TERNOPIL STATE MEDICAL UNIVERSITY

INSTITUTE OF NURSING

INTERNATIONAL NURSING SCHOOL

 

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 Duke University, has two tools—Mental Health Screening Questions and the OARS Social Resource Scale. They establish baseline data on clients’ well-being, available economic and social resources, physical and mental health status, and capacity for self-care.

 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) St. Louis: Mosby.

Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2nd Edition) St. Louis: Mosby-Elsevier.

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.

Bell, V., & Troxel, D. (2001). The Best Friends staff: Building a culture of care in Alzheimer’s programs. Baltimore: Health Professions Press.

Burbank, P.M. & Riebe, D. (2002). Promoting exercise and behavior change in older adults: Interventions with the transtheoretical model. New York: Springer.

Cicirelli, V.G. (2002). Older adults’ views on death. New York: Springer.

Ebersole, P., & Hess, P. (2004). Toward healthy aging (6th ed.). St. Louis: Mosby.

 

WEB SITES on Aging

American Diabetes Association, Facts and Figures: http://www.diabetes.org

Assisted Living Federation of America http://www.alfa.org

National Institute on Aging. http://www.nia.nih.gov