The complexity of factors that influence the lives of “older adults” is confounding. Older adults encompass many age groups and variations. especially from perspectives. To my children, I am an older adult at 41 years old. To me, an older adult is someone in their 80’s. To a centurion, an 80 year old may be their children, not an “older adult”. An older adult is comprised of people/patients that I would consider “geriatric”, or over 80 years old. The definition of Geriatric according to Webster is: “an aged person” (http://www.merriam-webster.com/dictionary/geriatric). As well, an aged person is open to interpretation. The majority of my nursing experience is with the geriatric patient or aged person. Most of my patients are at least 80 years old. I would like to share my thoughts, personal experiences and clinical awareness that I have gained working directly at the bedside with these older adults/geriatric patients.
Geriatric patients are often on far too many prescriptions or poly-pharmacy. These patients may see a PCP along with two or three specialists. This can lead to medication errors. Two common alterations in health maintenance that I see in the hospital are bradycardia or an elevated INR. The geriatric patient admitted with bradycardia is due to an accidental overdose of a beta blocker. The patient with the elevated INR is due to poor Coumadin monitoring.
Environment
Environment is directly linked to their quality of life and health maintenance of the older adult. Geriatric patients are often in a time of transition. Is there an ability to safely drive and live on their own or does the patient need a higher level of care with assistance from others. Even when a spouse or a family member is assisting in the life of the older adult, there often comes a time when the care becomes excessive and causes caregiver role strain. When one of my patients is to be discharged back home, I assess the patients environment at home. Many questions can be asked; are there stairs, close neighbors, what kind of family support is near, is lifeline accessed, are there carpets or throw rugs, can they drive?
Simple tasks that we take for granted as younger adults affect the overall safety of the older adult. Every winter and summer, there are reports concerning older adults that die due to extreme temperatures. Older adults on fixed incomes may not have the resources to pay electric bills. They may forget to properly set thermostats in the home simply due to forgetfulness. They are at high risk of illness or even death due to temperature extremes-secondary to less efficient thermoregulation or even depression.
Pain is probably a number one concern for the patient at end of life. Open communication with the patient and the family is essential. There are numerous medications that are safe and effective in dealing with any pain or physical distress. Financial obligations, property rights and wills are a material aspect of end of life issues. It only helps the family when these concerns are addressed and documented prior to end of life. Planning ahead can relieve anxieties for the older adult as well.
Health Maintenance
The geriatric patient is delicate. The physical changes that occur are drastic and cascading. The older person’s response and adaption to these changes varies. One such change of health maintenance is the older adult that is completely mentally intact yet exhibiting drastic physical decline. These patients can put themselves at greater risk of injury or demise as they are not willing to accept their own physical limitations. Often these patients have been living independently and are set back by a fall resulting in trauma or exacerbation of a chronic condition such as COPD. Due to declining health maintenance these patients need a higher level of care, such as assisted living. Many are resistant to give up their independence or make that move which brings them closer to the dreaded “nursing home”.Geriatric patients are often on far too many prescriptions or poly-pharmacy. These patients may see a PCP along with two or three specialists. This can lead to medication errors. Two common alterations in health maintenance that I see in the hospital are bradycardia or an elevated INR. The geriatric patient admitted with bradycardia is due to an accidental overdose of a beta blocker. The patient with the elevated INR is due to poor Coumadin monitoring.
Environment
Simple tasks that we take for granted as younger adults affect the overall safety of the older adult. Every winter and summer, there are reports concerning older adults that die due to extreme temperatures. Older adults on fixed incomes may not have the resources to pay electric bills. They may forget to properly set thermostats in the home simply due to forgetfulness. They are at high risk of illness or even death due to temperature extremes-secondary to less efficient thermoregulation or even depression.
Current healthcare financing
The older adult is often on a fixed income. Medicare and Social Security are in the topic of daily political debates. These social services are imperative to the overall health and security of the older adult. Each year, more and more regulations, reductions and restrictions are placed on these federal programs. A situation that is all too familiar and saddens me greatly is when my geriatric patients chose pain and illness over medication. I have older patients that refuse certain medications that the doctor has ordered for them, but they won't take them because “those medicines are not covered under my type of Medicare”. There are often geriatric patients that are admitted to the hospital due to an exacerbation of a chronic condition because they stop taking their medications due to inability to reimburse a copay. The exacerbation, as with CHF for example, is life threatening. Current healthcare financing is counter-productive in my opinion. The cost of a hospital admission is far more expensive than grandpa’s furosemide and potassium pills. Life style changes
I often appreciate the idea that life goes full circle. This helps me compartmentalize the aspects of growing old that are unpleasant as I work with my geriatric patients. This is possibly a coping mechanism for my own aging process and mortality. When we are born, we need to be fed, clothed, bathed and diapered. Most geriatric patients eventually require that these same activities of daily living are done for them as well. Loss on independence as discussed above can be a traumatic life style change. Alzheimer's disease (AD) and dementia has created multiples of life style changes for numerous older adults. At what point during the course of AD do you lose the awareness that you are losing your mind? I have personal experience with AD as my maternal grandmother died from complications secondary to Alzheimer's. As life expectancies increase so do the adaptations that older adults must make to live that longer life.End of life issues
The enculturalization of our mentation concerning end of life issues in our society needs to be reevaluated. There is not enough discussion concerning end of life issues in the first place. Death is too often considered gloomy, terrifying; to be avoided at all costs. Most of the geriatric patients I care for do not have advanced healthcare directives or POLST forms. I genuinely appreciate that one of our political leaders spoke of increasing funding for end of life and hospice care. But this concept was torn apart and ridiculed due to fear and ignorance. The first hospice program started in 1974 in Connecticut (Eliopoulos, 2005). This concept of adding quality and meaning into “end of life” should be embraced, shared-not feared. Pain is probably a number one concern for the patient at end of life. Open communication with the patient and the family is essential. There are numerous medications that are safe and effective in dealing with any pain or physical distress. Financial obligations, property rights and wills are a material aspect of end of life issues. It only helps the family when these concerns are addressed and documented prior to end of life. Planning ahead can relieve anxieties for the older adult as well.
Bioethical issues with aging
There are numerous bioethical issues that encircle the end of life discussion aforementioned. Ethics plays a strong role in decisions that the individual patients and their families make as well as the decisions made by the doctors and nurses. The geriatric population is growing. This growth will not be slowing down. The baby boomers are entering their retirement years. This will create new issues on the already suffering U.S. health care system. This ever-growing percentage of older adults is creating bioethical concerns over entitlement and rights to limited healthcare services. The Joint Commission for the Accreditation of Healthcare Organizations is changing bioethics as well as Medicare. The standards that hospitals are held to are changing every day. The increasing population of older adults means an increase of sicker patients in the system. The standards that the hospitals are held to continue to get more rigid. Reimbursement continues to decrease. Nationwide changes will need to be made to sustain these changes on this very fragile system. Community support systems
Community support systems vary depending on the individual community. Overall, there has been a decrease in funding across the board on all community support systems. The needs of the elders in our communities are becoming less of a priority. Due to fiscal irresponsibility and the greed of banks and the government, cost management and social service reductions have become the norm. It is helpful to the older adult if they have access to and the ability to navigate the internet to search for various types of community services. Many programs that used to be community based have been dissolved. Most care for the elderly is now from the private sector which offers services to the elder, for a cost. Homecare is a growing healthcare trend as it is more cost effective to treat geriatric patients with chronic conditions in their homes. Hospitals emergency departments have become new community support systems as the patient cannot be turned away for lack of funds. Family is the key. The breakdown of community based support systems have made it essential that the geriatric patient has family to turn to and support their goals in their final phase of life.