Family nursing must "go where there is no path" to help meet the health and social needs of the fast-growing population of people over age 65 in the next decade. There is much that we still do not know and must map out.
Population aging is an evolving process in which older persons appear in increasing proportions within the overall population. This demographic transition is brought about by declining fertility rates and falling death rates (Macfadyen, 1990). Although the majority of elderly persons retain functions until their very late years, it is estimated that for each good functional year that is added to life, 3.5 compromised years are added (Brody, 1987). This creates implications in the number of professionals and families needed to provide assistance as the pool of caregivers decreases. It also creates problems with the economy, as there will be fewer people to earn money in the defined productive workforce. Finally, the cost of providing health care to large numbers of persons of any age is expensive. Gerontological nurses in many countries are working with this awareness; nurses in developing countries will soon follow. In the following article, the questions of demographics, health, family, health and social services, and education of the elderly and their significant others will be described and discussed.
In 1988, it was estimated that there were more than 290 million persons in the world aged 65 years or older (WHO, 1989). By the year 2000, there will be 40 million in this age group, representing a growth of 2.4% annually. Today, more than half of the world's elderly people are living in the developing countries. Thirty years from now, it is estimated that 430 million elderly will be living in the developing countries, twice as many as in the developed countries. The two countries that will contribute greatly to this increase will be China and India.
Of this group, it is the oldest of the old, those aged at least 80 years, who are the fastest growing section of the population in developing and industrialized countries alike. In Sweden in 1985, 16.9% of the population was over 65 years of age, and those 80 years and older constituted 14%; in Norway, 13% were over 80 years of age out of 15.5% who were over 65 years of age. In the United Kingdom and Denmark, 15.1% of the population was over 65 years; 14.9% of those were over age 80. In the US, 12.5% of the population was over 65 years of age; 9.5% of those were over 80 years (WHO, 1989).
Life expectancy at birth is greatly affected by infant mortality and varies from 49 years in Bangladesh to 77 years in Japan. The life expectancy in Sweden is 76.6 years; in Norway it is 76.2; in Denmark it is 74.8; and in the US it is 74.6 years. In general, women can expect to live 3 to 8 years longer than men (Davies, 1989; Torrey, 1978). This has led to elderly women greatly outnumbering elderly men in most countries. It is estimated that 85% of women over the age of 75 are single, widowed, or divorced with very low incomes. Therefore, the social, economic, and health problems of the elderly are in large part the problems of elderly women. Not only do women have a longer life expectancy at birth, but female death rates are lower than male death rates at all ages in virtually all countries. Consequently, as a population ages, the percentage of women in each age cohort steadily increases. This trend is especially pronounced in developed countries, where the proportion of women among the oldest old reaches as high as 70%, with a resulting ratio of 1 man to 2.3 women.
In the developed countries, 70% to 80% of those persons 65 years and over enjoy good health and manage without help. About 6% to 7% are permanently living in nursing homes and or residential homes. About 12% to 15% of those living in their own homes need some form of health and social services. The leading causes of death in those aged 65 to 74 years are malignant neoplasms, ischemic heart disease, cerebrovascular disease, respiratory disease, and external causes (WHO, 1989). The relative importance of these five principal causes of death varies from country to country.
In looking at trends over the last 20 years, there has been an apparent decline in the death rate for all of the diseases except cancer. In the future, therefore, the elderly will enjoy better health. The decline in trends also suggests that a healthy lifestyle has an effect on life expectancy. While death rates for some diseases have decreased, there has been an increase in the number of different chronic diseases, bringing with it increased frailty and morbidity.
Elderly people who are ill live longer than previously, at least in the wealthier societies, and there are more cases of disease and disability that will be cared for rather than cured (WHO, 1989). This means that it is not so much the medical model that is needed but more the social-nursing-health model (Daatland, 1990). Petersson and Hollnagel (1984) found that doctor visits increase with age and that women make more visits than men. Hospital admissions for acute care increase even more steeply with age, and here, too, more women are involved than men. Although mortality has dropped from diseases such as diabetes, stroke, and heart attack, data from the US suggests that the morbidity for these illnesses has increased (Verbrugge, 1984).
Other health problems that make the elderly dependent on help are loss of hearing or vision, falls, osteoporosis, problems with pain, problems in the musculoskeletal system, and incontinence.
Mental health problems are a major problem; dementia will be the biggest challenge of the future. Estimates of the prevalence of dementia vary from 5% to 15% of all individuals over age 65. More impressive than the overall prevalence rate is the increase in prevalence with age. The demographic imperative of an increasingly older population indicates that the number of demented persons will continue to increase. No current medical treatment can cure, reverse, or stop the progression of this disorder of serious confusion and forgetfulness (Gilhooly, 1986).
Dementia represents a serious emotional and economic strain on the victims as well as their families, and represents a major policy issue to those in the political arena and in institutions of care. Many families are unable to provide continuous care as the disease progresses. Data from a study done by Larsson et al (1963) found that men with dementia survived slightly less than 5 years and women slightly more than 5 years. It appears that as developing countries become more industrialized, they will follow the same pattern of increasing age and increasing chronic illness during later life.
Industrialization and urbanization with a resulting nuclear family arrangement, together with geographical movement, mothers at work, and smaller houses, tend to separate the elderly and their children. This might lead one to believe that elderly in the developed countries are abandoned by their children and generally live a solitary and miserable life. Reality indicates, however, that personal ties between the generations continue to be strong and viable. Families help their aged members, and when they are unable to do so, a constellation of personal, social, and economic forces may be at work on the family unit. Thus, the collective social and cultural rejection of the aged has not been acted out on the individual or family level (Brody, 1977).
McPherson (1983) summarizes the affect of demography on the family:
Recent demographic changes, such as decreased family size, childless marriages, and fewer single adult daughters, combined with an increasing number of middle-aged women in the labor force, have led to a decrease in the availability and opportunity of adult children to care directly for the aging parents. As a result, more social and health care support services are provided by the private and government sectors. Nevertheless, in most societies, the family is the first and major resource for the elderly, of whom less than 10% are ever institutionalized.
Figure 1. Personal ties between the generations continue to be strong and viable.
In Japan, where the social norm and attitude is that the family should take care of the elders, data show a different picture. Maeda (1990) referred to a 1978 national study that revealed 69% of the bedridden elderly people in Japan were cared for in their homes. The same survey done only 6 years later disclosed that this proportion had been reduced to 56%. A study done by Japan's National Council of Social Welfare (1979) described caretakers in relation to the gender of the bedridden elderly. Sixty-one percent of the bedridden older men were cared for by their aged wives, and 22% were cared for by their son's wives. On the other hand, 50% of bedridden older women were cared for by their son's wives, and 28% were cared for by their own children.
A recent national study from Denmark (Platz, 1989; 1990) points out that families do take care of their elderly. This care, however, lasts for a short time and the problem necessitating care is often of an acute nature. If the care becomes more time-consuming on a regular basis and looks as if it might continue over a long time, then the family is often unable to cope.
If the health and social system does not become aware of the increasing family stress and provide input into the family system, then the family will have contact with the elderly less often. An example is a 78-year-old daughter-in-law who for a number of years had done the shopping and washing for her 92-year-old mother-in-law, who was incontinent. The daughter-inlaw had informed the home visiting nurse that she was no longer able to do this service because she was being treated for high blood pressure and problems with her arthritis, which resulted in her having difficulty carrying heavy things. All she could now manage was to care for herself and to visit with her mother-in-law. Because professional help was not provided, the daughter-in-law felt that the only solution was to visit only once a month instead of twice a week and phone less, as she could not handle the pressure of being told, "I am wet and have no dry, clean clothes. Come and help me."
HEALTH AND SOCIAL SERVICES
The emphasis on primary health care has had legislative support in many developed countries for the last 40 years, as well as being the main agenda for the World Health Organization since the Alma-Ata conference on Primary Health Care in 1978 (WHO, 1978). It appears, however, that the growth of community resources have not kept pace with the needs diverted away from institutional settings, including acute care hospitals.
The main reasons supporting people staying in their own homes are based on three arguments of preference, cost, and quality:
* Home care is preferred because even as they grow older and more frail, elderly persons prefer to remain in their own homes rather than in institutional settings;
* Community care is sometimes less costly. This does not always hold true, as many elderly now survive into their late 80s and 90s and are becoming so mentally or physically disabled that they require 24hour care; and
* Care in the community provides greater privacy, autonomy, and independence for the individual than does institutional care. In contrast, nursing homes, which have predominantly used the medical helping model, can contribute to individual apathy, dependence, and depression (McGilloway, 1979).
To adequately support the elderly and their families, it is necessary to have sufficient and appropriate resources, involving a large range and variety of services. There is a need for community nursing, social, and medical service. The home nursing service must include help for nursing care, continual assessment and management, basic nursing care health teaching, and rehabilitation measures. Other needed services include assistance with shopping and cleaning, Mealson-Wheels, luncheon clubs, clubs and handicraft centers, day centers, nursing homes, sheltered housing, visiting, bus passes, emergency calling systems to the fire department, special aids, special housing accommodations, outings, night care centers, recreational institutions, washing, and self-care groups.
All care must be given in collaboration with the elderly and the family in their cultural-social context. Decision making can, however, lead to ethical conflict, as the goal, norms, and value systems of the patient, the family, and the formal service provider may differ. Patients and nurses do not evaluate self-care ability in the same way; this was demonstrated by Lorensen (1985) and by Achterberg et al (1991) in studies in which nurses evaluated the patient's self-care ability and the patient filled out the same form. The nurses evaluated the patients as having less self-care than the patients listed. This indicated the need for dialogue between caregiver and patient before decisions about care are made. Kim (1991) and Holter and Lorensen (1991) show that although nurses support the inclusion of patients in the decision making process, this is often not done in individual practice situations. More research is needed in this area.
Most Danish communities now have a regular 24-hour on-call home nursing service so that clients can get the help they need in their own homes. A team, usually a registered nurse and a home helper, takes care of regularly assigned clients and helps them to bed, to the bathroom, take medication, do crisis intervention, etc. The team also responds to elderly clients who develop an acute need for nursing care, thus avoiding unnecessary hospital admission. The counties pay for this service and are also furnishing the service with cars.
In several countries, there will be beds in a nursing home to which the team can admit the elderly when needs exist that cannot be met in the home but that do not require acute care. This is possible in Denmark, which has a strong philosophy of self-help and integration into normal life in the community (Daatland, 1990). As such, the home care and long-term care institutions are viewed and administered as social rather than medical units and are organizationally under the county levels of government. This is not always the case in other Nordic countries. This is better service, both qualitatively and economically, than admitting elderly to a hospital. Moreover, as service to the frail elderly moves from the home to the institutionalized setting, there is increased risk to the person's self-determination.
Denmark and Norway are developing flexible models of long-term care. In Sksevinge county, Denmark, the staff from home nursing, public health nursing, day care center, and nursing home work from the same office and are under the same management (Wagner, 1988). This allows the staff to be moved to better serve patients' needs without having the patients moved from their homes. Several Danish municipalities have turned their nursing homes into apartments for the elderly and thus no longer have nursing homes. This is necessary in Denmark if the elderly are to maintain control of their pension; the law states that upon admission to a nursing home, the pension is paid to the nursing home and the elderly person is given only a small amount of spending money. Not all counties have changed their nursing homes that much to make it possible for the elderly to stay in control. However, many nursing homes are changing their function and philosophy from a medical model that focuses on disease to active rehabilitation that emphasizes functional health.
Figure 2. Home care rather than institutionalized settings is preferred by elderly persons.
The challenge is for the nursing staff to publish these programs so others can share in their experiences. Small and inexpensive, but very significant, changes that increase the quality of patient care are often instituted by the staff. Most often novel interventions are lost and will have to be rediscovered again and again. Systematic records of the daily interventions and results can be evaluated for further development. This is unfortunately not done unless outside funding is available or it is required by law.
Another model for the more healthy aged or the aged who are consciously working on maintaining independence is integrated housing with the communal concept of living (Kcehler,1991). In Copenhagen, for example, nine single women, from the age of 55 years, have moved into a housing block where one of the apartments is used for common facilities, such as eating or having classes (Zahle, 1986).
The concept of a common building is useful in building new-age integrated housing in urban areas. A building with washing facilities, guest accommodations, and areas to conduct classes, have large parties, dine, and do hobbies is gaining more acceptance. Added to this is the requirement that persons relocating to the new housing must commit themselves to the common community goal and be willing to help when needed, as well as pay for the common facilities. The intention is that all age groups are represented, that people know each other, and that an individual moves in before becoming dependent. The age of the people taking these initiatives is usually from 49 to 65 years of age. Nurses must consider the role of housing as a variable in elder support.
Perhaps the single most important thing that can be done to assist older persons and their families is education of the elder, the family, and the formal caregiver.
There is a lack of good information and teaching material for the elderly. Good and detailed instructions on caring for a hearing aid is an example. Nurses are developing these materials. For example, in Denmark, many elderly trip on small throw rugs, and a self-care group of well elderly have developed a slide series for prevention of falls called "It's Better With a Nail in the Carpet Than a Nail in the Hip." It would be worthwhile to systematically collect all of these ideas and initiatives, choose the more valuable ones, and develop a catalogue to give easy access to the information developed, as well as the process and implementation.
The family caretaker also needs considerable knowledge on aging, the particular illness, the intervention, available technology, and how to manage on a 24-hour basis. Here information is lacking. There really are no longitudinal studies that have described and tested nursing interventions of how to care for a person over 80 or 90 years old with different kinds of health problems. Longitudinal studies on elder persons in Glostrup, Denmark (Arendrup, 1989; Hagerup, 1987), and Goteborg, Sweden (Hagerup, 1987), are now making available data on formal physiological, psychological, and social values that can be used in teaching.
Education can promote understanding and the ability to cope with caring for long periods. If this burden becomes too great, however, it can lead to abuse of the older person. Caretakers need specific detailed knowledge to cope with caring for the elderly. They may also need psychological support. There is a need to help the family and professional caregiver cope with caring for the elderly when it has become clear that they will not benefit from treatment. The Appleton Consensus: Suggested International Guidelines for Decisions to Forgo Medical Treatment addresses this issue, as well as promoting public discussion to develop guidelines based on ethical principles (Stanley, 1988). The guidelines were developed by doctors, philosophers, economists, lawyers, and a nurse.
One of the biggest challenges for the future will be recruitment and retention of professionals into gerontological educational programs. In the future, fewer persons will be available to recruit into helping professions. Also, gerontology is still a low-pay and low-prestige area in which to work. This, together with changes in the political climate and the emphasis on hard values such as economic efficiency and business interests, put the solidarity towards elderly citizens to a hard test.
Recruitment and retention of persons in gerontology is a particular problem. Most nursing schools teach child health from a family perspective, yet few teach elder health from the family perspective. There is a great need to develop knowledge and theory in the area of family care with the elderly. Results of a study carried out by Wright and Bell (1989) indicated that family nursing education in a Canadian school of nursing was particularly strong in content areas of family assessment, family, and illness. There were, however, serious deficits in the teaching of family intervention and interviewing skills in terms of content, instructional methods, nursing literature, and integration of knowledge from other disciplines, as well as an advanced level of practice. Friedman (1986) states that there is a serious lack of systematic, comprehensive family assessment tools. Dyrholm (1985) found that most curricula for health-care personnel in Denmark contained only a few hours of content about the elderly, let alone content on families and older persons. This is of great concern, as the majority of clients are over 65 years of age both in hospitals and in communities.
In educating individuals who choose to work with the elderly, it is important to include theory and knowledge of change, attitudes towards the elderly person's family, and the latest research findings in relation to this group (Lang, 1990; Murphy, 1986). To help change negative stereotypical beliefs towards older persons, it is useful to add clinical experience with home visits (Lorensen, 1986). Most healthcare workers are educated in acute care institutions and have difficulty visualizing how older people live; thus, the professional caregiver may fail to tailor the health-care program for a return to the home environment.
In talking to nurses working in the community and those working in institutions, it becomes evident that they collect different data sets and design different plans of care. This is unfortunate, as it is the patients and their families who are caught in this lack of continuity and are confused by the health-care plan. Although education of new caregivers is important, re-education of existing caregivers is also important. A Danish study showed that a 4-week teaching program with clinical home visits was able to change experienced hospital staff's attitudes towards the elderly (Lorensen, 1987).
IMPLICATIONS FOR NURSING
This article has examined the health and social support of elderly families in developed countries from a global perspective within the areas of demographics, health, family, health and social services, and education. It is clear that the elderly population is increasing and that about 7% to 12% will need some form of help from the social and health-care system. It is equally clear that there are many new developments taking place at all levels to meet this challenge.
The major issues facing family nursing in relation to the elderly family currently and in the future are:
* Recruiting, retaining, and educating nursing personnel caring for the elderly and their families;
* Conducting research, theory development, and systematic data gathering from a family perspective;
* Influencing policy making and decisions to reflect the needs of families; and
* Setting up experimental units of care in agencies and in-home nursing to do research that demonstrates the effectiveness of interventions.
Effort such as these will support the family and formal support system as they in turn assist increasing numbers of older frail persons.
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