Celebrating Ten Years of Improving Health Care for Older Adults
Making Best Geriatric Practice
Standard Practice
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Older Adults are the Core Business of Health Care
Although almost all of us have visited a hospital, and many popular television shows bring the inside workings of hospitals into our living rooms, the extent to which older persons are more likely to be patients than any other demographic group in the United States is not always recognized. The statistics tell part of the story: Adults over age 65 use 50 percent of hospital days and 70 percent of home care services. Eighty-eight percent of people over age 65 have chronic health problems, which puts them at risk for hospitalization. Sixty-three percent of patients with cancer are over 65.
The numbers of older adults utilizing health care services will only grow with the inevitable shift in population demographics-that is, the "Baby Boom" generation reaching older age. "Older adults are not one subgroup of patients, but rather the core business of health care systems," says Terry Fulmer, PhD, RN, dean and Erline Perkins McGriff Professor, College of Nursing, New York University, and co-director of the Hartford Institute for Geriatric Nursing.
Numbers and percentages tell only part of the story, according to Elizabeth Capezuti, PhD, RN, co-director of the Hartford Institute for Geriatric Nursing. "The large population of older adults can present complex clinical challenges in almost every health care setting," she says. Older adults often have one or more chronic illnesses and take several medications, which can complicate their care, and they are undergoing major medical procedures in their 80s and 90s. Comorbidities and the aging process can combine so that older patients present differently than younger patients and often require a different skill set to manage their care. To effectively treat patients, nurses must be able to recognize red flags for potential problems that are unique to older people. For example, older adults metabolize drugs differently than younger people. This means they may need smaller doses of drugs, should take them for a shorter period of time, or should avoid certain drugs altogether. Some common pain killers and sleeping medications can cause delirium and confusion in older people. In addition, hospitalization itself places older patients at risk for complications, such as loss of mobility, incontinence, pressure ulcers, falls, and delirium.
The inescapable fact is that in almost all health care sites, a large portion of the caseloads of every member of the health care team, including nurses, are older adults. And these patients present clinical challenges for which special training is required.
According to Mathy Mezey, EdD, RN, director of the Hartford Institute for Geriatric Nursing, when nurses are properly prepared to work with older patients—and their families—significant improvements in outcomes are achieved. For example, older adults cared for by geriatric nurse practitioners and clinical specialists are less likely to be physically restrained, experience delirium as a by-product of hospitalization, be in pain, or be readmitted to the hospital from home or from a nursing home.3 The care that nurses trained in geriatrics provide can often mean the difference between older patients who leave the hospital functionally diminished and suffering from conditions such as pressure ulcers and delirium and patients who leave the hospital with few, if any, complications. Randomized controlled trials have shown that the care provided in geriatric units with specialized programs for evaluating and managing older adults results in significant reductions in functional decline, improvements in mental health, and reduction in the need to discharge patients to a long-term care facility, all with no increase in costs.4
However, until ten years ago, a nursing focus on care of older adult
patients was sadly lacking. At that time, less than 1 percent of the
2.2 million practicing registered nurses were certified in geriatrics;
less than .002 percent of registered nurses were geriatric nurse
practitioners or clinical specialists; only 23 percent of nursing schools
had a required course in geriatrics; and 60 percent of baccalaureate
nursing programs had no geriatric-expert faculty. This began to
change in 1996 with the inception of the Hartford Institute for
Geriatric Nursing.
3- Naylor MD, Brooten DA, Campbell RL,
Maislin GM, McCauley KM, Schwartz JS.
"Transitional Care of Older Adults Hospitalized
With Heart Failure: A Randomized Clinical
Trial." Journal of the American Geriatrics
Society. 2004. Vo. 52, Number 5, pp. 675-684.
4- Cohen HJ, Feussner JR, Weinberger M, et al.
"A Controlled Trial of Inpatient and Outpatient
Geriatric Evaluation and Management." New
England Journal of Medicine. 2002. Vol. 346,
Number 12, pp. 905-912.
Landefeld CS, Palmer RM, Kresevic DM,
Fortinsky RH, Kowal J. "A Randomized Trial of
Care in a Hospital Medical Unit Especially
Designed to Improve the Functional Outcomes of
Acutely Ill Older Patients." New England Journal
of Medicine. 1995. Vol. 332, Number 20, pp.
1338-1344.
Visit the Hartford Institute for Geriatric Nursing Web site: www.hartfordign.org