Long term care has evolved into a “catch all” phrase that is confusing to the lay as well as the professional community. The boundaries among primary, acute, and long term care have blurred. Instead of concentrating on acute care in hospitals, our health care system’s focus has switched to managing chronic conditions in a variety of settings from home to rehabilitation hospitals. The long term care goal switches from curing illness to helping individuals function as well as possible while maintaining dignity and independence. Individuals that require long term care have a compromised ability to live on their own due to their condition. Long term care encompasses help with activities of daily living (ADLs), such as bathing, dressing, eating, and toileting.
Services also include instrumental activities of daily living (IADLs) such as shopping, managing medication, meal preparation, household chores, money management, and transportation. The services provided are primarily low tech services that are designed to rehabilitate or compensate for loss of physical and/or mental functioning. The IRS utilizes these same terms to outline long term medical care deductions for the chronically ill. They define qualified long term care services as when a person is unable to perform at least two activities of daily living without substantial assistance or they need substantial supervision to be protected from threats due to severe cognitive impairment.
Need for Long Term Care
Long term care needs emerge from chronic medical and psychiatric conditions that occur from birth to death. They may result from chronic conditions such as diabetes, rheumatoid arthritis, heart diseas and chronic mental illness, that mature with time causing increasing functional limitations that eventually require more complex assistance. Accident victims also develop long term care needs such as injury that results in traumatic brain injury or paralysis. Long term care is not merely an extension of acute care but involves chronic, extended care that requires assistance with basic human needs such as housing and care. People who require long term care also require acute care for periods of exacerbations and other illnesses. The following are some statistics that exemplify the needs of long term care in the elderly population:
- The total elderly population of 65 and older is 13% of the total US population
- Life expectancy at 65
- For men: 17.1 years
- For women: 20.0 years
- After age 65, almost one half of all Americans will spend some time in a
- The demand for long term care increases dramatically with age, underscoring
the need to pay special attention to those over 85
- Leading causes of death for those age 65 and older:
- Heart disease
- Nursing home usage has been decreasing in the past decade most likely due
to alternative care arrangements such as assisted living and supportive care
- Nursing home residents have needs for care with the majority needing
assistance with more than 4 activities of daily living (ADLs)
- The nursing home will remain a necessary long term care option for elders
with severe disabilities, insufficient support systems, and inadequate living
It is essential that we keep in mind the health of our elderly population, the diseases that commonly afflict them, and the aging process itself. Each 85 year old person is unique and has a lifetime to develop their personal health history. Individuals that are admitted to nursing facilities commonly have multiple diagnoses that require care and attention. People are living longer, but they also are ill longer and require the use of medical care to meet their evolving needs. In the industry this is referred to as “quantity versus quality” and end of life issues become more and more complex.
Special Conditions that are Problematic in the long term care setting
Pressure Ulcers (decubitus ulcers, bed sores) are considered a serious condition in the long term care setting. They are caused by pressure applied to susceptible tissue over a period of time. They can develop in an incredibly short duration and are one of the most difficult conditions to treat. Prevention and good nursing is the best way to avoid them.
In long term care settings, development of a pressure ulcer was associated with a 92% mortality rate within three months.
Cognitive Issues are prevalent in the long term care setting. It is one of the main reasons why patients cannot be maintained in the home setting. The prevalence of dementia almost doubles every five years after the age of 60. Approximately 65% of dementias are Alzheimer’s type with the remaining being vascular and Parkinsonian.
- Alzheimer’s disease is manifested by memory impairment and difficulty learning and recalling information. When it is severe enough to interfere with social functioning, the long term care setting may be sought. The disease is progressive and over time patients forget how to meet their basic ADLs.
In very late stages they forget how to swallow and ultimately go into organ shutdown, which results in death. Psychotic symptoms of delusions, hallucinations and paranoia are common in 50% of this population and can be a clinical challenge in the long term care setting.
- Vascular dementia (VaD) is characterized by cerebral vascular disease. The course is generally of more sudden onset after a stroke. This disease usually follows the course of the patient’s vascular disease and can remain stable for long periods of time.
- Parkinson disease, also called Lewy body disease, is insidious and progressive
in nature. It follows the pattern of Alzheimer’s disease and can be accompanied by hallucinations.
Treatment for all of these types of dementias focuses on increasing tissue perfusionand prevention of further vascular events. The nursing focus is on creating a calm and stabilizing environment with maximum structure. Memory prompting, visual cues and repetitive learning techniques will help the patient cope and adjust to the setting. Prevention of wandering and keeping safe from harm due to their lack of reasoning are essential. Door alarms and wander guards are used to track patients and prevent them from exiting the safety of ther facility without accompaniment.
The medical issues that face the elderly are evolving throughout their lifetime. The normal process of aging causes a systematic wear and tear on the body that is predictable in general principles. Accomplishing the ADLs and IADLs are key determinants as to when an individual will need a long term care facility. When the challenges of life exceed their abilities to live independently, long term care is needed.
Shay Jacobson, RN, MA
Life Care Innovations
Oakbrook Terrace, Illinois