Learning Objectives
By the end of this section, you will be able to:
- Identify physiological health risks for the older adult stage
- Discover psychological health risks for the older adult stage
- Recognize psychosocial health risks for the older adult stage
Health risks for older adults correlate with long-term lifestyle choices, heredity, social circumstances, and SDOHs. While health risks depend on individual circumstances, nurses must be aware of the range of health risks for older adults. By understanding health risks in older adults, nurses can manage and promote disease prevention and appropriate management of existing health conditions. Nurses can focus on high-risk areas, including cognition, nutrition, mobility, and safety. In preventing illness in older adults, nurses across specialties can focus on physiological, psychological, and psychosocial health risks in caring for older adult clients. Because health status depends on age and coexisting illnesses, nurses must diligently provide individualized care, rather than generalized care, in this age group.
Physiological Health Risks
The physiological health risks are those factors affecting the normal biological function of the individual. These risks can range from acute to chronic illness, injuries, nutrition, and mobility issues. Many of these risks are interconnected. As individuals age, they face various physiological changes that elevate their susceptibility to specific health risks. The cardiovascular system undergoes alterations, heightening the chances of heart disease, high blood pressure, and atherosclerosis due to changes in blood vessels and the heart. Osteoporosis becomes a concern as bone density decreases, leading to an increased risk of fractures and falls. Arthritis, marked by joint cartilage degeneration and inflammation, contributes to pain and reduced mobility. Vision and hearing impairments intensify, affecting overall quality of life and increasing the likelihood of accidents. The aging process also involves a reduction in muscle mass and strength, contributing to frailty and a heightened risk of falls. Immune function weakens, making older adults more susceptible to infections and illnesses. Digestive issues, metabolic changes, respiratory problems, renal decline, and alterations in skin integrity further characterize the physiological health risks for older adults. Tooth loss introduces challenges like the use of dentures and the risk of malnutrition or choking from inadequately chewed foods. Elimination issues, including incontinence and constipation, present additional concerns.
Proactive measures, including maintaining a healthy lifestyle, regular exercise, a balanced diet, and consistent medical checkups, are essential to mitigating these risks. Additionally, staying socially active and mentally engaged contribute to overall well-being in aging individuals. Regular communication with healthcare providers is crucial for managing and addressing specific health concerns associated with the aging process. Nurses will find that by paying close attention to client needs, they can identify the interplay between physiological, psychological, and psychosocial risks to create a plan that simultaneously addresses multiple concerns.
Chronic Illness
A chronic illness can be described as a condition requiring medical attention or limiting usual daily activities for over one year (Centers for Disease Control and Prevention [CDC], 2022a). While chronic illness is not inevitable in older adulthood, it is prevalent. According to the National Council on Aging (NCOA) (2023), most adults older than 65 years of age have one chronic illness (95 percent), and a large majority have at least two chronic illnesses (80 percent). The NCOA (2023) also reports the most common and costly chronic illnesses are dementia, cancer, diabetes, and depression. Other high-cost, chronic conditions include hypertension, stroke, heart disease, lung disease, and arthritis. Chronic illness affects nearly all other physiological factors affecting older adults. Nurses must understand the distinct pathophysiology of specific diseases and the interrelationships between chronic illnesses that affect patient outcomes.
Accidental Injuries
Accidental injuries in older adults may include falls, burns, inappropriate medication ingestion, and transportation-related injuries. These injuries can range from mild to severe. Falls are one of the most common causes of injury in older adults. Falls are often linked to other health problems, such as high blood pressure, dizziness, poor mobility, weakness, and vision impairment. Identifying fall risk is crucial in protecting patients from acute injuries such as fractures, head injury, and skin injury, as well as sequelae of these acute injuries that may affect or worsen other health conditions.
Link to Learning
The CDC offers a fall risk prevention checklist to assist nurses, patients, and caregivers in evaluating fall risks in the home.
Functional Ability
Ramnath et al. (2018) describe functional ability as an individual’s ability to effectively complete ADLs without limitations related to pain or fatigue. Functional ability varies widely in the older adult population and is often related to chronic health conditions. Functional ability is related less to age than to overall wellness. Functional ability often determines an individual’s ability to remain independent. The longer a person can remain independent, the better is their quality of life. Nurses can assess areas of declining functional ability and create care plans to address these problems before they impede overall daily functioning. This relates primarily to completing ADLs such as bathing, home care, hygiene, cooking, and cleaning.
Clinical Judgment Measurement Model
Analyze Cues: Tuning in to Functional Ability
The nurse is caring for an older adult in an assisted living facility. The patient has returned recently from a hospital stay after a fall. Prior to the fall, this patient was independent in all ADLs except showering. The nurse notices that the patient has not finished dressing before it is time for breakfast. The nurse also finds that the patient’s hair is ungroomed, and her dentures are still by the bathroom sink. The nurse considers possibilities for the change in patient ability to perform ADLs. The nurse remembers the patient had an injury to her shoulder from the recent fall. The nurse recognizes the patient will need assistance with more tasks that require upper body mobility until her injury completely heals.
Mobility
Mobility also varies widely in the older adult population. Some individuals continue to hike, bike, and engage in other strenuous physical activities, while others have severe limitations in mobility. Mobility is affected by lifestyle, weight, pain, and cardiovascular health. Focusing on maintaining the maximum mobility for an individual affects illness status, nutritional status, elimination status, and psychological status. Mobility changes are correlated with a higher risk for falls, changes in cognition, increased pain, increased symptoms of depression, and an overall reduction in quality of life (Musich et al., 2018).
Nursing interventions promote a patient’s mobility and prevent the adverse effects of immobility. To avoid or minimize complications of immobility, mobilize the patient as soon as possible and to the fullest extent they are able to. Mobilization efforts, ranging from dangling on the edge of the bed, sitting up in a chair, and assisting with early ambulation, depend on the patient’s unique circumstances. Encourage the patient to perform ADLs independently and participate in prescribed physical therapy. Encourage or perform active or passive range of motion exercises as the physical therapist prescribes. Maintaining mobility also promotes balance, flexibility, and strength. By helping older adults improve overall mobility, nurses help reduce individual fall risk and improve overall safety of their patients. Be aware that pain and fear of falling can deter a patient’s willingness to ambulate or perform physical therapy.
Nutritional Imbalances
Nutritional status is also associated with various chronic health conditions, including dementia, kidney disease, heart failure, and chronic respiratory disease. In addition to the physical health of the individual, environmental and financial changes also affect the nutrition status of older adults. While up to 10 percent of older adults struggle with undernutrition, overnutrition and obesity are even more prevalent. Up to one-third of older adults experience the effects of overnutrition (Health in Aging, 2023).
Poor nutrition can contribute to health challenges for older adults, including the following (Norman et al., 2021):
- frailty
- fatigue
- increased fall risk
- worsening dementia
- increased fracture risk
- reduced skin integrity
- poor immune function
Patient Conversations
Nutritional Supplement Safety
Scenario: Vicki is a retired 70-year-old who enjoys walking her dog, painting, and reading. She sees her primary care provider every six months for follow-up on her hypertension and hypercholesterolemia. Claire works as a nurse in the primary care medical office, where Vicki is a patient. While Claire records her current medication list, Vicki discloses a long list of supplements she has recently started on the recommendation of her daughter-in-law. Claire remembers the CDC (2021c) reported that more than 50 percent of adults take one or more vitamins, mineral, or herbal supplements.
Nurse: Vicki, I don’t see these supplements in your medication history. About how long have you been taking these supplements?
Patient: I haven’t been taking them for a long time, maybe a month or so.
Nurse: What is your goal with the variety of supplements you are taking?
Patient: My daughter-in-law thinks I am not active enough and had me start some of these to help with my energy, like the B-vitamin complex and the vitamin D supplement. Also, I am trying to manage my cholesterol naturally, so I have started the red rice yeast supplement and a probiotic. Sometimes I have trouble sleeping, so I take melatonin several nights weekly, which has helped. I also started an immunity vitamin and a multivitamin to help prevent illness this winter.
Nurse: I understand that there are many vitamin and supplement preparations to choose from. Did you bring your vitamin bottles in today, or do you remember what is in the combination supplements you mentioned for energy and immunity?
Patient: Yes, I did remember to bring in the bottles.
Nurse: That’s great. We’ll look at them together, and then you and the provider can discuss it further. I see that both the immunity and multivitamins contain vitamin D and calcium. There are also some B vitamins in the immunity preparation. Your provider will review the total amounts with you to determine whether the doses are safe. Another concern we’ll want you to talk with the provider about is taking the red rice yeast supplement and your prescription cholesterol-lowering medication, as these can interact with each other and affect your liver.
Patient: I didn’t realize that. Vitamins are natural and safe, right? Do I really need to worry about taking too much?
Nurse: Vitamins and other supplements should always be considered like a medication. Many vitamins significantly benefit immunity, bone health, and gut health. However, taking too much of some vitamins or supplements can cause problems with your prescription medications. You did the right thing by bringing these in to discuss so your provider can help you safely manage your supplements.
Fluid and Electrolyte Imbalances
As individuals age, hydration status can become a significant concern. In individuals with chronic illness, hydration status can be affected by illnesses, medications, overall nutrition, and mental status changes. Hydration is directly related to nutrition status since it affects taste, swallowing ability, elimination, digestion, and nutrient absorption. Some older adults develop a decreased sense of thirst, contributing to dehydration risk. Therefore, it is crucial to check on older adults more frequently during heat waves to ensure they are adequately hydrated and to prevent dehydration-related complications. Older adults who experience dehydration are at higher risk for falls, urinary tract infection (UTI), constipation, skin damage, electrolyte imbalances, altered mental states, and kidney injury. Healthy electrolyte balance is directly related to hydration status; however, it can also be affected by certain medications, such as diuretics and blood pressure medications.
Psychological Health Risks
The psychological health risks include cognitive and emotional responses to aging and life changes. Some are short-term responses and are related to life events; others are progressive and associated with factors such as the death of family and friends, diagnosis of acute or chronic illness, debility from illness, loss of function or ability, and loss of independence. These factors may relate to emotional responses such as loneliness, hopelessness, and depression.
Dementia
Older adults are at high risk for cognitive impairment, including dementia. The CDC (2019) explains that dementia is a general term applied when an individual has trouble with daily functioning due to difficulty remembering, thinking, or making decisions. According to the National Institute on Aging (2022), various forms of dementia exist, such as vascular dementia, frontotemporal dementia, and Lewy body dementia; however, Alzheimer disease is the most prevalent. Alzheimer disease is a progressive disorder and general loss of cognitive function that presents with memory loss, behavior changes, and personality changes (National Institute on Aging, 2022).
The National Library of Medicine describes MCI as a decline in memory or thinking to a greater degree than expected for a person’s age. This cognitive decline may include forgetfulness and trouble with word-finding. Mild cognitive impairment (MCI) is often associated with a higher risk of developing other dementias. According to the CDC (2019), 5.6 million older adults live with dementia. As dementia progresses, individuals develop a profound difficulty performing ADLs. All types of dementia put older adults at risk for injury, infections, social isolation, and reduced quality of life (Figure 41.4).
Link to Learning
Information about memory problems is provided in this quick video by the National Institute on Aging that clarifies the features of early dementia compared with simple forgetfulness.
Delirium
Older adults with chronic illnesses or those undergoing surgical procedures are at high risk for delirium. A sudden onset of confusion secondary to a physical illness is termed delirium. Medication metabolism in older adults changes due in part to changes in how the body excretes medications. Sometimes, delirium can occur because of issues related to hydration, kidney function, or medication metabolism. Often dose adjustments are required depending on age. Medication interactions are also a risk factor for delirium. In particular, anesthesia-associated medications can often trigger a state of delirium. Acute infections are also a significant risk factor for delirium. The onset of delirium is a common sign of an infection, such as a UTI, in an older adult. Delirium can present as acute confusion in an adult with normal cognitive function or worsening dementia in an adult with an underlying cognitive disorder.
Depression
Older adults are at risk for depression in similar proportions to younger adults. However, the American Psychological Association (2022) reports a significant increase in depression in older adults in the last fifty years. Despite this increase, the CDC (2022b) reports a low percentage (1 to 5 percent) of older adults with depression. For adults requiring in-home or hospital care, the number increases significantly. Factors that put older adults at risk for depression include the following:
- chronic disease diagnosis or progression
- physical limitations
- reduced physical activity
- stress
- social isolation
- sleep disorders
Grief
Grief can play a significant role in the mental health of older adults (Figure 41.5). This grief may relate to the death of a spouse, friend, or other family member. Older adults may also experience grief over loss of function and independence. Understanding that the grief process is highly individual is crucial for nurses. Depending on the effectiveness of the individual’s coping strategy, grief may progress healthily or progress to mental health concerns, such as depression.
The normal grief process, explained initially by psychiatrist Elisabeth Kübler-Ross (Figure 41.6), has a somewhat predictable pattern. However, the timeline for grief response is highly specific to each individual. Normal grief includes the common feelings, behaviors, and reactions to loss. Normal grief reactions to a loss can include the following:
- physical symptoms such as hollowness in the stomach, tightness in the chest, weakness, heart palpitations, sensitivity to noise, breathlessness, tension, lack of energy, and dry mouth
- emotional symptoms such as numbness, sadness, fear, anger, shame, loneliness, relief, emancipation, yearning, anxiety, guilt, self-reproach, helplessness, and abandonment
- cognitive symptoms such as a state of depersonalization, confusion, inability to concentrate, dreams of the deceased, idealization of the deceased, or a sense of the presence of the deceased
- behavioral signs such as impaired work performance, crying, withdrawal, overreactivity, changed relationships, or avoidance of reminders of the deceased
The state of complicated grief is prolonged, delayed, or exaggerated in which individuals have trouble coping and progressing through the normal grief process. Complicated grief is seen in 10 to 20 percent of individuals experiencing the death of a romantic partner, with higher estimates for parents who have lost a child. Risk factors for developing complicated grief include sudden or traumatic death, suicide, homicide, a dependent relationship with the deceased, chronic illness, death of a child, multiple losses, unresolved grief from prior losses, concurrent stressors, witnessing a difficult dying process such as pain and suffering, lack of support systems, and lack of a faith system. Complicated grief may require professional assistance, depending on its severity. Factors contributing to complicated grief in older adults include lack of a support network, concurrent losses, poor coping skills, and loneliness. According to the End-of-Life Nursing Education Consortium, there are four types of complicated grief: chronic grief (normal grief reaction that does not subside), delayed grief (normal grief reaction that is suppressed or postponed), exaggerated grief (an intense reaction to grief), and masked grief (occurs when the survivor is unaware of behaviors that interfere with normal functioning due to the loss) (Table 41.4).
| Grief Type | Patient Behaviors |
|---|---|
| Chronic grief: normal grief reactions that do not subside and continue over very long periods | Carol lost her son in a motor vehicle accident ten years ago. She has ongoing depression and rumination about the day of the accident. Nearly daily, she cries and feels hopelessness for the loss of her son. She has been unable to work since the accident. |
| Delayed grief: normal grief reactions that are suppressed or postponed by the survivor consciously or unconsciously to avoid the pain of the loss | James’s wife died of colon cancer one year ago. Since that time, he has not discussed her death with friends or family and sometimes states, “it still feels like she might come through the door.” |
| Exaggerated grief: an intense reaction to grief that may include nightmares, delinquent behaviors, phobias, and thoughts of suicide | Jana’s sister died after contracting pneumonia two years ago. Jana continues to feel extreme fear about contracting an illness and rarely leaves her home even to shop. |
| Masked grief: grief that occurs when the survivor is unaware of behaviors that interfere with normal functioning due to the loss | Since the death of his wife, Gerald attends many social functions each day. By the time he arrives home, he is too tired to cook or care for his home. His family has noticed the decline in his physical appearance and his home. |
Loneliness
Grief is often tied to loneliness, particularly in older adults who have spent many years with a life partner. Losing close friendships or other familial relationships can also trigger loneliness. Loneliness can be a risk factor for and a result of social isolation. The term loneliness is defined as a subjective feeling of distress related to being alone or separated from other people (Cacioppo et al., 2014). The National Institute on Aging (2019) reports that loneliness in older adults may be associated with a variety of health effects, including the following:
- high blood pressure
- obesity
- poor immunity
- depression
- anxiety
- dementia
Social isolation may be associated with loneliness and depression, but research has found that feeling lonely is possible even while among other people. The same research shows that individuals can live alone and not experience loneliness (Cacioppo et al., 2014).
Hopelessness
A severe psychological state that involves a deep sense of failure or despair is called hopelessness. In older adults, hopelessness may develop from untreated depression, grief, or loneliness. Other contributors to hopelessness may be chronic pain, loss of independence, and abuse. Hopelessness may also stem from long-term difficulty moving through life stages and may relate to Erikson’s theory of integrity versus despair.
Psychosocial Health Risks
The psychosocial health risks encompass factors that affect both psychological and social well-being. Examples include chronic stress, social isolation, interpersonal conflicts, lack of social support, and exposure to adverse life events. Changes in living arrangements, limited transportation, and decreased financial resources may impede social interaction for some older adults. Older adults are at risk for health risks associated with a decrease in available and accessible resources. A decline in social interactions may lead to loneliness and depression. Role reversal is also a psychosocial issue for older adults as they navigate changing relationships with children and other caregivers. These factors can have a significant impact on mental health, emotional well-being, and the ability to cope with life’s challenges. Addressing psychosocial health risks is crucial for promoting a holistic approach to wellness.
Living Arrangements
Older adults’ living arrangements depend on physical independence, cognition, physical strength, financial security, and culture. A recent study reports that a similar number of older adults live with their spouse, children, or others compared to those living alone (Bolina et al., 2021). The same study concluded that while living arrangements significantly affect quality of life, each living arrangement has benefits and challenges for older adults. Some adults living with children, for example, experience less autonomy and social interaction. Adults who continue to live alone may experience continued autonomy; however, they may also experience less intimacy when not living with a significant other (Bolina et al., 2021). Loss of physical function is often associated with considering long-term care facilities, assisted living facilities, and cohabitation with adult children. Some older adults embrace a move that will afford them more assistance, while others grieve losing their home and independence.
Social Isolation
In older adults, social isolation refers to a condition where individuals experience limited social interaction and engagement. It can result from various factors, such as living alone, having few social connections, physical health challenges, mobility issues, lack of transportation, or the loss of friends and family. Social isolation is most prominent in older adults who live alone (Cacioppo et al., 2014). Social isolation can have detrimental effects on mental, emotional, and physical well-being, contributing to feelings of loneliness, depression, and a decline in overall health. Addressing social isolation involves fostering social connections, promoting community engagement, and providing support to enhance the social aspects of older adults’ lives.
Decreased Resources
Financial hardship is a prominent risk for many older adults. The National Council on Aging (2021) reports that up to 47 million older adults face financial concerns or the risk of financial insecurity. Financial strain may result from planned retirement, reduced ability to perform previous work skills, or chronic health issues. Older adults are also at risk for sudden changes in financial security, such as job loss, death of a spouse, acute illness, and injuries. Older adults may struggle to pay for monthly medications, long-term care, food, or basic living expenses. Nurses must also understand the concept of health resources and how this concept applies to healthcare access and health disparity (systematic differences in health outcomes and access to healthbcare between distinct groups, often associated with social, economic, or environmental disadvantages) among geographic and cultural groups.
Caregiver Role Strain
Caregiver role strain is a layered issue affecting many older adults. Individuals with declining health begin to rely on a spouse or partner for more intense care or assistance. Often, the care of older adults with increased frailty or progressive disease states falls to younger family members and children. Caregivers can experience stress from increased physical demands, increased responsibility in financial management, or reduced living space when an older adult moves in. Individuals taking on more caregiving tasks can quickly experience caregiver fatigue. Finding appropriate and consistent support is crucial for patients and their families. Nurses can support caregivers by acknowledging struggles and providing access to community and healthcare support services. This includes informing caregivers about adult day healthcare programs, which offer a way to keep a loved one at home while providing a much-needed break for caregivers.
Clinical Judgment Measurement Model
Take Action: Caregiver Support
A home health nurse is providing in-home wound care for an 89-year-old male with dementia who lives with his son. The son is very attentive and attends each visit in order to learn the proper way to care for the wound between nurse visits. The nurse notices the son seems fatigued and opens a conversation to discuss how the son is feeling. He breaks down and expresses intense feelings of being overwhelmed with working at home, caring for his father, and performing household duties. He has felt more caregiver strain as his father’s dementia progresses. The nurse expresses empathy in the moment and forms a plan for reducing the son’s caregiver strain. During the next two weeks the nurse is able to secure additional in-home care for the patient, arrange transportation services for appointments, and arrange for a case manager to help manage ongoing resource needs. She also encourages the son to attend a dementia caregiver support group at the local community center.
Elder Abuse
The CDC (2021b) reports that up to 10 percent of older adults living at home experience some form of abuse, neglect, or mistreatment. This elder abuse encompasses all direct actions and neglectful actions by a caregiver that cause harm or risk of harm to an older adult. The CDC (2021b) explains that elder abuse can occur in a variety of settings, including the patient’s home or long-term care facility. Several physical and psychological characteristics put an older adult at risk for abuse, including dementia, mental health disorders, and substance misuse. Psychosocial risk factors for abuse include social isolation, financial dependence, and low socioeconomic status. Forms of elder abuse identified by the CDC (2021b) include physical, sexual, psychological, financial, and neglect. Examples of elder abuse include inflicting physical harm through actions like hitting or restraining, engaging in nonconsensual sexual contact, causing emotional distress through threats or verbal abuse, illegally using an older adult’s financial resources, and neglecting to provide essential care and support for basic needs like food and medical care. While older adults often experience a higher risk for injury, awareness of frequent injuries or patterns can alert nurses to the possibility of abuse (Table 41.5).
| Physical | Psychological |
|---|---|
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