Staying Independent

At the age of 72, Helen was left with only a slight right-sided weakness following her stroke. The rehabilitation center where she received therapy recommended that Helen consider moving to an assisted living apartment. Because Helen was sometimes forgetful, assisted living staff could remind her to take her medications at the right time and also see that she ate three meals a day. In addition, help would be available 24 hours a day if she needed special assistance while allowing her to live independently in her own apartment. Not wanting to leave the house her husband had built for her, Helen decided to return to her own home. Helen didn't have any children and most of her long-time friends were gone. She was lonely and frequently forgot to take her medications. Within months, she began to lose weight and had frequent falls. One day, Helen sustained a second stroke, which was much worse than the first. Helen was now completely paralyzed on her right side and lost her ability to speak. Because Helen could no longer care for herself, an assisted living apartment was no longer an option and she was placed in a nursing home, What happened to Helen is common. Yet, there are several factors that often cause older adults to lose their ability to remain independent. The most common include physical changes as we age, hospitalizations, medication interactions and chronic diseases.

Physical Changes: The physical changes which occur with aging frequently pose problems with performing basic activities of daily living, such as bathing, dressing, walking, toileting, and eating. The limitations in performing activities of daily living (ADLs) are considered predictors of nursing home placement, increased use of physician and hospital services, less use of primary and preventative care, and quality of life.

Diseases and Hospitalizations: Older adults are particularly at risk for a decline in level of independence when hospitalized. It often becomes more difficult to cope with an acute illness, and one may be susceptible to complications or infections from their hospital stay. Often times those over 80 years of age are unable to recover ADLs, which may be lost during treatment (for example, unable to walk or get out of bed, or may have confusion or memory loss caused by medications). Although the decline in independence caused by an illness may be reversible, the length of time to recuperate may be long. In some instances one may never reach the level of independence enjoyed prior to the illness. Older patients are at particularly high risk of decline in independence when placed in situations in which there is a loss of function. This loss occurs when they stop doing things they would normally do for themselves. Although this frequently occurs in the hospitalized patient, acute illness in any setting can result in the same decline in activities. Similarly, progressive deteriorating chronic diseases, such as Parkinson's disease, arthritis, and peripheal arterial disease, are frequently associated with limitations in the ability to perform ADLs independently.

Medical Interactions: Although hospitalization frequently creates a risk to staying independent, the effects of many medications may pose an even greater risk for losing one's independence. Adverse drug reactions often account for many hospitalizations as well as loss of independence in those living at home. Although some of these serious effects are related to side effects, many more are the direct result from combining medications. Even over the counter medications should be used with caution. For instance, diphendramine is the active ingredient in many sleep aids because of its sedating side effect, however, its effects on memory in older adults poses a potential risk to independence. Therefore, even over the counter medications should be discussed with your healthcare provider. The table at the left lists a few medication safety tips, which may be useful in staying independent.

Help and Treatment: The loss of independence is frequently reported by older adults as their greatest fear. However, many times this fear further complicates the risk. In an effort to maintain independence it's not uncommon to refuse assistance. Research studies report that older patients who choose to stay at home with home health support frequently do worse than if they had chosen to live temporarily with family or in an assisted living apartment.

What to Do: Discuss the impact of illness and treatment on independence and quality of life with healthcare providers and family members. In my experience, patients are read detailed lists of the complications related to treatment, with little time spent on making sure they understand the results of treatment or the unfavorable potential impact on lifestyle. For example, does the patient with an aortic aneurysm and emphysema understand the possibility of becoming dependent on a breathing machine after surgery? Similarly, like Helen at the beginning of this article, does the stroke patient who's forgetful and living alone, understand that an alternative living arrangement, such as assisted living, is more likely to help her stay independent longer than by living alone? Staying as independent as possible is a journey. Just as one would gather certain information before plotting a map for a trip, information should be collected when faced with a situation in which a danger to staying independent exists. These situations may include: hospitalization, any acute illness that causes a restriction in physical activity, frequent falls, and confusion or increased forgetfulness. Key information in developing a plan to stay independent should include: what ADLs will be affected and for how long; what are my options regarding assistance to address my ADL needs; and, what resources are available to assist me to stay independent. Although staying independent is important to most individuals, accepting assistance when needed is probably the most important step to successful aging.

About the Author: Karen L. Rice, MSN, APRN, BC is an Adult Nurse Practitioner and Geriatric Resource Nurse at the Ochsner Clinic Foundation in New Orleans, Louisiana. She has written many articles on the subject of vascular disease. She received a Nightingale Award in 2002 as the Advanced Practice Nurse of the Year in Louisiana for her contributions to improving care of hospitalized older adults.