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Health Promotion of Chronic Obstructive Disease in the Elderly, Research Paper Example

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Research Paper

Outline

Introduction

  • Overview of the Problem/Significance
  • Etiology/Epidemiology
  • Pathophysiology and Clinical Presentation
  • Clinical Assessment
  • Health Needs and Differential Diagnosis
  • Developmental Stage Applications
  • Implications for families.

Clinical Management (Evidenced-based protocol for ANP management of the problem)

  • Health promotion and disease prevention
  • Health Teaching Plan
  • Pharmacokinetics of drugs or drug classes used in treatment of the problem
  • Future trends (in terms of clinical management).

Evaluation of Outcomes

  • Evaluation criteria and time frame

Conclusion

 

Abstract

Health promotion is crucial to the elderly, especially, when affected by long term illnesses such as Chronic Obstructive Pulmonary Disease (COPD).This document contains strategies essential to their care particularly pertaining to the Advanced Nurse Practitioner’s interpretation and management of the disorder from a health promotion perspective.

Introduction

Overview of the Problem/Significance

Recent research has shown where chronic obstructive pulmonary disease (COPD) is a disorder ‘characterized by incompletely reversible airflow limitation, measured by a decrease of FEV (1)/FVC ratio’ (Orvoen-Frija et.al, 2010). The international consensus is divided regarding a single threshold for a ratio defining airflow obstruction. As such, when classifying Chronic Obstructive pulmonary disease among the over 65 age group distinct variations may exist. However, a consensus has been reached regarding its progression after age 65 in identifying that there is a definite 15% increase in incidence after this age (Orvoen-Frija et.al, 2010).

Therefore, this is an indication that ageing populations inevitably would have a higher incidence of Chronic Obstructive pulmonary disease as time progresses.  Precisely, the challenge among aging populations is that often diagnosis, and subsequently management of COPD in the elderly is inadequate. It is difficult to diagnose since there may be other associating medical conditions. Consequently, the diagnosis may be made at a late stage resulting in a short time for effective health promotion interventions (Orvoen-Frija et.al, 2010).

The advantage of health promotion management in the younger age group is that there is the impact globally coordinated strategies. Researchers have posited that when planning for chronic Obstructive Pulmonary disease interventions among the elderly it should be designed from the premise of risks pertaining to their age. Considerations related to the biological changes incurred with age and the emotional disposition of aging ought to be integrated in planning (Orvoen-Frija et.al, 2010).

Major differences besides biological and psychosocial are tolerance to pharmacological therapies. Many drugs have serious side effects which manifest quicker in an aging over 65 age group body system than someone in their 30’s or 40’s. Specifically, many elderly are faced with nutritional difficulties along decreased mobility and social autonomy among other comorbidities.

Presently, there is very little or no data regarding pharmacological considerations for the elderly. As such, the same medications prescribed for younger people they have to use. It is therefore imperative that evidenced based health promotion practices be instituted in the management of chronic obstructive pulmonary disease among the elderly internationally (Orvoen-Frija et.al, 2010).

Importantly the significance of designing appropriate health promotion strategies is that direction will offered related to application of existing techniques which are beneficial for patients of any age while others will be evaluated regarding their appropriateness for elderly populations. These include pulmonary rehabilitation measures and palliative care, which is daily becoming a challenge for the elderly (Orvoen-Frija et.al, 2010).

The indefiniteness of palliative COPD management adds to the challenge of living. As an Advanced Nurse Practitioner the question as to whether palliative care resources catered to the elderly are appropriate? What is communicated about the disease to the elderly? Are resources fully utilized in helping them cope with the debilitating effects of chronic obstructive pulmonary disease?  Hence, the call for a Global COPD management initiative among the elderly, which coordinates the most efficient health care network organizations inclusive of medical practitioners and social work professionals (Orvoen-Frija et.al, 2010).

Etiology/Epidemiology

According to research findings people over age 65 are susceptible to chronic obstructive pulmonary disease due to mucus hypersecretion; respiratory infections and cardiovascular comorbidity. Chronic mucus hypersecretion (CMH), which is classified as coughing and bringing up sputum for more than three months at a minimum two consecutive years has been associated with the development of chronic obstructive pulmonary disease in the elderly (Pistelli,  Lange,  & Millerz, 2003).

A comparative analysis was conducted using an age stratified random sample of the elderly and younger populations applying Copenhagen City Heart Study criteria. Subjects 65 years and older showed a higher incidence of chronic mucous hypersensitivity; 13% in females and 18% in males. Also, there was a higher incidence among elderly who had a history of smoking. After applying multiple logistic regression a positive relationship was established among the variables ‘smoking, chest infections in childhood, recent chest infections and alcohol consumption of more than three drinks a day ‘ (Pistelli et.al, 2003) and Chronic Obstructive Pulmonary Disease in the  elderly.

Acute respiratory infections (ARI) showed another ranking towards being identified a predisposing factor for chronic obstructive pulmonary disease in the elderly. The Global Burden of Disease Study 5 of 1990 revealed that acute respiration infections among ranked 3rd for the leading cause of their death among the over 65 age group.  Recurrent pneumonia and bronchitis were cited as being the most common infections related to the development of chronic obstructive pulmonary disease.  The same research showed where primary community-acquired pneumonia was responsible for most hospitalizations in the U.K with more than 90% of patients over age aged 65. A positive relationship among acute respiratory infection smoking and air pollution was established (Pistelli et.al, 2003).

Cardiovascular comorbidity has been cited as a leading cause of chronic obstructive pulmonary disease among the elderly. There is immense evidence from various studies to support this conclusion. Definite associations emerging from a cause/effect relationship confirm that cardiovascular diseases are not simply the most relevant predisposing factor in development of COPD among the elderly; besides, the entire cardiovascular system could be directly affected through environmental pollutants that induce respiratory infections that place a burden on the two systems’ functions (Pistelli et.al, 2003).

Cohort studies reveal that ventricular or atrial arrhythmias were the most relevant comorbid factors. These increased the in-hospital mortality rate. Significantly, when bronchial obstruction in chronic obstructive pulmonary disease affected patients progressed towards it final stages pulmonary function parameters became irrelevant as prognosis predictors of prognosis. Subsequently, it was replaced by the importance of maintaining cardiovascular health for improved quality of life and daily survival (Pistelli et.al, 2003).

Further studies related to the epidemiology of Chronic obstructive disease among the elderly reveal that the overall incidence in an elderly population is 9.2/1,000 PY. There was a significantly higher occurrence difference among younger women. Researchers predict that a shifting of the disease towards women to be gaining momentum when a distribution by gender is considered. The conclusion was that later in their life cycle one of four men and one of six women now undiagnosed with the condition will ultimately develop it by age 55 years old (van Durme et.al, 2009).

Pathophysiology and Clinical Presentation

Resistance to airflow is a characteristic feature embodied in the pathophysiology of chronic obstructive pulmonary disease. There are significant mucociliary dysfunctions accompanied by inflammatory responses and structural changes.  Blockage and narrowing of the airway occurs due to alterations in bronchus/bronchioles’ elasticity. Subsequently, due to inflammation of the bronchus and bronchioles excess mucus is secreted, which decreases the surface area for air exchange (Hanania et.al, 2010).

Inflammation of the airway predisposed to neutrophils, macrophages and lymphocytes production. These cells along with reactive oxygen and protease enzymes are responsible. They damage alveolar tissue through a protease and oxygen chemical interaction. When patients with chronic obstructive pulmonary disease smoke or expose themselves to air pollutants it provokes neutrophils production. Ultimately, there is thickening of airways and acceleration of connective tissues and smooth muscle activity. This results in formation of fibrosis lung tissue (Hanania et.al, 2010).

Distinctly, aging and COPD is related to proinflammatory cytokines production increase. These include interleukin (IL)-6 and tumor necrosis factor (TNF)-α.They have been associated with ‘aging-related inflammatory diseases and correlated with degree of obstruction in COPD. An age-dependent decline in naïve T cells with oligoclonal expansion of CD8+ CD28null T cells from chronic antigenic stimulation has been described. The increase in CD8+ CD28null T regulatory cells inhibits antigen-specific CD4+ T cell responses, leading to a decline in adaptive immune response’ (Hanania et.al,2010, pp. 580). Clinical manifestations include a persistent cough that produces plenty mucus. It is often referred to as the smoker’s cough;” shortness of breath upon exertion; wheezing and tightening of the chest (Hanania et.al, 2010).

            Clinical Assessment

History taking must contain questions pertaining to whether the client smoke/d; cough or clear the throat several times; bring up mucous; wheeze; experience short of breath with minimal activity. Also, is this shortness of breath comparatively more than that experience by peers when performing the same activities? Is shortness of breath so pronounced that activities have to be avoided? Does it occur when conducting activities such as dressing or toweling drying after a bath? Does it keep you away from your job? Have you consulted with a doctor regarding this condition before? Have you ever been rushed to the emergency due to this shortness of breath experience? (Doherty, 2003).

     Physical assessment include osculation of the lung fields for abnormal sounds; palpation of the abdomen for distention or other associating dysfunctions and inspections of the respiratory tract and patient’s demeanor. Diagnostic testing include simple spirometry; full pulmonary function test to rule out associating pulmonary conditions; high-resolution computed tomography scanning; chest X-ray and blood evaluations (Doherty, 2003).

Health Needs and Differential Diagnosis

Health needs of elderly patients with chronic obstructive pulmonary disease vary with the stage of the conditions as well as associating health conditions such as cardio vascular disease, diabetes, endocrine disorders and chronic asthma. Differential diagnoses which ought to be ruled out include congestive cardiac failure could be ruled out upon detection of the comet-tail sign during bedside lung ultrasonography. Bronchiectasis could be differentiated though clubbing upon physical examination along with abnormal findings on CT scans and x-rays. Bronchiolitis obliterans offers differences in CT scans detecting mosaic attenuation with no evidence of emphysema. Besides, the condition occurs in a younger non-smoking age group. Chronic asthma can also be confused with chronic obstructive pulmonary disease. A significant difference, however, lies in the bronchodilator response and normal diffusion on pulmonary function tests

Developmental Stage Applications

According to Erikson’s (1993) psycho-social developmental stages, the 65 and over age group happen to fall within wisdom- ego integrity vs. despair category. It is soften characterized as late adulthood beginning from age 65 years old unto death. The elderly being investigated in this study are predominantly people over 65 years old. Many psychoanalysts argue that while these stage have been used as a guide there are many variations in relation to one’s culture and perception of the aging process (Crain, 2011).

Therefore, implications of caring for elderly patients with chronic obstructive pulmonary disease are that, not all of them experience despair either altogether wise or have ego integrity confusion. Precisely, health promotion interventionists must take this into consideration and conduct a survey of the population’s social-psychological health before planning programs for this age group.

Implications for families

Chronic obstructive pulmonary disease has a long term effect. As such, family support through the illness is important. More so, in the elderly age group many of them are either in nursing homes, adult living facilities or congregate dwellings. Family and family substitutes in the capacity of caregivers must understand the course of the disease and how to identify exacerbations.

Clinical Management (Evidenced-based protocol for ANP management of the problem)

The Adult Nurse Practitioner (ANP) as a health promotion provider is responsible for rendering health services complimentary to community health care specialists. Generally, ANPs functioning as community health care specialists make autonomous decisions according to the community’s public health protocol and are held accountable for them. He/she is expected to operate as leader, educator, consultant, researcher, and case manager (Leik, 2008).                

Health promotion and disease prevention

Health promotion related to chronic obstructive pulmonary disease follows five distinct standards of care guideline provided by the Chronic Respiratory Disease Service Improvement Framework (CSIF). These include prevention; early diagnosis; management during the of stable stages; treatment and support during acute exacerbations, end of life and care and support (Department of Health, Western Australia, 2012).

Prevention requires that health promotion strategies be aimed at teaching the elderly population to avoid pollutants such as second hand smoke; encourage screening for the presence of predisposing factors prior to age 65 years old; teach patients when diagnosed to self-manage of the condition; align with family members and support groups for help during exacerbations and provision of early hospice intervention.

Health Teaching Plan (Health Promotion)

Objective Content Strategy
1.To reduce the incidence of chronic obstructive pulmonary disease among the elderly population  Wide spread distribution of literature pertaining to the incidence of chronic obstructive pulmonary disease among the elder 65 years and over Provide data relevant to the topic and agencies, which could be contacted for more information
2.To promote early diagnosis through screening Collaborate with primary care providers in an education outreach program to have people between the ages of 50-60 be routinely screened for predisposing factors of chronic obstructive pulmonary disease Conduct workshops with primary health care providers offering evidence based data on the issue sensitizing them towards the need for screening this category of patients.
3.To initiate self-management during the stable stages Distribution of materials on self-management techniques Make information available at clinics doctor’s offices and hospitals and provide contact information for clarifications
 4.To provide treatment and support during acute exacerbations Providing information regarding how to recognize exacerbations and how to cope with the condition Collaborate with primary health care providers ; community health workers day care provider and adult family home administrators workshops related to patient education during exacerbations.
 5.To provide end of life and care and support Provide information regarding options for end of life interventions such as hospice and long term care interventions. Collaborate with primary health care providers ; community health workers day care provider and adult family home administrators workshops related to patient education during on end of life services available to them

Pharmacokinetics of drugs or drug classes used in treatment of the problem

Bronchodilators are often the first line of treatment regardless of age differences.  Recurrent symptoms accompanied by frequent exacerbations are treated with corticosteroid inhalers. Oxygen therapy has proven very useful also being administered as ‘A PaO2 level of <55 mm Hg on room air’ (Hanania et.al, 2010).   Elderly patients with comorbidity often present with drug interactions. As such, care should be taken when advising on medication self-management. Research has shown where there is a high incidence of medication non-compliance among the elderly, which is another health promotion challenge (Hanania et.al, 2010).

Future trends (in terms of clinical management).

Evidence based studies have unanimously revealed that inflammation is a common denominator in all chronic obstructive pulmonary dysfunctions. As such, future trends in clinical management are focused on treating inflammation. Arguments have been that traditional pharmacological therapies have not been able to address their clinical relevance as it relates to inflammations. Hence, it is not clear how effective they are at ‘improving respiratory mechanics, relieving dyspnea, increasing exercises tolerance, preventing exacerbations and improving quality of life’ (Roche et.al, 2011).

Therefore, alternatives must be designed for addressing unexplained exacerbations and inflammation. Future trends point towards the use of ‘inhaled corticosteroids only in combination with long-acting β2-agonists, when forced expiratory volume in 1 s (FEV1) is <50% predicted (60% pred for the salmeterol-fluticasone combination according to European marketing authorization) and when there is a history of frequent exacerbations’ (Roche et.al, 2011, pp. 110).  Also by adding budesonide to β2-agonists (formoterol) could improve exercise tolerance. Peroxisome proliferator activated receptor (PPAR) agonists have been discovered to be a valuable alternative to extensive steroid administration (Roche et.al, 2011).

Evaluation of Outcomes

Evaluation criteria and time frame

Objective Criteria Time Frame
1.To reduce the incidence of chronic obstructive pulmonary among the elderly population Incidence inquiry 2 years
2.To promote early diagnosis through screening Investigation into whether more elderly have been screened for chronic obstructive pulmonary disease Monthly evaluations for one year.
3.To initiate self-management during the stable stages Data collection on status of self-management Monthly evaluations for one year.
4.To provide treatment and support during acute exacerbations Treatment and support incidence reporting Monthly evaluations for one year.
5.To provide end of life and care and support End of life accessibility report Monthly evaluations for one year.

Conclusion

Summary

The foregoing discussion embraced a comprehensive research pertaining chronic obstructive pulmonary disease among the over 65 age group known as the elderly. They were identified as a high risk group for the condition with peculiar predisposing factors distinct from the younger age population. However, there are not enough specific research studies exclusively aimed and providing a scope of treatment relative to their age and predisposing conditions due to their age and psychosocial development.

Recommendations are that advance nurse practitioners along with other categories of health care providers join forces in undertaking studies. These results could add to the body of limited knowledge which now exists in the discipline and provide the evidence based foundation for contemporary speculations.

References

Department of Health, Western Australia (2012). Chronic Obstructive Pulmonary Disease Model

          of Care. Perth:  Health Networks Branch, Department of Health, Western Australia

Crain, W. (2011). Theories of Development: Concepts and Applications (6th ed.). Upper Saddle

River, NJ: Pearson Education, Inc.

Doherty, D. (2003). Identification and Assessment of Chronic Obstructive Pulmonary Disease in

        the Elderly. American Medical Directors Association. JAMDA

Hanania, A. Sharma, G., & Sharafkhaneh, A. (2010). COPD in the Elderly Patient

Semin Respir Crit Care Med. 31(5), 596-606.

Leik, C. (2008). Adult Nurse Practitioner Intensive Review: Fast Facts and Practice Questions.

New York. Springer Publishing Company.

Orvoen-Frija, E. Benoit, M. Catto, M. Chambouleyron, M. Duguet, A. Emeriau, J. Ferry, M.

Hayot, M. Jeandel, C. Morize, V. Nassih, K. Ouksel, H. Piette, F. Prefaut, C. Roche, N. de

Wazieres, B., & Zureik M (2010). Chronic obstructive pulmonary disease (COPD) in the

Elderly.  Rev Mal Respir, 27(8), 855-73

Pistelli, R.  Lange, P., & Millerz, D. (2003). Determinants of prognosis of COPD in the elderly:

mucus hypersecretion, infections, cardiovascular comorbidity. Eur Respir J. 21, Suppl.

40, 10s–14s

Roche, N.  Marthan, R., & Berger, P. (2011). Beyond corticosteroids: future prospects in the

management of inflammation in COPD. Eur Respir Rev  20(121), 175-182

van Durme, Y. Verhamme, K. Stijnen, T. van Rooij, F. Van Pottelberge, G. Hofman, A. Joos, G.

Stricker, B., & Brusselle, G.(2009). Prevalence, incidence, and lifetime risk for the

development of COPD in the elderly: the Rotterdam study. Chest.135(2),368-77

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