Extended care for older adults

Anatomy or system affected: All

Definition: The management of the health, personal care, and social needs of aging people as they experience decreases in physical, mental, and/or emotional abilities

The Problems Associated with Aging

The process of aging is inevitable. In the earlier stages of life, aging involves the acquisition and development of new skills and abilities, facilitated by the guidance and assistance of others. Later, the middle stages involve the challenges of maintaining and applying those skills and abilities in a manner that is primarily self-sufficient. Finally, in the end stages of life, aging involves the deterioration and loss of skills and abilities, with adequate functioning again being somewhat dependent on the assistance of others.

For many individuals, the final stages are brief, allowing them to live independently right up to their time of death. Thus, many experience little loss of their abilities to function independently. Others, however, endure more extended stages of later life and require greater care. For these individuals, losses in physical, emotional, and/or cognitive functioning frequently result in a need for specialized care. Such care involves whatever is necessary so that these individuals may live as comfortably, productively, and independently as possible.

The conditions leading to a need for long-term care are as varied as older adults themselves. Special needs for adults requiring extended care often include the management of physical, health, emotional, and cognitive problems. Physical problems dictating lifestyle adjustments include decreased speed, dexterity, and strength, as well as increased fragility. Changes to the five senses are also common. Visual changes include the development of hyperopia (farsightedness) and sometimes decreased visual acuity. Hearing loss is also common, such that softer sounds cannot be heard when background noise is present or sounds need to be louder to be perceived. Particularly noteworthy is that paranoia, depression, and social isolation often result as side effects of visual and hearing impairments and are not always signs of mental deterioration. Similarly, one’s sense of touch may be affected, such that the nerves are more or less sensitive to changes in temperatures or textures. Consequently, injuries attributable to a lack of awareness of potential hazards or hypersensitivities to temperature or texture may result. One example is a woman over sixty-five overdressing or underdressing for the weather because of an inability to judge the outside temperature properly. Another is an older man cutting or wounding himself out of a lack of awareness of the sharpness of an object. Finally, both taste and smell may change, creating a situation in which subtle tastes and odors become imperceptible or in which tastes and smells that were once pleasant become either bland or unpleasant.

Health problems among older individuals often demand increased management. Coordination of drug therapies and other medical interventions by a case manager is critical. Typical health conditions bringing older adults into long-term care settings may include heart disease and stroke, hypertension, diabetes mellitus, arthritis, osteoporosis, chronic pain, prostate disease, and cancers of the digestive tract and other vital organs. Estimates are that approximately 86 percent of the aged are affected by chronic illnesses. Long-term care addresses the medical management of these chronic illnesses and their impact on the individual.

An issue related to health and physical problems in the aged is malnutrition. For a variety of reasons, older adults often fall victim to malnutrition, which can contribute to additional health problems. For example, calcium deficiency can increase both the severity of heart disease and the likelihood of osteoporosis and tooth loss. Thus, a vicious cycle of medical problems can be put into motion. Factors contributing to malnutrition are multifaceted. Poverty, social isolation, decreased taste sensitivity, and tooth loss combine with lifelong dietary habits that can sometimes predispose certain individuals to malnutrition. As such, attention to the maintenance of healthy dietary habits in older adults is critical to successful long-term care, regardless of the type of setting in which the care is being given.

Along with these physical aspects of aging come emotional and cognitive changes. Depression, anxiety, and paranoia over health concerns, for example, are not uncommon. Additionally, concerns about the threat of losing one’s independence, friends, and former lifestyle may contribute to acute or chronic mood disorders. Suicide is a particular danger with older adults when mood disorders, such as depression, are present. Adults over sixty-five are one of the fastest growing groups among those who commit suicide. The stresses accompanying losing a spouse or enduring a chronic health problem can trigger suicide in depressed individuals. One should note, however, that older adults are not particularly prone to depression or suicide because of their age but that they are more likely to experience significant stressors that lead to depression.

More common, less lethal problems associated with conditions, such as depression, anxiety, and paranoia are weight change, insomnia, and other sleep problems. Distractibility, decreased ability to maintain attention and concentration, and rumination over distressing concerns are also common. Finally, some older adults may be observed as socially isolated and prone to avoidance behavior. As a result, some become functionally incapacitated because of distressing emotions.

What is critical to remember, in addition to these signs, is that some individuals may not describe their problems as emotional at all, even though that is the primary cause of their discomfort. Individual differences in how people express themselves must be taken into account. Thus, while some older adults may report being depressed or anxious, others may instead report feeling tired. Reports of low-level health problems that are vague in nature, such as aches and pains, are also common in those who are depressed. It is not uncommon for emotional problems to be expressed or described indirectly as physical complaints.

Decreased cognitive functioning may result from more serious problems, such as organic brain syndromes. These typically include problems, such as dementia from Alzheimer’s disease, Pick’s disease, Huntington’s disease, alcohol-related deterioration, or stroke-related problems. Other causes may be brain tumors or thyroid dysfunction. With all dementias, however, the hallmark signs are a deterioration of intellectual function and emotional response. Memory, judgment, understanding, and the experience and control of emotional responses are affected. Functionally, these conditions reveal themselves as a combination of symptoms, including increased forgetfulness, decreased ability to plan and complete tasks, difficulties finding names or words, decreased abilities for abstract thinking, impaired judgment, inappropriate sexual behavior, and sometimes severe personality changes. In some cases, affected individuals are aware of these difficulties, usually in the earlier stages of the disease's progression. Later, however, even though their behavior and abilities may be quite disturbed, they may be completely unaware of the severity of their problems. In these cases, long-term care often begins as a result of outside intervention by concerned friends and family members.

Options for Long-Term Care

Extended care for the aged requires an interdisciplinary effort that usually involves a team of physicians, psychologists, nurses, social workers, and other rehabilitative specialists. Depending on the nature of the problems requiring care and management, any of these professionals may take part in the care process. Additionally, the involvement of concerned individuals who are close to the older adult needing care is critical. Family members (including the spouse, children, and extended family) and close friends are invaluable sources of information and emotional and instrumental support. Their ability to assist an aging adult with instrumental tasks, such as cooking, housecleaning, shopping, and money and medication management, is crucial to the successful implementation of a long-term care plan.

In all cases, long-term care for the aged involves the design of a comprehensive plan to address the multifaceted needs of the individual. Just as younger persons have psychological, social, intellectual, and physical needs, so do older adults. As such, thorough assessment of an older individual’s abilities, goals, expectations, and functioning in each of these areas is required. A mental status exam and a thorough physical exam are usually the primary methods of evaluation. Once needs are identified, a plan can then be designed by the team of healthcare professionals, family and friends assisting with care, and, whenever possible, the older individual. In general, the overarching goal is to design a case management plan that maximizes the independent functioning of the aged person, given certain physical, psychiatric, social, and other needs.

Specific management strategies are designed for the problems that need to be addressed. Physical, health, nutritional, emotional, and cognitive problems all demand different management settings and strategies. Additionally, care settings may vary depending on the severity of the problems that are identified. In general, the more severe the problems, the more structured the long-term care setting and the more intense the psychosocial interventions.

For less severe problems, adequate management settings may include the individual’s own home, the home of a family member or friend, a shared housing setting, or a seniors’ apartment complex. Shared housing is sometimes called group-shared, supportive, or matched housing. Typically, it refers to residences organized by agencies where up to twenty people share a house and its expenses, chores, and management. Ideal candidates for this type of setting include older adults who want some daily assistance or companionship but who are still basically independent. Senior apartments, also called retirement housing, are usually “elderly-only” complexes that range from garden-style apartments to high-rises. Ideal candidates for this type of setting include nearly independent individuals who want privacy, but who no longer desire or can manage a single-family home. In either of these types of settings, the use of periodic or regular at-home nursing assistance for medical problems, or “home-helpers” for more instrumental tasks, might be a successful adjunct to regular consultation with a case manager or physician.

Problems of moderate severity may demand a more structured setting or a setting in which help is more readily available. Such settings might include continuing-care retirement communities or assisted-living facilities. Continuing-care retirement communities, also called life-care communities, are large complexes offering lifelong care. Residents are healthy, live independently in apartments, and are able to use cafeteria services as necessary. Additionally, residents have the option of being moved to an assisted-living unit or an infirmary as health needs dictate. Assisted-living facilities—also called board-and-care, institutional living, adult foster care, and personal care settings—offer care that is less intense than that received in a medical setting or nursing home. These facilities may be as small as a home where one person cares for a small group of individuals or as large as a converted hotel with several caregivers, a nurse, and shared dining facilities. Such settings are ideal for persons needing instrumental care but not round-the-clock skilled medical or nursing care.

When more severe conditions, such as incontinence, dementia, or an inability to move independently, are present, nursing, convalescent, or extended care homes are more appropriate settings. Intense attention is delivered in a hospital-like setting where all medical and instrumental needs are addressed. Typical nursing homes serve a hundred clients at a time, utilizing semiprivate rooms for personal living space and providing community areas for social, community, and family activities. Often, the decision to place an older adult in this type of facility is difficult to make. The decision, however, is frequently based on the knowledge that these types of facilities provide the best possible setting for the overall care of the individual's medical, health, and social needs. In fact, appropriate use of these facilities discourages the overtaxing of the older adult’s emotional and familial resources, allowing the older adult to gain maximum benefit. An older adult's placement into this type of facility does not mean that the family’s job is over; rather, it simply changes shape. Incorporation of family resources into long-term care in a nursing home setting is critical to the adjustment of the individual and family members to the older individual’s increased need for care and attention. Visits and other family involvement in the individual’s daily activities remain quite valuable.

Regardless of the management setting, some basic caveats exist with regard to determining management strategies. First and foremost, individuals should, whenever possible, be encouraged to maintain independent functioning. For example, even though physical deterioration, such as decreased visual or hearing abilities, may be present, there is no need to take decision-making authority away from the individual. Decreased abilities to hear or see do not necessarily mean a decreased ability to make decisions or think. Second, it is crucial to ask older adults to identify their needs and how they might desire assistance. Some individuals may wish for help with acquiring basic living supplies from outside the home, such as foods and toiletries, but desire privacy and no assistance within the home. In contrast, others may desire independence outside the home with regard to social matters but need more instrumental assistance within the home. Finally, it is important to recognize that even the smallest amount of assistance can make a significant difference in the lifestyle of the older adult. A prime example is availability of transportation. The loss of a driver’s license or independent transportation signifies a major loss of independence for any individual. Similarly, the challenges posed by public transit may seem insurmountable because of a lack of familiarity or experience. As such, simple and small interventions, such as a ride to a store or a doctor’s office, may provide great relief for older adults by assisting their efforts to meet their own needs.

Special management strategies may be required for specific problem areas. For physical deterioration, adequate assessment of strengths and weaknesses is important, as are referrals to medical, rehabilitative, and home-help professionals. Hearing and visual or other devices to make lifting, mobility, and day-to-day tasks easier are helpful. Similarly, assisting the aged with developing alternative strategies for dealing with diminished sensory abilities can be valuable. Examples would be checking a thermometer for outdoor temperature to determine proper dress, rather than relying purely on sensory information, or having a phone that lights up when it rings. Health conditions also demand particular management strategies, varying greatly with the type of problem experienced. In all cases, however, medical intervention, drug therapies, and behavior modification therapies are commonly employed. Dietary problems (such as malnutrition or diabetes), cardiovascular problems (such as heart attacks), and emotional problems (such as depression) often require all three approaches. Finally, cognitive problems, particularly those related to depression, are sometimes alleviated with drug therapies. Others related to organic brain syndromes or organic mental disorders require both medical interventions and significant behavior modification therapies and/or psychosocial interventions for older adults and their families.

Perspective and Prospects

Advances in modern medicine are continually extending the human lifespan. Cures for diseases, improved management of chronic health problems, and new technologies to replace diseased organs are facilitating this evolution. For many, these advances translate into greater longevity, the maintenance of a high quality of life, and fewer obstacles related to ageism. For others, however, the trade-off for longevity is some loss of independence and a need for extended care and management. Thus, the medical field is also affected by the trade-off of extending life, while experiencing an increasing need to improve strategies for long-term care for those who are able to live longer and longer despite health conditions.

As a result of this evolution, long-term care for the aged presents special challenges to the medical field. Over time, medicine has been a field specializing in the understanding of particular organ systems and the treatment of related diseases. While an understanding of how each system affects the functioning of the whole body is necessary, healthcare providers must struggle to understand the complexities in the case management required for high-quality long-term care for the aged. Care must be interdisciplinary, addressing the physical, mental, emotional, social, and familial needs of the aged individual. Failure to address any of these areas may ultimately sabotage the successful long-term management of older individuals and of their problems. In this way, medical, psychiatric, social work, and rehabilitative specialists need to work together with individuals and their families for the best possible results.

Integrated case management with a team leader allows a variety of services to be provided in an orchestrated manner. While specialty providers still play a role, managers (usually primary care physicians) ensure that complementary drug therapies, as well as psychiatric and other medical treatments are administered. Additionally, they are key in bringing forth family resources for emotional and instrumental support whenever possible, as well as community and social services when needed.

What was once viewed as helping a person to die with dignity is now viewed as helping a person to live as long and as productive a life as possible. As the population of the US ages in the 2020s and 2030s, investments in both home care facilities and large facility care options became critical in supporting older adults. Though smaller, home-based facilities retained popularity across Europe during the late twentieth and early twenty-first centuries, large care facilities were popular in the US. Following the COVID-19 pandemic, healthcare providers noted the importance of smaller facilities in maintaining the health of older adults.

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