can present similarly to a stroke; therefore it is again worthwhile considering the basics first, as it will save time and embarrassment.
Mobility aids such as Zimmer-frames/walking sticks should be accounted for, especially considering that elderly patients with common infections, for example urinary tract infections (UTI), can be confused and very unsteady on their feet.
This can subsequently lead to falls and result in hip fractures due to metabolic bone disease e.g. osteoporosis.
This is serious, as elderly patients who have these falls are susceptible to hip fractures, and potentially have a decreased mortality as a result, which could have been avoided.
Good nursing practise should be put in place to prevent this through anticipation. For example, assisting an elderly patient with accessing a toilet, using the commode, or wearing pads can reduce the risk of a fall. In some elderly patients with UTIs, catheterising would remove the need for the patient to regularly visit the toilet and decrease the 'falls risk'. However, conservative methods should have been followed prior to considering catheterisation, as it is unpleasant to have a tube placed in the bladder, and there is an added risk of introducing further infection. A harms-benefit ratio to the patient should also be considered. A harms-benefit ratio should be obtained by asking the questions (in this case), "would we be able to provide adequate assistance for this person to relieve themselves safely? Are they unsteady and at an increased risk of falling without assistance? Have they fallen already? Are they on bone-protection tablets, i.e. increased risk of complications from falls?
This should be the approach to managing a common problem like increased urinary frequency in an elderly person.
Unfortunately, it is also common for people to look for 'quick-fix' solutions that do not have our elderly patients’ best interests at heart. This can be illustrated in an eagerness to request catheterisation for an elderly person with mobility dependence that requires assistance. Also over sedating confused elderly patients to give the 'staff some peace!', when these people have psychological illness or dementia, and they have not been followed up with elderly psychiatry, or medication to address the issue.
This is not adequate care for anyone, so it begs the question, why do we allow this for our ageing population. "Is it because they don't complain? Or nobody listens?”
Attitudes in-line with this has led to gross neglect and some 'nightmarish' tales regarding elderly patients in nursing homes. For example, elderly residents who have not been changed for weeks, covered with bed sores, smelling of urine, and left alone for hours a day. "Is this worth living for?"
There was an article in the guardian in 2009 reporting on the submission of a dossier to the Care Quality Commission of 16 cases of elderly patients who were let down by health service staff.
Elderly patients may not complain as much as the younger generations, they may say passively, "I don't want to be a bother", but this should not deter from an active role in providing a clean, pain-free, infection-free, and mentally stimulating environment for them.
The Sixth Sense-Pain
Elderly people ‘groaning and grimacing’, could indicate undiagnosed pain. This is difficult for staff to detect, as patients with dementia often develop these mannerisms. There are several pain assessment tools for patients with dementia, in the form of numerical rating scales, for example ‘Doloplus 2’ and ‘Pacslac’. Unfortunately, they are not usually put into practise because of a lack of interest and training, which is required for nurses and carers to implement. This reflects the constraints of lack of finances in the care of the elderly.
How many medications are too many medications?
Another common finding in the elderly is that there is a shift towards over-prescribing medication, leading to the term, 'Polypharmacy'.
In defence of this, elderly patients tend to have more illness and disease (co-morbidities), due to influence of previous lifestyle and family history.
However, despite this, there still seems to be a lower threshold to prescribe medication.
This is not to say that elderly patients with chronic conditions, such as hypertension should be deprived of their anti-hypertensive medication, but in some cases other conservative methods should be attempted first. For example, depression, which is extremely common in the elderly (possibly after bereavement of a partner or through organic illness), is often addressed with medication. This seems to be viewed as a panacea, instead of offering bereavement counselling and cognitive behavioural therapies, as may have been done for younger patients.
This is subtle, but is a form of age-bias in the profession.
Other issues related to the elderly being prescribed multiple tablets, is that they can pose a challenge to swallow, and as a result can affect the dietary intake and nutrition, as they essentially 'fill up on tablets!’ 'You try swallowing 15 jelly beans/mints before your next meal, and see how that affects your intake'.
Another important point, which will be discussed shortly are the psychological aspects of ageing, for instance short-term memory loss and neuro-degenerative disorders i.e. dementia. These have a dramatic effect on the person's ability to remember when and how to take their medication.
This can be combated in some respects, with introducing 'pill-box systems' e.g. The Nomad system, which are supplied by the pharmacist. This has tablets in designated sections, corresponding with the days and times when to be taken. Although, this is a useful tool for elderly patients who tend to be forgetful; it is of limited use in patients who struggle to recall the day of the week.
Is intervention always the answer?
Inappropriate prescribing can also occur in hospital, whereby elderly patients are over-prescribed antibiotics for infections, e.g. chest infections. This can result in killing the natural gut flora in their bowel, thus causing diarrhoea (pseudo membranous colitis), and can subsequently lead to dehydration, which can potentially be life-threatening if not managed correctly in the right setting.
Nurses should also be aware (particularly if working in nursing homes), that some infections and illnesses in elderly patients can be managed perfectly well in the community. Unnecessarily admitting a patient to hospital can be more detrimental, as their immune system is weaker, and they are more susceptible to acquiring hospital infections (e.g. pneumonia).
Beware, undiagnosed depression in the elderly
We have to be careful that our social understanding of the elderly does not become a huge chasm of the unknown. These patients do suffer with depression, like us; they like mental stimulation, like us; and yes...as difficult it is to appreciate, they too may very well have sexual needs, like us!
The best way to keep this in mind is to think that we are the next elderly generation. Do we want people to leave us in a chair for hours at a time, with no social interaction, only to be changed and fed at regular intervals, and to be stripped of our independence and dignity?
"I should hope not!"
These are the same issues relevant to our senior population today. If we do not look at these people with consideration that they too have needs, and although may become physically dependant (like a child), this does not necessarily correspond with their underlying mentality or understanding of the world around them.
Misunderstandings in these areas have led to misdiagnoses of elderly patients with depression, as having dementia.
For example, a nurse may test an elderly person's thought process and memory recall (using a mini-mental state exam). The patient may even answer "I don't know" to the majority of questions hence giving a low mark, theoretically corresponding with dementia. However, if the patient has been more dismissive with their answers and not attempted them, in context with other symptoms, e.g. stunted-speech, poor appetite, and/or difficulty sleeping, this would fit more with depression than dementia. Therefore, remember to look at the person as a whole, not just a 'tick-box' system.
For patients with established dementia, it is important for their families to understand the condition. This is because neuro-degenerative conditions, like Alzheimer’s can affect personality and mood (as it involves the frontal lobe of the brain), and it's important that the family recognizes that any animosity or ignorance is a reflection of the condition, not the person.
This is very difficult for many families, and understandably, an emotionally distressing time. I have recalled some daughters commenting about their mothers' with severe dementia, expressing the 'foreign' nature of the condition, saying things like, "my mother died a long time ago, and this is someone else".
There are carer support groups available, which help families to cope.
No self-esteem without team effort
Ageing should not be discriminated against. It is part of life's cycle, and the same respect should be given to these people as for anyone from other 'walks of life'.
People with conditions such as diabetes, should not be referred to as 'diabetics', but instead, by their name, as a person with diabetes, as the condition should not take 'ownership' of the person.
The same applies for elderly patients. It is satisfactory to refer to these people as 'senior', 'mature', or 'elderly'; however, the childish terminology of 'old' should be avoided in practise as it is inappropriate.
With regards to independence, there are many opportunities to assist. This can be done on the mobility-front by using stair-lifts, shower and bath chairs introduced in the home, hand rails and 'safe' kitchen appliances.
All these things can be introduced in the home after assessment by occupational therapists.
In the home environment, nurses can visit to change dressings, take bloods, check medications etc. Paid carers may visit to provide personal care (to help with daily living activities).
This allows elderly people to maintain their independence, whilst manoeuvring around age-related impairments.
Elderly patients will often be visited by several members of a multi-disciplinary team (e.g. nurse, doctor, physiotherapist), which will give them some healthy social interaction. Team fragmentation and poor communication can be a constraint to effective delivery of care, and should be avoided.
Although independence is important to maintain, the patient's safety is paramount
Unfortunately, in some cases, elderly patients need be taken out of their home environment to preserve their best interests with regards to their health and safety.
An example of this would be an elderly lady with no close family, living alone, with type II diabetes (on medication). Now becoming more forgetful as she has been diagnosed with dementia, with signs of self-neglect and having exhausted all available community input.
In this case, this person may not be safe at home, and would possibly need to be moved to a residential/nursing home.
This can, understandably, be very difficult for patients to accept. One way to ease transition, is to be aware early of the issues these patients are struggling with, at home. Good communication with the multi-disciplinary team is essential, and sometimes it helps by introducing the patient early to these environments, for example day visits to residential homes to partake in activities, and meet other residents.
Respite care can also be introduced to relieve families, who will ultimately need to relinquish a loved one into full-time care.
Elderly medicine is a huge topic, too much to be covered in this article, and we have barely scratched the surface.
I hope this has raised some important points, and common problems related to the elderly population.
I would suggest we speak and listen to our elderly companions, not only to assess whether they have any concerns or problems, but interact with them! Don't ignore their needs.
One useful piece of advice given to me, when caring for any person of any age of any background is this:
"Imagine this person is your sister, brother, father, mother, grandfather, grandma, uncle, auntie, or best friend...or you...NOW HELP THEM!"
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