Working Toward a Wellness Model in the Care of Older Adults
For many years, as I grew up, I heard that old people have to live in nursing homes and eventually become senile. As a teenager I believed that old people had no interest in sex and that they did not live long if their parents did not live long. I was afraid, since I had heard that my mother lost her parents when she was nineteen! I knew that when you get old you do not feel good, you do not work anymore, and you wait for people to come to you. All these ideas are what we as health professionals call "myths of aging" (See Sidebar: Ten Myths of Aging).
Today our thrust is on education, prevention, and a positive attitude about aging. I believe it is important to understand the aging process, and to know that elderly persons are capable of new learning. It is important to accept changes and also to know that we can do something about the physical, emotional, and social changes that elderly people experience.
All of us undergo stressful situations on a daily basis; however, as people age and change they also have relocation and loss stressors. Aging women and men may encounter depression and anxiety more often than the rest of the population due to the loss of a spouse or a loved one. Many experience manageable, temporary changes in mental health, such as depression, that often result in loneliness since a large percentage of the elderly live alone in the community. The perception of loss is a major contributor to mental health. The adjustment to the loss of friends or relatives due to death, migration, or work contributes, particularly in old age, to the loss of self-esteem directly related to aging. Few geriatric mental health specialists exist to address these needs. It is then no surprise to find statistics that indicate very high rates of suicide, abuse, neglect, and acute illness by age for those 65 and over.
Elderly people have a need to belong and establish group connectedness to replace what has been lost. There are few opportunities for elderly persons to become part of a community. I suggest that adult day centers may provide older persons that opportunity to participate, share, communicate, and be touched in many ways. For the past ten years I have been looking at the advantages of using adult day care centers and have found that they are a means for preventing physical, emotional, and physical losses in older adults. Those older persons who regularly attend activities and programs at these centers have a better quality of life and prevent institutionalization for themselves.
Physical decline among older adults is expected and for that reason the older person will tend not to take preventive or curative measures very seriously. Non-compliance can be avoided if someone supervises the medication and therapy regimen needed to continue a productive quality of life -- attending programs during the day and participating in family activities at night. In the wellness model I propose, I empower the older adults to care for themselves, if possible, by getting plenty of sleep, exercise, and food. I encourage them to be involved in the community and the church or synagogue so they can be loved and provide guidance for the next generation. This has the added benefit of feeling needed. We must pay attention to elderly people across cultures in our environment and be attuned to their needs as they age with needs that are perhaps only vaguely familiar to us. We also must be aware of those older persons living with chronic illness who are not institutionalized so that we, together with professionals and caregivers, can help prevent their demise into the need for institutional living. There are 1.3 million hip fractures annually. Hip fractures are associated mostly with a decline in functional status and quality of life. The disability arising from a hip fracture may lead to death. Research shows that although more hip fractures occur in women, mortality rates from hip fractures in men are higher because of comorbidity, age, and mental confusion during hospitalization. Hip fractures result in the greatest amount of pain and disability in both men and women (Wishnia, 2001).
The goal for the service to Older Adults should be the promotion of a customer-centered delivery system that facilitates public-private sector partnering addressing the need for home and community-based care, nutrition and health promotion, advocacy and elder rights, access, and community participation. Ten years ago Stuifbergen (1990) talked about the disruption that chronic illness causes in families and the family system, and encouraged us to continue research to explore what factors differentiate patterns in family functioning to support families of the chronically ill. We have not done much to alleviate the stress and coping needs of families dealing with chronic illness and therefore we find changes in family organization, in emotional and interpersonal relationships, and in the energy that the family is able to direct toward the person undergoing that illness. Efforts are strong in curative procedures. However, we need to stress the importance of improving communication techniques with reality orientation and validation techniques between families and their loved ones.
Even though several organizations in the community have attempted to deal with the issues around the end-of-life and how to prepare families for that time, we still do not approach it as health care providers with the natural step for which this stage of life calls. There is not a clear definition for the assessment needed during the last days of one's life and particularly there are inconsistent attempts to promote comfort as behaviors of physical, mental, and emotional discomfort arise. We are not prepared to deal with the spiritual needs of adults coming from a variety of ethnic backgrounds or various religions. As survivors of wars and immigrant populations dwindle in this country, we are learning from them how important it is to properly communicate and let them talk to their children about their life stories. This activity is not only therapeutic but in some cases has avoided elder abuse. As health care professionals, we worry about the statistics we read regarding abuse of older persons in this country. Yet, I worry about those we don't yet know about as well as those elderly persons that commit suicide due to the fact that none of us intervened in time. As health care professionals, we realize that many improvements are needed in the management of clients and their families as they age and approach death, even when they are well.
The efforts of individual states to modify their health and social services delivery systems while continuing welfare reform, undertaking Medicaid managed care, and attempting to re-define long term care forces us in higher education to become increasingly aware of the need for understanding historical federal mandates. The understanding of these mandates enables the future professional to actively participate in the redesign of programs and services. We try to empower older adults to be politically active, to get heard, and to lobby for their needs. The need for systemic change and continued advocacy of older adults challenge us in the preparation future professionals receive in the university.
Nurses can play a significant role in helping elderly persons understand the modifiable risk factors affecting their chronic conditions. Furthermore, nurses and nurse practitioners can be very instrumental in assisting elderly persons toward finding the most beneficial ways to treat and intervene with pharmacological management to prevent acute episodes. Finally, the interdisciplinary team can assist the community dwelling adult to remain a viable member of society until he or she chooses to do so within this model of wellness.
Dr. Gracie Wishnia is Professor of Nursing at Spalding University in Louisville, Kentucky. She has been active in the aging field for over 12 years and brings wellness expertise to this field. She has an interest in the prevention of disability due to chronic illness, and has worked with stroke, heart failure, and many other disabilities.
Wishnia, G. (2001). Challenges in the care of adults with osteoporosis, Geriatric Nursing 2001 22:3, p. 160-164.
Copyright © 2002, Wayne E. Oates Institute. All rights reserved.