Promoting Healthy Partnerships with Community Elders

Promoting Healthy Partnerships with Community Elders

Learning Objectives

• Discuss selected health and social factors that impact health status and functional ability of the elderly.
• Differentiate between individual- and community-based health promotion strategies.
• Design and implement a health promotion initiative for community elders.

Introduction

Improvements in medicine, science, public health, and technology have enabled older populations to live longer and healthier lives than prior generations. As society anticipates the aging of the “baby boom” population, tremendous challenges of health promotion for elders confront society. Most health care providers agree that a major concern is assisting the elderly to live healthy, independent, and productive lives in their communities. The needs of community elders are as diverse and multifaceted as the elders themselves. Building communities in which elders can live satisfying lives requires a thorough understanding of the issues facing elders as they try to maintain their independence. Elderly populations no longer want to accept disability and chronic illness as inevitable. Health promotion and disease prevention activities are an increasing priority for older adults, their families, and the health care system. This chapter focuses on developing individual-focused as well as community-based health promotion strategies and partnerships with non-institutionalized elders. The terms elderly, older adults, aging, and senior citizens are used interchangeably to denote people aged 65 years and older.

Demographics of Aging in the United States

The older population, aged 65 years and above, numbered 35.9 million in 2003, representing 12.4% of the total U. S. population (Administration on Aging [AoA], 2004). The percentage of older Americans has more than tripled from that in 1900 (4.1%), and the number has increased more than 11 times (from 3.1 million to 36 million). A child born in 2002 could expect to live 77.3 years compared to about 29 years in 1900 (Administration on Aging [AoA], 2004). This phenomenal growth has occurred as a result of reduced mortality rates of children and young adults. By 2030, the older population will more than double to 71.5 million and the over-85 population is projected to increase from 4.7 million in 2003 to 9.6 million (Administration on Aging [AoA], 2004). Moreover, it is predicted that there will be as many people over age 65 years as there are people under 20. Of special note, the fastest-growing population of older Americans is the 85 years and older group. The older population will grow significantly between 2010 and 2030 as “baby boomers” (those born during America's post-World War II population explosion, beginning in 1946) begin to turn 65 years old (Administration on Aging [AoA], 2004). Aging represents a challenge around the world. Rapidly expanding numbers of very old people around the world represent a social phenomenon that is without precedent. In 2000, the number of persons 60 years and older was estimated at 605 million, with large proportions living in Asia and Europe (U. S. Department of Commerce, 2002).

Health Challenges, Risk Factors, and Concerns of Elders

Health Status

Morbidity and mortality patterns of the elderly generally follow 24224t1912y patterns of the population as a whole, with cardiovascular disease and cancer as the leading causes of death. The majority of older persons have at least one chronic condition and many have multiple conditions. In 2000 and 2001, the most frequently occurring conditions of the of the elderly included hypertension (49.2%); arthritic symptoms (36.1%); all types of heart disease (31.1%); any cancer (20.0%); and diabetes (15.0%) (Administration on Aging [AoA], 2004). In 2004, 37.4% of non-institutionalized elderly assessed their health as excellent or very good, compared to 65.8% for persons aged 18 to 64 (AoA, 2004). Elderly persons also have to cope with disabilities and activity limitations. In 1997, more than one-half of the older population reported having at least one disability, and over one-third reported at least one severe disability. The percentage of disabilities increases with age (AoA, 2004). As the percentage of elderly people 85 years and older grows, so will the severity and number of chronic illnesses and disabling conditions. Because chronic illness is often related to frailty in the elderly, creative, multidisciplinary approaches to chronic illness management will be needed to optimize independence and functional ability.

Access to Health Care

Accessibility and affordability of health care are challenges for the elderly, particularly for rural and poor elders. Many have not adequately planned for the medical expenses that often accompany the chronic illnesses common among older adults. Access to preventive services is often limited for the elderly. Medicare, the primary health insurance for older adults, offers very little coverage for health promotion and preventive services. Medicare coverage is often poorly understood, sometimes leaving elders paying for services that are covered by Medicare. Additionally, Medicare has many necessary health-related costs, such as prescription drugs and dental care that are not covered by Parts A or B. The elderly are among the greatest consumers of prescription drugs, many times paying for them out of pocket. With the passage of the Medicare Prescription Improvement and Modernization Act of 2003 (P.L. 108-173), it is anticipated that persons 65 and older will get help with paying for prescription drugs. While there are numerous Medicare Supplemental insurance plans available for purchase, many Medicare beneficiaries are unable to afford the cost of the premiums. Although state Medicaid programs provide coverage for some low-income older people, stringent eligibility requirements leave many without access to Medicaid health insurance. Although older adults have health needs that require a range of services on a continuum, not all services on the continuum are available to older adults in a variety of settings, leading to potential fragmentation of care.

Preventive services for the elderly are often neglected, because many providers do not see any point in prevention during the last years on the age continuum. A related issue is the recruitment and training of health professionals to provide medical and health care for seniors. Until the mid-1970s, medical schools placed little emphasis on geriatrics (Gelfand, 1999). However, professional nursing has been at the forefront in educating advance practice nurses in gerontology and adult nursing, as well as incorporating courses on aging in nursing curricula.

Alternative forms of health care, such as acupuncture and herbal medicine, may not be covered by insurance plans. Medicare Managed Care is now available to older people, as is Medicare supplemental insurance, which provides coverage for certain services that are not covered by Medicare. Elderly populations often need guidance in selecting Medicare supplement plans that can best meet their needs.

Transportation is another issue that impacts access to health care by the elderly, and rural elderly are hit hardest by lack of transportation. Elderly people often rely on friends; family members; lay taxi drivers (people who use private cars and often charge high fees); church volunteers; public transportation; and other forms of community-sponsored transportation to access health services. Nurses can play a key role during debates on Medicare and Social Security reform by promoting health care coverage not only to prevent illness, but also to keep older Americans from losing their savings as they try to pay for health care and, consequently, fall into poverty or sink deeper, if already poor.

Elder Abuse

As functional status and sensory acuity begin to decline, the elderly become vulnerable to an assortment of abusive and neglectful situations. According to the National Aging Information Center (NAIC, 1998), there are three basic categories of abuse: domestic, institutional, and self-neglect. Domestic elder abuse refers to maltreatment of an older person residing in his or her own home or the home of a caregiver. Institutional abuse occurs in residential facilities. Self-neglect refers to neglect inflicted when the safety or health of older people is threatened by their living alone. Elder abuse may take the form of physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, neglect by caretaker, or self-neglect (as noted above) (AoA, 2005).

The National Center on Elder Abuse reported an increase of 150% in state-reported elder abuse nationwide over a 10-year period, from 1986 to 1996. However, because abuse and neglect are largely hidden under the shroud of family secrecy, it is grossly underreported. Findings of the National Elder Abuse Incidence Study estimate that 500,000 older people in domestic settings were abused, neglected, or experienced self-neglect during 1996 (NAIC, 1998).

Mistreated elders are often frail, dependent, over age 70, and women. Typically, family members, not strangers, inflict abuse on elders. Elders who were abusive parents themselves are at higher risk of abuse. Elder abuse and neglect encompass a variety of events that harm older people, including trauma; swindling and fraud; unattended medical problems; poor hygiene; dehydration; malnourishment; battering; verbal abuse; forced confinement; and other types of mistreatment at the hands of family members, neighbors, and caregivers. Resolving abusive situations may require involvement of protective agencies as well as law enforcement. Community nurses need to be familiar with state abuse reporting laws and how to work with state adult protective services agencies.

Community Safety and Fear of Violence

Many community-dwelling elders are virtually prisoners in their homes because they fear becoming victims of muggings, break-ins, rapes, robberies, and scams. Rates of crime perpetrated against the elderly are different from those perpetrated against younger people. People older than 65 years are more likely to be victims of crime in or near their own homes because elderly people often lack access to transportation and do not travel great distances. The elderly are more vulnerable to crime. Due to declining physical strength to protect themselves, elderly people, especially women living alone, are easy prey for criminal victimization. Therefore, few venture outside and many take extraordinary measures to barricade themselves into their homes. This fear is compounded for the elderly poor who live in high-crime neighborhoods. The impact of criminal victimization is more devastating for the elderly than for younger adults. A low or fixed income makes it difficult for many older people to recoup from a robbery. These elderly often live in aging neighborhoods that are undergoing change and economic decline (Gelfand, 1999). Fear for their safety can be a deterrent to elderly people engaging in walking as a form of exercise. This fear can also cause social isolation. Community health nurses can facilitate neighborhood safety campaigns, such as crime watch programs.

Mental Health and Mental Wellness Challenges

Mental health is an important aspect of healthy aging. Ostir et al. (2004) found a link between positive emotions and frailty. They concluded that a positive outlook on life can help protect against physical and functional decline. Mental health issues faced by the elderly include social isolation and loneliness, depression, suicide, and alcohol addiction. Tremendous loss and role transition are associated with old age, including retirement, death of friends and loved ones, loss of vitality and energy due to illness or disability, and, in many cases, less contact with children and grandchildren who may live in a different city or state. Social isolation is associated with the very old (aged 85 and older), those in frail health, and the elderly living alone.

Depression is a common problem many elders encounter as they experience health and psychosocial changes. The prevalence of depression varies by setting, affecting up to 20% of community-dwelling elders, 25% of hospitalized elders, and as many as 40% of nursing home residents (Lammers, 2002). Depression is one of the most common risk factors for suicide. Suicide is at least eight times greater in the elderly population than the general population (U. S. Preventive Services Task Force, 1996). Community health nurses and other health care providers need to be aware of the signs and symptoms of elderly depression and suicidal tendencies. A number of depression scales are available for assessing levels of depression in elderly clients. Anxiety symptoms (feeling fearful, tense/keyed-up, or shaky/nervous) have been found to be common among depressed and non-depressed older persons (Mehta et al., 2003). Additionally, anxiety has been observed to be a significant risk factor for the progression of disability in older women (Brenes et al., 2005).

Accidents

Falls are the most common accidents experienced by people over age 70. It is estimated that about two-thirds of falls among the elderly are preventable. Whereas a fall in a younger person may not be problematic, a fall by an older person can have devastating results. Common risk factors for falls include use of medications or alcohol, poor physical condition, changes in visual acuity, inner ear disturbance, foot problems, gait and balance disorders, and hazards in the home and community. The presence of osteoporosis increases the likelihood of a broken bone when a fall occurs, particularly in women.

Several risk assessment tools for falls have been developed and are widely available. Scores can be calculated and reviewed with elders to plan fall-prevention strategies. Older adults are also at risk for accidental injury related to driving, fires, overmedication, and hypo- or hyperthermia. Decreased sensory acuity, impaired balance, decreased muscle strength, and decreased reaction time can diminish the ability of elderly people to interpret their environment. Community health nurses are in an excellent position to facilitate community-wide, as well as individual, injury prevention programs that target the elderly.

Disasters and the Elderly

Natural or human-made disasters, such as bioterrorism, can have a devastating effect on elderly populations. The terrorist acts that occurred on September 11, 2001 and the multiple large-scale weather disasters that have occurred during the past decade have heightened awareness of the special needs of elderly populations. Many elderly live alone and on limited incomes, making it nearly impossible to recover from a disaster without special assistance. The elderly are often slow to request help and are unlikely to follow through on a request. Additionally, they may have high nutritional needs, forget to take medicines, and become victims of fraudulent contractors (AoA, 2005). Recognizing the special needs of elderly populations during a disaster, the U.S. Congress passed the Older American Act, authorizing the AoA to provide assistance for the elderly through state agencies (AoA, 2005).

Healthy People 2010 and Older Adults

Healthy People 2010 established goals to increase quality and years of healthy life and to decrease health disparities for all Americans. The document indicates that the most important aspect of health promotion for older adults is to maintain health and functional independence to prevent morbidity and dependence. Objectives that address physical activity, nutrition, weight control, tobacco cessation, immunizations, and routine health screenings are focused on all age groups, including older adults (U. S. Department of Health and Human Services [USDHHS], 2002). When planning health education and health promotion programs for community elders, community nurses should incorporate priority areas and specific objectives addressed in Healthy People 2010. Selected Healthy People 2010 Objectives for older adults are summarized in Box 21-1.

Health Promotion and Health Protection Strategies for Community Elders

Health promotion and health protection are two elements of primary prevention. Health promotion denotes emphasis on helping people change their lifestyles and move toward a state of optimal health, whereas health protection focuses on protecting people from disease and injury by providing immunizations and reducing exposure to carcinogens, toxins, and environmental health hazards. The concept of health for the elderly must be revisited in planning health promotion interventions. Filner and Williams (1979) define health for the elderly as the ability to live and function effectively in society and to exercise self-reliance and autonomy to the maximum extent feasible, but not necessarily as freedom from disease. Messecar (2002) found that older people themselves define health as going and doing something meaningful, which consists of four components: 1) something worthwhile and desirable to do; 2) balance between abilities and challenges; 3) appropriate external resources; and 4) personal attitudinal characteristics. More than any other age group, older Americans are actively seeking health information and are willing to make changes to maintain their health and independence. Health promotion efforts should focus on modifiable risk behaviors, matched to the leading health problems by age (USDHHS, 2002). Hahn (2003) interviewed older ethnic women attending a senior center and found that they defined healthy as being able to perform meaningful activities, which in turn keep them healthy. It is evident from these views of health that health care goals for elderly persons must focus on improving functional ability, maintaining independence, and helping them find meaningful activities in life. To maximize health promotion for community elders, a multifaceted approach is needed. Interventions should target individuals and families as well as groups and communities.

Box Healthy People 2010 Objectives Related to Older Adults

Arthritis, Osteoporosis, and Chronic Back Conditions and Disorders

Individual- or Family-Focused Interventions

Individual- or family-focused health promotion/health protection interventions are designed to increase the individual's or family's knowledge, skills, and competence to make health decisions that maximize health-promoting and health-protecting behaviors. The goal is empowerment of the elderly and their families to make rational health decisions. Some categories of health promotion and health protection intervention that target the individual and/or family are:

• Health screenings
• Lifestyle modification
• Health education (one-to-one or group)
• Counseling
• Support groups
• Primary health care
• Immunizations
• Home safety
• In-home care (home health, personal care, or household assistance)
• Home-delivered meals
• Social support (telephone reassurance and home visiting)
• Case management
• Home maintenance help

Community-Focused Interventions

Community-focused interventions are activities and programs that are directed toward community elders as a whole or various elderly subgroups in a community. The goal of community-focused interventions is to improve community capacity and availability of the appropriate mix of health and social services required to prolong independence and functional status of community elders. Interventions at the community level primarily involve advocacy, political action, and participation in policy making that affects community elders. Examples of community-focused interventions are:

• Community-wide health educational campaigns that emphasize older people
• Holding campaigns in May, which is designated as “Older American Month”
• Community coalitions to address specific elderly issues, such as development of local information centers, telephone hotlines, or Internet sites
• Political involvement to advocate for needs of the elderly, such as preserving or expanding Medicare coverage for in-home services
• Collaboration with universities, churches, senior centers, senior housing projects, and other established community organizations to provide comprehensive services to subgroups of elders
• Crime prevention activities
• Participation in community-based health fairs.

Partnerships With Community Elders

Elderly populations, in general, are open to new health practices and respond to a variety of approaches that have the potential to improve their health. To plan effective health programs, community health nurses should validate proposed goals and strategies with the targeted elderly group. Involving elders in planning health promotion and disease prevention activities is essential because older people are sensitive to potential loss of independence, and involving them increases a sense of independence. Action steps for working with older adults in the community include:

• Plan programs where elders usually congregate, such as churches, senior centers, and retirement centers.
• Incorporate outreach activities into all programs.
• Be prepared to offer transportation to group activities.
• Anticipate needs of those with poor vision (e.g., use large print, limit handouts, use a quiet room or loudspeakers).
• Maintain a slow pace for activities and allow adequate time for responses.
• Allow plenty of time for elders to share life experiences.
• Keep teaching sessions relatively short.
• Incorporate multiple repetitions and reinforcement of information.
• Structure health education activities so the elderly feel comfortable asking questions or challenging information that is new or doubtful to them.
• Encourage the involvement of families, friends, and significant others.
• Advocate for improvements in community resources and policies that affect the elderly.

The following sections discuss selected health promotion and health protection needs of community elders.

Health Services

People over age 65 need regular primary health care services to maintain health and prevent disabling chronic illness and life-threatening conditions. Health promotion services that can form the basis for a community nursing intervention include:

• Immunizations (influenza, diphtheria, tetanus, pneumococcal vaccine)
• Screening for chronic illnesses, such as cancers, cardiovascular disease, and diabetes
• Management and control of existing chronic illnesses (health education, case management, and medication management)
• Knowledge of coverage and reimbursement practices (including alternative medicine) of Medicare/Medicare Managed Care, Medicare supplemental insurance, and specific state health insurance programs
• Community outreach and advocacy efforts to ensure linkage of elderly people to needed resources, such as health advocates, health coaches, and community gatekeepers. These individuals may be trained employees of businesses, churches, and corporations who can refer elders to community resources (Florio et al., 1996).
• Referral to existing state pharmacy assistance programs and advocacy to establish such programs where they are needed
• Education and outreach related to the Medicare Prescription Drug, Improvement and Modernization Act of 2003
• Education on medication management (scheduling, adherence, calendars, and so forth)
• Continuous source of primary care
• One-stop shopping for health care
• Connection to chronic illness support groups.

Nutrition

Adequate nutrition is important for older adults to maintain health, prevent disease, and slow down progression of existing chronic illnesses. To help the elderly improve or maintain nutritional status, it may be helpful to perform a nutritional assessment and build on existing strengths. An excellent tool that is readily available is the Nutrition Screening Checklist developed by the American Academy of Family Physicians, American Dietetic Association, and the National Council on Aging (Nutrition Screening Initiative, 1992).

Consider a nutritional health partnership program called “Eating Healthy, Deliciously!” Plan a class or a series of nutrition classes that focuses on basic nutrition as well as risk management nutrition (less salt, less fat, less sugar, more fiber, and so on). If special diet needs are to be covered, consider a series of classes and stratify the group according to specific dietary needs. Nutrition classes are more effective if they are highly interactive—incorporate recipe tasting and recipe sharing, build on existing positive habits, and include ethnic food preferences. Use of colorful, large-print posters and videos is appropriate. Reinforcing handouts are also helpful. Remember, many elderly people like to talk and share their experiences! Provide rewards for class attendance, such as canned goods, paper towels, macaroni, and other nonperishable, healthy food items. Enlist support of grocery stores for gifts. A major challenge is to get older people to attend these classes. Consider asking someone from the community or peer group to help with marketing and outreach.

Exercise and Fitness

The benefits of exercise are well established across the life span. Exercise activity for elders must be suitable to health and functional status. Brach et al. (2004) found that older adults who participate in 20 to 30 minutes of moderate-intensity exercise on most days of the week have better physical function than older persons who are active throughout the day or who are inactive. The following story offers a program idea for increasing exercise fitness.

While conducting a blood pressure screening clinic at a senior nutrition center, a nurse observed that the residents often arrive at the site around 8 AM. Their time was spent sitting until lunch was served at noon. A few played table games such as cards or dominoes, but there was little physical activity. While checking blood pressures, the nurse asked about physical activity and determined that most of them did not feel safe walking in their neighborhood, nor did they know of other forms of exercise. After validating the need for low-impact, chair-type exercise, a program was developed and several of the participants were trained as exercise leaders. The program was titled “Sitting Down, but Kicking High: Exercise for Seniors.” Under leadership of lay exercise leaders, the program was eventually incorporated into the daily activity schedule.

Fall Prevention

As described earlier in the chapter, falls among the elderly are a major concern. You may want to team up with occupational therapists and physical therapists to conduct a fall prevention class or classes at a location where elderly people normally congregate (of course, you probably will not impact the elderly needing this class the most; they are at home because of fear of falling if they go out). Some can administer a fall assessment questionnaire, some can perform balance testing, some can demonstrate ways to prevent falls, and still others can provide individualized counseling regarding fall hazards. This collaborative, multidisciplinary project can have tremendous impact on a problem that sometimes costs the elderly their independence or even causes death. You will need to market the project and obtain space for all screening, balance testing, demonstrations, and counseling. Consider having waiver and consent forms for balance testing in the event of an accidental fall.

Community Safety

To reduce fear of violence that often haunts older people, community nurses need to work with local law enforcement agencies to develop community programs. Prototype programs include Neighborhood Crime Watch Programs, Citizens on Patrol, and other civic organization safety programs. Elders need education regarding physical and psychological self-defense programs. Population-based media campaigns should concentrate on making elders aware of their vulnerability to specific types of crimes in the community, including frequency and time of day of occurrence. Additionally, direct deposit of monthly checks should be encouraged to decrease vulnerability to violence.

Summary

Promoting healthy partnerships with community elders is an exciting venture. A comprehensive paradigm of health for the elderly, including social and environmental health, is needed. The aging population is creating tremendous opportunities for community health nurses to provide innovative, evidence-based health promotion services for the elderly population. The focus of health care for this group will continue to shift from acute medical care to self-care, chronic illness management, and services that promote independence. Additionally, health promotion strategies will emphasize quality-of-life issues as more of the elderly are expected to experience a high level of functioning well into their 80s and 90s. Community health nurses have an opportunity to develop innovative approaches to improving quality of life for elders through advocacy and service delivery.

Critical Thinking Questions

• What impact does health promotion in younger years have on health status and functioning in older years?
• If frail elders residing in their homes are provided “lay case management” (such as a health advocate or health coach who calls or visits in-home periodically, supervised by professional nurses), will they experience longer independent living, better health functioning, fewer falls, and fewer hospitalizations than frail elderly who do not get such support?
• What is the appropriate mix of health and social services that can be provided through senior centers? Are such centers cost-effective?
• Assume that you have been asked to assess the needs of the elderly population in your community. Outline the specific data that you would collect. Describe how you would collect the data.
• Visit a senior center and ask a sample of the participants the following question: “What does being healthy mean to you?” Compare the answers to the World Health Organization's definition of health.
• Conduct an Internet search of innovative, evidence-based health promotion programs for elderly non-institutionalized populations. Discuss how such programs could be implemented in the local community.