Working with the aging patient
by Michael Stewart, MA
"The aging patient represents a whole different piece of the diversity puzzle,'" says Virginia Burggraf, DNSC, RNC, a gerontological nurse who serves as ANA grants development associate. Burggraf is a co-author of Gerontological Nursing: Current Practice and Research, published in 1996.
"As nurses, we can make a lot of incorrect assumptions about aging patients. We need to be open and flexible in our approach to them and not rely on preconceived notions about their level of activity or health awareness," Burggraf points out. "For instance, nurses should not assume that the aging patient is not sexually active. As a matter of fact, the over-50 group is at higher risk of HIV infection than some others.
"Additionally, nurses shouldn't assume that aging patients don't know about their disease -- or that, by the same token, just because they may have had an illness for several years, they know everything about it," she adds. "The nurse needs to assess what the patient knows about the disease and its prevention."
|Sensitivity to age, and its meaning within the patient's cultural context, can improve the treatment outcome by building trust and patience compliance with care instructions.|
Rita Munley Gallagher, PhD, RNC, a community health nurse and senior policy fellow in ANA's Department of Nursing Practice, concurs with this line of thought. "It's a mistake to assume that aging patients can't learn new things -- from new ways to exercise and new ways to dress to new ways to think about old ideas. In fact, many older individuals are using computers to learn all kinds of new things."
According to Burggraf, the first step in working with the aging patient is building a relationship of trust. "I tell them 'I am your nurse.' I may share that I'm 55 years old, widowed and a grandmother -- whatever it takes to establish some trust at the outset." According to Burggraf, it's also vital to take into account who the patient is and to look beyond the disease. "Is the patient Asian-American, African-American? Is he or she a member of the ever-growing group of 'graying' gay and lesbian Americans?"
A special consideration in working with the older patient is the greater likelihood that he or she has suffered the loss of a spouse or significant other. This loss can cast the patient into a dependency role that is frightening. The nurse can ask, "Who is it that you rely on for care?"
While 80 percent of informal caregiving is provided by family and friends of patients, Burggraf notes, "The older patient may not want a child helping them. That kind of reversal is an embarrassment."
During a hospitalization may be the first time the aging patient must confront questions like, "Who will help me with eating and using the toilet?" "Above all," says Burggraf, "the nurse shouldn't assume that the patient's child has become the 'parent' of the older adult. This diminishes the level of control the patient feels he or she has to deal with the illness and is a direct assault on a key component of the patient's identity -- that of being a parent."
Gallagher concurs, "While the likely caregiver for an aging patient who is a parent is that patient's female child or the wife of a male child, the mistaken assumption about the aging patient is that he or she will definitely need a caregiver. Many older patients are perfectly able to care for themselves."
"Nurses tend to focus on the particular body system or the condition that brought the patient into the hospital," says Burggraf. "However, with aging people, other systems have changed as well, and how they're handled may be the key to preserving the patient's self-respect." According to Burggraf, "normalization" is a key to a successful hospitalization. The patient and family need to feel they have "permission" to continue comfort measures used at home while in the hospital, whenever possible.
"Patients may want to have pictures of their loved ones near them and to use their own pillow from home. They may wish to pray with one another. Using a special tea, herbal remedy, vitamin, lotion, perfume or cologne may help better normalize the experience of hospitalization," Burggraf explains.
Gallagher points out that asking an open-ended question about how the patient is coping with the illness, such as "What are you doing at home for this?" versus just asking "What medication are you taking for this?" can garner more useful information from the patient. "It's vital that we know what the patient's been trying in terms of treatment. Some homeopathic or over-the-counter remedies can be very powerful. Aspirin, for instance, can be a very powerful medication. We need to look at the self-treatment the patient's been employing to see if it's helpful, harmless or benign, or harmful. If it's helpful or benign, a home remedy or comfort can certainly be integrated into the plan of care, and everyone involved in caring for the patient should know about it."
Nutritional practices are an area of particular concern with older patients. According to Burggraf, it's important not only to ask about dietary restrictions, but to cover such basics as, "Can you chew the steak?" If an older patient can use a favorite spice or seasoning from home, it can make hospital food more appetizing and palatable and thus help improve nutrition. Gallagher points out that, as people age, metabolic activity changes, and they may need smaller quantities of food. However, they have the same or greater need for nutrients. She notes, "When patients live alone, as is more likely to be true if they're older, they may not eat properly. It's important to determine what the person's been eating."
Aging adds another dimension of difference to the picture of diversity. Sensitivity to age, and its meaning within the patient's cultural context, can improve the treatment outcome by building trust and patient compliance with care instructions.
Michael Stewart, MA, is senior public relations specialist at the American Nurses Association.
Approaching the older patient
Ask, "Are there any procedures you're worried or fearful about?"
Ask, "Do you have previous experience with hospitalization?" and find out about the experience.
Find out how much the older patient knows, understands and remembers about his or her condition.
Ask, "How are you handling the problem at home?" (along with, "What medications are you taking?").
When asking about dietary restrictions, ask about the overall eating experience (e.g., "Can you chew the steak?").