Nursing 407 - Geriatric Healthcare
Chapter 11 – Chronic conditions; elder abuse
Failure to thrive
- Weight loss of >5% of baseline
- Poor appetite and nutrition
- Dehydration
- Immobility
- Depression
- Impaired immune function
- Low cholesterol levels
“Frailty”
- Preesence of 3 or more of the following:
- Unplanned weight loss (10 lb in past year)
- Weakness (measured by grip strength)
- Poor endurance and energy
- Slow walking speed
- Low level of physical activity
Consequences of frailty
- Progressive physiological decline
- Chronic illness
- Loss of organ function
- Recurrent acute illness
Risks of frailty
- Depedency
- Institutionalization
- Falls
- Injuries
- Mortality
- Slow recovery
- Hospitalization
Social risks of frailty
- Poverty
- Social isolation
- Functional decline
- Cognitive decline
The “geriatric cascade”
- 1. Frailty
- 2. Acute Illness
- 3. Worsened economic condition
- 4. stress of care provided
- 5. Poor treatment outcome or death
Strategies: meeting the needs of hospitalized elderly
- Diagnose all vague symptoms and complaints accurately
- Treat all relevant diseases
- Assess effect of current changes in health status
- Consider effect of acute illness on chronic disease
- Prevent complications of hospitalization
Health Trajectory
- Trajectory: the path of a moving object through space
- Also applies as a model for understanding the eventual course of one’s health status throughout time until death
Influences on the Health Trajectory
- Direct Influences
- Genetics
- Environment
- Wear and tear
- Nutrition
- Stress
- Disease
Indirect Influences
- Social relationships
- Education
- Finances
- Response to age-related changes
Chronic Conditions
- More than 50% of persons over 40 years of age have at least 1 chronic condition
- More than 80% of non-institutionalized persons over 65 years of age have at least 1 chronic condition
- Therefore, health care for the elderly should be oriented toward care of chronic disease regardless of the person’s age
- Health care should emphasize:
- Improving function
- Postponing deterioration and disability
- Preventing complications
Goals of Chronic Care Nursing
- Maintain or improve self care capacity
- Effective disease management
- Enhance body’s healing abilities
- Prevent complications
- Delay deterioration and decline
- Promote highest possible quality of life
- Ensure death with dignity and comfort
Effect of Chronic Disease on the Health Trajectory
- After each acute episode, patients are left with greater functional deficit or increased problems.
- The episodes become increasingly frequent andrefractory to treatment as the patient nears the end of life.
- Recognition of a pattern enables those at risk of imminent death to be managed more appropriately.
- The patient will then have the chance that most (but not all) patients prefer…to plan and prepare for death, together with their families.
Measuring Success in Chronic Care
- Use short term goals that are evaluated throughout the trajectory of the disease
Disease Trajectory
- Each disease, be it acute or chronic, has its own trajectory
- The disease trajectory influences the individual’s health trajectory
Disease Trajectory Patterns
- Evaluation occurs at each point of change in the trajectory
- Goals and interventions are modified to permit change in patient baseline status
Definition of elder abuse
- “The physical or psychologic mistreatment, neglect, or financial exploitation of the elderly.”
- Several types of abuse are common
- Each type may be intentional or unintentional
- Perpetrators are usually spouses or adult children
- May be other family members
- Paid or informal caregivers
Physical abuse
- “The use of force that results in physical or psychological injury.”
- Includes striking, shoving, shaking, beating, restraining and improper feeding
- May include sexual assault, i.e., any form of sexual intimacy without consent or by force or threat of force
Psychologic abuse
- The use of words, acts, other means that cause emotional stress or anguish
- Includes threats (e.g. of institutionalization), insults and harsh commands
- Remaining silent
- Ignoring the person
- Infantilization: encouraging the victim to become dependent on the abuser
Neglect
- Failing to provide essentials
- Food
- Medicine
- Personal care
Self-neglect
- The perpetrator is also the older person
- He or she fails to meet his own needs
- Typically involves:
- Physical disability/medical conditions
- Cognitive impairment/mental illness
- Inadequate social support
- Fear of discovery may prompt self-neglect
Characteristics of self-neglect in the elderly
- Inadequate personal hygiene
- Inadequate environmental hygiene
- Nonadherence to health activities
Financial abuse
- The exploitation of or inattention to a person’s possessions or funds
- Includes swindling
- Pressuring a person to distribute assets
- Managing a person’s money irresponsibly
Risk factors for elder abuse (1)
- Chronic disease and or functional impairment of the victim
- The elder person’s ability to escape, seek help, and defend himself is reduced or eliminated
- Social isolation of the victim
- Abuse of isolated persons is less likely to be detected and stopped
- Cognitive impairment
- Persons with dementia may act aggressively and disruptively, precipitating abuse
Risk factors for elder abuse (2)
- Substance abuse
- Alcohol or drug abuse
- Psychiatric disorder
- Schizophrenia, other psychoses
- Patients discharged from an inpatient facility may return to their elder parents’ home for care
- These younger patients may become violent once at home
- History of violence
- History of violence in a relationship and outside the family may predict abuse
- Violence is a learned response to life challenges
Risk factors for elder abuse (3)
- Dependence of abuser on victim
- Financial support, housing, emotional support
- Family member’s attempts to obtain resources from elderly person can result in abuse
- Dependence can produce resentment
- Stress affecting abuser
- Chronic financial problems
- Death in the family
- Responsibilities of caregiving
- Shared living arrangements
- Opportunities for tension and conflict are greater
“Bidirectional” dependency
- When the perpetrator is dependent on the older adult and the adult is dependent on the perpetrator
Social isolation and self-isolation
- Abused may be kept isolated purposefully by the abuser
- There may be a gradually declining availability of access
- Or, the older adult may self-isolate from fear of discovery
Difficulty of diagnosis
- Many signs are subtle
- Victim often unwilling or unable to discuss the abuse
- Shame
- Fear of retaliation
- Desire to protect the abuser
Obtaining the history
- If abuse suspected, client should be interviewed alone for at least part of the time
- Others may be interviewed separately
- Include general questions about feelings of safety
- If offered, note nature, frequency and severity of abusive events
- “Do you have family or friends who are willing to nurture, listen, and assist you?”
- (More practicable) “Do you feel safe at home?”
You are a “mandated reporter!”
- You must report suspected abuse!
- May be anonymous
- Report to Adult Protective Services if in the community
- May also report to Police Department
- Inside the facility, contact Social Services immediately