Primary Health Care of Elderly Women
Traditional health care of the expanding elderly population has focused on illness diagnosis and management. However, because more individuals, women especially, are living longer and living better, the emphasis should be shifted and modified to include primary health care for elderly people. Primary health care includes active health promotion and health maintenance, prevention of illness or disability, and attention to the quality as much as to the quantity of life. Unfortunately, the health concerns of elderly women, especially the oldest-old groups who live more or less independently,have been addressed inadequately in medical and nursing literature. Routine approaches to health care for women aged 70 and older must consider women’s apparent hardiness, potential social isolation, and unique worries about safety and independence. Nurse practitioners in adult health, family practice, and gerontology must expand their repertoire of health promotion and health maintenance strategies to meet the needs of this special population.This article outlines the role of the nurse practitioner in the care of the well elderly woman.
H e a l t h care providers in the United States are preparing to meet the needs of an increasing number of people aged 70 and older. By the year 2000, people in this age range will represent an estimated 13% (or more) of the national population; the majority of these elderly people will be women (U.S. Senate Special Committee on Aging, 1988). Health care goals for these healthy elderly women must emphasize health maintenance and improvement of function and well-being, while preventing disease and maintaining high-quality life. Support for self-care efforts of aging women also must be available from health care professionals (Kart & Dunkle, 1989). Scholars have studied the effects of aging on the physical health (Blair, 1990; Zoller, 1987)and emotional health (Kermis, 1986)of the older person. Nevertheless, “normal aging” is difficult to define, because physical and mental aging is a continuous developmental process that occurs at different rates to different individuals. Health in aging might be defined more in terms of freedom from significant impairment and satisfaction Address correspondenceto Melinda M. Swenson, RNC, PhD, School of Nursing, Indiana University, 1402 E. 10th St., Bloomington, IN 47401.
VOLUME 4, NUMBER 4, OCTOBER-DECEMBER, 1992
with the level of capability. Elderly women who are competent, relatively healthy, and independent also may be better served if health care providers define “successful aging” for each individual woman. It becomes imperative, then, that care providers, such as nurse practitioners (NPs), know the individual female client well, that the care provided is continuous and comprehensive, and that the relationship between the NP and the elderly woman exemplifies trust and rapport. Older women have more frequent acute illnesses than men of the same age group, and average more days in bed for an illness (Verbrugge, 1990). This phenomenon may reflect women’s greater probability to take action when ill. Women also have more long-term illnesses, chiefly arthritis, hypertension, heart disease, and sensory disorders. Nevertheless, 69%of aging people living independently rate their overall health as good or excellent; only 31% estimate that their health as fair or poor (National Center for Health Statistics, 1985). The implications for health promotion and self-care education are obvious but they have only recently been addressed by health care professionals. Unfortunately, many older woman are stereotyped
143
and sometimes even ignored in traditional primary care settings. This problem may be attributed to the faster pace and more direct intervention strategies that characterize these settings (Lubben, Chi, 8c Welter, 1989). Educational programs that prepare NPs emphasize sensitive in-depth interviewing, patience in gathering information, and use of creative approaches to patient education. Nurse practitioners can demonstrate their particular skills in evaluation and management of elderly women in ambulatory settings, often becoming the main care provider for the well elderly in an office or clinic environment.
HEALTH HISTORY AS A DATA BASE The first visit to an office or agency is crucial to continued success in providing care. Initial impressions may have lasting impact: Be sure the elderly female client is greeted with respect on the telephone; provide information about the expected length of the first visit and the expected costs, including any anticipated procedures or tests. Address the client by her surname unless she instructs otherwise. Encourage her to bring whomever she wishes to the first visit and all her prescription and nonprescription medications, hearing aid, glasses, and other assistive devices (cane, special shoes, walker). See the woman as promptly as possible. Identify yourself clearly, including your specific role in the health care setting. Sit close to the woman in your interview, speak distinctly (not necessarily loudly), and be sure she can see you as you speak. Use touch judiciously to indicate reassurance, empathy, and attention. Although it may be tedious in the “getting,” a complete health history is invaluable in the “having.” The history is a vital data base for understanding the woman herself, her life, her values, and her health risks. Include family members in the data collection, but focus on the client’s perceptions whenever possible. Talk to her, not about her. Some elderly women lack health knowledge or education about self-care. Nevertheless, they may be adept at self-diagnosis and may have already instituted self-care measures (which may or may not be entirely appropriate). Asking the woman what she thinks might have caused the current problem, as well as what she has already tried as a remedy, may provide insight into her abilities to assess her own health and report symptoms and concerns reliably. Be flexible about the order in which history information is collected and the pace of the communication. As with all clients, start with the chief concerns. Outline and summarize the history of the present problems. If she has brought a 144
list of problems (aging clients often do), read it carefully and ascertain if there is one concern that takes priority over the others. There may be time for only one or two of the main problems on the first visit: save the list for subsequent occasions. Multiple chronic conditions and multisystem disorders can be confusing: Try to examine each separately but consider how the conditions interact. Also consider interactions and cumulative effects of her prescription and nonprescription medications. Women may be vulnerable to the risks of multiple medications, perhaps because of changes in the lean-to-fatratio associatedwith aging (Magaziner, Cadigan, Fedder, & Hebel, 1989). Past medical history and review of symptoms should be done carefully and deliberately with the older woman. Include any physical difficulties, sensory impairments, and mental status. Investigate her nutritional status, assessing especially for undernourishment, which is common among older people (Cape, 1983). Other important areas that often are problems for the elderly include sleep (Caranasos, 1987), exercise (Shephard, 1987), and safety. The psychosocial history includes social habits such as alcohol, cigarette smoking, and other drug dependencies. Knowing the woman’s perception of her own current health status enables the NP to help the woman maintain realistic expectations. Understanding the woman’s living arrangements, her occupation before retirement, and any recent losses, deaths, or other unusual stressors gives the NP a context for interpreting the current concerns. Identifying the client’s support system (significant others, relatives, confidants, friends, neighbors) provides a list of people who might potentially be involved in the care of the elderly woman. After rapport and trust have been well established, the NP might ask (at a subsequent visit) sensitive, simple, and nonjudgmental questions about the woman’s wish to limit care and/or establish a ”living will.” Functional status assessment includes an evaluation of the woman’s ability to walk assisted or alone, her ability to dress herself and remain continent, and to cook and accomplish ordinary daily tasks. Ask if there are activities she is unable to do and for which she needs additional assistance. Offer examples in terms that can be understand easily: can she walk to the mailbox, open jars, climb stairs, or change a light bulb? Comprehensive functional assessment tools are available if time permits (Campbell & Thompson, 1990; Kane, Ouslander, & Abrass, 1984). Sometimes women fail to report symptoms to the NP, even though a symptom may be potentially dangerous. For example, Brody and Kleban (1981) studied the symptoms experienced by elderly people and investigated the reasons these symptoms were not
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
reported to anyone. The symptoms experienced by aging men and women included difficulty sleeping, shortness of breath, chest discomfort, swelling of feet or ankles, cough, loss of strength in arms or legs, tiredness, lightheadedness or dizziness, headaches, joint pain, nervousness, feeling “blue,” unsteadiness, trouble urinating, leaking urine, poor appetite, indigestion or gas, bleeding, constipation, forgetfulness, problems with vision, hearing, and teeth. Respondents in the Brody and Kleban study gave the following reasons for not reporting symptoms: (a) it was “no big deal”: the person knew the reason for the symptoms or was “used to it”; (b) nobody cares: there was no one to tell; (c) they believed that they could not do anything about it, so why bother? (d) they thought it was just part of growing old; (e) they planned to tell the health professional at the next appointment (“saving up the symptoms”);and (f) others already knew about the problem. If the NP is aware of some of these potential reasons for withholding information, he or she can structure the interview to “give permission” to the female client to reveal her true concerns in an atmosphere of trust and confidence. Mental status is a vital component in the assessment of any client, but particularly an elderly person, because cognitive dysfunction commonly accompanies acute illness and may confuse the management of long-term illnesses. Sensory impairments, especially vision and hearing (but also proprioception, taste, and smell), affect the accuracy of the health history and physical examination of an older woman. Brief mental status assessment includes evaluation of her appearance and dress, ability as a historian (memory), intellect and vocabulary, judgment, orientation, emotional status, and observation of her physical behavior.
TABLE 1. ASPECTS OF PHYSICAL EXAMINATION OF HEALTHY ELDERLY WOMEN Vital signs: General appearance Skin and integument Mouth: Neck: Chest: Breast: Lungs: Heart: Abdomen: Genitourinary: Extremities: Neurological assessment: Vision Hearing
temperature, pulse, sitting and standing blood pressure, height and weight posture, gait especially in sun-exposed areas, intertriginous areas teeth or dentures, buccal mucosa, tongue thyroid, nodes, carotid pulses/bruits. shape, symmetry, consistency, symmetry, self-breast examination adventitious sounds, decreased breath sounds rate, rhythm, murmurs shape, scars, prominent aortic pulsation, liver span pelvic examination and pap smear, rectal exam, assess PC muscle strength muscle tone and strength, joint mobility and tenderness, edema, peripheral pulses reflexes, sensation, cranial nerves screening screening
Note. Based on recommendations from the US. Preventive Services Task Force (1989).
discomfort or about “what you will find.” Elderly women seem particularly apprehensive about pelvic examinations, perhaps because their past experience with this procedure has been embarrassing and/or painful. The pelvic examination must be completed quickly and smoothly to ensure comfort and trust. Nurse practitioners who are skilled in conducting a physical assessment of the elderly woman will provide for the woman’s comfort and dignity: warm environment, adequate draping, padded table and stirrups, a semiupright position and a matter-of-fact, educational PHYSICAL EXAMINATIONS: approach. SPECIAL CONSIDERATIONS Overall, the physical examination aims to resolve the current concerns and functional problems. Key aspects Elderly clients demonstrate signs and symptoms of of the physical examination for an elderly woman who long-term and acute illness that may be unique, atypical, is essentially healthy are listed in Table 1. A health or unpredictable (Abrutyn, Berk, & Raft, 1988). appraisal checklist may be used to keep a record of Physiologic processes are slowed, contributing to necessary tests and procedures (Irvine, 1988). Use care in ordering laboratory tests and procedures: delayed development of symptoms and slowed reactions of the client. Effects of medications also may be delayed it makes little sense to order a n unnecessary test or one and become cumulative. Some of the most subtle whose results will not alter interventions. Commonly problems of elderly women are iatrogenic, related to used tests that are relatively inexpensive and may be medications, treatments, or misdiagnoses. The NP must reimbursed by third-party payers include dipstick differentiate the physiologic changes of aging from urinalysis, breast examination and mammogram, pap pathologic signs. Not all “normal” changes are smear, digital rectal exam and stool guiac, Westergren innocent, and not all diseases are significantly harmful. sedimentation rate, hemoglobin or hematocrit level, Many elderly people, perhaps especially women, fear thyroid function tests, and serum glucose level. physical examination. They may worry about bodily Cholesterol is probably worth evaluating and treating VOLUME 4, NUMBER 4, OCTOBER-DECEMBER, 1992
145
even in women older than aged 7 5 (Brown, Brunton, & Denke, 1990), though this intervention is still controversial.
TABLE 2. CAUSES OF POTENTIALLY REVERSIBLE COGNITIVE PROBLEMS IN AGING WOMEN
DIFFERENCES IN THE APPROACH: SPECIFIC CONCERNS OF AGING WOMEN ~~
~
Caring and curing, the interdependent roles of the NP, are central to providing service to elderly women. The art of providing primary health care to healthy elderly women represents a balance of these two approaches. The following guidelines should be used when DrovidinE health care to older women: ._ 1. Intervention is effective, even in the most elderly women. 2. Support of self-care efforts benefits the client. 3. Intervention should be aimed at the enhancement of functional level. Fix what is fixable without causing further functional deficiency. The cure must not be worse than the disease. 4. Multidisciplinary approaches expand care options, but require coordination by a case manager (such as an NP). 5. Ethical considerations affect intervention decisions 6. Sometimes the best intervention is no intervention. Listening with a sympathetic ear may be the best treatment for some conditions. 7 . Institutionalize only as a last resort: try to accomplish the woman’s goals while keeping her safely in her home. 8. Maintain hope and optimistic outlook, keep options open, and encourage realistic decisionmaking.
RECOGNIZING AND MANAGING FEARS Based on research examining women’s relationships to their home environments (Swenson, 1991), a major
concern of aging women who are living independently is fear of mental changes and the decreased ability to think. Not all psychological and cognitive changes are permanent, however. Consider the reversible causes of mental disability, outlined in Table 2. The NP must consider these potential situations when assessing and managing changes in mental function. Women in old age are afraid of conditions that would, almost by definition, reduce their independent status. Specific fears include strokes and fractures (or any catastrophic event that impairs mobility). Women worry about falls, especially when alone, particularly those involving hip fracture. Falls may be precipitated by 146
Medications Errors in self-administration )often because of miscommunication between provider and client) Inappropriate doses Polypharmacy Depression or acute crisis reactions Death of spouse or other close family member. Reactions to trauma Reactions to hospitalization Metabolic problems Electrolyte imbalances Thyroid abnormalities Kidney dysfunction/failure Liver problems Neoplasms Cardiac problems (decreased cardiac output) Circulatory problems (TIA, CVA) Pulmonary problems Emphysema Pulmonary edema Nutritional problems Vitamin deficiency Pernicious anemia Anorexia Dehydration Anemia Fever/sepsis Alcoholism or substance abuse
neurologic problems, orthostatic changes, cardiac arrhythmias, dehydration, vision problems, medications, and alcoholism (Schulman & Acquaviva, 1987). Aging women may have additional fears. Incontinence causes anxiety for the healthy elderly woman because it is a condition that can severely impair social acceptability and freedom (Kane et al., 1984); security is a problem, including fears of burglars or of physical attacks; and women dread pain, especially intractable pain or pain that is not acknowledged by others. Finally, one of the greatest fears of elderly women living independently is that of being alone or lonely, unneeded, and unloved (Swenson, 1991). With such women, client education becomes a particularly meaningful role. The efforts of the NP may enable the woman to maintain her independence by giving permission, information, and specific suggestions for self-care. Counseling may include (a) discussions about Kegal’s exercises and bladder assessment and training; (b) diet and nutrition; (c) safe indoor or outdoor exercise; (d) changes in sexuality (Mims & Swenson, 1980); (e) smoking cessation strategies; (f) recommendations about reduction in alcohol intake; (g) reminders to use house locks, seat
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
belts, and smoke alarms; and (h) encouragement to seek dental care and immunizations. Overall, the goal is to prevent injury and reduce physical and mental impairment, and promote a satisfactory level of health. A stable and predictable relationship with a caring
NP can provide physical and emotional comfort to a woman of advanced years. The NP, acting as an advocate for independence and autonomy whenever possible and appropriate, can be not only a source of health care and health information but a source of empowerment for successful aging.
References Abrutyn, E., Berk, S. L., & Raft, M. J. (1988, March 30). High-risk infections in the elderly. Patient Care, pp. 32-50. Blair, K. A. (1990). Aging: Physiological aspects and clinical implications. Nurse Practitioner, 75, 14-28. Brody, E. M., and Kleban, M. H. (1981). Physical and mental health symptoms of older people: Whom do they tell? Journal of the American Geriatrics Society, 29, 446-447. Brown, W. V., Brunton, S. A,, and Denke, M. A. (1990, March 15). Elevated lipids, older patients. Patient Care, pp. 157-1 77. Campbell, L. A., and Thompson, B. L. (1990). Evaluating elderly patients: A critique of comprehensive functional assessment tools. Nurse Practitioner, 75, 11-1 8. Cape, R. D. T. (1983). Nutrition and the elderly. In R. D. T. Cape, R. M. Coe, & I. Rossman (Eds.), Fundamentals of geriatric medicine. New York: Raven Press. Caranasos, G. J. (1987). Sleep disorders. In R.J. Haln (Ed.), Geriatric medicine annual: 7 987. Oradell, NJ: Medical Economics Books. Irvine, P. W. (1988). Health promotion and screening reminder checklist. Clinical report on aging. New York: Elsevier. Kane, R. J., Ouslander, J. G., and Abrass, I. B. (Eds.) (1984).€ssentials of clinical geriatrics. New York: McGraw-Hill. Kart, C. S. and Dunkle, R. E. (1989). Assessing capacity for self care among the aged. Journal of Aging and Health, 1 , 185193. Lubben, J. E., Chi, I., and Welter, P. G. (1989). Differential health screening of the well elderly by gender and age: Appropriate care or bias? Journal of Applied Gerontology, 8,335-354. Magaziner, J., Cadigan, D. A,, Fedder, D. O., and Hebel, J. R. (1989). Medication use and functional decline among community-
VOLUME 4, NUMBER 4, OCTOBER-DECEMBER, 1992
dwelling older women. Journal of Aging and Health, 7 , 470-484. Mims, F. H., & Swenson, M. M. (1980). Sexua1ity:A nursingperspective. New York: McGraw-Hill. National Center for Health Statistics. (1978). Vital and health statistics, Series 10, No. 126. Washington, DC: U.S. Government Printing Office. Schulraan, B. K., & Acquaviva, T. (1987). Falls in the elderly. Nurse Practitioner, 12, 30-37. Shephard, R. J. (1987). Prescribingexercise. In R. J. Ham (Ed.),Geriatric medicine annual: 7 987. Oradell, NJ: Medical Economics Press. Swenson, M. M. (1991) The meaning of home to elderly women. Unpublished doctoral dissertation, Indiana University, Bloomington, IN. U. S. Preventive Services Task Force. (1989). Guide to clinical preventive services: An assessment of the effectiveness of 769 interventions. Report of the US. Preventive Services Task Force. Baltimore: Williams & Wilkins. U. S. Congress Senate Special Committee on Aging (1988). Developments in aging: 1987. Volume 7 . (Senate Report 100291, Serial 13858). Washington, DC: US. Government Printing Off ice. Verbrugge, L. M. (1985). An epidemiological profile of older women. In M. R. Haug, A. M. Ford, & M. Sheafor (Eds.), The physical and mental health of aged women. New York: Springer. Verbrugge, L. M. (1990). Longer life but worsening health? Trends in health and mortality of middle-aged and older persons. In P. R. Lee & C. L. Estes (Eds.), The nations health (3rd ed.). Boston: Jones and Bartlett. Zoller, D. P. (1987). The physiology of aging. American Family Practice, 36,112-1 16.
147
Traditional health care of the expanding elderly population has focused on illness diagnosis and management. However, because more individuals, women especially, are living longer and living better, the emphasis should be shifted and modified to include primary health care for elderly people. Primary health care includes active health promotion and health maintenance, prevention of illness or disability, and attention to the quality as much as to the quantity of life. Unfortunately, the health concerns of elderly women, especially the oldest-old groups who live more or less independently,have been addressed inadequately in medical and nursing literature. Routine approaches to health care for women aged 70 and older must consider women’s apparent hardiness, potential social isolation, and unique worries about safety and independence. Nurse practitioners in adult health, family practice, and gerontology must expand their repertoire of health promotion and health maintenance strategies to meet the needs of this special population.This article outlines the role of the nurse practitioner in the care of the well elderly woman.
H e a l t h care providers in the United States are preparing to meet the needs of an increasing number of people aged 70 and older. By the year 2000, people in this age range will represent an estimated 13% (or more) of the national population; the majority of these elderly people will be women (U.S. Senate Special Committee on Aging, 1988). Health care goals for these healthy elderly women must emphasize health maintenance and improvement of function and well-being, while preventing disease and maintaining high-quality life. Support for self-care efforts of aging women also must be available from health care professionals (Kart & Dunkle, 1989). Scholars have studied the effects of aging on the physical health (Blair, 1990; Zoller, 1987)and emotional health (Kermis, 1986)of the older person. Nevertheless, “normal aging” is difficult to define, because physical and mental aging is a continuous developmental process that occurs at different rates to different individuals. Health in aging might be defined more in terms of freedom from significant impairment and satisfaction Address correspondenceto Melinda M. Swenson, RNC, PhD, School of Nursing, Indiana University, 1402 E. 10th St., Bloomington, IN 47401.
VOLUME 4, NUMBER 4, OCTOBER-DECEMBER, 1992
with the level of capability. Elderly women who are competent, relatively healthy, and independent also may be better served if health care providers define “successful aging” for each individual woman. It becomes imperative, then, that care providers, such as nurse practitioners (NPs), know the individual female client well, that the care provided is continuous and comprehensive, and that the relationship between the NP and the elderly woman exemplifies trust and rapport. Older women have more frequent acute illnesses than men of the same age group, and average more days in bed for an illness (Verbrugge, 1990). This phenomenon may reflect women’s greater probability to take action when ill. Women also have more long-term illnesses, chiefly arthritis, hypertension, heart disease, and sensory disorders. Nevertheless, 69%of aging people living independently rate their overall health as good or excellent; only 31% estimate that their health as fair or poor (National Center for Health Statistics, 1985). The implications for health promotion and self-care education are obvious but they have only recently been addressed by health care professionals. Unfortunately, many older woman are stereotyped
143
and sometimes even ignored in traditional primary care settings. This problem may be attributed to the faster pace and more direct intervention strategies that characterize these settings (Lubben, Chi, 8c Welter, 1989). Educational programs that prepare NPs emphasize sensitive in-depth interviewing, patience in gathering information, and use of creative approaches to patient education. Nurse practitioners can demonstrate their particular skills in evaluation and management of elderly women in ambulatory settings, often becoming the main care provider for the well elderly in an office or clinic environment.
HEALTH HISTORY AS A DATA BASE The first visit to an office or agency is crucial to continued success in providing care. Initial impressions may have lasting impact: Be sure the elderly female client is greeted with respect on the telephone; provide information about the expected length of the first visit and the expected costs, including any anticipated procedures or tests. Address the client by her surname unless she instructs otherwise. Encourage her to bring whomever she wishes to the first visit and all her prescription and nonprescription medications, hearing aid, glasses, and other assistive devices (cane, special shoes, walker). See the woman as promptly as possible. Identify yourself clearly, including your specific role in the health care setting. Sit close to the woman in your interview, speak distinctly (not necessarily loudly), and be sure she can see you as you speak. Use touch judiciously to indicate reassurance, empathy, and attention. Although it may be tedious in the “getting,” a complete health history is invaluable in the “having.” The history is a vital data base for understanding the woman herself, her life, her values, and her health risks. Include family members in the data collection, but focus on the client’s perceptions whenever possible. Talk to her, not about her. Some elderly women lack health knowledge or education about self-care. Nevertheless, they may be adept at self-diagnosis and may have already instituted self-care measures (which may or may not be entirely appropriate). Asking the woman what she thinks might have caused the current problem, as well as what she has already tried as a remedy, may provide insight into her abilities to assess her own health and report symptoms and concerns reliably. Be flexible about the order in which history information is collected and the pace of the communication. As with all clients, start with the chief concerns. Outline and summarize the history of the present problems. If she has brought a 144
list of problems (aging clients often do), read it carefully and ascertain if there is one concern that takes priority over the others. There may be time for only one or two of the main problems on the first visit: save the list for subsequent occasions. Multiple chronic conditions and multisystem disorders can be confusing: Try to examine each separately but consider how the conditions interact. Also consider interactions and cumulative effects of her prescription and nonprescription medications. Women may be vulnerable to the risks of multiple medications, perhaps because of changes in the lean-to-fatratio associatedwith aging (Magaziner, Cadigan, Fedder, & Hebel, 1989). Past medical history and review of symptoms should be done carefully and deliberately with the older woman. Include any physical difficulties, sensory impairments, and mental status. Investigate her nutritional status, assessing especially for undernourishment, which is common among older people (Cape, 1983). Other important areas that often are problems for the elderly include sleep (Caranasos, 1987), exercise (Shephard, 1987), and safety. The psychosocial history includes social habits such as alcohol, cigarette smoking, and other drug dependencies. Knowing the woman’s perception of her own current health status enables the NP to help the woman maintain realistic expectations. Understanding the woman’s living arrangements, her occupation before retirement, and any recent losses, deaths, or other unusual stressors gives the NP a context for interpreting the current concerns. Identifying the client’s support system (significant others, relatives, confidants, friends, neighbors) provides a list of people who might potentially be involved in the care of the elderly woman. After rapport and trust have been well established, the NP might ask (at a subsequent visit) sensitive, simple, and nonjudgmental questions about the woman’s wish to limit care and/or establish a ”living will.” Functional status assessment includes an evaluation of the woman’s ability to walk assisted or alone, her ability to dress herself and remain continent, and to cook and accomplish ordinary daily tasks. Ask if there are activities she is unable to do and for which she needs additional assistance. Offer examples in terms that can be understand easily: can she walk to the mailbox, open jars, climb stairs, or change a light bulb? Comprehensive functional assessment tools are available if time permits (Campbell & Thompson, 1990; Kane, Ouslander, & Abrass, 1984). Sometimes women fail to report symptoms to the NP, even though a symptom may be potentially dangerous. For example, Brody and Kleban (1981) studied the symptoms experienced by elderly people and investigated the reasons these symptoms were not
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
reported to anyone. The symptoms experienced by aging men and women included difficulty sleeping, shortness of breath, chest discomfort, swelling of feet or ankles, cough, loss of strength in arms or legs, tiredness, lightheadedness or dizziness, headaches, joint pain, nervousness, feeling “blue,” unsteadiness, trouble urinating, leaking urine, poor appetite, indigestion or gas, bleeding, constipation, forgetfulness, problems with vision, hearing, and teeth. Respondents in the Brody and Kleban study gave the following reasons for not reporting symptoms: (a) it was “no big deal”: the person knew the reason for the symptoms or was “used to it”; (b) nobody cares: there was no one to tell; (c) they believed that they could not do anything about it, so why bother? (d) they thought it was just part of growing old; (e) they planned to tell the health professional at the next appointment (“saving up the symptoms”);and (f) others already knew about the problem. If the NP is aware of some of these potential reasons for withholding information, he or she can structure the interview to “give permission” to the female client to reveal her true concerns in an atmosphere of trust and confidence. Mental status is a vital component in the assessment of any client, but particularly an elderly person, because cognitive dysfunction commonly accompanies acute illness and may confuse the management of long-term illnesses. Sensory impairments, especially vision and hearing (but also proprioception, taste, and smell), affect the accuracy of the health history and physical examination of an older woman. Brief mental status assessment includes evaluation of her appearance and dress, ability as a historian (memory), intellect and vocabulary, judgment, orientation, emotional status, and observation of her physical behavior.
TABLE 1. ASPECTS OF PHYSICAL EXAMINATION OF HEALTHY ELDERLY WOMEN Vital signs: General appearance Skin and integument Mouth: Neck: Chest: Breast: Lungs: Heart: Abdomen: Genitourinary: Extremities: Neurological assessment: Vision Hearing
temperature, pulse, sitting and standing blood pressure, height and weight posture, gait especially in sun-exposed areas, intertriginous areas teeth or dentures, buccal mucosa, tongue thyroid, nodes, carotid pulses/bruits. shape, symmetry, consistency, symmetry, self-breast examination adventitious sounds, decreased breath sounds rate, rhythm, murmurs shape, scars, prominent aortic pulsation, liver span pelvic examination and pap smear, rectal exam, assess PC muscle strength muscle tone and strength, joint mobility and tenderness, edema, peripheral pulses reflexes, sensation, cranial nerves screening screening
Note. Based on recommendations from the US. Preventive Services Task Force (1989).
discomfort or about “what you will find.” Elderly women seem particularly apprehensive about pelvic examinations, perhaps because their past experience with this procedure has been embarrassing and/or painful. The pelvic examination must be completed quickly and smoothly to ensure comfort and trust. Nurse practitioners who are skilled in conducting a physical assessment of the elderly woman will provide for the woman’s comfort and dignity: warm environment, adequate draping, padded table and stirrups, a semiupright position and a matter-of-fact, educational PHYSICAL EXAMINATIONS: approach. SPECIAL CONSIDERATIONS Overall, the physical examination aims to resolve the current concerns and functional problems. Key aspects Elderly clients demonstrate signs and symptoms of of the physical examination for an elderly woman who long-term and acute illness that may be unique, atypical, is essentially healthy are listed in Table 1. A health or unpredictable (Abrutyn, Berk, & Raft, 1988). appraisal checklist may be used to keep a record of Physiologic processes are slowed, contributing to necessary tests and procedures (Irvine, 1988). Use care in ordering laboratory tests and procedures: delayed development of symptoms and slowed reactions of the client. Effects of medications also may be delayed it makes little sense to order a n unnecessary test or one and become cumulative. Some of the most subtle whose results will not alter interventions. Commonly problems of elderly women are iatrogenic, related to used tests that are relatively inexpensive and may be medications, treatments, or misdiagnoses. The NP must reimbursed by third-party payers include dipstick differentiate the physiologic changes of aging from urinalysis, breast examination and mammogram, pap pathologic signs. Not all “normal” changes are smear, digital rectal exam and stool guiac, Westergren innocent, and not all diseases are significantly harmful. sedimentation rate, hemoglobin or hematocrit level, Many elderly people, perhaps especially women, fear thyroid function tests, and serum glucose level. physical examination. They may worry about bodily Cholesterol is probably worth evaluating and treating VOLUME 4, NUMBER 4, OCTOBER-DECEMBER, 1992
145
even in women older than aged 7 5 (Brown, Brunton, & Denke, 1990), though this intervention is still controversial.
TABLE 2. CAUSES OF POTENTIALLY REVERSIBLE COGNITIVE PROBLEMS IN AGING WOMEN
DIFFERENCES IN THE APPROACH: SPECIFIC CONCERNS OF AGING WOMEN ~~
~
Caring and curing, the interdependent roles of the NP, are central to providing service to elderly women. The art of providing primary health care to healthy elderly women represents a balance of these two approaches. The following guidelines should be used when DrovidinE health care to older women: ._ 1. Intervention is effective, even in the most elderly women. 2. Support of self-care efforts benefits the client. 3. Intervention should be aimed at the enhancement of functional level. Fix what is fixable without causing further functional deficiency. The cure must not be worse than the disease. 4. Multidisciplinary approaches expand care options, but require coordination by a case manager (such as an NP). 5. Ethical considerations affect intervention decisions 6. Sometimes the best intervention is no intervention. Listening with a sympathetic ear may be the best treatment for some conditions. 7 . Institutionalize only as a last resort: try to accomplish the woman’s goals while keeping her safely in her home. 8. Maintain hope and optimistic outlook, keep options open, and encourage realistic decisionmaking.
RECOGNIZING AND MANAGING FEARS Based on research examining women’s relationships to their home environments (Swenson, 1991), a major
concern of aging women who are living independently is fear of mental changes and the decreased ability to think. Not all psychological and cognitive changes are permanent, however. Consider the reversible causes of mental disability, outlined in Table 2. The NP must consider these potential situations when assessing and managing changes in mental function. Women in old age are afraid of conditions that would, almost by definition, reduce their independent status. Specific fears include strokes and fractures (or any catastrophic event that impairs mobility). Women worry about falls, especially when alone, particularly those involving hip fracture. Falls may be precipitated by 146
Medications Errors in self-administration )often because of miscommunication between provider and client) Inappropriate doses Polypharmacy Depression or acute crisis reactions Death of spouse or other close family member. Reactions to trauma Reactions to hospitalization Metabolic problems Electrolyte imbalances Thyroid abnormalities Kidney dysfunction/failure Liver problems Neoplasms Cardiac problems (decreased cardiac output) Circulatory problems (TIA, CVA) Pulmonary problems Emphysema Pulmonary edema Nutritional problems Vitamin deficiency Pernicious anemia Anorexia Dehydration Anemia Fever/sepsis Alcoholism or substance abuse
neurologic problems, orthostatic changes, cardiac arrhythmias, dehydration, vision problems, medications, and alcoholism (Schulman & Acquaviva, 1987). Aging women may have additional fears. Incontinence causes anxiety for the healthy elderly woman because it is a condition that can severely impair social acceptability and freedom (Kane et al., 1984); security is a problem, including fears of burglars or of physical attacks; and women dread pain, especially intractable pain or pain that is not acknowledged by others. Finally, one of the greatest fears of elderly women living independently is that of being alone or lonely, unneeded, and unloved (Swenson, 1991). With such women, client education becomes a particularly meaningful role. The efforts of the NP may enable the woman to maintain her independence by giving permission, information, and specific suggestions for self-care. Counseling may include (a) discussions about Kegal’s exercises and bladder assessment and training; (b) diet and nutrition; (c) safe indoor or outdoor exercise; (d) changes in sexuality (Mims & Swenson, 1980); (e) smoking cessation strategies; (f) recommendations about reduction in alcohol intake; (g) reminders to use house locks, seat
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
belts, and smoke alarms; and (h) encouragement to seek dental care and immunizations. Overall, the goal is to prevent injury and reduce physical and mental impairment, and promote a satisfactory level of health. A stable and predictable relationship with a caring
NP can provide physical and emotional comfort to a woman of advanced years. The NP, acting as an advocate for independence and autonomy whenever possible and appropriate, can be not only a source of health care and health information but a source of empowerment for successful aging.
References Abrutyn, E., Berk, S. L., & Raft, M. J. (1988, March 30). High-risk infections in the elderly. Patient Care, pp. 32-50. Blair, K. A. (1990). Aging: Physiological aspects and clinical implications. Nurse Practitioner, 75, 14-28. Brody, E. M., and Kleban, M. H. (1981). Physical and mental health symptoms of older people: Whom do they tell? Journal of the American Geriatrics Society, 29, 446-447. Brown, W. V., Brunton, S. A,, and Denke, M. A. (1990, March 15). Elevated lipids, older patients. Patient Care, pp. 157-1 77. Campbell, L. A., and Thompson, B. L. (1990). Evaluating elderly patients: A critique of comprehensive functional assessment tools. Nurse Practitioner, 75, 11-1 8. Cape, R. D. T. (1983). Nutrition and the elderly. In R. D. T. Cape, R. M. Coe, & I. Rossman (Eds.), Fundamentals of geriatric medicine. New York: Raven Press. Caranasos, G. J. (1987). Sleep disorders. In R.J. Haln (Ed.), Geriatric medicine annual: 7 987. Oradell, NJ: Medical Economics Books. Irvine, P. W. (1988). Health promotion and screening reminder checklist. Clinical report on aging. New York: Elsevier. Kane, R. J., Ouslander, J. G., and Abrass, I. B. (Eds.) (1984).€ssentials of clinical geriatrics. New York: McGraw-Hill. Kart, C. S. and Dunkle, R. E. (1989). Assessing capacity for self care among the aged. Journal of Aging and Health, 1 , 185193. Lubben, J. E., Chi, I., and Welter, P. G. (1989). Differential health screening of the well elderly by gender and age: Appropriate care or bias? Journal of Applied Gerontology, 8,335-354. Magaziner, J., Cadigan, D. A,, Fedder, D. O., and Hebel, J. R. (1989). Medication use and functional decline among community-
VOLUME 4, NUMBER 4, OCTOBER-DECEMBER, 1992
dwelling older women. Journal of Aging and Health, 7 , 470-484. Mims, F. H., & Swenson, M. M. (1980). Sexua1ity:A nursingperspective. New York: McGraw-Hill. National Center for Health Statistics. (1978). Vital and health statistics, Series 10, No. 126. Washington, DC: U.S. Government Printing Office. Schulraan, B. K., & Acquaviva, T. (1987). Falls in the elderly. Nurse Practitioner, 12, 30-37. Shephard, R. J. (1987). Prescribingexercise. In R. J. Ham (Ed.),Geriatric medicine annual: 7 987. Oradell, NJ: Medical Economics Press. Swenson, M. M. (1991) The meaning of home to elderly women. Unpublished doctoral dissertation, Indiana University, Bloomington, IN. U. S. Preventive Services Task Force. (1989). Guide to clinical preventive services: An assessment of the effectiveness of 769 interventions. Report of the US. Preventive Services Task Force. Baltimore: Williams & Wilkins. U. S. Congress Senate Special Committee on Aging (1988). Developments in aging: 1987. Volume 7 . (Senate Report 100291, Serial 13858). Washington, DC: US. Government Printing Off ice. Verbrugge, L. M. (1985). An epidemiological profile of older women. In M. R. Haug, A. M. Ford, & M. Sheafor (Eds.), The physical and mental health of aged women. New York: Springer. Verbrugge, L. M. (1990). Longer life but worsening health? Trends in health and mortality of middle-aged and older persons. In P. R. Lee & C. L. Estes (Eds.), The nations health (3rd ed.). Boston: Jones and Bartlett. Zoller, D. P. (1987). The physiology of aging. American Family Practice, 36,112-1 16.
147
