CHALLENGES OF AGING AND

THE CORNERSTONES OF
EXCELLENCE IN NURSING CARE
PART 2

1
 SLEEP AND THE OLDER ADULT
• Sleep is a natural periodic state of rest for the mind and
body that is necessary for health and human function.
Sleep complaints are common among older people, and
the incidence of sleep problems increases with age.
• Older adults experience age-related changes in the
nature of their sleep, including greater difficulty falling
asleep, more frequent awakenings, decreased amounts
of nighttime sleep, and more frequent daytime napping.

2
 SLEEP PATTERN DISTURBANCE
• NANDA (2012) recognizes this as an alternation in an individual’s
habitual pattern of sleep and wakefulness that causes discomfort
or interferes with a desired lifestyle. Defining characteristics
according to NANDA criteria include the following:
• Complaints of difficulty falling asleep (sleep latency greater than 30 minutes)
• Awakening too early in the morning
• Three or more nighttime awakenings
• Changes in behavior and function, including lethargy, listlessness, and irritability
• Decreased ability to function
• Dissatisfaction with sleep and not feeling well rested
• Presence of related factors including:
• Physical discomfort/pain
• Psychological discomfort
• Sleep hygiene problems (spending too much time in bed and lack of consistent bedtime and
awakening time with excessive napping)
• Environmental factors
3
• Sleep problems can be classified as transient (short
term), intermittent (on and off), and chronic (constant).
• Transient sleep problems may be caused by short-term health problems,
stress, worry related to a situational event like a move to a new residence,
or changes in sleep schedules such as those due to travel and jet lag.
• Intermittent sleep problems may be related to exacerbations of chronic
illness or recurrent anxiety.

• Insomnia is a condition defined as having trouble falling

or staying asleep occurring on most nights and lasting for
3 weeks (short term) or long term (chronic

4
 SLEEP ARCHITECTURE
• Normal sleep physiology is composed of four distinct stages when
measured by electroencephalography.
• Sleep ranges from stage 1 (light sleep) to stage 4 (deep sleep) and can
be classified as either REM sleep or NREM sleep
• During NREM sleep, growth hormone, prolactin, and thyroid-stimulating
hormones are released, aiding in physiological restoration.
• Deep sleep appears to stimulate physical restoration through the
release of growth hormone while decreasing blood pressure and
respiratory function
• With aging, the amount of time spent in deep sleep decreases as the
night progresses.
• In a healthy older adult, deep sleep comprises 33% of the first sleep
cycle, 17% of the second, 6% of the third, 2% of the fourth, and 1% of
the fifth.
5
 STAGES OF SLEEP
• Stage 1 is light sleep in which people feel as if they are drifting in and
out of sleep and can be accompanied by a feeling of falling with
sudden muscle contractions.
• In stage 2, brain waves slow and eye movements stop.
• Stage 3 sleep is characterized by slowing brain waves and sleep
spindles, which are bursts of electrical activity.
• In stage 4, the brain produces mostly delta waves characterized by
large, slow patterns of brain activity.
• During stages 1 and 2, sleepers are easily aroused from sleep, whereas
sleepers in stages 3 and 4 sleep are more difficult to arouse
• As the sleep stages progress, it becomes increasingly difficult to awaken
the sleeper, and the more frequent nighttime awakenings observed in
older people may be related to the reduced amount of slow-wave sleep
in this cohort.
6
• REM sleep is characterized by intense brain activity resulting in small, brief
muscle contractions.
• REM sleep is accompanied by an increase in heart rate and blood pressure.
• Breathing is irregular and shallow, eyes dart quickly from side to side, and limbs
become temporarily paralyzed.
• REM sleep is sometimes referred to as “dream sleep” because dreaming occurs
during REM sleep and is thought necessary for psychological restoration.
• REM sleep is necessary for learning, memory consolidation, and daytime
concentration.
• REM sleep occurs cyclically every 90 to 120 minutes throughout the night.
• As the night progresses, sleep becomes lighter and the person spends more time
in REM sleep.

7
 SLEEP DISRUPTION
• Abnormal sleep behaviors are a category of events that
can occur at any time throughout the life cycle but
become more common with advancing age. These
behaviors may include the following:
• Myoclonus or sudden contractions of muscles and tingling feelings in the legs,
also called restless leg syndrome. Complaints may include tingling, creeping,
crawling, or aching sensations in the legs.
• Habitual loud snoring, choking, or gasping, periods of sleep apnea or
disturbed or interrupted breathing during sleep.
• Unusual behaviors that may occur during sleep such as vivid dreams or
sleepwalking

8
 HEALTH PROBLEMS AND SLEEP DISRUPTION

• Various health problems and the medications used to treat

them are associated with sleep disruption in older people.
Dementia
• Older people with dementia endure even more sleep
disruptions than other older people.
• Sleep disruptions common in dementia such as those with
Alzheimer’s disease include:
• breakdown of the normal sleep–wake cycle with short periods of fragmented
sleep occurring throughout a 24-hour period,
• reduced stage 3 and REM sleep, and
• no stage 4 sleep
9
 Dementia
• Sleep disturbances in older people with dementia cause
caregiver stress, increase the potential for nursing home
placement, and cause serious problems for those providing
care in the nursing home or home environment
• In an attempt to promote more normal sleep patterns in those
with dementia, psychotropic medications may be
administered.
• These medications are usually indicated for short-term use
only. When used for chronic sleep problems, the side effects
may become problematic

10
 Snoring
• Many older people consider snoring a minor annoyance, but it can
signal a potentially serious condition known as sleep apnea, or
temporary interruption of breathing during sleep.
• For those affected by sleep apnea, there can be many temporary
interruptions in breathing, each lasting about 10 seconds
throughout the sleep period.
• These interruptions in breathing can occur as often as 20 to 30
times per hour.
• Symptoms of sleep apnea include the following:
• Heavy snoring, usually on inspiration
• Choking sounds or struggling to breathe during sleep
• Delays in breathing during sleep (usually with a reduction in blood-oxygen saturation),
followed by a snort when breathing begins
• Excessive daytime sleepiness
• Morning headaches
• Difficulty with concentration and staying awake during driving or other tasks
11
 Sleep Apnea
• Sleep apnea can be caused by problems with the central nervous system and
the brain or may be caused by partial obstruction of the airway when the
muscles in the throat, soft palate, and tongue relax during sleep.
• This can lead to partial or complete collapse of the airway, making breathing
labored.
• Apneic episodes are followed by brief awakenings, which usually occur without
the sleeper’s knowledge but can disrupt sleep and result in daytime drowsiness.
• If the older person does not fully experience deep sleep, the REM stage will not
occur.
• Risk factors for sleep apnea include:
• obesity (body mass index > 30),
• hypertension,
• male gender,
• atrial fibrillation,
• anatomical abnormality to the upper respiratory tract
• cigarette smoking and
• large neck size.
12
 Urinary Problems
• Older people may be awakened from sleep because of the need
to urinate.
• Common age-related alterations in urinary tract function include;
• urinary frequency,
• nocturia, and
• benign prostatic hypertrophy.
• These alterations result from changes in the renal and hormonal
systems that control urine production and from decreases in the
reservoir capacity of the bladder.
• Many older adults take diuretics, which increase urinary output.
• Older men may suffer from benign prostatic hypertrophy, which
inhibits complete emptying of the bladder and may be associated
with the sensation of always feeling the urge to void.
13
 Sleep Problems in Hospitals and Nursing
Homes
• When older people are hospitalized, they frequently
complain of sleep disruption.
• Studies of sleep in the acute care setting indicate that
patients have extremely fragmented and disturbed
sleep regardless of their diagnosis.
• Ironically, nurses contribute to their patients’ sleep
disruption, and the frequent repetitive delivery of
nursing care in the acute care setting leaves patients
little chance to sleep

14
 Alcohol and Caffeine
• Alcohol consumed at bedtime, after an initial stimulating effect,
may decrease the time required to fall asleep.
• Because of alcohol’s sedating effect, many older people with
insomnia consume alcohol to promote sleep.
• However, alcohol consumed within an hour of bedtime appears to
disrupt the second half of the sleep period.
• Further, many older people are on medications that have the
potential for serious interactions with alcohol.
• Both caffeine and nicotine increase the number of nighttime
awakenings and the length of time it takes to fall back to sleep.
• Because alcohol, caffeine, and nicotine are typically used in
conjunction with one another, the sedating and arousal effects
frequently interact, creating multiple sleep disturbances
15
 Sleeping Medications
• Prescription drugs have also been shown to affect sleep.
• It is generally agreed that long-term administration of
hypnotics is an inadequate treatment strategy for chronic
insomnia in the older adult.
• Hypnotic medications are generally recommended for
short-term use: about 2 weeks or less.
• Long-term use will blunt the effect of these medications.

16
 NURSING ASSESSMENT
Key assessment areas are as follows:
• Health History
• Diagnosed acute or chronic illness
• Current medications (including herbal and OTC)
• Chronic pain or pruritus
• Psychological problems
• Change in living conditions or sleep routines
• Current stressors or worries
• Nicotine, alcohol, or caffeine use
• Last complete medical examination

17
 NURSING INTERVENTIONS
• The nurse is in an ideal situation to intervene with older
people with sleep problems.
• Nursing interventions for sleep promotion should be
grounded in an understanding of the relationship
between mind and body.

18
• Sleep disturbances caused by underlying medical
problems should be referred for treatment.
• Nighttime pain should be investigated for cause and treated.
• Depression and anxiety disorders likewise require medical intervention and
treatment.
• The gerontological nurse should carefully measure the older patient’s blood
pressure, pulse, height, and weight.
• A nasal/oral examination can rule out nasal obstruction and defects in the
oral pharynx.
• The primary healthcare provider may wish to obtain laboratory tests to
examine thyroid function, ferritin levels, and other measurements such as
drug levels to rule out drug toxicity if suspected

19
• Sleep hygiene should be encouraged in any older
person with a sleep problem. Emphasis is placed on
correcting and improving problem behaviors or
inadequate environmental conditions in order to improve
sleep efficiency.
• Inadequate sleep hygiene refers to daily activities that interfere with the
maintenance of good quality sleep and daytime alertness.

• Environmental problems should be corrected if possible.

If the nighttime environment is too hot or cold, portable
air conditioners or heaters may be appropriate.

20
• The timing of medications should be examined for appropriateness.
• Dietary and lifestyle changes should be recommended after the older
person is appropriately educated regarding the harmful effects of
nicotine, caffeine
• Activities, hobbies, and special interests should be pursued, and multiple
long naps should be avoided because excessive daytime sleep and
boredom may interfere with nighttime sleep
• Appropriate exercise like walking and stretching should be
recommended, but not within 3 hours before bedtime.
• Sleep hygiene measures such as limiting time spent in bed to 8 hours a
night, avoiding daytime napping, and using the bed only for sleep and
sexual activity have been found to be an effective intervention

21
 PAIN MANAGEMENT
• Pain is an unpleasant sensory and emotional experience.
• The International Association for the Study of Pain (IASP)
defines pain in terms of both actual or potential tissue
damage and the emotional experiences associated with
pain.
• Acute Pain is often limited, warns of tissue damage.
• Often with signs of autonomic nervous system activation
• Intensity of pain indicates severity of injury or disease
• Chronic persistent ( > 3 months) - pain no longer signals
tissue damage.
• Autonomic signs are often absent.
22
 MECHANISM OF PAIN BASED ON
PATHOPHYSIOLOGY
Nociceptive pain: Results from stimulation of pain receptors.
Somatic: damage to body tissue, well localized
Visceral: from viscera, poorly localized, may have nausea
Neuropathic pain: Results from dysfunctions or lesions in either the
central or peripheral nervous systems.
Mixed pain syndromes: multiple or unknown mechanisms (e.g.
headaches, vasculitic syndromes).
Psychogenic Pain: somatoform disorders, conversion reactions.

23
 NEUROBIOLOGY
Myelinated A-delta and Unmyelinated C fibers respond
to thermal, mechanical, electrical or chemical stimuli.
Release of excitatory neurotransmitter glutamate and
substance P
Information transmitted to thalamus by spinothalamic
tract
Pain modulation: frontal cortex, hypothalamus,
descending pathway, endogenous analgesia by releases
of beta-endorphin, enkephalins, opioid peptides.

24
 AGE RELATED CHANGES:
Reduction in number and function of peripheral nociceptive
neurons.
Sensory threshold for thermal and vibratory stimuli increase with
age.
Pain receptors: 50% decrease in Pacini's corpuscles,10%-30%
decrease in Meissner's/Merkle's disks
Diminished endogenous analgesic response (endorphins)
in the older patients.

25
 AGE RELATED CHANGES:

Peripheral nerves :
Myelinated nerves
Decreased density
Increase abnormal/degenerating fibers
Slower conduction velocity
Unmyelinated nerves
Decreased number of large fibers (1.2-1.6 mm
No change in small fibers (0.4 mm)
Substance P content decreased

26
AGE RELATED CHANGES:

Central nervous system

Loss in dorsal horn neurons
Altered endogenous inhibition, hyperalgesia
Loss of neurons in cortex, midbrain, brainstem
18% loss in thalamus
Altered cerebral evoked responses
Decreased catacholamines, acetylcholine, GABA, serotonin
Endogenous opioids: mixed changes
Neuropeptides: no change

27
 PREVALENCE OF PAIN IN ELDERLY
 1 in 5 elderly have pain
• 18% above 65 are taking pain medications regularly
• One-fifth of adults 65 years and older said they had experienced
pain in the past month that persisted for more than 24 hours.
• Almost three-fifths of adults 65 and older with pain said it had
lasted for one year or more.
• Women report severely painful joints more often than men (10
percent versus 7 percent).

CDC′s National Center for Health Statistics 2006,

28
 PREVALENCE OF PAIN IN ELDERLY
1 Community-dwelling older adults: 25–56%
2 Nursing home residents: 45–80%
3 Greater than 50% patients dying of a variety of
illnesses, including cancer, COPD, CAD
4 31% of women & 19% of men > 75 yrs report pain in 3
or more sites

AGS panel on persistent pain in older persons, JAGS 50:s205-s224, 2002.

Ferrell B A: Pain evaluation and management in the nursing homes, Ann Intern Med, 123(9):681-687,1992.
Minner D M et.al., Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home health
services: A pathway, Home health care management and practice 17:294-301,2005.

29
 FACTORS AFFECTING
PERCEPTION OF PAIN
Pain affects quality of life far beyond the local region of
injury
Feeling of loneliness is predictor of psychological distress
Lack of intimate relationships, dependency, and loss increase
loneliness
Loneliness has been shown to lower pain threshold
 Loneliness is a risk factor for depression

30
 FACTORS AFFECTING THE
PERCEPTION OF PAIN
 Depression: lack of energy, avoidance of diversional
activities, decreased engagement in treatment
 Anxiety: may inhibit participation in rehab efforts
 Sleep disturbance: pain is best predictor of sleep
disturbance.
 Increased health care needs
 Isolation and reduced independence: Involvement with
family and friends can provide pleasurable
experience

31
 FACTORS AFFECTING
PERCEPTION OF PAIN
Focusing one's attention on pain makes the pain worse.
Patients who have low levels of pain remember it as
being worse than they originally reported.
Pain can be a learned response, rather than a purely
physical problem.
Psychosocial issues like patient’s belief about their pain ,
their coping skills, their involvement in the “sick role”, all
have an impact on how much pain patients feel, and how
it affects them.

32
 CHALLENGES OF PAIN
ASSESSMENT IN OLDER PATIENTS
Myths that having pain is “natural” with aging
Fears about addiction to pain medications
Sensory and cognitive impairments
Under-reporting
Co-morbidities complicating the clinical picture and caregivers' beliefs
and the reliability of patients' pain.
Lack of congruence between patients' and caregivers' perceptions of
pain
Caregiver may misinterpret pain perception
Stein, W.M. Pain in the nursing home. Clinics in Geriatric Medicine 17, 575-94,2001
Stewart, K. et. al. Assessment approaches for older people receiving social care: content and coverage. International Journal of Geriatric
Psychiatry 14, 147-56,1999.
Horgas, A.L. et. al. Pain in nursing home residents. Comparison of residents' self-report and nursing assistants' perceptions. Journal of
Gerontological Nursing 27, 44-53, 2001.
Weiner, D., et. al. Chronic pain associated behaviours in the nursing home: resident versus caregiver perceptions. Pain 80, 577-88,1999.

33
 PAIN ASSESSMENT

Unidimensional Scales: A single item that usually relates to

pain intensity alone.
Advantages: Easy to administer and require little time or
training to produce reasonably valid and reliable results
Disadvantages: Some require vision, hearing and attention,
pencil and paper

34
35
PAIN THERMOMETER

Pain as bad as it could be

Extreme pain
Severe pain
Moderate pain
Mild pain
Slight pain

No pain 36
(Herr and Mobily, 1993)
 PAIN ASSESSMENT
Obtain history of pain:
Ask about onset, pattern, duration, location, intensity, and
characteristics of the pain,
 Find out aggravating or palliating factors, and the impact
on the patient.
Evaluate psychological state of patient
Screen for depression
Anxiety
Assess social networks and family involvement

37
 PAIN ASSESSMENT IN DEMENTIA
Patients’ self report are still reliable
Reports from caregivers/family members are also
reliable if they are familiar with patient.
Behaviors exhibited may indicate pain
Facial pain scale
Do not use pain scales and ask to recall information
from past.

38
 PAIN ASSESSMENT IN ADVANCED
DEMENTIA
The Pain Assessment in Advanced Dementia (PAINAD) scale
Assess breathing independent of vocalization
Negative vocalization
Facial expression
Body language
Consolability
Each behavior is scored 0 to 2,higher the score more severe
the pain.

39
 PAIN ASSESSMENT IN
NONVERBAL PATIENTS
Checklist of Nonverbal Pain Indicators (CNPI):
Nonverbal vocal complaints (sighs, gasps, moans, groans, cries)
Facial grimacing
Bracing (clutching or holding onto furniture, equipment)
Rubbing (massaging affected area)
Restlessness
Verbal vocal complaints such as “ouch” or “stop”

Feldt K S., Pain Manag Nurs 1(1):13-21,2000.

40
 BARRIERS TO EFFECTIVE PAIN
MANAGEMENT
Study of 805 chronic pain sufferers, >50% changed
physicians due to lack of physician’s:
1)Willingness to treat the pain aggressively,
2)Failure to take the pain seriously,
3)Lack of knowledge about pain management

Chronic pain in America: roadblocks to relief. Survey conducted for the American Pain Society, The America Academy of Pain Medicine, and Janssen Pharmaceutica. Hanson, NY:
Roper Starch Worldwide, 2000.

41
 HEALTH CARE SYSTEM BARRIERS
 Lack of a neighborhood pharmacy
 Lack of transportation to the physician or pharmacy, an
absence of high doses of opioids at the pharmacy
 Lack of a home caregiver to assist with administering
drugs pose major obstacles to pain treatment

42
 PATIENT RELATED BARRIERS TO
EFFECTIVE PAIN MANAGEMENT
Communication: Patients with communication problems
with physician had worse pain control.

Psychological: Anxiety, distress, depression, anger, and

dementia, all of which can complicate assessment by
masking symptoms.

Attitudinal issues: Fear of addiction, tolerance, and side

effects, belief that pain was inevitable.

43
 TREATMENT
Age-Related Physiologic Changes
Decreased renal function
Decreased volume of distribution because of decreased
lean body weight
Decreased liver mass and hepatic blood flow
Decreased activity of some drug-metabolizing enzymes
Decreased serum protein concentrations
Decreased pulmonary function

44
WORLD HEALTH ORGANIZATION THREE-STEP
ANALGESIC LADDER

45
 TREATMENT
Nonopioid Analgesics for Older Adults
Acetaminophen:
1)Treatment of choice for Osteoarthritis
2)Exhibits an analgesic ceiling beyond which higher doses
do not provide greater pain relief.
3) Maximum dose 4 gm/day

46
 TREATMENT
Nonselective NSAIDs
Inhibit prostaglandin synthesis
Appropriate for short term use
All have ceiling effect
Risk of gastrointestinal bleed, renal impairment, platelet
dysfunction
Selective COX-2 inhibitors (celecoxib)
Reduced gastrointestinal side-effects and platelet inhibition

47
 TREATMENT WITH OPIOIDS
Stimulates mu opioid receptor.
Used for moderate to severe pain.
Used for both nociceptive and neuropathic pain.
Opioid drugs have no ceiling to their analgesic effects and
have been shown to relieve all types of pain.
Elderly people, compared to younger people, may be more
sensitive to the analgesic properties.
Advanced age is associated with a prolonged half-life and
prolonged pharmacokinetics of opioid drugs

48
 OPIOIDS
Can cause drowsiness, nausea, respiratory depression.
Tolerance: diminished effect of a drug associated with constant
exposure to the drug over time.
Tolerance develops to CNS side effects.
Tolerance does not develop to constipation!
(Prophylax with increasing fluid intake, osmotic laxatives or
stimulant laxatives)
Dependency: uncomfortable side effects when the drug is withheld
abruptly.
Drug dependence requires constant exposure to the drug for at
least several days.

49
 OPIOID ADDICTION
Addiction : drug use despite negative physical and
social consequences (harm to self and others) and the
craving for effects other than pain relief.
Pseudo-addiction: inadequately treated and un-relieved
pain leading to persistent or worsening pain complaints,
frequent office visits, requests for dose escalations.

50
NON-OPIOID MEDICATIONS FOR
PAIN
Tricyclicantidepressants ( amytriptyline, desipramine) for neuropathic
pain, depression, sleep disturbance. Not used often due to side-
effects.
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for
neuropathic pain.
Anticonvulsants ( gabapentin, pregabalin, carbamazepine)
for neuropathic pain. Carbamazepine can be used for trigeminal
neuralgia, may cause pancytopenia.
Muscle relaxants : for muscle spasm, monitor for sedation
Local anesthetics (lidocaine patch, topical voltaren gel, capsaicin).
Capsaicin depletes substance P, may take weeks to reach full effect,
adverse effects include burning and erythema. Lidocain patch FDA
approved for post herpetic neuralgia.
Placebos: unethical

51
 NON-OPIOID TREATMENT
Massage reduces pain, including release of muscle
tension, improved circulation, increased joint mobility,
and decreased anxiety
TENS unit: Can be considered for diabetic neuropathy
but not for chronic low back pain

52
NON-DRUG TREATMENT
Education: basic knowledge about pain (diagnosis, treatment,
complications, and prognosis), other available treatment options,
and information about over-the-counter medications and self-
help strategies.
Exercise: tailored for individual patient needs and lifestyle;
moderate-intensity exercise, 30 min or more 3-4 times a week
and continued indefinitely.
Physical modalities (heat, cold, and massage)
Cold for acute injuries in first 48 hours, to decrease bleeding or
hematoma formation, edema, and chronic back pain. Heat works
well for relief of muscle aches and abdominal cramping.

53
 NON-DRUG TREATMENT
Physical or occupational therapy; should be conducted
by a trained therapist
Chiropractic: Effective for acute back pain. Potential
spinal cord or nerve root impingement should be ruled
out before any spinal manipulation
Acupuncture: Performed by qualified acupuncturist.
Effects may be short lived and require repetitive
treatments

54
NON-DRUG TREATMENTS

Relaxation: repetitive focus on sound, sensation, muscle tension,

inattention towards intrusive thoughts. Requires individual acceptance
and substantial training.
Meditation: Guided or self-directed technique for calming the mind,
allows thoughts, emotions and sensations to travel through conscious
awareness without judgment.
Progressive muscle relaxation: Individual tensing and relaxing of
certain muscle groups.
Hypnosis: effective analgesic, state of inner absorption and focused
attention. Reduces pain by distraction, altered pain perception,
increased pain threshold.
Norelli L J et.al., : Behavioral approaches to pain management in the elderly, 24(2), Clinics in Geriatric Medicine, 2008.

55
 NON-DRUG TREATMENT
Cognitive-behavioral therapy: Pain is influenced by cognition,
affect and behavior.
Conducted by a trained therapist, focuses on changing individual
cognitive activity to modify associated behavior, thoughts, and
emotions.
10-12 weekly individual or group sessions
Participants have to be cognitively intact
Operant behavior therapy: Use of negative and positive
consequences to modify the behaviors.
Mind-body conditioning practices: Yoga, tai chi, qigong.
Norelli L J, et.al.,: Behavioral approaches to pain management in the elderly, 24(2), Clinics in Geriatric Medicine, 2008.

56
 CONSEQUENCES OF UNTREATED
PAIN
 Impaired function: Pain can lead to decreased activity
and ambulation leading to de-conditioning, gait
disturbances and injuries from falls.
Sleep deprivation: decrease pain thresholds, limit the
amount of daytime energy, increased risk of depression
and mood disturbances.
Increases financial and care giving burdens placed on
families and friends by increased utilization of health
care services.
Diminished quality of life by isolating individuals from
important social stimulation, amplifying the functional
and emotional losses already experienced from
undertreated pain.
Jakobsson, U. et.al., Old people in pain: A comparative study. Journal of Pain and Symptom Management, 26, 625-636,2003.
Weiner, D.K., et.al., Pain in nursing home residents; management strategies. Drugs and Aging, 18(1), 13-19,2001.
57
 VIOLENCE AND ELDER
MISTREATMENT
• Abuse and neglect of the elderly tends to regarded as
relatively recent phenomena.
• Elder abuse is alarming social problem, it is a
difficult, complex and sensitive area.
• It involve interpersonal relationships and difficulties in
relationships which may have lasted for years

58
 WHAT IS ELDER ABUSE?

• an all-inclusive term representing all types of

mistreatment or abusive behavior toward older
adults (Wolf, 2000, p.7)
• further defined as acts of commission (intentional
behavior) and omission (failure to act)
• self-neglect is the most common form of elder abuse
and the most difficult to detect and treat (Levine, 2003
and Reynolds Welfel et al., 2000)

59
TYPES OF ABUSE

•Physical •Medical
•Psychological •Abandonment
•Sexual •Neglect
•Material •Self-neglect
•Violation of Rights

60
FORMS OF ABUSE

Physical - hitting, pushing, slapping, punching,

restraining, pinching, force-feeding, physical restraint

Psychological - verbal aggression, intimidation, threats,

humiliation

Sexual - any kind of non-consensual sexual contact

61
FORMS OF ABUSE (CONTINUED)

Material - theft of cash or personal property, forced

contracts, misuse of income or other financial resources

Violation of Rights - deprivation of any inalienable

right such as voting, assembly, speech, privacy,
personal liberty

Medical - withholding medication or overmedicating

62
FORMS OF ABUSE (CONTINUED)

Abandonment - desertion of an elderly person for

whom one has agreed to care for, “dumping” a
cognitively impaired elder at an emergency room with
no identification

Neglect - failure to provide necessary physical or

mental care of an elderly person

Self-neglect - behavior that threatens one’s own health

or safety

63
PERPETRATORS OF ABUSE

• elder abuse can be perpetrated by nearly anyone

including paid or volunteer caregivers, medical and
long-term care employees, family members,
significant others, and in some cases strangers such
as a person who befriends an elderly person for the
purpose of exploiting them (Reynolds Welfel et al., 2000)

64
ELDER MISTREATMENT CHARACTERISTICS

65
 THEORIES OF THE ETIOLOGY OF ELDER
ABUSE

• “Psychopathology of the abuser”

• Caregivers who have preexisting conditions that impair their
capacity to give appropriate care

• “Transgenerational violence”
• Part of the family violence continuum
• is based on the belief that violence is a learned behavior pattern. A child
observes violence as an acceptable reaction to stress and then internalizes
this as an acceptable behavior. In cases of elder abuse, violent behavior
becomes cyclical: the abused – the child - becomes the abuser of the
parent.

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 THEORIES OF THE ETIOLOGY OF ELDER
ABUSE

• “Situational theory,” also know as “caregiver

stress
• Care burdens outweigh the caregiver’s capacity
• “Isolation theory”
• Mistreatment is prompted by a dwindling social network

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 CAREGIVERS FOR OLDER ADULTS SHOULD
BE ASSESSED

• For caregiver stress

• For substance abuse
• For a history of psychopathology
• Using the Caregiver Strain Index (CSI), which may
aid in assessment
• The Caregiver Strain Index (CSI) is a tool that can be used to quickly
identify families with potential caregiving concerns. It is a 13-question
tool that measures strain related to care provision. There is at least
one item for each of the following major domains: Employment,
Financial, Physical, Social and Time.

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POTENTIAL SIGNS OF MISTREATMENT
• Physical abuse
• Unexplained signs of injury such as bruises, welts, or scars,
especially if they appear symmetrically on two side of the
body
• Broken bones, sprains, or dislocations
• Report of drug overdose or apparent failure to take
medication regularly (a prescription has more remaining
than it should)
• Broken eyeglasses or frames
• Signs of being restrained, such as rope marks on wrists
• Caregiver’s refusal to allow you to see the elder alone

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• Emotional abuse
• In addition to the general signs above, indications
of emotional elder abuse include
• Threatening, belittling or controlling caregiver
behavior
• Behavior from the elder that mimic dementia, such
as rocking, sucking, or mumbling to oneself

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 NEGLECT BY CAREGIVERS OR SELF-
NEGLECT

• Unusual weight loss, malnutrition, dehydration

• Untreated physical problems, such as bed sores
• Unsanitary living conditions: dirt, bugs, soiled bedding
and clothes
• Being dirty or unbathed
• Unsuitable clothing or covering for the weather
• Unsafe living conditions (no heat or running water;
faulty electrical wiring, other fire hazards)
• Desertion of the elder at a public place
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Financial exploitation
• Significant withdrawals from the elder’s accounts
• Sudden changes in the elder’s financial condition
• Items or cash missing from the senior’s household
• Suspicious changes in wills, power of attorney, titles, and policies
• Addition of names to the senior’s signature card
• Unpaid bills or lack of medical care, although the elder has enough
money to pay for them
• Financial activity the senior couldn’t have done, such as an ATM
withdrawal when the account holder is bedridden
• Unnecessary services, goods, or subscriptions
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Sexual abuse
• Bruises around breasts or genitals
• Unexplained venereal disease or genital infections
• Unexplained vaginal or anal bleeding
• Torn, stained, or bloody underclothing

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 DETECTION AND TREATMENT BARRIERS
• detection of elder abuse is difficult because denial is an
integral feature of abuse, victims may feel too ashamed
to disclose maltreatment or believe they are to blame
for or deserve the abuse

• dependence on an abuser can make a victim reluctant to

report for fear of how he/she will survives without the
perpetrators help

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DETECTION/TREATMENT BARRIERS
(CONTINUED)

• victims may not define their situation as abuse

especially in a dysfunctional family environment
where violence or mistreatment has been
“normalized” (Brown et al., 2004, Levine, 2003)

• cognitive, auditory, speech, visual impairments,

isolation or restraint may make reporting impossible
for the victim of elder abuse

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DETECTION/TREATMENT BARRIERS
(CONTINUED)

• ageism can negatively affect detection of elder

abuse as it is common to view the elderly as
confused or demented, to trivialize elders’
complaints, and to adhere to the perception that
elder abuse doesn’t exist

• physical injuries may be masked by clothing or by

isolating the victim

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DETECTION/TREATMENT BARRIERS
(CONTINUED)

• fast paced medical services and heavy caseloads

of social service providers may not allow time for
adequate assessment

• basic lack of information of where to turn for help

impedes the intervention and treatment for both
perpetrator and victim of abuse

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 NURSES SHOULD PLAN FOR EDUCATIONAL
INTERVENTIONS FOR THE CAREGIVER

• Disease management
• Aging changes
• Maximizing healthcare services
• Respite services:
• Short-term, temporary care provided to an individual in their home or outside their home
• Designed to give the primary caregiver(s) a break from their care giving duties
• Respite may be just a few hours or several days in length depending on the plans of the
caregiver
• Respite may be planned in advance or may be made available to assist in a
crisis/emergency situation

• Behavioral management
• Caregiver support groups
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 HEALTH EDUCATION TO PREVENT ELDER
ABUSE

Instructions to a caregiver:-
If the caregiver overwhelmed by the
demands of caring for an elder, instruct (he
/she ) to do the following:
• Request help, from friends, relatives, or local respite
care agencies, so you can take a break, if only for a
couple of hours.
• Find an adult day care program.
• Stay healthy and get medical care for yourself when
necessary.
• Adopt stress reduction practices.
• Seek counseling for depression, which can lead to
elder abuse.
• Find a support group for caregivers of the elderly.
• If caregiver is having a problems with drug or
alcohol abuse, get help. 79
 INSTRUCTIONS TO A CONCERNED
FRIEND OR FAMILY MEMBER
• Watch for warning signs that might indicate elder abuse. If you
suspect abuse, report it.

• Take a look at the elder’s medications. Does the amount in the vial
matched with the date of the prescription?

• Watch for possible financial abuse. Ask the elder if he may scan
bank accounts and credit card statements for unauthorized
transactions.

• Call and visit as often as you can. Help the elder consider you a
trusted confidante.

• Offer to stay with the elder so the caregiver can have a break —
on a regular basis, if you can.
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 INSTRUCTIONS TO THE ELDERLY

• Make sure your financial and legal affairs are in order. If they
aren’t, enlist professional help to get them in order, with the
assistance of a trusted friend or relative if necessary.

• Keep in touch with family and friends and avoid becoming

isolated, which increases your vulnerability to elder abuse.

• If you are unhappy with the care you’re receiving, whether it’s in
your own home or in a care facility, speak up. Tell someone you
trust and ask that person to report the abuse or neglect.

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 CARE AT THE END OF LIFE
• Death is as natural a part of life as is birth.
• Although birth is embraced with joy and celebration,
death is frequently denied and often prolonged for the
sake of the living.
• Nurses have a unique opportunity and an obligation to
help patients and their families through the dying
process.
• Viewing death as a natural process—not a medical
failure—is of utmost importance

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• The nurse who helps the patient die comfortably and with
dignity provides the following benefits of good nursing care:
• Attention to pain and symptom control
• Relief of suffering
• Coordinated care across settings with high-quality communication between
healthcare providers
• Preparation of the patient and family for death
• Clarification and communication of goals of treatment and values
• Support and education during the decision-making process, including the
benefits and burdens of treatment

• To achieve these goals, the nurse must be well educated,

have appropriate supports in the clinical setting, and develop
a close collaborative partnership with hospice and palliative
care service providers
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 DELIVERY OF END-OF-LIFE CARE
• Relief of suffering, whether physical, emotional, or spiritual, should be
made available to all patients from the moment of diagnosis with a life-
limiting or debilitating illness
Hospice Care
• provides support for people in the last phase of life-limiting illness
through expert medical care, pain and symptom management, and
emotional and spiritual support so that they may live as fully and
comfortably as possible.
• focuses on the whole person by caring for the body, mind, and spirit.
• The goal is for the patient to live their last days as fully and
comfortably as possible
• The hospice nurse assumes the role of specialist in the management of
pain and control of symptoms and assesses the patient’s and family’s
coping mechanisms, available resources to care for the patient, the
patient’s wishes, and the support systems in place
84
 Palliative Care
• “an approach that improves the quality of life of patients and their
families facing the problem associated with life-threatening illness,
through the prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and
other problems, physical, psychosocial and spiritual.” (WHO 2011)
• Nursing interventions that help the patient enhance their quality of life,
reduce pain and suffering, optimize functionality, and promote
appropriate goal setting and decision making are integral to the
provision of excellent palliative care.
• Regardless of the stage of the disease or the need for curative
therapies, palliative care is appropriate for patients with life-limiting,
serious illness.
• It can be delivered concurrently with life prolonging care or as the main
focus of care

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• Although palliative care can be delivered to patients of any age,
including children, it is especially appropriate when provided to
older people who have:
• Acute, serious, life-threatening illness (such as stroke, trauma, major myocardial infarction,
and cancer where cure or reversibility may or may not be a realistic goal but the burden
of treatment is high)
• Progressive chronic illness (such as end-stage dementia, heart failure, renal or liver failure,
and frailty)

• Palliative care may take place across all settings including

hospitals, outpatient clinics, long-term care facilities, or the home.
• The patient and family are supported during the dying process
and following the death of their loved one.
• The care provided emphasizes quality of life until the moment of
death

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 THE NURSE’S ROLE
• The nurse providing quality end-of-life care to an older
person and their family assumes the role of expert
clinician.
• As an expert clinician, the nurse completes physical,
psychological, social, and spiritual assessments, and
designs and implements plans of care (in collaboration
with the patient, family, and interdisciplinary team) to
meet the needs of the patient.

87
 CORE PRINCIPLES FOR THE CARE OF
PATIENTS
• Communicate effectively with the patient, family, and healthcare team
members.
• Display sensitivity and respect for individual, cultural, and spiritual beliefs and
customs.
• Recognize one’s own attitudes, feelings, values, and expectations about death.
• Alleviate pain and symptoms and promote comfort.
• Assessing, managing, and referring psychological, social, and spiritual problems.
• Collaborate with the interdisciplinary team while promoting the nursing role.
• Provide access to and evaluate the impact of traditional, complementary, and
technological therapies that may improve the quality of the patient’s life.
• Provide access to palliative care and hospice services.
• Respect the right of patients and families to refuse treatment.
• Promote and support evidence-based clinical research in practice

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 PAIN AT THE END OF LIFE

• Merciful relief of pain is essential for quality end-of-life care

in the older patient and nurses have a primary role in
assessing and managing pain at the end of life.
• Pain during the dying process is feared by patients and
families and if unrelieved, creates distress, despair, and
suffering; however, through ongoing assessment of levels of
pain, administration of pain medication, and evaluation of
the effectiveness of the pain management plan, the nurse
may help alleviate the distress associated with untreated
pain in the older adult

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 PAIN DURING THE DYING PROCESS
• Pain at the end of life is complex and multifactorial
• The concept of “total pain” must be taken into consideration when
assessing for and managing pain at the end of life.
• Total pain recognizes that pain at the end of life is more than just
physical suffering; it also includes associated emotional, social,
and spiritual suffering.
• To enhance quality of life, an interdisciplinary team approach is
necessary so that all of these domains are adequately assessed
and relief of all types of pain may be provided
• As disease advances and pain worsens, it is important for the
nurse to recognize that the patient’s goals of care are apt to
change
• For example, patients may sacrifice being alert in order to better
control their pain.
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SUGGESTED STRATEGIES FOR THE MANAGEMENT OF
COMMON SYMPTOMS IN OLDER PATIENTS
AT THE END OF LIFE

91
SUGGESTED STRATEGIES FOR THE MANAGEMENT OF
COMMON SYMPTOMS IN OLDER PATIENTS
AT THE END OF LIFE

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93