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Being Sensitive to Seniors' Needs

Monday May 17, 2004
Olivia Durchsprung, program coordinator for Lawrence Park Adult Day Services in Broomall, PA, leads a word game for a group of patients. The answer to the puzzle pictured is
Olivia Durchsprung, program coordinator for Lawrence Park Adult Day Services in Broomall, PA, leads a word game for a group of patients. The answer to the puzzle pictured is "don't overreact."
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Nurses can best serve elderly patients - and their caregivers - by administering age-appropriate care to help patients in this age group maintain wellness and a good quality of life.

US Census Bureau figures from 2000 show that more than 3.1 million people 65 and older live in Pennsylvania, Delaware and New Jersey. In fact, Pennsylvania ranks No. 2 behind Florida as having the highest percent of its population in this age group. Almost 40% of the civilian, noninstitutionalized seniors in these three states have a disability.
Appropriate nursing interventions, geared to the specific needs of this age group, can help maintain quality of life and maximize wellness. Helping the elderly remain independent longer promotes these goals and relieves some of the burden on caregivers. Nurses are an integral part of the multidisciplinary teams that exist to offer support to the elderly - and their caregivers.
Adult Day Services
After the passage of the Older Americans Act in 1965, the federal government created a funding stream for adult day services. Main Line Health Adult Day Services was created about 20 years after this legislation was passed, says Karen E. Reever, director of Community Senior Health for Main Line Health, part of Jefferson Health System. The program includes three adult day facilities, among them, Lawrence Park Adult Day Services in Broomall, PA.
"The goal [of adult day services] is to keep the patient in the home," Reever says. Both the patients and their caregivers benefit from the services the facility provides.
Julie Hochreiter, RNC, BS, director of the Lawrence Park facility, notes that by offering support and financial counseling to caregivers, Main Line Health enables elderly patients to remain at home with their families for as long as possible.
Lawrence Park cares for 40 to 50 clients on a single day. Hochreiter says clients fall into one of three groups - cognitively intact but physically impaired, early to moderate dementia, and advanced dementia and/or very frail elderly. As the director and only nurse there, Hochreiter monitors medical conditions, performs treatments, administers medications, and oversees the staff providing care.
Each client receives an individual approach. Upon enrollment, a team assesses the patient and draws up a care plan, taking into account nutrition, a physical and behavioral assessment, and seven instrumental activities of daily living. "When you've seen one Alzheimer's patient, you've only seen one," says Hochreiter, emphasizing her philosophy of individual care.
Clients are kept busy during their time at Lawrence Park. There is no TV time, and napping is discouraged, Hochreiter says. Instead, the patients are engaged in exercise, music, and games. Some Montessori techniques - best known for their applications in early childhood education - are used to encourage interaction between clients. "Patients too impaired to have relationships on their own now have relationships outside their home," says Reever.
For caregivers, Main Line Health Day Services provide access to information and counseling, says Reever. Family service directors, who are social workers, help caregivers who are struggling with whether to enroll an elderly family member in the program. Paying the $54-per-day cost is an issue for some caregivers, and the family service directors help determine whether financial aid is available through agencies such as the County Area Agency on Aging, the Veterans Administration, or long-term care insurance.
Reever says research has already demonstrated that adult day services reduce caregiver burden.1 Main Line Health received a research grant to further this work from the recently reauthorized Older Americans Act's National Family Caregiver Support Program, which provides funding for demonstration projects that study whether adding services geared to family members reduces that burden even more.
Health System-Based Support
With more than half its hospital admissions age 65 and older, Christiana Care Health System, Wilmington, DE, knew it had to address the special needs of its elderly patients. Thus, We Improve Senior Health - or WISH - was born.
WISH began as an inservice training program to sensitize nurses from a few select facilties in the health system to the needs of elderly patients. In particular, the program targets needs associated with falls, depression, skin breakdown, problem weight loss, delirium, sleep disorders, incontinence, and medication management. The 30 nurses who received the training took their new knowledge back to their units and became the experts on elderly patient care in their departments. Now, two-and-a-half years later, more than 300 nurses, therapists, home health aides, patient care technicians, and other health-care workers from across the Christiana Care system have gone through the WISH program, says Denise L. Lyons, RN, MSN, APRN, BC, geriatric clinical nurse specialist, and WISH program coordinator.
The success of WISH can be measured both in terms of less and more. The staff reports decreases in polypharmacy, drug reactions, and the need for catheters and incontinence products. Not only are the patients happier, but Lyons says staff morale also has increased. Employees have stopped Lyons as she makes rounds and shared their experiences with WISH methodology - "I got that Foley removed" or "The [medication] was discontinued," they'll say.
Aime Hastings, RN, MSN, is the patient care coordinator for a 41-bed medical unit at Christiana Hospital, Wilmington, DE, where a large number of the patients are over 65. She found that going through the WISH program made her even more sensitive to her patients. For example, now she looks at why a patient might be delirious rather than just treating the delirium. She's now aware that the need to urinate at night might be the cause of falls, which can be addressed by simply changing the timing of a patient's diuretic.
Hastings also notes that having a team that specializes in the elderly population helps identify problems more quickly. For example, polypharmacy might explain a change in mental status. "[Having the WISH team] causes better outcomes at discharge," Hastings says. "People come in expecting to be placed often can go home with family and home health support."
Recognizing Warning Signs at Home
About two years ago, a multidisciplinary leadership group at Holy Redeemer Health System, based in Meadowbrook, PA, was discussing the value of home care and what the system could do for patients. Toni M. Hague, RN, vice president of Home Care and Hospice Services, challenged the clinical leaders to do something different to improve safety and quality of life for their home care patients. "We looked at patients who were quite elderly and have acute illness, and the issues that contribute to it," she says.
Out of those conversations came Life Assess, a multidisciplinary program allowing at-risk seniors to continue living safely and comfortably in their homes. This innovative program proved so outstanding that Holy Redeemer was awarded the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Gold Standard of Healthcare Quality for Disease Specific Certification.
Staff from Holy Redeemer's two home health agencies, Holy Redeemer Home Care and Hospice Services (in PA) and Holy Redeemer Visiting Nurse Agency (in NJ), came up with four conditions commonly found in patients 85 and older who live at home. These "geriatric syndromes" are depression, dementia, falls risk, and urinary incontinence. A two-page tool used during the admission process enables staff to evaluate each patient and intervene as needed.
Preliminary results show improvement in patient care since Life Assess was implemented. For example, the NJ division went six months without a patient fall that required hospitalization. In one case, a patient was not progressing well with physical therapy. The screening was positive for depression, and the physician ordered medication. After this, the patient was able to participate in therapy and even return to the local senior center. Another patient, 89 years old, screened positive for depression, but brushed aside offers of mental health assistance. Four months later, she told her home health clinician that she had seen a psychiatrist, motivated to do so by questions asked by the Holy Redeemer screening process.
Bob Heineman, director of Rehabilitation, Home Care and Hospice Services, was instrumental in the development of the Life Assess program. Heineman cites multiple beneficiaries of the program: It's enriching for the clinicians who gave birth to the project, the elderly who realize they don't have to be depressed or incontinent, and the healthcare team that experiences improved communication and more successful recruitment throughout the staff.
Interventions such as these programs improve the quality of life for the elderly and their caregivers. What's more, nurses' sensitivity to the special needs of the older patient population can help keep more seniors safe - and healthy - longer.