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Coming of Age: New geriatric care models and technological advances offer better treatment options
U.S. Census statistics show the number of Americans over 65 will nearly double between 2005 and 2030, expanding from 13% of the population in 2000 to 20% in 2030, for a total of 72 million people. Though many older adults are active and in good health, most have at least one chronic condition and use healthcare services more often than other segments of the population. Although evidence shows elderly people benefit from caregivers who understand the needs of their age group, less than 1% of nurses have training in geriatric care, according to the Institute of Medicine?s 2008 report ?Retooling for an Aging America: Building the Health Care Workforce.?
?The biggest problem is the lack of providers who are prepared to care for this population,? says Tara A. Cortes, RN, PhD, FAAN, executive director of the Hartford Institute for Geriatric Nursing at the New York University College of Nursing. The Hartford Institute is working to ensure that all nurses have geriatric competence. It has developed assessment tools, core competencies, evidence-based protocols, advance practice curriculum, and programs such as NICHE (Nurses Improving Care to Healthsystem Elders).
?Nursing is positioned perfectly to be the driver of care for older adults,? Cortes says, noting that nurses already are experts at managing care, providing education, looking at patients holistically and working in interdisciplinary teams, all crucial components of geriatric care.
Technology
New technologies for an aging population include devices to measure gait and determine risk of falls; monitors that measure and transmit medical data; senior-friendly computers for communication and entertainment; tracking devices that determine whether a patient has left a bed or opened a refrigerator; robots that clean houses, assist with bathing and even hold limited conversations; and smaller, more user-friendly versions of complex equipment found in hospitals, such as ventilators, hemodialysis machines and X-rays.
Engineers are coming to gerontological nurses and other clinicians who work with older adults to see what elderly people need, says Martha S. Anderson, DNP, CNS, FNGNA, associate professor at Jefferson College of Health Sciences in Roanoke, Va., and a board member of the National Gerontological Nursing Association. Anderson is also an advanced practice clinician at the Carilion Clinic Center for Healthy Aging in Roanoke. She is working with a team that includes engineers from the University of Virginia and Virginia Tech and is developing a wristband that senses agitation in patients with dementia.
?And all of these engineers and researchers are looking at ways to find that their project is useful and needed,? she said.
Chronic Illness Management
Studies show the elderly often are not too old for interventions, whether surgery, medications or lifestyle changes, says Deborah A. Chyun, RN, PhD, FAHA, FAAN, associate professor and director of the Florence S. Downs PhD Program in Nursing Research and Theory Development. The National Institutes of Health reports even moderate physical activity provides significant benefits. Strength and balance training is shown to reduce falls by up to half.
Another element of chronic illness care is pain management. ?For the longest time there was a myth that persons with dementia did not feel pain,? says Marti Buffum, RN, DNSc, PMHCNS-BC, associate chief of nursing service for research at the VA Medical Center in San Francisco and associate clinical professor in the department of community health systems at the University of California, San Francisco School of Nursing. But studies show nurses and physicians tend not to give pain medication unless patients report pain, which people with severe dementia are often unable to do. ?Everybody is afraid to overmedicate, so they don?t medicate as readily,? Buffum says.
There are about 17 such tools, which require nurses to carefully observe patients for behavioral signs of pain, including changes in appetite, vocalizations, sleep patterns, facial expressions, mobility, personal interactions and posture. Nurses should also ask family members about unusual behaviors. Interventions can include non-pharmacological methods, such as aromatherapy, comforting touch or other types of distraction.
Studies show that about one in five older adults has a diagnosable mental disorder. Yet the understanding that older people may benefit from mental health screenings and interventions is a relatively new concept, says Kathleen C. Buckwalter, RN, PhD, FAAN, professor of gerontological nursing research and director of the University of Iowa John A. Hartford Center of Geriatric Nursing Excellence. As part of the Geropsychiatric Nursing Collaborative, a national four-year project designed to improve the education of nurses caring for seniors with mental health disorders, Buckwalter is working to implement core competencies at all levels of nursing education.
Buckwalter sees an increasing role for nurse-centered models of mental health care in nursing homes, with geropsychiatric nurses training staff to make assessments, provide interventions and offer activities to promote mental health. Other settings where geropsychiatric nurses can play expanded roles include inpatient units, prisons, homeless shelters, telehealth and dementia care units.
?The big thing for geropsychiatric nurses right now is translating research into practice,? she says.
Long-Term Care
Nursing homes are increasing or adding rehabilitation services, allowing some patients to stay until they are strong enough to return home. ?Much of our work should be geared to what we can do to make the patient safe at home? by providing a spectrum of care with the elderly patient at the center, says Cortes, the Hartford Institute director.
The Program of All-Inclusive Care for the Elderly and other models are demonstrating ways to integrate services for seniors in their homes. Visiting nurses at all levels are caring for elderly patients in their homes, and successful pilot programs use advanced-practice nurses to provide transition care after hospital discharge. ?People are moving across and between systems a lot more than they used to,? says Margaret Wallhagen, GNP-BC, PhD, AGSF, FAAN, professor in the Department of Physiological Nursing at UCSF, meaning they need someone to coordinate care.
One in four long-term facilities now offers ?person-centered care.? Organizations such as Pioneer Network offer private rooms, cafe-style dining, pets and group activities geared to the interests of the residents. As institutional care becomes more homelike, elderly people and their families may be more attracted to a group setting, says Marie Boltz, RN, PhD, GNP-BC, assistant professor at the New York University College of Nursing and associate director for practice at the Hartford Foundation.
Baby boomers are expected to demand as many choices as possible, but an obstacle to person-centered, long-term care, whether in the home or at a facility, is cost. ?The cost is escalating so much that people have to look more creatively? at ways to provide long-term care, Wallhagen says.
Since more than half of all hospital patients are older than 65 and the number is expected to increase, it is imperative for all healthcare providers to have competency in geriatric care, says Deborah A. D?Avolio, PhD, APRN-BC, a geriatric nurse specialist with the 65-Plus Program (a NICHE program) and nurse scientist at the Yvonne L. Munn Center for Nursing Research at Massachusetts General Hospital, Boston. ?What we?ve learned is that when nurses learn to incorporate these special things within their assessment, all patients in the unit benefit, regardless of their age.?
Cathryn Domrose is a staff writer.
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