FAMILY CARE GIVING

Gerontological Nursing Ninth Edition

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Gerontological Nursing Ninth Edition

Charlotte Eliopoulos, PhD, MPH, RN Specialist in Holistic Gerontological Care

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Acquisitions Editor: Natasha McIntyre Director of Product Development: Jennifer K. Forestieri Development Editor: Meredith L. Brittain Editorial Assistant: Leo Gray Production Project Manager: Priscilla Crater Design Coordinator: Elaine Kasmer Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Production Services/Compositor: SPi Global

9th Edition

Copyright © 2018 Wolters Kluwer

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services).

Nursing diagnoses in this title are reprinted with permission from: Herdman, T.H. & Kamisuru, S. (Eds.) Nursing Diagnoses — Definitions and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.

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Printed in China

Cataloging in Publication data available on request from publisher ISBN 9780060000387

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

LWW.com

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Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and U.S. Virgin Islands.

Acquisitions Editor: Natasha McIntyre Director of Product Development: Jennifer K. Forestieri Development Editor: Meredith L. Brittain Editorial Assistant: Leo Gray Production Project Manager: Priscilla Crater Design Coordinator: Elaine Kasmer Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Production Services/Compositor: SPi Global

9th Edition

Copyright © 2018 Wolters Kluwer

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services).

Nursing diagnoses in this title are reprinted with permission from: Herdman, T.H. & Kamisuru, S. (Eds.) Nursing Diagnoses — Definitions and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.

9 8 7 6 5 4 3 2 1

Printed in China

Cataloging in Publication data available on request from publisher ISBN 9781496377258

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

LWW.com

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This book is dedicated to my husband, George Considine, for his unending patience, support, and encouragement.

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Preface

Whether they are aware of it or not, most nurses today are doing some form of gerontological nursing. Hospitals are caring for increasing numbers of older adults whose age-related changes, multiple diagnoses, and psychosocial complexities present many challenges. Settings that provide long-term care are expanding beyond the nursing home. More older adults are remaining in the community and presenting new demands for nursing services to be provided in innovative ways. Growing numbers of older individuals are heading multigenerational households and caring for younger family members, which brings them into contact with nurses in specialties beyond geriatrics.

Not only do older individuals have a greater presence in various specialties but they also are presenting new challenges. They are better informed about their health conditions and expect to have explanations for treatment decisions. Many are using complementary and alternative therapies and desire approaches that integrate those therapies into conventional care. They not only want their diseases managed but they also want to enhance their function so they can enjoy an active, meaningful life. They may make choices that forfeit treatments that can extend the quantity of life for those that offer the freedom to enjoy a high quality of life for whatever time remains. Such challenges demand that nurses not only be knowledgeable about aging and geriatric care but also skillful at assessing that which is important to the older person and providing care that addresses the person holistically. It is indeed an exciting time to be a gerontological nurse!

Gerontological Nursing has evolved since its first publication. In the early editions of the text, the focus was on providing facts about the aging process and the unique modifications that were necessary to properly assess, plan, and provide care to older adults. We now understand that a “one size fits all” approach to nursing older adults is inappropriate as the diversity of this population grows. In addition to expecting from the gerontological nurse assistance with managing their medical conditions, today’s older adults may seek guidance on the selection of brain exercises to improve mental function, the value of an herbal supplement over their prescription drug, strategies to fill the void resulting from retiring from a job they enjoyed, suggestions for the best lubricant to facilitate sexual intercourse, opinions as to the value of marijuana in controlling their pain, and recommendations for the best type of approach to reduce their wrinkles. This edition of Gerontological Nursing provides the evidence-based knowledge that can help the gerontological nurse address, with competency and sensitivity, the complexities of meeting the comprehensive, holistic needs of the older population.

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Text Organization Gerontological Nursing, Ninth Edition, is organized into five units. Unit 1, The Aging Experience, provides basic knowledge about the older population and the aging process. The growing cultural and sexual diversity of this population is discussed, along with the navigation of life transitions and the changes to the body and mind that typically are experienced.

Unit 2, Foundations of Gerontological Nursing, provides an understanding of the development and scope of the specialty, along with descriptions of the various settings that provide services to older persons. This unit reviews legal and ethical issues that are relevant to gerontological nursing and offers guidance in applying a holistic model to gerontological care.

Unit 3, Health Promotion, addresses the importance of measures to prevent illness and maximize function. Chapters dedicated to nutrition and hydration, sleep and rest, comfort and pain management, safety, and medications guide the nurse in promoting basic health and preventing avoidable complications. A chapter dedicated to spirituality supports the holistic approach that is meaningful in gerontological care. In addition, because people often feel sufficiently comfortable with nurses to discuss sensitive matters, a chapter on sexuality and intimacy is included.

Unit 4, Geriatric Care, encompasses chapters dedicated to respiration, circulation, digestion and bowel elimination, urinary elimination, reproductive system health, mobility, neurologic function, vision and hearing, endocrine function, skin health, and cancer. A review of the impact of aging, interventions to promote health, the unique presentation and treatment of illnesses, and integrative approaches to illness are discussed within each of these areas. In addition to a chapter on mental health disorders, a chapter reviewing delirium and dementia is included in recognition of the prevalence and care challenges of these conditions in the geriatric population. Because chronic conditions affect most of this population, the last chapter of this unit is dedicated to nursing actions that can assist older individuals in living a full life with chronic conditions.

The unique challenges gerontological nurses face in various care settings are discussed in Unit 5, Settings and Special Issues in Geriatric Care. Chapters in this unit cover rehabilitative care, acute care, long-term care, family caregiving, and end-of-life care.

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Features A variety of features enrich the content:

Learning Objectives prepare the reader for outcomes anticipated in reading the chapter. Chapter Outlines present an overview of the chapter’s content. Terms to Know define new terms pertaining to the topic. Communication Tips offer suggestions to facilitate patient education and information exchange with older adults. Consider This Case features present clinical situations that offer opportunities for critical thinking. Concept Mastery Alerts clarify fundamental nursing concepts to improve the reader’s understanding of potentially confusing topics, as identified by Misconception Alerts in Lippincott’s Adaptive Learning Powered by prepU. Key Concepts emphasize significant facts. Points to Ponder pose questions to stimulate thinking related to the content. Assessment Guides outline the components of general observations, interview, and physical assessment of major body systems. Nursing Diagnosis Highlights provide an overview of selected nursing diagnoses common in older adults. Nursing Care Plans demonstrate the steps in developing nursing diagnoses, goals, and actions from identified needs. Bringing Research to Life presents current research and describes how to apply that knowledge in practice. Practice Realities pose real-life examples of challenges that could be faced by a nurse in practice. Critical Thinking Exercises guide application. Resources and References assist with additional exploration of the topic.

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Teaching and Learning Package A comprehensive teaching/learning package has been developed to assist faculty and students.

Resources for Instructors Tools to assist you with teaching your course are available upon adoption of this text at http://thePoint.lww.com/Eliopoulos9e.

An E-book on gives you access to the book’s full text and images online. The Test Generator lets you put together exclusive new tests from a bank containing hundreds of questions to help you in assessing your students’ understanding of the material. Test questions link to chapter learning objectives. This test generator comes with a bank of more than 900 questions. PowerPoint Presentations provide an easy way for you to integrate the textbook with your students’ classroom experience, via either slide shows or handouts. Multiple choice and true/false questions are integrated into the presentations to promote class participation and allow you to use i-clicker technology. Clinical Scenarios posing What If questions (and suggested answers) give your students an opportunity to apply their knowledge to a client case similar to the one they might encounter in practice. Assignments (and suggested answers) include group, written, clinical, and web assignments. An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course. A QSEN Competency Map and a BSN Essentials Map show you how content connects with these important competencies. Suggested Answers to the Critical Thinking Exercises in the book allow you to gauge whether students’ answers are on the right track by giving you main points that students are expected to address in the answers. Plus a Sample Syllabus, Strategies for Effective Teaching, and Learning Management System Cartridges.

Resources for Students An exciting set of free resources is available to help students review material and become even more familiar with vital concepts. Students can access all these resources at http://thePoint.lww.com/Eliopoulos9e using the codes printed in the front of their textbooks.

Current Journal Articles offer access to current research available in Wolters Kluwer journals. Watch & Learn Video Clips explain How to Assist a Person Who Is Falling, Alternatives to Restraints, and the Five Stages of Grief. (Icons in the textbook direct readers to relevant videos.) Recommended Readings expand the network of available information. Plus Learning Objectives from the textbook, Nursing Professional Roles and Responsibilities, and Heart and Breath Sounds.

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A Fully Integrated Course Experience We are pleased to offer an expanded suite of digital solutions and ancillaries to support instructors and students using Gerontological Nursing, Ninth Edition. To learn more about any solution, please contact your local Wolters Kluwer representative.

Lippincott CoursePoint+ Lippincott CoursePoint+ is an integrated digital learning solution designed for the way students learn. It is the only nursing education solution that integrates:

Leading content in context: Content provided in the context of the student learning path engages students and encourages interaction and learning on a deeper level. Powerful tools to maximize class performance: Course-specific tools, such as adaptive learning powered by prepU, provide a personalized learning experience for every student. Real-time data to measure students’ progress: Student performance data provided in an intuitive display lets you quickly spot which students are having difficulty or which concepts the class as a whole is struggling to grasp. Preparation for practice: Integrated virtual simulation and evidence-based resources improve student competence, confidence, and success in transitioning to practice.

vSim for Nursing: Co-developed by Laerdal Medical and Wolters Kluwer, vSim for Nursing simulates real nursing scenarios and allows students to interact with virtual patients in a safe, online environment. Lippincott Advisor for Education: With over 8,500 entries covering the latest evidence-based content and drug information, Lippincott Advisor for Education provides students with the most up-to-date information possible, while giving them valuable experience with the same point-of- care content they will encounter in practice.

Training services and personalized support: To ensure your success, our dedicated educational consultants and training coaches will provide expert guidance every step of the way.

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Simulation and Other Resources

vSim for Nursing | Gerontology, a virtual simulation platform (available via ). Co-developed by Laerdal Medical and Wolters Kluwer, vSim for Nursing | Gerontology includes 12 gerontology patient scenarios that correspond to the National League for Nursing (NLN) Advancing Care Excellence for Seniors (ACES) Unfolding Cases. vSim for Nursing | Gerontology helps students develop clinical competence and decision-making skills as they interact with virtual patients in a safe, realistic environment. vSim for Nursing records and assesses student decisions throughout the simulation, then provides a personalized feedback log highlighting areas needing improvement.

Lippincott DocuCare (available via thePoint). Lippincott DocuCare combines web-based electronic health record simulation software with clinical case scenarios. Lippincott DocuCare’s nonlinear solution works well in the classroom, simulation lab, and clinical practice.

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Reviewers

Carol Amann, PhD, RN-BC, CDP

Assistant Professor for the Villa Maria School of Nursing Gannon University Erie, Pennsylvania

Jan Atwell, MSN, RN

Clinical Assistant Professor Missouri State University Springfield, Missouri

Judy L. Barrera, RN, CNS

Clinical Learning Lab Coordinator Galen College of Nursing Louisville, Kentucky

Evelyn Biray, RN, MS, PMed, CCRN, CMSRN

Professor of Nursing Long Island University Brooklyn New York, New York

Dr.Melissa Brock , MSM, MSN, ANP-C, DHEd

Nursing Professor Indiana Wesleyan University Indianapolis, Indiana

Celeste Brown-Apoh, RN, MSN

Instructor Rowan College at Burlington County Pemberton, New Jersey

Jean Burt, MSN, RN

Instructor Wilbur Wright College Chicago, Illinois

Nicola Contreras, MSN, RN

VN/ADN Faculty

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Galen College of Nursing San Antonio, Texas

Sherri Cozzens, RN, MS

Nursing Faculty De Anza College Cupertino, California

Jodie Fox, MSN, RN-BC

Assistant Professor Viterbo University Lacrosse, Wisconsin

Florida Freeman, PhD, MSN, RN

Professor of Nursing University of St. Francis Joliet, Illinois

Betsy D. Gulledge, PhD, RN, CNE, NEA-BC

Associate Dean/Assistant Professor of Nursing Jacksonville State University Jacksonville, Alabama

Kris Hale, MSN, RN

Professor/Department Chair San Diego City College San Diego, California

Cheryl Harrington, MSN, RN, MHA

Clinical Simulation Specialist Morningside College Sioux City, Iowa

Mary Jane Holman, RN

Instructor Louisiana State University Shreveport Shreveport, Louisiana

Laly Joseph, DVM, DNP, MSN, RN, C, ARNP, BC

Clinical Assistant Professor Fairleigh Dickinson University Teaneck, New Jersey

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Ronnie Knabe, MSN, RN, CCRN

Associate Professor, Nursing Bakersfield College Bakersfield, California

Amy Langley

Health Science Division Director Snead State Community College Boaz, Alabama

Debora Lemon, MN, RN

Associate Professor Lewis-Clark State College Lewiston, Idaho

Susan McClendon, MSN, RN, CNS

Nursing Faculty Lakeland Community College Kirkland, Ohio

Mary Alice Momeyer, DNP, ANP-BC, GNP-BC

Assistant Clinical Professor The Ohio State University College of Nursing Columbus, Ohio

Jon F. Nutting, MA, RN-BC

Instructor Galen College of Nursing Tampa Bay Campus St. Petersburg, Florida

Teresa M. Page, DNP, EdS, MSN, RN, FNP-BC

Assistant Professor of Nursing Liberty University Lynchburg, Virginia

LoriAnn Pajalich, MS, RN, CNS, GCNS-BC

Assistant Professor of Nursing Wilkes University Wilkes-Barre, Pennsylvania

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Debra Parker, DNP, RN

Assistant Professor Indiana Wesleyan University Marion, Indiana

Cordelia Schaffer, MSN, RN, CHPN

Associate Professor Westminster College Salt Lake City, Utah

Crystal Schauerte-O’Connell

Program Coordinator, Year 2 Algonquin College Ottawa, Ontario

Maura C. Schlairet, EdD, MA, MSN, RN, CNL (A/H)

Professor of Nursing Valdosta State University Valdosta, Georgia

Nichole Spencer, MSN, APRN, ANP-C

Assistant Professor of Nursing William Jewell College Liberty, Missouri

Carolyn Sue-Ling, MSN, MPA, RN

Instructor University of South Carolina Aiken Aiken, South Carolina

Michael T. Valenti, AAS, BS, MS

Assistant Professor of Nursing Long Island University Brookville, New York

Stephanie Vaughn, PhD, RN, CRRN, FAHA

Professor/Director School of Nursing California State University, Fullerton Fullerton, California

Erica Williams-Woodley, MSN, NP

Assistant Professor of Nursing

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Bronx Community College New York, New York

Jane Zaccardi, MA, RN, GCNS-BC

Director of Practical Nursing and Health Occupations Programs Johnson County Community College Overland Park, Kansas

For a list of the contributors to the Instructor Resources and a list of the reviewers of the Test Generator questions accompanying this book, please visit http://thepoint.lww.com/Eliopoulos9e.

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Acknowledgments

There are many individuals who played important roles in the birth and development of this book. I will always be grateful to Bill Burgower, a Lippincott editor, who decades ago responded to my urging that the new specialty of gerontological nursing needed resources by encouraging me to write the first edition of Gerontological Nursing. Many fine members of the Wolters Kluwer team have guided and assisted me since, including Natasha McIntyre, Acquisitions Editor, who consistently offered encouragement and direction; Meredith Brittain, Senior Development Editor, who brought a new set of eyes to the book and ironed out the rough edges through her fine editorial skills; Dan Reilly and Leo Gray, Editorial Assistants at different points in this project, who attended to the details that contribute to a quality finished product; and Priscilla Crater, Production Project Manager, who shepherded the book from manuscript through printed pages.

Lastly, I am deeply indebted to those mentors and leaders in gerontological care who generously offered encouragement and the many older adults who have touched my life and showed me the wisdom and beauty of aging. The insight these individuals provided could have never been learned in a book!

Charlotte Eliopoulos

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Brief Contents

UNIT 1 THE AGING EXPERIENCE 1 The Aging Population 2 Theories of Aging 3 Diversity 4 Life Transitions and Story 5 Common Aging Changes

UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6 The Specialty of Gerontological Nursing 7 Holistic Assessment and Care Planning 8 Legal Aspects of Gerontological Nursing 9 Ethical Aspects of Gerontological Nursing 10 Continuum of Care in Gerontological Nursing

UNIT 3 HEALTH PROMOTION 11 Nutrition and Hydration 12 Sleep and Rest 13 Comfort and Pain Management 14 Safety 15 Spirituality 16 Sexuality and Intimacy 17 Safe Medication Use

UNIT 4 GERIATRIC CARE 18 Respiration 19 Circulation 20 Digestion and Bowel Elimination 21 Urinary Elimination 22 Reproductive System Health 23 Mobility 24 Neurologic Function 25 Vision and Hearing

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26 Endocrine Function 27 Skin Health 28 Cancer 29 Mental Health Disorders 30 Delirium and Dementia 31 Living in Harmony With Chronic Conditions

UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32 Rehabilitative and Restorative Care 33 Acute Care 34 Long-Term Care 35 Family Caregiving 36 End-of-Life Care Index

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Contents

UNIT 1 THE AGING EXPERIENCE 1 The Aging Population Views Of Older Adults Through History

Characteristics Of The Older Adult Population

Population Growth and Increasing Life Expectancy Marital Status and Living Arrangements Income and Employment

Health Insurance

Health Status Implications Of An Aging Population

Impact of the Baby Boomers Provision of and Payment for Services

2 Theories of Aging Biological Theories Of Aging

Stochastic Theories Nonstochastic Theories

Sociologic Theories of Aging

Disengagement Theory Activity Theory Continuity Theory Subculture Theory Age Stratification Theory

Psychological Theories of Aging

Developmental Tasks Gerotranscendence

Nursing Theories of Aging

Functional Consequences Theory Theory of Thriving Theory of Successful Aging

Applying Theories of Aging to Nursing Practice

3 Diversity Increasing Diversity Of The Older Adult Population

Overview Of Diverse Groups Of Older Adults In The United States

Hispanic Americans Black Americans Asian Americans Jewish Americans

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Native Americans Muslims Gay, Lesbian, Bisexual, and Transgender Older Adults

Nursing Considerations For Culturally Sensitive Care Of Older Adults

4 Life Transitions and Story Ageism

Changes In Family Roles And Relationships

Parenting Grandparenting

Loss Of Spouse

Retirement

Loss of the Work Role Reduced Income

Changes In Health And Functioning

Cumulative Effects Of Life Transitions

Shrinking Social World Awareness of Mortality

Responding To Life Transitions

Life Review and Life Story Self-Reflection Strengthening Inner Resources

5 Common Aging Changes Changes To The Body

Cells Physical Appearance Respiratory System Cardiovascular System Gastrointestinal System Urinary System Reproductive System Musculoskeletal System Nervous System Sensory Organs Endocrine System Integumentary System Immune System Thermoregulation

Changes To The Mind

Personality Memory Intelligence

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Learning Attention Span

Nursing Implications Of Age-Related Changes

UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING 6 The Specialty of Gerontological Nursing Development Of Gerontological Nursing

Core Elements Of Gerontological Nursing Practice

Evidence-Based Practice Standards Competencies Principles

Gerontological Nursing Roles

Healer Caregiver Educator Advocate Innovator

Advanced Practice Nursing Roles

Self-Care And Nurturing

Following Positive Health Care Practices Strengthening and Building Connections Committing to a Dynamic Process

The Future Of Gerontological Nursing

Utilize Evidence-Based Practices Advance Research Promote Integrative Care Educate Caregivers Develop New Roles Balance Quality Care and Health Care Costs

7 Holistic Assessment and Care Planning Holistic Gerontological Care

Holistic Assessment Of Needs

Health Promotion–Related Needs Health Challenges–Related Needs Requisites to Meet Needs

Gerontological Nursing Processes

Examples Of Application

Applying the Holistic Model: The Case of Mrs. D The Nurse As Healer

Healing Characteristics

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8 Legal Aspects of Gerontological Nursing Laws Governing Gerontological Nursing Practice

Legal Risks In Gerontological Nursing

Malpractice Confidentiality Patient Consent Patient Competency Staff Supervision Medications Restraints Telephone Orders Do Not Resuscitate Orders Advance Directives and Issues Related to Death and Dying Elder Abuse

Legal Safeguards For Nurses

9 Ethical Aspects of Gerontological Nursing Philosophies Guiding Ethical Thinking

Ethics In Nursing

External and Internal Ethical Standards Ethical Principles Cultural Considerations

Ethical Dilemmas Facing Gerontological Nurses

Changes Increasing Ethical Dilemmas for Nurses Measures to Help Nurses Make Ethical Decisions

10 Continuum of Care in Gerontological Nursing Services In The Continuum Of Care For Older Adults

Supportive and Preventive Services Partial and Intermittent Care Services Complete and Continuous Care Services Complementary and Alternative Services

Matching Services To Needs

Settings And Roles For Gerontological Nurses

UNIT 3 HEALTH PROMOTION 11 Nutrition and Hydration Nutritional Needs Of Older Adults

Quantity and Quality of Caloric Needs Nutritional Supplements Special Needs of Women

Hydration Needs Of Older Adults

Promotion Of Oral Health

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Threats To Good Nutrition

Indigestion and Food Intolerance Anorexia Dysphagia Constipation Malnutrition

Addressing Nutritional Status And Hydration In Older Adults

12 Sleep and Rest Age-Related Changes in Sleep

Circadian Sleep–Wake Cycles Sleep Stages Sleep Efficiency and Quality

Sleep Disturbances

Insomnia Nocturnal Myoclonus and Restless Legs Syndrome Sleep Apnea Medical Conditions That Affect Sleep Drugs That Affect Sleep Other Factors Affecting Sleep

Promoting Rest and Sleep in Older Adults

Pharmacologic Measures to Promote Sleep Nonpharmacologic Measures to Promote Sleep Pain Control

13 Comfort and Pain Management Comfort

Pain: A Complex Phenomenon

Prevalence Of Pain In Older Adults

Types of Pain Pain Perception Effects of Unrelieved Pain

Pain Assessment

An Integrative Approach To Pain Management

Complementary Therapies Dietary Changes Medication Comforting

14 Safety Aging And Risks To Safety

Importance Of The Environment To Health And Wellness

Impact Of Aging On Environmental Safety And Function

Lighting

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Temperature Colors Scents Floor Coverings Furniture Sensory Stimulation Noise Control Bathroom Hazards Fire Hazards Psychosocial Considerations

The Problem Of Falls

Risks and Prevention Risks Associated With Restraints

Interventions To Reduce Intrinsic Risks To Safety

Reducing Hydration and Nutrition Risks Addressing Risks Associated With Sensory Deficits Addressing Risks Associated With Mobility Limitations Monitoring Body Temperature Preventing Infection Suggesting Sensible Clothing Using Medications Cautiously Avoiding Crime Promoting Safe Driving Promoting Early Detection of Problems Addressing Risks Associated With Functional Impairment

15 Spirituality Spiritual Needs

Love Meaning and Purpose Hope Dignity Forgiveness Gratitude Transcendence Expression of Faith

Assessing Spiritual Needs

Addressing Spiritual Needs

Being Available Honoring Beliefs and Practices Providing Opportunities for Solitude

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Promoting Hope Assisting in Discovering Meaning in Challenging Situations Facilitating Religious Practices Praying With and for

16 Sexuality and Intimacy Attitudes Toward Sex And Older Adults

Realities Of Sex In Older Adulthood

Sexual Behavior and Roles Intimacy Age-Related Changes and Sexual Response

Menopause As A Journey To Inner Connection

Symptom Management and Patient Education Self-Acceptance Andropause

Identifying Barriers To Sexual Activity

Unavailability of a Partner Psychological Barriers Medical Conditions Erectile Dysfunction Medication Adverse Effects Cognitive Impairment

Promoting Healthy Sexual Function

17 Safe Medication Use Effects Of Aging On Medication Use

Polypharmacy and Interactions Altered Pharmacokinetics Altered Pharmacodynamics Increased Risk of Adverse Reactions

Promoting The Safe Use Of Drugs

Avoiding Potentially Inappropriate Drugs: Beers Criteria Reviewing Necessity and Effectiveness of Prescribed Drugs Promoting Safe and Effective Administration Providing Patient Teaching Monitoring Laboratory Values

Alternatives To Drugs

Review Of Selected Drugs

Analgesics Antacids Antibiotics Anticoagulants Anticonvulsants

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Antidiabetic (Hypoglycemic) Drugs Antihypertensive Drugs Nonsteroidal Anti-inflammatory Drugs Cholesterol-Lowering Drugs Cognitive Enhancing Drugs Digoxin Diuretics Laxatives Psychoactive Drugs

UNIT 4 GERIATRIC CARE 18 Respiration Effects Of Aging On Respiratory Health

Respiratory Health Promotion

Selected Respiratory Conditions

Chronic Obstructive Pulmonary Disease Pneumonia Influenza Lung Cancer Lung Abscess

General Nursing Considerations For Respiratory Conditions

Recognizing Symptoms Preventing Complications

Ensuring Safe Oxygen Administration

Performing Postural Drainage Promoting Productive Coughing Using Complementary Therapies Promoting Self-Care Providing Encouragement

19 Circulation Effects Of Aging On Cardiovascular Health

Cardiovascular Health Promotion

Proper Nutrition Adequate Exercise Cigarette Smoke Avoidance Stress Management Proactive Interventions

Cardiovascular Disease And Women

Selected Cardiovascular Conditions

Hypertension

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Hypotension Congestive Heart Failure Pulmonary Emboli Coronary Artery Disease Hyperlipidemia Arrhythmias Peripheral Vascular Disease

General Nursing Considerations For Cardiovascular Conditions

Prevention Keeping the Patient Informed Preventing Complications Promoting Circulation Providing Foot Care Managing Problems Associated With Peripheral Vascular Disease Promoting Normality Integrating Complementary Therapies

20 Digestion and Bowel Elimination Effects Of Aging On Gastrointestinal Health

Gastrointestinal Health Promotion

Selected Gastrointestinal Conditions And Related Nursing Considerations

Dry Mouth (Xerostomia) Dental Problems Dysphagia Hiatal Hernia Esophageal Cancer Peptic Ulcer Cancer of the Stomach Diverticular Disease Colorectal Cancer Chronic Constipation Flatulence Intestinal Obstruction Fecal Impaction Fecal Incontinence Acute Appendicitis Cancer of the Pancreas Biliary Tract Disease

21 Urinary Elimination Effects Of Aging On Urinary Elimination

Urinary System Health Promotion

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Selected Urinary Conditions

Urinary Tract Infection Urinary Incontinence Bladder Cancer Renal Calculi Glomerulonephritis

General Nursing Considerations For Urinary Conditions

22 Reproductive System Health Effects Of Aging On The Reproductive System

Reproductive System Health Promotion

Selected Reproductive System Conditions

Problems of the Female Reproductive System Problems of the Male Reproductive System

23 Mobility Effects Of Aging On Musculoskeletal Function

Musculoskeletal Health Promotion

Promotion of Physical Exercise in All Age Groups Exercise Programs Tailored for Older Adults The Mind–Body Connection Prevention of Inactivity Nutrition

Selected Musculoskeletal Conditions

Fractures Osteoarthritis Rheumatoid Arthritis Osteoporosis Gout Podiatric Conditions

General Nursing Considerations For Musculoskeletal Conditions

Managing Pain Preventing Injury Promoting Independence

24 Neurologic Function Effects Of Aging On The Nervous System

Neurologic Health Promotion

Selected Neurologic Conditions

Parkinson’s Disease Transient Ischemic Attacks Cerebrovascular Accidents

General Nursing Considerations For Neurologic Conditions

Promoting Independence

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Preventing Injury

25 Vision and Hearing Terms to Know

Effects of Aging on Vision and Hearing

Sensory Health Promotion

Promoting Vision Promoting Hearing Assessing Problems

Selected Vision and Hearing Conditions and Related Nursing Interventions

Visual Deficits Hearing Deficits

General Nursing Considerations for Visual and Hearing Deficits

26 Endocrine Function Effects Of Aging On Endocrine Function

Selected Endocrine Conditions And Related Nursing Considerations

Diabetes Mellitus Hypothyroidism Hyperthyroidism

27 Skin Health Effects Of Aging On The Skin

Promotion Of Skin Health

Selected Skin Conditions

Pruritus Keratosis Seborrheic Keratosis Skin Cancer Vascular Lesions Pressure Injury

General Nursing Considerations For Skin Conditions

Promoting Normalcy Using Alternative Therapies

28 Cancer Aging And Cancer

Unique Challenges for Older Persons With Cancer Explanations for Increased Incidence in Old Age

Risk Factors, Prevention, And Screening

Treatment

Conventional Treatment Complementary and Alternative Medicine

Nursing Considerations For Older Adults With Cancer

Providing Patient Education

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Promoting Optimum Care Providing Support to Patients and Families

29 Mental Health Disorders Aging And Mental Health

Promoting Mental Health In Older Adults

Selected Mental Health Conditions

Depression Anxiety Substance Abuse Paranoia

Nursing Considerations For Mental Health Conditions

Monitoring Medications Promoting a Positive Self-Concept Managing Behavioral Problems

30 Delirium and Dementia Delirium

Dementia

Alzheimer’s Disease Other Dementias Caring for Persons With Dementia

31 Living in Harmony With Chronic Conditions Chronic Conditions And Older Adults

Goals For Chronic Care

Assessment Of Chronic Care Needs

Maximizing The Benefits Of Chronic Care

Selecting an Appropriate Physician Using a Chronic Care Coach Increasing Knowledge Locating a Support Group Making Smart Lifestyle Choices Using Complementary and Alternative Therapies

Factors Affecting The Course Of Chronic Care

Defense Mechanisms and Implications Psychosocial Factors Impact of Ongoing Care on the Family The Need for Institutional Care

Chronic Care: A Nursing Challenge

UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE 32 Rehabilitative and Restorative Care Rehabilitative And Restorative Care

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Living With Disability

Importance of Attitude and Coping Capacity Losses Accompanying Disability

Principles Of Rehabilitative Nursing

Functional Assessment

Interventions To Facilitate And Improve Functioning

Facilitating Proper Positioning Assisting with Range-of-Motion Exercises Assisting with Mobility Aids and Assistive Technology Teaching About Bowel and Bladder Training Maintaining and Promoting Mental Function Using Community Resources

33 Acute Care Risks Associated With Hospitalization Of Older Adults

Surgical Care

Special Risks for Older Adults Preoperative Care Considerations Operative and Postoperative Care Considerations

Emergency Care

Infections

Discharge Planning For Older Adults

34 Long-Term Care Development Of Long-Term Institutional Care

Before the 20th Century During the 20th Century Lessons to Be Learned From History

Nursing Homes Today

Nursing Home Standards Nursing Home Residents Nursing Roles and Responsibilities

Other Settings For Long-Term Care

Assisted Living Communities Community-Based and Home Health Care

Looking Forward: A New Model Of Long-Term Care

35 Family Caregiving The Older Adult’s Family

Identification of Family Members Family Member Roles Family Dynamics and Relationships

Scope Of Family Caregiving

Long-Distance Caregiving

Protecting The Health Of The Older Adult And Caregiver

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Family Dysfunction And Abuse

Rewards Of Family Caregiving

36 End-of-Life Care Definitions Of Death

Family Experience With The Dying Process

Supporting The Dying Individual

Stages of the Dying Process and Related Nursing Interventions Rational Suicide and Assisted Suicide Physical Care Challenges Spiritual Care Needs Signs of Imminent Death Advance Directives

Supporting Family And Friends

Supporting Through the Stages of the Dying Process Helping Family and Friends After a Death

Supporting Nursing Staff

Index

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Index of Selected Features

Consider This Case

For Chapter 1

For Chapter 2

For Chapter 3

For Chapter 4

For Chapter 5

For Chapter 6

For Chapter 7

For Chapter 8

For Chapter 9

For Chapter 10

For Chapter 11

For Chapter 12

For Chapter 13

For Chapter 14

For Chapter 15

For Chapter 16

For Chapter 17

For Chapter 18

For Chapter 19

For Chapter 20

For Chapter 21

For Chapter 22

For Chapter 23

For Chapter 24

For Chapter 25

For Chapter 26

For Chapter 27

For Chapter 28

For Chapter 29

For Chapter 30

For Chapter 31

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For Chapter 32

For Chapter 33

For Chapter 34

For Chapter 35

For Chapter 36

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Assessment Guides

Assessment Guide 11-1 Nutritional Status

Assessment Guide 13-1 Pain

Assessment Guide 15-1 Spiritual Needs

Assessment Guide 16-1 Sexual Health

Assessment Guide 18-1 Respiratory Function

Assessment Guide 19-1 Cardiovascular Function

Assessment Guide 20-1 Gastrointestinal Function

Assessment Guide 21-1 Urinary Function

Assessment Guide 22-1 Reproductive System Health

Assessment Guide 23-1 Musculoskeletal Function

Assessment Guide 24-1 Neurologic Function

Assessment Guide 25-1 Vision and Hearing

Assessment Guide 27-1 Skin Status

Assessment Guide 29-1 Mental Health

Assessment Guide 30-1 Mental Health

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Nursing Care Plans

Nursing Care Plan 7-1 Holistic Care For Mrs. D

Nursing Care Plan 18-1 The Older Adult With Chronic Obstructive Pulmonary Disease

Nursing Care Plan 19-1 The Older Adult With Heart Failure

Nursing Care Plan 20-1 The Older Adult With Hiatal Hernia

Nursing Care Plan 20-2 The Older Adult With Fecal Incontinence

Nursing Care Plan 21-1 The Older Adult With Urinary Incontinence

Nursing Care Plan 22-1 The Older Adult Recovering From Prostate Surgery

Nursing Care Plan 23-1 The Older Adult With Osteoarthritis

Nursing Care Plan 24-1 The Older Adult With A Cerebrovascular Accident: Convalescence Period

Nursing Care Plan 25-1 The Older Adult With Open-Angle Glaucoma

Nursing Care Plan 30-1 The Older Adult With Alzheimer’s Disease

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UNIT 1 The Aging Experience

1. The Aging Population 2. Theories of Aging

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3. Diversity 4. Life Transitions and Story 5. Common Aging Changes

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CHAPTER 1

The Aging Population

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CHAPTER OUTLINE

Views Of Older Adults Through History

Characteristics Of The Older Adult Population

Population Growth and Increasing Life Expectancy

Marital Status and Living Arrangements

Income and Employment

Health Insurance

Health Status

Implications Of An Aging Population

Impact of the Baby Boomers

Provision of and Payment for Services

LEARNING OBJECTIVES After reading this chapter, you should be able to:

1. Explain the different ways in which older adults have been viewed throughout history. 2. Describe characteristics of today’s older population in regard to:

life expectancy marital status living arrangements income and employment health status

3. Discuss projected changes in future generations of older people and the implications for health care.

TERMS TO KNOW Comorbidity: the simultaneous presence of multiple chronic conditions

Compression of morbidity: hypothesis that serious illness and decline can be delayed or postponed so that an extended life expectancy results in more functional, healthy years

Life expectancy: the length of time that a person can be predicted to live

Life span: the maximum years that a person has the potential to live

“Families forget their older relatives … most people become senile in old age … Social Security provides every older person with a decent retirement income … a majority of older people reside in nursing homes … Medicare covers all health care–related costs for older people.” These and other myths continue to be perpetuated about older people. Misinformation about the older population is an injustice not only to this age group but also to persons of all ages who need accurate information to prepare realistically for their own senior years. Gerontological nurses must know the facts about the older population to effectively deliver services and educate the general public.

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VIEWS OF OLDER ADULTS THROUGH HISTORY The members of the current older population in the United States have offered the sacrifice, strength, and spirit that made this country great. They were the proud GIs who served in wars, the brave immigrants who ventured into a new country, the bold entrepreneurs who took risks that created wealth and opportunities for employment, the campus rebels who advocated for the rights of minorities, and the unselfish parents who struggled to give their children a better life. They have earned respect, admiration, and dignity. Today, older adults are viewed with positivism rather than prejudice, knowledge rather than myth, and concern rather than neglect. This positive view was not always the norm, however.

Historically, societies have viewed their elder members in a variety of ways. In the time of Confucius, there was a direct correlation between a person’s age and the degree of respect to which he or she was entitled. The early Egyptians dreaded growing old and experimented with a variety of potions and schemes to maintain their youth. Opinions were divided among the early Greeks. Plato promoted older adults as society’s best leaders, whereas Aristotle denied older people any role in governmental matters. In the nations conquered by the Roman Empire, the sick and aged were customarily the first to be killed. And, woven throughout the Bible is God’s concern for the well-being of the family and desire for people to respect elders (Honor your father and your mother … Exodus 20:12). Yet, the honor bestowed on older adults was not sustained.

Medieval times gave rise to strong feelings regarding the superiority of youth; these feelings were expressed in uprisings of sons against fathers. Although England developed Poor Laws in the early 17th century that provided care for the destitute and enabled older persons without family resources to have some modest safety net, many of the gains were lost during the Industrial Revolution. No labor laws protected persons of advanced age; those unable to meet the demands of industrial work settings were placed at the mercy of their offspring or forced to beg on the streets for sustenance.

The first significant step in improving the lives of older Americans was the passage of the Federal Old Age Insurance Law under the Social Security Act in 1935, which provided some financial security for older persons. The profound “graying” of the population started to be realized in the 1960s, and the United States responded with the formation of the Administration on Aging, enactment of the Older Americans Act, and the introduction of Medicaid and Medicare, all in 1965 (Box 1-1).

Box 1-1 Publicly Supported Programs of Benefit to Older Americans

1900 Pension laws passed in some states

1935 Social Security Act

1961 First White House Conference on Aging

1965 Older Americans Act: nutrition, senior employment, and transportation programs

Administration on Aging

Medicare (Title 18 of Social Security Act)

Medicaid (Title 19 of Social Security Act) for poor and disabled of any age

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1972 Supplemental Security Income (SSI) enacted

1991 Omnibus Budget Reconciliation Act (nursing home reform law) implemented

Since that time, American society has demonstrated a profound awakening of interest in older persons as their numbers have grown. A more humanistic attitude toward all members of society has benefited older adults, and improvements in health care and general living conditions ensure that more people have the opportunity to attain old age and live longer, more fruitful years in later adulthood than previous generations (Fig. 1-1).

FIGURE 1-1 • It is important for gerontological nurses to be as concerned with adding quality to the lives of older adults as they are with increasing the quantity of years.

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CHARACTERISTICS OF THE OLDER ADULT POPULATION Older adults are generally defined as individuals aged 65 years and older. At one time, all persons over 65 years of age were grouped together under the category of “old.” Now it is recognized that much diversity exists among different age groups in late life, and older individuals can be further categorized as follows:

young-old: 65 to 74 years old: 75 to 84 years oldest-old 85+

The profile, interests, and health care challenges of each of these subsets can be vastly different. For example, a 66-year-old may desire cosmetic surgery to stay competitive in the executive job market; a 74-year-old may have recently remarried and want to do something about her dry vaginal canal; an 82-year-old may be concerned that his arthritic knees are limiting his ability to play a round of golf; and a 101-year-old may be desperate to find a way to correct her impaired vision so that she can enjoy television.

In addition to chronological age, or the years a person has lived since birth, functional age is a term used by gerontologists to describe physical, psychological, and social function; this is relevant in that how older adults feel and function may be more indicative of their needs than their chronological age. Perceived age is another term that is used to describe how people estimate a person’s age based on appearance. Studies have shown a correlation between perceived age and health, in addition to how others treated older adults based on perceived age and the resultant health of those older adults (Sutin, Stephan, Carretta, & Terracciano, 2014).

How people feel or perceive their own age is described as age identity. Some older adults will view peers of similar age as being older than themselves and be reluctant to join senior groups and other activities because they see the group members as “old people” and different from themselves.

Any stereotypes held about older people must be discarded; if anything, greater diversity rather than homogeneity will be evident. Further, generalizations based on age need to be eliminated as behavior, function, and self-image can reveal more about priorities and needs than chronological age alone.

COMMUNICATION TIP Not all persons of the same age will be similar in terms of language style, familiarity with current terms, use of technology, education, and life experience. Communication style and method must be based on assessed language competency, style, and preference of the individual.

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Population Growth and Increasing Life Expectancy There was a significant growth in the number of older people for most of the 20th century. Except for the 1990s, the older population grew at a rate faster than that of the total population under age 65. The U.S. Census Bureau projects that a substantial increase in the number of individuals over age 65 will occur between 2010 and 2030 due to the impact of the baby boomers, who began to enter this group in 2011. In 2030, it is projected that this group will represent nearly 20% of the total U.S. population.

Currently, persons older than 65 years represent more than 13% of the population in the United States. This growth of the older adult population is due in part to increasing life expectancy. Advancements in disease control and health technology, lower infant and child mortality rates, improved sanitation, and better living conditions have increased life expectancy for most Americans. More people are surviving to their senior years than ever before. In 1930, slightly more than 6 million persons were aged 65 years or older, and the average life expectancy was 59.7 years. The life expectancy in 1965 was 70.2 years, and the number of older adults exceeded 20 million. Life expectancy has now reached 78.2 years, with over 34 million persons exceeding age 65 years (Table 1-1). Not only are more people reaching old age, but they are living longer once they do; the number of people in their 70s and 80s has been steadily increasing and is expected to continue to increase. The population over age 85 years is projected to double by the year 2036 and triple by 2049. The life span currently is 122 years for humans.

TABLE 1-1 Differences in Life Expectancy at Birth by Race, Sex, and Hispanic Origin

Source: National Center for Health Statistics. (2013). Table 18. Life expectancy at birth, at age 65, and at age 75 by sex, race, and national origin: United States, selected years. Health, United States, 2013. Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/hus/hus13.pdf#018; U.S. Census Bureau. Table 10. Projected life expectancy at birth by sex, race, and Hispanic origin for the United States. Retrieved from http://www.census.gov/population/projections/data/national/2012/summarytables.html

KEY CONCEPT More people are achieving and spending longer periods of time in old age than ever before in history.

Although life expectancy has increased, it still differs by race and gender, as Table 1-1 shows. From the late 1980s to the present, the gap in life expectancy between white people and black people has widened because the life expectancy of the black population has declined. The U.S. Department of Health and Human Services attributes the declining life expectancy of black people to heart disease, cancer, homicide, diabetes, and perinatal conditions. This reality underscores the need for nurses to be concerned with health and social issues

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of persons of all ages because these impact a population’s aging process.

Whereas the gap in life expectancy has widened among the races, the gap is narrowing between the sexes. Throughout the 20th century, the ratio of men to women had steadily declined to the point where there were fewer than 7 older men for every 10 older women. The ratio declined with each advanced decade. However, in the 21st century, this trend is changing, and the ratio of men to women is increasing.

Although living longer is desirable, of significant importance is the quality of those years. More years to life means little if those additional years consist of discomfort, disability, and a poor quality of life. This has led to a hypothesis advanced by James Fries, a professor of medicine at Stanford University, called the compression of morbidity (Fries, 1980; Swartz, 2008). This hypothesis suggests that if the onset of serious illness and decline would be delayed, or compressed, into a few years prior to death, people could live a long life and enjoy a healthy, functional state for most of their lives.

POINT TO PONDER A higher proportion of older adults in our society means that younger age groups will be carrying a greater tax burden to support the older population. Should young families sacrifice to support services for older adults? Why or why not?

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Marital Status and Living Arrangements The higher survival rates of women, along with the practice of women marrying men older than themselves, make it no surprise that more than half of women older than 65 years are widowed, and most of their male contemporaries are married. Married people have a lower mortality rate than do unmarried people at all ages, with men having a larger advantage.

Most older adults live in a household with a spouse or other family member, although more than twice the number of women than men live alone in later life. The likelihood of living alone increases with age for both sexes. Most older people have contact with their families and are not forgotten or neglected. Realities of the aging family are discussed in greater detail in Chapter 35.

KEY CONCEPT Women are more likely to be widowed and living alone in late life than are their male counterparts.

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Income and Employment The percentage of older people living below the poverty level has been declining, with about 10% now falling into this category. However, older adults still do face financial problems. Most older people depend on Social Security for more than half of their income (Box 1-2). Women and minority groups have considerably less income than do white men. Although the median net worth of older households is nearly twice the national average because of the high prevalence of home ownership by elders, many older adults are “asset rich and cash poor.” The recent decline in housing prices, however, has made that asset a less valuable one for many older adults.

Box 1-2 Social Security and Supplemental Security Income Social Security: a benefit check paid to retired workers of specific minimum age (e.g., 65 years), disabled workers of any age, and spouses and minor children of those workers. Benefits are not dependent on financial need. It is intended to serve as supplement to other sources of income in retirement.

Supplemental Security Income (SSI): a benefit check paid to persons over age 65 and/or persons with disabilities based on financial need.

Although the percentage of the total population that older adults represent is growing, they constitute a steadily declining percentage of workers in the labor force. The withdrawal of men from the workforce at earlier ages has been one of the most significant labor force trends since World War II. There has been, however, a significant rise in the percentage of middle-aged women who are employed, although there has been little change in the labor force participation of women 65 years of age and older. Most baby boomers are expressing a desire and need to continue working as they enter retirement age.

CONSIDER THIS CASE

Mr. and Mrs. Murdock are both 67 years of age and in good health. Mr. Murdock owns and manages several investment properties that require hi