Healthcare Providers Requiring Proficiency in Geriatrics, Regardless of Specialty
By Debra Wood, RN, contributor
March 25, 2012 - America’s aging, and the country lacks sufficient numbers of healthcare practitioners skilled in caring for this special population.
“Every day in America, 10,000 people turn age 65,” said Robert Roush, EdD, MPH, president of the National Association of Geriatric Education, director of the Texas Consortium Geriatric Education Center, and associate professor of geriatrics at the Baylor College of Medicine in Houston. “This rate of aging will continue until 2029 when all 77 [thousand] baby boomers reach the age of 65.”
The U.S. Census Bureau reports more than 40 million people are age 65 or older and represent 13 percent of the total population, and the nation’s 90-plus population reached 1.9 million in 2010, tripling over the prior three decades.
“The population is living longer, and we are looking at a time period of up to 10, 15, 20 or up to 40 years of older adulthood,” said Kathleen Blais, EdD, RN, professor emeritus at Florida International University’s College of Nursing and Health Sciences in Miami. “As they age, they develop more concurrent illnesses.”
Despite the growing numbers, and knowing older adults require more healthcare services, few healthcare professionals specialize in geriatrics. The Institute of Medicine (IOM) in its 2008 report “Retooling for an Aging America: Building the Health Care Workforce,” called for the training of more healthcare providers in the basics of geriatric care.
“Every discipline has a dearth of members which have adequate training to care for older adults,” Roush said. “You have a huge number of people out there who require more time with a clinician that has more knowledge than the good, run-of-the-mill healthcare provider.”
Why specialized care?
Marie Boltz, Ph.D., APRN, BC, director of practice initiatives at the Hartford Institute for Geriatric Nursing at New York University (NYU), said clinicians need specialized assessment skills and must consider a patient’s social and functional needs. However, she added, “There’s a gap in knowledge preparation. Physicians, nurses and other people are not prepared in their training programs to care for older adults.”
Jennifer Kim, MSN, GNP-BC, indicated older adults have varied physical, psychosocial, emotional and functional needs.
Jennifer Kim, MSN, GNP-BC, assistant professor of nursing and geriatric coordinator at Vanderbilt University School of Nursing in Nashville, Tenn., added, “Geriatric care is extremely different.”
Vanderbilt will convert its adult nurse practitioner program with a geriatric focus to an adult-gerontology primary care nurse practitioner program to help meet the demand for geriatric care providers.
“[Older adults] have varied needs: varied physical, psychosocial, emotional and functional needs,” Kim added. Elders are physically frailer and are more likely to have cognitive and neurosensory impairments. Dementia interferes with an older adult’s ability to self-manage his or her care.
Rose Ann DiMaria-Ghalili, Ph.D., RN, CNSC, said all nurses need to be prepared to care for older adults.
“When a person is older you have to consider functional status and quality of life,” said Rose Ann DiMaria-Ghalili, Ph.D., RN, CNSC, associate professor and John A. Hartford Foundation Claire M. Fagin Fellow at the College of Nursing and Health Professions at Drexel University in Philadelphia.
Janet C. Mentes, Ph.D., APRN, BC, FGSA, reported that older adults often have geriatric syndromes.
“A lot of times, older persons have geriatric syndromes, and these are not diseases or diagnoses, but health problems an older person is likely to have,” added Janet C. Mentes, Ph.D., APRN, BC, FGSA, associate professor at the University of California, Los Angeles. That includes an increased risk of falls, incontinence, dehydration and delirium.
In addition, older adults often present atypically and not with classic symptoms of disease. A change in mental status or function may be the primary sign of an acute illness.
Older adults also may react differently to medication and some patients may be on 20 different drugs, added Gizaw H. Woldehiwot, M.D., a geriatrician at Levindale Hebrew Geriatric Center and Hospital in Baltimore.
“Unless individuals trained in geriatric medication [manage these cases], the patient ends up having so many complications,” Woldehiwot said. “But there are not enough of us. Treating elderly individuals is challenging.”
The American Geriatrics Society reports as of March 2011 there were 7,162 board certified geriatricians, one for every 2,620 Americans age 75 or older. It also indicated that the median salary for private-practice geriatricians was $183,523 in 2010, $5,879 less than a family physician's salary and $21,856 less than the average general internist.
“Moneywise, it’s not conducive,” Woldehiwot said. “General practitioners are not interested to be trained.”
Woldehiwot recommends including geriatrics in medical residency programs and changing reimbursement to compensate physicians for the additional time needs to assess an elder patient’s cognition and living arrangements in addition to medical issues. Geriatricians also must communicate and educate their patients’ families.
Gizaw H. Woldehiwot, M.D., recommends incentives for geriatricians.
“It takes a lot of encouragement and incentive for geriatricians to see this kind of patient,” Woldehiwot said.
Kim agreed that older patients take more time, saying patients often have multiple needs and co-morbidities.
“It’s more of a balancing process, because their needs are complex,” Kim said.
IOM recommended paying higher salaries and wages for geriatric specialists caring for older adults. But reimbursement remains a problem.
Despite those challenges, Kim said she is passionate about geriatrics and the relationships that develop with patients as she listens to their stories and helps address their needs.
“It’s a blessing and gratifying knowing I am helping assist them at the end of life,” Kim said. “It’s an honor.”
With people living longer, surgeons are more willing to operate on older adults for elective and emergent conditions, said Bernadette Henrichs, Ph.D., CRNA, CCRN, director of the nurse anesthesia program at Goldfarb School of Nursing at Barnes-Jewish College and a faculty member at Washington University in St. Louis, Mo.
“You have to treat each one as if they have not-so-healthy hearts, lungs, kidneys,” Henrich said. “They have a lot of co-morbidities, and I feel they are much more fragile.”
That requires giving fewer narcotics and induction agents. Any drugs that cross the blood–brain barrier, such as atropine, can result in confusion, which increases the risk of mortality in the months after surgery.
“We have to our best to prevent confusion post op,” Henrichs said.
During a procedure, a drop in blood pressure that a young body can typically withstand could cause a stroke or heart attack in an older adult, she said. She aims to keep blood pressure within 10 percent of the patient’s normal. She also recommends giving fluids in the pre-op holding area. Tachycardia can cause a myocardial infarction in the elderly.
“We have to be aggressive in treating the pressure and heart rate,” Henrichs said. “We have to try to keep the pressure close to where their pressure runs.”
“Healthcare professionals caring for aging adults need to understand age-related physiological changes, body system changes and changes that occur with cognition,” said Amy Cotton, MSN, GNP-BC, FNGNA, president of the National Gerontological Nursing Association (NGNA) in Lexington, Ky.
Oftentimes, older patients do not experience the typical signs and symptoms. For example, an older patient with hypoglycemia might just appear more confused rather than present with classic symptoms.
“It’s being able to see subtle differences,” Cotton said. “Geriatric assessment is important for health professionals.”
Nurses must remain attuned to changes that may occur and what they might represent, Blais added.
Yet, there are not a lot of nurses going into geriatrics, DiMaria-Ghalili said. Drexel and Florida International include a course in older adult care as part of their undergraduate programs, both at the end of their studies.
“We put it at the end from the perspective that older adults have complex, multiple-system health problems,” Blais said.
Drexel received the American Academy of Nursing’s (AAN’s) Geriatric Nursing Collaborative’s 2011 award, recognizing the college’s leadership in preparing the next generation of nurses in addressing older adults’ mental health needs. The American Association of Colleges of Nursing (AACN) and the Geriatric Institute of Nursing at NYU have outlined 19 geriatric baccalaureate competencies for nurses, DiMaria-Ghalili said.
Preparing more clinicians
Recognizing the need to prepare more people to care for older adults, the Health Resources and Services Administration (HRSA) provides some funding for Geriatric Education Centers, which provide education about care for the older adult to at least four disciplines including medicine. Intraprofessional programs provide 40 hours to 160 hours of continuing education. Each of the 45 recipients receive between $200,000 to $400,000. The centers also work with high school students to increase their interest in geriatric healthcare careers and educate policymakers about the need for more geriatric practitioners.
UCLA School of Nursing received a HRSA grant to introduce the “Caring for Older Adults Young Scholars” program to get students interested in caring for older adults and to pursue a doctoral degree. Students attend a gerontology-nurse interest group and view aging-related films at an assisted living facility and discuss the movies with residents. Eleven students in the school’s BSN and master’s entry program have completed the mentorship honors program and four recently entered it.
Cotton said NGNA’s members are committed to improving the quality of older persons’ healthcare in the settings where they work, which includes acute and long-term care, home care and clinics. Before NGNA’s annual conference, it offers educational programs, open to nonmembers, to learn about best practices regarding medications, assessments and interventions.
Nurses Improving Care for Healthsystem Elders (NICHE), a membership program of the Hartford Institute at the NYU College of Nursing, provides educational programs for nurses and other disciplines, including protocols and project management tools related to steering a geriatric program in a hospital. The more than 350 participating hospitals network and clinicians learn from each other. NICHE promotes the use of Acute Care for Elders (ACE) units and geriatric resource nurses.
The American Academy of Nursing’s two-year Building Academic Geriatric Nursing Capacity (BAGNC) Predoctoral Scholarship Program supports full-time doctoral education for nurses committed to careers in academic geriatric nursing.
“The goal of the program is to train the next generation of leaders in geriatric care,” said DiMaria-Ghalili. “With the changing demographics in the United States, all nurses need to be prepared to care for older adults.”