Chapter 10: Promoting Independence in Later Life Bonnie M. Wivell, MS, RN, CNS

Chapter 10: Chapter 10: Promoting Promoting

Independence in Independence in Later LifeLater Life

Bonnie M. Wivell, MS, RN, Bonnie M. Wivell, MS, RN, CNSCNS

Maintaining Maintaining IndependenceIndependence

Many factors contribute to the Many factors contribute to the ability of older adults to continue ability of older adults to continue their independencetheir independence

Maintaining maximum independence Maintaining maximum independence while maintaining maximum QOLwhile maintaining maximum QOL

Influences of Environment Influences of Environment and Living Situationand Living Situation

Living skillsLiving skills Kohlman Evaluation of Living SkillsKohlman Evaluation of Living Skills

Self-careSelf-care Safety and healthSafety and health Money managementMoney management Transportation and phone useTransportation and phone use Work and leisureWork and leisure

Housing influencesHousing influences Assist with decisionAssist with decision Distribution of belongingsDistribution of belongings Fiscal considerationsFiscal considerations

Self-CareSelf-Care Maintaining interestsMaintaining interests Doing for othersDoing for others Frailty: general decline in physical Frailty: general decline in physical

function that may increase function that may increase vulnerability to illness and declinevulnerability to illness and decline ExhaustionExhaustion Grip strengthGrip strength Walking speedWalking speed Low caloric expenditureLow caloric expenditure

Role Role Changes/TransitionsChanges/Transitions

RetirementRetirement Health to illnessHealth to illness Loss of a spouseLoss of a spouse

Widows/WidowersWidows/Widowers DivorceDivorce

Role reversal: care provider to care Role reversal: care provider to care recipientrecipient

Driving a carDriving a car Strong emotional and psychological Strong emotional and psychological

implicationsimplications

Role Role Changes/TransitionsChanges/Transitions

IADLs = shopping, errandsIADLs = shopping, errands

ADLs = personal careADLs = personal care

Caregiving – often needed long Caregiving – often needed long before acceptedbefore accepted

Caregiving OptionsCaregiving Options SettingsSettings

Senior living complexSenior living complex Assisted livingAssisted living Paid caregiversPaid caregivers Extended care facilitiesExtended care facilities

FamilyFamily StressorsStressors

TimeTime CostCost

Use of humor can provide stress reliefUse of humor can provide stress relief

SocializationSocialization

Maintaining connection to othersMaintaining connection to others

RelationshipsRelationships

CompanionshipCompanionship

PsychoSocial and Spiritual PsychoSocial and Spiritual InfluencesInfluences

Stress managementStress management Expression of emotionExpression of emotion ExerciseExercise Deep breathingDeep breathing Day dreaming/Guided imageryDay dreaming/Guided imagery Progressive relaxationProgressive relaxation MeditationMeditation

Goal attainmentGoal attainment

Maximizing FunctionMaximizing Function

Many factors influence the ability of Many factors influence the ability of the older adult to maintain and the older adult to maintain and maximize functionmaximize function

““So you want to live to be 100. Well, So you want to live to be 100. Well, start with this: No smoking, no start with this: No smoking, no drinking, no chewing. And always drinking, no chewing. And always clean your plate. Well, you can drink clean your plate. Well, you can drink a little bit, but not much!”a little bit, but not much!”

Preventing Complications Preventing Complications of Existing Illness or of Existing Illness or

DiseaseDisease NutritionNutrition

SleepSleep

ExerciseExercise

Fall preventionFall prevention

Value of RehabilitationValue of Rehabilitation

GoalsGoals Promote independencePromote independence

Maximize functionMaximize function

Prevent complicationsPrevent complications

Promote quality of lifePromote quality of life

Use of/Alternatives to Use of/Alternatives to RestraintsRestraints

Personal strengthening and rehab programPersonal strengthening and rehab program Use of personal assistance devices such as Use of personal assistance devices such as

hearing aids, visual aids and mobility deviceshearing aids, visual aids and mobility devices Use of positioning devices such as body and Use of positioning devices such as body and

seat cushions, padded furnitureseat cushions, padded furniture Safer physical environment design, including Safer physical environment design, including

removal of obstacles that impede movement, removal of obstacles that impede movement, placement of objects and furniture in familiar placement of objects and furniture in familiar places, lower beds, adequate lightingplaces, lower beds, adequate lighting


Regular attention to physical and personal Regular attention to physical and personal needs, including toileting, thirst, hunger, needs, including toileting, thirst, hunger, socialization, and activities adapted to socialization, and activities adapted to current ability and former interestscurrent ability and former interests

Design of physical environment for close Design of physical environment for close observation of staffobservation of staff

Efforts to increase staff awareness of Efforts to increase staff awareness of person’s individual needs – including person’s individual needs – including assignment of staff particularly to the assignment of staff particularly to the person, in effort to improve function and person, in effort to improve function and decrease difficult behaviors.decrease difficult behaviors.


Living environment designed to Living environment designed to promote relaxation and comfort, promote relaxation and comfort, minimize noise, provide soothing minimize noise, provide soothing music and appropriate lightingmusic and appropriate lighting

Provision of massage, art, movement Provision of massage, art, movement activitiesactivities

Use of bed, chair and door alarms to Use of bed, chair and door alarms to alert to the need for assistancealert to the need for assistance

Financial ConsiderationsFinancial Considerations

Help as needed:Help as needed: Medicare/MedicaidMedicare/Medicaid Food stampsFood stamps GrantsGrants Church programs/pantriesChurch programs/pantries AARP and other aging agencies for the AARP and other aging agencies for the

state or countystate or county

Community ResourcesCommunity Resources

Know what is available in your own Know what is available in your own community:community: Senior centersSenior centers Wellness programs through hospitalsWellness programs through hospitals Church groups for socialization and Church groups for socialization and

supportsupport VNA/Hospice when neededVNA/Hospice when needed

Community ResourcesCommunity Resources

Problem-based support groupsProblem-based support groups Meals on WheelsMeals on Wheels Geriatric case managementGeriatric case management Eldercare facilitiesEldercare facilities Community clinicsCommunity clinics

Other Recommendations to Other Recommendations to Promote Healthy AgingPromote Healthy Aging

Eat breakfast every day.Eat breakfast every day. Select high-fiber food like whole grain Select high-fiber food like whole grain

breads and cereals, beans, vegetables, breads and cereals, beans, vegetables, and fruits.and fruits.

Have three servings of low-fat milk, Have three servings of low-fat milk, yogurt or cheese a day. Dairy products yogurt or cheese a day. Dairy products are high in calcium and vitamin D and are high in calcium and vitamin D and help keep your bones strong as you age. help keep your bones strong as you age. Or take a calcium and vitamin D Or take a calcium and vitamin D supplement.supplement.


Drink plenty of water. You may Drink plenty of water. You may notice that you feel less thirsty as notice that you feel less thirsty as you get older, but your body still you get older, but your body still needs the same amount of water. needs the same amount of water.

Ask your health care provider about Ask your health care provider about ways you can safely increase the ways you can safely increase the amount of physical activity you do amount of physical activity you do now.now.


Fit physical activity into your Fit physical activity into your everyday life. For example, take everyday life. For example, take short walks throughout your day. short walks throughout your day. You do not have to have a formal You do not have to have a formal physical activity program to improve physical activity program to improve your health and stay active.your health and stay active.

Get enough sleep.Get enough sleep. Stay connected with family, friends Stay connected with family, friends

and community.and community.


Healthy AgingHealthy AgingBonnie M. Wivell, MS, RN, Bonnie M. Wivell, MS, RN,

CNSCNS

Healthy People 2000 and 2010 Healthy People 2000 and 2010 InitiativesInitiatives

Purpose:Purpose: Health promotionHealth promotion Document baselinesDocument baselines Set objectivesSet objectives Monitor progressMonitor progress

Healthy People 2000 target goalsHealthy People 2000 target goals Met for mammogram screening and influenza Met for mammogram screening and influenza

vaccinationvaccination Fell short forFell short for

Pneumococcal vaccinationPneumococcal vaccination Physical activity, overweight, eating fruits and vegetablesPhysical activity, overweight, eating fruits and vegetables Reducing hip fractures, and fall-related deathsReducing hip fractures, and fall-related deaths

Toolkit for HP 2010 available at Toolkit for HP 2010 available at http://http://www.health.gov/healthypeople/state/toolkitwww.health.gov/healthypeople/state/toolkit

Medicare CoverageMedicare Coverage

Nutrition therapy for persons with Nutrition therapy for persons with diabetes and kidney diseasediabetes and kidney disease

An initial physical examination that An initial physical examination that includes prevention counselingincludes prevention counseling

Smoking cessation—for those who have Smoking cessation—for those who have an illness caused by or complicated by an illness caused by or complicated by tobacco usetobacco use

Comprehensive health promotion Comprehensive health promotion programs for beneficiaries with heart programs for beneficiaries with heart problemsproblems

Health Behavior ChangeHealth Behavior Change

Theory that attempts to explain the Theory that attempts to explain the processes underlying the learning of processes underlying the learning of new health behaviorsnew health behaviors

Health contract/calendarHealth contract/calendar Initial assistance from clinicianInitial assistance from clinician Relies on self-management capabilities Relies on self-management capabilities

of individualof individual

Recommendations for Recommendations for Healthy AgingHealthy Aging

ExerciseExercise 30 minutes on most days of the week30 minutes on most days of the week Walking indoors in inclement weatherWalking indoors in inclement weather Neighborhoods can contribute to less exerciseNeighborhoods can contribute to less exercise http://topics.healthvideo.com/m/26757081/exehttp://topics.healthvideo.com/m/26757081/exe

rcise-can-help-you-live-longer.htmrcise-can-help-you-live-longer.htm http://topics.healthvideo.com/m/28352903/voluhttp://topics.healthvideo.com/m/28352903/volu

nteering-could-be-healthy-for-the-elderly.htmenteering-could-be-healthy-for-the-elderly.htme=healthy-=healthy-aging&brand_nameaging&brand_name==healthlinehealthline

NutritionNutrition See Nutrition Bull’s-eyeSee Nutrition Bull’s-eye Goal is to consume foods in centerGoal is to consume foods in center

Mental HealthMental Health http://medicalnewstoday.healthology.com/hhttp://medicalnewstoday.healthology.com/h

ybrid/hybrid-autodetect.aspx?content_idybrid/hybrid-autodetect.aspx?content_id=2516&focus_handle=&=2516&focus_handle=&brand_namebrand_name==medicalnewstodaymedicalnewstoday

Life review: autobiography saved in print or Life review: autobiography saved in print or on other mediaon other media Stronger life satisfaction, promote feeling of Stronger life satisfaction, promote feeling of

well-being, improved self-esteem, reduced well-being, improved self-esteem, reduced depressiondepression

DepressionDepression Increases likelihood of death from cancer and Increases likelihood of death from cancer and

heart diseaseheart disease Suicide: older adults account for 25% of all Suicide: older adults account for 25% of all

suicide deaths suicide deaths

Model Health Promotion Model Health Promotion ProgramsPrograms

Healthwise Healthwise Developed in Boise, IdahoDeveloped in Boise, Idaho Handbook in 17Handbook in 17thth edition edition 190 common health problems190 common health problems

Chronic Disease Self-Management Chronic Disease Self-Management Program Program Nurse researcher at Stanford University SOMNurse researcher at Stanford University SOM Peer-led, community basedPeer-led, community based

Project Enhance Project Enhance Enhance fitnessEnhance fitness Enhance wellness, which focuses on mental Enhance wellness, which focuses on mental

healthhealth


Ornish Program for Reversing Heart DiseaseOrnish Program for Reversing Heart Disease Vegetarian dietVegetarian diet Fat intake of 10% or less of total caloriesFat intake of 10% or less of total calories Moderate aerobic exercise 3 x/weekModerate aerobic exercise 3 x/week Yoga and meditation an hour a dayYoga and meditation an hour a day Support groupsSupport groups Smoking cessationSmoking cessation

Benson’s Mind/Body Medical Institute Benson’s Mind/Body Medical Institute MD affiliated with Harvard Medical SchoolMD affiliated with Harvard Medical School Relaxation response to stressRelaxation response to stress Proper nutrition and exerciseProper nutrition and exercise Reframe negative thinking patternsReframe negative thinking patterns


Strong for Life Strong for Life Home based exercise programHome based exercise program For disabled and nondisabled older For disabled and nondisabled older

adultsadults Focuses on strength and balanceFocuses on strength and balance Exercise video, trainer’s manual, and Exercise video, trainer’s manual, and

user’s guideuser’s guide

The BoomersThe Boomers

Longest-livedLongest-lived Best-educatedBest-educated HealthiestHealthiest Most-engagedMost-engaged Largest cohort of retirees everLargest cohort of retirees ever

35 million age 65 or older in 2000 to 35 million age 65 or older in 2000 to more than 70 million in 2030more than 70 million in 2030

GreenhousesGreenhouses Alternative to nursing homesAlternative to nursing homes

Robert Wood Johnson Foundation grantRobert Wood Johnson Foundation grant Promote autonomyPromote autonomy

A home environmentA home environment Own private room and bathOwn private room and bath

Not in all states yet (under development in Akron, Not in all states yet (under development in Akron, CO)CO)

Employee turnover rate is much lower than in Employee turnover rate is much lower than in nursing homenursing home Better payBetter pay EmpowermentEmpowerment 1:5 staff ratio1:5 staff ratio 1:20 RN ratio1:20 RN ratio 1:120 administrator ratio1:120 administrator ratio

Watch VideoWatch Video

YouTubeYouTube Greenhouse alternative to nursing Greenhouse alternative to nursing

homeshomes


Quality of LifeQuality of LifeBonnie M. Wivell, MS, RN, Bonnie M. Wivell, MS, RN,

CNSCNS

Quality of Life (QOL)Quality of Life (QOL)

DefinitionDefinition Complex conceptComplex concept Satisfaction/dissatisfaction with lifeSatisfaction/dissatisfaction with life A person’s sense of well-beingA person’s sense of well-being

As we age, QOL is dependent on our As we age, QOL is dependent on our ability to maintain autonomy and ability to maintain autonomy and independenceindependence

Ferrell and Grant QOL Ferrell and Grant QOL ModelModel

Successful vs. Active Successful vs. Active AgingAging

Successful aging: Successful aging: Person has avoided disease and disease-related Person has avoided disease and disease-related

disabilitydisability Has a high level of cognitive and physical functioning Has a high level of cognitive and physical functioning

that allows the individual to be engaged with lifethat allows the individual to be engaged with life Active AgingActive Aging

Adopted by WHO in the late 1990sAdopted by WHO in the late 1990s Supports autonomy, independence and activitySupports autonomy, independence and activity Strategies that promote QOL decrease disabilities Strategies that promote QOL decrease disabilities

associate with chronic illnessassociate with chronic illness Increase elders’ participation in the social, cultural, Increase elders’ participation in the social, cultural,

economic, and political aspects of societyeconomic, and political aspects of society Lower the cost of medical treatmentLower the cost of medical treatment Plan for old age and choose healthy lifestylesPlan for old age and choose healthy lifestyles

Determinants of HealthDeterminants of Health Gender and cultureGender and culture BehavioralBehavioral

Physical activityPhysical activity NutritionNutrition SmokingSmoking Alcohol useAlcohol use Medication adherenceMedication adherence

PersonalPersonal Genetics and Genetics and

psychological factorspsychological factors Physical environmentPhysical environment

Neighborhoods and Neighborhoods and safe housingsafe housing

Social EnvironmentSocial Environment SupportSupport EducationEducation LiteracyLiteracy ViolenceViolence AbuseAbuse

EconomicEconomic IncomeIncome Social protectionSocial protection

Social ServicesSocial Services Health promotionHealth promotion Disease preventionDisease prevention

Helping the Patient Willing to Helping the Patient Willing to QuitQuit

The 5 AsThe 5 As Ask about useAsk about use Advise to quitAdvise to quit Assess willingnessAssess willingness Assist with planAssist with plan Action (provide Action (provide

help)help)

The 5 RsThe 5 Rs RelevanceRelevance RisksRisks RewardsRewards RoadblocksRoadblocks RepetitionRepetition

Alcoholism in the ElderlyAlcoholism in the Elderly Under-recognizedUnder-recognized 1/3 of older alcoholic persons developed the 1/3 of older alcoholic persons developed the

problem later in lifeproblem later in life 62% of community dwelling elderly found to drink 62% of community dwelling elderly found to drink

alcoholalcohol Effects may be increasedEffects may be increased

Pharmacologic changes associated with agingPharmacologic changes associated with aging Alcohol and drug interactions may be more seriousAlcohol and drug interactions may be more serious

Physiological changes related to aging can alter Physiological changes related to aging can alter the presentation of medical complications of the presentation of medical complications of alcoholismalcoholism

Beneficial but recommended that they limit intake Beneficial but recommended that they limit intake to one drink per dayto one drink per day

Alcoholism in the Elderly Alcoholism in the Elderly (cont’d)(cont’d)

Assess for:Assess for: Cognitive declineCognitive decline Non-adherence with appointmentsNon-adherence with appointments Psychiatric historyPsychiatric history InsomniaInsomnia Poorly controlled HTNPoorly controlled HTN Frequent fallsFrequent falls GI problemsGI problems Nutritional deficienciesNutritional deficiencies Delirium during hospitalizationDelirium during hospitalization

CA of the head, neck, esophagus, and liver CA of the head, neck, esophagus, and liver are associated with chronic alcohol abuseare associated with chronic alcohol abuse

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Chapter 10: Promoting Independence in Later Life Bonnie M. Wivell, MS, RN, CNS