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FEATURES: A New Look at the OLD: CE

The Challenge to Come: The Care of Older Adults: The senior boom is on its way, and with it comes new demands on clinicians. A new AJN series asks: are nurses ready?

Stotts, Nancy A. EdD, RN, FAAN; Deitrich, Carole E. MS, GNP, RN

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Nancy A. Stotts is a professor and Carole E. Deitrich is a clinical professor in the Department of Physiological Nursing at the University of California, San Francisco. This article is a first in a series that is supported in part by a grant from the Atlantic Philanthropies to the Gerontological Society of America (see Nursing Resources, page 28 ). Ms. Stotts (nancy.stotts@nursing.ucsf.edu) and Ms. Deitrich (carole.deitrich@nursing.ucsf.edu) are the series editors. The authors of this article have no significant ties, financial or otherwise, to any company that might have an interest in this educational activity.

PLACING THE PAN OF HOT MANICOTTI in the middle of her kitchen table, Marie Caputo takes a seat across from her granddaughter. “Okay, you eat now,” she demands, her Brooklyn pedigree evident in her brusque delivery. She’s wearing a dress she made on a recent visit to relatives in North Carolina; its pale-blue-and-white flowers set off the silver in her white hair.

The small patch of basal-cell carcinoma on her nose has healed (she had refused to return to the “rough” physician but allowed the “gentle” one to remove it). Relatively healthy for a 95-year-old, she finds getting around to be her greatest difficulty, but she’s motivated to stay mobile.

“It’s lonely living here all alone,” she says to her granddaughter. “I got old, and now I want someone to talk to.”

Yet when her granddaughter asks whether she’d like a live-in assistant, Ms. Caputo shakes her head in astonishment. “What do I need with that?” she asks. “I’m fine.” Remembering her small, frail grandmother’s determination over the years—watching her feed quarters into Atlantic City slot machines for hours on end, for example—her granddaughter drops the matter. Such is the dilemma of many adults caring for their elderly loved ones.

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AN AGING SOCIETY

A child born in 1900 had a life expectancy of just 47 years. 1 But now that the average American lives 77.2 years, largely because of improved sanitation and the control of communicable and infectious diseases, people like Ms. Caputo—Americans 65 years of age and older, whom we refer to collectively as “older adults”—are no longer an insignificant minority in the United States. The population is aging, no matter what cosmetic creams or procedures Americans pursue to retain the image of youth.

In 2002, 35.6 million people in the United States were ages 65 and older. 1 By 2030 that number is expected reach 71.5 million. At 13% of the total U.S. population, older Americans already account for 49% of all days of hospital care and 50% of all physician hours. 2 And the number and severity of disabilities increase with age. According to the Alliance for Aging Research, “the average 75-year-old has three chronic conditions and regularly uses about five prescription drugs, as well as multiple over-the-counter remedies.” In 2002 more than half of older adults reported at least one disability. By the time they reach age 80, three out of four older adults have a disabling condition. Commonly occurring conditions include hypertension, arthritis, heart disease, cancer, sinusitis, and diabetes. 1 (See Figure 1, above.)

FIGURE. Gerald Gross...
FIGURE. Gerald Gross...
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Figure 1
Figure 1
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In a plea to U.S. health care providers, the alliance has urged “good geriatric health care techniques,” 2 but the question remains: are nurses prepared to face the coming senior boom?

In an effort to help nurses answer that question, AJN has formed a partnership with the Gerontological Society of America to present “A New Look at the Old,” a new bimonthly series. Most nurses, whether they work in geriatrics or in pediatrics, on a medical–surgical unit or in an ICU, work with older adults. The articles in this series will focus on specific aspects of care, challenging nurses’ misconceptions and illuminating aspects of care, including the following:

* older adults’ presenting symptoms, which are often different from those of younger adults

* polypharmacy

* cognitive impairment

* immobility

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A SOCIAL CONTEXT

Early in the 20th century, those who escaped the vicissitudes of infectious disease and grew old usually died at home. The poor and those with no home or family went to “poor farms,” or almshouses. Such “old-age assistance,” as it was called, was largely a local matter. In 1935 this changed with the establishment of the Social Security Act, which provided federal funding for the elderly, disabled, and poor. This legislation significantly enhanced the resources older adults had to meet their basic needs.

By 1961, 15 million Americans were older than 65 and a person’s life expectancy was “moving beyond the 70 year mark,” and it was at this time that the issue of aging secured a place in the national consciousness. 3 The first White House Conference on Aging, a four-day event in January 1961, focused on health care. More than 3,000 people attended; topics discussed included the “Rehabilitation of Disabled Middle-Aged and Older People” and the “Role and Training of Professional Personnel.” 4, 5 Nursing care warranted special discussion: for example, it was recommended that nurses be given specific training in the rehabilitation of nursing home residents, and emphasis was placed on the importance of specialized training in geriatrics.

Lifestyles of people over 65 were also addressed. One paper noted that “a growing number of our elder citizens are contributing to a better image of what the later years can be,” concluding, “old age can be a personally rewarding and socially fruitful experience.” 3 One conference attendee created her legacy by fighting for, and embodying, exactly that point: Maggie Kuhn, 54, who attended as an observer with her church, went on to start the Gray Panthers, an activist group representing older Americans in the 1970s and beyond (she was forced to retire at age 65). Kuhn later credited her experience at the conference with her “interest in the problems of the aged.” 6

Passage of the Medicare and Medicaid laws in 1965 drastically altered health care for older Americans. As the results of a study for the Senate Committee on Aging were reported in 1964, “only two-fifths of the insured aged [had] policies which [would] cover three-fourths of the hospital bill.” Those unable to afford insurance relied on family or on state and local programs, charities, and hospitals. 7 With the addition of Medicare and Medicaid to the Social Security Act, people over 65—even poor Americans—could be ensured access to health care. And the government’s commitment to meeting the needs of older adults grew that year with the creation of the Older Americans Act of 1965. Upon signing the bill, President Lyndon Johnson said that it “clearly affirms our nation’s sense of responsibility toward the well-being of all of our older citizens.” 8 The Older Americans Act established the Administration on Aging, the first federal resource dedicated solely to the needs of older adults. It also established local centers that would provide older adults with food, employment, and transportation services. Quietly, responsibility for the care of older adults was shifting from the family to the federal government.

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FIGURE. Francis Aust...
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In the 1970s, as activism rocked the nation, the Gray Panthers emerged as a major political force, joining people of all ages in many different fights, from the struggle for peace in Vietnam to getting people to view “health care as a human right.” Kuhn’s belief that “well-aimed slingshots can topple giants” fueled the organization’s campaigns, bringing the issues of all Americans—and the voices of older adults—to the forefront of national awareness. 6 (See www.graypanthers.org.) And from these efforts grew new organizations focused on specific aspects of aging. The National Citizens’ Coalition for Nursing Home Reform, founded in 1975 by Elma Holder (a member of the Gray Panthers’ Long Term Care Action Project), became one of the nation’s strongest advocates for nursing home residents, eventually helping to pass the Nursing Home Reform Act, part of the 1987 Omnibus Reconciliation Act. 9

The federal government furthered its commitment to older Americans by forming the Nutrition Services Incentive in 1972 and authorizing the National Institute on Aging in 1974.

Nurses were also participating in the dialogue. Most notable was Irene Mortenson Burnside, PhD, RN, FAAN, a geropsychiatric nurse and author of one of the first textbooks on geriatric nursing, Psychosocial Nursing Care of the Aged, published in 1973. Burnside, who died in 2003, is credited with helping to make geriatric nursing a nursing specialty. She wrote and spoke extensively, believing that, “the psychosocial care of the elderly in the United States needs improvement.” 10, 11

In 1983 Medicare’s prospective payment system established billing categories and set costs for in-patient hospital services. In an effort to cut costs, hospitals shortened stays and discharged patients at higher levels of acuity than before. Today the trend continues. In 2004 many frail older adults are being cared for at home—as they were in the early 20th century. The difference now is that family members must operate technologically complex equipment, administer IV drugs, and change complicated dressings.

Want to discuss what you’ve read in this article or other issues related to nurses caring for older adults? Go to www.nursingcenter.com/ajnolderadults to participate in a discussion forum with the series authors and editors.

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THE OLDEST OLD

At 90 years of age, Jeanne Calment of Arles, France, made a deal with her attorney: he’d pay her $500 a month until her death, whereupon he’d inherit her apartment. 12 Thirty years later, the attorney died at age 77. Calment lived another two years, and at the time of her death at age 122, she had lived longer than any person in recorded history.

That deal was made in 1965. Today her lawyer might have had second thoughts, if he’d been paying attention to recent U.S. statistics. According to the New England Centenarian study, “centenarians are the fastest growing segment of our population,” followed by those older than age 85. 13 In fact, by 2002, 4.6 million adults 85 years of age and older, a group known as the “oldest old,” lived in the United States. By 2030 this number is expected to grow to 9.6 million. 1 Ninety percent of the study participants “were functionally independent the vast majority of their lives up until [an] average age of 92 years,” but in general, the need for health care corresponds to age: while 5% of 65-year-olds need long-term care, 50% of those who reach age 90 are in need of it. 2

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Long-term care.

In the United States, there are approximately 1.6 million nursing home residents. 1 A closer look at the statistics reveals that in 2000 only about 4.5% of older adults were residents of nursing homes. Yet the proportion requiring institutionalization increases markedly with age. Only 1.1% of 65-to-74-year-olds are institutionalized, while 4.7% of 75-to-84-year-olds and 18.2% of those who’re 85 and older are in need of long-term care.

Despite these statistics, we may not see the expected upsurge in the nursing home population in coming years. As gerontologist Robert Butler is quoted by AARP, “For the first time in human history, the prospect of living a long, healthy, and prosperous life has become a reality for the majority of people . . . What was the privilege of the few has become the destiny of many.” 14 It’s possible that the upcoming older generation will have better health and that age-related decline will be slowed, thereby reducing the proportion of people in nursing homes. And today’s growing emphasis on community-based care may lead to additional decreases in the number of people living in nursing homes.

Nevertheless, there already are too few professionals prepared to care for older adults. For example, the Alliance for Aging Research estimates that 2,400 academicians who teach geriatrics are necessary in the United States to train new providers, “integrate geriatrics into medical practice, and develop standards of care for older people.” 2 As of 2002 there were fewer than 600 academicians in the field.

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IMPLICATIONS FOR NURSING

In The Nursing of the Elderly Sick: A Practical Handbook of Geriatric Nursing, published in 1953, T. N. Rudd wrote of his patients, “No longer are we dealing with individuals before whom life is opening as a flower, nor with those who are producers of bread for their families. Bread-winning days are now passed, the sun is folding in its rays and the days of diminishing significance are upon them.” 15 Fifty years later the perception of aging has changed, and there is a greater emphasis on diet, exercise, and the treatment of chronic disease. Nonetheless, many still equate growing older with cognitive decline, physical and psychological frailty, and diminishing motor skills. 16 As a result, the care given to older adults is often less aggressive than that given to others. The Alliance for Aging Research, for example, notes a “tendency for physicians to underprescribe blood thinners, β-blockers, [angiotensin-converting enzyme] inhibitors, and other cardiovascular drugs to older patients after coronary incidents.” 2

When disease does strike older adults, the effects can be more debilitating than in younger adults. In addition, presentation may be different (for example, sepsis may not be accompanied by fever), so it’s important to anticipate subtle signs and symptoms. Finally, the care of older adults requires knowledge of both physiologic and psychosocial phenomena; the loss of independence that results from physical decline can have adverse psychological consequences, such as depression, and social isolation can accompany role changes such as those brought about by retirement or widowhood. The American Psychiatric Association notes that adults over 65 have the highest suicide rate in the country. (For more information go to www.psych.org/public_info/elderly.cfm.) Appropriate support can facilitate a more positive response to these changes.

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The field of geriatric nursing.
FIGURE. Two bathers ...
FIGURE. Two bathers ...
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With just 63 training programs in the United States, the number of certified advanced practice geriatric nurses is small; in 2002 approximately 4,200 nurses had been certified in geriatric care since 1991. 17 In the fall of 2003, very few people were enrolled full time in programs to become certified gerontologic nurse specialists. 18 Given the low number of trained professionals and the growing population of older adults, it’s likely that advanced practice nurses specializing in adult or family practice are caring for many older adults. 17

Nevertheless, the field has grown significantly since 1950, when Geriatric Nursing, the first American textbook on nursing care of older adults, was published. It received a major boost in 1966 when the ANA established the geriatric nursing division (a title changed 10 years later to “gerontological nursing” to reflect a broader approach, concerned with “health maintenance, illness prevention, illness management, and quality-of-life promotion”). 19 The field was further augmented that year as Duke University implemented a program to prepare clinical nurse specialists in geriatrics. Nursing certification in gerontology became possible in 1975.

Since then, three initiatives have changed the face of geriatric nursing. In 1980 the W. K. Kellogg Foundation provided funding to nursing schools for the preparation of geriatric nurse practitioners. From 1982 to 1987 the Robert Wood Johnson Foundation funded the Teaching Nursing Home Program to demonstrate that affiliations between nursing homes and university nursing schools could improve patient care and help to contain costs. And starting in 1996, the John A. Hartford Foundation made possible the Hartford Institute for Geriatric Nursing at New York University, which was created to promote education, good practice, research, policy, and consumer education related to geriatric nursing. These programs have both improved geriatric nursing education and increased awareness of the benefits of this specialization. In addition, as a result of research generated by these programs into best care practices, many patients now experience improved clinical outcomes and reduced care costs.

While further work is needed, much has been done to develop the scientific basis for geriatric nursing. Over the last few decades, research has identified conditions commonly seen in older adults, as well as needs and problems specific to that population. Current research addresses broad topics such as family caregiving, functional status, exercise, depression, dementia, delirium, mental health, and elder abuse, as well as specific conditions, such as incontinence, pressure ulcers, and hypertension.

Complete the CE test for this article by using the mail-in form available in this issue or visit NursingCenter.com’s “CE Connection” to take the test and find other CE activities and “My CE Planner.”

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REFERENCES

1. U.S. Department of Health and Human Services, Administration on Aging. Profile of older Americans. 2003. http://www.aoa.gov/prof/Statistics/profile/2003/2003profile.pdf.

2. Alliance for Aging Research. Medical never-never land. 2002. http://www.agingresearch.org/brochures/nevernever/nevernever.pdf.

3. Planning Committee on Education for Aging, White House Conference on Aging. Background paper on education for aging. Washington, DC: U.S. Government Printing Office; 1961:2–3.

4. Planning Committee on Rehabilitation, White House Conference on Aging. Background paper on rehabilitation. Washington, DC: U.S. Government Printing Office; 1961.

5. Planning Committee on the Role and Training of Professional Personnel, White House Conference on Aging. Background paper on the role and training of professional personnel. Washington, DC: U.S. Government Printing Office; 1961. p. 104–10.

6. Maggie Kuhn: founder of Gray Panthers. 2002. http://mtmt.essortment.com/maggiekuhn_rfxw.htm.

7. U.S. Congress. Material submitted for the published record of the hearing. In:Medical care for the aged. Washington, DC; 1964.

8. U.S. Department of Health and Human Services, Administration on Aging. A layman’s guide to the Older Americans Act. 2004. http://www.aoa.gov/about/legbudg/oaa/laymans_guide/laymans_guide.asp.

9. National Citizens’ Coalition for Nursing Home Reform. History at a glance. 2004. http://www.nccnhr.org/public/50_541_1953.cfm.

10. Ebersole P. Irene Mortenson Burnside: her light shines on. Geriatr Nurs 2003;24(4):232–5.

11. Burnside I. Working with the elderly. Group processes and techniques. North Scituate, MA: Duxbury Press; 1978. p. 3.

12. AARP. Posing questions, finding answers. In:Aging under the microscope. 2002. http://www.niapublications.org/pubs/microscope/chapter1.pdf.

13. Boston University School of Medicine. A look at centenarians. 2004. http://www.bumc.bu.edu/Departments/PageMain.asp?Page=5749&DepartmentID=361.

14. AARP. The future of aging. In:Aging under the microscope. 2002. http://www.niapublications.org/pubs/microscope/chapter5.pdf.

15. Rudd T. The nursing of the elderly sick. London: Faber and Faber, Ltd; 1953. p. 12.

16. Palmore E. Ageism in gerontological language. Gerontologist. 2000;40(6):645.

17. Mezey M, Fulmer T. The future history of gerontological nursing. J Gerontol A Biol Sci Med Sci 2002;57(7): M438–41.

18. American Association of Colleges of Nursing. 2003–2004 enrollment and graduations in baccalaureate and graduate programs in nursing. 2004.

19. Elipoulos C. A guide to the nursing of the aging. Baltimore, MD: Williams and Wilkins; 1987. p. 3–4.

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