Case Studies in Gerontological Nursing for the Advanced Practice Nurse E-Book
Meredith Wallace Kazer
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Case Studies in Nursing
- Sprache: Englisch
As the fastest growing population sector worldwide, older adults are seen in almost every care setting in which clinicians practice. Developed as a resource for advanced practice nurses in any setting, Case Studies in Gerontological Nursing for the Advanced Practice Nurse presents readers with a range of both typical and atypical cases from real clinical scenarios. The book is organized into six units covering cases related to ageism, common health challenges, health promotion, environments of care, cognitive and psychological issues, and issues relating to aging and independence. Each case follows a similar format including the patient's presentation, critical thinking questions, and a thorough discussion of the case resolution through which students and clinicians can enhance their clinical reasoning skills. Designed to promote geriatric clinical education through self-assessment or classroom use, Case Studies in Gerontological Nursing for the Advanced Practice Nurse is a key resource for all those dedicated to improving care for older adults.
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Table of Contents
Cover
Title page
Copyright page
Contributors
Introduction
Abbreviations and Acronyms
Section 1: The Aging Population
Case 1.1 Recipe for Successful Aging
OBJECTIVE
CRITICAL THINKING
RESOLUTION
Case 1.2 Cultural Competence Is a Journey
CRITICAL THINKING
RESOLUTION
Case 1.3 The Ugly Face of Ageism
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
ADVANCED PRACTICE CRITICAL THINKING
RESOLUTION
ADVANCED PRACTICE CRITICAL THINKING
Case 1.4 If Only We Had National Health Insurance
OBJECTIVE
ASSESSMENT
CRITICAL THINKING
RESOLUTION
TOOLBOX
Section 2: Common Health Challenges of Aging
Case 2.1 The Heart of It All
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.2 I Have This Thing on My Skin
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.3 Why Is My Mother Wearing a Diaper?
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.4 My Aching Back
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.5 More Than Just Constipation
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.6 Are You in the Hospital Again?
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.7 It Hurts When I Pee
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.8 The History Reveals All
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.9 Kneedless Pain
OBJECTIVE
DIAGNOSTICS
ASSESSMENT
CRITICAL THINKING QUESTIONS
RESOLUTION
Case 2.10 Life after a Right CVA
OBJECTIVE
ASSESSMENT
CRITICAL THINKING
RESOLUTION
Case 2.11 It Takes My Breath Away
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.12 What’s Shaking?
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.13 Too Much to Manage
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 2.14 Them Bones, Them Bones
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Section 3: Health Promotion
Case 3.1 Never Too Old to Quit
OBJECTIVE
ASSESSMENT
CRITICAL THINKING
RESOLUTION
Case 3.2 Protection by Prevention
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 3.3 Is Being Careful Enough?
OBJECTIVE
ASSESSMENT
CRITICAL THINKING
RESOLUTION
Case 3.4 Sick and Tired of Being Sick and Tired
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 3.5 To Screen or Not to Screen
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Section 4: Environments of Care
Case 4.1 Who Says I Can’t Go Home
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 4.2 Regressing in Rehab
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 4.3 There’s No Place Like Home
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 4.4 Caring for the Caregiver
OBJECTIVE
Critical Thinking
RESOLUTION
Case 4.5 Transitions
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 4.6 Shifting the Focus of Care
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 4.7 Without a Home
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 4.8 A Place Called Home
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 4.9 Aging in Place
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Section 5: Cognitive and Psychological Issues in Aging
Case 5.1 The Diabolical Ds
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 5.2 What a Difference a Day Makes
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 5.3 I Don’t Feel Good
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 5.4 Understanding Distress
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Section 6: Issues of Aging and Independence
Case 6.1 Too Much of a Good Thing
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 6.2 Driving in My Car
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 6.3 Sex Does Not Stop with Seniority
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 6.4 Hidden Pathology
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 6.5 Taking Control of the Pain
OBJECTIVE
ASSESSMENT
DIAGNOSTICS
CRITICAL THINKING
RESOLUTION
Case 6.6 The Road toward End-of-Life Decision Making: Who Has the Right of Way?
OBJECTIVE
ASSESSMENT
CRITICAL THINKING
RESOLUTION
Index
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Library of Congress Cataloging-in-Publication Data
Case studies in gerontological nursing for the advanced practice nurse / editors, Meredith Wallace Kazer, Leslie Neal-Boylan.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8138-2378-2 (pbk.: alk. paper)
ISBN-10: 0-8138-2378-1 (pbk.: alk. paper)
ISBN-13: 978-1-1182-7782-9 (epdf)
ISBN-13: 978-1-1182-7784-3 (epub)
ISBN-13: 978-1-1182-7779-9 (mobi)
1. Geriatric nursing–Case studies. I. Kazer, Meredith Wallace, PhD, RN. II. Neal-Boylan, Leslie.
[DNLM: 1. Nursing Care–Case Reports. 2. Aged. WY 152]
RC954.c42 2012
618.97′0231–dc23
2011017809
A catalogue record for this book is available from the British Library.
Contributors
EDITORS
Meredith Wallace Kazer, PhD, APRN, A/GNP-BC, FAAN
Associate Professor and Graduate Program Director
School of Nursing
Fairfield University
Fairfield, CT
Leslie Neal-Boylan, PhD, RN, CRRN, APRN, FNP-BC
Professor and Graduate Program Coordinator
Nursing Department
Southern Connecticut State University
New Haven, CT
CONTRIBUTORS
Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN
Professor
Director—Adult, Family, Gerontological and Women’s Health Primary Care Specialty
Yale University School of Nursing
New Haven, CT
Marie Boltz, PhD, APRN, BC
Associate Director for Practice, Hartford Institute for Geriatric Nursing
Assistant Professor, New York University College of Nursing
New York, NY
Kimberlee-Ann Bridges, MSN, RN-BC, CNL
Surgical Unit Clinical Nurse Leader
Danbury Hospital
Danbury, CT
Frieda R. Butler, PhD, MPH, FAAN, FGSA
Gerontological Consultant and Professor Emerita
College of Health and Human Services
Department of Global and Community Health
George Mason University
Fairfax, VA
Dympna Casey, RGN, BA, MA, PhD
Aras Moyola
School of Nursing and Midwifery
National University of Ireland
Galway, Ireland
Donna Packo Diaz, MS, RN
Coordinator
APDA Parkinson Center
Hospital of Saint Raphael
New Haven, CT
Karen Dick, PhD, GNP-BC, FAANP
Graduate Program Director and Clinical Associate Professor
College of Nursing and Health Sciences
University of Massachusetts Boston
Boston, MA
Ashley Domingue, MSN, RN, ANP-BC, GNP-C
Foundation Medical Partners
Nashua, NH
Annemarie Dowling-Castronovo, PhD(c), RN
Assistant Professor and Jonas Scholar
Evelyn L. Spiro School of Nursing
Wagner College
Staten Island, NY
Everol M. Ennis, Jr., MSN, APRN, A/GNP-BC
Nurse Practitioner
Community Health Services, Inc.
Hartford, CT
Bonnie Cashin Farmer, PhD, RN
Associate Professor
School of Nursing
University of Southern Maine
Portland, Maine
Susan C. Frazier, MS, NP-C, GNP-BC
Steward Skilled Care Team
Fall River, MA
Patricia C. Gantert, MSN, RN-BC
Medical Educator/Diabetes Resource Nurse
St. Vincent’s Medical Center
Bridgeport, CT
Christine M. Goldstein, LCSW-R, OSW-C
Good Samaritan Home Health Agency
Bay Shore, NY
Susan A. Goncalves, DNP(c), MS, RN-BC
Nurse Manager Med/Surg Unit
St. Vincent’s Medical Center
Bridgeport, CT
Philip A. Greiner, DNSc, RN
Associate Dean for Faculty Development in Scholarship and Teaching and Professor
College of Health Professions
Pace University
Pleasantville, NY
Kendra M. Grimes, MSN, APRN, GNP-BC
Yale University School of Nursing
New Haven, CT
Shelley Yerger Hawkins, DSN, APRN, FNP, GNP, FAANP
Associate Professor of Nursing
Coordinator, Nurse Practitioner Programs
University of Arkansas Medical Sciences
Little Rock, AR
Rebecca Herter, MSN, RN
A/GNP Candidate
Yale University School of Nursing
New Haven, CT
Melanie J. Holland, BSN, MS
Adjunct Professor
Quinnipiac University
Hamden, CT
Outreach Nurse
St. Vincent’s Medical Center
Bridgeport, CT
Cynthia S. Jacelon, PhD, RN, CRRN, FAAN
Associate Professor
School of Nursing
University of Massachusetts
Amherst, MA
Jaclyn R. Jones, MSN, APRN, NP-C
Yale School of Nursing
Yale University
New Haven, CT
Evanne Juratovac, PhD, RN (GCNS-BC)
Assistant Professor, Frances Payne Bolton School of Nursing
Faculty Associate, University Center on Aging and Health
Case Western Reserve University
Cleveland, OH
Jina Ko, MSN, RN, ANP-C
Nurse Practitioner
White Memorial Medical Center
Los Angeles, CA
Barbara L. Kramer, MSN, RN, CHPN
Palliative Care Coordinator
Good Samaritan Home Health Agency and Catholic Home Care
Bay Shore, NY
Alison Kris, PhD, RN
Assistant Professor
Fairfield University
School of Nursing
Fairfield, CT
Devon Kwassman, MSN, RN
A/GNP Candidate
Yale University School of Nursing
New Haven, CT
Kimberly O. Lacey, DNSc, MSN, CNS
Assistant Professor
Department of Nursing
Southern Connecticut State University
New Haven, CT
Amanda LaManna, MSN, RN, NP-C
Adult Nurse Practitioner
Miami University Student Health Services
Oxford, Ohio
Antoinette Larkin, RGN, H. Dip. Gerontology
Clinical Nurse Specialist in Elderly Care
Portiuncula Hospital
Ballinalsoe
Galway, Ireland
Julie M. L. Lautner, MSW, MSN, RN
A/GNP Candidate
Yale University School of Nursing
New Haven, CT
Kathleen Lovanio, MSN, APRN, F/ANP-BC
Assistant Professor, VANA
Fairfield University School of Nursing
Fairfield, CT
Geraldine Marrocco, EdD, APRN, CNS, ANP-BC
Assistant Professor
Yale University School of Nursing
New Haven, CT
Bernard McCarthy, MSc
Lecturer
School of Nursing and Midwifery
National University of Ireland
Galway, Ireland
Elizabeth McGann, DNSc, RN, GCNS-BC
Professor of Nursing
Department of Nursing
Quinnipiac University
Hamden, CT
Anne Moore, DNP, RN
Director of Spine and Surgical Business Planning
Hospital of Saint Raphael
New Haven, CT
Kathy Murphy, RN, BA, DipN, RNT, MSc, PhD
Professor of Nursing
School of Nursing and Midwifery
National University of Ireland
Galway, Ireland
Nicholas R. Nicholson, Jr., PhD, MPH, RN, PHCNS-BC
Postdoctoral Fellow
Geriatric Clinical Epidemiology and Aging Related Research
School of Medicine
Yale University
New Haven, CT
Kenneth S. O’Rourke, MD
Associate Professor
Section on Rheumatology and Immunology
Wake Forest University School of Medicine
Winston-Salem, NC
Maureen E. O’Rourke, RN, PhD
Adjunct Assistant Professor of Internal Medicine-Hematology/Oncology
Wake Forest University School of Medicine
Winston-Salem, NC
Kelly Smith Papa, MSN, RN
Director of Education
Alzheimer’s Resource Center of Connecticut
Plantsville, CT
Lynn Price, JD, MSN, MPH, FNP-BC
Associate Professor
Department of Nursing
Quinnipiac University
Hamden, CT
Valerie C. Sauda, RN-BC, MS
Geriatric Nurse Service Instructor
Nursing Department
Eastern Maine Community College
Bangor, ME
Mary Shelkey, PhD, ARNP
Assistant Professor
College of Nursing
Seattle University
Seattle, WA
Eileen O’Connor Smith, BSN, RN-C
Director of Nursing
Alzheimer’s Resource Center of Connecticut
Plantsville, CT
Cathi A. Thomas, MS, RN, CNRN
Assistant Clinical Professor, Neurology
Parkinson Disease and Movement Disorder Center
Boston University Medical Campus
Boston, MA
Christine Tocchi, PhD(C), MSN, APRN, GNP-BC
Pre-Doctoral Scholar
Yale University School of Nursing
Yale University
New Haven, CT
Claire Welford, RGN, DipNS, BNS–Hons., MSc, PGC–TLHE
School of Nursing and Midwifery
National University of Ireland
Galway, Ireland
Cora D. Zembrzuski, PhD, APRN
Gero-psychiatric Consultant
MedOptions, Inc.
Behavioral Health Consultants
Old Saybrook, CT
Introduction
By Meredith Wallace Kazer and Leslie Neal-Boylan
Older adults are the fastest growing population cohort worldwide. In the U.S., the Administration on Aging (2009) reports that there were over 38.9 million older adults in the country, which reflects a 13.0% increase over the last decade for a total of 12.8% of the total population. One in every eighth person in the U.S. is an older adult. If individuals survive to the age of 65, they will likely live an average of 18.6 more years for an average life span of approximately 84 years. It is predicted that the older adult population will increase from 40 million in 2010 to 55 million in 2020, which represents a 36% increase for this decade. The fastest growing population of older adults is the 85+ population, which is expected to increase from 5.7 million in 2010 to 6.6 million in 2020.
The rapid growth of older adults in the U.S. positions this population in almost every care setting in which clinicians practice. Except for those clinicians who choose to work solely with maternal clients, most clinicians will care for older adults in an array of care environments. Even pediatric clinicians will encounter older adult parents as grandparents raising grandchildren, and these situations will require knowledgeable and experienced clinicians to assist in negotiating the many challenges of older adulthood. However, geriatric education or education that focuses on the care of this population has not kept pace with the increased prevalence of older adults in health care settings. In the latest available survey, Gilje, Lacey, and Moore (2007) revealed that just over 50% of baccalaureate nursing programs surveyed offered a stand-alone geriatric course. In order to provide cost-effective and evidence-based care to meet the great needs of the rising population of older adults, geriatric education is needed in all educational institutions that prepare clinicians to care for older adults. Most importantly, resources with which to facilitate geriatric education are greatly needed.
This book was developed as a resource for geriatric clinical education. Using real cases, this book provides thoughtful clinical scenarios through which clinicians can enhance clinical reasoning and gain geriatric nursing knowledge. The cases in this book were chosen to illustrate both typical and atypical situations that occur in geriatric practice. Readers are encouraged to go beyond simply trying to find the answers regarding the diagnoses and treatment plans for the patients involved in these cases toward the development of new ideas and knowledge. The usefulness of each case is enhanced if readers consider various scenarios for the patient in light of how the patient’s conditions or circumstances might affect the family within the care setting. Remembering that the patient is part of an environment will help enhance readers’ understanding of the condition from multiple perspectives.
This book is organized around 6 sections that focus on conditions and environments that impact older adults. The first section provides an overview of issues that impact the geriatric population. Contained within this section is a case study that discusses the elements of successful aging. The section proceeds with an issue that is becoming more prevalent within health care education—the need for cultural competence. The Administration on Aging (2009) reports that in 2008, 19.6% of older adults were minorities: 8.3% were African American, 6.8% were persons of Hispanic origin (who may be of any race), approximately 3.4% were Asian or Pacific Islander, and less than 1% were American Indian or Native Alaskan. By the year 2010, these minority populations are projected to increase from 5.7 million in 2000 (16.3% of the older adult population) to 8.0 million in (20.1% of older adults) and then to 12.9 million in 2020 (23.6% of older adults). This drastic increase in the cultural diversity of older adults requires that clinicians analyze their views and values regarding other cultures, learn essential elements of these cultures that impact health care choices, and facilitate the delivery of culturally competent health care interventions across care settings.
Section 1 proceeds to focus on two other major issues that impact older adults. Ageism, which is defined as a negative attitude or bias toward older adults that results in the belief that older people cannot or should not participate in societal activities or be given equal opportunities afforded to others (Holohan-Bell & Brummel-Smith, 1999), affects health care of older adults and impacts access to services. Ageism has the power to deprive older adults of their dignity and respect and may facilitate the disengagement of older adults from society. Ageism also has the potential to influence policies and care decisions for older adults. The rising costs of health care, limited reimbursement options for older adults, and low income among older adults also impact health care greatly. The median income of older adults in 2008 was only $25,503 for males and $14,559 for females, and approximately 3.7 million older adults (9.7%) were below the poverty level in 2008. Section 1 includes cases that address both of these issues.
Section 2 focuses on common health conditions that affect older adults. In developing a framework for cases in this section, a review-of-systems approach was used. Thus, the cases reflect health care conditions that impact all systems from head to toe. Because cardiac conditions are major challenges as patients age, this section begins with a case study that focuses on this system. Common skin conditions, bowel and bladder issues, and musculoskeletal concerns are represented within the early cases in this section. Other commonly occurring conditions such as stroke, sexually transmitted diseases, chronic obstructive pulmonary disease, Parkinson disease, and osteoporosis are also featured within this section.
There is a common misconception prevalent in health care that health promotion activities are not useful for older adults in their later years. Many clinicians incorrectly believe that after 60, 70, or 80 years of poor health behaviors such as drinking, smoking, or poor nutrition, older adults cannot benefit from programs focused on improving health practices acquired early in life and continued into older adulthood. The reality is that older adults are certainly not “too old” to stop smoking and drinking excessive amounts of alcohol, improve food choices, start exercising, develop sleep hygiene habits, and enhance their overall health and safety. Older adults may benefit from health promotion activities, even in their seventh, eighth, ninth, and tenth decades of life. Section 3 provides case studies in which older adults find themselves in need of health promotion activities and successfully engage in them. Contained within this section are cases discussing older adults challenged with primary prevention interventions, such as immunizations, smoking cessation, and good sleep hygiene development. This section also discusses secondary prevention strategies such as screening for prostate cancer.
While the majority of older adults live in their own homes, the Administration on Aging (2009) reports that approximately 31% (11.2 million) of noninstitutionalized older adults live alone (8.3 million women; 2.9 million men). As individuals age, living alone presents a number of challenges to living a quality life. For many older adults, institutional living and assisted living are often alternatives to living alone; but these alternatives also involve challenges. Section 4 presents case studies on the challenges of living alone and in institutions. The transition between environments, homeless older adults, and lack of fit in care environments are also among the cases presented in this section.
Many older adults approach their later years cognitively intact. However, a syndrome commonly known as the three Ds (delirium, depression, and dementia) occurs frequently in the older adult population. Section 5 presents cases that illustrate the similarities and difference in the presentation of the three Ds and provides information to help clinicians to effectively detect these conditions and to implement early treatment. In so doing, the consequences of these cognitive and psychological conditions may be prevented.
Finally, the last section of this book presents cases on special issues among older adults that may impact levels of independence. Polypharmacy and its impact on one older adult is the focus of the first case study in this section. The section continues to explore the challenge of driving, as well as the challenge of continued sexual health among older adults, amidst declining function and overall health. Pain management and end-of-life decision making cases are also present in this section to help clinicians anticipate and manage these special issues among the older adult population.
As readers progress through this book, they will be interested in and impressed with the depth and breadth of the case studies in gerontological nursing. Each section focuses on a different area of concern for older adults and contains cases that illustrate the issue in a manner that enhances the readers’ understanding. Using this pedagogical method of learning, readers will enhance their knowledge and understanding regarding the vast array of issues of interest to clinicians who provide advanced care to older adults. Consequently, improved health care may be provided, resulting in improvement of the quality of life of the fastest growing U.S. population.
REFERENCES
Administration on Aging (2009). Profile of Older Americans. Washington, D.C: Journal of Professional Nursing, 23, 21–29.
Gilje, F., Lacey, L., & Moore, C. (2007). Gerontology and geriatric issues and trends in U.S. Nursing programs: A national survey.
Holohan-Bell, J., & Brummel-Smith, K. (1999). Impaired mobility and deconditioning. In J. Stone, J. Wyman, & S. Salisbury (Eds.), Clinical gerontological nursing. A guide to advanced practice (pp. 267–287). Philadelphia, PA: W.B. Saunders.
Abbreviations and Acronyms
Section 1: The Aging Population
Case 1.1 Recipe for Successful Aging
By Christine Tocchi, PhD(C), MSN, APRN, GNP-BC
Case 1.2 Cultural Competence Is a Journey
By Jina Ko, MSN, RN, ANP-C and Julie M. L. Lautner, MSW, MSN, RN
Case 1.3 The Ugly Face of Ageism
By Shelley Yerger Hawkins, DSN, APRN, FNP, GNP, FAANP
Case 1.4 If Only We Had National Health Insurance
By Philip A. Greiner, DNSc, RN
Case 1.1
Recipe for Successful Aging
By Christine Tocchi, PhD(C), MSN, APRN, GNP-BC
Mrs. R presents to the primary-care practice for an annual examination. She is new to the practice and has several health questions she would like to discuss regarding aging as she is now a “senior” and needs to stay healthy to care for her 88-year-old mother with early stage Alzheimer disease. Mrs. R is 65 years old and describes her overall health as good. She was diagnosed with hypertension and hypercholesterolemia approximately 15 years ago and has been seeing her former primary physician every 6 months for checkups. Mrs. R also has osteoarthritis of the right knee with occasional pain and stiffness. She is concerned that she may need to have knee replacement surgery in the future. Mrs. R recently relocated to a new apartment to accommodate being the primary caregiver for her mother. Mrs. R is not sure how to manage her mother’s routine health care.
Mrs. R has a past medical history of hypertension, hypercholesterolemia, and osteoarthritis of the right knee. Her past surgical history includes a tonsillectomy at age 7 and cholecystectomy at age 41. Her medications are: HCTZ, 12.5 mg daily; atorvastatin, 20 mg daily; and Tylenol Arthritis, 2 tablets as needed for knee pain with an average of once a day administration and twice a day “on bad days”. She has a mammogram annually. Her last Pap smear was 2 years ago. She had a colonoscopy at age 55. Both tests revealed no abnormal findings. TB: unknown. She has no known allergies (NKA). Her functional status reveals that she is independent in all activities of daily living and instrumental activities of daily living. She drives her own automobile. Her father died at age 63 of myocardial infarction (MI). Her mother is alive, age 88, with a history of mild stage Alzheimer disease, hypercholesterolemia, and osteoarthritis of both knees. Mrs. R is not sure of her paternal and maternal grandparents’ health history. Mrs. R has 2 brothers ages 69 and 67 living in Puerto Rico with unknown health history. She has 2 younger brothers living in the United States. Her 60-year-old brother has a health history of MI at age 48, hypertension, and diabetes mellitus. Her 57-year-old brother has hypercholesterolemia. Mrs. R also has 2 sisters living in the United States. One sister, age 62, has diabetes mellitus, hypertension, and a history of breast cancer. Her 55-year-old sister is alive and in good health. Mrs. R also has 3 children: 2 sons, ages 42 and 40, are both in good health; and her daughter, age 37, is also in good health. She has 8 grandchildren.
Mrs. R is a recently retired home health aide. She has a high school diploma and has received certification as a home health aide. She is divorced and currently residing in a 2-bedroom apartment of a 2-family house with her 88-year-old mother. Mrs. R is the primary caregiver for her mother. One sister lives locally and works full-time. This sister lives with her family on the first floor of the 2-family house. The sister sporadically assists with primary caregiving of mother when she is not working. Mrs. R’s other siblings live within 20 miles but only visit during the holidays. Mrs. R’s children all live locally, work full-time, and have children. Mrs. R provides child care for her daughter’s 7- and 10-year-olds after school 3 days per week. Her son’s family comes to dinner every Sunday. Mrs. R has a boyfriend whom she sees approximately 3 times per week. The couple dines at a local restaurant weekly without her mother.
Mrs. R states that her finances are adequate and include Social Security and a “small” amount of savings. She also does alterations occasionally for a local tailor for extra income. Mrs. R has a 20 pack year history of smoking. She has not smoked for 25 years. Mrs. R denies a history of alcohol abuse or use of recreational drugs. She has approximately 1 glass of wine per day with dinner. Mrs. R is sexually active. She denies dyspareunia or sexual problems with herself or her partner. She has no history of sexually transmitted diseases.
Hobbies:
Mrs. R enjoys cooking and has a weekly card game with her girlfriends. Most of her day is spent shopping, doing housework, babysitting, and overseeing the care of her mother.
Mrs. R currently denies any pain, discomfort, or constitutional symptoms. She does state that she has intermittent right knee pain associated with arthritis. The pain and stiffness occur on cold or rainy days and with extended walking or sitting. The pain is described as a “bad ache,” 7 on a scale of 1–10; and its duration is 30 minutes to 1 hour. Stretching, heat, and Tylenol Arthritis are all effective. She averages 2 Tylenol Arthritis tablets per day and twice a day on “bad days”. She denies headache. Mrs. R states that she has noticed some difficulty with blurred vision at night when driving and requires reading glasses for any “close work”. She denies any hearing loss or tinnitus. She denies nasal congestion, drainage, epistaxis, sore throat, or a cough. On a rare occasion, she has experienced dyspnea on exertion without chest pain or palpitations, which is relieved with rest. Mrs. R also denies any abdominal pain, nausea, vomiting, constipation, or diarrhea. On occasion, she has experienced indigestion after a large meal, which is relieved with Tums. She complains of rare stress incontinence with laughing or sneezing, but no urge incontinence, dysuria, hematuria, or retention difficulties. She wakes to void once per night. Mrs. R denies any vaginal drainage. She denies any joint pain except knee pain. She denies muscle weakness, paresthesia, edema, or difficulty with balance or gait. Mrs. R denies episodes of lightheadedness, vertigo, syncope, tremors, or falls in the past 6 months. She describes her mood as good, without depressive symptoms, anxiety, or mood swings. She also describes her memory as good with rare “forgetfulness” of names or misplacing things but “it always comes to me in a couple of minutes”.
OBJECTIVE
Mrs. R is a 65-year-old female in no acute distress. Her BP is 126/78; her pulse is 78; and her respirations are 12. She is 64 inches tall and weighs 125 lb. Her head is normocephalic. PERRLA. External ear canals are without drainage, erythema, or swelling. Her TMs are intact. Her neck is supple. There is no evidence of lymphadenopathy, thyroidomegaly, or carotid bruits. Her thorax is symmetrical, and her breath sounds are clear to auscultation. Cardiac examination reveals S1, S2 with no murmurs, gallops, or clicks. Her abdominal examination is benign. Her extremities have no evidence of cyanosis, clubbing, or edema. Her neurological examination is nonfocal, without evidence of rigidity, myoclonus, cogwheeling, or tremors. She has a positive get-up-and-go test, and her Romberg sign is negative.
CRITICAL THINKING
What are the current statistics on life-expectancy trends of the older adult population that will guide recommendations for care for Mrs. R?
How can Mrs. R successfully age without becoming dependent on others for physical support?
What are the current rates of disability in older adults and methods to prevent disability?
What are the most important areas to assess in Mrs. R. in order to help to promote health and prevent disease and complications associated with chronic illness?
What is the plan of treatment for Mrs. R based on her history and physical examination results?
RESOLUTION
What are the current statistics on life-expectancy trends of the older adult population that will guide recommendations for care for Mrs. R?
The growth in the number and proportion of older adults in the United States is increasing at an unprecedented rate. The older adult population is currently 12.8% of the U.S. population; 1 in 8 Americans are greater than 65 years of age. It is estimated that this population will increase to approximately 20% by the year 2030 (U.S. Department of Health and Human Services, 2008). The older adult population comprises a large heterogeneous group of age categories and ethnicity. Older adults like Mrs. R are frequently characterized as young old (65–75 years of age), old old (75–85 years of age), or oldest old (those 85 years of age and greater). The baby boomers (those born between 1946 and 1964) will start turning 65 in 2011, and the number of older people will increase dramatically during the 2010–2030 period. The oldest-old population is the fastest growing segment of the population and is projected to grow rapidly after 2030, when the baby boomers move into this age group. The U.S. Census Bureau projects that the population age 85 and over could grow from 5.3 million in 2006 to nearly 21 million by 2050 (Federal Interagency Forum on Aging-Related Statistics, 2006).
With the expected increase in the number of older adults, there is also an anticipated change in the racial/ethnic composition of this cohort. It is projected that by 2030, more than 1 in 3 older adults will be from 1 of 4 minority groups: African American, Asian/Pacific, Hispanic, and American Indian (Federal Interagency Forum on Aging-Related Statistics, 2010).
Because of the projected increase in the older-adult population, the health and the usage of health care services of this group will be of great concern to public policy. Population information will be needed in order to evaluate their impact on Medicare and Medicaid (Kramarow, Lubitz, Lentzner, & Gorina, 2007). Some states have higher concentrations of older adults and will need to analyze available resources to accommodate the projected rise of this population. Presently, the majority of older adults reside in 10 states: Florida, Pennsylvania, West Virginia, Iowa, North Dakota, Rhode Island, Maine, South Dakota, Arkansas, and Connecticut (Administration on Aging, 2009). Health care resources, transportation options, availability of caregivers, and health policy will all be affected by the increase in the number of older adults.
Life expectancy:
The decline in adult mortality over the past half century has contributed to the steady increase in life expectancy. In 2004, the average life expectancy at birth in the United States was 75.2 and 80.4 for men and women. At age 65, the average male was expected to live another 17.1 years and females another 20 years (Centers for Disease Control and Prevention, 2006). The extended life span of humans is largely due to advances in medical science that have prevented or decreased the occurrence of acute illness. Chronic disease and degenerative illness have replaced acute illness as the leading causes of death for older adults.
How can Mrs. R successfully age without becoming dependent on others for physical support?
Successful aging allows older adults like Mrs. R to maintain autonomy and remain living independently in the community. However, there is a lack of a universal definition or measurement of successful aging. The World Health Organization, the White House Conference on Aging, and the National Institute of Aging have emphasized that successful aging goes beyond avoidance of disease and disability. Rowe and Kahn (1997), whose model was used in the MacArthur Research Network on Successful Aging, defined successful aging as including low probability of disease and disease-related disability, high cognitive and physical functional capacity, and active engagement in life. Other components in the literature identify life satisfaction, presence of illness, longevity, personality, environment, and self-rated health (McReynolds & Rossen, 2004).
Research suggests that good lifestyle choices have an essential role in successful aging. The literature indicates that adequate physical activity, even initiated in later years, contributes to high physical and cognitive functioning and overall health (Aranceta, Perez-Rodrigo, Gondra, & Orduna, 2001; Fillit et al., 2002; Houde & Melillo, 2002; Mattson, Chan, & Duan, 2002; Oguma, Sesso, Paffengarger, & Lee, 2002). Specifically, physical activity increases muscle tone, flexibility, cardiovascular health, positive mood, and cognition. It also prevents falling, which is a significant health issue for older adults.
Nutrition is a powerful and modifiable lifestyle factor that can delay or prevent chronic disease in later life and potentially may add extra years of health, productivity, and functioning (Shikany & White, 2000). The leading causes of death of older adults in the United States (which include coronary heart disease, cancer, and stroke) are associated with diet. However, older adults like Mrs. R are at risk of undernutrition due to physiological changes related to digestion, metabolism, and nutrients. Many older adults may have poor nutritional intake because of a decrease in sense of taste or an increase in chewing or swallowing difficulties.
Social support contributes to physical and cognitive function and engagement in life (Lange-Collette, 2002). Psychologists believe social support provides a stress buffering effect on health (Cohen, 2004). Stress is thought to activate physiological systems such as the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) cortical axis (Cohen, Kessler, & Gordon, 1995). Prolonged activation of these systems is thought to place an individual at risk for a variety of physical and psychological illnesses. Social support may interrupt the stress–physical decline cycle. Maintaining active social relationships and involvement may provide the necessary emotional support to deter the chronic activation of the sympathetic nervous system and HPA axis. Social support may also promote a sense of fulfilling important social roles, enhance feelings of self-control and competency, and facilitate healthful lifestyle behaviors that prevent chronic illness and disability, such as exercise and healthy nutrition (Krause, Herzog, & Baker, 1992; Mendes de Leon, Glass, & Berkman, 2003).
What are the current rates of disability in older adults and methods to prevent disability?
The World Health Organization (2010) defined disability as an umbrella term, covering impairments, activity limitations, and participation restrictions. Research indicates that older adults have significantly increased prevalence of disability, particularly non-Caucasians; and the suggested contributing factor is the current epidemic of obesity (Seeman, Merkin, Crimmins, & Karlamangia, 2010). Older obese adults are more likely than nonobese cohorts to have certain chronic conditions and report higher levels of disability (Kramarow et al., 2007). Prevention of disability is a significant factor for maintaining independence and successful aging. Maintaining a healthy lifestyle and managing chronic illness are important methods in prevention of disability.
Chronic disease:
Chronic illness causes most death among older Americans (Kramarow et al., 2007). Results from the National Health Interview Survey indicated that nearly one-third of older adults in 2004–2005 reported having been diagnosed with some form of health disease, and approximately half reported having been diagnosed with arthritis. An individual’s risk for having more than one chronic condition increases with age in 62% of Americans greater than 65 years of age; 1 in 5 Americans have multiple chronic conditions (Volgeli et al., 2007). The most prevalent conditions for the older adult population include arthritis (57%), hypertension (55%), pulmonary disease (38%), diabetes (17%), cancer (17%), and osteoporosis (16%) (Partnership for Solutions National Program Office, 2004).
To manage chronic illness, older adults like Mrs. R often have multiple health care providers. The average number of physicians seen by Medicare patients ranges from 4 (with 1 chronic condition) to 14 (with 5 or more conditions) (Volgeli et al., 2007). As the number of health care providers increases, it is increasingly more challenging for patients to comprehend, recall, and reconcile instructions (National Academy of Social Insurance, 2003). Also, patients with multiple conditions tend to take more medications and are more likely to suffer adverse drug events (Boyd, Darer, Boult, Fried, Boult, & Wu, 2005; Gandi et al., 2003; Gurwitz et al., 2003; Tinetti, Bogardus, & Agostini, 2004).
What are the most important areas to assess in Mrs. R. in order to help to promote health and prevent disease and complications associated with chronic illness?
Older adults often present with complex medical problems that have been managed by multiple providers and have lengthy medication lists, several health concerns, and misconceptions about normal aging and health management. The goal of the first primary care visit is to properly evaluate the older adult with attention to their special needs. Subsequent visits will focus on addressing any additional health concerns, health promotion, and prevention.
The purpose of the initial assessment is to complete a comprehensive history and a physical examination and to assess for common geriatric syndromes (Table 1.1.1) and iatrogenic illnesses. Iatrogenic illnesses are any illnesses that result from a diagnostic procedure or therapeutic intervention, that are not natural consequences of the patient’s disease, and that are associated with medications, diagnostic and therapeutic interventions, nosocomial infections, and environmental hazards. Also essential to the care of older adults is complete health maintenance (Table 1.1.2) and immunization records (Table 1.1.3).
TABLE 1.1.1. Common Geriatric Syndromes.
Iatrogenic IllnessWeight loss and malnutritionCognitive impairmentDepressionUrinary incontinenceImmobility & gait disordersFallsVisual and hearing impairmentsDizzinessSyncopeSleep disordersPressure ulcersPainTABLE 1.1.2. Health Maintenance.
Eye examHearing examColonoscopyMammogramPap smearBone density testDental examFoot examFunctional ability testSocial supportTABLE 1.1.3. Immunizations.
PneumoniaInfluenzaTetanusZosterWhat is the plan of treatment for Mrs. R based on her history and physical examination results?
Hypertension. Order laboratory diagnostics to identify secondary causes and screen for target organ damage. Initial diagnostic evaluation may include assessment of kidney function (electrolytes), urine screening for protein or microalbumin, blood sugar levels, and an electrocardiogram. Continue hydrochlorothiazide.
Hypercholesteremia. Order lipid panel. Continue atorvastatin.
Osteoarthritis. Tylenol Arthritis, 1–2 tablets as needed but not to exceed 3 doses per day. Referral to orthopedic specialist for evaluation of osteoarthritis of the right knee.
Physical activity. Thirty minutes of physical activity per day is recommended for health promotion and prevention. This will be especially important in this case with Mrs. R’s history of hypertension and risk for coronary heart disease and diabetes mellitus.
Nutrition. Low fat diet with emphasis on fruits, vegetables, complex carbohydrates, and protein.
Referrals. Gastroenterology for colonoscopy and gynecology for annual examination, Pap smear, mammography, and dexometry.
Recommendations. Ophthalmology for funduscopic examination. Mrs. R should have her mother assessed by a geriatrician to discuss pharmacological and nonpharmacological treatment options for Alzheimer disease.
Overall, this case underscores an opportunity for earlier identification of disease to improve treatment outcomes. Beyond the personal plan of care, the provider may pursue opportunities to offer staff education to accomplish this goal in the future.
REFERENCES
Administration on Aging (2009). A profile of older Americans. Washington, DC: Department of Health and Human Services.
Aranceta, J., Perez-Rodrigo, C., Gondra, J., & Orduna, J. (2001). Community-based program to promote physical activity among elderly: The Gerobilbo Study. Journal of Nutrition, Health, & Aging, 5, 238–242.
Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. Journal of the American Medical Association, 294, 716–724.
Centers for Disease Control and Prevention (2006). Faststats: Life expectancy. Retrieved from http://www.cdc.gov/nchs/fastats/lifexpec.htm table 11
Cohen, S. (2004). Social relationships and health. The American Psychologist, 59, 676–684.
Cohen, S., Kessler, R. C., & Gordon, L. U. (1995). Strategies for measuring stress in psychiatric and physical disorders. In S. Cohen, R. C. Kessler, & L. U. Gordon (Eds.), Measuring stress (pp. 3–28). New York: Oxford University Press.
Federal Interagency Forum on Aging-Related Statistics (2006). Older Americans 2006: Key indicators for well-being. Hyattsville, MD. Retrieved from http://www.agingstats.gov/Agingstasdotnet/Main_Site/Data/2006_Documents/OA_2006.pdf
Federal Interagency Forum on Aging-Related Statistics (2010). Older Americans 2010: Key indicators of well-being. Hyattsville, MD. Retrieved from http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data
Fillit, H. M., Butler, R. N., O’Connell, A. W., Albert, M. S., Birren, J. E., Cotman, C. W., … Tully, T. (2002). Achieving and maintaining cognitive vitality and aging. Mayo Clinic Proceedings, 77, 681–696.
Gandi, T. K., Weingrt, S. N., Borus, J., Seger, A. C., Peterson, J., Burdick, E., … Bates, D. W. (2003). Adverse drug events in ambulatory care. The New England Journal of Medicine, 348, 1556–1564.
Gurwitz, J. H., Field, T. S., Harrold, L. R., Rothschild, J., Debellis, K., Seger, A. C., … Bates, D. W. (2003). Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Journal of the American Medical Association, 289, 1107–1116.
Houde, S. C., & Melillo, K. D. (2002). Older adults: An integrative review of research methodology and results. Journal of Advanced Nursing, 38, 219–234.
Kramarow, E., Lubitz, J., Lentzner, H., & Gorina, Y. (2007). Trends in the health of older Americans, 1970–2005. Health Affairs, 26, 1417–1425.
Kraus, N., Herzog, A. R., & Baker, E. (1992). Providing support to others and well-being in later life. Journal of Gerontology: Psychological Sciences, 47, P300–P311.
Lange-Collette, J. (2002). Promoting health among perimenopausal women through diet and exercise. Journal of the American Academy of Nurse Practitioners, 14, 172–177.
Mattson, M. P., Chan, S. L., & Duan, W. (2002). Modification of brain aging and Neurodegenerative disorders by genes, diet, and behavior. Physiological Reviews, 82, 637–672.
McReynolds, J. L., & Rossen, E. K. (2004). Importance of physical activity, nutrition, and social support for optimal aging. Clinical Nurse Specialist CNS, 18, 200–206.
Mendes de Leon, C. F., Glass, T. A., & Berkman, L. F. (2003). Social engagement and disability in a community population of older adults: The New Haven EPESE. American Journal of Epidemiology, 157, 633–642.
National Academy of Social Insurance (2003). Medicare in the 21st century: Building a better chronic care system. Washington, DC: National Academy of Social Insurance.
Oguma, Y., Sesso, H. D., Paffengarger, R. S., & Lee, I. M. (2002). Physical activity and all cause mortality in women: A review of the evidence. British Journal of Sports Medicine, 36, 162–172.
Partnership for Solutions National Program Office (2004). Chronic conditions: Making the case for ongoing care. Partnerships for Solution: John Hopkins University.
Rowe, J. W., & Kahn, R. L. (1997). Successful aging. The Gerontologist, 37, 435–440.
Seeman, T. E., Merkin, S. S., Crimmins, E. M., & Karlamangia, A. S. (2010). Disability trends among older Americans: National health and nutrition examination surveys, 1988–1994 and 1999–2004. American Journal of Public Health, 100, 100–107.
Shikany, J. M., & White, G. L. (2000). Dietary guidelines for chronic disease prevention. Southern Medical Journal, 93, 1138–1151.
Tinetti, M. E., Bogardus, S. T., & Agostini, J. V. (2004). Potential pitfalls of disease-specific guidelines for patients with multiple conditions. The New England Journal of Medicine, 351, 2870–2874.
U.S. Department of Health and Human Services (2008). Population of older adults. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General. Retrieved from http://aspe.hhs.gov/dalcp/reports/
Volgeli, C., Shields, A. E., Lee, T. A., Gibson, T. B., Marder, W. D., Weiss, K. D., & Blumental, D. (2007). Multiple chronic conditions: Prevalence, health consequences, and Implications for quality, care management, and costs. Society of General Internal Medicine, 22, 391–395.
World Health Organization (2010). Disabilities. Retrieved from http://www.who.int/topics/disabilities/en/
ADDITIONAL RESOURCES
Administration on Aging (2007). A profile of older Americans. Washington, DC: Department of Health and Human Services.
Population Reference Bureau (2003). Which states are the oldest? Retrieved from www.prb.org/articles/2003/whichstatearetheoldest.aspx
Case 1.2
Cultural Competence Is a Journey
By Jina Ko, MSN, RN, ANP-C, and Julie M. L. Lautner, MSW, MSN, RN
Ms. L is an 82-year-old woman complaining of lower abdominal pain for 2 weeks. Her 16-year-old grandniece, Joan, is with her today and is translating on Ms. L’s behalf. Ms. L recently arrived in the U.S. from Taiwan to be with her sister MengFei, age 74, and her sister’s family. Ms. L speaks Taiwanese, Japanese, and some Mandarin. Her English is very limited. Ms. L is not married and does not have any children. Her health history is sparse with no reported medical or surgical history, allergies, or medications. Joan reports that Ms. L occasionally sees a traditional Chinese herbalist for “better health.”
When the provider comes into the room, Ms. L has not changed into a gown as instructed and is sitting on a chair next to Joan. During the initial assessment, Ms. L seems reluctant to reveal any specific health history to the provider; but as Joan translates, Ms. L points to her lower abdomen-pelvis area and reports ongoing pain for “many years” that has recently gotten “much worse”. Ms. L agrees and nods to subsequent questions or responds in short, abrupt, negative statements, as both Ms. L and Joan seem increasingly uncomfortable with the more focused line of questioning. The provider becomes impatient with Ms. L’s vague answers and detached demeanor as the time allotted for the history and physical is quickly dwindling away. She instructs Ms. L to change into her gown and sit on the examining table while she steps out. Ms. L appears reluctant to change, and begins speaking rapidly with Joan. Joan tells the provider that Ms. L has never been undressed in front of a health care provider before. The provider tries to assure Ms. L that she needs her to change into the gown in order to perform the exam and steps out, assuming that Ms. L will understand once the exam begins. Upon returning to the room, Ms. L is gowned and sitting on the table, but remains silent and does not offer any eye contact. The provider begins the abdominal part of the physical examination without using Joan to translate the process since their allotted time is almost over. When asked to get into position for a pelvic exam, Ms. L becomes increasingly agitated. The provider asks Joan to explain that this is a normal part of the exam and that it is necessary to examine her for the source of her pain. Ms. L shakes her head and refuses. The provider begrudgingly relents and tells Joan that she will have to schedule Ms. L for abdominal and transvaginal ultrasounds instead. Ms. L does not return for her ultrasounds as scheduled, and subsequent calls to the household to reschedule are unsuccessful.
CRITICAL THINKING
What do you know about cultural diversity in the geriatric population? What is cultural competence and why does it matter to those in health care?
Would a lesson in cultural competence have aided the provider and improved her care for this individual, or would her interaction have remained the same?
Time constraints can be challenging in practice. Was the provider right to rush the exam? As it turns out, Ms. L has valid reasons for her discomfort with the exam process. Would a more comprehensive history have improved care? Why or why not?
What could the provider have done better in this first visit to establish a better foundation for care with Ms. L?
What are some guiding principles behind cultural competence that can further help practitioners to become more proficient?
RESOLUTION
What do you know about cultural diversity in the geriatric population? What is cultural competence and why does it matter to those in health care?
The U.S. is an increasingly diverse population, particularly among older adult groups. The Centers for Disease Control and Prevention indicate that while the non-Hispanic Caucasian population will decrease from 83% of all older adults in 2003 to only 72% in 2030, other racial and ethnic older adult group numbers will increase dramatically (2007). More specifically, the Hispanic/Latino older adult population will increase by nearly 50% during that same time frame, the African American older adult population will increase by 20%, and the Asian older adult population will increase nearly 60%—the largest older adult population group increase in the U.S. The evidence is clear that ethnic and cultural diversity is on the rise in the U.S., particularly among older adult populations; and clinicians must be able to work with and among a diverse population base in order to provide the best, most comprehensive care.
A clear, singular definition of cultural competence does not exist. In their work Towards a Culturally Competent System of Care, Cross and colleagues provide a pivotal foundation upon which current interpretations and extrapolations of cultural competence derive (Cross, Bazron, Dennis, Isaacs, 1989). They write, “Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations” (Cross et al., 1989, p. iv). The authors cite the following key elements that contribute to becoming more culturally competent: 1) valuing diversity, 2) having the capacity for cultural self-assessment, 3) being conscious of the dynamics inherent when cultures interact, 4) having institutionalized culture knowledge, and 5) having developed adaptations to service delivery reflecting an understanding of cultural diversity (Cross et al., 1989).
The work of Cross and colleagues was significant in that it moved beyond previous ideas of cultural awareness, knowledge, or sensitivity, ideas which had failed to include the coalescing of behaviors, policies, and attitudes that allow agencies and organizations to work effectively in cross-cultural situations (Adams, 1995, as cited by the Center for Effective Collaboration and Practice, n.d.). Instead, cultural competence calls upon agencies, organizations, policies, and policy builders to recognize the need for successful communication and working relationships in order to participate in the breakdown of potentially biased and stereotyped care that frequently undermines and underserves large portions of the population. The need for self-assessment emphasizes that stereotyped, biased, or racist viewpoints are incompatible with and are opposed to successful cross-cultural work, particularly on the individual level.
Over the last 20 years, the literature on cultural competence in health care has expanded greatly. Most readers of this text have been exposed to the concept of cultural competence at some point, as health care professionals have been on the front lines of the cultural competence movement. Having been faced with the complexities of working with diverse populations, providers understand that failed interactions can have life-or-death consequences. Despite these lessons, few can say with confidence that they are truly culturally competent. All too often, cultural competence is interpreted as an end point without the need for ongoing critical followup and assessment; yet this is far from accurate.
Would a lesson in cultural competence have aided the provider and improved her care for this individual, or would her interaction have remained the same?
