Nursing And The Aging Family Essay

(Week # 12: July 20 to July 26 – Main post under Assignment by Wed, July 22 at 11:59 PM EST).

Students are required to post a minimum of three times per week (1 main post answering the question 100% before Wednesday at 11:59 PM EST and 2 peer responses by Sunday at 11:59 PM EST). The three posts in each individual discussion must be on separate days (same day postings / replies will not be accepted).Nursing And The Aging Family Essay

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Chapter 23 – Neurological Disorders. Amyotrophic Lateral Sclerosis (ALS)
Chapter 24 – Mental Health.Bipolar disorder
Questions:

1. Choose one neurological disorder discussed in your textbook. Mention signs and symptoms of the chosen disease / disorder.

2. Discuss its management and important nursing implications.

Guidelines: The answer should be based on the knowledge obtained from reading the book, no just your opinion. If there are 4 questions in the discussion, you must answer all of them. Your grade will be an average of all answers.

Grading Criteria: Student mentions one neurological disease / disorder from the textbook (25%). Student mentions signs and symptoms of the chosen disease / disorder (25%). Student discusses management of the mentioned disease / disorder (25%). Student discusses important nursing implications.Nursing And The Aging Family Essay

n 2002, I published an article in Michigan Family Review about taking care of elderly parents, a literature review hot off the press of a newly earned PhD in nursing. My dissertation research unexpectedly coincided with the “lived experience” of taking care of my own suddenly and seriously ill 80 year-old mother. Well, not really all that unexpected—after spouses, the most likely primary caregiver of an older adult was (and still is) an adult daughter. Still, I was taken aback when the demand hit home. My distraught feelings then didn’t come close to the sympathetic, earnest calm with which I had regarded the phenomenon from my ivory tower. Nor did they match the confident reassurances that I had dispensed to the worried families of patients throughout years of clinical practice. In short, literature, dissertation, and personal experience confirmed that parent care could be hard and stressful.Nursing And The Aging Family Essay

Now, for a fifteen-year postscript to the 2002 article, I face a different lived experience, but still one typical of a growing number of the elderly. Many adult women belong to the “sandwich generation” (Miller, 1981), meaning they are women in the middle—concurrently taking care of aging parents and of their own dependent children (Brody, 2003). When I took care of my mother, I was a member of the sandwich generation alright but, more accurately, a member of the open-faced sandwich generation (Abaya, N.D.). That is, I was pressed between demands of parent care and career, but without that extra layer of my own children. Now, I look in the mirror and see my aged mother. However, my mother had me and three other children. Facing my own seniority means wondering who will care for me. Who will take on the roles that I and my siblings assumed for our mother?Nursing And The Aging Family Essay

In this article, I examine the situation of older adults like me who do not have adult children. I consider potential solutions to my personal situation informed by recent literature and 40 years of nursing experience across a wide variety of practice settings—from hospital to home care, nursing education, policy and research. First person narratives and recommendations by gerontologists are incorporated from a special issue of the Gerontologist (“Aging: it’s personal”), in which scientists and gerontologists applied their professional identities to their own personal experiences with aging (Pruchno, 2017). This essay begins with examining the special case of caregivers for childless elders and concludes with recommendations for health systems reform organized according to a lifespan family systems perspective on intergenerational support needs and framed within an emergent model for public health and disability (Drum, 2009).

Demographic Realities of Aging Societies, or “Honey, I Shrunk the Family!”
In 1989, Disney studios produced a hit movie called “Honey, I shrunk the kids” in which an eccentric inventor creates a machine that accidentally turns his children into miniatures. The movie spawned a few sequels with similar titles and a TV show. The movies were fictional, of course, but real events of prolonged life span and reduced fertility have led to the shrinking of American families, a trend seen worldwide in industrialized countries (National Institute on Aging [NIA], 2011).Nursing And The Aging Family Essay

After World War II, people in the USA turned attention to raising a family and the birthrate soared during the infamous “Baby Boom”. Meanwhile, improved health and living conditions changed prospects for a long life in industrialized countries, raising the average life expectancy from 50 years in 1900 to 80 years in 1980 (NIA, 2011). The increase in life span and subsequent years of old age dependency was balanced by the availability of many adult children able to help (Redfoot, Feinberg, & Houser, 2013), but not for long. The total fertility rate (number of children per female across her lifespan) declined from a high of 3.8 in the late 1950s to less than 2 children in 2010 (Mather, 2012). In the US, the proportion of the population aged 65 and older has grown from eight per cent in 1950 to 14 per cent in 2012, and is predicted to reach 20 % by 2030 (less than 15 years away from now) (Redfoot, Feinberg, & Houser, 2011). The number of people aged 65 and older who will be living alone and who are also without living children or siblings will increase from 682,000 in 1990 to 1.2 million (Stone, 1999). Childlessness among older populations may increase up to 21% by 2040, when I would be 87 and almost 50% of my age-related peers would have only one or two children (Johnson, Toohey, & Weiner, 2007). The risk of becoming unmarried and childless, or with children out of contact may be as high as 22.6% (Carney, Fujiwara, Emmert, Liberman, & Paris, 2016).Nursing And The Aging Family Essay

I am not yet an elder orphan, the term used to describe older adults without children, spouses, or partners (Painter, 2016; Carney et al. 2016), even though my own family is shrinking, with all parents, parents-in-law, and their siblings (our aunts and uncles) having passed on. My older siblings and siblings-in-law are for the most part independent despite accumulating chronic conditions. Some of them have adult children and there are a few young grandchildren. There is research to show that—not surprisingly—older adults without children turn to other family members and/or non-kin for help. While the majority of family caregivers are spouses, adult children, daughters- or sons-in law, approximately 24% of family caregivers fit another category that includes siblings, nephews or nieces (Schultz & Eden, 2016). Still, siblings of older adults are likely to be in the same age bracket as the care recipient and subject to similar risks of aging. Nephews and nieces–with a shrinking sibling pool themselves to rely on for help—may have more than two sets of older adult relatives (i.e., parents, parents-in-law, and aunts/uncles).Nursing And The Aging Family Essay

Shrinking family size is not completely compensated for by age-related peers or other relatives and affects the pool of caregivers available to any older adult. Since paid caregivers are often needed to augment the labor of family and friends, it’s important to include them in estimates of caregiver supply. Using a population-based method, Redfoot, Feinberg and Houser (2013) calculated a “caregiver support ratio” based on the number of potentially available caregivers for the likely number of care recipients, taking into account family and paid help. Both groups were based on age. Caregivers (e.g., adult children, spouses, and paid help) were 45-64 years old, and care recipients were 80 years and older. From 1990 to 2010, the Baby Boomers swelled the ranks of caregivers producing a caregiver ratio of 6.6 to 7.2 caregivers per older adult. But that number shrinks to 6.1 in the 2020s, and drops to 4.1 caregivers per older adult in 2030 (OUCH! There I am again on the cutting edge at 78 years old!). Due to population aging, a caregiver shortage looms on the horizon.Nursing And The Aging Family Essay

Preparing for Dependency to Preserve Autonomy and Protect Caregivers
So how do I prepare myself and my caregiving network for the future? Laditka (2017) tells the story of her own father’s transitions to care which maintained autonomy by his being involved in decision-making about care options. She organized her approach according to the research of Loe (2011, cited by Laditka, 2016) who found that older adults who learned how and when to ask for help actually created more personalized care arrangements and maintained meaningful lives of dignity. Laditka was ready to help her father—when he was ready to accept that help. Help was a negotiation based on preferences, resources, and abilities. Laditka’s father’s transitions from independent living in a New York apartment to a senior community in North Carolina were anticipated and eased by his daughter (Laditka), who was available to assist as the father was ready due to increasing frailty.Nursing And The Aging Family Essay

Someone without children or other primary caregiver would either need to find a friend or extended family member, or an employee (e.g., a geriatric case manager) for comparable guidance in later life. Elder orphans—like all elders—are advised to engage in health promoting behaviors, to get their affairs in order, to down-size and de-clutter, to identify and nurture supports such as durable powers of attorney, health care decision proxies, to make realistic assessments of abilities, and to get familiar with community supports and options (Ianzanito, 2016; Painter, 2016).Nursing And The Aging Family Essay

System Pitfalls for Elders and Caregivers
Sadly, despite the best-laid plans, elders and their caregivers often face enormous challenges when health fails. Numerous studies and first person accounts point to problems in the health care system itself. Elders, the chronically ill and disabled, and their caregivers must navigate a disorganized, costly and confusing system (Kane & West, 2005; Kane, 2011; Reinhard, 2004). For a special issue of The Gerontologist (2017), scientists and practitioners were invited to apply their professional identities to their personal experiences with aging. Nearly half of the resulting articles were about challenges experienced as family caregivers of older adults (Pruchno, 2017). In addition to the day-to-day demands of meeting a person’s needs, older adults and their caregivers faced a disjointed health care system, wherein the coordination of care, and navigating between the acute care and long term care systems resulted in enormous frustration. High quality care was elusive: caregivers told of catching dangerous medication errors, averting inappropriate treatment, and struggling to find appropriate care, all from a state of perpetual anxiety and exhaustion (e.g., Fredman, 2017; Kaiser & Kaiser, 2017; Moon, 2017; Taylor & Quesnel-Vallee, 2017).Nursing And The Aging Family Essay

Urging healthy self-care is a common approach toward the stressed caregiver (e.g., Tarantine, 2014). In part to prevent the burden of receiving or giving care, Rowe and Kahn advanced the popular concept of “Successful Aging”, targeting and charging individuals to live more healthily (Rowe & Kahn, 1997). Better health habits would lead to less disability and disease, and reduce caregiving demands. Strengthening the individual makes sense, especially given that many stressors are beyond personal control. However, personal fortitude weakens in the face of the unrelenting frustration encountered by many older adults and their caregivers, leading Rowe (2015) to call for the successful aging of societies. Rowe described the recommendations of the MacArthur Foundation Research Network to evaluate social systems and promote policies leading to a multigenerational, family and life-course perspective that supports aging.Nursing And The Aging Family Essay

Key Principles: Families, Generations, Life-span, Housing and Specialty Care
Family health is “the collective emotional and physical health of a family” (Ziemba, 2002). Family is defined as the network identified by the older adult of friends and relatives. In short, a patient’s family consists of whomever they say. Within such families, exchanges occur of social, emotional, physical and/or financial support. A function of the family is to balance the needs and resources among family members (including intergenerational members) to maintain the health of individual members and of the family unit.Nursing And The Aging Family Essay

Research on caregiving is still focused on an individual “primary” caregiver, and not on the caregiver network. Thinking about family systems forces a focus on networks. For example, relevant policy changes could include extending eligibility for family leave to other members of the family, including nieces, nephews, and siblings (Schulz & Eden, 2016). This would allow childless elders to rely on a care network in ways that allow their sandwich status to become less important.

The current US health care system is a threat to intergenerational relationships in families and intergenerational justice within society. The first step to promote family health is universal health care coverage. Adult children face a more uncertain future if they have had to forego employment or health insurance in order to provide care to a parent, or to other family members. Caregivers should not be forced to choose between taking care of their own health, or that of parents, or children, or other relatives. This injustice extends to paid caregivers. The backbone of this sector is composed of direct care workers (more commonly known as nurses’ aides), who receive such low wages and benefits that they themselves do not have any health care insurance, despite the hazardous workload. The quality of elder care would increase if those paid caregivers could rely on health care coverage, too (Better Jobs Better Care, 2004).Nursing And The Aging Family Essay

A lifespan approach extends the concept of “aging” beyond the seemingly-sudden crossover into the golden years, and looks holistically at the needs of people from birth to death. Many challenges of taking care of someone are similar no matter what their age or relationship to the caregiver. Even though older adults form the largest group, over a third of long term care recipients are younger adults or children with disabilities (Weiner & Sullivan, 1999.) Normalization rather than the pathologizing of aging and disability emphasizes inclusion and the realization that the able-bodied are merely temporarily so (disability activists call them “temporarily able-bodied,” or “TABs”). Normalization means confronting the dependency/independence dialectic and shaping supportive social and built environments.Nursing And The Aging Family Essay

Integration of Medical care, Long Term Care and Public Health
The dominant philosophy in the US is obsessed with what has been termed a medical model of care (Ziemba, Perry, Takahashi, & Algase, 2009). A medical model emphasizes acute care interventions, medical diagnosis, and treatments of medicine and surgeries, most typically administered in doctors’ offices and hospitals. Many miracles of modern medicine are invaluable but the model is inadequate when long term care is needed because of chronic illness or disability. “Nursing home” is what most people think of when they hear the phrase “long term care.” However, there are many alternatives to nursing homes. Universal health care is only a partial solution because is still represents a medical, treatment-based model of care. For long term care, the medical model represents a bias toward institutional care (i.e., traditional nursing home) and lack of autonomy (Wiener & Sullivan, 1999). To signal the change to a social model, disability advocates prefer the term “long term services and supports” (LTSS).Nursing And The Aging Family Essay

Drum and colleagues (2009) criticized policies and practices around disability that foster isolation and despair. Such policies contribute to excess disability, which is helplessness or inability to perform some activity due to restrictive conditions rather than due to the disability itself. A modern public health approach to disability has evolved from a focus on prevention of disabling injuries to one based on shaping the socio-political and built environment. Policies and attitudes shape the creation of a social environment for inclusion rather than isolation. In turn, key features of the environment such as accessible housing, stores and transportation are fostered. Universal design can facilitate inclusion and social participation for many individuals across society (Steinfeld & Maisel, 2012; Universal Design, 2016). Integrated approaches to transportation such as “Complete Streets” (Smart Growth America, 2017) can promote physical exercise and can benefit not only the elderly, but also pedestrians, parents pushing baby strollers, and adults and children using bicycles or wheelchairs.

Aging services have already benefitted from social movements to improve the lives of people with disabilities of younger age. The Individuals with Disabilities Education Act of 1990 updated earlier laws to guarantee education to children with disabilities. The Americans with Disabilities Act of 1990, more widely known for its impact on inclusion and accessibility in the workplace, formed the basis for the landmark Olmstead decision which compelled states to provide people eligible for Medicaid funded LTSS the choice to receive services in the home, rather than the previously existing default of nursing homes.Nursing And The Aging Family Essay

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Several of the nation’s leading private foundations have recently initiated efforts to redesign our nation’s public and private-sector arrangements for meeting the needs of a growing elderly population. Among these foundations’ major concerns have been the nation’s inadequate financing and delivery systems of long-term care for the elderly. A particular focus of their reform agenda has been to expand home and community-based delivery of services as a complement or alternative to expanding the nursing home system.Nursing And The Aging Family Essay

This essay reviews recent work of the most active foundations engaged in producing social policy changes through improved home and community-based care for the elderly. It reports both the broad strategies and major projects by which these private philanthrophic foundations now seek to influence the evolution of these American institutions and practices. 1 It is based mostly on interviews with foundation officials and researchers, supplemented by a reading of foundation reports. For comparison, this review also includes a brief description of related government efforts and discusses some critical differences in reform strategies and priorities of the foundation and government actors.Nursing And The Aging Family Essay

WHY SUPPORT HOME AND COMMUNITY-BASED CARE PROGRAMS?
In recent years, home and community-based care for the elderly has attracted the energy and resources of people interested in social change. This emphasis reflects a concern that elderly individuals with assistance needs be supported in continuing to live with maximum independence in their own residences or with their families, as a part of society. 2 The elderly consistently prefer such service orientations, by a large margin, to systems that place disabled elderly persons in nursing homes or other institutions. 3 Thus, nursing home placements are usually considered the alternative to be avoided by those who emphasize home and community-based service systems.Nursing And The Aging Family Essay

Why is it that expanding a formal home and community-based service system is now an issue? Despite the growth of nursing homes, for example, the vast majority of the elderly with assistance needs do continue to live in their own residences or with relatives. They also receive most of their needed assistance from family caregivers, supplemented by some purchasing of services available in their communities. The American system of long-term care is predominantly a home and community-based system. There are three basic reasons, however, for such an emphasis, all of which are important for understanding how and why private philanthropies and government agencies have chosen strategies for fostering such changes.Nursing And The Aging Family Essay

The first of these reasons for investing in new systems of home and community-based care for the elderly lies in projections of the demographics of American society. Over the next half-century the nation is going to have a great many more people age sixty-five and over (an increase from 27 million today to 51 million in 2020 and 67 million in 2040) and all of our country’s private and public service institutions for long-term care services will thus need to be expanded far beyond current levels. Over the next half-century, the eighty-five and older age group, with the highest assistance needs, will be the fastest growing part of American society. 4 Thus the home and community-based system, as the major service deliverer, will need to handle much of this expansion. Exhibit 1 shows how long-term care assistance needs, as reflected in nursing home use, increase much faster even than the size of the aged population.Nursing And The Aging Family Essay

Exhibit 1 Number Of Nursing Home Residents Per 1,000 Persons By Age Group And Sex. 1980

Source: Health Care Financing Administration, Office of the Actuary, data from the Division of National Cost Estimates.
A rapidly increasing, and increasingly aging, elderly population will increase the caregiver burden imposed on families and informal caregivers in meeting the needs of the frail elderly. Concern for these burdens is a second major factor shaping the leading-edge thinking about caregiving for the frail elderly. As reported by the National Long-Term Care Survey in 1982, 2.2 million caregivers were involved in providing unpaid assistance to 1.2 million noninstitutionalized elderly persons. Typically, these caregivers were women (72 percent), 80 percent of caregivers reported providing unpaid assistance seven days a week, and, on average, caregivers spent four hours a day providing such services. Over one-third of caregivers were over sixty-five years old themselves, had incomes of below or near poverty, and/or reported themselves to be in fair or poor health. 5 Such caregiver burdens, already of concern, will rise as the disabled elderly population grows and as the ratio of elderly persons in the total population increases from 12 percent today to 17 percent in 2020 and 22 percent in 2040. Similarly, the rising numbers of women entering the workforce will also reduce the potential caregiver population. Thus, an increasing number of home and community-based services may need to be met through new delivery and financing arrangements, via market mechanisms, by organized nonprofit and for-profit providers, rather than through informal family assistance.Nursing And The Aging Family Essay

The third set of circumstances—to which government policymakers as well as social activists are responding—is that government long-term care policies have financed a nursing home-based service system, rather than home and community-based care. This nursing home system is now very expensive and its costs are still growing rapidly. The Medicaid program, enacted in 1965, made open-ended reimbursement available for nursing home care and, in the two decades since, the nursing home industry expanded from $2.1 billion to $35.2 billion of annual revenues, with government programs providing half of the funding. 6 Moreover, federal Medicaid funds have been allocated on the basis of state spending and per capita income, without regard to the number of poor or elderly persons in need of assistance. Partly as a result, long-term care service growth has occurred at differing paces in different areas of the country; the ratio of nursing home beds per 1,000 elderly now varies by more than 4:1 among different states. Nursing And The Aging Family Essay

FOUNDATION ACTIVITIES
These basic sets of circumstances have formed the background for major private philanthropic foundations, as well as government, to search for ways in which they could usefully address these problems. Private foundation activities can be grouped into six broad strategies.

INCREASE NATIONAL LEARNING.
A first strategy supported by foundations has been to support national studies and reports about the needs of a growing elderly population and ways of meeting those needs. Such efforts are aimed at deepening understanding of this issue by American opinion leaders and decisionmakers, in the public and private sector, as well as to advance expert knowledge.

Among the leading foundation efforts to educate American leaders and the public about the needs of a growing elderly population is The Commission on Elderly Persons Living Alone, supported by The Commonwealth Fund. The commission is chaired by Robert Butler, an expert on the elderly and former director of the National Institute of Aging, and focuses on the deliberation and conclusions by twenty leaders from different arenas of American life. The population group that is the commission’s particular focus is likely to need many forms of public and private support, and the commission is considering expanded income, medical insurance, housing, and other needs, as well as home and community-based services. The commission is now funding a series of studies to educate itself about the major problems faced by this group and the options for assisting them, and it will probably support selected demonstration projects in the process of reaching its conclusions.Nursing And The Aging Family Essay

A second major approach to advancing understanding of the nation’s long-term care needs—support of expert research and analysis—is reflected in work by Alice Rivlin and Joshua Weiner at the Brookings Institution with support from The Robert Wood Johnson, John A. Hartford, Retirement Research, Villers, and Greenwall Foundations. This research involves detailed projections of the nation’s future need for long-term care services and a comprehensive analysis of public and private-sector finance and delivery options. A book on these research efforts, currently titled Reforming Long-Term Care, will be published by Brookings later this year.

Similar projects to rethink the design of the nation’s long-term care system are now being supported by two other foundations. Lewin and Associates, supported by a grant from The Villers Foundation, will produce a synthesis of public program experience with home and community-based care, bringing together experts to distill the evidence on the best ways to provide these services. InterStudy, through a grant from The Pew Memorial Trust, is conducting a broad assessment of the nation’s financing, organization, and delivery for long-term care services. It will analyze potential improvements and develop recommendations.Nursing And The Aging Family Essay

A third approach to informing leaders and the public of the problems of home and community-based care is to directly support communication efforts to bring them such information. Such thinking has led The Villers and Retirement Research Foundations to support the National Health Policy Forum in Washington, D.C. in developing an information series on the needs of the elderly for congressional and executive branch staff. This series has included several sessions on home and community-based care of the elderly. To provide a broader public understanding of the personal problems that are faced by elderly persons trying to cope with the inadequacies of the nation’s current retirement, health, and long-term care system, The Villers Foundation is supporting a book by Dick Margolis, Poor Finishes (Pantheon, forthcoming).Nursing And The Aging Family Essay

DEVELOP CURRENT SYSTEM’S CAPACITY.
A second strategy for social change is to encourage existing institutions that already provide home and community-based care to expand and improve coordination of these services. Such efforts usually combine several years of start-up support, with expectations that private markets and/or public programs will provide continuation financing for worthwhile innovations, and a demonstration approach, which seeks to encourage substantial nationwide interest in seeking foundation grants and to develop highly visible models throughout the country so that others will be encouraged to follow these leaders.

The Living-at-Home initiative, which is sponsored by The Commonwealth Fund, Pew Memorial Trust, Duke Endowment, and Arthur Vining Davis and John A. Hartford Foundations, in collaboration with thirty-five other foundations, is a leading current example of this strategy. This program will provide grants to twenty communities to develop their services management capacity for home and community-based care for the elderly. Such systems will include improved access to the system, for example, through a centralized telephone number, and case management to coordinate the home and community-based care services provided by multiple agencies.Nursing And The Aging Family Essay

The Program for Hospital Initiatives in Long-Term Care, supported by The Robert Wood Johnson Foundation, was designed to assist hospitals that wanted to expand their services into home and community-based care. This program started with funding for twenty-four site demonstrations. The participating hospitals must agree to provide enrolled elderly persons a full, comprehensive range of medical and longterm care services, including needs assessment, in-home care, personal care, day care, congregate housing or supported residential care, nursing home care, and emergency services.

Through its recent Supportive Services Programs for Older Americans, The Robert Wood Johnson Foundation is seeking to expand the capacities of nonprofit home health agencies that cover large areas with high concentrations of older persons. These grants, made in February 1987, will encourage home health agencies to expand into nontraditional services, such as home maintenance and repair, respite care, housekeeping, and transportation, which will help individuals to function as independently as possible in the community. The program will provide support over four years to projects in as many as twenty communities.Nursing And The Aging Family Essay

Through a grant from The John A. Hartford Foundation, InterStudy is now assessing the most promising ways in which health maintenance organizations (HMOs) and other managed care systems can expand their long-term care services and will assist in the replication of the most promising approaches. InterStudy has also received a grant from the Retirement Research Foundation to undertake a comprehensive national survey of private-sector case-management services for long-term care, which will provide improved information on current capabilities and approaches to providing those services. The John A. Hartford Foundation is also supporting development of adult day care prototypes through a grant to the University of North Carolina.

CREATE NEW INSTITUTIONS TO MANAGE CARE.
Home and community-based care programs, if they are to serve the severely disabled elderly, may involve expenses equal to or greater than the $15,000–$25,000 per year needed to finance nursing home care and substantial management efforts to coordinate care and keep individuals out of nursing homes. This has led several experts to be strongly interested in developing a new integrated insurance/management mechanism for long-term care services.Nursing And The Aging Family Essay

The prototype of such a model for medical care is the HMO. A number of foundations have now joined to assess expanding the HMO concept to include long-term care services needed by an elderly population. This demonstration model, called the social health maintenance organization (SHMO), is being supported by The Robert Wood Johnson, Pew Memorial Trust, Commonwealth Fund, Henry J. Kaiser Family, and Bush Foundations, along with eleven other foundations, in four sites. The major coordinator of this initiative has been Brandeis University. Nursing And The Aging Family Essay