A century ago, extended families usually took care of their elderly at home. Since then, families have grown smaller and more dispersed, and the elderly have gotten older. The average lifespan of adults today is 83, which is 18 years longer than in 1908, according to the National Institute on Aging.
While research, antibiotics and life-saving technology have extended the average American lifespan, fattier diets, sedentary lifestyles and the natural effects of aging are creating more health challenges for today’s elderly. A growing population of older and sicker patients is spurring a greater demand for nurses, therapists and clinicians with expertise and training in geriatric care.
At Wesley Woods Geriatric Hospital of Emory Healthcare, most of the patients are older than 65. The facility treats patients recovering from intensive care units, as well those with chronic conditions such as diabetes, pulmonary or heart diseases, and neurological and psychological conditions like dementia.
“We use a multidisciplinary team approach,” said Betty Mace, RN-BC, MSN/MHA, director of nursing administration at Wesley Woods. “Our nurses, physicians, physical therapists, occupational therapists, speech pathologists, social workers, pharmacists and dieticians round on their patients daily. They put their heads together to provide the best care.
“We focus on trying to be a restraint-free environment and our staff needs to know how to distinguish between dementia, delirium and depression.”
Caring for the elderly is challenging. Sometimes it requires ingenuity to distract a confused patient who wants to take out an IV line. It also requires understanding malnutrition and dehydration issues, reinforcing oral hygiene, regulating pain management and treating delicate skin wounds.
Other important elements of geriatric care include physical and occupational therapy to increase strength and mobility, and an emphasis on patient safety, since falls and breaks are more likely in this population. Educating and supporting families is a large part of the job, as well.
“Working with the elderly takes passion, compassion, patience and excellent clinical judgment, but these patients have so much wisdom to share with us,” Mace said.
At Wesley Woods, preceptors help new nurses learn the ropes. The hospital offers an annual gerontology review course for those who want to become geriatric- certified and a yearly dementia workshop to update employees about the latest research.
“We have to stay up on everything, because the field is changing so quickly,” she said.
Despite the challenges, the rewards are gratifying, Mace said.
“Seeing patients get better and sending them home with a better quality of life, that’s such a feeling of accomplishment,” she said.
Helping seniors live well at home is the mission of home health agencies like Camellia Home Health and Hospice. Home care presents different challenges, but Gladys Paul, director of nursing for Camellia's Lawrenceville location, can't imagine doing anything else.
Paul, who started her home health nursing career in New York City’s housing projects in 1990, likes her patients and the autonomy of practice.
“It’s just you and the patient. You have to be smart and establish a rapport, because you are in their home,” said Paul, RN, BSN, MBA.
When Paul started working in the field, there was more time to visit with patients, but an increase in paperwork, government regulations and the complexity of cases have made the pace more intense.
“There’s a rise in demand for home health services, but it can be hard attracting workers. Not everyone wants to deal with the driving or the many responsibilities,” she said.
Clinicians treat patients who have been released from the hospital sooner than in past years, and they often have multiple diagnoses.
“They may come home the day after an operation and we must be there to provide care, therapy and education for them and their families,” Paul said.
Camellia’s team includes physicians, nurses, aids, social workers, hospice staff and physical, occupational and speech therapists.
“Every visit has to be justified. You must know your purpose before going and document everything you did carefully for reimbursement,” Paul said. “Any change in condition must be reported to a physician, but it can sometimes take hours to get a change in orders. The work day can sometimes seem never-ending.
“But the bottom line is that we’re responsible for our patents, so we look at them and their situations as a whole.”
Clinicians have to know about disease states and aging issues, but they also must be well-versed on finances, household safety, nutrition and adequate caretaking. Family dynamics, education and support are a large part of home health care, especially when dementia is a factor.
Learning is a constant for geriatric home health care workers.
“We train them on different disease specific models, but the care must be patient-specific,” she said.
They also must learn to relate to patients from different socio-economic and educational backgrounds.
“You can’t assume someone understands just because he nods,” Paul said. “You may have to use pictures or hands-on demonstrations.”
Therapy and rehab
At Heritage Healthcare, providing compassionate care to the elderly is never just about rehabilitation and therapy. It's also about listening, communicating and problem solving, said Kendra Guthrie, area manager for the rehab management provider that specializes in contract rehabilitative services and post-acute nursing care.
Guthrie, DPT, supervises other therapists who provide rehabilitation therapy at 15 Georgia assisted living and nursing care facilities. She chose her career path after coming into contact with geriatric patients when she moved to Orlando after graduating from college.
“There were so many job opportunities in skilled nursing and long-term care facilities, and I fell in love with this specialty,” she said.
Guthrie enjoys working with medically complex cases, appreciative clients and getting to know her patients.
“They’ve lived their lives and they have stories and wisdom to share. You get to know their families and they know yours,” she said.
Geriatric therapy requires more than orthopedic and neurological knowledge.
“You need to know medical diagnoses, symptoms of diseases and side effects of medications. Your patient may have Parkinson’s disease, high cholesterol and poor vision. She may have suffered a stroke and be on multiple medications,” she said.
At one time, dementia was a diagnosis of exclusion, meaning that the medical condition was determined by process of elimination rather than by testing or examination. But new research is helping therapists chose better strategies based on knowing what part of the brain is affected by dementia and how the condition presents in patients.
“We can’t cure dementia, but we can improve people’s quality of life by helping their balance, gait, strength, stamina and pain management,” Guthrie said. “We have a whole bag of tricks like manual manipulation, electrical stimulation, low-vision therapies and exercises to help people achieve their best quality of life and do more of what they enjoy.
“Exercise isn’t at the top of older people’s lists of things to do, so you have to think outside the box to get participation. It helps to find a hobby or sport that interested them in the past.”
Guthrie uses ping pong or Wii golf and bowling to get patients up and moving.
“They see it as fun, but they’re getting socialization and working on balance, strength and endurance,” she said.
“We work hard, but we feel good about what we’re able to accomplish at the end of the day. When you work in sports medicine, people want to see big results, like returning to their sport, but our patients are so appreciative of the least little thing you can do to help them.”
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Credit: Christina Matacotta