The aging population faces various challenges. Older adults face a number of challenges like aging process, social norms, expectations, economical pressure, and environmental changes. Age related changes affect almost all the systems of the body. The heart pumps less, calcium collects in blood vessels, cataract develops in the eyes, hearing fades, wear and tear process of joints causes pain, and lungs, liver and kidneys become less efficient. Most often, health problems such as diabetes, heart diseases, depression, grief, alcohol use and elder abuse accompany the normal aging process.

Often, old age refers to a dependent life or loneliness. It adds to the problem when the older people face some kind of health ailment. Especially, people suffering from chronic or life-threatening illnesses are a significant challenge for critical care nurses. Early diagnosis and timely management of the age-related or accompanied health problems may empower the elderly population to achieve a life more functional, active and independent in their later years.

Older adult care requires a multidisciplinary approach including a primary care provider, geriatric nurse practitioner, physical and occupational therapists, pharmacists and other health care members. This course aims at identifying age-related and processes and challenges, nursing care and ethical issues.

Figure 1: Older adult care (Source: www.clear-healtheconomics.ca)

Aging can be defined as:

“Aging is a decline or loss (detuning) of adaptation with increasing age, caused by a time-progressive decline of Hamilton's forces of natural selection [1].”

Collectively, aging is a universal, intrinsic, progressive and deleterious process or phenomenon. Aging can be classified as chronological and physiological aging. Growing old is chronological aging while physical aging varies person to person depending upon the capability of the individual to face internal and external stressors and his/her genetic makeup. In United States, 43.1 million people were recorded as 65 or above in 2012 and are expected to be doubled in 2050 [2]. Texas law clearly states that every individual should be treated with dignity and respect for the personal integrity irrespective of race, religion, national origin, gender, age, disability, marital status or source of payment.

Rose [3] defines aging as “a persistent decline in the age-specific fitness components of an organism due to internal physiological degeneration.”

The above definitions impart that older adults require multidisciplinary approach to offer them enjoyable physiological, mental, and socioeconomic support. Otherwise, aging deteriorations and the accompanied health issues may lead to gloomy and substandard life in the later years of age. In this regard, nursing care services for older adults are of prime importance.

Figure 2: Aging (Source: ww.scicrunch.com)

Various biological and physiological changes occur with increasing age. Genetically determined wear and tear process, decreased elasticity of the skin due to increased collagen cross-linkages, increased incidence of autoimmune disease, slowed cellular replication, apoptosis, increased exposure to free radicals, and process of mutation and selection all contribute to aging process. Apoptosis refers to programmed cell death in our body which is a normal process. However, dysregulated apoptosis may lead to certain conditions like Parkinson’s disease, Alzheimer’s disease and cancer. Free radicals accumulate in the older bodies and are not counteracted by antioxidants completely, leading to enhanced cellular damage. Also, autoimmunity is increased in old age as the body cannot differentiate between the healthy and diseased cells.

Older adults have to face many losses in physical, social and psychological arenas. For example, brain atrophies due to neural degradation as the individual gets old. In old age, individuals may lose up to 15% of their brain function as compared to the amount they had in their adolescence [4]. Vision decreases and hearing fades. Incidence of diseases like heart diseases, hypertension, stroke and pathological hip fractures increases in old age. Interestingly, such conditions are found more in those with decreased vision or hearing loss or both [5].

Figure 3: Nursing care of elderly (Source: ww.mbadr.hubpages.com)

Muscle strength declines up to 30-40% between 30 and 80 years of age due to muscle atrophy, leading to increased incidence of falls and fractures [6]. These falls may be associated with medical, sensory, environmental and psychosocial factors. Arthritis in old age adds to the restricted mobility among older adults. Rheumatoid arthritis and osteoarthritis affect joints and mobility.

Additionally, older adults face insomnia caused by physical and psychological changes with advancing age. Conditions like restricted daily activity, physical illnesses, poor psychosocial support, depression, and broken relationships contribute to sleep disorders among older adults. The image below demonstrates innate immunity related dysfunctions in old age.

^{Figure 4: Age-dependent dysregulation of innate immunity (Source: www.nature.com)}

Older adults may have to face several challenges. They might have three major challenges like cognitive challenges, visual challenges and hearing challenges. Other challenges may include depression, suicide, grief, mourning, bereavement, alcohol and substance abuse, and elder abuse. Therefore, long-term care for older adults is mandatory.

Cognitive Challenges

Aging causes normal changes in cognitive process that refers to:

• Reduced processing speed

• Greater tendency to be distracted

• Reduced capacity to process and remember new information

The following strategies given in the image below can be applied to help with the above mentioned cognitive challenges:

Figure 5: Cognitive strategies

Most of older patients face visual problems. Two-third of patients above 65 suffer from vision problems but may managed as follows:

Figure 6: Visual strategies in old age (Source: www.www.pbs.org)

Hearing problems are common above the age of 60 years. The following strategies can be applied to help hearing problems:

Figure 7: Hearing strategies

Death of spouse and loss of friends are major factors contributing to depression and hopelessness. Older women experience greater depression and once depressed often remain depressed; especially those who have been enjoying long happy marital life as compared to those who have short unhappy marital life [7]. Higher incidence of various diseases and conditions add to the depression. For instance, an individual with hypertension and depression experiences three times more stroke as compared to those without depression [8].

Older adults are also at increaded risk of suicide as they cannot express their emotions and endorse suicidal ideation, especially those who are divorced or widowed [9,10].

Although grief, mourning and bereavement are used to express the same meaning, however, they keep specific meanings for a specific expression or period. Grief refers to a loss while mourning is the expression of grief and bereavement is the period of grief and mourning.

Patients suffering from terminal illnesses should be counseled before death to avoid indulging in grief.

Individuals with their love-one’s death should be encouraged to express their emotions and talk about the deceased as these activities lead to the acceptance of reality. It is very important for elderly people as they are also confronted with their own mortality.

Bereavement services, professional services and support groups should be provided to the families as bereavement may cause physical and psychological issues.

Figure 8: Mediators of grief

Figure 9: Tasks of mourning

Figure 10: Quote (Source: www.tvministriesok.com)

Alcoholism or substance abuse among the older adults is a hidden problem as they feel ashamed of telling about their substance abuse. In the old age, various factors contribute to this abuse such as:

• Self-medication to mitigate physical symptoms of the issued being faced

• Difficulty sleeping or chronic pain

• Mourning a loved one

• Loss of social supports

• Loneliness

However, older adults experience late onset of alcoholism. Individuals with late onset of alcoholism or substance abuse are less prone to develop physical, psychosocial and legal issues. Accompanied age related changes may change the diagnostic criteria and tolerance of the older adults. Moreover, there are just few treatment protocols for the treatment of alcoholism in the elderly.

Figure 11: The elderly may be at greater risk of alcoholism (Source: www.baylor.edu)

Any intentional or negligent act by a health care provider or any other person what results in harm or serious risk for a vulnerable adult refers to elder abuse.

WHO defines elder abuse as “a violation of human rights and a significant cause of illness, injury, loss of productivity, isolation and despair.”

Elder abuse is classified as domestic elder abuse, institutional abuse, and self-neglect or self-abuse.

The National Center on Elder Abuse demonstrates seven types of behavior that imparts elder abuse.

Figure 12: Elder Abuse

Nursing homes (NHs) play a key role for the long term care of the elderly people suffering from significant illness or disability. In United States, about 1.6 million people reside in NHs and the number is expected to grow double till 2030 [11]. Out of 1.6 million people, 83.3% are of 65 or above and 2/3 suffer from multiple chronic diseases. There is higher number of women living in NHs. Institutions providing long term care to the older adults are supposed to offer personal, social, and medical services.

Although NHs are an integral part of long term care; people prefer to live in their homes or community based options where they can avail patient-centered and responsive care. Various key factors lead to NHs admission of the older adults such as:

• Non-Hispanic white race

• Lower income bracket

• Restricted daily activities

• Cognitive impairments or a history of falls or fractures

• Chronic diseases such as diabetes, cardiac conditions, stroke

• Limited social supports for widowed, divorced, few or no children

Long term older adult care is a complicated service as it often requires medical as well as psychosocial care. In this regard, specialized assessment tools are available to assist care plans for the older adults.

Figure 13: Nursing homes (Source: www.triagelogic.com)

For geriatric care, Texas board of nursing (BON) states as “All licensed vocational nurses (LVNs), registered nurses (RNs), and advanced practice registered nurses (APRNs) are required to complete at least two contact hours in every licensure cycle beginning after January 1, 2014. The content must include information relating to elder abuse, age related memory changes and disease processes, including chronic conditions, and end of life issues. However, the board may not require a license holder to complete more than six hours of continuing education under this section.”

In all states of America, “Ombudsman Program” under the Title VII Older Americans Act serves the older adults and their families who believe or complaint of their rights being violated. The volunteers from this program investigate the problems and issued faced by the elderly people and advocate on their behalf to provide information about their rights and then ask for changes in the institutions to offer best possible quality of life.

The following ethical issues affect the quality of life experienced by the older adults:

Figure 14: Ethical issues and the older adults (Source: www.netce.com)

As the nation’s demographic shifts and life expectancy increases, older adult care is becoming crucial and more important. This patient population needs a multidisciplinary approach to manage medical, social, psychological and environmental issues. It is very important to investigate and know the beliefs and values to help this population with their potential psychosocial problems. As life expectancy increases, nursing homes should prepare to be more equipped and modernized improving quality of care and life for the older adult population.

Figure 15: Steps to successful aging (Source: www.my.clevelandclinic.org)

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