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Long Term Care

Neuro Group

Indira Miller

on 22 April 2015

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Transcript of Long Term Care

Thank You!
Before we get started....
Why do you think it is important to discuss this?
Life Expectancy
• Life expectancy has increased since 1975...
• Expected outcome: By 2030, the elderly population in America will be larger than the population of children 1 to 14 years of age.

Causes of Growing Elderly Population
• Medical advances, infectious disease control, food handling and sanitation improvements, safe drinking water, and an increase in concern for health hazards.
• Birth rates are down
• Baby boomers are now reaching old age

Affects of Healthcare
• There is a shortage of workers to care for this population
• Increase in this population increases the amount and severity of chronic illnesses.
• Larger concern in assisting patients with coping with their illnesses rather than curing them because of older age.

Neuro Group (Group 4):

Karina Bedosky-Arellano
Camille Brenke

Fatmata Jimmy
Rose Kepnang
Xiangbin Kong

Indira Miller
Michele Preko
Carly Privott

Alexa Stuart
Jordan Timmel
Long Term Care in the Aging Population
Lack of Holistic Care
Importance of Holistic Care to Sexual Health
Long Term Care?
Older Adult?
Here's why it's important...
Different Challenges For Different Settings
Older adults with care needs live in a variety of settings

Traditional community housing

Retirement/Senior housing

Independent/Assisted living settings

In relation to Traditional community housing:

there is a higher likelihood of unmet needs in retirement/senior housing

there is a lower likelihood of unmet needs in assisted/independent living settings

Why do you think this is?

not being able to leave their home/building
going without groceries or personal items
going without eating
going without bathing
going without a hot meal
going without handling bills and banking matters
making a mistake in taking medications

What do most of these things have in common?

the most common unmet need is getting outside for all settings excepted assisted living

whereas in assisted living settings the most common unmet need is getting to the toilet in time

Levels of mismanaging medicine are more prevalent in traditional settings rather than assisted living

Shortages of Nurses and Consequences of Unqualified Professionals
Managing Challenging Behaviors
People have more challenges as they age

more susceptible to complications

some of these complications result from the failure of hospital systems to support appropriate care for older adult patients with chronic illnesses and their resulting complex needs

Hospitals are “institutionally ageist because older patients who do not fit the prescribed, almost industrial, model of hospital admission and discharge are identified as a problem”

Nurses have more challenges in caring for this population

short staffing
- In efforts to fix this problem it is estimated that the long-term care workforce will need to expand by 2% a year from now until 2050, producing an additional four million new jobs. This means more job opportunities for nurses!

emphasis on efficiency rather than quality due to limited time

these challenges undermine their ability to provide basic care

Nurses often view hospitalized older adults as a “waste of time”
Why do you think this is?
Caring for them is more time-consuming than caring for younger people

Frustration due to failure of the system’s design to manage the patients’ complex needs

One study confirmed this phenomenon: that the system is to blame and not the patients

The aim of the study was to explain how nurses’ manage practice with hospitalized older adults from the perspective of nurses

Found that nurses’ negative beliefs about aging are documented in hospital settings and the systems within healthcare institutions frequently do not support appropriate care of hospitalized older adults

Explained by two components: building synergy and minimizing strain

1) Synergy: teaming up with other care providers and families

2) Minimizing strain: synergy relieves strain

When we are strained we are…

-more inclined to feel misunderstood

-more likely to identify inadequate resources

A nursing facility resident's behavior generally comes to the staff's attention in one of three ways:

1. A medical diagnosis of a psychiatric or organic mental disorder.

2. Effects from a psychoactive medication a resident is taking.

3. Language or behavior displayed by the resident that concerns someone a.k.a. target behavior.

When does a behavior require intervention?
Methods to Intervene?

1. Identify Goals of Treatment

Goals: relevant to patient's needs, problems, strength and limitations (Individualized)

2. Identify Appropriate Individuals

3. Consult with an Health Care Provider

Always refer to the Nursing Process: Implementation and Evaluation
Methodology of Assessing Behaviors and Documentation
Healthcare professionals in nursing homes may encounter challenging behaviors in several situations:

During a new patient evaluation.

When observing a minor change (possible delirium) or slow decline in behavior and function

When monitoring pharmacological and non-pharmacological interventions over time.

New or Old Medications

Physical Health

Psychiatric Illness



Interactions with Others
Review Progress
-Adjust the interventions in accordance with goals

Seek and Address Compilations of Treatments
-Implementation of medications and restraints can have adverse effects

Consider and Address Adverse Drug Reactions (ADR)
-Many medications can affect mental status and behavior

The Cost of Losing Patient-Centered Care
General Information:
-Qualitative assessment of the patient’s perspective on quality of care

-The gain insight into the experiences of elderly patients in nursing homes and recipients of home care services in order to identify problem areas in nursing care.
-Subjects: 72-90 year old individuals with chronic illness

-Primary sources:
Patient Interviews
Spouse Interviews

According to the study, recipients of long-term care …


… due to shortcomings amongst the caregivers

Why do they feel alienated?

-Foreign environment

-Task-oriented vs. Person-oriented

“When the other’s face is absent in the caring encounter, the patient may not feel confirmed as a human being”

What is alienation?
Alienation is feeling out of place
Variety of Settings
Relationship of Settings
Types of Unmet Needs
Compare and Contrast Settings
More Challenges for Older Adults
Challenges for Nurses
Nurse's Perceptions
Nurses Perceptions cont.
One Study
Solution: "Orchestrating Care"
How to determine when behavior is a problem that needs intervention?
Methods of Intervention
Situations Where Problematic Behaviors Arises
Cause Identification
Monitoring Behavior Interventions
Empirical Study
Empirical Study cont.
Lack of adequate nurse-patient communication

Isolated from family and world

Importance of rapport

“The patients in this study experienced not being secure about when, or if, the caregiver would open an avenue for communion”

Lack of confidence in care

Complete dependence on caregivers

Inconsistency and lack of reliability

Why provide Holistic Care?
The basis of these experiences of insecurity, loneliness, and isolation stem from a lack of person-centered care

All dimensions of person is important
-Psychosocial, Spiritual, Emotional > Empower the individual
-Diagram of 6 facets of health

What are some ways to implement holistic care and to orient care to the individual?
Outcomes of Comfort Touch in Institutionalized Elderly Female Residents
Comfort touch—one of the most frequently used nursing intervention

Elders frequently respond more readily to touch than verbal communication

Previous studies show elders with dementia who experience human contact are positively affected as far as quality of life and functional ability

To examine whether comfort touch improved the self-perceptions of institutionalized elderly women on five research variables:


-Well-being and social processes

-Health status

-Life satisfaction

-Faith or belief

Five Holistic Variables
-Psychological aspect; refers to a person recognizing virtues of self and accepting deficiencies

Well-being and social processes
-Sociocultural aspect; refers to life situations that affect a person’s outlook on life

Health status
-Physiological aspect; refers to structure and function of bodily systems

Five Holistic Variables cont.
Life satisfaction/self-actualization
-Developmental aspect; refers to level of perceived satisfaction for life and achievements

Faith or belief
-Spiritual aspect; refers to a reflection of spirituals beliefs, purpose in life and relationships of these to lifestyle

Each of the variables were measured using different scales such as Rosenberg’s Self-Esteem Scale, Bradburn’s Affect Balance Scale and the JAREL Spiritual Well-being Scale.

Conducted in two nursing homes

42 elderly women; 65 years or older

Participants ranged from 6 months to 185 months in a nursing home

Nurses engaged in
5 minute socials
with them
twice a week for four weeks

Socials included handshaking, patting hands, forearms, or shoulders

All five variables improved at a significant level. It is recommended that nurse’s engage in this kind of
therapeutic intervention

Older Adult Sexuality
Sexual health is defined by the World Health Organization as “……a state of physical, mental and social well-being in relation to sexuality”.

This definition makes no distinction based on age.

Research shows that older adults can remain sexually interested and capable into their 90s, even in the presence of physical illness.

A review of the guidelines from the Centers for Medicare and Medicaid Services (CMS) supports sexual expression for older adults in residential settings. These include the right of married couples to share a room and the right to accommodations that account for sexual preferences.

Staff trainings that address stereotypes and false beliefs, such as reviewing Maslow's hierarchy of needs, in which sex falls under physiological and intimacy falls under love and belonging.

Having staff members take the Staff Attitudes about Intimacy and Dementia Survey.
The sexual needs and wellbeing of older people living in residential aged care receives inadequate attention in practice, it is easily dismissed by care staff, and remains a significant challenge for aged care service providers.

Prior to entering aged care facilities, prospective residents are frequently not provided with information about how their sexual needs will be respected, nor do aged care nurses routinely enquire about sexual practices and conduct sexual health assessment.
Discomfort with their own sexuality or fear of offending the patient and family.

The perspective of the staff members, their biases, and means of addressing these biases. Long-term care staff members may make assumptions about lack of sexual desire. When staff members observe sexual behavior among residents, they often view it as problematic.

The study reported in this paper represents the first step: delivering education to nursing staff that involves examining personal biases and improving knowledge about sexuality and older people.

-Facility managers and educators further need to ensure that staff training and education also focuses on how to conduct a sexual health and sexual needs assessment.

-To be meaningful and effective, these assessments also need to be supported by guidelines and policy

What is sexual health?
What is Sexual Health?
Why is sexual health important to the wellbeing of older adults in the long-term care facilities?
Challenges in recognizing the sexual need of older adults
Strategies for Improvement
Benefits of Control-Enhancing Interventions in Long-Term Care Setting
Restraints and It's History
Defined as “physical devices used to limit a patient’s movement”; can be chemical too

Used to be acceptable bedside care to prevent from harm

Since 1987, government and accrediting agencies have worked to reduce or eliminate use of restraints

Federal agencies reinforce that primary responsibility is to protect and promote patient’s rights and that restraints may only be used to protect patient, staff, or others

Commonly used restraints: geriatric chairs, belts, bedrails

What do we already know?
Physical restraints are commonly used by nurses in acute and long-term care in many countries.

use of physical restraints has not proved to be beneficial, actually well known to be associated with many direct and indirect negative effects.
-skin breakdown and contractures, incontinence, delirium, depression, anxiety, respiratory difficulties, and even death

The majority of educational interventions aiming to reduce the use of physical restraints focus on changing nurses’ attitudes. Although several studies have investigated nurses’ attitudes towards physical restraint, a systematic review collecting, describing and synthesizing the evidence is lacking so far.

Nursing Considerations/Trends
In qualitative studies, nurses’ attitudes towards the use of physical restraints in geriatric care were predominantly negative; however, the nurses also described a perceived need for using restraints in clinical practice

 Prevention of falls was identified as a primary reason for using restraints

“absence of a clear policy on restraint use within our organization, as confirmed by the participating nurses, typically contributed to ignorance or confusion at the beginning of the interview”

Movie Time!!
The Greying America
“Baby Boomer” cohort bears more weight than previous cohorts

Loss of functional status with increasing age leads to increasing need for assistance in daily life.

Advances in medical technology to prolong human life has led to unprecedented challenges for geriatrics as healthcare professionals struggle to maintain quality of life in long-term care facilities.

Locus of Control
Locus of Control: One’s perception of the degree of control that their actions have on outcomes.

“When an individual is presented with a situation or event over which he or she has no control… the person may learn to feel helpless, hopeless, or depressed"
-E.g. Learned Helplessness

Long-term facilities place residents at risk for diminishment of locus of control due to...
-scheduled mealtimes, recreational, and visitation times
-set times to wake and sleep
-as well as high level of assistance with ADL’s and IADL’s
-insufficient inclusion of elder into discussion of care

Problems and Solutions
Reasons for Loss of locus of control in long-term care residents can be broken down into two categories:

I. Inattention to Modifiable life-style risk-factors
II. Insufficient promotion of patient self-care
III. Diminishment of sense of purpose

Solution: Control-Enhancing nursing interventions to…

I. Promote “aging-well”
II. Encourage patient self-care and activity within patient’s functional capabilities
III. Allocate tasks/responsibilities to patients

Control-Enhancing Intervention:
"Aging Well"
While some decline in functional status such as loss of mobility and cognitive function is a normal process of aging, much decline is preventable.

“Aging Well” refers to a certain way of living that maintains quality of life for as long as possible by incorporating modifiable risk factor management into daily life.

What are some ways to manage/prevent decline in functional status?
Keep a healthy weight

Regular exercise

Lifestyle modifications

Dietary modifications
-Fruits and veggies
-Cut out junk food
-High in sugar or salt

Control-Enhancing Intervention:
"Aging Well"
While some decline in functional status such as loss of mobility and cognitive function is a normal process of aging, much decline is preventable.

“Aging Well” refers to a certain way of living that maintains quality of life for as long as possible by incorporating modifiable risk factor management into daily life.

Studies show significant short-term and long-term benefits to physical and mental well-being. Therefore, promoting improvement of functional status (ability to carry out ADL’s & IADL’s)

Control-Enhancing Intervention:
Tasks/Responsibilities for Residents
Control-Enhancing Interventions
Control-Enhancing Intervention:
Patient Self-Care
Encouraging the patient to do all that is within their physical and cognitive limits is shown to benefit patient-outcome

Ex. Encourage patient to…
-Shave, bathe, dress independently
-Ambulate In hallways

Also, nurse must include patient as much as possible about care (medications, procedures).
-Making decisions: Health care proxy?

Allocation of tasks/responsibilities to long-term care residents permits greater sense of purpose within community

Ex. Individual Responsibilities for…
-taking care of/ watering plants
-planning social event (movie night, pot-luck)

Older adults tend to base perception of their health upon perceived functional status.

Implementing interventions to…
-promote lifestyle changes that improve and prevent decline of ADLs/IADLs
-that allow the patient greater inclusion in their plan of care, including increased level of self-care
-and that allow greater sense of purpose through allocation of personal tasks/responsibilities

… will have beneficial impact on the tendency towards decline of locus of control in this cohort





Another Movie!!
(Lehning & Austin, 2010)
(Freedman & Spillman, 2014)
Elder Abuse in Long Term Care
Cognitive impairment worsens with age after 65 years.
-Its manifested by signs such as failing memory, mental confusion, delusions, paranoia, difficulty concentrating, and difficulty communicating.

Thinking, memory, or communication problems are cognitive impairments that affect Instrumental Activities of daily living which may lead to abuse

Patients with physical impairments are at a higher risk of abuse and neglect since they can't process normal activities of daily living

Impairments in long term care presents a need for frequent assistance or treatment from caregivers.

Loss of self control and reduced energy from staff leads to anger and frustration thus neglect and abuse are the result.

(Conner et al., 2011)
Why Abuse May Occur
(Dahlke et al., 2014, p. 3)

(Freedman & Spillman, 2014)
(Freedman & Spillman, 2014)
(Freedman & Spillman, 2014)
(Levenson, 2003)
(Levenson, 2003)
(Levenson, 2003)
(Levenson, 2003)
(Levenson, 2003)
(Levenson, 2003)
(World Health Organization, 2015)
(Butts, 2001)
(Butts, 2001)
(Butts, 2001)
(Butts, 2001)
(Butts, 2001)
(Butts, 2001)
(Bell, 2013)
(Bell, 2013)
(Bell, 2013)
(Bell, 2013)
(Taylor et al., 2015)
(Scheepmans et al., 2014)
(Mohler & Meyer, 2014)
(Mohler & Meyer, 2014)
(Scheepmans et al., 2014, p. 5)
(Mohler & Meyer 2014)
(Anderson-Hanley et al., 2003)
(Anderson-Hanley et al., 2003)
(Anderson-Hanley et al., 2003)
(Anderson-Hanley et al., 2003, p. 111)
(Anderson-Hanley et al., 2003)
(Anderson-Hanley et al., 2003)
(Anderson-Hanley et al., 2003)
(Anderson-Hanley et al., 2003)
(Anderson-Hanley et al., 2003)
(Taylor, Lillis, LeMone, & Lynn, 2015)
(Weiner, 2002)
(Dahlke et al., 2014, p. 3)
(Dahlke, Phinney, Hall, Rodney, & Baumbusch, 2014)
(Dahlke et al., 2014)
(Dahlke et al., 2014)
(Dahlke et al., 2014)
(Dahlke et al., 2014)
(Taylor et al., 2015, p. 707)
(Conner et al., 2011)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013, p. 7)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013, p. 7)
(Svanstrom, Johansson Sundler, Berglund, & Westin, 2013)
Full transcript