Many of the illnesses or problems experienced by the elderly have the potential to be prevented, postponed, or reversed, even after age 65. This has tremendous implications for those people concerned with the rising healthcare costs and growing elderly population.
Avoidance of disease, reversal of the effects of disease and restoration of function, and early detection of problems in an asymptomatic state can have far-reaching implications on the costs of health care, even after the age of 65 years. Unfortunately, scientific research on the effectiveness of preventative programs and interventions for the elderly is minimal. Very few studies have been conducted, and the studies that have been attempted provide conflicting results due to the variability of the samples studied, the methods used, and the definition of outcomes.1
This article will describe four of the common health problems of the elderly - osteoporosis, falls, cognitive impairment, and depression - that appear amenable to prevention, delay, or reversal by action initiated after age 65. Primary and secondary measures for a number of problems will be described. Primary prevention is health promotion and education that precedes disease or dysfunction; secondary prevention focuses on early diagnosis and prompt treatment to halt a problem. Because much of the literature reflects the focus of health care - a medical approach with tertiary prevention being the accepted method - it is important to emphasize that primary and secondary prevention are possible and appropriate and can be done by all nurses. However, this article will focus on the activities and opportunities for community health nurses and parish nurses/health ministers.
Osteoporosis is the second most common skeletal disorder, after arthritis, in the world and is the leading cause of fractures in the elderly. Many investigators have reported either a multifactorial etiology or an endocrine decrease as the primary cause of osteoporosis.2-4
Postmenopause is a time of high risk for women. At this time, bone mass rapidly declines as a result of normal hormonal aging changes, accentuated by certain risk, factors. The goals for nursing care of the woman over 65 years of age would consist of slowing the bone loss and replacing the bone previously lost.5 The primary aim is the prevention of fractures.
No therapy has been found to be totally effective in reversing the process of osteoporosis. It has been generally accepted that a calcium intake of 1,000 to 1,500 mg/day and weightbearing exercise during adolescence and adulthood would be of great benefit in preventing osteoporosis.
Primary preventative activities, where no significant bone loss has occurred, would consist of the recommended daily intake of calcium, vitamin D, and moderate fitness exercise no matter what the age of the woman. This can increase bone mass and retard bone loss.6 Health education on the important influence of nutrition and exercise is needed.
The efficacy and safety of estrogen replacement therapy (EKT) after age 65 is still under debate. Christiansen et al found that when ERT was begun during the early postmenopausal period, when the bone loss is accelerated, in women who were previously untreated, it was effective in halting further bone loss.7 During this accelerated phase, bone loss occurs at a rate of 2% to 3% per year. If started 3 years after the last menstrual period, the ERT would have less benefit. At this time, the rate of bone loss would have slowed. By 8 to 10 years after menopause the loss rate would be only 0.3% to 0.6% per year.8
An analysis of ERT in women from the Framingham longitudinal cohort study examined the incidence rates for hip fractures in women who took estrogen postmenopausally and in those who did not. The relative risk of women obtaining hip fractures with no previous estrogen use was 69 times greater than those women who were former users of estrogen. The study found that estrogen use between the ages of 65 and 74 years may protect against hip fracture in the subsequent 2 years.9 Christiansen et al7 and Lindsay et al10 demonstrated that when perimenopausal estrogen therapy is discontinued after 2 to 4 years, bone loss resumes at rates comparable to those in untreated women. As a result, initiating ERT for women 65 years and over appears to be of questionable benefit as a primary or secondary measure.
Screening for osteoporosis at the secondary preventative level presents some difficulties. It is difficult to detect the condition early in the disease process. The various radiologic techniques that have been developed have questionable accuracy in detecting osteoporosis and measuring bone loss.11
Osteoporosis does present a number of opportunities for primary and secondary prevention by the community health nurse. Calcium intake is important as a primary or secondary measure for the woman 65 years old and older, depending on the woman's pre-65 calcium intake and the amount of bone loss that has occurred. Calcium absorption decreases with aging, and a calcium intake of 1,000 to 1,500 mg/day is recommended for all postmenstrual women. In women with established osteoporosis and women at high risk of fractures, at least 1500 mg/day of calcium is urged.12
When seeing clients in a clinic or in a home, the nurse can assess the nutritional status of the client. Investigation of other family members and their health may also be done. Discussions with the elderly regarding foods high in calcium, meal preparation for one or two, and sample meal plans may be needed. To supplement the woman's calcium intake, a number of calcium preparations are available. Nonprescription oral supplements, such as calcium carbonate, phosphate, lactate, or gluconate, can be purchased. White suggests some guidelines when discussing supplements:
* Avoid bone meal or dolomite-based preparations because of the possibility of lead contamination;
* Avoid calcium supplements that contain vitamin D; this will avoid excessive ingestion of vitamin D;
* Preparations containing crushed oyster shell or calcium carbonate usually require fewer daily tablets because of their high availability of calcium;
* Take divided doses of calcium supplements on an empty stomach to increase absorption.13
Emphasizing the vital role of vitamin D in the absorption of calcium is important. Outlining the foods high in vitamin D and encouraging the person to go outdoors for 1 5 minutes each day ought to be included.
Exercise is imperative for those who do not yet have osteoporosis or for those who may already have the problem. It has been found that as little as 1 hour of weight-bearing exercise a week helps maintain bone mass.14 Walking should be encouraged.
Screening, as a secondary activity, could also be included with the health assessment to detect those at risk or identify those who have the condition earlier in the disease process. Currently, early identification of osteoporosis in its earliest stages cannot be done efficiently and at reasonable cost by the various radiologic tests. A more recent manual method detects a significant loss of stature in the individual. Loss of height is frequently the first clinical sign of osteoporosis. If the height loss exceeds that of normal aging, it is then suspected that osteoporosis is present. The Arm Span Method (height loss is calculated by subtracting the current height from the outstretched arm span) and the Recall Method (height loss is calculated by subtracting the current height from the person's memory of her past maximum height) can be easily and quickly employed by a nurse in the home or in the clinic.
Accidents are the fifth leading cause of death in those over age 65. Approximately two thirds of accidents are falls. Some research has indicated that many falls (40% to 50%) are accidental, usually resulting from a combination of environmental hazards and age-related changes. Environmental factors that contribute to falls and injuries are potentially modifiable and are important to consider in prevention. Clark, in studying 450 women with fractures of the femur, estimated that one quarter of the fractures were clearly preventable and half were possibly preventable by alteration of the environment.15 As the person's age increases, after age 75 in particular, environmental factors begin playing a decreasing role; the health condition of the senior also needs to be regarded. Prevention of the underlying disease process could have possibly occurred, as well as prevention of the environmental hazards.
A variety of elements have been identified as factors associated with falls in the elderly in a variety of settings. Physiological causes include acute illness or chronic health problems, impaired vision, impaired mobility, dizziness, vertigo, orthostatic hypotension, syncope, drop attacks, poor mental status, cardiovascular and musculoskeletal problems, some medications, substance abuse, depression, and metabolic disorders. Environmental factors in the institution, as well as in the home, are significant in the causes of falls. Such hazards as improper footwear, inadequate lighting, throw rugs, cords, slippery floors, severe weather conditions, and poorly maintained equipment (eg, wheelchairs) have been identified.16
Prevention of falls can occur at the primary and secondary levels. At the primary level, education of seniors, elimination of environmental hazards, and referral to support services are important activities that the nurse can do when seeing the senior in a clinic or home setting.
Health teaching pertaining to adequate nutritional and fluid intake should be emphasized. Electrolyte imbalances and dehydration must be avoided. Certain medications, such as diuretics, antihypertensives, hypnotics, antidepressants, nitrates, and antianxiety agents, can directly and indirectly be causative factors in falling. The medications may interact with each other or create conditions, such as urinary frequency from diuretics, that may lead to falls.
Health teaching can also include information on the normal aging process and resultant adaptations that should be made; for example, rising slowly from a seated position, avoiding sudden turns, using mechanical aids, seeking treatment for dizziness, or wearing appropriate footwear. Additional health teaching regarding environmental hazards is important. Thorough questioning about the home is necessary. If possible, a home assessment to identify possible hazards could be done. Planning with the senior in eliminating any hazards is crucial. The nurse must have a strong knowledge of community support services to assist the senior in creating a safer environment, such as home care equipment, home help (homemakers, handymen), and government grants available to repair or renovate home hazards.
Secondary prevention would include identifying seniors at risk for falling and then preventing falls. The health assessment conducted by the nurse is important in assessing the senior's risk status. Information on gait, functional status, musculoskeletal status, cardiovascular status, home environment, medications, and past history are critical. If the senior did experience a fall, a careful history of its details, such as time, location, and description of the fall, will provide hints to help prevent future falls. Discover if the senior "blacked-out" during, before, or after the fall. Was there dizziness, dyspnea, one-sided weakness, any warning signs? Was the senior able to help himself up afterwards? Was there a witness? Do not readily accept the frequent response of "I just tripped." Craven and Bruce listed several factors that place the senior at risk of falling:
* A history of previous falls;
* Health problems;
* A history of falling while carrying out activities of daily living;
* Some degree of isolation in living arrangements; and
* Women who are older than 75 years of age.17
Awareness of these characteristics must be reflected in the assessment.
In the United States, it is estimated that approximately 5% of people over 65 years of age suffer from a form of dementia.18 It is being discovered that there is an alarmingly high number of these people whose dementia is not permanent, but rather is reversible or treatable. A study by Larson et al found that nearly 28% of 200 patients diagnosed with suspected dementia showed some improvement after appropriate medical or psychiatric intervention.19 Among the cognitively impaired, Besdine estimates that 10% to 15% have reversible disease.18 Health professionals are also realizing that a considerable percentage of cognitive impairment can be prevented.
There are several different types of cognitive impairment: delirium, multiinfarct dementia, senile dementia, and affective disorders. Delirium is almost always reversible. It tends to have an abrupt onset, fluctuates in severity over time, and is associated with fluctuating states of consciousness. It is an acute medical emergency.20 Possible causes can be infections or medications such as tricyclic antidepressants, antihistamines, or antiparkinson agents.1
Multi-infarct dementia is often associated with hypertension or cardiac arrhythmias. It is caused by multiple cerebral infarcts resulting from frank strokes or numerous silent strokes. People with this condition usually have gait disturbance and pseudobulbar palsy, as well as cognitive impairment. It is not always preventable.
Senile dementia consists of a number of different forms and causes, some of which can be reversed, prevented, or treated. One form of dementia is Alzheimer's disease, which is the most common of the dementias and is irreversible.
In the early stages of a dementia, it would be very difficult to detect the difference between simple memory loss and dementia. In normal aging, the memory impairment is largely subjective. The senior may describe such symptoms as forgetting the names of persons and places, being unable to concentrate as well as previously, and needing to jog the memory by writing things down. Such memory impairment does not seriously interfere with daily functioning and it usually does not progress.20
In true dementia, there is a global disturbance of mental functioning. In addition to memory impairment, there is a loss of intellectual abilities severe enough to interfere with functioning at work or in social relationships; impairments of abstract thinking; loss of judgment; aphasia; or personality changes.18 The senior finds it difficult to carry out routine activities that he/she has performed efficiently for years. The senior needs to be observed or studied at different times to note a decrease in mental functioning.
Reversible causes of cognitive impairment that may be confused for dementia can include drug toxicities, depression, metabolic disorders, infections or fever, cardiovascular disorders, brain disorder, pain, sensory deprivation, institutionalization, alcohol, anemia, chronic lung disease with hypercapnia, nutrient deficiencies, accidental hypothermia, and chemical intoxication.18 Cognitive impairment from these causes is preventable.
Careful assessment with knowledge of the aging process is crucial in determining whether the changes in the senior are due to normal aging or an underlying pathological process. A brief examination of mental status should be done. Note appearance, mood, affect, psychomotor function, speech, thought process, and content (including suicidal and homicidal ideation) in the history.1 Take into account memory, orientation, reasoning, judgment, and mental arithmetic. Evaluate the senior's emotional state. Early in the dementing process, a senior almost always reacts emotionally to the perception that he/she is losing cognitive function. Careful questioning should be done to decrease defensiveness or denial by the senior.
Recent conflict in interpersonal relationships may be an early clue to cognitive loss. Look for a personal or family history of depression; this may reflect pseudodementia (a reversible, depression-induced dementia).18 Consider the onset of the changes, whether it is rapid or gradual. Carefully examine the medication the senior is taking. Thorough physical assessment and lab testing are essential to consider and rule out various causes. Obtain a collateral history from a child or the spouse of the senior. They can provide valuable information to refute or enhance the information given by the senior. Assessment may have to take place over several visits to observe change in the person over time.
Affective disorders, which include depression, can be preventable and reversible. Greater detail about depression will be discussed below. Depression and drug intoxication predominate among the many causes of reversible mental impairment in the elderly.18
Health education of health professionals, society, and seniors about normal aging changes by community nurses is a critical aspect of primary prevention. The nurse should educate people that memory loss is not a normal part of aging. Health teaching to seniors, individually and in groups, ought to emphasize that noticeable cognitive changes in a senior may be treatable or reversible. Discussions with seniors on dealing with losses and life events should occur. Again, this can be done individually or in groups. Selfhelp groups can be initiated by the nurse and continued by the seniors themselves. Health teaching regarding medications, side effects, usage, and informing the physician of medications being taken is essential.
Depression is the most prevalent of all psychiatric disorders in the elderly, and it is more common in this age group than in any other population. However, there is a lack of consensus about the prevalence of depression. Various studies cite prevalence rates ranging from 13% to 20%.21,22 The discrepancies may be due to lack of consensus on a definition of depression by researchers and whether symptoms or diagnoses are measured in the studies.
The detection and diagnosis of true depression is very difficult. The symptoms may imitate those of other diseases, such as dementia, hypothyroidism, or withdrawal from a chemical substance; they may accompany an organic illness, such as cancer; or they may be confused with a person "feeling low" or "off-color."
The detection of depression can be influenced by a number of factors:
* Physical illness, such as hypothyroidism, Parkinson's disease, or an infectious process;
* Medications - the drugs used to treat an illness may cause, mask, or exacerbate the symptoms of depression. Some medications may actually cause depressive symptoms, such as antihypertensives, central nervous system depressants, digoxin, oral hypoglycemics, steroids, and cytotoxic agents23;
* Chemicals - blockage or inhibition of monoamine neurotransmitter function in parts of the brain that regulate mood, energy, or sleep can result in clinical symptoms of depression;
* Changes in social ties;
* Society's negative view of aging.
Risk factors for depression and depressive symptoms include the recent loss of a child or spouse or other close family member, or the anniversary date of the loss; a change in the support network, for example, relocation, unplanned retirement, or loss of a friend; changes in physical function, such as progressive deterioration from a chronic illness or growing difficulty in mastering activities of daily living; and being female.
Any person over 65 years of age is at high risk of developing depression. Knowledge of the normal aging process, life events, and risk factors enables nurses to practice primary prevention. Health education is very important to prevent depression. Education on the potential hazards of medication should be emphasized to seniors whenever encountered in the home or clinic setting. Questioning to discover all medicinal products the senior has at home is vital - whether borrowed, over-the-counter, or saved for "just in case." Discussion of the medications that may cause depression is important.
Health sessions with groups of seniors can be beneficial. Discuss normal aging with these seniors: frequent losses over a short period, changes in physical health, coping with loss and change, formation of support systems, importance of developing interests in activities or current events, being aware of the risk factors for depression, and "case-finding" - becoming a volunteer or friend to someone who lacks a support system before depressive symptoms develop. In any counseling, the strengths of the senior should be identified and highlighted. Strengths are used to help the person work on any limitations. Reminiscence is a very important part of any health counseling at the primary, secondary, or tertiary level. The senior needs to review the past to recount accomplishments and happy moments and to confront unhappy or unresolved events.
Screening is an important part of secondary prevention. The health assessment should identify the presence of risk factors for depression. Nutrition, elimination, neurological status, sleep patterns, and sexual function must be investigated. Conduct an indepth assessment of the client's feelings. Ask such questions as "Are you depressed?", "How do you see the future?", "Do you ever go to bed wishing you wouldn't wake up in the morning?"
There are a number of tools that have been developed that screen for depression, for example, the Beck Depression Inventory24 and Jung's SelfRating Depression Scale.25 Early recognition of depression can provide intervention to assist the senior and the family with this problem, which influences all facets of daily living.
Primary and secondary prevention can be successful for a number of health problems if implemented after the age of 65 years. The long-held belief that aging accompanies disease is being refuted. As more research is conducted into aging, many other conditions will be recognized as preventable after age 65. The community health or parish nurse can be instrumental in educating the public, the elderly, and other health professionals about "normal" aging changes. As knowledge grows in this area, the future may exhibit a decrease in the prevalence of these preventable conditions as a result of primary and secondary activities.
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