Chapter 32 – Long-Term CareLinks to an

Chapter 32 – Long-Term CareLinks to an external site. Transitions across the Continuum Ray is 85 years old and was recently admitted to the hospital from his own home following a fall with resultant fracture of the right hip. He was brought to the hospital by paramedics after a neighbor checked on him because they had not heard any sounds from his apartment. He had been lying on the floor for 8 hours unable to call for help. He lives alone in a one-bedroom condominium. His wife of 50 years died 4 years ago. His three adult children and their families live out of state, but keep in close contact with their father and visit several times a year. The last time they saw their father was 4 months before his hospitalization. Prior to the hip fracture, Ray was fairly capable of taking care of himself, but since the death of his wife, his memory and mood have declined. He is hard of hearing in both ears but often refuses to wear his hearing aids, claiming that they distort all sounds and are a bother. He only occasionally left his apartment and had lost a great deal of weight. His neighbors reported that he was falling frequently and there were repeated calls to 911 for assistance. He had several “fender-benders” and had limited his driving to shopping and church. His children were becoming increasingly worried about him living alone. He refused to consider moving to live nearer or with his children or to assisted living. He did not want to be a bother to his children. His home is full of family pictures, pictures from his worldwide travels with his wife, memorabilia from his days as a police officer, and antique furniture. He has a little dog who gives him great enjoyment. Following a surgical repair of his fractured hip, he experienced a delirium and his mental status declined. He received physical therapy but had difficulty following the orders for partial weight bearing on the affected leg. He became incontinent and required an adult brief. He also developed a necrotic pressure ulcer on his right heel. The hospital case manager recommended to the family that he be transferred to a skilled nursing facility for further rehabilitation, treatment of the pressure ulcer, and possible long-term care placement. It was felt that he could not return safely to his home due to his mental status and functional decline. His finances were limited, so a home that accepted both Medicare and Medicaid was recommended. Even though the family had promised their father that they would never put him in a nursing home and felt terrible, they agreed with the decision and felt relieved that he would not be living alone. Worried that he would be upset, they decided not to tell him that he would not be going home. They decided to sell his apartment to provide some money for his nursing home care. The children divided the furniture and memorabilia between them and sold the remaining household items. The little dog was given to a shelter. They chose not to tell him that they had done this and when he asked, they said: “When you get better, then you can go home.” Ray’s mental status continued to decline. He was unable to walk independently, experienced weight loss, sleep problems, and became more withdrawn. What are your thoughts on what the family is telling him? Chapter 33: Intimacy and Sexuality Sexuality in Late Life George was a 70-year-old man who had been widowed for 6 years. He lived alone in a lovely home in the hills of San Francisco. His many friends tried to introduce him to a lady who would be attractive to him, but they were unaware of his real concerns. Although George was attracted to young, energetic women, often barely older than his daughters, he was justifiably cautious regarding their sincere attraction to him because he had a considerable estate. In addition, his sexual desire was waning and his capacity for sexual performance was unpredictable. One thing George expressed fairly frequently was, “I don’t like demands made on me.” To further complicate the picture, George had begun to take medication to reduce his benign prostatic hypertrophy (BPH) that had become increasingly troublesome. The medication further reduced his sexual desire. In addition, George’s sleep pattern was disturbed by the need to arise three or four times each night to void. George came to the clinic for follow-up evaluation of his BPH, and, while talking with the nurse, he began crying uncontrollably, much to his embarrassment and the nurse’s surprise, because George had always seemed to be a rather solid and stoic fellow who was reluctant to discuss feelings. What do you say? Chapter 34: Relationships, Roles, and Transitions Retirement Sandy was a professor at a small, private college in a metropolitan area. Although she had taught nursing for 25 years and loved her work, it had been a demanding year and she was very tired. A rumor had recently circulated that the college was in trouble financially. Some of the most affluent alumni could no longer be counted on for gifts and endowments because the football coach had not produced a winning team for several years. Because the tuition was becoming exorbitant, the college had recently lost some students to one of the three state college campuses within driving distance of the city. The trustees of the college, in a move to cut expenses, offered an incentive to professors who were willing to retire early; an extra year of service credit was presented for every 6 years worked. Sandy was only 55 years old but thought that the 4 years of extra credit would bring her near the minimum retirement age for Social Security (an error, of course, because her age did not change with her service credit). Rather impulsively, Sandy decided to accept the offer after telling colleagues, “Well, you know how I love to travel. Why wait until I’m too old to enjoy retirement? Why don’t you think about the offer, too? This is a once-in-a-lifetime opportunity.” Near the end of the academic year, the celebrations began: recognition, plaques, expressions of gratitude from students, and envy from her associates. The send-off was wonderful. In the summer, Sandy withdrew her savings and booked a cruise to the Greek islands. The journey was lovely, and she enjoyed every moment. Sandy began to feel depressed when she got off the ship but knew it was only because the elegant cruise was over. However, as fall came around, Sandy began to feel more depressed. Most of her friends were teachers, and they were all back at work. Sandy briefly thought of going to Pittsburgh to visit her sister but decided against the idea because she and her sister had really never been very compatible. Then Sandy was hit with some of the realities of early retirement: she was unable to withdraw any of her considerable tax-deferred savings before she was 59½ years of age without significant penalty, her health insurance coverage was considerably less comprehensive after retirement, her colleagues were all busy, and she was very bored. Then the real blow fell. The college, in desperation, had dipped into the retirement funds to remain solvent, and the retirees’ pensions were now at risk. Sandy’s sister, who was a nurse, called to announce that she wanted to come and stay a few days while she attended a conference in the city. When she arrived, Sandy overwhelmed her with the litany of woes. If you were Sandy’s sister, what would you do?

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