The nature of physiological and pathological processes in later life and the need for a specific approach to the management of elderly patients poses the geriatrics and geriatrician in a separate clinical discipline. Therefore, most of the problems associated with a diagnosis, treatment, and rehabilitation of such treated persons still should have been solved by a nurse and other medical workers. These ones, therefore, require a broad general clinical training and an ability to solve many related and cross-cutting issues. Meanwhile, as experience shows, any nurse must appeal for help to specialists in the management of elderly patients, placing high hopes on them as in the diagnostic and treatment process. Here, the peculiar redistribution of medical duties occurs, resulting in an elderly patient and depending on the nature and number of diseases (or syndromes). It becomes an object for attention for physicians of various specialties. Each of them usually treats an own disease, losing a vision of special geriatric problems, as a whole, in elderly patients. Often consultants appoint a little information and sometimes costly diagnostic tests to the elderly, being burdensome for their age and conditions. At the same time, it turns out that the participation of related professionals in the diagnostic process and special studies have not reduced a misdiagnosis and delayed in later life diseases such as tuberculosis, sepsis, pulmonary embolism, urinary tract infections, and malignant tumors. Thus, the paper presents common health issues the elderly have. As a case, the study reveals the nurse’s behavior to cooperate with such a patient.
Common Issues a Nurse May Face
The need for an integrated approach to the elderly patient on the basis of broad clinical training for a physician can be most clearly illustrated by the following example. It presents the patient with diabetes. The nature of the flow and specific complications of this disease along with frequent co-morbidities require from the nurse's some relevant knowledge and skills not only in endocrinology. However, such nursing practitioner should obtain with some skills in in such clinical areas as cardiology (i.e. arterial hypertension, diabetic cardiomyopathy, and heart failure), nephrology (diabetic nephropathy), urology (urinary tract infection and neurogenic bladder), neurology (polyneuropathy), ophthalmology (diabetic retinopathy, cataracts), orthopedics, and surgery (diabetic foot). Often, the repeated visits to specialists for the recognition of complications and further therapy are not always a virtue to an elderly patient.
The reality of clinical geriatrics is felt particularly by administrating elderly patients with various mental disorders. They involve especially depression and dementias, which are often not recognized by internists because of their lack of familiarity with this disease (Diachun et al.). In addition, the relatively high frequency of these mental disorders hides various manifestations of internal organs (somatoform disorders). The most typical ones include ischemic heart disease, hyperventilation syndrome, intestinal problems, etc. the lack of familiarity of nurses with similar manifestations or simply ignorance of such ones (it means that only 49% of internists detect some awareness in this area) leads to a persistent search of a possible issue (Stehouwer et al.). Such problem may be a pathology of internal organs, a series of undue surveys, contributing to depression and phobic disorders. The appointment of medical treatment should not be even mentioned on this. It is usually not only ineffective, but also capable of causing various adverse reactions, including depression, for the elderly patients (Gorbien and Eisenstein; Moynihan, Doust and Henry).
In geriatric practice, there are various relationships between depression and somatic disorders. The first one may accompany a physical illness related to hospitalization of a patient or being pathogenesis-related somatic diseases. Such ones are always connected with with cancer, cardiovascular, respiratory disorders, and osteon-articular apparatus. It has been found out that depression among the old people occurs in 60% with severe and 20% with mild physical disorders (Carson and Margolin). Lately, there has been a clear tendency of psychiatry to merge with other clinical medicine sections. Such an approach to postgraduate training of nurses has already had a positive impact on the level of diagnosis for mental disorders in elderly patients, especially identifying depression.
The main emphasis of current trends in geriatrics should be placed on community-acquired forms of any patient, mainly in the hospital, at home, in day care, etc. The nurse should be aware that the placement of elderly patients into a medical institution itself is a stressful situation. The reason is that it violates the stereotypes of their formed life (familiar decor, ambiance, and some domestic rituals). Patients with vascular disorders of the brain, mild forms of depression, and dementia especially negatively react to the hospital. Here is a high probability of delirium occurrence in the first week of hospitalization. It has been found out that some factors that accelerate the onset of delirium in hospitalized elderly patients. Such ones are considered to be physical limitation, a poor diet, taking more than three medications, bladder catheterization, and iatrogenic disorders. There are some examples once such patients are hospitalized. They may involve for the exacerbation of coronary artery disease or hypertension or cerebral vascular insufficiency, when such elderly people refuse food, being poorly oriented in the environment, have the marked confusion, incontinence, and unexplained fall in the first days of their treatment. Injuries during falls are one of the problems of treating the elderly hospitalized patients. Almost 36% of them fall out of bed at the same time, with the majority of cases in the evening and at night when trying to get out of bed or in a dream; 28 % of them fall from an access without an obturator mechanism (Fragala, Perry and Fragala). Increasing the length of stay increases their risk of falling, especially missing some observation of patients, stroke or their consequences as well as the appointment of sedatives.
Another problem of hospitalizing the elderly people is nosocomial infections, i.e. mortality at this age being quite high. The main forms of nosocomial (hospital) infections are pneumonia, urinary tract infections, and wound infections. The factors such as increased microbial colonization of mucous membranes of the respiratory tract in a hospital setting, the presence of diabetes, other lymphoproliferative diseases, and immunodeficiency states predispose the development of nosocomial infections at an older age. In this regard, there is a need for strict indications for hospitalization of the elderly patients who have risk factors for infection. Underestimating these factors may lead to severe, intractable infectious complications in some case. Of course, the desirability and feasibility of hospitalization cannot be put under question in the situations requiring an immediate observation and intensive therapy. However, a nurse must always remember that the risk associated with hospitalization in these patients may exceed the potential benefits. Unfortunately, due to the poorly developed community-acquired forms of medical and social care for the elderly, hospitalization of such patients is often done mainly for social reasons. It occurs due to a permanent loss of a functional ability as a result of cerebrovascular diseases, chronic illnesses of the musculoskeletal system, a severe heart failure, and the social status of the elderly (i.e. loneliness). The trend to save usual conditions of the elderly patients’ life as long as possible is an important must-have of any nurse. The humanistic care for such people greatly influences their hospital stay.
Working with Elderly
From the nurse’s experience being built on practice and observation, elderly patients need more understanding and support than others. Thus, the work of the nursing practitioner is associated not only with a great exercise, but also with a big emotional stress. It is important to establish some contact with every such patient. The nurse must be able to demonstrate understanding of the difficulties and problems of the elderly person. However, the practitioner should not seek the resolving to these problems. There are few rules of the effective first care given to the patient. They are quite common and useful for any case.
The nurse should be able to create a pleasant atmosphere during a conversation. The lighting level comes first. Too much or too little light can exhaust or strain the eyes of the patient. It might interfere to focus on the issues. If light cannot be eliminated, the nurse should offer to go to another room to continue the conversation. The patient may also behave awkward if he/she feels that a talk to someone else bothers the cooperation. The nursing practitioner should ask visitors to leave the place for some time. However, a chance should be given to a friend or a family member to attend the patient if he/she desires this.
The nurse has to understand whether the treated person is ready to talk. If the patient is tired, afraid of anything or got some pain, he/she will be too depressed and taciturn. Here, the nurse must transfer acquaintance for the next time. Usually the conversation takes at least 15 minutes. The nurse should not rush; the dialogue may last for an hour to receive good results. The nursing practitioner may divide the conversation into several parts if there is no enough time for it.
The nurse also has to get all available information about the elderly patient before having a talk. Thus, she/he will save the own time and will not exhaust the patient with redundant questions. However, the nurse should try to quickly draw conclusions from the information received, since the treated person could not give all the data before. It is better for the nursing practitioner to be sure of the correct address of the patient, the phone, age, a place of work, and so on. The nurse needs to achieve a trusting relationship with the person under analysis. An interested look and a periodic repetition of the elderly patient’s words will help to achieve the desired results. The nurse must not look sharp, inaccessible or indifferent. She/he should explain the purpose of the conversation for the patient to understand what benefits both will take from this talk. It is rather easy by giving examples of how the information has helped to determine the correct treatment and care.
The tone of the conversation should be mild but persuasive for the patient to feel safe. Usually, the nurse starts the talk by asking the treated person how she/he feels. Allowing the elderly patient to talk about the illness, the nurse can identify the symptoms that should be examined. This means will also help to assess the emotional state of the person and the level of understanding. The nursing practitioner should not disclose the information obtained from the patient. Allowing the person to answer to questions freely is rather important. However, if the latter one evades the topic discussed, the nurse should return back to the subject. To do this, the practitioner may tactfully ask some questions about the illness debated. During the conversation, the nurse must speak simply and clearly. He/she should better avoid using medical terms. Usually, the patient does not want to remain unclear of the illness. However, the nurse must pay attention to the fact that the elderly person will surely respond.
Practicing an exact wording in questions is also important. Thus, the nurse tries to quire the things that require more answers than simply yes or no. Unfinished issues are focusing the patient and make him/her give more complete replies. The nurse should ask questions in order to talk about the definite complaint in details if the patient demands to pay attention to it. Details are important when the nurse uses some unfamiliar terminology.
The functioning of medical teams engaged in the community (home hospital) is very essential for society. Moreover, multilateral surveillance and monitoring of elderly patients (i.e. their specific physical and mental health problems) is appropriate from the standpoint of optimizing community care to geriatric patients. The composition of these teams, as the international experience has showed, can go along with a supervising physician (geriatrician), a specially trained nurse, a therapist, and a social sister. It is determined to solve various social and domestic issues. The implementation of the principle of community curation for elderly patients with severe chronic diseases (heart failure and obstructive pulmonary disease) largely depends on the education of the patient and his/her family. It will ensure the compliance with the prescribed treatment, diet regime, frequent home visits by nurses, and early detection of symptoms being amenable to correct the outpatient basis.