As the proportion of people aged over 65 continues to grow, the proportion of elderly patients with stomas continues to grow (Ebersole and Hess, 1998). Currently, in the UK the average life expectancy is 83 years for men and 87 years for women. Certain areas of the UK, especially on the south coast of England, have high populations of people over the age of 70 years - as high as 27.9%. In 2000, 10.6% of the population was over the age of 80 (Black, 2000). For many of these patients, there are already other long-standing physical problems and cognitive problems which are going to be complicated further by stoma surgery. For those patients needing to learn self-care for their new stoma, individual assessment of the patient's psychological and cognitive function will be needed to assess how teaching strategies can be adapted. Fine and gross impairment in motor skills will complicate package opening, skin cleansing and appliance application. Visual and hearing impairments make it difficult to understand everything that is being said in teaching situations, and alteration of teaching patterns will be needed to cope with these situations. Although older patients may be effective practitioners, they require a longer period of time to learn appliance application and this often entails a longer hospital stay until the patient feels able to cope on discharge home.
Long-term memory is often better than short-term memory in elderly people, so they find it difficult to repeat something that has been shown to them the day before. To help with this it is easier if teaching can be associated with their long-term memory. In instructing the older patient a quiet environment is needed where there will be no continual interference, such as a need by others to use the bathroom, the telephone ringing or bleeps going off. Even if the patient has not admitted to a hearing impairment, the nurse should face the patient during teaching and use straightforward sentences as opposed to medical jargon. Although written information may be given, the patient may be unable to read adequately or not at all. If it has been ascertained before teaching the patient that there is an inability to read, written information on appliance changing can be given in picture form, using pictures put together from the various patient teaching booklets. Those patients with visual acuity problems may manage better with enhanced light or may need sunlight reduced if the room is too bright. For those who are blind the use of tapes and Braille cards helps reinforce teaching.
A fear that many elderly people have is that their spouse may be asked to help with the changing of the appliance and that they will become dependent on another. The family may worry that they will have to have the relative to live with them after discharge from hospital or may be asked to participate in some part of the patient's care. Family support and acceptance of the ostomate are essential for the successful rehabilitation of the patient and his or her discharge back into the community. Usually patients with diverticular disease who have had a stoma are in the older age group (see Chapter 7) and feel that they will find it difficult to continue in their own home, and may express the wish to sell their home and move into a nursing home or sheltered accommodation because they feel that they will not be able cope with a stoma. At this stage patients should be encouraged not to make any wide-ranging decisions until they have had a chance to go home and assess their situation as they begin to recover from surgery.
Often, for some elderly patients admitted as an emergency for surgery for diverticular disease, it may be the first time that they have been into hospital for an extended period of time and had an operation. Some elderly people with diverticular disease will put up with severe pain at home and try not to be admitted to hospital. They may well be debilitated and confused on admission, as well as having pain, and be put in a bed with cotsides next to a stranger. Some will have difficulty in understanding staff from other cultures and some do not understand that there are also male nurses. Faced with the loss of basic bodily functions, disrupted routines and postoperative confusion, elderly patients may feel that they have regressed to childhood and become tearful and aggressive. Elderly people, when informed that a stoma will be needed for their surgery for diverticular disease, will fear that they will have to have a special diet and become worried about the financial implications of this. They should be assured that a special diet is not necessary, but what will be needed is a natural high-fibre diet; it may be necessary to give them written details about what should be eaten. It must be stressed to the patient that, although a list of suitable foods has been written down for them, these are not the only foods that they should eat, but ones that should be included in an all-round healthy diet.
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