Health promotion is an important activity throughout the life span. Older adults are not too old to stop smoking, start exercising, or change their diets. One of the greatest challenges is to dispel misconceptions about health promotion among older adults.
It is important for the nurse to understand normal physiological changes that occur with age and to know how to adapt teaching strategies to accommodate for normal aging changes.As chronic illnesses become more prevalent after the fifth or sixth decades of life, a majority of health teaching for older adults focuses on illness and disease management. Older people are often coping with varying types of loss, including the loss of a spouse, life-long friends, and individual physical capabilities. It is important to interact with each elderly patient as a unique individual, capable of learning and changing. Patient teaching for older people should be delivered with the same enthusiasm and conviction with which it is provided to younger patients. In addition to specific disease issues or treatment recommendations, many older adults are interested in sexuality and aging, exercise, nutrition, and other topics related to preventing illness and promoting quality of life. The older patient’s barriers to independence should be assessed to help him or her find ways to maximize strengths and promote independence. The nurse is often in an excellent position to help patients follow medical recommendations by providing information, considering patients‘ individual needs, building an awareness of community services that can help lessen social isolation, and helping them maintain their independence.
Learning capacity usually remains at an efficient level well into the 80s. In fact, the inability to absorb new information may be the first indication of a subclinical disease process in an aging person. Instead of using stereotypical modifications, such as shorter sessions or a slower pace, make sure to assess each older person individually.8 Although ill elderly learn with difficulty, many older people require no modification in teaching strategies. It is important to give all older learners a chance to show their inquisitiveness and lifelong experience.
Assessing learning needs for the older adult
During all phases of the teaching-leaning process (including assessment, planning, implementation, and evaluation), you should focus your attention not just on the existing medical problem, but also on the potentially numerous functional and psychosocial problems that are common to old age. A detailed history is a critical part of the assessment. If the patient is not a reliable informant, a family member or significant other should be included. Besides the medical history, a comprehensive social history can identify potential problems with the home environment, support systems, financial resources, and various stresses that may be contributing to the medical problem. An accurate diet history is especially important if the patient is being placed on any kind of diet restriction. It is good practice to ask the elderly patient to bring in all medications, both prescription and over-the-counter, for complete evaluation.
With advancing age, there is a corresponding normal decline in sensory function, including vision, hearing, and touch. Two-thirds of the frail elderly have vision and hearing deficits. In addition, there is a normal decline in physical dexterity and endurance. Eighty percent of people over 65 have some form of chronic disease. The effects of chronic diseases, together with the normal changes that occur with aging, may impede learning.
Doing a psychosocial assessment also yields important information about the patient’s ability to follow a recommended treatment plan. There are many reasons why an elderly patient may not follow a treatment plan. The patient may not see that the medical regimen is pertinent to his or her well-being. The patient may simply not choose to make lifestyle changes and instead choose to continue long-standing habits and patterns. The patient may choose not to accept a new treatment regimen based on his or her perceptions of quality vs. quantity of life. Finally, the patient, although willing, may be unable to carry out treatment recommendations. The single most important issue in health care management for many people of advanced age is that of personal resources, including the presence of a support person or caregiver in the home, adequate finances, availability of transportation, and a safe and accessible home environment.
The following patient situations illustrate these issues:
- A 67-year-old patient with a new diabetic diet had received days of planned teaching. When asked what she would make for breakfast the day after she returned home, she said that she planned to make her husband and herself a big plate of sausage, gravy, and biscuits. In this situation, the nurse did not probe deeply enough to learn what foods she usually prepared and whether she intended to change her cooking habits.
- A 69-year-old patient was discharged home after demonstrating step by step daily dressing changes from healing burns on his lower legs. When the patient returned to clinic visits, the burns were not healing as expected. It was then learned that he had no plumbing in his home and no access to a bathtub. Obviously, everyone assumed that the patient had bathing facilities and that if he did not, he would tell them.
- A 74-year-old patient was admitted for control of her diabetes. She was not able to correctly draw up and give insulin because of functional hand limitations due to arthritis. The patient stated that she was confident that her 80-year-old sister, with whom she lived, was all the support she would need. However, the home health nurse found on the first home visit that the sister was blind. This situation shows the importance of verifying that an adequate support system is in place.
Teaching strategies to consider for older adults
Consider using specific teaching techniques when providing health teaching for older people. Some elders have increasing difficulty understanding complex sentences, are less proficient than younger people in drawing inferences, and have problems with motor tasks. Present new information at a slower rate than you do for younger patients. Speak in a low tone of voice and allow enough time for the patient to assimilate and integrate conceptual material. Allow plenty of time for the assimilation and integration of conceptual material, and emphasize concrete rather than abstract material. It is important to reduce environmental distractions, both to compensate for any age-related hearing loss and to help the patient with attention and concentration. Group teaching may help some elderly patients increase their health-related problem solving abilities. When suggesting lifestyle changes, be aware that many elderly patients are cautious and may not make changes easily. The implications for patient teaching are that we must take more time in teaching and that we should deliver the educational materials in small increments so that the material can be integrated.
In order for the teaching-learning plan to be effective, it must be individualized to fit the needs and lifestyle of the older patient, and in order for goals to be mutually acceptable, the patient must participate actively in goal setting. The ability to comply with expected behavioral changes depends heavily on the changes being perceived as important by the patient, the changes being able to fit into the patient’s lifestyle, and the availability of adequate resources. In planning patient teaching for an elderly person, goals must be must be individualized not only in accordance with what the patient needs, but with what he or she chooses to do. For example, an 84-year-old patient with COPD and the nurse may agree that to be less short of breath is a goal. The nurse can then plan a teaching program designed to help the patient feel less breathless and can tie interventions such as pursed lip breathing, exercise, activity planning, medications, and nutrition to this one goal.
Compensating for impairments that interfere with learning
If the elderly patient has impaired vision, use adequate diffused light, and avoid having the older patient face a direct source of light. If the patient has prescription glasses, make sure they are being worn, and use large print for labels and instructions. To compensate for hearing loss, use a low-pitched voice, speak clearly and slowly, and face the patient while talking. Encourage the patient who has a hearing aid to use it. Ask the patient questions to verify that he or she has understood what you have said, and give written information as backup to what you’ve presented orally. To compensate for limited endurance, keep teaching sessions short-no more than 10 to 15 minutes-and schedule them to allow the patient rest as needed. During the teaching of any activity or skill, the pace must be set by the patient. Remember that musculoskeletal and nervous system limitations result in joint stiffness and reduced reaction time. These changes affect the performance of simple tasks such as opening a medicine bottle, as well as complex tasks such as transferring from chair to bed. Never rush the older person and do not set time limits on task performance.
With advancing age, a person’s memory is better for information that is heard than it is for information that is seen. Therefore, an older person is more likely to remember information he or she hears than information that he or she reads. To increase learning for a patient with memory loss, repeat the message frequently, and question the patient regularly to determine the level of retention. Pay particular attention to the language you use. Select clear, simple, terminology, and talk on the patient’s level. Some elderly patients are highly educated and will prefer that you use and explain medical terminology; others will prefer that you keep interactions short and simple. Be sure to avoid making assumptions about terms, and help the patient problem solve what to do if instructions can’t be followed for any reason. For example, if a patient is taking a medication „before meals,“ what happens if the patient doesn’t eat-should the drug be taken anyway or skipped until before the next meal?
Keep in mind that return demonstrations are important for elderly patients to ensure that they are able to do psychomotor skills independently. For example, one patient was given instructions for an inhaler, but was not asked to do a return demonstration and didn’t know that the cover should be removed from the inhaler before using it. As a result, she didn’t get the intended therapeutic effect from inhaled medication. Another patient was discharged home in a wheelchair. The physical therapist showed his elderly wife how to do a car to wheelchair transfer, but never asked her to return demonstrate. When they arrived home, the wife was unable to help the patient out of the car, nor was she able to manage and manipulate the wheelchair in the home because she had never had the opportunity to practice these techniques.
Help your older patients and their families with information about how to obtain resource information. Some older patients can access Internet Web sites on their own as sources of health information. In other instances, children and grandchildren may wish to take on the task of locating resource materials on the Internet. The following Web sites are among the many useful ones for elders and their caregivers:
- Agency for Health Research and Quality (AHRQ) guidelines: www.ahrq.gov/consumer
- Administration on Aging: www.aoa.dhhs.gov/elderpage
- Caregiving: www.caregiving.com/support
- Medicare: www.medicare.gov
In order to plan and implement individualized approaches to health teaching, the nurse must take age and developmental level into account. When working with children, you must assess cognitive and psychosocial development. This will influence the level of the teaching strategies chosen and help identify whether parental or peer involvement would facilitate learning. If psychomotor skills are part of the learning need, you must determine whether the child has enough physical maturation to realistically perform the skill. When assessing an adult, emphasis on the developmental stages is different than when assessing a child. The average adult possesses cognitive capacities to learn, so assessing the precise level of cognition becomes less important. Is important to assess current knowledge about the content area. Assess physical skills by focusing on past experience with skills and the adult’s feelings about manipulative competencies. This helps to determine the amount and type of practice that will be needed to master psychomotor skills. Assessment of older adults needs to focus on the physical changes experienced by a given individual. Psychosocial assessment is also important in working with adult age groups. In working with the elderly patient, you may feel overwhelmed trying to teach a patient and family when the frail elderly person may have multiple medical problems and more than 10 medications, and is dependent in several activities of daily living. Yet these patients and families need the most education and support you can provide. Through careful assessment of developmental factors, selection of teaching strategies that are age-appropriate, and compensation where needed to overcome normal deficits seen with aging, you can plan and implement effective patient teaching.