Approaches to Older Adult Care
Objectives:
§
Geriatrics and
Gerontology.
§
Case Management
and Needs Assessment.
§
Techniques or
tools available to assess the needs of older adults.
In general, nursing service to
seniors can be divided into two approaches: geriatrics and gerontology. In
addition, healthy older adults can be effectively cared for in the community
through case management approaches.
Geriatrics and Gerontology
Geriatrics is the medical
specialty that deals with the physiology of aging and with the diagnosis and
treatment of diseases affecting the aged. Geriatrics focuses on abnormal
conditions and the treatment of those conditions, and geriatric nursing in the
past has focused primarily on the sick aged.
Gerontology refers to the
study of all aspects of the aging process, including economic, social,
clinical, and psychological factors, and their effects on the older adult and
on society. Gerontology is a broad, multidisciplinary practice, and gerontologic nursing concentrates on promoting the health
and maximum functioning of older adults (Eliopoulos, 2001).
Community
health nurses work with many older people. In one instance, the nurse works to
promote and maintain the health of a vigorous 80-year-old man who lives alone
in his home. As another example, the nurse gives postsurgical
care at home to a 69-year-old woman, teaches her husband how to care for her,
and helps them contact community resources for shopping, meals, housekeeping,
and transportation services. Perhaps nursing intervention focuses on teaching
nutrition and maintaining a healthful lifestyle in an extended family that
includes a 73-year-old grandmother. The nurse may also lead a bereavement support
group for senior citizens whose spouses have recently died.
A
community health nurse works with older adults at the individual, family, and
group levels. However, a community health perspective must also concern itself
with the aggregate of older adults. There are many groups composed of seniors,
such as those who attend an adult day care center, belong to a retirement
community, live in a nursing home, or use Meals on Wheels. Other groups include
residents of a senior citizens’ apartment building, retired
business and professional women, older postcataract-surgery
patients at risk for glaucoma, the older poor, AD sufferers, and the homeless
elderly.
Case Management and Needs Assessment
The
case management concept involves assessing needs, planning and organizing
services, and monitoring responses to care throughout the length of the caregiving process, condition, or illness. This concept,
which has been practiced by community health nurses for many years, focuses
primarily on the health needs of clients. Social workers use case management to
address their clients’ social needs, including their financial problems. Some
HMOs provide a coordinated system of services for their enrolled clients.
However, many communities provide no such advocate for their older residents,
and a more comprehensive, community-wide system is needed to serve the entire
older population. Such a system might be based on an agency specifically
designed to serve as case manager or “agent,” to assess clients’ needs and
assemble existing agencies and services to meet those needs.
Various techniques or tools are
available to assess the needs of older adults:
The
Older Americans Resources and Services Information System (OARS), developed by
• Clients’
capacity for self-care is assessed by the Capacity for Self-Care Index, which
ascertains clients’ ability to go outdoors, climb stairs, move about their
homes, bathe, dress, and cut their toenails.
• The Barthel Index assesses functional independence.
• The Katz
Index of Activities of Daily Living is based on an evaluation of the functional
independence or dependence of clients with respect to bathing, dressing,
toileting, and related tasks.
• The
Instrumental Activities of Daily Living Scale looks at an older adult’s ability
to perform such activities as using the telephone, shopping, doing laundry, and
handling finances.
• Other
techniques, such as the Ability to Perform Work-Related Activities survey,
determine an elderly person’s physical, psychological, and social needs. A
frequently overlooked area of assessment is an elderly client’s spiritual needs
(Moberg, 2001). Religious dedication and spiritual
concern often increase in later years. Limited ability or lack of
transportation may prevent older people from attending religious services or
engaging in spiritually enhancing activities. Self-health ratings, including
clients’ reports on their spiritual needs, provide another useful assessment
technique. A tool to assess a client’s self-care practices is on Fig. 23-8 ↓.
Age-friendly PHC centres toolkit.
1.Health services for the aged -
organization and administration. 2.Primary health
care. 3.Community health centers
- organization and administration. I.World Health Organization. II.Title:
Age-friendly primary health care centres.
ISBN
978 92 4 159648 0 (NLM classification: WT 31)
©
World Health Organization 2008
Version for the Web Age-friendly
PHC centres toolkit.
Background of the Age-friendly PHC Centres Toolkit
The toolkit builds upon the concepts and principles of
the WHO’s Active Ageing Policy Framework, published in 2002 on the occasion of the Second World
Assembly on Ageing in Madrid (1). The Active Ageing Policy Framework calls on
policy-makers, governments, and the non-governmental sector to optimize
opportunities for health, participation and security in order to enhance the
quality of life of people as they age.
The framework recognizes that active and healthy ageing
depends on a variety of determinants that surround individuals throughout the
life course:
_ Cross-cutting determinants: culture and gender
_ Determinants related to health and social service
systems e.g. health promotion and disease prevention.
_ Behavioural determinants e.g.
tobacco use and physical activity.
_ Determinants related to personal factors e.g.
biological and psychological factors.
_ Determinants related to the physical environment
e.g. safe housing and falls.
_ Economic determinants e.g. income and social
protection
These determinants and the interplay between them are
good predictors of how well individuals age; they cope with illness and
disability; or remain active contributors of their community.
The World Health Organization (WHO) has recognized the
critical role that primary health centres play in the health of older persons
in all countries and the need for these centres to be accessible and adapted to
the needs of older populations. Consequently, all primary health care workers
should be well versed in the diagnosis and management of the chronic diseases
and the so-called four giants of geriatrics: memory loss, urinary incontinence,
depression and falls/immobility that often impact people as they age.
Objectives
The toolkit aims at:
_ Improving the primary
health care response for older persons.
_ Sensitizing and educating
primary health care workers about the specific needs of their older clients.
_ Assisting primary health workers in how to operate
the geriatric care instruments/tools
contained in the toolkit.
_ Raising awareness of the
accumulation of disabilities – both minor and major –experienced by older
people to primary health workers.
_ Providing guidance on how
to make primary health care management procedures more responsive to the needs
of older people.
_ Providing guidance on how
to do environmental audits to test primary health care centres for their
age-friendliness.
Methods
The toolkit comprises a number of tools (evaluation
forms, slides, figures, graphs, diagrams, scale tables, country guidelines,
exam sheets, screening tools, cards, checklists, etc) that can be used by
primary health care workers to assess older persons' health. The four geriatric
giants were the focus of the toolkit development. A literature research for
instruments on these four subjects was done and studies on reliability and validity
of questions common to all instruments were consulted.
Clinical
assessment and key management approaches for the four geriatric giants
* The organized clinical approach is an efficient way
to identify, assess and manage patient care. The clinical approach as
illustrated in the flowchart following further is a stepwise flow from the
10-minute comprehensive screening through identification of health problems;
assessment; management and follow-up.
* Patients who come to the PHC centre for health care
will be screened by a trained community health aid in the waiting room (Step
1).
* If the screening is positive for any of the four
geriatric giants, steps 2, 3 and 4 as specified below will be followed.
* If a nutritional problem is identified, the patient
should be referred to the doctor.
* If a hearing or vision problem is identified, the
patient should be referred to the doctor for an appropriate action.
The organized clinical process consists of the
following four steps:
Step 1: 10-minute comprehensive screening (Tool 1)
* Should be done by a member of the PHC centre while
the patient is waiting to see the doctor and included in the medical record.
* Try to provide privacy for the patient as much as
possible.
TOOL 1.
Step
2: Geriatric giants assessment
_ Assessment by doctors using questionnaire and
physical examination.
_
Where there are multiple conditions, the doctor needs
to prioritize assessment and decide which condition to work up in the first
visit and schedule subsequent visits for other conditions. The following order
is suggested:
1. Memory
loss
2.
Depression
3.
Urinary Incontinence
4.
Falls/immobility
Step
3: Diagnosis, treatment and education
_ Establish diagnosis.
_ Plan pharmacological and non pharmacological
management strategies.
_
Counsel patients and family/caregivers on appropriate
targets for reducing risk, including education. This can be done by nurse or a
community health worker.
_
Refer to appropriate services when needed.
Step
4: Follow-up
_ Assess response and effectiveness of treatment.
_
Change clinical management as necessary.
_
If needed, discuss referral for specialty evaluation
and management.
Readings
Allender, J.
A., Spradley, B.W. (2001). Community Health Nursing: Concepts and
Practice (5th edition). Lippincott Williams & Wilkins; 5th edition (January 15, 2001). 799 pages. ISBN-13: 978-0781721226. Chapter 30, Pp. 719-726.
Stanhope, M.,
& Lancaster, J. (2000). Community and Public Health
Nursing (5th Edition)
Stanhope, M.,
& Lancaster, J. (2006). Foundations of Nursing in the
Community: Community-Oriented Practice (2nd Edition)
Allender, J.
A., Spradley, B.W. (2004). Community Health Nursing: Promoting and
Protecting the Public's Health (6th Edition) Lippincott
Williams & Wilkins, 2004. – 992 p.
Additional
readings:
Age-friendly Primary Health Care Centres TOOLKIT // World Health Organization, 2008.
Cicirelli,
V.G. (2002). Older adults’ views on death.
Ebersole, P.,
& Hess, P. (2004). Toward healthy aging (6th ed.).
WEB SITES on Aging
American Diabetes Association,
Facts and Figures: http://www.diabetes.org
Assisted Living Federation of
National
Institute on Aging. http://www.nia.nih.gov