5
Chronic Illness and Older Adults
Sherry A. Greenberg
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cognition Nutrition
Family Dynamics Sensory Perception
Functional Ability
Mobility
LEARNING OUTCOMES
1. Explain the characteristics of a chronic illness. 6. Distinguish among care alternatives and ways to create
2. Describe the prevention and major causes of chronic illness. systems of care to meet needs of older adults.
3. Describe the demographics of aging. 7. Describe common problems of older adults related to
4. Explain the needs of special populations of older adults. hospitalization and acute illness and the nurse’s role in
5. Describe types of elder mistreatment and appropriate assisting them.
nursing interventions. 8. Describe the nurse’s role in health promotion and managing
the special needs of older adults.
KEY TERMS
ageism Medicaid
elder mistreatment (EM) Medicare
ethnogeriatric old-old adult
frail older adult young-old adult
gerontologic nursing
This chapter discusses issues related to chronic illness and aging. of life for nearly 1 out of 10 Americans. Many older adults live
The older adult population is growing rapidly. You need to con- with more than 1 chronic illness. Some live with 6 or more. In
sider their multiple, complex health care conditions and needs 2016, 38% of older adults age 65 and older had at least 1 chronic
when planning and providing comprehensive nursing care. condition. 47% had 2 to 3 chronic conditions, and 15% had
Functional ability in those with chronic illness and older adults 4 or more chronic conditions.1 A large portion of U.S. health
is interrelated with several concepts. These include mobility, care dollars goes toward treating chronic illnesses. Managing a
perfusion, nutrition, cognition, and sensory perception. Family chronic illness greatly affects the lives of older adults, families,
dynamics and caregiving shape the care provided to those who and caregivers. Table 5.2 presents the impact of some chronic
need help to meet their needs. illnesses.
In addition to people living longer, other societal changes
have contributed to the increase in chronic illnesses. These
CHRONIC ILLNESS include insufficient physical activity, lack of access to fresh fruits
Illness can be categorized as either acute or chronic (Table 5.1). and vegetables, and tobacco and alcohol use.2
The U.S. health care system faces a growing burden of chronic
illness as the population ages. Chronic illnesses account for 70% Trajectory of Chronic Illness
of all deaths in the United States. Chronic illness results in lim- The person with a chronic illness can move from a level of opti-
itations in physical functioning, work productivity, and quality mum functioning, with the illness well controlled, to a period
63
,64 SECTION 1 Concepts in Nursing Practice
of physical instability. Corbin and Strauss proposed a view of is to learn to prevent or manage the crisis. First, they need to
chronic illness as a trajectory (Fig. 5.1) with overlapping phases understand the potential for the crisis to occur. Second, they
(Table 5.3).3 This trajectory depicts the common course of most need to know ways to prevent or modify the threat. This often
chronic conditions. In addition, Corbin and Strauss identified involves adhering to a prescribed medical and overall health
the 7 tasks of those who are chronically ill (Table 5.4). We dis- plan. Patients need to know the signs and symptoms of the
cuss these tasks in the next sections. onset of a crisis or exacerbation. Depending on the chronic ill-
ness, signs and symptoms may occur suddenly (e.g., bleeding in
Preventing and Managing a Crisis a patient with inflammatory bowel disease) or slowly (e.g., heart
Most chronic illnesses have the potential for an acute exacer- failure in a person with untreated hypertension). It is important
bation of symptoms. This may result in further disability or for the patient and caregiver to have a plan to manage a crisis
death. Examples include the patient with heart disease who has that is likely to occur.
another myocardial infarction or the patient with asthma who
has a severe attack. A major task for the patient and caregiver Carrying Out Prescribed Treatment Plan
Treatment plans vary in degree of difficulty and the impact they
have on the person’s lifestyle. Some plans may be perceived as
TABLE 5.1 Characteristics of Acute and challenging or time-consuming, such as changing a dressing
Chronic Illness multiple times a day or following a toileting program. However,
they generally save time, prevent complications, and improve
Description Characteristics
outcomes.
Acute Illness
Diseases that have a rapid onset • Usually self-limiting Controlling Symptoms
and short duration • Responds readily to treatment
Examples: colds, influenza, acute • Complications infrequent
An important task for those with chronic illnesses is to learn
gastroenteritis • After illness, return to previous level of to control symptoms so that they can continue to do what mat-
functioning ters to them. Some alter their lifestyle by learning to plan ahead.
People with heart failure adjust the time they take diuretics
Chronic Illness when going out for the day to avoid needing to rush to a bath-
Diseases that are prolonged, do • Permanent impairments or deviations room. Encourage independence in decision making and collab-
not resolve spontaneously, from normal orating with the health care provider (HCP) about treatment
rarely cured completely • Irreversible pathologic changes
plans to avoid an exacerbation of the illness. Others may change
Examples: Table 5.2 • Residual disability
their living space. Patients and their families need to learn about
• Special rehabilitation needed
• Need for long-term medical and/or
the pattern of symptoms, such as typical onset, duration, and
nursing management severity, so that lifestyle may be changed accordingly while
maintaining safety.
TABLE 5.2 Impact of Chronic Illnesses
Chronic Illness Impact Chapter
Cancer • 2nd leading cause of death 16
• Risk increases with age
Cardiovascular disease, including heart • Affects about 17 million adults 37, 38, and 62
disease and stroke • Account for 33% of U.S. deaths annually
• Heart disease is leading cause of death in United States
• Heart failure is a common cause of hospitalization and rehospitalization
• Stroke is 5th leading cause of death
• Stroke is a common cause of serious disability
COPD • Affects many older adults 31
• 4th leading cause of death
Diabetes • Affects >30 million Americans 53
• 25% of adults in United States do not know they have diabetes
• 7th leading cause of death
Human immunodeficiency virus (HIV) • Nearly 50% of those living with HIV in the United States are over 50 years old 15
• Older adults more likely to receive diagnosis of HIV infection later in course of
disease
Obesity • Affects 43% of adults age 60 and over 45
• Major contributor to other health problems and chronic diseases
Data from Centers for Disease Control and Prevention: CDC’s chronic disease press releases. Retrieved from www.cdc.gov/chronicdisease/
resources/publications/aag.htm; www.cdc.gov/hiv/group/age/olderamericans/index.html; and https://www.cdc.gov/nchs/fastats/leading-causes-of-
death.htm.
, CHAPTER 5 Chronic Illness and Older Adults 65
Health
Acute
Onset Comeback
Stable Stable
Downward
Crisis
Stable
back
e
Com
Stable
Dy
ing
Illness Months
TIME
Fig. 5.1 The Chronic Illness Trajectory is a theoretical model of chronic illness. The trajectory model of chronic
illness recognizes that chronic illness will have many phases (Table 5.3). (From Woog P: The chronic illness
trajectory framework: the Corbin and Strauss nursing model, New York, 1992, Springer.)
TABLE 5.3 Chronic Illness Trajectory TABLE 5.4 7 Tasks of People With Chronic
Phases Description Illness
Onset • Signs and symptoms are present • Prevent and manage a crisis
• Disease diagnosed • Carry out prescribed treatment plan
Stable • Illness course and symptoms controlled by treatment • Control symptoms
plan • Reorder time
• Person maintains daily activities • Adjust to changes in course of disease
Acute • Active illness with severe and unrelieved symptoms or • Prevent social isolation
complications • Attempt to normalize interactions with others
• Hospitalization may be needed for management Source: Corbin JM, Strauss A: A nursing model for chronic illness
Comeback • Gradual return to an acceptable way of life management based upon the trajectory framework, Sch Inq Nurs Pract
Crisis • Life-threatening situation occurs 5:155, 1991.
• Emergency services are necessary
Unstable • Unable to keep symptoms or disease course under
control Adjusting to Changes in the Course of Disease
• Life disrupted while patient works to regain stability Some diseases, such as multiple sclerosis, have unpredictable
• Hospitalization not required courses that make planning activities difficult. Part of the per-
Downward • Gradual and progressive deterioration in physical or son’s task is to develop a personal identity that includes the
mental status chronic illness and to adjust to the necessary lifestyle changes.
• Accompanied by increasing disability and symptoms For example, a person with a mechanical heart valve taking war-
• Continuous changes in daily life activities
farin may need to avoid sports that have a high risk for injury.
Dying • Patient has to relinquish life interests and activities, let
go, and die peacefully
Preventing Social Isolation
• Immediate weeks, days, hours preceding death
Social isolation may occur with chronic illness. The person
Source: Woog P: The chronic illness trajectory framework: the Corbin may choose to withdraw from social activities. For example, a
and Strauss nursing model, New York, 1992, Springer.
woman with aphasia after a stroke may not want to go out in
public because she is embarrassed about communication issues.
Sometimes others withdraw from the ill person.
Reordering Time
People with chronic illness often report having too much or Attempting to Normalize Interactions With Others
too little time. Treatment plans that require large amounts of Most persons with chronic illness try to manage symptoms so
time for the person, as well as caregivers, may require chang- that they can hide their disabilities or disfigurement. This may
ing schedules or eliminating other activities. For example, the involve wearing a prosthesis. They may want to show they can
patient with a new ileostomy needs to plan for increased time in function the same as a person without a disability or chronic
the bathroom to change the drainage bag. illness. An example is a woman with heart failure who stops
Chronic Illness and Older Adults
Sherry A. Greenberg
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cognition Nutrition
Family Dynamics Sensory Perception
Functional Ability
Mobility
LEARNING OUTCOMES
1. Explain the characteristics of a chronic illness. 6. Distinguish among care alternatives and ways to create
2. Describe the prevention and major causes of chronic illness. systems of care to meet needs of older adults.
3. Describe the demographics of aging. 7. Describe common problems of older adults related to
4. Explain the needs of special populations of older adults. hospitalization and acute illness and the nurse’s role in
5. Describe types of elder mistreatment and appropriate assisting them.
nursing interventions. 8. Describe the nurse’s role in health promotion and managing
the special needs of older adults.
KEY TERMS
ageism Medicaid
elder mistreatment (EM) Medicare
ethnogeriatric old-old adult
frail older adult young-old adult
gerontologic nursing
This chapter discusses issues related to chronic illness and aging. of life for nearly 1 out of 10 Americans. Many older adults live
The older adult population is growing rapidly. You need to con- with more than 1 chronic illness. Some live with 6 or more. In
sider their multiple, complex health care conditions and needs 2016, 38% of older adults age 65 and older had at least 1 chronic
when planning and providing comprehensive nursing care. condition. 47% had 2 to 3 chronic conditions, and 15% had
Functional ability in those with chronic illness and older adults 4 or more chronic conditions.1 A large portion of U.S. health
is interrelated with several concepts. These include mobility, care dollars goes toward treating chronic illnesses. Managing a
perfusion, nutrition, cognition, and sensory perception. Family chronic illness greatly affects the lives of older adults, families,
dynamics and caregiving shape the care provided to those who and caregivers. Table 5.2 presents the impact of some chronic
need help to meet their needs. illnesses.
In addition to people living longer, other societal changes
have contributed to the increase in chronic illnesses. These
CHRONIC ILLNESS include insufficient physical activity, lack of access to fresh fruits
Illness can be categorized as either acute or chronic (Table 5.1). and vegetables, and tobacco and alcohol use.2
The U.S. health care system faces a growing burden of chronic
illness as the population ages. Chronic illnesses account for 70% Trajectory of Chronic Illness
of all deaths in the United States. Chronic illness results in lim- The person with a chronic illness can move from a level of opti-
itations in physical functioning, work productivity, and quality mum functioning, with the illness well controlled, to a period
63
,64 SECTION 1 Concepts in Nursing Practice
of physical instability. Corbin and Strauss proposed a view of is to learn to prevent or manage the crisis. First, they need to
chronic illness as a trajectory (Fig. 5.1) with overlapping phases understand the potential for the crisis to occur. Second, they
(Table 5.3).3 This trajectory depicts the common course of most need to know ways to prevent or modify the threat. This often
chronic conditions. In addition, Corbin and Strauss identified involves adhering to a prescribed medical and overall health
the 7 tasks of those who are chronically ill (Table 5.4). We dis- plan. Patients need to know the signs and symptoms of the
cuss these tasks in the next sections. onset of a crisis or exacerbation. Depending on the chronic ill-
ness, signs and symptoms may occur suddenly (e.g., bleeding in
Preventing and Managing a Crisis a patient with inflammatory bowel disease) or slowly (e.g., heart
Most chronic illnesses have the potential for an acute exacer- failure in a person with untreated hypertension). It is important
bation of symptoms. This may result in further disability or for the patient and caregiver to have a plan to manage a crisis
death. Examples include the patient with heart disease who has that is likely to occur.
another myocardial infarction or the patient with asthma who
has a severe attack. A major task for the patient and caregiver Carrying Out Prescribed Treatment Plan
Treatment plans vary in degree of difficulty and the impact they
have on the person’s lifestyle. Some plans may be perceived as
TABLE 5.1 Characteristics of Acute and challenging or time-consuming, such as changing a dressing
Chronic Illness multiple times a day or following a toileting program. However,
they generally save time, prevent complications, and improve
Description Characteristics
outcomes.
Acute Illness
Diseases that have a rapid onset • Usually self-limiting Controlling Symptoms
and short duration • Responds readily to treatment
Examples: colds, influenza, acute • Complications infrequent
An important task for those with chronic illnesses is to learn
gastroenteritis • After illness, return to previous level of to control symptoms so that they can continue to do what mat-
functioning ters to them. Some alter their lifestyle by learning to plan ahead.
People with heart failure adjust the time they take diuretics
Chronic Illness when going out for the day to avoid needing to rush to a bath-
Diseases that are prolonged, do • Permanent impairments or deviations room. Encourage independence in decision making and collab-
not resolve spontaneously, from normal orating with the health care provider (HCP) about treatment
rarely cured completely • Irreversible pathologic changes
plans to avoid an exacerbation of the illness. Others may change
Examples: Table 5.2 • Residual disability
their living space. Patients and their families need to learn about
• Special rehabilitation needed
• Need for long-term medical and/or
the pattern of symptoms, such as typical onset, duration, and
nursing management severity, so that lifestyle may be changed accordingly while
maintaining safety.
TABLE 5.2 Impact of Chronic Illnesses
Chronic Illness Impact Chapter
Cancer • 2nd leading cause of death 16
• Risk increases with age
Cardiovascular disease, including heart • Affects about 17 million adults 37, 38, and 62
disease and stroke • Account for 33% of U.S. deaths annually
• Heart disease is leading cause of death in United States
• Heart failure is a common cause of hospitalization and rehospitalization
• Stroke is 5th leading cause of death
• Stroke is a common cause of serious disability
COPD • Affects many older adults 31
• 4th leading cause of death
Diabetes • Affects >30 million Americans 53
• 25% of adults in United States do not know they have diabetes
• 7th leading cause of death
Human immunodeficiency virus (HIV) • Nearly 50% of those living with HIV in the United States are over 50 years old 15
• Older adults more likely to receive diagnosis of HIV infection later in course of
disease
Obesity • Affects 43% of adults age 60 and over 45
• Major contributor to other health problems and chronic diseases
Data from Centers for Disease Control and Prevention: CDC’s chronic disease press releases. Retrieved from www.cdc.gov/chronicdisease/
resources/publications/aag.htm; www.cdc.gov/hiv/group/age/olderamericans/index.html; and https://www.cdc.gov/nchs/fastats/leading-causes-of-
death.htm.
, CHAPTER 5 Chronic Illness and Older Adults 65
Health
Acute
Onset Comeback
Stable Stable
Downward
Crisis
Stable
back
e
Com
Stable
Dy
ing
Illness Months
TIME
Fig. 5.1 The Chronic Illness Trajectory is a theoretical model of chronic illness. The trajectory model of chronic
illness recognizes that chronic illness will have many phases (Table 5.3). (From Woog P: The chronic illness
trajectory framework: the Corbin and Strauss nursing model, New York, 1992, Springer.)
TABLE 5.3 Chronic Illness Trajectory TABLE 5.4 7 Tasks of People With Chronic
Phases Description Illness
Onset • Signs and symptoms are present • Prevent and manage a crisis
• Disease diagnosed • Carry out prescribed treatment plan
Stable • Illness course and symptoms controlled by treatment • Control symptoms
plan • Reorder time
• Person maintains daily activities • Adjust to changes in course of disease
Acute • Active illness with severe and unrelieved symptoms or • Prevent social isolation
complications • Attempt to normalize interactions with others
• Hospitalization may be needed for management Source: Corbin JM, Strauss A: A nursing model for chronic illness
Comeback • Gradual return to an acceptable way of life management based upon the trajectory framework, Sch Inq Nurs Pract
Crisis • Life-threatening situation occurs 5:155, 1991.
• Emergency services are necessary
Unstable • Unable to keep symptoms or disease course under
control Adjusting to Changes in the Course of Disease
• Life disrupted while patient works to regain stability Some diseases, such as multiple sclerosis, have unpredictable
• Hospitalization not required courses that make planning activities difficult. Part of the per-
Downward • Gradual and progressive deterioration in physical or son’s task is to develop a personal identity that includes the
mental status chronic illness and to adjust to the necessary lifestyle changes.
• Accompanied by increasing disability and symptoms For example, a person with a mechanical heart valve taking war-
• Continuous changes in daily life activities
farin may need to avoid sports that have a high risk for injury.
Dying • Patient has to relinquish life interests and activities, let
go, and die peacefully
Preventing Social Isolation
• Immediate weeks, days, hours preceding death
Social isolation may occur with chronic illness. The person
Source: Woog P: The chronic illness trajectory framework: the Corbin may choose to withdraw from social activities. For example, a
and Strauss nursing model, New York, 1992, Springer.
woman with aphasia after a stroke may not want to go out in
public because she is embarrassed about communication issues.
Sometimes others withdraw from the ill person.
Reordering Time
People with chronic illness often report having too much or Attempting to Normalize Interactions With Others
too little time. Treatment plans that require large amounts of Most persons with chronic illness try to manage symptoms so
time for the person, as well as caregivers, may require chang- that they can hide their disabilities or disfigurement. This may
ing schedules or eliminating other activities. For example, the involve wearing a prosthesis. They may want to show they can
patient with a new ileostomy needs to plan for increased time in function the same as a person without a disability or chronic
the bathroom to change the drainage bag. illness. An example is a woman with heart failure who stops
