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