CONCEPTS, PRINCIPLES AND THEORIES IN THE CARE OF OLDER ADULT

NCM 114 CARE OF THE OLDER ADULT

CONCEPTS, PRINCIPLES AND THEORIES IN THE CARE OF OLDER ADULT

A. PERSPECTIVE ON AGING
B. DEMOGRAPHY OF AGING AND IMPLICATIONS FOR HEALTH AND NURSING
CARE
C. IMPACT OF AGING MEMBERS IN THE FAMILY
D. THEORIES OF AGING AND ITS NURSING IMPLICATIONS
E. PHYSIOLOGICAL CHANGES IN AGING AFEECTING VARIOUS SYSTEMS

A. PERSPECTIVE ON AGING
1. Aging is a developmental Process
- Aging is associated with changes in dynamic biological, physiological, environmental,
psychological, behavioral, and social processes. Some age-related changes are benign, such as
graying hair. Others result in declines in function of the senses and activities of daily life and
increased susceptibility to and frequency of disease, frailty, or disability. In fact, advancing age is
the major risk factor for a number of chronic diseases in humans.

PERSPECTIVE VIEW ABOUT AGING

 Aging to refer to the passing of time for an individual—the inevitable chronological

change in our age from year to year.
 “Aging” to refer to other things— a progression of physical decline, a change in
family roles (e.g., becoming a grandparent), a change in work status (retirement), or
forgetting where you left your keys. While some of these may be associated with
increasing age.
 Aging is not associated with physical decline for all individuals at all points in time.

B. Demography of Aging and Implications for Health and Nursing Care.

 Global Aging

World Population Ageing 2019:

- Population ageing is a global phenomenon: Virtually every country in the world is
experiencing growth in the size and proportion of older persons in their population.
- Population ageing has been fastest in Eastern and South-Eastern Asia and Latin America
and the Caribbean.
- Throughout most of the world, survival beyond age 65 is improving
- Conventional indicators of population ageing that are based on chronological age (years
since birth), with a fixed threshold of “old age” at age 65, show that populations are
becoming older in all regions of the world.
- New measures of population ageing based on prospective age (years of life remaining),
with a dynamic threshold of “old age” that rises progressively with increasing life
expectancy, point toward a slower process of population ageing than what is indicated by
the conventional measures.
- Indicators that incorporate both demographic and economic information suggest that the
extent of population ageing depends on age-patterns of production and consumption.
- The consumption of older persons is financed in various ways around the world, including
through public transfers, private transfers and income from assets and labour.
- Population ageing will put increased financial pressure on old-age support systems.
- Population ageing does not lead inevitably to macroeconomic decline—with well-chosen
policies, just the opposite may be true.
- Life expectancy has increased rapidly since the Age of Enlightenment. In the early 19th
century, life expectancy started to increase in the early industrialized countries while it
stayed low in the rest of the world. This led to a very high inequality in how health was
 distributed across the world. Good health in the rich countries and persistently bad health in
those countries that remained poor. Over the last decades this global inequality decreased.
No country in the world has a lower life expectancy than the countries with the highest life
expectancy in 1800. Many countries that not long ago were suffering from bad health are
catching up rapidly.

 Since 1900 the global average life expectancy has more than doubled and is now above
70 years. The inequality of life expectancy is still very large across and within countries.
in 2019 the country with the lowest life expectancy is the Central African Republic with
53 years, in Japan life expectancy is 30 years longer.
 Differences in life expectancy across the world
-The world map shows the latest data published by the United Nations for life expectancy.
- Life expectancy is a measure of premature death and it shows large differences in health
across the world.

- The population of many of the richest countries in the world have life expectancies of
over 80 years. In 2019 the life expectancy in Spain, Switzerland, Italy, and Australia was
over 83 years. In Japan it was the highest with close to 85 years.
- In the countries with the worst health life expectancy is between 50 and 60 years. The
population of the Central African Republic has the lowest life expectancy in 2019 with 53
years.

World Health Ranking

B. Demography of Aging and Implications for Health and Nursing Care.

2. Aging in the Philippines
- According to a 2018 study by the Philippine Institute for Development Studies (PIDS), the
Philippines is on its way to becoming an “ageing society” in 2032. This means that in 13 years,
Filipinos aged 65 years old and older will make up 7 % of our country’s total population. In
2069, this figure will go up to 14 %, making the Philippines an “aged society”. PIDS research
fellow Michael Abrigo says that “Population ageing is not a bad thing. It represents a story of our
collective success as Filipinos. It means that we are able to conquer the challenges such as those
related to income, health and education.”

- The current life expectancy for Philippines in 2020 is 71.28 years, a 0.18% increase from 2019.
- The life expectancy for Philippines in 2019 was 71.16 years, a 0.18% increase from 2018.
- The life expectancy for Philippines in 2018 was 71.03 years, a 0.23% increase from 2017.
- The life expectancy for Philippines in 2017 was 70.87 years, a 0.23% increase from 2016.
- Philippines has rank # 123 with the rate of 68.3

C. Impact of Aging members in the family.

 Caring for aging parents has multiple impacts on the family life, including emotional,
physical, financial and structural effects. As family members make plans and reflect on
future as a caregiver/s, they take time to appreciate the strength derive from working
together and the unique bonds share as family.

1.Emotional Effects - Caring for aging parents prompts a range of impulses and emotions.
"Guilt for not being able to do more for parents; anger for having to set aside own needs or
shift priorities; and fear and anxiety, including anticipatory grief and fear of financial
strain."

- Thomas and Segur also identify positive emotional effects of caring for aging parents, such as
"enrichment that comes with relationships between grandparents and grandchildren; increased
opportunity to pass on stories and knowledge to younger generations; and [the] younger
generations having a sense of being able to give back to parents and grandparents," resulting in a
"greater connection" between family members.
 2. Financial Effects - Caring for aging parents often means extra costs related to home
health care, medical expenses not covered by insurance and extra insurance premiums for
services such as long-term care.
- Thomas and Segur say that some families explore options for financial support that can make
family life more enjoyable, emphasizing that "there is no shame in utilizing what support is out
there."

3. Structural Effects - When a person live with his/her aging parents or assume a high
amount of daily care for them, he/she experience a change in family roles. Thomas and
Segur describe this as a "shift in family structure and hierarchy related to [the] matriarch or
patriarch no longer being in their role." When this occurs, "someone new [has] to take their
place."
- This shift can cause guilt and stress, as family members work to find a place in the new family
dynamic, but it can also result in more open communication among family members.

4. Physical Effects - Prioritizing parents' care can ease their pain and worry, but might
impact health. Families who share responsibilities and secure outside help experience less
stress and have the time and resources to maintain their health and relationships with all
members of the family.

5. Positive Effects - some families have the opposite experience by creating what he/she
describes as a positive "wiring" in their brains to produce more potentially positive
outcomes. These people reflect on what makes them feel good for caring for their aging
parents. They consider what moments in their days make them smile. They revel in the
moments with loved ones that increase their sense of self-worth and they end up creating
closer bonds with both the older and younger generations.

D. Theories of Aging and Its Nursing Implications.

1. Biological Theories
a. Stochastic Theories based on random events that cause cellular damage that
accumulates as the organism ages.
• Free radical Theory – membrane, nucleic acids and proteins are damaged by free
radicals which causes cellular injury and aging.
Orgel/Error Theory – Errors in DNA and RNA synthesis occur with aging.
Wear and Tear Theory – cells wear out and cannot function with aging.
Connective tissue/Cross – link Theory – with aging, proteins impede metabolic
processes and cause trouble with getting nutrients to cells and removing cellular waste products.

b.Nonstochastic Theories based on genetically programmed events that cause cellular damage
that accelerates aging of the organism.
• Programmed Theory – cells divide until they are no longer able to, and this triggers
apoptosis or cell death.

• Gene/Biological Clock Theory – cells have a genetically programmed aging code.

• Neuroendocrine Theory – problems with the hypothalamus – pituitary – endocrine gland
feedback system cause disease, increased insulin growth factor accelerates aging.
• Immunological Theory – aging is due to faulty immunological function, which is linked
to general well – being.

2. Psychological Theories
• Human Needs Theory
• Theory of Individualism
• Stages of Personality Development Theory
• Life – Course (Life Span Development) Paradigm
• Selective Optimization with Compensation Theory
Human Needs Theory
 - Human Needs Theory. Maslow surmised that a hierarchy of five needs motivates human
behaviour: physiologic, safety & security, love & belonging, self – esteem and self –
actualization.
- Although Maslow does not specifically address old age, it is clear that physical,
economic, social and environmental constrains can impede need fulfillment of older adults.
Maslow asserts that failure to grow leads to feelings of failure, depression and the perception that
life is meaningless.
- Theory of Individualism (Jung’s Theory)
Jung proposes a life – span view of personality development rather than attainment of basic
needs. Jung defines personality as being composed of an ego or self – identity with a
personal and collective unconsciousness.
- As individuals age, Jung proposes that elders engage in an “inner search” to critique their
beliefs and accomplishments. Successful aging means acceptance of the past and an ability
to cope with functional decline and loss of significant others
- Neugarten (1968) supports Jung’s association of aging and introspection and asserts that
“interiority” promotes positive inner growth. Subsequent theorists also describe
introspection as a part of healthy aging. (Eriksonnnn, 1063; Havighurst et al, 1968)

Stages of Personality Development Theory

Erikson’s Theory focuses on individual development.
- Progression to a subsequent life stage requires that tasks at prior stages be completed
successfully.
- Older adults experience the developmental stage known as “ego integrity versus despair”.
Erikson proposes that this final phase of development is characterized by evaluating one’s
life and accomplishments for meaning.
- In later years, Erikson and colleagues expanded upon his original description of integrity
versus despair, noting that older adults struggle with letting go, accepting the care of others,
detaching from life, physical and mental decline. (Erikson, Erikson, & Kivnick, 1986)
- Several authors have expanded upon Erikson’s work. Peck (1968) refined the task within
Erikson’s stage of ego integrity versus despair into three challenges: ego differentiation
versus work role reoccupation, body transcendence versus body preoccupation and ego
transcendence versus ego preoccupation.
- Major issues such as meaningful life after retirement, the empty nest syndrome, dealing
with the functional decline of aging, and contemplating one’s mortality are consistent with
Peck’s conceptualization.
- Butler and Lewis (1982) later defined the challenges of late life as adjusting to infirmity;
developing satisfaction with one’s lived life, and preparing for death, mirroring those tasks
described earlier by Peck.

Life – Course (Life Span Development) Paradigm

- The central concepts of the life-course perspective blend key elements in psychological
theories such as life stages, tasks, and personality development with sociological concepts
such as role behavior and the interrelationship between individuals and society.
- The central tenet of life – course is that life occurs in stages that are structured according
to one’s roles, relationships, internal values and goals. Individuals may choose their goals
but limited by external constraints. Goal achievement is associated with life satisfaction
(Buhler, 1933).

- Individuals must adapt to changed roles and relationships that occur throughout life, such
as getting married, finishing school, completing military service, getting a job and
retirement(Cunningham & Brookbank, 1988). Successful adaptation to life change may
necessitate revising beliefs in order to be consistent with societal expectations.
- Selective Optimization with Compensation Theory

- According to Baltes’s Theory (1987), individuals learn to cope with the functional losses
of aging through process of selection, optimization and compensation. Aging individuals
 become more selective in activities and roles as limitations present themselves; at the same
time they choose those activities and roles that are most satisfying(optimization).

-Finally, individuals adapt by seeking alternatives when functional limits prohibit

sustaining former roles of activities.
- As people age, the pass through critical life points related to morbidity, mortality and
quality of life. The outcome of these critical junctures may result in lower or higher order
functioning that is associated with higher or lower risk, respectively, for mortality.
Selective optimization with compensation is a positive coping process that facilitates
successful aging. (Baltes & Baltes, 1990)

Implications for Nursing

- In a quest for a theoretical framework to guide caregiving in nursing homes, Wadensten
(2002) and Wadensten and Carlsson (2003) studied 17 Nursing Theories that were
generated from 1960’s to the 1990s and found that none of the theorists offer advice on
how to apply their theory to caring for the older adult. Wadensten wrote that existing
“Nursing theories do not provide guidance on how to care for older people or on how to
support them in the developmental process of aging. There is a need to develop a nursing
care model that more than contemporary theories, takes human aging into consideration”
(2002). Others concur that nursing needs to develop more situation – specific theories of
aging to guide practice.

Nursing Theories of Aging

• Functional consequences Theory – Environmental and biopsycholosocial consequences

impact functioning. Nursing’s role is risk reduction to minimize age – associated disability
in order to enhance safety and quality of living.

• Theory of thriving – failure to thrive results from a discord between the individual and
his or her environment or relationships. Nurses identify and modify factors that contribute
to disharmony among these elements.

Physiology of Aging
- Aging is a process that begins at conception and continues for as long as we live. At any
given time throughout our lifespan, the body reflects:

- its genetic component and

- its environmental experience.
- In other words, our bodies reflect our genetic capacity to adapt and repair, as well as the
cumulative damage from disease processes. Aging highlights our strengths and our
weaknesses.
- In our society we currently think of the "young old" as being around 65 to 74 years of
age, the "middle old" 75 to 84 and the "old old" 85 years +. With advancing age, all of the
body systems eventually demonstrate reduced efficiency, slowed building & replacement
and actual loss of tissue. While an individual' s aging experience is unique, there are
generalizations which can be observed for each of the body systems.

E. Physiologic changes in aging various systems.

1. Integumentary -The primary function of the skin is to protect the organism from the
environment. It accomplishes this by providing a barrier that regulates temperature, retains fluid
and absorbs shock and ultraviolet radiation, among other things. As we age, the dermis decreases
in thickness by about 20%. As it thins it loses vascularity, cellularity and sensitivity. Its ability to
exchange or retain internal heat is diminished. The skin becomes thin, fragile and slow to heal.
Sweat and sebaceous glands are reduced both in number and effectiveness. Sensory neurons are
decreased by 30% from the age of 10 years to 90 years old.
- Subcutaneous fat deposition is altered in the elderly. Muscle, blood vessels and bone become
more visible beneath the skin due to thinning of subcutaneous fat on the extremities. Fat
deposition occurs mainly on the abdomen and thighs.

2. Musculo – skeletal - Muscle mass is a primary source of metabolic heat. When muscles
contract, heat is generated. The heat generated by muscle contraction maintains body
temperature in the range required for normal function of its various chemical processes.

- As early as the third decade of life there is a general reduction in the size, elasticity and strength
of all muscle tissue. The loss of muscle mass continues throughout the elder years. Muscle fibers
continue to become smaller in diameter due to a decrease in reserves of ATP, glycogen,
myoglobin and the number of myofibrils. As a result, as the body ages, muscular activity
becomes less efficient and requires more effort to accomplish a given task. The elderly are less
efficient at creating the heat necessary to drive the important biochemical reactions necessary for
life.

3. Respiratory - Lung function diminishes with age. The major contributing factors are the
progressive loss of elastic recoil within lung tissue, the chest wall becomes stiff, and there is a
decrease in alveolar surface area. These changes diminish the efficiency of gas exchange and
make it more difficult to exercise.

4. Cardiovascular - Despite cardiovascular disease, often combined with a slowdown in

the autonomic nervous response, the cardiovascular function of a resting healthy elder is usually
adequate to meet the body's needs. Cardiac output of healthy exercising elders can usually be
maintained, allowing moderate continued physical activity throughout their lives.

5. Hematopoietic and Lymphatic - Aging is associated with a marked increase in a

number of diseases, including many types of cancer. Due to the complex and multi-factorial
nature of both aging and cancer, accurate deciphering of causative links between aging and
cancer remains a major challenge.

6. Gastrointestinal – gastrointestinal symptoms can be quite common and range from mild
constipation or acid reflux to more serious conditions like infectious colitis or bowel ischemia.
Older adults more likely to use medication, such as certain heart medication or non – steroidal
anti - inflammatory drugs to treat pain, that can increase the risk of gastrointestinal ulceration or
bleeding. Risk of developing colon cancer or diverticulitis also increases by age.

7. Urinary - Aging increases the risk of kidney and bladder problems such as: Bladder
control issues, such as leakage or urinary incontinence (not being able to hold your urine), or
urinary retention (not being able to completely empty your bladder) Bladder and other urinary
tract infections (UTIs) Chronic kidney disease.

8. Nervous - the nervous system changes with age. There is loss of neurons in both the
brain and spinal cord. There is loss of neuronal dendrites which reduces the amount of synaptic
transmission. The sense of smell, taste, sight, touch and hearing are all diminished over time.
Depression can be the result of impaired synaptic activity.

9. Special senses – aging can affect all of the senses, but usually hearing and vision are
most affected. Devices such as glasses and hearing aids, or lifestyle changes can improve the
persons’ ability to hear and see.

10. Endocrine - Old age is accompanied by a generalized reduction in hormone production

and activity. This reduction affects most metabolic functions of the body. Water, mineral,
electrolyte, carbohydrate, protein, lipid and vitamin disorders are all more common in the
elderly. Nutrition and the ability to use food for energy is seriously affected in the elder
population.
- Diabetes is common in the elderly. There are many causes but a primary mechanism involves
the inability of skeletal muscle to absorb glucose. Over time skeletal muscle becomes less
responsive to insulin.
- Recent research indicates that the elderly are at risk for nutritional deficiencies due to anorexia.
Age related anorexia has been linked to a lower satiety threshold. Elders feel "full" sooner which
may be due to changes in hormone receptor or trigger mechanisms.
11. Reproductive - Unlike women, men do not experience a major, rapid (over several
months) change in fertility as they age (like menopause). Instead, changes occur gradually during
a process that some people call andropause. Aging changes in the male reproductive system
occur primarily in the testes