Aging and Long-Term Care

Course #99353 - $15 • 3 Hours/Credits


Self-Assessment Questions

    1 . Individuals who are 77 years of age are categorized as
    A) young-old.
    B) middle-old.
    C) oldest-old.
    D) fragile-old.

    AN OVERVIEW OF THE ELDERLY IN THE UNITED STATES

    The age at which one is considered "older" or "senior" is always evolving and is influenced by culture and societal life expectancy. In England in 1875, old age was defined as 50 years or older, as stated in the Friendly Societies Act [88]. Today, most developed countries in the world use the chronologic marker of 65 years as a definition of old age; in some cases, the age of 62 years is used as a chronologic marker because, in the United States, one could receive social security benefits starting at this age [87]. However, Mohanty notes that using the criterion of age at retirement or when one becomes eligible to receive retirement benefits is not universal, given the fact that there are so many in the world who live in areas in which there are no formal definitions of retirement [88]. Using these chronologic markers to define old age is arbitrary, but they can be useful when studying the group as a whole [2]. The elderly can be further divided into various segments: the young-old, defined as 65 to 74 years of age; middle-old, defined as 75 to 84 years of age; and the oldest-old, defined as those who are 85 years of age and older [3]. In 2010, there were 53,364 persons 100 years of age and older in the United States [94]. Worldwide, in 2015, there were more than 500,000 centenarians, and it is estimated by 2050, there will be 3.7 million, with the greatest growth in China [90]. In the United States, it is projected that there will be 9.7 centenarians per 10,000 people by 2050 [90].

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    2 . The cross-linkage theory of physiologic aging maintains that
    A) replication of cells slows with aging.
    B) each species has a genetically determined maximum life span.
    C) the body's proteins undergo changes, decreasing elasticity of skin.
    D) the body loses its ability to discern foreign bacteria and viruses as it ages.

    BIOLOGIC PROCESSES AND PHYSICAL WELL-BEING IN OLDER ADULTS

    Biologic and physiologic changes are part of aging. Although it is not known why these changes occur, biologic theories of physiologic aging include [3,7,86,95,121,140,143]:

    • Wear and tear: Aging is genetically determined, and as a result, the tissues and muscles eventually deteriorate.

    • Cross-linkage: The body's proteins attach to other structural substances, thus decreasing elasticity in the skin and causing other physical changes in the organs and slowing of physiologic processes.

    • Autoimmune: As the body ages, it is unable to recognize the difference between healthy and diseased cells, causing it to react against itself.

    • Cellular aging: The replication of cells slows as a result of aging.

    • Apoptosis theory: Aging is due to inevitable pre-programmed cell death in our bodies. Apoptosis is a normal process in the body, but it is speculated that if dysregulated apoptosis could lead to Alzheimer disease, Parkinson disease, or cancer.

    • Free radical: As free radical exposure increases in older organisms, the antioxidant system is not able to counteract the free radicals that have been generated and accumulated during the life of the cell, resulting in cellular death. Experimental findings have not conclusively supported this theory.

    • Evolutionary: Humans' developmental life cycles are affected by mutation and selection. In other words, all biologic dimensions are affected by mutation, and there will be variations among human beings. This will lead to a natural selection of those who are more fit to survive in an environment. Aging leads to vulnerability.

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    3 . Which of the following is more common among persons with sensory loss?
    A) Stroke
    B) Hip fractures
    C) Hypertension
    D) All of the above

    BIOLOGIC PROCESSES AND PHYSICAL WELL-BEING IN OLDER ADULTS

    The losses in the physical arena for the elderly can be numerous, which may then compound and/or have implications in social and psychologic arenas. Studies have shown that brain tissues atrophy due to natural cell degeneration, with the volume of the brain decreasing by 15% or more between adolescence and old age [122]. Crews notes that the health status of older persons with vision and hearing loss is poorer compared with those without vision or hearing loss [10]. Rates of heart disease, hypertension, hip fractures, and stroke are higher among those with sensory loss [10]. In a study of more than 1,000 elders, 53.7% of those with impaired vision also had hypertension, compared with 43.1% of those without impaired vision. Of those with impaired hearing, 27.6% experienced heart disease, compared with 18.6% of those without a hearing loss [10]. Interestingly, the rates double when persons have both hearing and vision impairment. Almost one-fifth (19.9%) of persons with both impairments had experienced a stroke, while only 8% with no sensory loss had experienced a stroke [10].

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    4 . Factors that affect older adults' lack of testing for HIV infection include all of the following, EXCEPT:
    A) Prevalence is extremely low.
    B) Older adults harbor the misconception that they are not at risk.
    C) Symptoms of HIV infection mimic age-related illnesses, such as dementia.
    D) None of the above

    BIOLOGIC PROCESSES AND PHYSICAL WELL-BEING IN OLDER ADULTS

    In industrialized countries, it is estimated that 10% to 15% of human immunodeficiency virus (HIV) infections occur in adults 50 years of age and older, and approximately one of every nine new HIV diagnoses in the United States occur in those 50 years of age or older [17,18,126]. This prevalence may be higher in developing countries [18]. In 2016, there were an estimated 6,812 newly diagnosed cases of HIV among adults 50 years of age and older, accounting for 17% of total diagnoses in the United States. Of these, 841 diagnoses occurred in persons 65 years of age and older. In 2015, approximately 47% of all individuals with living with HIV were 50 years of age and older, and 2,749 people 55 years of age and older died from HIV disease [97]. However, older adults are not generally considered an at-risk group. This has led to a lack of targeted education and screening among older adults. For example, only 32% of state departments of public health websites contained information about HIV/AIDS in elderly individuals [167].

    Older adults living with HIV experience a variety of other medical conditions that place them at even further risk for frailty and other diseases of aging. Among older persons with HIV, more than half are considered pre-frail and experience challenges with instrumental activities of daily living (e.g., cooking, cleaning, managing finances, doing laundry) [195].

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    5 . According to Erikson, the major task in late adulthood is resolution of
    A) trust versus mistrust.
    B) initiative versus guilt.
    C) integrity versus despair.
    D) generativity versus stagnation.

    CHALLENGES AND ADJUSTMENTS ASSOCIATED WITH AGING

    Erik Erikson, a prominent developmental theorist, had a more optimistic view of aging, focusing on the positive ways of overcoming the various crises one encounters throughout life [25,26]. Erikson postulated eight stages of psychosocial development. Each stage provides the individual with a choice of two alternatives to consider and accept; one is an opportunity for growth, while the other results in unhappiness. In late adulthood, individuals confront the challenge of integrity versus despair. During this stage, individuals reflect on their lives, and determine if they have lived a life of purpose. If so, the individual will feel contentment, having attained integrity [26].

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    6 . Which of the following is NOT a mediator of grief response?
    A) Mode of death
    B) Nature of attachment
    C) Changes and concurrent stressors
    D) Occurrence of holidays or significant days

    CHALLENGES AND ADJUSTMENTS ASSOCIATED WITH AGING

    In cases of terminal illness, grief counseling should begin before death occurs, with a focus on life meaning and contributions [37]. Awareness and understanding of the mediators of grief responses can assist in recognizing individuals who may be at increased risk for adapting poorly to the loss. These mediators are [38]:

    • Nature of attachment (how close and/or dependent the individual was with regard to the deceased)

    • Mode of death (the suddenness of the death)

    • Historical antecedents (how the individual has handled loss in the past)

    • Personality variables (factors related to age, gender, ability to express feelings)

    • Social factors (availability of social support; involvement in ethnic and religious groups)

    • Changes and concurrent stressors (number of other stressors in the individual's life, as well as coping styles)

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    7 . Which of the following factors is predictive of an elder entering a nursing home?
    A) Acute disease(s)
    B) Non-white race
    C) Higher income bracket
    D) Cognitive impairments or a history of falls

    LONG-TERM CARE

    In 2018 in the United States, 56% of those 65 years and older required long-term services [213]. Institutions providing long-term care to older individuals often provide a variety of services, including personal, social, and medical services. Key factors that predict elders entering a nursing home include [111]:

    • Non-Hispanic white race

    • Lower income bracket

    • Restricted activities of daily living

    • Cognitive impairments or a history of falls

    • Chronic diseases (e.g., diabetes, cardiac conditions, stroke)

    • Limited social supports (e.g., widowed, divorced, few or no children)

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    8 . The Michigan Alcohol Screening Test-Geriatric (MAST-G) was specifically developed in order to accurately assess alcohol abuse and dependence in older adults. It varies from the standard MAST test in its focus on
    A) social and binge drinking.
    B) loss of consciousness or memory as a result of drinking.
    C) effects of drinking on occupation and family relationships.
    D) drinking in response to grief and changes in drinking patterns over time.

    ASSESSMENT TOOLS FOR OLDER ADULTS

    There are several screening tools available for assessing older adults with problem drinking. The Drug Abuse Screening Test (DAST) is a 28-item questionnaire consisting of yes or no responses. The Short Michigan Alcohol Screening Test (SMAST) is a 13-item questionnaire with a similar response format. These instruments are commonly used but may not be appropriate for the elderly population. However, a longer version of the SMAST, the Michigan Alcohol Screening Test-Geriatric (MAST-G) was specifically developed in order to accurately assess alcohol abuse and dependence in older adults [46]. The MAST-G consists of 24 items, which may limit its incorporation into regular screening procedures. As opposed to the standard MAST, this version focuses more on drinking in response to grief and changes in drinking patterns over time.

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    9 . All of the following are interventions for older adults that support active engagement, EXCEPT:
    A) Individual therapy with a specialist
    B) Group activities that provide support
    C) Activities emphasizing elders' control
    D) Activities targeted at a specific subgroup, such as widowers

    GENERAL GUIDELINES FOR INTERVENTIONS

    Increasing or intensifying social networks can involve various approaches. Cattan and White identified three key aspects of interventions for older adults that support active engagement: group activities that provide support (e.g., support for bereavement), interventions targeted to a specific subgroup (e.g., widowers), and activities or interventions emphasizing elders' control [70]. Several interventions for older adults that focus on decreasing social isolation have been identified and may be classified into four general categories [71]. The first type of intervention to address isolation is one-on-one telephone support services, whereby a counselor checks in with elders periodically. Second, teleconferencing, whereby a group of elders are brought together via a phone conference, has been found to be a cost-effective and useful intervention. Third, face-to-face support groups were found to be beneficial in reducing social isolation, particular groups that last for at least five months [71]. Lastly, with increasing Internet accessibility, e-mails and Internet support groups can also be beneficial for older individuals. Older adults who have access to and use computers have more social support and are less likely to experience loneliness [217]. A study exploring the use of videoconferencing with frail elders in Australia found that the patients preferred videoconferencing with a pain specialist over a face-to-face consultation [116]. A systematic review found that social connectedness and support were increased in elders who used Internet technologies, although the effects were short term [187]. As discussed, loneliness is often intertwined with other variables, such as shyness or limited resources. Therefore, interventions should not simply focus on providing venues for older adults to meet; interventions and programs that focus on people's expectations about friendships and relationships are equally important [157].

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    10 . Which of the following is an option when obtaining informed consent for an elder with a significant cognitive impairment?
    A) Call an attorney
    B) Disregard informed consent
    C) Consult with family members to determine the best course of action
    D) Have a surrogate caregiver provide informed consent and the elder provide assent

    ETHICAL PRACTICE WITH ELDERS

    The issues of an elder's mental capacity and self-determination come into play with informed consent, particularly if cognitive impairments are present. Informed consent involves three dimensions: the communication of the information, the opportunity to ask questions, and the process of making a decision [162]. As stated, an elder's self-determination should be promoted. It must involve not only the communication of the information but also giving older adults the opportunity to ask questions about their care, the intervention, and/or services provided to them and empowering them to make the decision. However, there may be times when an elder cannot give informed consent. One way to assess if the elder understands the intervention is to have him/her reiterate what the intervention entails [6]. However, there are a few options when an elder's capacity is compromised. First, a surrogate caregiver could provide consent. Second, double informed consent could occur, whereby the surrogate caregiver gives informed consent and the elder client gives assent. Finally, it is possible to obtain early informed consent from the elder via legally binding documentation of wishes prior to any cognitive impairment [6].

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