INTERVENSI KEPERAWATAN LANSIA PRIMARY PREVENTION

INTERVENTION

Primary & Secondary Prevention

Annisa Wuri Kartika

Preambule.

Chronic diseases account for 7 of every 10 deaths; affect the quality of life of 90 million Americans.1993 vs. 2001: US adults reported:

Deterioration in:physical healthmental healthability to do their usual activities

Increase in unhealthy days 5.2 to 6.1 daysAdults 45-54 years old had consistently greater deterioration than younger or older adults.

http://apps.nccd.cdc.gov/HRQOL/TrendV.asp?State=1&Measure=5&Category=13according to a recent study from the Centers for Disease Control and Prevention. Adults average physically unhealthy days per month increased from 3.0 in 1993 to 3.5 days in 2001, mentally unhealthy days from 2.9 to 3.4 days, and activity limitation days from 1.6 to 2.0 days. Overall unhealthy days--a summary measure of population health--increased from 5.2 to 6.0 days. Most of these increases occurred in the years since 1996. The percentage of U.S. adults rating their health as fair or poor also increased from 13.4% in 1993 to 15.5% in 2001. The study also found: Adults 45-54 years old had consistently greater increases than younger or older adults.

BRFSS data

Health Status of Older Adults88% - at least one chronic condition

50% - at least two chronic conditions

34% experience some activity limitation

26% assess health as fair or poor

41% of older African Americans

40% of older HispanicsCDC-MIAH 2004; CDC/NCHS Health US, 20024Increasingly, community-based organizations are being seen as having an important role to play in improving health outcomes for older people. Persons with fair or poor health, serious chronic disease, and/or IADL limitations, and minority groups are often targeted for health-related services. But health-related interventions can benefit all elderly persons.Heart Disease32%

Cancer22%

Stroke 8%

Chronic Respiratory 6%

Flu/Pneumonia 3%

Diabetes 3%

Alzheimers 3%CDC-MIAH 2004; CDC/NCHS Health US, 2002Leading Causes of Death, Age 65+ (2001)Chronic Disease

Modifiable Lifestyle Risk factorsSmokingPhysical inactivityInadequate dietAlcohol abuseSocial isolation

Guiding PrinciplesMake Prevention a Priority

Start with the Science Evidence

Work for Equity and Social Justice

Foster InterdependenceAging networkHealth carePublic healthLong term careMental healthResearch* James Marks, MD

8PRIMARY PREVENTION_Healthy Ageing_

Healthy ageingWHO defines health as:a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmityWHO defines active ageing as: the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age allowing people to realize their potential for physical, social and mental well-being throughout the life courseWHO (2001) suggests a major determinant of healthy ageing is living an independent life for as long as possible

Healthy Older People ViewCan have health problems and still age wellKeeping active (mentally and physically)Enjoying lifeKeeping engagedPositive attitudeMeaningful engagementGood relationships with family and friendsPhysical activity important

Active Ageing FrameworkHealthPrevention of chronic disease and disabilityReducing risk factors and increasing protective factors throughout the life courseHealth and social servicesEducation and training to caregivers.

Cont,.ParticipationLife long education and learning opportunitiesactive participation in economic developmentformal and informal work and voluntary activitiesfull participation in family & community lifeSecurity (social, financial and physical) & rights

Evidence for Healthy AgeingKeeping activeSocial and meaningful participationEating wellEnvironments that support healthMental wellbeingGood relationships with family and friendsOptimism

Benefits to Older AdultsReviewed in A New Vision of AgingLonger life

Reduced disabilityLater onsetFewer years of disability prior to deathFewer falls

Improved mental healthPositive effect on depressive symptomsPossible delays in loss of cognitive function

Lower health care costs

http://www.cfah.org/programs/aging

Social Ecologic Model of Healthy AgingIndividualInterpersonalOrganizationalCommunityPublic PolicyMcLeroy et al., 1988, Health Educ Q; Sallis et al., 1998, Am J Prev Med17Cont,The health and well-being of older adults will be improved only if we work from a broad perspective.

Comprehensive planning and partnerships at all levels are required.

Harassing individuals about their bad habits has very little impact.

Changes at the individual level will come with improvements at the organizational, community and policy levels. 18Level of PreventionPrimary prevention involves measures to prevent an illness or disease from occurring, for example, immunizations, proper nutrition, and regular fluoride dental treatments.Secondary prevention refers to methods and procedures to detect the presence of disease in the early stages so that effective treatment and cure are more likely ( Routine mammograms, hypertension screening)Tertiary prevention is needed after the disease or condition has been diagnosed and treated. This is an attempt to return the client to an optimum level of health and wellness despite the disease or condition.Primary PreventionIdeal health promotion behaviors at the level of primary prevention, include: smoking cessation and limited alcohol consumption, good nutrition, exercise, adequate sleep, safe lifestyles, and updated immunizations.Cont,.One of the greatest barriers surrounds misconceptions about the benefits of health promotion for older adults.Another barrier lies in the challenge of separating the normal changes of aging from pathological illness. For example, joints normally stiffen as one ages, causing the older adult to use the joint less for fear that the stiffness may worsenA final barrier to improving the health promoting activities of older adults is their own motivation to change. In fact, this is the most important factor in improving healthOlder adults are never too old to improve their nutritional level, start exercising, get a better nights sleep, and improve their overall health and safety.

Health Promotion As Primary PreventionOn their face, both health promotion and primary prevention seek to avoid the untoward consequences of illness, accidents, environmental stressors, and less than ideal personal habitsHealth promotion must be concerned with well-being, not just the absence of disease or infirmity.

Health promotion of the elderlyHealth promotion is the process of enabling people to increase control over & improve their health by developing their resources to maintain or enhance well being.

Health promoting is an action for health using knowledge, communication & understanding24Objectives of health promotionIncrease quality and years of healthy life Maintain functionEliminate health disparities and independency Improve (enhance) quality of lifeExtend life expectancy premature mortality caused by chronic& acute diseases

Health Promotion (Strategies)EducationPhysical activity programsVolunteeringAge friendly cities

Health EducationMost common form of health promotionRelies on health literacyDelivery methods Health professional Peer education Mass media

Physical activity programsPhysical activity guidelines Group based programs Benefit of social component Higher participation rates Increased physical activityBarriers ageism, ageist stereotypes, built environment, hard to reach groups

Volunteering Volunteering is generally defined as unpaid work for or through an organization Benefits: Morbidity Functional health Self reported health Life satisfaction Possibility of maintaining physical and cognitive activity Strong personal and emotional support Opportunity to contribute to othersNot all volunteering has equal benefit

Age Friendly CitiesStarted in 2005 by WHO, 33 citiesInclusion of older people in planning and development (focus groups)Global Age Friendly Cities GuideGlobal Network to help cities see themselves from the perspective of older people in order to identify where and how they can become more age-friendly

SampelMedanPayakumbuhBalikpapanMakasarJakarta pusatDepokBandungSemarangSurakartaYogyakartaSurabayaMalangDenpasarMataram

33 Component of health promotionExercise NutritionRest & sleep High risk behaviorSpiritual well-being Psychosocial well-beingPeriodic medical check up

1- ExerciseConsumption of body fatImprove cardio-vascular capacity ( by blood flow----- keep tissue healthyControl hypertension& blood sugarImprove respiratory function Improve joint flexibilityImprove pattern of sleep & rest independency Improve sense of well being & relaxationMaintain minds function Promote sense of normalityPeristaltic movementPhysical benefitsPsychological benefitsImprove mood stateImprove self-imageReduce stressEnhance sleepImprove depressive state of elderly

Role of the nurse during exercise I- Assessment done at the beginning of exercise program include:History & physical examination (CVS, resp, musculoskeletal & neurological system)Renal & liver function testsECG,& exercise stress testAssess range of motion & use of assistive devices.Assess environmental hazardsII-Set a regular time to exercise each day III- Before starting exercise the nurse should advice the elderly about:Document baseline resting function status (ht &resp rate, bl.sugar) 10 minutes warms up stretching exerciseDrink water before and after exercise is important as water will be lost during exerciseClothes worn during exercise should allow for easy movement and perspiration.Athletic shoes provide both support and protectionOutdoor exercise should be avoided in extremely hot or cold weather.IV . During exerciseMonitor heart & resp. rateStop exercise if elderly has fatigue , chest pain or heart & resp. rateAfter exercise:10 minutes cooling up at end of exercise Monitor pulse rate during cooling for returning to resting ht. rate

2- NutritionIt is neglected especially those living alone or with low income.Factors affecting nutritional status:Age related changesPsychosocial factorsEconomic factorsCultural factors

Nutritional requirement of elderly1- CaloriesCaloric requirement diminished by 10% in age 51-75 years and by 20-25% in age more than 75 years. (man = 1960 cal, woman = 1700 cal)N.B: Fat yield 9 cal/gram, CHO and protein yield 4 cal/gram, mineral and water yield no calories 2- Protein requirement0.8 g/kg body wt A balanced diet of a healthy elderly should contain 12-14% of total caloric intake.During infection, stress, trauma protein to 1.6 or 1.5 g/kg body wt 3-Fat requirementFat either saturated or unsaturated Total fat intake limited to 30 % or less of total energy intakeSaturated fat limited to 10-15% of total energy intakeDietary cholesterol intake limited to 300mg/ day or less

4- Carbohydrates requirementCHO is essential for maintaining normal bl. glucose level & preventing protein break down.50% of total calories---- CHO Complex CHO as vegetables, grains, fruitsComplex CHO has vit, minerals, fibers which help in bowel elimination& bl. cholesterol level.5-Fluid intakeElderly at high risk for dehydration due to: Thirst sensationInadequate fluid intake (2000-3000 cc/day) requiredSome medications, such as for high blood pressure or anti-depressants, and diureticSome medications may cause patients to sweat moreFrail seniors have a harder time getting up to get a drink when theyre thirsty, or they rely on caregivers who cant sense that they need fluidsAs we age our bodies lose kidney function and are less able to conserve fluid (this is progressive from around the age of 50, but becomes more acute and noticeable over the age of 70) Illness, especially one that causes vomiting and/or diarrhea, also can cause elderly dehydration6- Vitamins & mineral requirementsCalcium for mineralization of bone & has a role in blood & cardiac function. Daily requirement 1200 mg./day if there is no contraindicationsVitamin D needed for calcium absorption & metabolism.

Nurse Role Assessment involves: nutritional history, physical examination, anthropometric measurements, biochemical evaluation, cognitive & mood evaluationHealth history related to nutritionAnthropometric measurementClient and family education Dietary guideline for old personsEat a variety of food - Maintain a healthy weightChoose a diet low in fat, - Use sugar & salts in moderate saturated & cholesterol Choose a diet plenty of - Drink 200-3000cc/daily vegetables, fruits & grain products3- Rest& sleepPerson spend 1/3 of his life in sleepSleep is time for cell growth & repairElderly need 5-7 hrs at nightImportance of Rest& sleep:Conserve energyProvide organ respite (rest)Restore the mental alertness & neurological efficiency Relieve tension

Nursing measures adopted to promote sleepEngage in exercise program Avoid exercise within 3-4 hour of bedtime.Spend time out door in the sunlight each day but avoid period between 12 Md to 3 PM sunshine exposure.Engage in relaxing activities near bedtime Avoid tobacco at bedtimeAvoid drink any caffeinated beverages before mid afternoon.Limit fluid intake after the dinner hour if nocturia is a problem.Limit daytime naps to 30 minutes or less.Avoid using the bed for watching TV, writing bills, and reading. 4- High Risk BehaviorIt is behavior that damage physical health.It includes: Over the counter medication (multiple medications )Smoking Caffeine

SmokingNicotine & toxic substances in cigarette has impact on de-toxication process in the body-cell damage & variety of diseases as cancer, respiratory, CVD, risk of osteoporosisCessation of smoking improves cerebral blood flow& pulmonary functionInterventions to stop smoking usually surround behavioral management classes, and support groups are available to community-dwelling older adults. Nicotine-replacement therapy and anti-depression medications are also helpful in assisting the older adult to quit smoking.

Multiple MedicationOlder people consume many medication adverse drug reaction The most common over the counter medication: Analgesics, laxatives & antacids followed by cough products, eye wash& vitamins.Caffeine

Found in coffee, tea, soft drinks, chocolateIt is mood elevatorIt stimulates sympathetic nervous systemmotor activity muscle capacity & alertness Rapid pulse calcium excretion

5- Spiritual Well- beingSpiritual Well-being is the practice and philosophy of the integral aspects of mental, emotional and overall wellbeing.Spiritual Well-being is a state in which the positive aspects of spirituality are experienced, incorporated and lived by the individual and reflected into ones environment. Signs of spiritual distress: Doubt DespairGuilt BoredomExpression of anger toward god 6- Psychosocial Well- being* Psychosocial changes may alter an individual relationship with others. * Physical well-being depend on: Psychosocial wellbeingSocial structurePersonal relationships7- Periodic medical examinationImportance of Periodic medical examination:Assess elderly level of well-beingDetect early signs of diseaseEducate client how to promote his healthReinforce promoting & protecting behaviorsIf examination done at home, it permit evaluation of environment

ImmunizationsVaccinationPeriodInfluenza (over 65y)Annually (mid October to mid November)Tetanus & diphtheriaEvery 10 yearsPneumococcal vaccinationOnce at age 65y, revaccination for high risk fatal pneumonia/6 y

Fall PreventionFall prevention interventions include a thorough assessment of the environment in which the older adult lives.Area rugs and furniture that may be fall hazards should be removed and appropriate lighting and supports should be added to areas in which older adults ambulate. Many homes and facilities have placed a patients mattress on the floor to prevent injuries from falling out of bed.The use of wall-to-wall carpeting also pads a patients fall, resulting in less injury on impact. The use of an alarm for the bed or wheelchair to alert caregivers of an older adults mobility may assist older adults who have had falls in the pastRole of the nurse in health promotionAssessment to his physical health, Psychosocial Well- being, lifestyle pattern, hobbies, high risk behaviors, knowledge, believes& attitudes that affect health & wellbeing.Assess health needs Assess social , environmental & cultural influences on health behaviorsLifestyle modifications is a comprehensive approach for effective change in heath promotion behaviors Nurse role should directed toward helping elderly to cope with his function level delay disabilities & impairments.Nurse identify environmental hazards & make necessary modificationsIdentify social needs & encourage participation & social support groups.Nurse should inform elderly & caregivers about aging process, common disorders & disabilities , different services available Encourage elderly to take better care to them, avoid high risk behaviors,& hazards affecting their health.Regular and continuous evaluation is important aspect of nurses role

Role of the nurse in health promotionSECONDARY PREVENTION

Secondary PreventionBased on early detection of disease screening or case-finding, followed by treatmentStrategies for detecting disease at an early stage involve annual physical examinations; laboratory blood tests for tumor markers, cholesterol, and other highly treatable illnesses; and diagnostic imaging for the presence of internal disease.Screening process of evaluating a group of people for asymptomatic disease or risk factor for developing disease, usually occur in community setting and applied to a populationCase finding process of searching for asymptomatic disease and risk factor among pepople in clinical settingThe Process of Screening

Types of health screeningHealth screeningPeriodBlood PressureEach Dr. visit or 3-6 monthsHeight & wtPeriodically as part of comprehensive physical examinationDental check upOnce / year( annually)Fecal occult blood& sigmoidoscopy ( annually)

Vision including glaucoma testEvery 2 yearsHealth screeningPeriodHearingEvaluate periodically Cholesterol level Every 5 yearsCancer screeningAnnuallyMammography for women under 70 y1-2 years Digital rectal examination AnnuallyTypes of health screeningGeneral Screening Recommendations*check with your doctor for specific recommendationsPap test every 1-3 years up to age 65

Lipid Screen every 5 years, starting mid-thirties (male) or mid-forties (female) up to age 70

Mammogram every 1-2 years, age 40-74, then optional

Fecal Occult Blood every year, age 50-80+

Lower GI Endoscopy depending on individual factors, every 5-10 years, starting at age 50

PSA optionally, every year up to age 70 (men)

Bone density mid-sixties (women)Evidence for OT within mental health, well being and older peopleGraff et al 2007 Effects of Community OT on Quality of Life, Mood and Health Status of Dementia Patients and Their Caregivers: A Randomised Control Trial. Journal of Gerontology. Vol.62A, No 9 1002-1009.Sample - 135 community dwelling older people with mild to moderate dementia and their informal caregiversIntervention - 2 groups ; OT intervention group ( environmental modification, cognitive behavioural strategies, problem solving) and no OT intervention for 10 weeks. Outcome measures - Dementia Quality of Life Instrument, the Cornell Scale for Depression, Centre for Epidemiologic Studies Depression Scale, General Health Questionnaire 12 and Mastery Scale used with patients and their carers.Results - Overall Dementia Quality of Life was significantly better in the intervention group compared to the control group and significant 12 weeks post intervention.63Adults aged 65 + in Netherlands

Evidence for OT in health promotion training for older people with visual difficultiesEklund et al (2008) A randomized control trial of a health promotion programme and its effect on ADL dependence and self-reported health problems for the elderly visually impaired. Scandinavian Journal of Occupational Therapy. Vol.15, pp68-74.Sample - 229 older people (65 years +) who have macular degeneration Intervention -Activity based health promotion programme compared to an individual programme- both led by OT`s Outcome measures Functional tasks e.g. stairs, bath, dressing etc., SF-36 and self-rating scales for health issues such as coronary, vascular, musculoskeletal, psychological and fatigue issues.Results - The health promotion maintained their ADL independence level despite lowered visual acuity whilst individual intervention group increased dependence in ADL. Both groups lowered general health levels but the health promotion groups reported fewer health problems- maintained at 28 months post intervention64OT`s led both the Activity based health promotion programme and the standard individual programme

The health promotion group took place 1 x 2hours per week and the programme consisted of self care, orientation, meals, communication, finance, problem solving, other professions such as lighting expert, optician,

The standard individual programme consisted of magnifiers, glasses, lighting info, optician, glasses and literature on the condition.Evidence for OT regarding well being and life engagement for older peopleHorowitz and Chang (2004) Promoting well-being and engagement in life through occupational therapy lifestyle redesign. Topics in Geriatric Rehabilitation. Vol.20, No.1, pp46-58.

Sample - 28 older people with a range of chronic conditions (depression, COPD, diabetes and spinal stenosis)

Intervention - 16 week experimental group for lifestyle redesign( focused on daily routines, physical and mental activity, nutrition, medication, home and community safety and assistive technology) controlled with usual adult day programme.

Outcome measures -Mini-Mental Status Exam, Functional Status Questionnaire, SF-36(V2), Centre for Epidemiological Studies Depression Scale, Life Satisfaction Index-Z Scale, and the Master Scale. Results -a favourable outcome for the experimental groups in relation to Role Functioning, Bodily Pain, General Health Survey SF-36,Social Activity on the Functional Status Questionnaire and Centre for Epidemiological Studies Depression Scale.65NB limited statistical power of results due to small sample sizeThank You