In 2005, an estimated one in six individuals was over the age of 65, representing 16 percent of the UK population[1]. The National Statistics Office reports that the largest population increase was evidenced in the 85+ age group, growing by more than 64,000 (6 per cent) in 2005, totalling 1.2 million individuals[2]. Many factors are responsible for this the growth rate in the over 65, primarily in the later older adult stage of 85+, as healthcare and technology are improving and leading to increased survival rates, coupled by the post World War One baby boomers reaching their later adult years[3].
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Increasingly, nursing and other professional groups are utilizing Enquiry Based Learning (EBL) that uses situations from real life to analyse issues while learning from a nursing perspective with an emphasis on refining capabilities in actual nursing practice[4]. Researchers emphasize the open-ended questioning used for complex problems or scenarios that allow the nurse to seek out new evidence[5].
Using an Enquiry Based Learning scenario, this paper will present the case of special needs family and with an emphasis on life stage analysis of the elderly. Following a brief case presentation, this paper will define the maturity-old age life stage, describing various factors specific to maturity that influence the person’s biological, psychological and social perspectives. Personal and practical nursing experience with mature/older patients is presented followed by what has been learned from the research on how to effectively provide nursing care in terms of knowledge, skills and attitudes to older individuals.
Case presentation
This is the case of a nuclear family. Mr. and Mrs. Smythe’s are adults with two children, a daughter E. who is 14 years old and pregnant and a son who is 4 years old afflicted with Downs Syndrome and suffers with intermittent breathing problems due to the Down’s syndrome. Both children live at home with their parents. Mrs. And Mrs. Smythe are reasonably healthy with no chronic health concerns at this time. Mr. Smythe works full time in a position outside of the home. Mrs. Smythe is a full-time homemaker.
Mr. Smythe’s two parents are both alive at 82 years of age and living together in their own dwelling. Both parents are reasonably healthy for their age with no chronic health problems identified at this time.
Mrs. Smythe’s father, Mr. Jones, is 86 and a recent widower (of three months). Following the death of her mother, Mrs. Smythe invited her father to live with her family. Mr. Jones is in fair health, although he is depressed and having difficulty adjusting to the new environment at his daughter’s home, the issues with her children and the loss of his wife all occurring within a short time.
Assessment
Life stage identification
This paper will focus on the three individuals in Erikson’s Maturity stage of life, aged 65 to death[6]. This life stage is marked by the psychosocial integrity vs. despair conflict, such that individuals are reflecting back on their lives and either accepts the thought of their death with a sense of accomplishment and fulfilment or a feeling of despair and regret[7]. Smith[8] identifies the 65+ age group as belonging in Levinson’s late adulthood developmental stage.
Factors specific to maturity – Physiological/biological
As individual ages, many physiological changes take place in virtually all physiological systems, ranging from the endocrine, cardiovascular, gastrointestinal, skin, hair and nails and nervous system[9]. Globally, there is a reduction in cells and cellular metabolism, as the body gradually becomes less efficient[10]. Skin looses subcutaneous fat, things and there is a reduction of collagen and elastin combined with a 50 percent reduction in cell replacement[11]. Respiratory muscles degenerate and respiratory capacity decreases, alveoli decline in size and the lungs become more rigid as the individual ages.[12] The heart reduces in size and contractile strength and cardiac efficiency is reduced by as much as 30 – 35 percent[13]. There is a general decrease in height, bone mass, muscle mass and collagen with less joint elasticity[14]. Sleep patterns are altered, with regular wakeful periods during the night[15]. The aging body does not readily distinguish between host cells and infection along with a reduced ability to absorb vitamin B12, decreasing hematocrit and hemoglobin levels. Of particular importance is the reduced drug clearance by approximately 50 percent, often leading to increased risk of drug interactions among elderly individuals who are frequently on more than one pharmaceutical agent[16].
Factors specific to maturity – Psychological and Sociological
The death of a spouse is the leading cause of disruptive life-event stress and conflict[17] affecting the way an individual understands themselves and their role in society and the family. Rokach and Brock found that loneliness has a strong correlation with self-esteem in the elderly[18]. Marital status and the death of a spouse contribute to feelings of isolation and loneliness in the elderly, creating a sense of stigma in the individual, causing emotional distress, feelings of rejection and isolation, especially when care is taken over by others such with the death of a spouse[19]. In particular, men have a difficult time with their own emotions, perceiving their social needs for companionship rather than isolation as a sign of weakness[20]. When older individuals are also faced with a reduction in income and job status, the older individual reportedly has a greater propensity towards solitude, isolation and loneliness[21].
Warner[22] found that those elderly adults who maintained their own independence had less of a need for dependent behaviour because of social cues, whereas those who were dependent, such as Mrs. Smythe’s father, Mr. Jones, reacted with a greater sense of learned dependency and associated social contact seeking behaviours.
Practical nursing experience that provides a basis for nursing intervention in this case
With the knowledge provided by two factors: research and LEIPAD[23], the three elderly individuals were administered the LEIPAD multidimensional assessment to gain a baseline for intervention[24]. LEIPAD is believed to be a stronger single assessment tool than using a combination of The SF-36, Barthel Index of activities of daily living and the Abbreviated Mental test, even though the Barthel Index is recommended by both the Royal College of Physicians of London and the British Geriatrics Society[25]. Mr. Jones requires the greatest intervention due to losses of his wife, independence and immediate social circle. Additionally, Mr. Jones has daily coping issues with his grandchildren.
To date, practical nursing experience has primarily focused on education related to chronic diseases and disease prevention with elderly patients. Inconsistency is noted when relating to patients and relating to older members of one’s family, where greater emphasis is placed on psychological and social wellbeing.
What has been learned from using the EBL approach to this case?
In addition to the amount of research one can use to prepare and expand one’s horizons with an EBL approach, such as using the LEIPAD assessment rather than the Barthel Index, is the use of open-ended questions that solicit a wealth of information. Most practitioners like to keep answers to questions short or they will cut patients off in mid-sentence. Open-ended questions allow for further probing by active listening and a participatory manner.
References
Austin, Shari. Oral Health and Older Adults. Journal of Dental Hygiene, 2003.
De Leo, Diego, Diekstra, Rene, Lonnqvist, Jouko , Trabucchi, Marco, Cleiren, Marc, Frisoni, Giovanni B., Dello Buono, Marirosa, Haltunen, Aro, Zucchetto, Mauro, Rozzini, Renzo, Grigoletto, Francesco, & Sampaio-Faria, Jose. LIEPAD, An Internationally Applicable Instrument to Assess Quality of Life in the Elderly. Behavioral Medicine, 1998.
Ginsberg, Gary, Hattis, Dale, Russ, Abel & Sonawane, Babasaheb. Pharmacokinetic and Pharmacodynamic Factors that can Affect Sensitivity to Neurotoxic Sequelae in Elderly Individuals. Environmental Health Perspectives, 2005.
Hutchins, Bill. Principles of Enquiry-Based Learning, Centre for Excellence in Enquiry-Based Learning Resources – University of Manchester, 2006.
Kahn, Peter & O’Rourke, Karen. Understanding Enquiry-Based Learning. In Barrett, T., McLabhrainn, I. & Fallon, H. eds. Handbook of Enquiry & Problem Based Learning, Galway: CELT, 2005.
Lyons, Ronald Al., Crone, Peter, Monaghan, Stephen, Killalea, Dan & Daley, John A. Health Status and Disability Among Elderly People in Three UK Districts. Age and Ageing, 1997.
Office for National Statistics; General Register Office for Scotland and Northern Ireland Statistics and Research Agency. Population Estimates. 2006 [Online]. Available from: http://www.statistics.gov.uk/CCI/nugget.asp?ID=6 (cited 1 May 2007).
Price, Robert. Enquiry-Based Learning: An Introductory Guide. Nursing Standards, 2001.
Rokach, Ami & Brock, Heather. Loneliness and the Effects of Life Changes. The Journal of Psychology, 1997.
Smith, Mark K. Life Span Development and Lifelong Learning. [Online]. Infed. Available from: http://www.infed.org/biblio/lifecourse_development.htm (cited 1 May 2007).
Tosey, Paul & McDonnell, Juliet, Mapping Enquiry Based Learning: Discourse, Fractals and a Bowl of Cherries. 2006. [Online]. Available from: http://www.com.survey.ac.uk/learningtolearn (cited 30 April 2007).
Warner, Dorothy Ann. Empowering the Older Adult through Folklore. Adultspan Journal, 2006.
Winters, Angela. Erikson’s Theory of Human Development. [Online]. Ezine Articles. Available from: http://ezinearticles.com/?Ericksons-Theory-of-Human-Development&id=20117 (cited 1 May 2007).
