Running head: IMPACT OF AGING ON THE ELDERLY 1

Impact of Aging on the Elderly

Julianna Brauchle

Cedar Crest College

Abstract

Successful aging is defined by Rowe and Kahn (1997) as possessing three main components: low

probability of disease and disease-related disability, high cognitive and physical functional

capacity, and active engagement with life. The purpose of this paper is to complete a

comprehensive geriatric assessment on an elderly person that is struggling to maintain healthy

aging in their day to day life and recognize any problem areas in their functionality. Different

geriatric assessment tools were utilized in order to identify problem areas and to create a nursing

care plan to promote the health and wellness of the elderly individual. These problem areas

included sleep disorders and depression. Research was utilized to further develop a care plan in

order to increase the well-being of the elderly individual according to the problem areas

previously identified. This care plan includes nursing diagnoses, goals, interventions, and

evidence based rationales related to the problem areas identified during the client’s assessment,

including sleep disorders and depression.

Keywords: aging, successful aging, assessment, geriatric, sleep disorders, depression

Impact of Aging on the Elderly

History and Health Assessment

Jane Doe, who’s name was changed in order to provide privacy, is a 92-year-old female

living in her home with her oldest daughter. Jane has lived in her home since 1946, and has no

plans of moving out. She has a history of emphysema in which she is on a continuous 2 liters per

minute oxygen therapy treatment for. She has a home care aide that comes in twice a week to

bathe her and clean the small area she lives in. Jane also has what she calls “extremely mild

depression” (J. Doe, personal communication, February 8, 2017), in which she is taking

Paroxetine to treat.

Activities of Daily Living

Jane’s activities of daily living (ADL’s) were evaluated using the Katz Index of

Independence in Activities of Daily Living (ADL) (Katz, 1983), (See Appendix A for ADL

assessment). Upon evaluation, Jane scored a four out of six. Jane needs assistance with bathing

and is partially incontinent, which gave her zero points in those categories. She is able to dress

herself, is able to toilet herself, is able to transfer herself without assistance, and is able to feed

herself which gave her four points.

Instrumental Activities of Daily Living

Instrumental activities of daily living (IADL’s) were assessed with Jane using the Lawton

Instrumental Activities of Daily Living Scale (Lawton & Brody, 1969) (See Appendix B for

IADL assessment). Jane scored a four out of eight on the Lawton IADL scale. She is able to

operate the telephone by herself, she does her own laundry completely, is responsible for taking

her own medication in correct dosages at the correct time, and manages her day-to-day purchases
IMPACT OF AGING ON THE ELDERLY 4

but needs help with banking. Jane needs her meals prepared and served to her, is completely

unable to shop alone, does not travel at all, and does not participate in any housekeeping tasks.

Communication

Jane does not have any impairments that prevent her from communicating. Jane has no

speech deficit and speaks loudly and clearly with ease. Her sight is intact and she demonstrates

this by reading aloud a paragraph from her newspaper without any difficulty. Jane’s hearing was

assessed using the Hearing Handicap Inventory for the Elderly Screening Version (HHIE-S)

(Ventry & Weinstein, 1983) (See Appendix C for assessment). Jane scored a 12 which suggests a

mild to moderate hearing handicap. She finds it hard to hear someone speaking in a whisper, and

finds it difficult to hear when she is in a loud restaurant, and also has arguments with family.

Economic Status

Jane did not want to share very much about her economic status. She did, however, state

that she had “no plans of moving into a long-term care facility” (J. Doe, personal

communication, February 8, 2017). She also stated that she does have a living will, and that her

son is in charge of her finances. Her son is also her power of attorney.

Living/Home Environment

A home safety assessment was retrieved from A Place for Mom (2015) and used to assess

Jane’s home (see Appendix D for assessment). The assessment revealed a need for improvement

that was discussed with Jane, as throw rugs created a further fall risk, along with her oxygen

tubing that is wrapped around the halls and is a significant tripping hazard. Since Jane does not

often leave her home, the front entry is not an immediate danger, but in an emergent situation it

would be. Further communication with her daughter occurred and the necessary changes were

noted.
IMPACT OF AGING ON THE ELDERLY 5

Mental Health

To assess the mental health of Jane, a few different assessment tools were utilized. First,

the Mini-Cog (Borson et al., 2006) (See Appendix E for assessment and clock drawing) was

used. Jane scored a two out of five on this assessment as she did not draw the correct time and

she only remembered two of the three words after the distractor. Next, the Montreal Cognitive

Assessment (Nasreddine, 1996) (See Appendix F for assessment) was used. Jane scored a 26 out

of 30. The Geriatric Depression Scale (Yesavage et al., 1983) (See Appendix G for assessment)

was then utilized to score Jane’s depression. She scored an eight out of 15 which is suggestive of

depression, as she answered each question based upon how she felt in the last week. She did not

feel happy most of the time, in fact she often felt helpless, bored, and worthless.

Physical Health and Nutrition

To assess Jane’s nutritional status, the Mini- Nutritional Assessment Short-Form

(Rubenstein, 2001) (See Appendix H for assessment) was utilized. She scored a seven out of 14

possible points, which is indicative of malnourishment. Jane has a BMI of 17.9, has lost about 6

pounds over the last three months, and does not go out of her house which all put her at risk for

malnutrition. However, she recently had a fall that resulted in an injury on her right leg. The

Hendrich II Fall Risk Model (Hendrich, 1995) (See Appendix I for assessment) was used to

further investigate Jane’s fall risk. She scored a six which puts her at high risk for a fall, as she is

unable to stand without multiple attempts, has symptomatic depression, and altered elimination.

Social Support

Jane’s social support, as she stated, includes her children, and her neighbors. She

occasionally finds that some of her friends come and visit her, but not on a consistent basis to

consider them a part of her support team (J. Doe, personal communication, February 8, 2017).
IMPACT OF AGING ON THE ELDERLY 6

Her neighbors visit her on a regular basis to check up on her, but other than them she claims she

does not have a support system.

Sleep

Jane expressed her concern with her sleep. In order to better assess her sleep patterns, two

assessments were performed. First, the Pittsburgh Sleep Quality Index (Buysse et al., 1989) (See

Appendix J for assessment) was used to measure the quality and patterns of her sleep. Jane

scored an eight, which indicates she sleeps poorly according to the Pittsburg Sleep Quality Index

(Buysse et al., 1989). Next, the Epworth Sleepiness Scale (Johns, 1991) (See Appendix K for

assessment) was used to measure average daytime sleepiness. Jane scored a 15 on this

assessment which reflects a lot of daytime sleepiness and that she should seek medical advice.

Impact of Aging and Coping Mechanisms

Jane can be directly quoted as saying “old age sucks… it’s exhausting. There are so many

things you want to do but can’t” (J. Doe, personal communication, February 8, 2017). Her life

has been impacted greatly by aging. Jane was once a local gym teacher, loved to dance, and

played tennis three times a week. After her emphysema started, she had to change her lifestyle

and is now no longer able to do the things she once loved to do. She also stated “all of my tennis

partners are dead now anyways, I am the only one still here. What fun would it be if I could still

play, without my friends around to play with? Getting old really is awful because it’s lonely, all

of your friends die off and you are left with only yourself” (J. Doe, personal communication,

February 8, 2017). Jane does not like the impact that aging has had on her life.

Aging has been a largely negative subject in Jane’s life. Growing older has left Jane

feeling lonely and depressed. She has been on a Selective Serotonin Reuptake Inhibitor for three

years now in an attempt to combat her depression, however she expresses that she still cries and
IMPACT OF AGING ON THE ELDERLY 7

feels sad a lot of the time. Jane claims that the stereotypes are true about aging. One specific

stereotype that she is referring to is that North Americans “depict later life as a time of ill health,

loneliness, dependency, and poor physical and mental functioning” (as cited in Dionigi, 2015). It

has been found that “aging self-stereotypes had a direct impact on physiological function, with

negative aging stereotype primes increasing cardiovascular stress in white and African American

older individuals, respectively, before and after mental challenges” (as cited in Dionigi, 2015).

Jane does not have any cardiovascular issues, however she does have a negative self-image on

her aging, which may have had an impact on her aging process. According to Dionigi (2015),

“the fear of being perceived as sick could actually discourage people from seeking medical

assistance, indicating that the concept of stereotype threat is working in conjunction with the

internalization of negative stereotypes”. Jane has avoided seeking medical care for a fall she

recently had because she does not want to be seen as sick. Her direct quote was “I do not need to

go to see a doctor for this cut, nothing is wrong, I will heal like I have always healed- that does

not change just because I am old” (J. Doe, personal communication, February 8, 2017). The

negative stereotype of aging and being feeble led her to forego medical assistance, which can

impact her health in the future.

Coping Mechanisms

Jane claims that in order to cope with her loneliness, she stays inside of her home and

watches TV or reads (J. Doe, personal communication, February 8, 2017). She also stated that

she would rather stay at home than to go out and meet new friends, because any friend she makes

that is her own age is probably going to die soon anyway, so what’s the point (J. Doe, personal

communication, February 8, 2017). These coping mechanisms are described as being

“maladaptive coping mechanisms more commonly used in depressed older adults” (Raut et al.,
IMPACT OF AGING ON THE ELDERLY 8

2014). According to the Raut et al. (2014) study, “considerable variation is seen among the

coping strategies which are used by the lonely and the choices of coping strategies are affected

by the individuals age, life experience, cultural background, and the availability methods of

alleviating loneliness”. This same study also claims that “common coping strategies used by

elderly include active solitude, social contact, sad passivity, increased activity distancing, and

denial” (Raut et al., 2014). Jane has displayed the use of these maladaptive coping mechanisms

quite clearly. She chooses to live in solitude, as she would rather be alone than feel the pain of

losing another friend. She distances herself from other people out of fear of losing them, and she

is in denial of what it means to age.

To Jane, successful aging is “not being sick, being able to hold an intellectual

conversation, and not to feel like I am dying every day of my life” (J. Doe, personal

communication, February 8, 2017). She feels as though she has successfully aged in the sense

that she is able to hold an intellectual conversation and talk to a person without forgetting too

much, but her emphysema is her sickness and it prevents her from feeling good every day. She

claims that she doesn’t feel as though she is dying every day, but most days she wishes she

would (J. Doe, personal communication, February 8, 2017).

Problem Areas

The first of two main problem areas in relation to Jane is her sleep pattern. Upon

evaluation by both the Pittsburgh Sleep Quality Index (Buysse et al., 1989) and the Epworth

Sleepiness Scale (Johns, 1991), it was found that Jane sleeps poorly and has a significant amount

of daytime sleepiness, respectively. Aside from the assessments done, which indicate a need for

further medical evaluation to assist in proper sleeping maintenance, it has been noted by Jane’s

neighbor that she sleeps for most of the day off and on, as every time her neighbor walks up to
IMPACT OF AGING ON THE ELDERLY 9

the door she is napping. It has also been stated that “the transition from adulthood to middle and

old age is characterized by a shift to earlier sleep-wake schedules, poor sleep consolidation,

reduced total sleep time, disorganized circadian rhythms, and decreased circadian amplitude…

all factors that are also often affected by mood disorders” (Robillard et al., 2014). Sleep is Jane’s

priority problem area, as sleep disorders are linked to a lot of other health problems that can

develop from lack of sleep. One problem that sleep deficiency is linked to is mood disorders,

namely depression, in which Jane has been diagnosed with.

As cited in the study done by Robillard et al. in 2014, “decreased energy levels, apathy,

and daytime fatigue are hallmark features of depressive syndromes and are likely to result from,

and be further exacerbated by, sleep-wake disturbances”. Jane expresses all of these symptoms

on a regular basis, and also has difficulty sleeping at night. Her lack of sleep can be contributing

to her depression, along with other factors.

Jane has been clinically diagnosed with depression, and is on medication for it, however

this is still a large problem area in her life. Upon assessment, Jane’s Geriatric Depression Scale

(Yesavage et al., 1982) score was a little high, indicating that she may have mild depression that

is not being fully treated. Coupled with her subjective symptoms of crying often and feeling

extremely lonely, Jane still has a significant problem with her depression. According to a study

done in 2014, Lin et al. stated that it has been shown that “stroke, loss of hearing, poor eyesight,

cardiac disease, and chronic lung disease were factors associated with depression in old age”.

Jane has a history of chronic lung disease- emphysema, and also a mild to moderate loss of

hearing. These can be contributing to her depression, along with sleep deprivation. These

unresolved “depressive symptoms had higher rates of clinic visitation and re-hospitalization”
IMPACT OF AGING ON THE ELDERLY 10

(Lin et al., 2014). This is a major problem for Jane, especially since she already does not like to

seek out medical care, and actually avoids it at all cost.

Nursing Diagnoses

Four pertinent nursing diagnoses were laid out for Jane, in respect to two of her major

problem areas, which were described as being sleep deprivation and depression.

Sleep Problem Area

The first priority nursing diagnoses in relation to Jane’s sleep problem area is as follows:

sleep deprivation related to age-related sleep shifts as evidenced by difficulty falling and

remaining asleep, dozing off during the day, and fatigue. Goals for this client are to verbalize

understanding of sleep disorder by end of care, report improvement in sleep and rest pattern, and

to adjust lifestyle to accommodate chronobiologic rhythms by end of care.

A number of interventions can be used in order to help improve sleep deprivation. The

first priority is to assess the client’s age and developmental stage, as the need for sleep varies

widely among individuals and age groups (Alhola & Kantola, 2007). Sleep structures also

change with aging, as slow wave and sleep efficiency decrease, and alterations in the circadian

rhythm occur, and sleep complaints also become more frequent (as cited in Alhola & Kantola,

2007). The second priority intervention is the the implementation of effective age-appropriate

bedtime rituals. Sleep stimulus control therapy eliminates behaviors in the bedroom that can

exacerbate sleep deprivation, including techniques such as making sure the bedroom is restful

and comfortable, going to bed only if you feel sleepy, and avoiding sleep-fragmenting substances

such as caffeine, nicotine, and alcohol (Am, 2009). These two interventions will assist in

combatting sleep deprivation as related to Jane’s sleep pattern.

The second priority diagnosis for Jane is readiness for enhanced sleep related to

expression of desire to enhance sleep as evidenced by the patient stating “I would really like to

be able to sleep better at night rather than napping during the day” (J. Doe, personal

communication, February 8, 2017). Goals for Jane are to identify individually appropriate

interventions to promote sleep at night and verbalize feeling rested after sleep.

The first priority intervention is to review with Jane her usual bedtime rituals, routines,

and sleep environment needs, along with her sleep in general. This will provide information on

Jane’s management of the situation and will also identify areas that might be modified when the

need arises, as this is the best method for “detecting sleep-wake problems in ambulatory older

people, to simply inquire about sleep on a regular basis” (Am, 2009). Furthermore, “the patient’s

responses should indicate how to proceed with any further history, focused physical examination,

or laboratory interventions” (Am, 2009). This is the first priority because it is so essential in

finding how to proceed with any potential problems. The second priority intervention would be

to initiate the use of relaxation therapy. Relaxation therapy is used because it “guides individuals

to a calm steady state when they wish to go to sleep” (Am, 2009). This is useful because it helps

promote sleep in the elderly individual on their own terms. Lastly, the third priority intervention

for Jane’s desire to enhance sleep is to explore or implement use of non-pharmacological

measures to help sleep, such as a warm bath, light protein snack before bedtime, and comfortable

room temperature. The rationale for this is that non-pharmacological aide can enhance sleep

without the undesired side effects of medications (Doenges, Moorhouse, & Murr, 2016).

Depression Problem Area

The first priority diagnoses for Jane when related to her depression is impaired social

interaction related to fear of death of friends as evidenced by verbalized discomfort with making
IMPACT OF AGING ON THE ELDERLY 12

new friends as client believes they will die. Goals for Jane are identifying feelings that lead to

poor interactions, and resumption of sustaining relationships with friends and family members in

one month.

The primary intervention for Jane is to determine the use of coping skills and defense

mechanisms, as the use of active solitude, social contact, sad passivity, and increased activity

distancing and denial are defense mechanisms commonly used by the depressed elderly (Raut et

al., 2014). This can become an obstacle for creating friendships and other relationships, and

further cause impaired social interaction. The secondary intervention for Jane is to seek

community programs for client involvement that promote positive behaviors that Jane is striving

to achieve, as this can minimize feelings of isolation, which can increase feelings of self-worth

(Raut et al., 2014).

The secondary diagnosis for Jane is disturbed thought processes related to depressed

mood as evidenced by high geriatric depression score scale score and verbalization of depressed

feelings such as crying and sadness. Goals for Jane are to discuss irrational thoughts about self

and other by the end of the first day, discuss medication treatment for depression with physician.

The primary intervention for Jane is to help her identify negative thinking and thoughts,

as these thoughts add to feelings of hopelessness and loneliness and contribute to a negative

thought process (Raut et al., 2014). The secondary intervention for Jane is to discuss

pharmacological intervention with her health care provider. The rationale for this is that “the

effectiveness of pharmacological treatment of depression is not substantially affected by age.

Identification of depression, choice of appropriate treatment, titration of medications, monitoring

of side-effects, and adequate duration of treatment will improve outcomes for older persons
IMPACT OF AGING ON THE ELDERLY 13

(Frank, 2014). These interventions will help to improve Jane’s depression from more than one

approach, which will allow her to correct her disturbed thought processes.

Conclusion

Jane’s major problem areas of sleep disorders and depression can be fixed using the

nursing care plan set forth in this paper.

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