24.1 Healthcare Concerns and Decisions of Older Adults

Access to Care for Older Adults

Access to care is a very complex issue for older adults for many reasons. For some older adults, access is no issue; for others, every step of the process is a barrier or a potential barrier. Challenges like locating providers and scheduling appointments, lack of transportation, lack of knowledge for use of technology, the general affordability of care, and cultural considerations that may lead to actual and perceived barriers to care may affect access to health care for older adults. The need to see various specialists and the possible need for more frequent visits may add to access issues.

Adults aged sixty-five and over have access to Medicare for health-care insurance coverage. Medicare Part A is available with enrollment, and Part B is available with enrollment and a premium. Medicare Part A covers hospital and rehabilitation care while Part B covers ambulatory or home care. Some older adults have secondary insurance to supplement Medicare. Older adults with limited income may be eligible for Medicaid, health insurance available based on income, in the state where they reside. Some clients have both Medicare and Medicaid.

Seeking medical care, particularly preventative care, is important for older adults. For older adults who are eligible for Medicare and/or Medicaid, there may be resources available for locating care. Some people have very little or no access to care, however. Older adults who do not hold citizenship or are visiting from other countries do not have access to Medicare or Medicaid in most circumstances. Those without insurance must either pay out of pocket for care if they can afford it or, if available, can access care in community-funded clinics or care systems.

Locating care in itself can be difficult in some cases. Even in large cities, insurers may limit coverage that providers accept. Resources, such as telehealth/e-health virtual services, that are mainly available via the Internet may not be available for, or understood by, older adults. Wilson et al. (2021), while acknowledging the benefit of improved electronic services design, assert that education in use of computerized data would greatly influence older adults’ engagement with the resource. Further, such education could also address older adults’ perceptions of information presented online and provide clarity. This educational aspect is an excellent opportunity for nurses. Whether as educators or facilitators, nurses are well positioned as trusted professionals to promote knowledge acquisition in the older adult community.

Transportation to appointments can be a major barrier to care. Many older adults may not drive, may not have caregivers to assist, or may live in areas that do not have public transportation. Even those who do live in areas that have public transportation may not be able to afford the cost, or may be physically or mentally unable to navigate the complex routes.

Cultural barriers are complex because some of the barriers are perceived rather than actual; that does not, however, make them easier to navigate. This is particularly true in mental health care. According to the National Council for Mental Wellbeing (2019), culture can impact mental health by creating a cultural stigma (seeing mental health challenges as a weakness) that can cause people to avoid seeking care as well as attempt to hide their mental health challenges. Symptoms may be misunderstood when the mental health provider is of a different culture than the client because the descriptors may differ when describing physical and mental symptoms. Culture can determine the amount of support that a person can expect from their community or their family. Lastly, culturally specific resources may be difficult or time-consuming to locate (National Council for Mental Wellbeing, 2019).

Partnering with Providers of Care for Older Adults

The family of the older adult is of primary importance. The family of the client needs support just like the client. In some cases, the definition of family includes a close trusted friend, an extended family member, a caregiver, care managers, or a guardian. The care of older adults may require a team, and in some cases, the team includes multiple health-care professionals. In addition to the client and their family caregivers, the team may include nurses, social workers, therapists, and case managers, as well as medical specialists. Communication between members of the team is imperative to prevent errors in care and ensure continuity (Bhatt & Swick, 2017).

Chronic Disease

The National Council on Aging provides statistics on chronic conditions in adults aged sixty-five and older. According to its research, 80 percent of older adults have at least one chronic condition, and up to 68 percent have two or more (National Council on Aging, 2023). There are many factors that affect a person’s likelihood of developing a chronic disease, from genetic predisposition to risk factors like smoking or environmental exposure. People can make choices—like lifestyle changes and consistent medical care—in their lives to prevent or reduce the risks and effects of chronic illnesses if they choose to do so. Table 24.1 lists the top ten chronic conditions for adults over the age of sixty-five.

Self-Management

Chronic disease is a normal part of aging, and millions of people struggle to manage these chronic illnesses and their symptoms. A person’s active involvement in their own health-care decisions and intervention to promote their own best possible wellness with the help of the health-care team is considered self-management. Older adults age sixty-five and above are prescribed medications more commonly than any other age group in the United States. Being able to correctly self-manage medications involves establishing habits, establishing routines, setting reminders, and keeping track of current medications with dosages, frequency, and times.

There are available programs, such as the Chronic Disease Self-Management Program (CDSMP), that provide workshops for adults with at least one chronic disease. The focus is on decision-making, action planning, and problem-solving for disease management. It is an interactive program with goals to increase knowledge of ways to manage chronic disease; motivate older adults to manage the challenges associated with chronic diseases, as well as their physical and psychological well-being; and help increase confidence. The target audience is adults with arthritis, those with one or more chronic conditions, and older adults.

One of the most significant barriers to self-management of chronic health issues and medications is cognitive status. The older adult with cognitive issues, such as mild or moderate cognitive impairment, may be unable to adhere to medication regimens or make decisions. The management of chronic disease and management may fall to a family member or caregiver. Low health and medical literacy can also be a barrier to self-management. If a person or caregiver is unable to fully understand the illness or disease and the related treatment, it can compromise their ability to manage the illness or disease.

Health Literacy

As with all people, older adults have varying levels of cognitive ability, education, and general knowledge. The ability to obtain, comprehend, and utilize information in the process of making health decisions is called personal health literacy, according to the National Institutes for Health (NIH). It is a crucial component to healthy aging. Critical to this process are resources to inform a decision and the ability to understand and use the resources. Personal health literacy is a very important factor to consider when nurses provide education in any form, when giving instructions for care, and when asking a person to provide informed consent, for instance.

Defined by the Health Resources and Services Administration (HRSA), organizational health literacy is how well an organization assists clients and family members to receive and understand information used to render health decisions (2022). The ability of persons and families to make a well-informed health-care decision may be dependent on the hospital’s ability to provide the needed information and professional staff to assist, in a way that consumers can understand. The seminal study by the National Center for Education Statistics (2006) reports that 71 percent of older adults age sixty and above have difficulty with using printed materials, 80 percent have difficulty with using forms or charts, and 68 percent have difficulty with interpreting numbers and doing calculations.

Nutrition and Housing

The U.S. Department of Agriculture (USDA) has a long list of resources for older adults and nutrition as well as other helpful resources, such as an older adult care locator, exercise and physical activity guidance, and general health tips. The MyPlate Plan gives a personalized food plan based on a person’s age, sex, height, weight, and physical activity level. Figure 24.2 shows a sample meal plan appropriate for a ninety-year-old female who is 5ft 2in and 110 pounds and is minimally active. For older adults, the MyPlate recommendations include the following:

• Make eating a social event.
• Drink plenty of liquids.
• Add a touch of spice.
• Make the most of your food choices.
• Be mindful of your nutrient needs.
• Keep food safe (U.S. Department of Agriculture, 2022).

Figure 24.2 MyPlate Plan offers customized nutrition plans for individuals. (credit: “Start simple with MyPlate Plan” by USDA Food and Nutrition Service/U. S. Department of Agriculture, Public Domain)

According to Feeding America (2023), 5.5 million seniors (sixty and over) experienced hunger in 2021. That represents 7.1 percent of all seniors or one in fourteen. Seniors’ health is severely affected by hunger, which exacerbates chronic illnesses, including diabetes, asthma, and depression. Federal poverty income guidelines for 2024 are set for individuals as annual income of $15,060 (Healthcare.gov, 2024). Older adults who have an income at or below 185 percent of the federal poverty income guidelines are eligible for the Supplemental Nutrition Assistance Program (SNAP). SNAP provides a debit card that can be used to buy food. Moreover, Meals on Wheels is a community-based meal program and provides healthy meals to homebound older adults who have limited resources.

Housing also plays a major role in older adults aging in a healthy manner. Older adults live in a variety of types of housing: individual homes, alone or with family; standard apartments or senior apartments; independent living facilities; assisted living facilities; personal care homes; memory care facilities; and nursing homes. The most challenging part of housing for older adults is paying for care when they can no longer live independently or when they require significant care. Private caregivers are very expensive as is institutional care. Most of this is paid privately. Medicaid and long-term care insurance are the only means of funding for facility-based long-term care, with Medicaid only paying for nursing home care for eligible people.

Individual homes, apartments, and senior apartments are generally the same in terms of services. Either independent older adults provide their own care, transportation, and management or family/caregivers assist them. A senior adult apartment complex may provide additional services, such as activities, meals, and on-site home health or pay-for-service caregivers. Independent living facilities usually provide some or all meals, nursing staff in an emergency, as well as utilities and routine housekeeping.

Characteristics of assisted living facilities (ALF) differ from state to state, are regulated by the states, and are generally licensed in categories based on intensity of services. All levels of assisted living (sometimes referred to as Level 1, 2, or 3) help with activities, meals, housekeeping, caregiving, and employ varying levels of nursing staff. The independent living category requires that residents are able to evacuate in an emergency, get to the dining room under their own power, and may receive minimal supervision and assistance. The second category includes facilities that provide more care and can have residents that require assistance with mobility and activities of daily living, more hands-on care, and more supervision. The third category may be known as memory care and provides secured facilities or units within a larger assisted living. Residents of these facilities range from those who wander independently to those who require total care by caregivers, but not intensive nursing care.

As far as nursing staff, most facilities have licensed vocational nurses (LVN)/licensed practical nurses (LPN) to provide direct care and administer medications; a registered nurse is designated in a supervisory role. Medication aides may be present in some facilities. Nursing assistants generally provide most of the basic direct care twenty-four hours a day, as well as caregivers the residents may have individually.

Personal care homes are considered assisted living facilities but are different in that they are usually standard houses in neighborhoods housing multiple residents and maintaining caregivers twenty-four hours a day. This type of housing runs the entire spectrum of care, from houses that care for younger people with psychiatric or developmental issues who only require medication administration and supervision, to total care residents who are ventilator-dependent with feeding tubes. The staff in these facilities are trained on the job and do not require licensing or formal training programs. According to the Compendium of Residential Care and Assisted Living Regulations and Policy (Carder et al., 2015) published by the Department of Health and Human Services, the range of in-service or continuing education time that states required of the direct care staff ranges from unstated to eleven+ hours. There is no requirement to have a nurse on staff. Most states require licensing, but do not stop unlicensed facilities from opening and continuing to care for clients.

Some long-term or extended care facilities are categorized as “nursing homes” and provide full care for multiple residents with varying levels of need and ability. These facilities are staffed twenty-four hours a day with nurses, usually LVNs/LPNs, with RNs designated in a supervisory role, and nursing assistants providing the personal care. Within these facilities are residential clients as well as skilled nursing clients. “Skilled” is a reimbursement term, which means the service will qualify for insurance coverage. Such services include rehabilitative therapies and complex nursing care that has more of a medical focus, such as wound care or intravenous therapy. Clients admitted for skilled care remain for a temporary time before they return to their previous living situation, usually after an acute hospital stay.

Caregiver Considerations for Older Adults

Resources for older adults often include finding caregivers. A caregiver for an older adult must be prepared to provide multiple types of support and assistance. The goal should always be to provide assistance in a way that promotes as much independence as possible while maintaining safety. Autonomy is an important goal to maintain as long as possible because it contributes to quality of life. A caregiver should be prepared to provide several basic types of care. Personal care entails helping with activities of daily living (ADLs), such as bathing, dressing, grooming, or other personal care that the client may require. Household help or instrumental activities of daily living (IADLs) include cleaning, laundry, cooking, yard work, or repairs. Emotional support means spending time, talking, or otherwise offering reassurance that the client is cared for. Health-care support involves assisting with going to doctor appointments, handling medication, and even making medical decisions if the client is not able to and the caregiver has the legal authorization to represent the client.

Quality of Life in Older Clients

Many factors affect our lives on a daily or continual basis. Some factors may not seem like they would significantly affect our lives, but the buildup of frustration due to lack of resources or any number of difficulties in accessing care or day-to-day necessities can lead to dissatisfaction with life or with a period of life. A person’s individual view of their health, comfort, and ability to enjoy activities of daily living is considered their quality of life (QOL). This is a very individual concept and would be different for each person asked. QOL also changes as a person ages and as their physical and medical situation changes. For example, a healthy person in their sixties may consider a high QOL to mean being active, engaged, and healthy. A person in their nineties with severe cognitive impairment, on the other hand, may define QOL as being provided comfort care and an ability to eat and enjoy their food. QOL is rooted in a person’s culture, faith, condition, and personal life experiences. Consider QOL when making decisions on care both medically and in caregiving.

Advance directives are documents that describe the person’s wishes in advance of when the information may be needed and usually include a living will or health-care surrogate designation. An advance directive is created by a person when they are still in a cognitively intact status; it gives directions to their medical providers to be used in certain situations, such as code status when they have an irreversible terminal illness. Advance directives are very helpful in making sure that the health-care team follows the client’s wishes even if they cannot speak for themselves. They are also helpful for the family so that they do not have to guess what their loved one wants for end of life or in the case of a terminal illness. These legal instructions also prevent a family member from making changes to the end-of-life plan when the client is no longer able to participate in the conversation. Refer families interested in creating advance directives to the National Institute on Aging.