Increasing geriatric care needs prompt credentialing changes

With geriatric care needs increasing, credentialing changes ahead
With geriatric care needs increasing, credentialing changes ahead

America is getting older. According to the U.S. Census Bureau, a substantial number of baby boomers began reaching retirement in 2010, and the number of aging, retired boomers will continue to climb for the next two decades.

By 2030, more than 70 million Americans will be older than 65. And there's no question that the retirement of the baby boomer generation will have a monumental impact on the healthcare budget and on geriatric medicine in particular.

Baby boomers, obesity and old age

People born in this country between 1946 and 1964 have higher rates of obesity than previous generations of elderly Americans. As they continue to age, this population will be increasingly at risk for metabolic complications, such as diabetes, hypertension and cardiovascular disease.

In addition, they will be susceptible to typical geriatric complications, including respiratory infection and pneumonia, depression, Alzheimer's Disease, dementia and cognitive decline, and cancer and other chronic diseases and disorders.

Fall prevention, oral health, insomnia and medication adherence are crucially important and frequently challenging facets of care for elderly and frail patients.1-6

With advances in disease management, patients are living longer with these ailments. Caring for these patients will require that PAs and NPs adjust their focus.

New geriatric challenges

In addition to familiar facets of geriatric clinical care, new challenges will arise. For the first time, appreciable numbers of elderly HIV/AIDS-positive patients will require care, including the management of age- and comorbidity-related issues with highly active antiretroviral therapy (HAART) medications.7

Geriatric medicine's emphasis on coordinated team care—and on functional and quality-of-life outcomes—represents an obvious fit with the patient-centered emphasis of NPs and PAs.

In addition to hospitals, geriatric NPs and PAs work in assisted-living and long-term care facilities such as nursing homes.5   These challenging work environments make skills such as empathy, compassion, patience, good communication and emotional endurance crucially important.

Students considering a career in geriatric medicine should be sure that they are comfortable around and enjoy working with elderly patients.

A short supply of NPs and PAs

The anticipated and dramatic expansion of approximately 30 million newly insured patients under the Patient Protection and Affordable Care Act will place additional strains on clinician staffing.

The clinical care of Medicare beneficiaries is expected to fall increasingly to a relatively small supply of PAs, NPs and other nurses.8 The AAPA's 2008 census identified only 162 geriatric-specialty PAs — just 0.6% of the 27,568 PAs who responded to the census. NPs are also in short supply.9

“There's been a nursing shortage from 1999 on, really, for nurses at the bedside at hospitals and other institutions,” Johnson, PhD, FAAN, the dean of the George Washington University School of Nursing said. “With the economic crisis, that's abated somewhat. But by 2017, a lot of people who stayed in workforce will have retired.”

Expanding training programs

That has prompted an expansion in NP and PA training programs not seen since the 1970s, according to Alex Stagnaro-Green, MD, MHPE, senior associate dean for graduate medical education at George Washington University School of Medicine.

“We're really integrating geriatrics heavily into our adult NP program, because there will no longer be a geriatrics-specific certification,” Dr. Johnson says. “We've started adding genetics and genomics into the program, and palliative care, particularly looking at care of the frail elderly with palliative needs. And we've been heavily focused on quality improvement and patient safety in primary care.”

With respect to the level of care provided, NPs are typically more team-oriented and, thus, are able to be more patient-centered than physicians.

At a time when the potentially-dangerous practice of off-label sedation of the elderly are making headlines, studies show NPs are significantly more willing to manage elderly dementia-associated behaviors with nonpharmaceutical interventions than physicians or psychologists.10,11

Changes in geriatric certification

To date, RNs specifically caring the elderly have been certified in geriatric care, and likewise geriatric NPs (GNPs) trained for a degree in this particular subfield.

The American Academy of Nurse Practitioners Certification Board (AANPCP) certifies GNPs through a national exam. However, the Advanced Practice Registered Nurses (APRN) Consensus Work Group model for nursing education, has decided to eliminate gerontological nursing-specific certification from its national certification exams by 2015.

The APRN model will subsume geriatric medicine training into a broader category of gerontology and care of the frail adults as a part of the gerontology/adult population competency criterion — one of six population foci of the NP curriculum. This change reflects a philosophy of incorporating geriatric nursing skills into all NP training, and into clinical care specializations like mental health and women's health nursing.

GNP-specific certification exams will no longer be offered by the APRN after 2014. However, the AANPCP will begin offering Adult-Gerontology Primary Care NP certification exams in early 2013, and the demand for gerontology-trained NPs is expected to climb for the next 10 to 20 years.

“For students and APRNs who are new to geriatrics, please keep all of your career options open,” Gerontological Advanced Practice Nurses Association (GAPNA) President Elizabeth Galik, PhD, CRNP, urged in August 2012.12 “No matter where you practice, you will encounter older adults in some capacity and your geriatric clinical experiences and continuing education will make you a more competent and well-rounded provider.”

Bryant Furlow is a freelance medical writer in Albuquerque, New Mexico.


References

  1. Conn VS, Hafdahl AR, Cooper PS, et al. “Interventions to improve medication adherence among older adults: meta-analysis of adherence outcomes among randomized controlled trials.” The Gerontologist. 2009;49(4):447-462.
  2. Baker DI, Gottschalk M, Bianco LM. “Step by step: integrating evidence-based fall-risk management into senior centers.” The Gerontologist. 2007;47(4):548-554.
  3. Krishnan P, Hawranik P. “Diagnosis and management of geriatric insomnia: a guide for nurse practitioners.” Journal of the American Academy of Nurse Practitioners. 2008;20:590-599.
  4. Sarin J, Balasubramaniam R, Corcoran AM, et al. “Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.” Journal of the American Medical Directors Association. 2007;9(2):128-135.
  5. Intrator O, Feng, Z, Mor V, et al. “The employment of nurse practitioners and physician assistants in U.S. nursing homes.” The Geronotologist. 2005;45(4):486-495.
  6. Delaney C, Barrere C. “Advanced practice nursing students' knowledge, self-efficacy, and attitudes related to depression in older adults.” Holistic Nurse Practitioner. 2012;26(4):210-220.
  7. Capriotti T. “HAART meds: implications for the older adult patient.” Clinical Advisor. May; 2012.
  8. Furlow B. “Health & Science Career Advice: Medical schools scrambling: increases in patients creates large demand for new clinicians.” Washington Post.
  9. American Academy of Physician Assistants (AAPA). “2008 AAPA Physician Assistant Census report for geriatrics.”
  10. Cohen-Mansfield J, Jensen B, Resnick B, Norris M. “Knowledge and attitudes toward nonpharmacological interventions for treatment of behavior symptoms associated with dementia: a comparison of physicians, psychologists, and nurse practitioners.” The Gerontologist. 2012;52(1):34-34.
  11. Boston Globe. Health & Wellness: Which nursing homes overuse antipsychotic drugs? Potent sedatives not recommended for many elderly residents who get them.
  12. Gerontological Advanced Practice Nurses Association (GAPNA). “Expanding the reach of gerontological advanced practice nursing.” 

All documents accessed December 21, 2012.

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