In Search of a Healthy Old Age: Morbidity and Mortality Trends Return to the Beginning
A. Most Common Causes of Morbidity and Mortality in Elders
Fact #10. Mortality rates for all three of the leading causes of death -- heart disease, cancer and stroke - are declining (Federal Interagency Forum on Aging Related Statistics, 2000; National Institutes of Health, 2002).
Mortality rates for heart disease and stroke have declined by about a third since 1980, while cancer rates are going down by about 1% each year (Federal Interagency Forum on Aging Related Statistics, 2000; National Institutes of Health, 2002).
What does this mean?
More older patients are living longer. What can you do to help your patients enjoy those extra years in good health? Do you need to focus more on health promotion? Could a patient use a referral to a senior center to start participating in activities he or she enjoys?
Fact #11. The most common conditions among elders that don't cause death reduce quality of life.
The most common chronic conditions among Medicare beneficiaries in 1999 were arthritis (57%), hypertension (55%), heart disease (37%), urinary incontinence (19%), diabetes (17%), cancer (17%), osteo/broken hip (16%), and Alzheimer's disease (2%) (Gluck & Hanson, 2001).
What does this mean?
Your elder patients are right to be concerned about quality of life and loss of independence. Which among these conditions do you need to pay more attention to? Do you regularly discuss incontinence, the pain they experience from arthritis, or their fear of falling and breaking a hip? Assisting a patient with one of these, even if it is not your main concern, may make them happier and healthier and convince them that you understand their needs.
When evaluating an elders, consider the effects of these prevalent conditions. Depression may be related to the social isolation of urinary incontinence. A sedentary lifestyle may be caused by arthritis. Ask about common chronic conditions and you may come up with the source of the problem.
B. Disability among the Elderly
Fact # 12. A significant minority of your patients over 65 are not satisfied with their health. For the "oldest-old" disability is a significant barrier to well being.
In 1999, 26.1% of those 65 and over said their health was "fair" or "poor." In a 1998 survey, 28.8% of those 65-74 said that they had a limitation caused by chronic illness. Of those over 75, over half said that they had such limitations (Administration on Aging, 2001e). Women can expect to live with some disability for 15 years while men average about 12 years of disability (AARP, 2002).
What does this mean?
The disability of your elderly patients may be preventing them from carrying out your medical advice. For example, are they not taking medication because they forget? Do they have transportation to the pharmacy to fill a prescription? Does their arthritis keep them from opening the bottle? Maybe you can suggest some of the new devices that help with all these problems. When you make two different appointments instead of combining them into one do you consider how hard it is for your patient to walk up the stairs to your office? What can you, as a health care practitioner, do to make it easier for your disabled patients to use your services and follow your advice?
Your patient's health goals may be different from your own. One survey found that many disabled people yearn most to do the simple things in life like doing an errand alone or cooking a meal (Gibson et al., 2003). While curing disease may be your goal, helping an elderly person do small tasks for as long as possible may be what they truly want from you.
Fact #13. Your patients likely have fewer disabilities than in the past.
The rate of disability among elders has dropped 2.6% annually from 1994 through 1999. This includes a newly detected decline in disability among Black seniors. This decline may be the result of public health improvements, medical progress, lifestyle changes, and increases in education (National Institutes of Health, 2001).
What does this mean?
While a good proportion of your elder patients may still have disabilities, they may be without disabilities longer. So, even though you may have more older patients, their overall condition may become more like your younger patients. As time goes by, you may need to rely less on age as a guideline for what is appropriate care and more on other measures, like overall functioning.
Most of the dire predictions of the needs of older Americans for long term care may be wrong (Redfoot & Pandya, 2002). Nurses who are planning how resources will be used in the future, whether nationally or at a community or facility-level, will need to keep a close eye on what is actually occurring and re-adjust strategies to reflect lower disability rates.
C. Depression and Mental Health Conditions among the Elderly
Fact #14. Very likely, a number of your elderly patients have depression and other mental health conditions.
Between about 15 and 20% of older people have some mental disorder including anxiety, severe cognitive impairment, and mood disorders. (Husaini, et al, 2000; American Association for Geriatric Psychiatry, 2002). Whatever the true figure is, it represents a large proportion of the elderly population.
What does this mean?
Consider how your patient's medical conditions may affect mental health. Great sadness is a reasonable response to tremendous losses that many of your elder patients face. If, for example, you are treating an elder for a condition that will mean a loss of independence or if a patient has recently lost a spouse, look for signs of depression that may need evaluation and treatment.
Unfortunately, stereotypes of the elderly include difficult behavior that can be a symptom of a treatable mental condition. Do you have a patient who calls repeatedly for no medically valid reason? Perhaps he or she is anxious and needs a referral to a mental health provider. Do some patients always ruin your schedule by talking to you or your staff forever? Maybe they have depression related to social isolation and could use a suggestion about getting a volunteer to visit with them or spending some time at a senior center.
Fact #15. Suicide is a real risk for your depressed elder patients.
According to the National Institute of Mental Health, older adults are the population most at risk for suicide. In fact, white men over age 85 have the highest suicide rate of any population. What can you do about it? Plenty. Nearly 75 % of elder suicides saw a physician, and therefore likely a nurse, within a month of their death (National Institute of Mental Health, 2003).
What does this mean?
Take depression, even that which may not seem to meet the threshold of clinical depression, among your elder patients seriously. It is not a normal part of aging and should be treated in elders just as it is in younger people.
Consider whether "accidents," such as medication overdoses, may be suicide attempts. Is there a pattern that might indicate risky behavior? Perhaps you should be evaluating your patient for depression.
Fact #16. Your elder patients with mental disorders are probably not receiving the care they should.
Only half of elders with mental disorders receive any treatment and only a small percentage of these receive care from a mental health provider. One reason may be that, unlike other services, Medicare only pays half the cost of mental health services (American Association for Geriatric Psychiatry, 2002). As a result, your lower income older patients may not be able to afford mental health care.
What does this mean?
Give your low income patients information about facilities or mental health providers that offer free or discounted services like community mental health centers. Some senior centers and other elder service agencies offer mental health care at no or low cost.
Remember that your older patients may be reluctant to go to a mental health professional. They may have grown up with the idea that only "crazy" people sought mental health services and that they might be "put away" in an institution. Emphasizing the organic nature of much mental illness or that depression is to be expected given a patient's losses may help to remove stigma. Discussing the success of recent treatments may also give patients the hope that will motivate them to seek help.
D. Healthy Behavior Leads to a Healthy Old Age
Fact # 17. Seniors are better at some healthy behaviors than others.
American elders are smoking 30% less but have twice the obesity rate as 20 years ago (Wright, 2002). Higher obesity rates should not be a surprise since about one-third or more of older adults engage in no leisure time activity. Only 16% engage in exercise 30 or more minutes five or more times per week, a rate that has not improved over the past 10 years. (Agency for Healthcare Research and Quality and the Centers for Disease Control, 2002). However, in a survey of people 50 to 79, 93% said they had gotten their blood pressure checked in the previous year, 82% discussed health issues with their doctor, 78% engaged in some weight management, 76% had their cholesterol checked, and 73% participated in some kind of stress management. (RoperASW, 2002).
What does this mean?
You may have more success in getting your patients to change unhealthy habits by building on small successes. When appropriate, start with easy tasks like "stress reduction" or getting blood pressure checked. You might try very modest diet and exercise goals. Then, when your patient has some self-confidence, make the goals tougher but still within reach.
Do your obese but frail patients know that they have many fitness options open to them? Aerobics, weight strengthening, yoga, Tai Chi, and other exercise programs can all be adapted for the very frail. These classes may be offered at senior centers, health clubs, or community organizations like Ys.
Fact #18. Your older patients probably know what they should be doing, they just don't do it.
A survey of people 50 to 79 found that about two-thirds believed that exercise is the best thing you can do for your health. They also knew that it is important to eat right (81%), maintain healthy weight (78%), get enough exercise (77%), reduce stress (75%), and get health screenings (75%). So, they know what they need to do. Now, what will get them to do it? In a survey asking about motivation to do healthy behaviors, seniors frequently cited feeling good, promoting fitness and health, and socialization. They rarely mentioned "medical advice" (Pascucci, 1992).
What does this mean?
Congratulations. All the health education you have been doing has made a difference. So, keep it up! Continue to put those brochures out in your waiting room and work advice about healthy habits into your discussions with your patients.
Ask your patients what motivates them and use it. If socialization is what they enjoy, refer them to a mall walking group or a group exercise class at their community center. If feeling good is what they are after, what about recommending a relaxing massage after workouts?
For those patients who will not change their behavior, find out what barriers they face. Do they live in a neighborhood that is not safe for them to walk in? Can they afford nutritious food? Do they need to be told that that even the most frail can benefit from fitness activities? Are they so afraid of falling and breaking a hip that they will not venture outside? Once you know what the real problem is you may be able to adapt your recommendation or correct misinformation.
