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:

• Summarize the models and goals of care for the older adult.
• Discuss the major age-related physiologic changes impacting older adults and related assessment and management recommendations.
• Discuss cognitive and psychosocial changes impacting the health of older individuals and related management recommendations.
• Identify key elements in the functional assessment of the older adult.
• Discuss risk factors and assessment strategies for falls prevention and home safety.
• Explain the risks, safety, and management of medications for older adults.
• Relate strategies for supporting family caregivers of elders.
• Discuss legal and ethical considerations in the care of the older adult.
• Review the assessment and management of elder abuse victims.
• Clarify the principles that guide end-of-life care.

INTRODUCTION

By 2034, older adults 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 occurrence is the nation’s “baby boom” generation of the 1950s and 1960s.

Starting in 2030, when all baby boomers will be older than 65, they will make up 21% of the population, up from 15% in 2020. By 2060, nearly 1 in 4 Americans will be 65 years and older, the number of those 85 and older will triple, and there will be a half million who are 100 years and older.

Other important causes for this increase in the aging population in the United States and around the world include advancements in disease control and health technology, lower infant and child mortality rates, improved sanitation, and better living conditions that have occurred during the twentieth century. During this period, the leading cause of death changed from infectious diseases to chronic noncommunicable diseases, resulting in increased life expectancy. As this trend continues, the United States is facing greater demands for healthcare, in-home caregiving, and assisted-living facilities (WHO, 2020; U.S. Census Bureau, 2019a).

In 2018, the Health Policy Institute of the University of Pittsburgh wrote that by 2050 adults age 65 and older will make up over 20% of the total U.S. population. The institute notes that meeting the healthcare needs of an aging America will require sizable changes in our existing approach to treatment and service delivery and finds that the fragmented U.S. healthcare system is “ill-suited” to address an expanding aging population’s complex needs (UPHPI, 2018).

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.

Demographics of Aging

Generally, the older adult population is defined as 65 years and older and grouped under the category of “old.” It is now recognized that there are differences within this age group, which may be further categorized as:

• Young-old: 65 to 74
• Old: 75 to 84
• Oldest old: 85+ (the fastest-growing segment)

In 2019 the U.S. Census Bureau (2019b) estimated the number of the persons ages 65 and older to be over 54 million. In 2020 the CDC reported that the average life expectancy for both sexes and all races and ethnic origins was 78.6 years. At age 65, the estimated remaining life expectancy was 18.1 years for men and 20.6 years for women.

By racial and gender comparison, White females have the longest life expectancy, followed by Black females, White males, and Black males. By Hispanic origin, Hispanic females have the longest life expectancy, followed by non-Hispanic White females, Hispanic males, Non-Hispanic Black females, Non-Hispanic White males, and Non-Hispanic Black males.

The population of centenarians (100+) is overwhelmingly female (84%), lower educated, more impoverished, widowed, and more disabled as compared to other older adults.

The CDC also reported in 2019 that 22% of noninstitutionalized persons aged 65 and over were in fair or poor health, and those who needed help with personal care from others was 7%. Persons aged 65 and over comprised 84% of nursing home residents and 93% of those living in residential care communities (CDC, 2021).

The leading causes of death among this population include:

• Heart disease
• Cancer
• Cerebrovascular disease (stroke)
• Chronic lower respiratory disease (COPD)
• Alzheimer’s disease
• Diabetes mellitus
• Nephritis, nephrotic syndrome, and nephrosis
• Unintentional injuries
  (Maul, 2018; Eliopoulos, 2018)

The Aging Process

Aging is associated with an accumulation of DNA damage and delayed repair of DNA throughout life. Defects in the repair of DNA or excessive damage that overcomes the repair capacity are more likely to occur, increasing the prevalence of age-related disease.

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. In fact, aging is a major risk factor for a number of chronic diseases (see below), and many diseases appear to accelerate the aging process, manifesting in declines in function and quality of life (NIA, 2020; Kane et al., 2018).

Along with physiological changes, behavioral and psychological factors such as physical activity, smoking, cognitive and social engagement, personality, and psychosocial stress play a major role in health across the lifespan. Along with these changes, increasing age brings changes in cognition and emotions, which can impact subjective well-being, social relationships, decision-making, and self-control (NIA, 2020).

Aging and Chronic Disease

Older adults have fewer acute illnesses (e.g., pneumonia, flu, broken bones, heart attack) than younger age groups and a lower death rate from them, although they do require longer periods of recovery and have more complications. Most older adults, however, have at least one and often multiple chronic conditions that have a significant impact on independence and quality of life, and are the leading causes of death among this population (Eliopoulos, 2018).

It is estimated that 80% of those 65 years or older have one chronic disease and that 50% have two or more. The most common of these include:

• Heart disease
• Arthritis
• Respiratory problems
• Cancer
• Diabetes
• Stroke

These conditions often impair functional capacity and limit the person’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Kennedy-Malone et al., 2019; NIA, 2020).

Adults with chronic diseases have a greater prevalence of subjective (self-reported) cognitive decline, and prevalence increases with age. Adults with a history of stroke have the highest prevalence, followed by COPD and heart disease. Chronic conditions often require close medical management and self-care activities such as taking medications as prescribed. However, managing a chronic condition can be made increasingly difficult with the presence of memory loss or confusion (Taylor et al., 2020).

CHRONIC DISEASE AND POLYPHARMACY

In 2017, prescriptions for chronic conditions accounted for more than two thirds of all prescriptions in the United States (CDC, 2021). Older patients with multiple comorbidities often require management with more than one medication. This increases the risk of polypharmacy and its negative outcomes. Polypharmacy in geriatrics is defined as a patient age 65 or older receiving five or more appropriate medications for treatment of various chronic conditions. Older adults with multiple subspecialist physicians and no primary care physician are particularly vulnerable to polypharmacy.

Negative consequences of polypharmacy include:

• Increased risk of adverse drug events
• Increased mobility issues
• Increased mortality
• Increased need for long-term care placement
• Medication nonadherence
• Decreased quality of life
• Increased use of the healthcare system
  (Halli-Tierney et al., 2019; CDC, 2021)

CHRONIC ILLNESS AND FUNCTIONAL CAPACITY

Chronic health conditions often impair the physical, psychological, cognitive, and social abilities to perform ADLs and IADLs that allow an individual to live independently in the community. ADLs include bathing, dressing, personal hygiene, toileting, functional mobility, and self-feeding. IADLs include managing money, preparing meals, shopping for necessary items, taking medications as prescribed, and maintaining the home.

Many health issues (e.g., falls) common to people over age 65 can be prevented, many (e.g., hypertension) can be effectively treated, and others (e.g., visual impairment, hearing loss, mobility problems) can be compensated for with assistive devices and/or rehabilitative interventions. Nurses, physical therapists, occupational therapists, and other rehabilitation specialists can address a person’s ability to function in the home or living environment at the highest possible level of independence and can also identify any environmental safety risks (e.g., loose rugs, uneven steps, clutter, etc.), appropriate adaptive equipment, durable medical equipment, or assistive devices that might be needed (Kennedy-Malone et al., 2019).

Aging and Long-Term Care

Loss of the ability to care for oneself safely and appropriately means further loss of independence and can often lead to the need for care by family and informal caregivers (i.e., unpaid individuals) or formal caregivers (i.e., paid care providers associated with a service system). Long-term care includes a wide range of services and supports available to meet personal care needs. These services and the percentage of users ages 65 and older include:

• Adult day services centers: 62.5%
• Home health agencies: 81.9%
• Hospice care agencies: 94.6%
• Nursing homes: 83.5%
• Residential care communities: 93.4%
  (CDC, 2021)

The costs of long-term care can be very expensive, and many individuals may be financially unprepared for this type of expense (see box below).

Ageism and Healthcare

Aging is not solely a biological process. It is embedded in social contexts and shaped by social factors. Ageism is a term that refers to bias and discrimination based on age. Stereotypes about aging, particularly in North America, are primarily negative—a time of ill health, loneliness, dependency, and poor physical and mental functioning (Donizzetti, 2019).

Stereotypes of ageism influence:

• Self-perception
• How older adults view other older adults
• Cognitive and physical performance
• Ability to recover from illness
• Health behaviors such as decisions to engage in cognitive, social, and physical activity
• Seeking medical assistance
• How older adults are treated by others and society as a whole

Older adults are often perceived to be vulnerable, lonely, physically and mentally impaired, and “old-fashioned.” They are expected to be slow and poor thinkers, movers, and talkers. All of these stereotypes have the potential to affect the mental, physical, social, and emotional well-being of an older adult and ultimately their length and quality of life.

Negative attitudes toward and discriminatory treatment of older adults are present in the healthcare community, across professional disciplines, and across care settings, having an effect on the quantity and quality of care provided to older patients and a profound influence on the type and amount of care offered, requested, and received.

Despite the growing need for more providers with geriatrics expertise, many medical and nursing students come to view the care of older adults as frustrating, uninteresting, and less rewarding overall. Attitudes are further shaped by the persistent misconceptions that older patients are demented, frail, and somehow beyond saving.

Ageism in the healthcare system discriminates against older adults in several ways, putting them at risk for undertreatment and overtreatment. For example, if a nurse has the belief that older adults are less healthy, less alert, and more dependent, then their initial assessment of the patient will reflect this belief. Or if the occupational or physical therapist believes that dependence in self-care normally goes with the aging process, the older patient will likely not be questioned regarding their strengths and abilities.

Other factors that increase the risk for under- and overtreatment include the decline in the number of providers with advanced geriatrics training. Secondly, more practitioners are opting out of participation in the Medicare system. Thirdly, older adults are frequently excluded from clinical trials of medications that are meant to help them, resulting in data that is problematic when caring for those with multiple chronic illnesses (Ouchida & Lachs, 2020).

Research has found that adults 65 years and older who hold more negative age stereotype beliefs and who perceive more age discrimination have a worsened perception of their own aging. Given the important role of self-perceptions, it is important that clinicians promote more positive self-perceptions in order to maintain or increase older adults’ well-being (Marquet et al., 2019).