What is extended care for seniors?

The Problems Associated with Aging

The process of
aging is inevitable. In the earlier stages of life, aging involves the acquisition and development of new skills and abilities, facilitated by the guidance and assistance of others. Later, the middle stages involve the challenges of maintaining and applying those skills and abilities in a manner that is primarily self-sufficient. Finally, in the end stages of life, aging involves the deterioration and loss of skills and abilities, with adequate functioning again being somewhat dependent on the assistance of others.

For many individuals, the final stages are brief, allowing them to live independently right up to their time of death. Thus, many experience little loss of their abilities to function independently. Others, however, endure more extended stages of later life and require greater care. For these individuals, losses in physical, emotional, and/or cognitive functioning frequently result in a need for specialized care. Such care involves whatever is necessary so that these individuals may live as comfortably, productively, and independently as possible.

The conditions leading to a need for long-term care are as varied as the elderly themselves are. Special needs for elders requiring extended care often include the management of physical, health, emotional, and cognitive problems. Physical problems dictating lifestyle adjustments include decreased speed, dexterity, and strength, as well as increased fragility. Changes to the five senses are also common. Visual changes include the development of hyperopia (farsightedness) and sometimes decreased visual acuity. Hearing loss is also common, such that softer sounds cannot be heard when background noise is present or sounds need to be louder in order to be perceived. Particularly noteworthy is that paranoia, depression, and social isolation often result as side effects of visual and hearing impairments in elders; they are not always signs of mental deterioration. Similarly, one’s sense of touch may also be affected, such that the nerves are either more or less sensitive to changes in temperatures or textures. Consequently, injuries
attributable to a lack of awareness of potential hazards or supersensitivities to temperature or texture may result. One example would be an elderly woman overdressing or underdressing for the weather because of an inability to judge the outside temperature properly. Another would be an elderly man cutting or wounding himself out of a lack of awareness of the sharpness of an object. Finally, both taste and smell may change, creating a situation in which subtle tastes and odors become imperceptible or in which tastes and smells that were once pleasant become either bland or unpleasant.

Health problems among the aged often demand increased management as well. Coordination of drug therapies and other medical interventions by a case manager is critical, as a result of increasing sensitivities in elders to physical interventions. Typical health conditions bringing elderly people into long-term care settings may include heart disease and stroke, hypertension, diabetes mellitus, arthritis, osteoporosis, chronic pain, prostate disease, and cancers of the digestive tract and other vital organs. Estimates are that approximately 86 percent of the aged are affected by chronic illnesses. Long-term care addresses both the medical management of these chronic illnesses and their impact on the individual.

An issue related to health and physical problems in the aged is malnutrition. For a variety of reasons, elders often fall victim to malnutrition, which can contribute to additional health problems. For example, calcium deficiency can increase both the severity of heart disease and the likelihood of osteoporosis and tooth loss. Thus, a vicious cycle of medical problems can be put into motion. Factors contributing to malnutrition are multifaceted. Poverty, social isolation, decreased taste sensitivity, and tooth loss combine with lifelong dietary habits that can sometimes predispose certain elders to malnutrition. As such, attention to the maintenance of healthy dietary habits in the elderly is critical to successful long-term care, regardless of the type of setting in which the care is being given.

Along with these physical aspects of aging come emotional and cognitive changes. Depression, anxiety, and
paranoia over health concerns, for example, are not uncommon. Additionally, concerns about the threat of losing one’s independence, friends, and former lifestyle may contribute to acute or chronic mood disorders.
Suicide is a particular danger with the elderly when mood disorders such as depression are present. Elderly people are one of the fastest growing groups among those who commit suicide. The stresses accompanying losing a spouse or enduring a chronic health problem can often be triggers to suicide for depressed elders. One should note, however, that elders are not particularly prone to depression or suicide because of their age but that they are more likely to experience significant stressors that lead to
depression.

More common, less lethal problems associated with conditions such as depression, anxiety, and paranoia are weight change, insomnia, and other sleep problems. Distractibility, decreased ability to maintain attention and concentration, and rumination over distressing concerns are also common. Finally, some elders may be observed as socially isolated and prone to avoidance behavior. As a result, some become functionally incapacitated because of distressing emotions.

What is critical to remember, in addition to these signs, is that some elders may not describe their problems as emotional at all, even though that is the primary cause of their discomfort. Individual differences in how people express themselves must be taken into account. Thus, while some elders may report being depressed or anxious, others may instead report feeling tired. Reports of low-level health problems that are vague in nature, such as aches and pains, are also common in elders who are depressed. It is not uncommon for emotional problems to be expressed or described indirectly as physical complaints.

Decreased cognitive functioning may result from more serious problems than depression, such as organic brain syndromes. These typically include problems such as dementias from Alzheimer’s disease, Pick’s disease, Huntington’s disease, alcohol-related deterioration, or stroke-related problems. Other causes may be brain tumors or thyroid dysfunction. With all dementias, however, the hallmark signs are a deterioration of intellectual function and emotional response. Memory, judgment, understanding, and the experience and control of emotional responses are affected. Functionally, these conditions reveal themselves as a combination of symptoms, including increased forgetfulness, decreased ability to plan and complete tasks, difficulties finding names or words, decreased abilities for abstract thinking, impaired judgment, inappropriate sexual behavior, and sometimes severe personality changes. In some cases, affected individuals are aware of these difficulties, usually in the earlier stages of the disease processes. Later, however, even though their behavior and abilities may be quite disturbed, they may be completely unaware of the severity of their problems. In these cases, long-term care often begins as a result of outside intervention by concerned friends and family members.

Options for Long-Term Care

Extended care for the aged requires an interdisciplinary effort that usually involves a team of physicians, psychologists, nurses, social workers, and other rehabilitative specialists. Depending on the nature of the problems requiring care and management, any of these professionals may take part in the care process. Additionally, the involvement of concerned individuals who are close to the elder needing care is critical. Family members (including the spouse, children, and extended family) and close friends are invaluable sources of information and of emotional and instrumental support. Their ability to assist an elder with instrumental tasks such as cooking, housecleaning, shopping, and money and medication management is crucial to the successful implementation of a long-term care plan.

In all cases, long-term care for the aged involves the design of a comprehensive plan to address the multifaceted needs of the elder. Just as younger persons have psychological, social, intellectual, and physical needs, so do elders. As such, thorough assessment of an elder’s abilities, goals, expectations, and functioning in each of these areas is required. A mental status exam and a thorough physical exam are usually the primary methods of evaluation. Once needs are identified, a plan can then be designed by the team of health care professionals, family and friends assisting with care, and, whenever possible, the elder. In general, the overarching goal is to design a case management plan that maximizes the independent functioning of the aged person, given certain physical, psychiatric, social, and other needs.

Specific management strategies are designed for the problems that need to be addressed. Physical, health, nutritional, emotional, and cognitive problems all demand different management settings and strategies. Additionally, care settings may vary depending on the severity of the problems that are identified. In general, the more severe the problems, the more structured the long-term care setting and the more intense the psychosocial interventions.

For less severe problems, adequate management settings may include the elder’s own home, the home of a family member or friend, a shared housing setting, or a seniors’ apartment complex. Shared housing is sometimes called group-shared, supportive, or matched housing. Typically, it refers to residences organized by agencies where up to twenty people share a house and its expenses, chores, and management. Ideal candidates for this type of setting include elders who want some daily assistance or companionship but who are still basically independent. Senior apartments, also called retirement housing, are usually “elderly-only” complexes that range from garden-style apartments to high-rises. Ideal candidates for this type of setting include nearly independent elders who want privacy, but who no longer desire or can manage a single-family home. In either of these types of settings, the use of periodic or regular at-home nursing assistance for medical problems, or “home-helpers” for more instrumental tasks, might be a successful adjunct to regular consultation with a case manager or physician.

Problems of moderate severity may demand a more structured setting or a setting in which help is more readily available. Such settings might include continuing care retirement communities or assisted-living facilities. Continuing care retirement communities, also called life-care communities, are large complexes offering lifelong care. Residents are healthy, live independently in apartments, and are able to use cafeteria services as necessary. Additionally, residents have the option of being moved to an assisted-living unit or an infirmary as health needs dictate. Assisted-living facilities—also called board-and-care, institutional living, adult foster care, and personal care settings—offer care that is less intense than that received in a medical setting or nursing home. These facilities may be as small as a home where one person cares for a small group of elders or as large as a converted hotel with several caregivers, a nurse, and shared dining facilities. Such settings are ideal for persons needing instrumental care but not round-the-clock skilled medical or nursing care.

When more severe conditions such as incontinence, dementia, or an inability to move independently are present, nursing, convalescent, or extended care homes are more appropriate settings. Intense attention is delivered in a hospital-like setting where all medical and instrumental needs are addressed. Typical nursing homes serve a hundred clients at a time, utilizing semiprivate rooms for personal living space and providing community areas for social, community, and family activities. Often, the decision to place an elder in this type of facility is difficult to make. The decision, however, is frequently based on the knowledge that these types of facilities provide the best possible setting for the overall care of the elder’s medical, health, and social needs. In fact, appropriate use of these facilities discourages the overtaxing of the elder’s emotional and familial resources, allowing the elder to gain maximum benefit. An elder’s placement into this type of facility does not mean that the family’s job is over; rather, it simply changes shape. Incorporation of family resources into long-term care in a nursing home setting is critical to the adjustment of the elder and family
members to the elder’s increased need for care and attention. Visits and other family involvement in the elder’s daily activities remain quite valuable.

Regardless of the management setting, some basic caveats exist with regard to determining management strategies. First and foremost is that the aged individuals should, whenever possible, be encouraged to maintain independent functioning. For example, even though physical deterioration such as decreased visual or hearing abilities may be present, there is no need to take decision-making authority away from the elder. Decreased abilities to hear or see do not necessarily mean a decreased ability to make decisions or think. Second, it is crucial to ask elders to identify their needs and how they might desire assistance. Some elders may wish for help with acquiring basic living supplies from outside the home, such as foods and toiletries, but desire privacy and no assistance within the home. In contrast, others may desire independence outside the home with regard to social matters but need more instrumental assistance within the home. Finally, it is important to recognize that even the smallest amount of assistance can make a significant difference in the lifestyle of the elder. A prime example is availability of transportation. The loss of a driver’s license or independent transportation signifies a major loss of independence for any elder. Similarly, the challenges posed by public transit may seem insurmountable
because of a lack of familiarity or experience. As such, simple and small interventions such as a ride to a store or a doctor’s office may provide great relief for elders by assisting their efforts to meet their own needs.

Special management strategies may be required for specific problem areas. For physical deterioration, adequate assessment of strengths and weaknesses is important, as are referrals to medical, rehabilitative, and home-help professionals. Hearing and visual or other devices to make lifting, mobility, and day-to-day tasks easier are helpful. Similarly, assisting the aged with developing alternative strategies for dealing with diminished sensory abilities can be valuable. Examples would be checking a thermometer for outdoor temperature to determine proper dress, rather than relying purely on sensory information, or having a phone that lights up when it rings. Health conditions also demand particular management strategies, varying greatly with the type of problem experienced. In all cases, however, medical intervention, drug therapies, and behavior modification therapies are commonly employed. Dietary problems (such as malnutrition or diabetes), cardiovascular problems (such as heart attacks), and emotional problems (such as depression) often require all three approaches. Finally, cognitive problems, particularly those related to depression, are sometimes alleviated with drug therapies. Others
related to organic brain syndromes or organic mental disorders require both medical interventions and significant behavior modification therapies and/or psychosocial interventions for elders and their families.

Perspective and Prospects

Advances in modern medicine are continually extending the human life span. Cures for dread diseases, improved management of chronic health problems, and new technologies to replace diseased organs are facilitating this evolution. For many, these advances translate into greater longevity, the maintenance of a high quality of life, and fewer obstacles related to ageism. For others, however, the trade-off for longevity is some loss of independence and a need for extended care and management. Thus, the medical field is also affected by the trade-off of extending life, while experiencing an increasing need to improve strategies for long-term care for those who are able to live longer and longer despite health conditions.

As a result of this evolution, long-term care for the aged presents special challenges to the medical field. Over time, medicine has been a field specializing in the understanding of particular organ systems and the treatment of related diseases. While an understanding of how each system affects the functioning of the whole body is necessary, health care providers must struggle to understand the complexities in the case management required for high-quality long-term care for the aged. Care must be interdisciplinary, addressing the physical, mental, emotional, social, and familial needs of the aged individual. Failure to address any of these areas may ultimately sabotage the successful long-term management of elderly individuals and of their problems. In this way, medical, psychiatric, social work, and rehabilitative specialists need to work together with elders and their families for the best possible results.

Integrated case management with a team leader is increasingly the trend so that a variety of services can be provided in an orchestrated manner. While specialty providers still play a role, managers (usually primary care physicians) ensure that complementary drug therapies as well as psychiatric and other medical treatments are administered. Additionally, they are key in bringing forth family resources for emotional and instrumental support whenever possible, as well as community and social services when needed.

What was once viewed as helping a person to die with dignity is now viewed as helping a person to live as long and as productive a life as possible. Increasing awareness that old age is not simply a dying time has facilitated an integrated approach to long-term care. The news that elders can be as social, physical, sexual, intellectual, and productive as their younger counterparts has greatly stimulated improved long-term care strategies. No longer is old age seen as a time for casting elders aside or as a time when a nursing home is an inescapable solution in the face of health problems affecting the aged. Alternatives to care exist and are proliferating, with improved outcomes for both patients and care providers.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. Arlington, Va.: Author, 2000.

Cassel, Christine K., ed. Geriatric Medicine. 4th ed. New York: Springer, 2003.

Foreman, Marquis D., K. Milisen, and Terry T. Fulmer. Critical Care Nursing of Older Adults: Best Practices. 3d ed. New York: Springer, 2010.

Ham, Richard, et al., eds. Primary Care Geriatrics: A Case-Based Approach. 5th ed. St. Louis, Mo.: Mosby/Elsevier, 2007.

Katz, Paul R., Robert L. Kane, and Mathy D. Mezey. Advances in Long-Term Care. Vol. 1. New York: Springer, 1991.

Levin, Mora Jean. How to Care for Your Parents: A Practical Guide to Eldercare. New York: W. W. Norton, 1997.

Matthews, J. L. Long-Term Care: How to Plan and Pay for It. 9th ed. Berkeley, Calif.: Nolo, 2012.

Miller, Carol A. Nursing for Wellness in Older Adults. 6th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2012.

Namazi, Kevan H., and Paul K. Chaftez, eds. Assisted Living: Current Issues in Facility Management and Resident Care. Westport, Conn.: Auburn House, 2001.

Nicholl, Claire, and K. Jane Wilson. Elderly Care Medicine. 8th ed. Oxford: Wiley-Blackwell, 2012.

Weisstub, David N. Aging: Caring for Our Elders. Boston: Kluwer Academic, 2001.